Understanding and Coding MDS 3.0 Item Q0620: Reason Referral to Local Contact Agency Not Made
Understanding and Coding MDS 3.0 Item Q0620: Reason Referral to Local Contact Agency Not Made
Introduction
Purpose:
The transition of care from a long-term care facility to a community setting is an important aspect of resident-centered care. When a resident expresses a desire to return to the community, a referral to a Local Contact Agency (LCA) is typically made to facilitate this transition. However, there are situations where this referral is not made. MDS Item Q0620, Reason Referral to Local Contact Agency Not Made, is used to document the reason why a referral was not made, ensuring that the resident's wishes and the facility's actions are clearly recorded. 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 Q0620?
Explanation:
MDS Item Q0620, Reason Referral to Local Contact Agency Not Made, is part of Section Q, which focuses on participation in assessment and goal setting related to discharge planning and community living. This item is used to document the reason why a referral to an LCA was not made, despite the resident expressing interest in returning to the community. The reasons can vary, and accurate documentation is essential to ensure that the resident's preferences are respected and that any barriers to community discharge are properly addressed.
This item is crucial for transparency in discharge planning, ensuring that both the resident's desires and the facility's actions are well-documented.
Guidelines for Coding Q0620
Coding Instructions:
To correctly code Item Q0620, follow these steps:
- Assess the Resident’s Situation: Evaluate why the referral to the Local Contact Agency was not made, considering factors such as the resident’s health status, safety concerns, or other barriers to community discharge.
- Select the Appropriate Reason Code: Based on the assessment, select the appropriate code that corresponds to the reason for not making the referral. Possible reasons include:
- 1: Resident/representative declined referral.
- 2: Resident did not indicate a desire to return to the community.
- 3: Referral not made due to resident’s health condition.
- 4: Resident will remain in the facility; referral not appropriate.
- 5: Referral not made for other reasons (specify the reason in documentation).
- Enter the Code in Item Q0620: Record the selected reason code in Item Q0620. Ensure that the code accurately reflects the situation as documented in the resident's care plan and assessment records.
- Document Additional Details: If the reason falls under "other reasons," provide additional documentation to specify the particular circumstances that prevented the referral.
Example Scenario:
A resident expresses interest in returning to the community, but after evaluation, it is determined that their health condition is too unstable to support a safe transition. The care team decides not to make the referral to the Local Contact Agency due to these health concerns. The MDS Coordinator documents this decision in Item Q0620 by selecting code 3 ("Referral not made due to resident’s health condition"). This coding ensures that the reason for not proceeding with the referral is clearly recorded, supporting transparency in the discharge planning process.
Best Practices for Accurate Coding
Documentation:
Maintain thorough documentation of the resident's expressed wishes and the reasons for not making the referral. This documentation should support the coding of Item Q0620 and ensure that the resident's care plan reflects their current situation and preferences.
Communication:
Ensure effective communication with the resident and their representative about the decision not to make a referral. This helps manage expectations and ensures that the resident understands the reasoning behind the decision.
Training:
Provide regular training to staff on how to handle situations where a referral to a Local Contact Agency is not made. Staff should be familiar with the reasons that justify this decision and understand the importance of documenting these reasons accurately in the MDS.
Conclusion
Summary:
MDS Item Q0620 is essential for documenting the reason why a referral to a Local Contact Agency was not made when a resident expressed interest in returning to the community. By accurately 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 maintain the integrity of your facility’s documentation and improve resident outcomes.
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 reasons for not making referrals to Local Contact Agencies.
Disclaimer
Please note that the information provided in this guide for MDS 3.0 Item Q0620: Reason Referral to Local Contact Agency Not Made 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.
