Step-by-Step Coding Guide for Item Set Q0610A: Referral Been Made to Local Contact Agency

This guide outlines the process for accurately coding and documenting referrals made to a local contact agency for residents, as specified in Q0610A of the MDS 3.0.

1. Review of Medical Records

• Objective: To verify if a referral to a local contact agency has been made for the resident.
• Key Points:
  • Thoroughly review the resident's care plans, social service documentation, discharge planning notes, and communication logs for evidence of a referral to a local contact agency.
  • Look for documentation that explicitly states a referral has been made, including the date of referral and the name of the agency.

2. Understanding Definitions

• Objective: Clarify the concept of "Referral Been Made to Local Contact Agency."
• Key Points:
  • Referral: An official notification or direction to a local contact agency, usually intended to assist the resident in receiving community-based services, support for returning to the community, or transition planning.

3. Coding Instructions

• Objective: Provide specific guidelines for coding referrals to local contact agencies.
• Key Points:
  • Code 1: If a referral has been made to a local contact agency during the current assessment period.
  • Code 0: If no referral has been made during the current assessment period.

4. Coding Tips

• Double-check the dates to ensure the referral falls within the current MDS assessment period.
• Maintain awareness of the various types of local contact agencies that could be relevant based on the resident's needs and preferences.

5. Documentation

• Clearly document the process of making a referral to a local contact agency in the resident's medical record, including the date of referral, agency name, reason for referral, and any follow-up actions taken.
• Ensure that the documentation is accessible and easy to locate for coding and future reference.

6. Common Errors to Avoid

• Failing to document the referral process thoroughly in the resident's medical records.
• Misinterpreting communications with local agencies as referrals when no formal referral process has been initiated.

7. Practical Application

• Scenario: A resident expressing a desire to return to their home in the community is assessed by the social services team. After determining the resident's needs for home modifications and in-home support services, the social worker makes a formal referral to a local aging agency that coordinates community reintegration services. This referral, including all pertinent details, is documented in the resident's social service file and care plan.

The Step-by-Step Coding Guide for item Q0610A in MDS 3.0 Section Q is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.