BINDER BASICS:

RESTORATIVE
NURSING

A “how-to” framework
for the implementation
of an effective restorative
nursing program.
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 Restorative Nursing| Table of Contents

TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
How to Use This Binder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1: Commitment to Quality of Care . . . . . . . . . . . 2

Definition of Restorative Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Quality of Life/Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 2: Restorative Caseload . . . . . . . . . . . . . . . . . . . . 4

Designated Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Staffing Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Managing Caseload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 3: Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Identification of Candidates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Levels of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 4: Care Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Active/Passive Range of Motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Splint or Brace Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Bed Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Dressing and/or Grooming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Eating and/or Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Amputation/Prosthesis Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Toileting Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

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 Restorative Nursing| Table of Contents

Chapter 5: Documentation . . . . . . . . . . . . . . . . . . . . . . . . 13
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Daily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Weekly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chapter 6: Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Resident Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Facility Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 7: QAPI Activities . . . . . . . . . . . . . . . . . . . . . . . . . 16

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Quality Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Performance Improvement Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 8: Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

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 Restorative Nursing| Introduction

INTRODUCTION
Introduction
Functional decline affects the quality of life for residents
because maintaining independence is important to them. A
decline in the ability to perform activities of daily living may
put residents at risk for depression, withdrawal, and social
isolation. Complications associated with immobility, such as
incontinence and pressure injuries, can arise. This sets the
background for regulations regarding quality of care and
quality of life. Many factors can contribute to functional
decline, highlighting the complexities associated with ensuring
residents achieve or maintain their highest practicable level of
functioning.
The Compliance Store understands the challenges associated
with developing programs related to complex issues. This binder
was developed as a “how-to-framework” for implementing a
restorative nursing services program. The structure begins with establishing a commitment to
quality care and determining a staffing model for the program. After identifying residents who
may benefit from the services, the binder turns to a discussion on the required elements of a
program. These sections cover care planning, documentation, and monitoring. The binder
concludes with considerations for QAPI activities and training of staff, residents, and families.

How to Use This Binder

The intent of this binder is to provide a blueprint for developing or remodeling a restorative
nursing services program. Although modeled after guidance located in the RAI manual,
it is not all-inclusive. It is expected that facilities will incorporate additional state-specific
information, or information specific to the duties assigned to their restorative nursing staff.

Step 1: Read It
The first step in using this binder is to read it in its entirety in order to gain a baseline knowledge
of the content.

Step 2: Print Documents

Organize a binder with dividers according to each chapter. Suggested documents for
each section are listed within the chapter content with links to sample documents on The
Compliance Store website.

Step 3: Treat it as a Blueprint

Use the chapter information and printed documents as a blueprint to quick start program
development or to refine an existing program.

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 Restorative Nursing| Commitment to Quality Care

COMMITMENT TO
QUALITY CARE
Definition of
Restorative Nursing
According to Taber’s
Cyclopedic Medical
Dictionary, restorative pertains
to restoration, which is the
return of something to its
previous state. Functional
restoration refers to the
improvement of a person’s
ability to participate in
activities and environments in
which he or she was previously
competent. Restoration is
typically one of many goals
of nursing care. CMS defines
a restorative nursing program
in Section O of the Resident
Assessment Instrument (RAI) Manual as “nursing interventions that promote the resident’s
ability to adapt and adjust to living as independently and safely as possible”. While residents
may be referred to the program by rehabilitation professionals, this program is designed,
implemented, and maintained by nursing staff.

Quality of Life/Quality of Care

In order to remain eligible to accept Medicare and Medicaid residents, nursing facilities
must maintain substantial compliance with state and federal regulations. Inspections are
conducted by state, and sometimes federal, surveyors looking for deficiencies in those
regulations, which are organized into various regulatory sections. Specific regulations are
further divided into F-Tags, and deficiencies are “cited” by F-Tag numbers.
Surveyors use interpretive guidance, found in Appendix PP of the State Operations Manual,
to determine compliance with each regulation. Various critical element pathways are also
used to determine compliance. Even though the survey process is computer based, printable
copies of the critical element pathway forms are available. CMS Form 20080 is used to ensure
that facilities obtain and provide necessary rehabilitative or restorative services. This form
directs surveyors to cite F-676, a quality of life deficiency, if a facility does not provide the
appropriate treatment and services to maintain, restore, or improve the resident’s functional
ability. CMS Form 20120 is used for a resident with concerns related to range of motion (ROM),
mobility, and/or positioning. It directs surveyors to cite F-684 for positioning concerns and
F-688 for ROM or mobility concerns. These are quality of care deficiencies.

