Incontinence: Documentation risks and payment issues

One of the most frequent issues related to quality of care, quality of life and payment is the documentation and treatment of urinary incontinence, which surprises many clinical and operational managers. Incontinence is currently not given the clinical focus it needs because of changes in the survey process and the overall focus on quality of life and quality of care for all residents. Most residents in skilled care facilities (SNFs)—both short- and long-stay—have some level of documented incontinence that does not receive the focus it needs.


Let me share with you the story of a very active independent 85-year-old elder who decided to have a hip replacement. The hospital stay went as expected, and the transfer to the rehab unit was seamless. The only problem was that on the way to the rehab unit the woman realized that she had no control of her bladder; she left the hospital with complete loss of control. She was catheterized for her entire hospital stay, leaving her incontinent. As the staff was putting a brief on her shortly after she was admitted to the SNF, she told the nurse, “I did not sign up for this. What can I do to change this situation?”

The incontinence became the focus of this woman’s stay and a larger problem than the healing and rehab of the hip. Remember the plan of care is unique and individual for every resident. It needs to include the assessment of and treatment of this elder’s incontinence. Right?


The risks and payment possibilities in this case are similar to a high percentage of the short-term admissions in rehab today as well as the changes in continence status of many of the long-term stay elders that are admitted to the hospital for short-term stays. Today, the facility database includes the continence status of each resident every time an MDS 3.0 data set is done, as well as the documentation of interventions—toileting programs—to improve continence status.

The definitions in the RAI Manual, Chapter 3, Section H, are very clear on how to code this important data. All clinical staff needs to use these definitions in their documentation of assessments, daily care and planning discussions to create an absolutely accurate database.


The survey process will focus on the level of continence and the interventions used to improve the independence and quality of life of the resident as well as minimize the risks of incontinence becoming a quality-of-care issue. If the level of continence is not coded accurately in the database, many residents who do not meet the definition will be coded as continent.

The definition of incontinence in the RAI Manual, April 2012, Chapter 3, and Section H, page H-7 is “The involuntary loss of urine.” If the resident has stress or postural incontinence or leaks urine at any time, this definition categorizes them as incontinent. If this item on the assessment is coded properly the majority of the elders in a SNF will be coded at some level of incontinence.

Currently many facilities have coded high percentages of their census as always continent in Section H0300 of the data set, representing them as having no episodes of any incontinence—even stress incontinence. A surveyor will know that statistic is wrong and proceed to check on the accuracy of the coding on the MDS and the data in the record. The regulatory process requires an accurate assessment of the continence status, the identification of any underlying potential reversible causes and the provision of services to reverse or minimize the incontinence—even stress incontinence.

The MDS 3.0 update of April 2012 also has a new item in Section M item M1040H—Moisture Associated Skin Damage—which is defined as skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused by incontinence, wound exudate or perspiration.

MASD is also referred to as incontinence dermatitis. So the MDS is asking us to code our negative outcomes from improper or inadequate incontinence care on the data set. This is a new-high risk item that needs to be tracked by the clinical staff and monitored by the facility quality assurance process.

Evaluation of the efficiency and outcomes of current products being used to manage and treat incontinence needs to be done as part of the response to this coding. Remember a surveyor could walk into the building with a list of all residents who have this issue and look for interventions and planning to alleviate the problem.

The second risk area that needs to be addressed is the sudden change in continence status that many elders experience after a hospitalization—caused by the almost universal catheter use during entire hospital stays. Frequently, considerable damage is done to the lower urinary tract and sphincters by the catheters. They often are the wrong size for the resident or are left unsecured causing additional brushing to the interior of the bladder wall. This unexpected issue can have a significant negative impact on the elder who was not prepared to deal with an increase in incontinence as part of their recuperation.

In our earlier case study, the elder was independent, scheduled an elective surgical procedure and rehab, and understood the risks and the reality of the rehabilitation, but did not expect total incontinence. During her short-term rehab stay her incontinence became the dominant issue she wanted to deal with and was a major focus of her entire rehab plan and the plan of care.

