Attachment 3 RUGs IV and III Description.pdf

RUGs IV Descriptions

Rehabilitation Plus Extensive Services: Residents satisfying all of the following three conditions: Having a minimum activity of daily living (ADL) dependency score of 2 or more.

Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. While a resident, receiving complex clinical care and have needs involving tracheostomy care, ventilator/respirator, and/or infection isolation.

Rehabilitation: Residents receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.

Extensive Services: Residents satisfying the following two conditions: Having a minimum

ADL dependency score of 2 or more. While a resident, receiving complex clinical care and have needs involving: tracheostomy care, ventilator/respirator, and/or infection isolation.

Special Care High: Residents satisfying the following two conditions: Having a minimum

ADL dependency score of 2 or more. Receiving complex clinical care or have serious medical conditions involving any one of the following: comatose, septicemia, diabetes with insulin injections and insulin order changes, quadriplegia with a higher minimum ADL dependence criterion (ADL score of 5 or more), chronic obstructive pulmonary disease (COPD) with shortness of breath when lying flat, fever with pneumonia, vomiting, weight loss, or tube feeding meeting intake requirement, parenteral/IV feeding, or respiratory therapy.

Special Care Low: Residents satisfying the following two conditions: Having a minimum

ADL dependency score of 2 or more. Receiving complex clinical care or have serious medical conditions involving any of the following: cerebral palsy with ADL dependency score of 5 or more, multiple sclerosis with ADL dependency score of 5 or more, Parkinson’s disease with

ADL dependency score of 5 or more, respiratory failure and oxygen therapy while a resident, tube feeding meeting intake requirement, ulcer treatment with two or more ulcers including venous ulcers, arterial ulcers or Stage II pressure ulcers, ulcer treatment with any Stage III or

IV pressure ulcer, foot infections or wounds with application of dressing, radiation therapy while a resident, or dialysis while a resident.

Clinically Complex: Residents receiving complex clinical care or have conditions requiring skilled nursing management, interventions or treatments involving any of the following: pneumonia, hemiplegia with ADL dependency score of 5 or more, surgical wounds or open lesions with treatment, burns, chemotherapy while a resident, oxygen therapy while a resident, IV medications while a resident, or transfusions while a resident.

Behavioral Symptoms and Cognitive Performance: Residents satisfying the following two conditions: Having a maximum ADL dependency score of 5 or less. Having behavioral or cognitive performance symptoms, involving any of the following: difficulty in repeating words, temporal orientation, or recall (score on the Brief Interview for Mental Status <=9), difficulty in making self understood, short term memory, or decision making (score on the Cognitive

Performance Scale >=3), hallucinations, delusions, physical behavioral symptoms toward

Attachment 3: RUGs IV and III Description others, verbal behavioral symptoms toward others, other behavioral symptoms, rejection of care, or wandering.

Reduced Physical Function: Residents whose needs are primarily for support with activities of daily living and general supervision. Calculations identify residents who are receiving restorative nursing services as recorded on the MDS and include: urinary and/or bowel training program, passive and/or active range of motion, amputation/prosthesis, training, splint or brace assistance, dressing or grooming training, eating or swallowing training, transfer training, bed mobility and/or walking training, communication training.

Resource Utilization Groups (RUGs) III Descriptions

Community Nursing Home SOP Page 1 of 1

Original Date: o5/02/2016

Community Nursing Home Program Level of Care – Descriptions – RUG III

Level of Care determinations are based on the VA Resource Utilization Groups (RUGS-III) case-mix, the industry standard. A case-mix system categorizes patients into groups according to their level of care needs. RUGS-III, like other case-mix systems, defines patients for clinical and reimbursement purposes.

Additional information on RUGS III use for VA purposes can be acquired from the Contracting Officer in concert with the appropriate

VA community health official.

Reduced Physical Functioning / Behavioral Group / Impaired Cognition Group: RUG Scores: BB2, BB1, BA2, PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1, IA2, IB2, IB1, IA1. This is the standard skilled care group. This is a catch-all patient grouping. It includes all patients who are not specifically identified in the hierarchy below, except those with minimal care needs who are listed above. The grouping includes most patients who receive a clinically complex treatment but have light to moderate ADL deficiencies and basic to moderate behavior management. It also includes most of the patients who are without special characteristics or needs but need care because of reduced physical functioning.

Clinically Complex Group: RUG Scores: CC2, CC1, CB2, CB1, CA2, CA1. These residents receive complex clinical care or have conditions requiring skilled nursing management and interventions for conditions and treatments such as dialysis, radiation therapy, chemotherapy, burns, coma, septicemia, pneumonia, foot infections or wounds, internal bleeding, dehydration, tube feeding, oxygen, transfusions, IV antibiotic therapy, hemiplegia. Patients may also be receiving care for some moderate to severe behavioral management due to medical, neurological, or psychiatric conditions and patients may be highly disabled in ADLs.

Special Care Group: RUG Scores: SSC, SSB, SSA. These residents receive complex clinical care or have serious medical conditions such as multiple sclerosis, quadriplegia, respiratory therapy, ulcers, stage III or IV pressure ulcers, radiation, surgical wounds or open lesions, tube feeding, parental feeding, fever with dehydration, pneumonia, comatose, or Suctioning. Patients may also be receiving care for some moderate to severe behavioral management due to medical, neurological, or psychiatric conditions. These patients may be moderately or highly disabled in ADLs.

Extensive Services Group: RUG Scores: SE3, SE2, SE1. These residents receive complex clinical care or have complex clinical needs such as IV feeding or medications, suctioning, tracheostomy care, ventilator/respirator and co-morbidities that make the resident eligible for other RUG categories.

Rehabilitation Group: RUG Scores: RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, RLA. These residents receive physical therapy (PT), occupational therapy (OT), or speech therapy (ST). Therapy must be performed by a licensed PT, licensed OT, licensed speech therapist, or PT/OT assistants who have completed an approved program and work under the supervision of a licensed therapist. Therapy must be approved by a VA provider for a specific period of time, not to exceed one month. Therapy approvals may be recertified by a VA provider. A copy of the therapy notes will be sent to the VA facility each month, or at the discretion of the

VA facility, the therapy notes can be reviewed on-site.

Rehabilitation Plus Extensive Services Group: RUG Scores: RUX, RUL, RVX, RVL, RMX, RHX, RML, RHL, RLX. These residents receive physical therapy (PT), occupational therapy (OT), or speech therapy (ST) AND receive IV feeding or medications, suctioning, tracheostomy care or ventilator/respirator. Therapy must be performed by a licensed PT, licensed OT, licensed speech therapist, or PT/OT assistants who have completed an approved program and work under the supervision of a licensed therapist.

Therapy must be approved by a VA provider for a specific period of time, not to exceed one month. Therapy approvals may be recertified by a VA provider. A copy of the therapy notes will be sent to the VA facility each month, or at the discretion of the VA facility, the therapy notes can be reviewed on-site.

HIV+/AIDS Care: Specialized services for HIV+ and/or AIDS patients. May be specialized program care of an individual patient.

Ventilator Dependent Care: Level of care is self explanatory. This level of care is used in cases which cannot be covered by the ventilator care rates outlined above. Placements are made on an individual, case-by-case basis, and must be made via contract modification. Rates shall be determined based on care needs and shall be negotiated prior to placement with rates incorporated into the contract modification document; however, rates are restricted to VA allowable and maximum rates, and rates are subject to reasonableness determinations.