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 Restorative Nursing| Commitment to Quality Care

Quality of life and quality of care are fundamental principles that apply to all care,
treatment, and services provided to facility residents. CMS emphasizes the importance
of these principles as evidenced by separate regulatory sections within long-term care
regulations with those names. It is reasonable that a decline in functional abilities would
negatively affect a resident’s quality of life. Quality care is paramount in preventing
unavoidable decline. Implementation of an effective restorative nursing program establishes
a commitment to quality care, and results in improved quality of life of facility residents.

SUGGESTED DOCUMENTS
In addition to survey procedures, this binder section is reserved for documents that establish
commitment to quality care through development and implementation of a restorative
nursing program. Examples include:
▶▶ Restorative Nursing Programs Policy
▶▶ Positioning, Mobility & Range of Motion (ROM) Critical Element Pathway: CMS-20120
Form
▶▶ Specialized Rehabilitative or Restorative Services Critical Element Pathway: CMS-
20080 Form

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 Restorative Nursing| Restorative Caseload

RESTORATIVE CASELOAD
Designated Nurse
Facilities indicate the provision of
restorative nursing programs through
Section O, item O0500, of the
Minimum Data Set (MDS). The RAI
manual provides guidance regarding
these programs. In order to code
these services, evidence of periodic
evaluation by a licensed nurse must be
present in the resident’s medical record.
Additionally, restorative activities
must be supervised by a registered or
licensed practical nurse.
An effective restorative nursing program requires consistent oversight. Designating a single
person who is responsible for the program is ideal. Depending on the size of the facility,
this person may or may not have additional duties. To support the successful execution of
the program, responsibilities related to the program should be clearly defined in program
documents, policies and procedures, and/or job descriptions. Because this is a nursing
program, a nurse must serve as the leader.

Staffing Models
There are many different restorative nursing program models in practice today. Some facilities
have designated restorative aides who provide the formal activities, while others train all
nursing assistants to do so. Based on experience, this binder is written from the perspective of
using designated restorative aides. Recognizing that staffing patterns differ, some information
related to training all nursing assistants will be presented also. Whatever the model, the
resident must be placed in the center of the team and cared for by staff with the appropriate
skills to do so competently.

Managing Caseload
When deciding what staffing model to implement, the facility must assess the resident
population and determine what services the residents need. Designated restorative aides
may have specific duties related to other facility programs, such as dining services or
obtaining resident weights. Leaders must account for all duties when determining how many
residents may be served, based on the number of restorative aides available. Conversely,
if opportunities for improvement exist, additional restorative aides may need to be added
to the staffing plan. When staffing challenges pose barriers to successful implementation of
the program, the Restorative Nurse, in collaboration with the interdisciplinary team, should
prioritize the residents and/or services that are provided.

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 Restorative Nursing| Restorative Caseload

Facilities may take the following steps to determine the maximum number of residents who
may be on restorative caseload at a time:
♦♦ Total the number of work hours per day for all scheduled restorative aides.
♦♦ Analyze the time it typically takes to perform non-restorative program activities (i.e.
dining room duties, snack distribution, meetings, documentation, breaks).
♦♦ Subtract the number of non-restorative program hours from the total scheduled hours.
This is the number of hours available for restorative program tasks.
♦♦ Divide the number of available hours by 15 minutes, the typical expected number of
minutes per program task. This is the maximum number of program tasks that may be
performed on a given day within the allotted time.
♦♦ The number of program tasks that may be performed on a given day typically equals
the number of residents who may be served. However, if a resident requires more than
one task, the number of residents will be reduced.
After determining the maximum number of residents who may be served by the restorative
aides, prioritize residents and make assignments. Account for potential staffing challenges
(i.e. restorative aide absence or pulled to the floor), and make alternative assignments. To
promote continuity of care, make same-staff assignments as possible so that one particular
aide is assigned to the same resident daily.

