Understanding and Coding MDS 3.0 Item Q0610A: Referral Made to Local Contact Agency

Understanding and Coding MDS 3.0 Item Q0610A: Referral Made to Local Contact Agency

Introduction

Purpose:
Supporting residents' wishes to transition from a long-term care facility to a community setting is a critical aspect of person-centered care. When a resident expresses a desire to return to the community, a referral to a Local Contact Agency (LCA) is often the first step in facilitating this transition. MDS Item Q0610A, Referral Made to Local Contact Agency, is used to document whether a referral has been made to the LCA for community discharge planning. 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 Q0610A?

Explanation:
MDS Item Q0610A, Referral Made to Local Contact Agency, is part of Section Q, which focuses on the resident’s participation in discharge planning and their desire to return to the community. This item specifically documents whether a referral to a Local Contact Agency has been made in response to the resident’s expressed interest in transitioning to a community setting. The LCA is responsible for assisting residents in exploring community living options and providing the necessary support for a successful discharge.

Accurately documenting the referral process is crucial for ensuring that the resident’s preferences are respected and that appropriate steps are taken to facilitate their transition to the community.

Guidelines for Coding Q0610A

Coding Instructions:
To correctly code Item Q0610A, follow these steps:

1. Assess the Resident’s Wishes: Determine if the resident has expressed a desire to return to the community. This desire should have been documented during previous assessments or care planning meetings.
2. Confirm the Referral Status: Verify whether a referral to a Local Contact Agency has been made. This typically involves checking the resident’s records or discussing with the interdisciplinary team responsible for discharge planning.
3. Select the Appropriate Response:
   • 0: No - Select this code if a referral to the LCA has not been made.
   • 1: Yes - Select this code if a referral to the LCA has been made.
4. Enter the Response in Item Q0610A: Record the selected response in Item Q0610A. Ensure that the documentation in the resident’s records supports the response.

Example Scenario:
A resident has expressed a strong interest in returning to their home in the community. After evaluating the resident’s health and social situation, the care team decides to make a referral to the Local Contact Agency to begin the discharge planning process. The MDS Coordinator documents this referral in Item Q0610A by selecting code 1 ("Yes"). This ensures that the referral process is accurately recorded and that the resident’s transition to the community is appropriately supported.

Best Practices for Accurate Coding

Documentation:
Maintain thorough documentation of the resident’s expressed wishes and the actions taken to facilitate their transition to the community. This includes documenting the referral to the Local Contact Agency and any follow-up actions.

Communication:
Ensure clear communication with the resident, their family, and the interdisciplinary team about the referral process. This helps align expectations and ensures that all parties are aware of the steps being taken to support the resident’s transition to the community.

Training:
Provide regular training to staff on the importance of making and documenting referrals to Local Contact Agencies. Staff should understand the role of the LCA in supporting community discharges and the procedures for initiating a referral.

Conclusion

Summary:
MDS Item Q0610A is essential for documenting whether a referral to a Local Contact Agency has been made for a resident interested in transitioning to a community setting. By accurately coding this item and ensuring proper 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 transition to the community is well-coordinated and successful.

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 3-24] for detailed guidelines on the CAA process and the importance of documenting referrals to Local Contact Agencies.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item Q0610A: Referral Made to Local Contact Agency 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.