O0500: Restorative Nursing Programs

Item Rationale

Health-related Quality of Life

• Maintaining independence in activities of daily living and mobility is critically important to most people.

• Functional decline can lead to depression, withdrawal, social isolation, and complications of immobility, such as incontinence and pressure ulcers/injuries.

Planning for Care

• Restorative nursing program refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.

• A resident may be started on a restorative nursing program when they are admitted to the facility with restorative needs, but are not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.

Steps for Assessment

1. Review the restorative nursing program notes and/or flow sheets in the medical record.

2. For the 7-day look-back period, enter the number of days on which the technique, training or skill practice was performed for a total of at least 15 minutes during the 24-hour period.

3. The following criteria for restorative nursing programs must be met in order to code O0500:

• Measurable objective and interventions must be documented in the care plan and in the medical record. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident’s medical record.

• Evidence of periodic evaluation by the licensed nurse must be present in the resident’s medical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established.

• Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity.

• A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents. Restorative nursing does not require a physician’s order. Nursing homes may elect to have licensed rehabilitation professionals perform repetitive exercises and other maintenance treatments or to supervise aides performing these maintenance services. In situations where such services do not actually require the involvement of a qualified therapist, the services may not be coded as therapy in item O0400, Therapies or O0425, Part A Therapies, because the specific interventions are considered restorative nursing services (see item O0400, Therapies and O0425, Part A Therapies). The therapist’s time actually providing the maintenance service can be included when counting restorative nursing minutes. Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs.

• This category does not include groups with more than four residents per supervising helper or caregiver.

Coding Instructions

• This item does not include procedures or techniques carried out by or under the direction of qualified therapists, as identified in Speech-Language Pathology and Audiology Services item O0400A or O0425A, Occupational Therapy item O0400B or O0425B, and Physical Therapy item O0400C or O0425C.

• The time provided for items O0500A-J must be coded separately, in time blocks of 15 minutes or more. For example, to check Technique—Range of Motion [Passive] item O0500A, 15 or more minutes of passive range of motion (PROM) must have been provided during a 24-hour period in the last 7 days. The 15 minutes of time in a day may be totaled across 24 hours (e.g., 10 minutes on the day shift plus 5 minutes on the evening shift). However, 15-minute time increments cannot be obtained by combining 5 minutes of Technique—Range of Motion [Passive] item O0500A, 5 minutes of Technique—Range of Motion [Active] item O0500B, and 5 minutes of Splint or Brace Assistanceitem O0500C, over 2 days in the last 7 days.

• Review for each activity throughout the 24-hour period. Enter 0, if none.

Technique

Activities provided by restorative nursing staff.

• O0500A, Range of Motion (Passive)

Code provision of passive movements in order to maintain flexibility and useful motion in the joints of the body. These exercises must be individualized to the resident’s needs, planned, monitored, evaluated and documented in the resident’s medical record.

• O0500B, Range of Motion (Active)

Code exercises performed by the resident, with cueing, supervision, or physical assist by staff that are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record. Include active ROM and active-assisted ROM.

• O0500C, Splint or Brace Assistance

Code provision of (1) verbal and physical guidance and direction that teaches the resident how to apply, manipulate, and care for a brace or splint; or (2) a scheduled program of applying and removing a splint or brace. These sessions are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

Training and Skill Practice

Activities including repetition, physical or verbal cueing, and/or task segmentation provided by any staff member under the supervision of a licensed nurse.