SUGGESTED DOCUMENTS
Documents that establish how the restorative nursing program is staffed are recommended to
be placed in this binder section. Examples include:
▶▶ Restorative Aide Job Description
▶▶ Restorative Aide Time Analysis
▶▶ Restorative Nurse Job Description
▶▶ Restorative Staffing Needs Assessment
▶▶ Sample Restorative Schedule

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 Restorative Nursing| Identification

IDENTIFICATION
Identification of Candidates
The RAI manual provides examples of when
a resident may be started on a restorative
nursing program. Typically, this includes when
restorative needs are identified, but the resident
is not a candidate for formalized rehabilitation
therapy, or the resident is discharged from
formalized therapy. Restorative needs are
identified through a combination of quality
data review and comprehensive resident
assessments. Refer to Chapter 7 for QAPI
activities. How restorative needs are identified
through the assessment process is discussed
below.

Physical Assessment
Initial physical assessments establish a resident’s baseline function. A comprehensive
assessment includes obtaining the recent history of the resident’s prior functioning. This helps
to identify any cognitive or physical functioning areas that may benefit from intervention to
restore the resident to his or her prior level of functioning. For long-term residents, the physical
assessment may be compared to prior assessments to identify changes in function. The
premiere quality of life regulation, F-675, requires facilities to provide the necessary care and
services to attain or maintain the highest practicable physical, mental, and psychosocial well-
being. Based on the resident’s assessment, the interdisciplinary team may further determine
whether the resident requires restorative services, or maintenance services.
MDS
The MDS is used to assess each resident’s clinical condition, cognitive and functional status,
and use of services. Section O, item O0500, is used to indicate the provision of restorative
nursing services. The coding reflects the number of days in which the restorative tasks were
performed at least 15 minutes a day in the last 7 calendar days. The following types of
services, or techniques, are included:
♦♦ Range of motion (passive) ♦♦ Walking
♦♦ Range of motion (active) ♦♦ Dressing and/or grooming
♦♦ Splint or brace assistance ♦♦ Eating and/or swallowing
♦♦ Bed mobility ♦♦ Amputation/prosthesis care
♦♦ Transfers ♦♦ Communication

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 Restorative Nursing| Identification

Considering the types of restorative services for which the MDS assesses, facilities are to look
at functional abilities related to those services when identifying residents who may benefit
from restorative services. The MDS assesses those abilities in the following sections.
♦♦ Section B assesses the resident’s ability to hear, understand, and communicate with
others.
♦♦ Section C assesses the resident’s attention, orientation, and ability to register and
recall new information. This data is useful when determining whether communication
problems are functional in nature, or are related to cognition.
♦♦ Section G assesses functional status, limitations in range of motion, use of mobility
devices, and the potential for rehabilitation.
♦♦ Section H assesses the use of and response to toileting programs. (See Chapter 4.)
♦♦ Section K assesses for signs and symptoms of possible swallowing disorder.
The completed MDS must be analyzed and combined with other relevant information
to develop an individualized care plan. This includes identifying restorative needs, and
implementing interventions to address those needs.

Specialized Rehabilitation Assessment

Rehabilitative therapy requires the skills of a therapist to furnish a recognized therapy
service safely and effectively. The goal of rehabilitation is improvement of an impairment
or functional limitation. Improvement is evidenced by successive objective measurements
whenever possible. Evaluations, re-evaluations, and assessment of progress are required to
justify continued therapy. Professional judgment is used to determine that continued therapy
is reasonable and necessary, or whether maintenance therapy is warranted. Skilled therapy
services are covered when an individualized assessment of the resident’s clinical condition
demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist
are necessary for the performance of safe and effective services in a maintenance program.
Otherwise, the resident may be referred to restorative or nursing staff for carrying out the
functional maintenance program.

Levels of Care
Each resident’s assessment is used to determine whether a resident requires specialized
rehabilitation services, restorative services, maintenance services that require licensed nurse
oversight (i.e. qualifies as restorative nursing services), or maintenance services that do not
require licensed nurse oversight. Restorative nursing program documents should provide
guidance for deciding when the services of restorative aides are required, or when services
may be provided safely by nursing assistants. The two types of services may be identified as
Maintenance services or Level II services.

