By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource
Understanding how well someone can communicate is a foundational component to good care. It’s easy to take for granted how important it is to do something as simple as ask for a glass of water or tell someone when you’re uncomfortable. Getting this assessment right is critical to everything else.
Getting this right took on new significance when CMS changed the guidance for completing the PHQ2-9. In the past, when a patient presented with enough nonsensical answers during the interview, you could proceed to the Staff Assessment. Now CMS says you can only proceed to the Staff Assessment when the patient is properly coded as “Rarely/never understood.” So, we have one more reason to be skilled at this assessment area.
Here is the language from the RAI Manual for B0700:
Code 0, understood: if the resident expresses requests and ideas clearly.
Code 1, usually understood: if the resident has difficulty communicating some words or finishing thoughts but is able if prompted or given time. They may have delayed responses or may require some prompting to make self understood.
Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet).
Code 3, rarely or never understood: if, at best, the resident’s understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet).
It may be helpful to understand a few key things:
1. Being understood means how well they get their message across — not how they do it. They can write, speak another language, or use gestures. If most people can easily understand what the resident is trying to get at, then they are understood.
2. We are prone to scoring “0” when an individual talks and scoring other values when they don’t. But talking doesn’t always mean communicating.
3. The MDS specifically looks for how well they are understood. It is also tempting to score “0” if someone can communicate at all, but the MDS specifically wants to know if it’s always, usually, sometimes, or rarely/never.
4. There is a strong correlation between understanding (comprehension) and being understood (expression). Individuals who struggle to follow instructions during care or answer simple questions will very likely also struggle to express themselves accurately and reliably. So, use a problem in comprehension as an alert for possible problems with expression.
What might “rarely or never” look like in real-world individuals?
A patient with significant dementia who barely speaks for whom care is pre-planned or scheduled.
A patient with aphasia who says the same few words for all needs.
Patients where there’s that one CNA who can decipher what the resident needs from their facial expressions, body movements, gestures, or verbalizations. Or when you need a familiar family member to figure out what the patient is trying to tell you (but not because they speak a language you don’t!)
Patients who speak, but where care must generally be provided on a schedule or anticipated because they cannot intentionally express their needs. For example:
A patient who can answer simple social questions like “How are you?” but says “No, not today,” every time they are asked if they’re hungry, thirsty, or need the restroom.
A patient who is hyperverbal — that is, they talk a lot — but what they say has little meaning. They may ask for the same things over and over even after they’ve been provided, or they get agitated when you give them what they ask for because it wasn’t what they really wanted.
An interdisciplinary approach to assessment is essential here, especially when determining how significant a communication challenge is. Include your SLP anytime you suspect communication is compromised to get their expert assessment into the record to support you.
It’s very important that other documentation corroborates what we end up coding in this section of the MDS. If the team successfully completed the PHQ2-9, the BIMS, or any other interview, then you cannot also code B0700 as “rarely/never understood.” If the interviews were attempted but terminated because the patient couldn’t respond, then make sure there is documentation of that interaction in the record. If others on the care team are documenting that the patient is expressing all wants and needs, then coding “rarely/never understood” on the MDS will come under some scrutiny. Sometimes, people document what they’re used to documenting, and they need a reminder to document specific problems.
And finally, don’t forget that your goals and strategies for managing any communication impairment, no matter how severe, should be included in the care plan. The Communication CAA care plan is the right place to detail this problem. Look at SLP evaluations and talk with direct care staff (especially CNAs) for the interventions that will ensure that each resident’s needs are met and we know how to best facilitate communicating with them.
MDS RAI Manual Coding Corner:
B0700: Makes Self Understood
Steps for Assessment
1. Assess using the resident’s preferred language or method of communication.
2. Interact with the resident. Be sure they can hear you or have access to their preferred method for communication. If the resident seems unable to communicate, offer alternatives such as writing, pointing, sign language, or using cue cards.
3. Observe their interactions with others in different settings and circumstances.
4. Consult with the primary nurse assistants (over all shifts) and the resident’s family and speech-language pathologist.
This item cannot be coded as Rarely/Never Understood if the resident completed any of the resident interviews, as the interviews are conducted during the look-back period for this item and should be factored in when determining the residents’ ability to make self understood during the entire seven-day look-back period.
Source: MDS RAI Version 1.18.11 Page B-8