CMS Manual System - Louisiana Department of Health and Hospitals

education, creativity, success, and financial or emotional independence. The
assessment should consider the resident‘s normal everyday routines and lifetime
preferences.
(xiv) Medications
―Medications‖ refers to all prescription and over-the-counter medications taken
by the resident, including dosage, frequency of administration, and recognition of
significant side effects that would be most likely to occur in the resident. This
information must be in the resident‘s clinical record.
(xv) Special treatments and procedures
―Special treatments and procedures‖ refers to treatments and procedures that are
not part of basic services provided. For example, treatment for pressure sores,
naso-gastric feedings, specialized rehabilitation services, respiratory care, or
devices and restraints.
(xvi) Discharge potential
―Discharge potential‖ refers to the facility‘s expectation of discharging the
resident from the facility within the next 3 months.
(xvii) Documentation of summary information regarding the additional
assessment performed on the care areas triggered by the completion of the MDS.
―Documentation of summary information (xvii) regarding the additional
assessment performed through the CAAs refers to documentation concerning
which CAAs have been triggered, documentation of assessment information in
support of clinical decision making relevant to the CAAs, documentation
regarding where, in the clinical record, information related to the CAAs can be
found, and for each triggered CAA, whether the identified problem was included
in the care plan.
(xviii) Documentation of participation in assessment
―Documentation of participation in the assessment‖ refers to documentation of
who participated in the assessment process. The assessment process must include
direct observation and communication with the resident, as well as
communication with licensed and nonlicensed direct care staff members on all
shifts.