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 Restorative Nursing| Identification

Maintenance Services
Helping residents retain their abilities and improve, whenever possible, fall within the scope of
a nursing assistant’s job description. Some basic, restorative nursing care practices that do not
require licensed nurse oversight include:
♦♦ Maintaining proper positioning and body alignment.
♦♦ Encouraging and assisting residents, as needed, in turning and position changes.
♦♦ Encouraging residents to remain active and assisting with any exercises according to
the plan of care.
♦♦ Promoting independence in ADLs, performing tasks for residents only as needed to
ensure completion of tasks.
♦♦ Assisting residents in adjustment to their disabilities and use of any assistive devices.
♦♦ Assisting residents with range of motion exercises, performing passive range of motion
for residents who lack active range of motion ability.
♦♦ Promoting continence with various toileting and/or bowel and bladder training
activities.
The services described above may be indicated on a resident’s plan of care and carried out
by a nursing assistant. Licensed nurse oversight provided as a routine function of supervising
nursing assistants does not deem the service a formal restorative service.

Level II Services
Most restorative nursing programs are initiated upon discharge from specialized rehabilitation
services. The need for rehabilitation typically follows an acute medical episode and change
in condition. The resident remains at risk for further decline if the skills learned in therapy are
not reinforced, or the resident is not monitored for follow-through. Licensed nurse oversight
is required for monitoring the resident’s condition, identifying actual or potential risks, and
evaluating progress with restorative or maintenance activities. This service is beyond the
scope of a nursing assistant, and therefore, qualifies as a restorative function. As such, the
resident’s plan of care will identify the problem being addressed, measurable objectives,
and specific individualized interventions/procedures to be provided. Each resident’s unique
characteristics and risks will be considered when setting priorities for the restorative caseload.

SUGGESTED DOCUMENTS
This binder section is reserved for documents that help staff determine when restorative
nursing services would be beneficial for a resident. In addition to information from the RAI
manual related to restorative nursing services, place documents similar to the following
examples:
▶▶ MDS Coding Tips Related to Restorative Nursing
▶▶ Rehab/Restorative In-House Communication Form
▶▶ Restorative Nursing Services Algorithm

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 Restorative Nursing| Care Planning

CARE PLANNING
Overview
Measurable objectives and interventions
must be documented in the care
plan and in the medical record in
order for services to meet the criteria
for a restorative nursing program.
Restorative tasks are typically care
planned as part of an intervention for
an identified problem, need, or strength
of the resident. As a nursing function,
a physician’s order is not required for
implementing restorative services. Since
a periodic evaluation by a licensed
nurse must be present in the medical
record, some facilities choose to establish
a separate restorative care plan. This
ensures that program goals are clearly
identified, and facilitates the evaluation of interventions for effectiveness. Care plans may be
individualized according to the types of restorative tasks assessed by the MDS.

Active/Passive Range of Motion

Range of motion refers to the extent of motion a resident exhibits through a given joint. Active
range of motion is movement performed by the resident without any assistance. Passive
range of motion is performed by someone other than the resident. Range of motion tasks are
comprised of exercises to maintain flexibility and avoid contractures in the joints: shoulders,
elbows, wrists, hands, hips, knees, ankles, and feet. Typical exercises include, but are not
limited to extension, flexion, rotation, abduction, and adduction. A care plan for these
exercises would include the type of motion (active or passive), affected joints/extremities,
frequency (how many times per day or week), and duration (in minutes per frequency).

Splint or Brace Assistance

A splint is a movable or immovable device designed for the fixation, union, or protection of
an injured part of the body. A brace refers to a variety of devices used for holding joints or
limbs in place. The terms are often used interchangeably. Restorative tasks related to splints/
braces include verbal and physical guidance and education on how to apply, manipulate,
and care for the splint or brace. The tasks may also involve a scheduled program of
application or removal. A care plan for splint or brace assistance may indicate the type of
splint, affected extremity, a wear schedule, and monitoring for evidence of skin breakdown
related to the device.

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 Restorative Nursing| Care Planning

Bed Mobility
Bed mobility includes moving to and from a lying position, turning side to side, and positioning
self in bed. Bed mobility tasks are comprised of repetition, physical or verbal cueing, and/
or task segmentation to improve or maintain the resident’s self-performance. A care plan
for these activities would include the type of task (verbal cueing for turning, positioning,
or moving from a lying position), frequency of repetitions, frequency of encounters, and
duration (in minutes per encounter).

Transfers
Transfers refer to the movement between surfaces either with or without assistive devices.
The movements may be bed to chair, chair to toilet, chair to chair, etc. Transfer tasks are
comprised of repetition, physical or verbal cueing, and/or task segmentation to improve or
maintain the resident’s self-performance. Considerations for care planning include the type
of transfer, level of assistance or cueing to provide, frequency (how many times per day or
week), and duration (in minutes per frequency).