• O0500D, Bed Mobility

Code activities provided to improve or maintain the resident’s self-performance in moving to and from a lying position, turning side to side and positioning themself in bed. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

• O0500E, Transfer

Code activities provided to improve or maintain the resident’s self-performance in moving between surfaces or planes either with or without assistive devices. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

• O0500F, Walking

Code activities provided to improve or maintain the resident’s self-performance in walking, with or without assistive devices. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

• O0500G, Dressing and/or Grooming

Code activities provided to improve or maintain the resident’s self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

• O0500H, Eating and/or Swallowing

Code activities provided to improve or maintain the resident’s self-performance in feeding oneself food and fluids, or activities used to improve or maintain the resident’s ability to ingest nutrition and hydration by mouth. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

• O0500I, Amputation/ Prosthesis Care

Code activities provided to improve or maintain the resident’s self-performance in putting on and removing a prosthesis, caring for the prosthesis, and providing appropriate hygiene at the site where the prosthesis attaches to the body (e.g., leg stump or eye socket). Dentures are not considered to be prostheses for coding this item. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

• O0500J, Communication

Code activities provided to improve or maintain the resident’s self-performance in functional communication skills or assisting the resident in using residual communication skills and adaptive devices. These activities are individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

Coding Tips and Special Populations

• For range of motion (passive): the caregiver moves the body part around a fixed point or joint through the resident’s available range of motion. The resident provides no assistance.

• For range of motion (active): any participation by the resident in the ROM activity should be coded here.

• For both active and passive range of motion: movement by a resident that is incidental to dressing, bathing, etc., does not count as part of a formal restorative nursing program. For inclusion in this section, active or passive range of motion must be a component of an individualized program that is planned, monitored evaluated, and documented in the resident’s medical record. Range of motion should be delivered by staff who are trained in the procedures.

• For splint or brace assistance: assess the resident’s skin and circulation under the device, and reposition the limb in correct alignment.

• The use of continuous passive motion (CPM) devices in a restorative nursing program is coded when the following criteria are met: (1) ordered by a physician, (2) nursing staff have been trained in technique (e.g., properly aligning resident’s limb in device, adjusting available range of motion), and (3) monitoring of the device. Nursing staff should document the application of the device and the effects on the resident. Do not include the time the resident is receiving treatment in the device. Include only the actual time staff were engaged in applying and monitoring the device.

• Remember that persons with dementia learn skills best through repetition that occurs multiple times per day.

• Grooming programs, including programs to help residents learn to apply make-up, may be considered restorative nursing programs when conducted by a member of the activity staff. These grooming programs would need to be individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record.

Examples

1. Resident V has lost range of motion in their right arm, wrist, and hand due to a cerebrovascular accident (CVA) experienced several years ago. They have moderate to severe loss of cognitive decision-making skills and memory. To avoid further ROM loss and contractures to their right arm, the occupational therapist fabricated a right resting hand splint and instructions for its application and removal. The nursing coordinator developed instructions for providing passive range of motion exercises to their right arm, wrist, and hand three times per day. The nurse’s aides and Resident V’s spouse have been instructed in how and when to apply and remove the hand splint and how to do the passive ROM exercises. These plans are documented in Resident V’s care plan. The total amount of time involved each day in removing and applying the hand splint and completing the ROM exercises is 30 minutes (15 minutes to perform ROM exercises and 15 minutes to apply/remove the splint). The nurse’s aides report that there is less resistance in Resident V’s affected extremity when bathing and dressing them.

Coding: Both Splint or Brace Assistance item (O0500C), and Range of Motion (Passive) item (O0500A), would be coded 7.

Rationale: Because this was the number of days these restorative nursing techniques were provided.

2. Resident R’s right shoulder ROM has decreased slightly over the past week. Upon examination and X-ray, their physician diagnosed them with right shoulder impingement syndrome. Resident R was given exercises to perform on a daily basis to help improve their right shoulder ROM. After initial training in these exercises by the physical therapist, Resident R and the nursing staff were provided with instructions on how to cue and sometimes actively assist Resident R when they cannot make the full ROM required by the exercises on their own. Their exercises are to be performed for 15 minutes, two times per day at change of shift in the morning and afternoon. This information is documented in Resident R’s medical record. The nursing staff cued and sometimes actively assisted Resident R two times daily over the past 7 days.

