ADL Facility Assessment Checklists - Kansas Foundation for ...

ADL Decline: Program ChecklistsThis is a series of self-assessment checklists for nursing home staff to use to assess processes relatedto activities of daily living (ADL) decline in the facility, in order to identify areas that needimprovement. These checklists focus on issues primarily related to the “late-loss” ADLs of transfers,toilet-use, bed mobility and eating. Since self-care management involves dressing, grooming, andbathing, as well as, transfers, toilet-use, bed mobility, and eating, self-care items are also included.DirectionsIncludedA staff person or team of persons knowledgeable about the facility policies, protocols, andcurrent practices should complete these checklists.In order for this checklist to be most useful in identifying areas that need improvement, itshould be completed thoughtfully and with critical judgment applied to each step. Answeraccording to what is currently happening in your facility, not what should be happening.When answering questions on the checklists, if you are not sure or answer “no” to one ofthe questions, see the Quality Improvement Worksheet A: Identifying Areas forImprovement to collect data to investigate further.Checklists on the following ADL-related topics are included:Screening for ADL function and ADL declineAssessmentCare PlansMonitoring and Reassessing ADL functionStaff Education and TrainingProvided By:800-432-0770 kfmc.org

Checklist: Screening for ADL Function and ADL DeclineDoes your facility have a process to screen residents’ ADL function?(An ADL screening process should be brief (~15minutes or less). If a resident requires more in-depth assessment,then a comprehensive evaluation by the appropriate clinical discipline should be performed.)______ No. If no, this is an area for improvement. Use this checklist and the Quality ImprovementWorksheets to guide your team in implementing a process for screening ADL function amongresidents.______This is an area we are working on. Our target date for revising our process for screening forADL function is __________. If needed, use the Quality Improvement Worksheets to guide yourimprovement process.______Yes. Please continue to the questions below.Does your facility’s process for screening for ADL function include the following components?Yes No1. Does your facility have a policy and procedure forwhen, how, and who will screen residents for ADLfunction and ADL decline? Y N2. Does your facility screen the residents’ ADLfunction:a. Upon admission?b. Upon readmission?c. With any significant change in condition and/orchange in ADL functional ability?d. With each MDS assessment?3. Does your facility use a validated, standardizedmeasure of ADL function? (Examples: MDSscores, Katz ADL Scale, Barthel Index)4. If a significant change in ADL status is identified,does your facility have a process leading to acomprehensive assessment of the resident’s ADLfunction if needed?If any of the above elements in your process are missing:YYYYYYNNNNNNPersonResponsible:Comments:• Choose one element to focus your quality improvement effort on first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.If none of the above elements are missing from your facility’s processes, please continue to the nextchecklist.

Checklist: ADL AssessmentIf your facility has an ADL assessment process, does it include the use of specific assessment formsfor ADL decline?______ No. If no, this is an area for improvement. Use this checklist and the Quality ImprovementWorksheets to guide your team in implementing a form for assessing ADL function that includesthe key components.______This is an area we are working on. Our target date for revising our form for assessing for ADLfunction is __________. If needed, use the Quality Improvement Worksheets to guide yourimprovement process.______Yes. Please continue to the questions below.Does your facility’s assessment form include the following components?Yes No1. Reason for this assessment (new admission,MDS assessment, change in condition, other) Y N2. Prior level of ADL function (prior toadmission or at time of last screen/assessment) Y N3. Current level of ADL functiona. Eating/Feeding (type of diet, liquid/solidconsistency, adaptive/assistive equip,positioning)b. Toilet use (toilet, bedside commode)c. Transfers (bed to chair, to wheelchair, tocommode)d. Bed Mobility (amount of assistanceneeded, adaptive equip)e. General mobility (ambulation, wheelchairmobility, amount of assistance needed,other)f. Gait (on level surfaces, stairs, ramps,uneven surfaces, use of assistive devices)g. Bathing (amount of assistance needed,adaptive equip)h. Grooming (amount of assistance needed,adaptive equip)i. Dressing (amount of assistance needed,adaptive equip)YYYYYYYYYNNNNNNNNNPersonResponsible:Comments:

Checklist: ADL Assessment (Cont.)4. Neuro-musculoskeletal:a. ROMb. Strengthc. Coordinationd. Loss of Balancee. Dizzinessf. History of fallsg. Sensation (touch, temperature, proprioception)h. Edemai. Vision, hearingj. Communicationk. Other (describe)5. Use of adaptive/assistive equipment:a. Orthosesb. ProsthesesYesc. OtherY N6. Pain Y N7. Communication ability Y N8. Cognition, alertness, orientation, safety awareness Y N9. Other health conditions & components that mayinfluence ADL functiona. Adverse drug reactionb. Total number of medications >3c. Aspirationd. Depressione. Deliriumf. Psychosisg. Fluid, electrolyte imbalanceh. Nutritional deficitsi. Skin breakdownj. Use of restraintsYYYYYYYYYYYYYYYYYYYYYYYNoNNNNNNNNNNNNNNNNNNNNNNNPersonResponsible:Comments:

Checklist: ADL Assessment (Cont.)10. Environmental factors:a. FurnitureYesb. Building (configuration, size of room)Y Nc. OtherY N11. Family Support, caregiver involvement Y N12. Customs, religious beliefs that may affect healthcare Y N13. Ability to learn:YNoNPersonResponsible:Comments:a. Barriers to participation/learning (vision, hearing,language, comprehension, memory, depression,interest…)b. Preferred learning style14. Current treatment interventionsa. Frequency, duration, time of dayb. Response to treatments15. Need to refer resident to other health professionalfor management of health components outside yourprofessional scope of practice?16. Follow-up recommendations:a. Revise current ADL goals, plan of careb. Refer to therapy for comprehensive assessmentc. Recommend equip, environmental modifications,etc.d. Initiate ADL/restorative programe. Continue current restorative programf. Discharge from ADL/restorative programg. Other (describe)YYYYYYYYYYYYNNNNNNNNNNNNIf any of the above elements in your process are missing:• Choose one element to focus your quality improvement effort on first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.If none of the above elements are missing from your facility’s processes, please continue to the nextchecklist.

Checklist: ADL Care PlansDoes your facility have a care planning process to improve/maintain ADL function and prevent orminimize ADL decline?______ No. If no, this is an area for improvement. Use this checklist and the Quality ImprovementWorksheets to guide your team in implementing a care planning process that includes the keycomponents.______This is an area we are working on. Our target date for revising our care planning process is__________. If needed, use the Quality Improvement Worksheets to guide your improvementprocess.______Yes. Please continue to the questions below.Do care plans for your facility's residents include the following components?Yes No1. Does the care plan include ADL goals (shorttermand long-term) as defined by theresident? Y N2. Does the care plan indicate:a. The specific cause of each deficitb. The type of interventions or treatments tobe performedc. Frequencyd. Duratione. Amount of assistance requiredf. Equipment requiredg. Special positioning required5. Does the care plan include education of theresident and family related to theinterventions, ADL program, assistivetechniques, and use of adaptive/assistiveequipment to prevent decline?6. Does the plan indicate referrals made to otherhealth professionals, and reasons?7. Does the plan indicate when a reassessmentwill be completed?YYYYYYYYYYNNNNNNNNNNPersonResponsible:Comments:

Checklist: ADL Care Plans (Cont.)If any of the above elements in your process are missing:• Choose one element to focus your quality improvement effort on first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.If none of the above elements are missing from your facility’s processes, please continue to the nextchecklist.