Walking
Walking, or ambulation, may be performed with or without assistive devices. Repetition,
cueing, and task segmentation may be provided in order to improve or maintain the
resident’s self-performance or endurance. A care plan for walking may include verbal cues
required for maintaining appropriate posture or use of the device, distance to ambulate,
frequency of ambulation (how many times per day or week), and duration (in minutes per
frequency). Often, documentation will reflect a resident walking greater distances in shorter
lengths of time, indicating the resident may no longer require restorative services.

Dressing and/or Grooming

Self-care in these activities of daily living refers to the ability to dress and undress, bathe,
or perform other personal hygiene tasks. Restorative tasks may include cueing, task
segmentation, and helping residents learn to use adaptive equipment. A care plan for
dressing/grooming may indicate the type of task (dressing, bathing, applying makeup),
verbal/physical cues on performing the task or appropriate use of equipment, frequency
(how many times per day or week), and duration (in minutes per frequency).

Eating and/or Swallowing

Restorative activities provided to improve or maintain the resident’s self-performance in
feeding self, or activities used to improve or maintain the resident’s ability to ingest nutrition
and hydration by mouth are coded on the MDS as eating and/or swallowing programs.
For restorative purposes, eating is defined as how the resident eats and drinks by mouth.
Swallowing refers to the process of manipulating the food in the mouth, chewing, and
pushing the food back to swallow. Residents who take a long time to feed self or who exhibit
swallowing problems and/or difficulty feeding self are typical candidates for the restorative
program. Care plans for restorative eating and/or swallowing may include detailed steps or
techniques for swallowing, level of assistance to provide, preferred location for meals (i.e.
restorative dining area), food texture, liquid consistency, and frequency (how many meals
per day).

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 Restorative Nursing| Care Planning

Amputation/Prosthesis Care
A prosthesis is a device that serves as a replacement of a missing body part (i.e. arm or leg) or
organ (i.e. eye). Restorative services involve activities to improve or maintain the resident’s self-
performance in putting on and removing the prosthesis, and providing appropriate hygiene at
the site where the prosthesis attaches to the body. A care plan for amputation/prosthesis care
may indicate the type of prosthesis, affected extremity, a wear schedule, and monitoring for
evidence of skin breakdown related to the device. Be sure to indicate the frequency of tasks
(how many times per day or week) and duration (in minutes per frequency).

Communication
Communication involves the ability to send and receive messages through speech and
language. Restorative communication activities are provided to improve or maintain the
resident’s self-performance in functional communication skills or assisting the resident in using
residual communication skills and adaptive devices. Impairments in hearing, speech, and
understanding speech are often addressed with restorative activities. Considerations for care
planning include the type of communication exercise (i.e. word finding, vocalization), type
of adaptive device, level of assistance or cueing to provide, frequency (how many times per
day or week), and duration (in minutes per frequency).

Toileting Program
Although not coded in MDS Section O, toileting programs are restorative in nature. Typically, a
resident requires a toileting program when there is evidence of a decline, including the onset
of functional incontinence or other types of incontinence. The goal of a toileting program
is to restore as much bowel or bladder function as possible. Because toileting needs do not
disappear “after hours”, assigning the responsibility of toileting programs solely to restorative
staff is not recommended. However, restorative staff must understand and follow facility
policies and procedures for carrying out the toileting programs. A care plan for a resident on
a toileting program may include a toileting schedule, cues or reminders for bladder training,
and detailed documentation of the resident’s continence status.

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 Restorative Nursing| Care Planning

SUGGESTED DOCUMENTS
Documents that support person-centered care for residents requiring restorative nursing
services are recommended to be placed in this binder section. Examples include:
▶▶ Restorative Amputation/Prosthesis “I” Care Plan
▶▶ Restorative Bed Mobility “I” Care Plan
▶▶ Restorative Communication “I” Care Plan
▶▶ Restorative Dressing/Grooming “I” Care Plan
▶▶ Restorative Eating/Swallowing “I” Care Plan
▶▶ Restorative Range of Motion (Active) and/or (Active Assisted) “I” Care Plan
▶▶ Restorative Range of Motion (Passive) “I” Care Plan
▶▶ Restorative Self-Transfer “I” Care Plan
▶▶ Restorative Splinting “I” Care Plan
▶▶ Restorative Walking “I” Care Plan
▶▶ Toileting Program “I” Care Plan

