In order for us to capture in room isolation for our COVID positive residents, what is needed for supportive documentation? Also, is there a length of time this resident has to be in isolation in order to capture it?
The resident must have an “active” infection that is highly transmissible or with epidemiologically significant pathogens caused by physical contact or airborne or droplet transmission. CDC notes that COVID-19 causes infection through respiratory droplets carrying infectious virus with recommendations of Standard, Contact, and Airborne Precautions with eye protection for COVID-19. Therefore, residents who have COVID-19 require isolation. Include documentation of this type of isolation. Per CDC, the time period for isolation is to be based on symptoms, severity of illness and if severely immunocompromised as defined here.
Document indicators to confirm “active disease” that may include COVID-19 positive test or presumptive positive test, physician indication (e.g., note, order) that condition is active, signs and symptoms indicating continuing infection and complications, and ongoing therapy with medications for treatment of COVID-19 including any side effects or therapeutic monitoring.
“Single room isolation” is required. Recommend including supporting documentation that the resident is in room alone & remains in their room with all services taken to the resident such as meals, therapy and activities. If the resident must go to another healthcare setting for medically necessary services such as blood transfusion that the facility is not able to provide, single room isolation can still be coded.
Per RAI Manual, for O0100 Column 2: Special Treatments, Procedures, and Programs is to code is to review the resident’s medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days. As long as there is documentation of “single room isolation” for “active” infection in the medical record during the last 14 days, it can be coded on the MDS.
- Centers for Disease Control and Prevention. (2020, August 10). Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
- Center for Medicare and Medicaid Services. (2019, October). MDS 3.0 RAI Manual. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html