Coding: Range of motion (active) item (O0500B), would be coded 7.

Rationale: Because this was the number of days restorative nursing training and skill practice for active ROM were provided.

3. Resident K was admitted to the nursing facility 7 days ago following repair to a fractured hip. Physical therapy was delayed due to complications and a weakened condition. Upon admission, they had difficulty moving themself in bed and were dependent for transfers. To prevent further deterioration and increase their independence, the nursing staff implemented a plan on the second day following admission to teach them how to move themself in bed and transfer from bed to chair using a trapeze, the bed rails, and a transfer board. The plan was documented in Resident K’s medical record and communicated to all staff at the change of shift. The charge nurse documented in the nurse’s notes that in the 5 days Resident K has been receiving training and skill practice for bed mobility for 20 minutes a day and transferring for 25 minutes a day, their endurance and strength have improved, and they require only substantial/maximal assistance for transferring. Each day the amount of time to provide this nursing restorative intervention has been decreasing, so that for the past 5 days, the average time is 45 minutes.

Coding: Both Bed Mobility item (O0500D), Transfer item (O0500E), would be coded 5.

Rationale: Because this was the number of days that restorative nursing training and skill practice for bed mobility and transfer were provided.

4. Resident D is receiving training and skill practice in walking using a quad cane. Together, Resident D and the nursing staff have set progressive walking distance goals. The nursing staff has received instruction on how to provide Resident D with the instruction and guidance they need to achieve the goals. They have three scheduled times each day where they learn how to walk with their quad cane. Each teaching and practice episode for walking, supervised by a nursing assistant, takes approximately 15 minutes.

Coding: Walking item (O0500F), would be coded 7.

Rationale: Because this was the number of days that restorative nursing skill and practice training for walking was provided.

5. Resident J had a CVA less than a year ago resulting in left-sided hemiplegia. Resident J has a strong desire to participate in their own care. Although they cannot dress themself independently, they are capable of participating in this activity of daily living. Resident J’s overall care plan goal is to maximize their independence in ADLs. A plan, documented on the care plan, has been developed to assist Resident J in how to maintain the ability to put on and take off their shirt with no physical assistance from the staff. All of their shirts have been adapted for front closure with hook and loop fasteners. The nursing assistants have been instructed in how to verbally guide Resident J as they put on and takes off their shirt to enhance their efficiency and maintain their level of function. It takes approximately 20 minutes per day for Resident J to complete this task (dressing and undressing).

Coding: Dressing or Grooming item (O0500G), would be coded 7.

Rationale: Because this was the number of days that restorative nursing training and skill practice for dressing and grooming were provided.

6. Resident W’s cognitive status has been deteriorating progressively over the past several months. Despite deliberate nursing restoration attempts to promote their independence in feeding themself, they will not eat unless they are fed.

Coding: Eating and/or Swallowing item (O0500H), would be coded 0.

Rationale: Because restorative nursing skill and practice training for eating and/or swallowing were not provided over the last 7 days.

7. Resident E has Amyotrophic Lateral Sclerosis. They no longer have the ability to speak or even to nod their head “yes” or “no.” Their cognitive skills remain intact, they can spell, and they can move their eyes in all directions. The speech-language pathologist taught both Resident E and the nursing staff to use a communication board so that Resident E could communicate with staff. The communication board has been in use over the past 2 weeks and has proven very successful. The nursing staff, volunteers, and family members are reminded by a sign over Resident E’s bed that they are to provide them with the board to enable Resident E to communicate with them. This is also documented in Resident E’s care plan. Because the teaching and practice using the communication board had been completed 2 weeks ago and Resident E is able to use the board to communicate successfully, they no longer receive skill and practice training in communication.

Coding: Communication item (O0500J), would be coded 0.

Rationale: Because the resident has mastered the skill of communication, restorative nursing skill and practice training for communication was no longer needed or provided over the last 7 days.