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 Restorative Nursing| Documentation

DOCUMENTATION
Purpose
Documentation, whether handwritten
or keyboarded into an electronic
medical record, serves as a record
of resident care and a means of
sharing information about the resident
with others. According to F-842, a
facility must maintain medical records
that are complete, accurately
documented, readily accessible,
and systematically organized.
Documentation is used to support
the coding of the MDS. Accordingly,
requirements for documentation
include evidence of the task
performed and the amount of time the task was performed on any given day. Additional
criteria include the problem being addressed, measurable objective, interventions, and
periodic evaluation by a licensed nurse.

Daily
Daily documentation serves as a record that the relevant task or intervention was conducted
or provided. This is usually done on a flowsheet that describes the specific treatment to
provide as outlined in the plan of the care. The restorative aide initials the task as completed,
and indicates how much time was spent performing the task. If the treatment is refused,
or withheld, a narrative note of explanation is required. The restorative aide should also
document any unusual incidences, such as new onset of pain or swelling, and report to the
nurse. For payment purposes, residents must receive six days of restorative services for two
or more activities in order to receive payment. (Some states may have different guidelines.)
Daily charting also serves as supportive documentation for billing purposes.

Weekly
Evidence of periodic evaluation by the licensed nurse must be present in the resident’s
medical record. Standards of practice have translated this into a weekly progress note.
When not contraindicated by state practice act provisions, a progress note written by
the restorative aide and countersigned by a licensed nurse is sufficient to document the
restorative nursing program once the purpose and objectives of treatment have been
established. The narrative may include information such as the use of assistive devices,
endurance and tolerance level, and the amount of assistance needed and why (i.e. poor
balance, tendency to lean to one side, weakness).

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 Restorative Nursing| Documentation

Monthly
Measurable objectives are to be included in the resident’s plan of care, along with the
duration of the program. The duration may be up to 30 days or more, and the end date
may not coincide with routine care plan review dates. Monthly documentation is typically
completed by the Restorative Nurse so that the goal is evaluated in a timely manner.
This documentation would reflect how the resident is progressing towards his/her goals,
comparing status with the last week or month. The Restorative Nurse may also take the
monthly note as an opportunity to determine duration/frequency and set priorities for
caseload management.

SUGGESTED DOCUMENTS
This binder section is reserved for documents that establish charting responsibilities and
sample documentation forms. Examples include:
▶▶ Restorative Nursing Documentation Policy
▶▶ Restorative Nursing Progress Notes
▶▶ Restorative Nursing Services Daily Documentation Form
▶▶ Restorative Nursing Services Nurse Evaluation Form

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 Restorative Nursing| Monitoring

MONITORING
Resident Level
Evidence of periodic evaluation by a
licensed nurse is only one aspect of
resident-level monitoring. Processes
for assuring care plans are followed as
written are important to a successful
restorative program. This also includes
assuring interventions are monitored
for effectiveness. A major element of
monitoring effectiveness of a care
plan for a resident on restorative
caseload is monitoring progress
towards his or her goals. This is usually
accomplished through licensed
nurse oversight and documentation.
However, someone other than the Restorative Nurse should also audit restorative processes to
ensure all elements of each resident’s program are documented as required.

Facility Level
In addition to monitoring residents for effective care plans, a facility has the responsibility to
monitor the effectiveness of any programs affecting resident care. Facility-level processes
should be in place for making sure the restorative nursing program is implemented and
maintained as designed. This may be accomplished through a combination of self-
assessment, various audits, and policy review. Quality indicators may also be used for
evaluating the effectiveness of the program. Refer to Chapter 7 for more information.

SUGGESTED DOCUMENTS
Documents that establish monitoring processes for the restorative nursing program are
suggested for placement in this binder section. Examples include:
▶▶ Resident Chart Audit – Restorative Nursing
▶▶ Restorative Nursing Caseload Tracking Form
▶▶ Restorative Nursing Program Self-Assessment
 

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 Restorative Nursing| QAPI Activities

QAPI ACTIVITIES
Overview
CMS defines QAPI as the
coordinated application of two
mutually reinforcing aspects
of a quality management
system: Quality Assurance
(QA) and Performance
Improvement (PI). QAPI takes
a systematic, comprehensive,
and data-driven approach
to maintaining and improving
safety and quality in nursing
homes while involving all
nursing home caregivers
in practical and creative
problem solving. Various quality
measures are central to QAPI.

