Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
DEFINITIONS
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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DEFINITIONS
Use this item when the facility is completing content tied to Section J and needs to stay anchored to v1.20.1.
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
HOSPICE SERVICES A program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record. TERMINALLY ILL “Terminally ill” means that the individual has a medical prognosis that their life expectancy is 6 months or less if the illness runs its normal course. Intent: This item provides an opportunity for screening in the areas of fever, vomiting, fluid deficits, and internal bleeding. Clinical screenings provide indications for further evaluation, diagnosis and clinical care planning.
Timely assessment is needed to identify underlying causes and risk for complications.
Implementation of care plans to treat underlying causes and avoid complications is critical.
1. Review the medical record, interview staff on all shifts and observe the resident for any
indication that the resident had vomiting, fever, potential signs of dehydration, or internal bleeding during the 7-day look-back period.
Check all that apply (blue box) J1550A, fever J1550B, vomiting J1550C, dehydrated J1550D, internal bleeding J1550Z, none of the above Coding Tips Fever: Fever is defined as a temperature 2.4 degrees F higher than baseline. The resident’s baseline temperature should be established prior to the Assessment Reference Date. Fever assessment prior to establishing base line temperature: A temperature of 100.4 degrees F (38 degrees C) on admission (i.e., prior to the establishment of the baseline temperature) would be considered a fever. Vomiting: Regurgitation of stomach contents; may be caused by many factors (e.g., drug toxicity, infection, psychogenic). Dehydrated: Check this item if the resident presents with two or more of the following potential indicators for dehydration:
1. Resident takes in less than the recommended 1,500 ml of fluids daily (water or
liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards.
2. Resident has one or more potential clinical signs (indicators) of dehydration,
including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity).
3. Resident’s fluid loss exceeds the amount of fluids they take in (e.g., loss from
vomiting, fever, diarrhea that exceeds fluid replacement). Internal Bleeding: Bleeding may be frank (such as bright red blood) or occult (such as guaiac positive stools). Clinical indicators include black, tarry stools, vomiting “coffee grounds,” hematuria (blood in urine), hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that requires packing. However, nose bleeds that are easily controlled, menses, or a urinalysis that shows a small amount of red blood cells should not be coded as internal bleeding.