New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter A - Medical Facilities-minimum Standards
Article 1 - General
Part 400 - All Facilities-General Requirements
Section 400.13 - Forms (Hospital/Community Patient Review Instrument)

1. OPERATING CERTIFICATE NUMBER: Enter the seven or eight character identifier stated on the facility's/agency's operating certificate. For a hospital there will always be seven (7) numbers followed by an "H" in the eighth box. For a certified home health agency and a county Department of Health, there will only be seven (7) numbers with no letters. This means the first answer box to the left will remain blank. For a residential health care facility, there will be seven (7) numbers followed by an "N" which indicates a nursing facility.

2. SOCIAL SECURITY NUMBER: Do not leave blank; enter zero in far right hand box if patient does not have a number.

3. OFFICIAL FACILITY NAME: Print the formal name of the hospital/community agency, etc.

4. PATIENT NAME: When completing the H/C-PRI do not use nicknames. Print last name first (e.g., Brant, Diana C).

6. MEDICAL RECORD NUMBER/CASE NUMBER: Enter the unique number assigned by the hospital/agency to identify each patient. It is not the Medicaid, Medicare or Social Security number, unless that is the number used to identify patients. If there is no assigned case number for the community based patient, leave this question blank.

7. HOSPITAL ROOM NUMBER: Enter the numbers and/or letters which identify the patient's room in the hospital or other applicable community facility. If the patient is residing in the community when the H/C-PRI review is completed, then print the address in question 4., "Patient Name." (Community is defined as a personal dwelling, Adult Home, congregate housing, or other domicillary type facilities/dwellings.)

8. NAME OF HOSPITAL UNIT/BUILDING/DIVISION: Print the name of the hospital unit, such as "med-surgery," where the patient was reviewed. Include any other unique hospital location identifiers, such as specific building names where the unit is located. However, if the patient has changed units or buildings or will be moving, then print instead where the patient can be located in the future (if known). If the patient is reviewed in the community, then this question is not applicable and can be left blank.

11A. DATE OF HOSPITAL ADMISSION OR INITIAL AGENCY VISIT: Enter in numerical format the month, day and year the patient was admitted to this hospital for the purposes of this review. (Use most recent hospitalization date for multiple hospitalizations.) Do not include the date of Alternate Level of Care status (ALC), rather enter this date, if applicable, in Question 11B. If the patient is being reviewed in the community, enter the date of the initial patient visit by the certified home health care agency, nursing home or any other qualified agency/organization. This visit may be a followup to a referral made by the patient, the patient's family, the patient's physician, etc.

11B. DATE OF ALTERNATE LEVEL OF CARE STATUS: Enter in numerical format the day, month and year the patient went onto Alternate Level of Care status (ALC) in the hospital. If the patient has entered ALC status more than once during this hospital stay, enter the most recent ALC admission date. (That is, this patient was on ALC status, but was discharged because of an acute episode and then went back to ALC status.) If the patient is not on ALC status or is in the community during this review, enter a zero (0) in far right hand box.

12. MEDICAID NUMBER: Enter these numbers if patient has such coverage.

13. MEDICARE NUMBER: available, whether or not the coverage is being used. If not, enter only one zero in the far right hand box.

14. PRIMARY PAYOR: Enter the one source of coverage which pays for most of the patient's current hospitalized stay; for patients in the community enter what is covering the patient's community health care needs. Code "other" only if the primary payor is not Medicaid or Medicare. "Other" includes self-pay and private insurance.

15. REASON FOR PRI COMPLETION: Select the one reason why the PRI is being completed. This is for preadmission review purposes.

# 1 RHCF Application from Hospital means the patient resides in the hospital at the time of this H/C-PRI review and is applying for admission into a residential health care facility (RHCF, HRF or SNF). This H/C-PRI is being completed by a qualified hospital assessor or another qualified assessor (i.e., RHCF assessor, certified home health care agency assessor) who enters the hospital to review the patient.

# 2 RHCF Application for Community means the patient resides in the community during this H/C-PRI review. Include Adult Homes and other domicillary care facilities.