Quality Measures
A quality measure is a mechanism for assessing physical and clinical conditions, abilities, or
outcomes, and are used for many purposes – internal monitoring, consumer comparison-
shopping, quality reporting, and ranking of facilities.

Outcome Measures
An outcome measure tracks the result of health care/health status and the resident’s
experience of that care. CMS publicly reports many function-related quality measures:
♦♦ Percent of residents who made improvements in function
♦♦ Percent of residents whose ability to move independently worsened
♦♦ Percent of residents experiencing one or more falls with major injury
♦♦ Percent of residents with a urinary tract infection
♦♦ Percent of residents who have/had a catheter inserted and left in their bladder
♦♦ Percent of residents who lose control of their bowels or bladder
♦♦ Percentage of residents who lose too much weight

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 Restorative Nursing| QAPI Activities

Facilities may rely solely on publicly reported data, or they may choose to establish other
outcome measures. For example, a facility may choose to monitor actual incidence of
decline in range of motion or cognitive functioning.

Process Measures
A process measure looks at the specific steps in a health care process that lead, either
positively or negatively, to a particular outcome metric. Examples of process measures
related to restorative nursing services include, but are not limited to:
♦♦ Completeness of restorative aide documentation
♦♦ Compliance threshold for documentation that supports MDS coding
♦♦ Performance of range of motion exercises in accordance with facility policy and plan
of care
The measures used for tracking and trending should be clearly documented and presented
to the QAA Committee to fulfill QAPI requirements.

Performance Improvement Projects

Facilities are required to set priorities for performance improvement activities and conduct at
least one distinct performance improvement project (PIP) annually. Performance on various
function- or restorative-related measures can help inform decision making related to the
project. Other considerations for project implementation include, but are not limited to:
♦♦ Assembling a multidisciplinary team with a clinical leader
♦♦ Determining root cause of the problem
♦♦ Implementing changes to address the root cause of the problem
♦♦ Monitoring effectiveness of the changes
♦♦ Presenting results to QAA Committee, governing body, and staff
Once actions are implemented, facilities are to continue tracking performance to ensure
that improvements are realized and sustained.

SUGGESTED DOCUMENTS
This binder section is reserved for documents that support improved quality of care related to
restorative nursing services provided in the facility. Examples include:
▶▶ Restorative Nursing Dashboard
▶▶ Functional Mobility Performance Improvement Project (PIP) Worksheet - Template

©2019 The Compliance Store, LLC. All rights reserved. - 17 -

 Restorative Nursing| Training

TRAINING
Staff
One criteria that must be met
in order to code a restorative
task on the MDS is that nursing
assistants/aides must be
trained in the techniques that
promote resident involvement
in the activity. Additionally,
CMS requires a trained,
competent staff. F-726
includes basic restorative
services in the list of skills and
techniques necessary to care
for residents’ needs. Due to
the complexities involved in
providing restorative services,
training should go beyond the
classroom to the bedside to show that staff are competent. The amount and types of training
necessary are based on a facility assessment, and may be accomplished through a variety of
methods.

Residents
A resident has the right to be fully informed of his or her total health status, including the risks
and benefits of proposed care, of treatment options, and treatment alternatives. As the
center of care, an educated resident is in the best position to make informed decisions. In
addition to educational/training tasks as part of the resident’s restorative plan of care (i.e.
brace or splint assistance, communication strategies), topics of education may include risk
factors for decline and ways to minimize the risk. Explaining how the restorative tasks will
benefit the resident may improve participation.

Families
Family members or other designated representatives are important members of the resident’s
care team. As such, education is important to their ability to make informed decisions and
understanding their role in the resident’s overall plan of care. They will benefit from the same
topics of education as the resident, and may be able to understand information that is more
detailed. Documentation to support the education, and response to education, is important
to demonstrating a facility’s due diligence in providing evidence-based care.

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 Restorative Nursing| Training

SUGGESTED DOCUMENTS
Documentation that demonstrates training of staff, residents, and families related to
restorative nursing services are recommended to be placed into this binder section. Examples
include:
▶▶ Restorative Nursing Training Plan
▶▶ Restorative Aide Competency Form
▶▶ Restorative Nurse Competency Form
▶▶ Resident/Family Education Documentation Form

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