Understanding and Coding MDS 3.0 Item Q0110E: "Assessment and Goal Participation: Other Legally Authorized Representative"

Understanding and Coding MDS 3.0 Item Q0110E: "Assessment and Goal Participation: Other Legally Authorized Representative"

Introduction

Purpose:
In long-term care settings, it is essential to ensure that residents' preferences and goals are incorporated into their care plans, especially when they cannot participate directly. In such cases, a legally authorized representative may be involved in the assessment and goal-setting process. MDS Item Q0110E, "Assessment and Goal Participation: Other Legally Authorized Representative," is used to document the involvement of a legally authorized representative in these discussions. This article provides detailed guidance on how to correctly code this item to ensure accurate documentation and compliance with CMS standards.

What is MDS Item Q0110E?

Explanation:
MDS Item Q0110E, "Assessment and Goal Participation: Other Legally Authorized Representative," is part of Section Q, which focuses on the resident’s involvement in setting goals for their care and discharge planning. This item specifically captures whether a legally authorized representative, such as a legal guardian or power of attorney, participated in the assessment and goal-setting process on behalf of the resident. This is crucial when the resident is unable to communicate their preferences due to cognitive or physical limitations.

Accurate documentation of the involvement of a legally authorized representative is essential for ensuring that the resident’s care plan reflects their best interests as determined by their representative.

Guidelines for Coding Q0110E

Coding Instructions:
To correctly code Item Q0110E, follow these steps:

1. Determine the Involvement of a Legally Authorized Representative: Assess whether a legally authorized representative was involved in the assessment and goal-setting process. This could include a legal guardian, power of attorney, or another individual legally recognized to make decisions on behalf of the resident.
2. Select the Appropriate Response:
   • 1: Yes - Select this code if a legally authorized representative was involved in the assessment and goal-setting process.
   • 0: No - Select this code if a legally authorized representative was not involved.
3. Enter the Response in Item Q0110E: Record the selected response in Item Q0110E. Ensure that the resident’s care plan includes documentation of the representative’s involvement and any decisions made during the process.
4. Document the Representative’s Role: If a legally authorized representative was involved, provide additional documentation detailing their role, the decisions made, and how these were incorporated into the resident’s care plan.

Example Scenario:
A resident with severe dementia is unable to participate in discussions about their care plan. The resident’s son, who holds power of attorney, participates in the assessment and goal-setting process on behalf of the resident. The MDS Coordinator documents the son’s involvement in Item Q0110E by selecting code 1 ("Yes"). This ensures that the resident’s care plan reflects the decisions made by the legally authorized representative.

Best Practices for Accurate Coding

Documentation:
Maintain thorough documentation of the involvement of the legally authorized representative in the assessment and goal-setting process. This should include notes on the representative’s decisions and how these were integrated into the care plan. This documentation supports the coding of Item Q0110E and ensures that the resident’s care plan aligns with their legal representative’s guidance.

Communication:
Ensure effective communication between the care team and the legally authorized representative. Clear communication is crucial for understanding the representative’s decisions and for ensuring that these decisions are accurately reflected in the resident’s care plan.

Training:
Provide regular training to staff on the importance of involving legally authorized representatives in the care planning process and how to document their participation accurately. Staff should be familiar with the legal requirements and documentation standards when working with representatives.

Conclusion

Summary:
MDS Item Q0110E is essential for documenting the involvement of a legally authorized representative in the assessment and goal-setting process for residents who cannot participate directly. By correctly coding this item and ensuring clear documentation, healthcare professionals can support resident-centered care while maintaining compliance with CMS regulations. Following the guidelines and best practices outlined in this article will help ensure that the resident’s care plan reflects the decisions of their legally authorized representative.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-16] for detailed guidelines on the CAA process and the role of legally authorized representatives in assessment and goal participation.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item Q0110E: "Assessment and Goal Participation: Other Legally Authorized Representative" was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.