One of the most important parts of the continence assessment is the determination of the elder’s continence status before the hospitalization or admission and how they managed their self-care. Once this is documented, the change in continence can be determined and the facility services can be established to determine the underlying, potentially reversible causes. Then a resident-specific plan can be established to resolve or minimize the incontinence.

If the incontinence cannot be reversed or the person does not respond to retraining, prompted voiding or scheduled toileting, establish a plan to maintain skin dryness and minimize exposure to urine with the use of properly designed, sized and applied products. Many toileting programs are successful when the program combines the use of proper incontinence products with retraining and strengthening which can increase independence and positive outcomes.

Elders are willing to participate in active programs to improve their independence with toileting if staff takes the time to explain that some incontinence is reversible. The elder in the case study was totally surprised by the level of incontinence she was experiencing when she was discharged from the hospital. At first she was very depressed, but once she had the opportunity to work with the staff and the therapists on her strengthening and exercise retraining program, her retraining program became an important part of her rehab, re-establishing her independence and eventual return to living in the community.


The clinical and therapy staffs need to be aware that most urinary retraining programs involve a coordination of the services between the two departments to achieve long-lasting results. The rehab plan will assist the resident with balance, strength and ambulation as well as work to strengthen the muscles of the inner thigh and the perineum. The clinical staff will work to assist the resident to try to control their voids and encourage the proper timing of toileting, treat potentially reversible causes and assist the resident to be independent and dignified during the process.

Elders want to be in control of their elimination whenever possible. For many residents, it is a primary issue they want to solve. One of the more successful retraining programs combining nursing and therapy treatments is called Beyond Kegels. This program, written by a therapist, combines exercises that can be included in the overall therapy treatment plan with nursing interventions to increase control for many people with new onset of functional incontinence. At times, a consultation with a urologist is necessary to provide diagnostic and treatment plans or medication, if possible. Facilities should develop relationships within the community for consults in this area if help is needed to develop effective treatment plans.


Another issue related to incontinence and the proper treatment is cost and payment. The treatment of incontinence is expensive and involves almost all SNF residents at some time. Reversing any level of incontinence and supporting resident independence is an important economic and operational decision. Toileting programs are important and can be part of payment with restorative programs. The current RUG IV payment system counts a toileting program as one of the two required restorative programs for payment under the Low Rehab category. Many case-mix states will count restorative programs as a payment split for Medicaid residents to increase case mix. Properly designed toileting programs can have a very positive impact on product use as well as overall resident outcomes.

Facilities without active toileting programs are losing opportunities to provide better care and are wasting money on unnecessary incontinent product use. Toileting programs also increase the use of a variety of products for the resident and frequently overall costs go down because the use of briefs is not always the appropriate approach. Operational managers need to be sure that their incontinence products are the appropriate size and type for the situation. Managing this with your vendor can produce significant cost savings and improved outcomes and quality of life for residents.

Continence and interventions must be coded accurately. Many clinical staff members do not use the proper definition present in the RAI Manual in their documentation. Strive to identify properly each resident’s history of continence, the changes in continence and the proper interventions used to reverse or modify incontinence, to restore as much independence and dignity as possible. If the incontinence cannot be reversed, then the use of proper products and sizing is essential. The current regulatory process is focused on incontinence, and SNFs must have an interdisciplinary operational approach to reduce risk and deal with costs and payment issues. Look at your current facility database for the number of residents in the various categories of continence and the numbers and types of toileting programs you are coding. You may find that the data does not match the definitions or the services you are providing. You may need to focus on the issue of reversing or improving levels of incontinence as a program to improve quality of care and quality of life.

Leah Klusch, RN, BSN, FACHCA, is founder and executive director of the Alliance Training Center.

Topics: Articles , Clinical , Executive Leadership , MDS/RAI , Rehabilitation