16. DECUBITUS LEVEL: Enter the level of skin breakdown (located at pressure points) using the qualifiers stated below:

Documentation For a patient to be coded as level 4, documentation by a licensed clinician must exist which describes the following three components: * A description of the patient's decubitus. * Circumstances or medical condition which led to the decubitus. * An active treatment plan.

Definition

LEVELS:

#0 No reddened skin or breakdown.

#1 Reddened skin, potential breakdown.

#2 Blushed skin, dusty colored, superficial layer of broken or blistered skin.

#3 Subcutaneous skin is broken down.

#4 Necrotic breakdown of skin and subcutaneous tissue which may involve muscle, fascia and bone.

#5 Patient is at level 4, but the documentation qualifier has not been met.

17. MEDICAL CONDITIONS: For a YES to be answered for any of these conditions, all of the following qualifiers must be met:

Time Period Condition must have existed during the past week.

Documentation Written support exists that the patient has the condition.

Definitions See chart below. (Examples are for clarification and are not intended to be all-inclusive.)

19. EATING:

#3 "Requires continual help..." means that the patient requires a staff person's continual presence and help for reasons such as: patient tends to choke, has a swallowing problem, is learning to feed self, or is quite confused and forgets to eat.

#5 "Tube or parenteral feeding..." means that all food and drink is given by nursing staff through the means specified.

20. MOBILITY:

#3 "Walks with constant supervision and/or assistance. . ." may be required if the patient cannot maintain balance, has a history of falls, has stress fracture potential, or is relearning to ambulate.

21. TRANSFER: Exclude transfers to bath or toilet.

#4 "Requires two people. . ." may be required for reasons such as: the patient is obese, has contractures, has fractures (or stress fracture potential), has attached equipment that makes transfer difficult (for example, tubes). There must be logical medical reasons why the patient needs the help of two people to transfer. This reason should be documented in the medical record.

#5 "Bedfast. . ." may refer to a patient with acute dehydration, severe decubitus, or terminal illness.

22. TOILETING:

Definition - INCONTINENT 60% or more of the time the patient loses control of his/her bladder or bowel functions, with or without equipment.

#1 "Continent. . . Requires no or intermittent supervision" and

#2 ". . . and/or assistance" can refer to the continent patient or the incontinent patient who needs no/little help with his/her toileting equipment (for example, catheter).

#3 "Continent. . . Requires constant supervision/total assistance..." refers to a patient who may not be able to balance him/her self and transfer, has contractures, has a fracture, is confused or is on a rehabilitation program. In addition this level refers to the patient who needs constant help with elimination/incontinence equipment (for example, colostomy, ileostomy).

#4 "Incontinent. . . Does not use a bathroom" refers to the patient who does not go to a toilet room, but instead may use a bedpan or continence pads. This patient may be bedbound or is mentally confused to the extent that a scheduled toileting program is not beneficial.

#5 "Incontinent. . . Taken to a Bathroom. . ." refers to a patient who is on a formal toileting schedule; this should be documented in the medical record. This patient may be on a formal bowel and bladder rehabilitation program to regain or maintain control, or the toileting pattern is known and it is better psychologically and physically for the patient to be taken to the toilet (for example, prevent decubiti).

A patient may have different levels of toileting capacity for bowel and bladder function. To determine the level of such a patient, note that level four and five refer to incontinence of either bladder or bowel. Thus if a patient receives the type of care described in one of these levels for either type of incontinence, enter that level.

Example 1:

A patient needs constant assistance with a catheter (level 3) and is incontinent of bowel and is taken to the bathroom every four hours (level 5). In this instance, enter level 5 on the PRI because they are receiving the type of care described in this question for bowel incontinence.

Example 2:

The patient requires intermittent supervision for bowel function (level 2), and is taken to the toilet every two hours as part of a bladder rehabilitation program. Enter level 5, as the patient is receiving this type of care for bladder incontinence.

23. VERBAL DISRUPTION: Exclude verbal outbursts/expressions/utterances which do not create disruption as defined by the PRI.

24. PHYSICAL AGGRESSION: Note that the definition states "with intent for injury."

25. DISRUPTIVE, INFANTILE OR SOCIALLY INAPPROPRIATE BEHAVIOR: Note that the definition states this behavior is physical and creates disruption.