Checklist: Monitoring and Reassessing ADL FunctionDoes your facility have a process to monitor and regularly reassess ADL function/abilities ofresidents currently in an ADL or restorative nursing program?______ No. If no, this is an area for improvement. Use this checklist and the Quality ImprovementWorksheets to guide your team in implementing a process to monitor and reassess ADL functionthat includes the key components outlined below.______This is an area we are working on. Our target date for revising ADL monitoring andreassessment process is __________. If needed, use the Quality Improvement Worksheets toguide your improvement process.______Yes. Please continue to the questions below.Does your facility’s monitoring and reassessment process include the following components?1. Does your documentation system allow you torecord:YesNoPersonResponsible:Comments:a. Current health condition, comorbidities thatmay influence functionYNb. Response to current interventionsYNc. Type of interventions, treatments providedYNd. Type of ADL performed (eating, transfers)YNe. Level of self-performanceYNf. Amount of assistance given by caregiverYNg. Devices/equip requiredYNh. Frequency ADLs performed (daily, 3x/wk)YNi. Duration of activity (30 mins, etc.)YNj. Progress toward established goalsYNk. Cancellation, refusal of treatment and reasonYNl. Resident’s attitude toward ADL programYNm. Change in statusYNn. Need for reassessmentYNo. Need for referral to other health professionalto mange condition(s) outside yourprofessional scope of practiceYN2. Does your facility have a policy and procedure forreassessing residents at regular intervals afterthey have started a restorative program?YN

Checklist: Monitoring and Reassessing ADL Function (Cont.)3. Does your facility have a process for therestorative nurse aide or certified nurse aide tonotify an RN and rehab designee of a change inresident’s response to ADLs &/ or restorativeprogram?4. Does your facility discuss residents’ ADL statusand related issues at the interdisciplinary careplanning meeting?5. Does your facility reassess the resident when theresident or family expresses a concern regardinga change or decline in ADL abilities?YesYYYNoNNNPersonResponsible:Comments:If any of the above elements in your process are missing:• Choose one element to focus your quality improvement effort on first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.If none of the above elements are missing from your facility’s processes, please continue to the nextchecklist.

Checklist: Staff Education and TrainingDoes your facility have initial and ongoing education on ADL function and decline to both nursingand non-nursing staff?______ No. If no, this is an area for improvement. Use this checklist and the Quality ImprovementWorksheets to improve your staff education and training on ADL function and decline.______This is an area we are working on. Our target date for implementing an education program onADL function and decline is:__________. If needed, use this checklist, current accepted clinicalguidelines and the Quality Improvement Worksheets to guide your facility’s education program.______Yes. Please continue to the questions below.Does your facility’s education program for ADL function and decline include the followingcomponents?1. Are nursing staff aware of current facilitypolicy (if there is one) for when, how, andwho:a. Screens residents for ADL function andADL decline?b. Assesses residents for ADL function andADL decline?c. Reassesses residents for ADL functionand ADL decline?d. Communicates results of screening andassessment to MDS coder?YesYYYYNoNNNNPersonResponsible:Comments:2. Are staff's learning needs with regard to ADLfunction and disability regularly assessed? Y N3. Does staff training address all healthcomponents influencing function anddisability (e.g., physiological, psychological,anatomical, functional, environmental, andsocial)?4. Does staff training on ADL managementoccur at orientation and at least quarterlythereafter?5. Does education staff provide disciplinespecificeducation for prevention of ADLdecline (ex. Activities, Dietary, Rehab, SocialServices, etc.)?YYYNNN

6. Is there a designated clinical “expert”available at the facility to answer questionsfrom all staff about ADL function andrestorative programs?7. Is the education provided at the appropriatelevel for the learner (i.e. CNA vs. RN)?8. Does the education include staff training ondocumentation methods related to ADLdecline?9. Are all staff aware of the process foridentifying health conditions that mayinfluence functional ability?10. Are all staff aware of the environmentalfactors that can influence ADL function?11. Are appropriate staff trained on how to makereferrals to other health professionals whennecessary?YesYYYYYYNoNNNNNNPersonResponsible:Comments:If any of the above elements in your facility’s education and training program are missing:• Choose one element to focus your quality improvement effort on first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.Once you have completed worksheets for any missing items on any/all of the checklists you are finished.This material is provided by the Kansas Foundation for Medical Care, Inc. (KFMC), the Medicare Quality Improvement Organization for Kansas, under contract with the Centers for Medicare& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services and prepared by Quality Partners of Rhode Island The contents presented do not necessarilyreflect CMS policy. 10SOW-KS-NH_LAN-12-18