Q0110: Participation in Assessment and Goal Setting
Q0110: Participation in Assessment and Goal Setting
Item Rationale
Health-related Quality of Life
• Residents who actively participate in the assessment process and in development of their care plan through interview and conversation often experience improved quality of life and higher quality care based on their needs, goals, and priorities.
Planning for Care
• Each care plan should be individualized and residentdriven. Whenever possible, the resident should be actively involved—except in unusual circumstances such as if the individual is unable to understand the proceedings or is comatose. Involving the resident in all assessment interviews and care planning meetings is also important to address dignity and self-determination survey and certification requirements (CFR §483.24 Quality of Life).
• During the care planning meetings, the resident should be made comfortable and verbal communication should be directly with them.
• Residents should be asked about inviting family members, significant others, and/or guardian/legally authorized representatives to participate, and if they desire that they be involved in the assessment process.
• If the individual resident is unable to understand the process, their family member, significant other, and/or guardian/legally authorized representative, who represents the individual, should be invited to attend the assessment process whenever possible.
• When the resident is unable to participate in the assessment process, a family member or significant other, and/or guardian or legally authorized representatives can provide information about the resident’s needs, goals, and priorities on the resident’s behalf.
Steps for Assessment
1. Review the clinical record for documentation that the resident, family member and/or significant other, and guardian or legally authorized representative participated in the assessment process.
2. Ask the resident, the family member or significant other (when applicable), and the guardian or legally authorized representative (when applicable) if they actively participated in the assessment process.
3. Ask staff members who completed the assessment whether or not the resident, family or significant other, or guardian or legally authorized representative participated in the assessment process.
Coding Instructions for Q0110, Participation in Assessment and Goal Setting
Record the participation of all those who participated in the assessment process. Check all that apply.
• Code A, Resident: if the resident actively participated in the assessment process.
• Code B, Family: if a member of the resident’s family actively participated in the assessment process.
• Code C, Significant other: if a significant other of the resident actively participated in the assessment process.
• Code D, Legal guardian: if a legal guardian actively participated in the assessment process.
• Code E, Other legally authorized representative: if a legally authorized representative actively participated in the assessment process.
• Code Z, None of the above: if none of the above actively participated in the assessment process.
Coding Tips
• While family, significant others, or, if necessary, the guardian or legally authorized representative can be involved, the response selected must reflect the resident’s perspective if they are able to express it, even if the opinion of family member/significant other or guardian/legally authorized representative differs.
• Significant other does not include nursing home staff.
DEFINITIONS
RESIDENT’S PARTICIPATION IN ASSESSMENT
The resident actively engages in interviews and conversations to meaningfully contribute to the completion of the MDS 3.0. Interdisciplinary team members should engage the resident during assessment in order to determine the resident’s expectations and perspectives during assessment.
FAMILY OR SIGNIFICANT OTHER
A spousal, kinship (e.g., sibling, child, parent, nephew), or in-law relationship; a partner, housemate, primary community caregiver or close friend. Significant other does not include staff at the nursing home.
GUARDIAN/LEGALLY AUTHORIZED REPRESENTATIVE
A person who is authorized, under applicable law, to make decisions for the resident, including giving and withholding consent for medical treatment.