EXCLUDE the following behaviors:

* Verbal outbursts

* Social withdrawal

* Hoarding

* Paranoia

26. HALLUCINATIONS: For a "YES" response, the hallucinations must occur at least once per week during the past week (7 days) (in addition to meeting the other qualifiers noted above for an active treatment plan and psychiatric assessment.)

27. PHYSICAL AND OCCUPATIONAL THERAPIES:

* For each therapy these three types of information will be entered on the PRI: "Level," "Days" and "Time" (hours and minutes).

* For a patient not receiving a therapy at all, the "Level" will always be entered in the answer key as #1 ("does not receive"), the "Days" will be entered 0 (zero) and the "Time" will be 0 (zero).

* Use the chart on the following page to understand the qualifiers for each of the three types of information that will be entered. Whether patient is receiving maintenance or restorative therapy will make a difference in terms of the qualifiers to be used.

27. LEVEL QUESTION: QUALIFIERS

27. DAYS AND TIME PER WEEK QUESTION: QUALIFIERS

* Qualifiers not met: Do not enter on the PRI any days and time of therapy which do not meet both these qualifiers under each type of therapy.

28. NUMBER OF PHYSICIAN VISITS: Enter "0" (zero) unless the patient need qualifiers stated below are met. If, and ONLY if, the patient meets all the patient need qualifiers, then enter the number of physician visits that meet the physician visit qualifiers.

* Do not answer this question for hospitalized patients, unless an alternate level of of care status. Enter "0" (zero).

* PATIENT TYPE/NEED QUALIFIERS: The patient has a medical condition that (1) is unstable and changing or (2) is stable, but there is high risk of instability. If this patient is not closely monitored and treated by medical staff, an acute episode or severe deterioration can result. Documentation must support that the patient is of this type (for example, terminally ill, acute episode, recent hospitalization, post-operative).

* PHYSICIAN VISIT QUALIFIER: If, and only if, the patient meets the PATIENT TYPE/NEED QUALIFIER, then enter the number of physician visits during the past week that meets the following qualifications:

* A visit qualifies only if there is physician documentation that s/he has personally examined the patient to address the pertinent medical problem. The physician must make a notation or documentation in the medical record as to the result of the visit for the unstable medical condition (e.g., change medications, renew treatment orders, nursing orders, order lab tests).

* Do not include phone calls as a visit nor visits which could have been accomplished over the phone.

* For community-based patient, the physician visit may occur in the patient's own home, physician's office, outpatient clinic or hospital.

29. PRIMARY MEDICAL PROBLEM: Follow the guidelines stated below when answering this question.

* NURSING TIME The primary medical problem should be selected based on the condition that has created the most need for nursing time during the past week (7 days). A review of the medical record for nursing and physician notes during the past week may be necessary. For community-based patients review what is requiring the most care time from informal supports and health care professionals if any.

* JUDGMENT This decision may require the assessor to use her/his own professional judgment in deciding upon the primary problem.

* ICD-9 Refer to the ICD-9 codes for common diagnoses (attached at the end of these instructions) for easy access to the most frequently used numbers. An ICD-9 code book containing the complete ICD-9 listing should be available in the nursing and/or medical records office of a facility.

* NO ICD-9 NUMBER - Enter "0" zero in the far right box if no ICD-9 number can be found for the patient's primary problem (or if the patient does not have a primary medical problem). If you cannot locate the ICD-9 code for the primary medical problem, PRINT THE NAME OF THE PRIMARY MEDICAL PROBLEMin the space provided on the PRI.

QUALIFIED ASSESSOR NUMBER:

31. QUALIFIED ASSESSOR: The individual who has completed and/or reviewed the PRI. To be complete, each assessment must be signed by the qualified nurse assessor.

ICD-9 CODES FOR COMMON DIAGNOSES

(Listed alphabetically within body system category)

* Not otherwise specified

Footnotes

* Qualifiers not met: Do not enter on the PRI any days and time of therapy which do not meet both these qualifiers under each type of therapy.