Managing assessment and documentation for a successful incontinence program

Incontinence management is a critical issue in skilled nursing facilities, especially as it relates to increased regulatory oversight, budgetary considerations, rehospitalization rates and quality of life for residents. The proper documentation of incontinence is essential in the clinical record and in the MDS database.

During a recent Long-Term Living webinar, Leah Klusch, RN, BSN, FACHCA, executive director, Alliance Training Center, offered strategies to elevate resident outcomes and reduce regulatory risk with the incontinence documentation and assessment process. Clinical and therapy staff must be aware of continence status and interventions to improve the status of continence, she asserted.

“There’s a significant regulatory focus on quality of life and quality of care,” Klusch said. “You’re expected to follow standards of practice. Do you and your clinical team and medical director understand the standards of practice when dealing with continence?"

The current regulatory focus also follows individualization of plans and services; safety and reporting events; care transitions; QAPI (quality assessment and performance improvement) and documentation of outcomes to achieve independence.

Every regulatory focus can be connected to the incontinence issue, Klusch said. “Most residents in skilled nursing facilities have a level of incontinence, review the new definitions. A lack of quality programs and interventions can produce significant negative outcomes including rehospitalizations and survey citations. This is a complicated clinical and psychosocial issue requiring interdisciplinary services.”

Start with the RAI Manual (April 2012 update, Chapter 3, Section H) referring to the narrative, definitions and coding directions, Klusch advised. “The coding on the MDS 3.0 is very different from the MDS 2.0 coding, and the documentation in the clinical record needs to change as well,” said Klusch. “Ask your staff: ‘How have you changed your documentation of continence or incontinence since October 2010 and then in April 2012?’”


  • Begin with the regulatory tags related to incontinence issues.
  • Look at related tags—falls, care planning, rehab/restorative care, dignity, quality of care, quality of life, skin, accuracy of assessments—“all very dangerous issues with significant regulatory risk,” cautioned Klusch.
  • Review coding of MDS documents Section H and compare with clinical documentation.
  • Compile samples of facility data related to numbers of residents coded with continence, incontinence at various levels, with and without toileting programs.
  • Review for accuracy—clinical and administrative staff—and look for ways to improve accuracy of data.

For a detailed review of RAI Manual references, appropriate communication with residents about continence and team preparation, register to download the archived webinar, “Getting it Right: Elevating Outcomes and Reducing Risk with Your Incontinence Documentation and Assessment Process,” presented by Long-Term Living.

Topics: Articles , Executive Leadership , Facility management , MDS/RAI