Cracking the Code: Individualized Toileting Programs

It’s 6:30 am, and Mrs. Carter has already had an incontinent episode. The nurse aide changes her brief and plans to toilet her again in two hours. Later that morning, another staff member takes the resident to the bathroom just after breakfast. The care plan indicates she should be toileted every two hours and as needed.

At first glance, the plan just described sounds like a toileting program. But is it?

At this juncture, coding H0200 and H0500 can become tricky. Routine bathroom assistance, check-and-change care, and a standard schedule may all be appropriate care interventions, but they do not automatically meet the Long-Term Care Facility Resident Assessment Instrument User’s Manual (RAI User’s Manual) definition of an individualized toileting program. This article describes four key strategies to help the nurse assessment coordinator (NAC) distinguish between meeting basic care needs with toileting interventions and implementing a true toileting program.

Strategy 1: Know what qualifies as a toileting program.

A toileting program is simply that, a program, not just a task. A toileting program must be a specific approach, based on an assessment of the resident’s’ toileting needs that is organized, planned, documented, monitored, and evaluated.

Here are three examples of systematic urinary toileting approaches:

• Bladder rehabilitation/bladder retraining: The resident follows a timetable for voiding and attempts to delay urination rather than responding immediately to urgency.

• Prompted voiding: Staff regularly monitor continence, prompt the resident to toilet according to a schedule, and offer praise or positive feedback.

• Habit training/scheduled voiding: Toileting is scheduled at regular intervals based on the resident’s individual voiding habits or needs.

In contrast, simply checking a resident’s incontinent brief and changing it when needed is not a toileting program. Neither are simply recording wet or dry episodes or providing random assistance to the bathroom, even if it follows an established routine. The RAI User’s Manual specifically excludes simply tracking continence, changing pads or wet garments, and random toileting or hygiene assistance from its definition of a toileting program.

This distinction is important because routine care may sound like a toileting program in documentation. For example, a care plan stating “toilet every two hours and as needed” does not, by itself, constitute an individualized program. The assessor must be able to connect the intervention to an assessment of that resident’s unique elimination pattern.

Consider these two scenarios:

Scenario 1: Toileting program

Mrs. Lewis has urinary incontinence most afternoons. Staff completed a 3-day voiding diary and identified that she typically voids about 30 minutes after lunch and again approximately two hours later. Based on this pattern, the interdisciplinary team (IDT) developed a scheduled toileting program. Staff assist Mrs. Lewis to the bathroom after lunch and again two hours later, document whether she voids and remains continent, and review her response to determine whether the schedule needs adjusting. The program is included in the care plan and has been communicated to direct care staff.

Why it qualifies: The intervention is based on an assessment of Mrs. Lewis’s individual voiding pattern. It is organized, planned, documented, monitored, and evaluated. This example matches the definition of an individualized toileting program.

Scenario 2: Not a toileting program

Mr. Davis is frequently incontinent of urine. His care plan states, “Toilet every two hours and as needed.” Staff routinely offer bathroom assistance during rounds, and they check and change his brief when wet. The medical record does not contain an assessment of his usual voiding pattern, documentation explaining why the two-hour schedule was selected, or evidence that staff are monitoring his response to verify whether the intervention reduces incontinent episodes.

Why it doesn’t qualify: Although staff are providing appropriate incontinence care and offering toileting assistance consistently, the record does not qualify as an individualized toileting program. A routine schedule without an assessment of the resident’s unique voiding pattern, monitoring, and evaluation does not meet the criteria for a toileting program.

The same individualized approach applies to bowel programs. For H0500, the record must show that the bowel toileting program is based on an assessment of the resident’s unique bowel pattern, has been communicated to the resident and staff, and includes documentation of the resident’s response and subsequent evaluation.

Key Takeaway: A schedule alone does not make an intervention a toileting program. Look for the full process: assessment, individualized intervention, communication, monitoring, and evaluation.

Strategy 2: Follow the sequence at H0200A – C.

Urinary toileting programs require the assessor to answer three related questions. However, the NAC must understand the intent of each item to code accurately. The first item, H0200A, asks about a trial of a toileting program. Its intent is to identify only if a trial has been attempted, not necessarily that a full program has yet been established. The look-back for this item is also unique, reviewing the most recent admission/entry or reentry or since urinary incontinence was first noted within the facility.

To code that a trial occurred during this period, there must be evidence of an individualized resident-centered trial toileting program that includes at least three days of toileting patterns and prompts. However, as previously clarified, simply tracking continence status using a bladder record or voiding diary is not considered a trial. If no trial was attempted, the assessor skips to H0200C. If a trial was in place, the resident’s response is coded at H0200B. The response is captured as no improvement, decreased wetness, completely dry (continent), or unable to determine or trial in progress.

The Centers for Medicare & Medicaid Services does not establish a precise numerical threshold for “decreased wetness.”

Clinical judgment is needed to decide if a decrease in wetness occurred, but the manual clarifies that the improvement should be “clinically meaningful.” It offers one less incontinent void per day as an example.

The last item, H0200C, has a different look-back period of seven days. It asks whether the resident is currently managed with a systematic urinary toileting program or trial. However, to code yes, documentation must support that the program was carried out on four or more days during the 7-day look-back period. If the program was in place but implemented on fewer than four days, the assessor would code “0. No” for this item. The RAI User’s Manual also clarifies that the resident does not have to be awakened overnight for the program to qualify. A systematic daytime toileting program may still be coded yes.

Common Pitfall: Do not assume H0200A and H0200C must always match. They are coded for distinct goals over different look-back periods.

Strategy 3: Apply the same individualized thinking to bowel programs.

H0500 is simpler to code than H0200, but the documentation standard remains important. H0500 asks whether a toileting program is currently being used to manage the resident’s bowel continence. Code 1 only when the resident is currently on a toileting program targeted specifically toward bowel continence. Otherwise, code 0.

During the 7-day look-back period, the assessor should verify three elements:

1. The facility implemented an individualized bowel toileting program based on the resident’s unique bowel pattern.

2. The program was communicated to staff and the resident, as appropriate, through the care plan, flow records, reports, and other communication.

3. The record contains documentation of the resident’s response and subsequent evaluation when needed.

Developing the program may involve looking beyond the timing of bowel movements. The RAI User’s Manual suggests considering adequate fluid intake, dietary fiber, exercise, and scheduled opportunities to attempt a bowel movement. If the program decreases or resolves bowel incontinence, it should be maintained. If it does not, staff must consider whether another reversible or treatable cause is contributing to the incontinence.

For residents who do not respond to a toileting trial and have no other reversible or treatable cause, supportive management remains appropriate, such as regular check-and-change care and good skin care. However, supportive management should not be coded as a bowel toileting program unless the requirements of H0500 are met.

Strategy 4: Understand the impact on restorative nursing case-mix groups.

Toileting programs do more than describe how the facility manages incontinence. For some residents, they can also affect the Nursing case-mix group under the Patient-Driven Payment Model (PDPM). The PDPM Nursing classification includes a restorative nursing count for residents who fall into the Behavioral Symptoms and Cognitive Performance or Reduced Physical Function categories. The RAI User’s Manualcites urinary toileting programs at H0200C and bowel toileting programs at H0500 among the services that may count toward this total. However, even if the resident is on both a urinary and a bowel program, it only counts as one program.

Toileting programs also differ from the other restorative program requirements. All other nursing restorative programs, coded at O0500, require at least 15 minutes per day to count the day. Toileting programs do not have a minute requirement, but they do require evidence the program was implemented. Additionally, to impact case-mix classification, the programs coded at O0500 must have been provided on at least six days during the 7-day look-back period.

For example, H0200C may be coded “1. Yes” when an individualized urinary toileting program was conducted on four or more days during the 7-day look-back period. This length of time meets the criteria for one restorative program for the PDPM count.

Key Takeaway: Do not work backward from a desired case-mix group. First decide if the resident clinically needs an individualized toileting program and whether the documentation supports section H coding. Then determine separately whether the resident has two or more programs to meet the PDPM restorative nursing requirements. Accurate coding should always reflect the care the resident actually received.

Conclusion

Accurate coding of toileting programs demands more than finding a toileting schedule in the care plan. The NAC must verify if the intervention represents a systematic, individualized approach based on the resident’s actual urinary or bowel pattern.

Most importantly, remember the purpose behind the coding. A well-designed toileting program is not simply an MDS documentation exercise. It gives the IDT an opportunity to preserve continence when possible, reduce the effects of incontinence, and support each resident’s dignity, function, and quality of life.

Jessie McGill, RN, BSN, RAC-MT, RAC-MT, is a regular contributor to Park Place, and is the curriculum development specialist for the American Association of Post-Acute Care Nursing.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.