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Federal Regulations Governing the Resident Assessment Instrument Process

February 17, 2020
Documentation, Billing, & Coding By Terry Raser, Senior Consultant

The statutory authority for the Resident Assessment Instrument (RAI) is located in the Social Security Act  amended by the Omnibus Budget Reconciliation Act (OBRA) of 1987 at Section 1819(f)(6)(A-B) for Medicare and 1919(f)(6)(A-B) for Medicaid. The Social Security Act requires the Secretary of the Department of Health and Human Services to specify a tool of core elements for use in conducting assessments of nursing home residents. The tool is called the Minimum Data Set (MDS). It has grown over the years to 51 pages and is slated per the draft form to expand to 61 pages October 1, 2020. Nursing homes that are Medicare certified, Medicaid certified, or both are required to conduct an initial and periodic assessment of residents admitted to the nursing home, per the OBRA '87 regulations.

Resident_Assessment_Instrument


The Federal regulations at 42 CFR 483.20(b)(1) and 483.20 (c) in the State Operations Manual (SOM), Appendix PP requires facilities to use a RAI specified by The Centers for Medicare & Medicaid Services (CMS). These regulations apply to all residents in Medicare and/or Medicaid certified long-term care facilities regardless of their payor source.

RAI Process Components

There are three basic components to the RAI process: MDS Version 3.0, the Care Area Assessment (CAA) process, and the RAI Utilization Guidelines. The concept of the three components is to gather information about the resident’s functional status, strengths, weaknesses, and preferences. If the process is followed as designed, each component flows into the next.

  • MDS: A core set of screening, clinical and functional status elements that forms a foundation of a comprehensive assessment. 
  • CAA: The items in the MDS identify current or potential problems or conditions that using evident-based clinical resources can help determine whether or not to care plan the problem or condition. The CAA is a further investigation of areas that trigger based on the coding of the MDS. The CAA Summary provides a location to identify the triggered areas and whether the triggered area will be care planned or not.
  • Utilization Guidelines: Provides instructions for when and how to use the RAI. This includes completion time frames.

Federal Regulatory Requirements for the RAI Process

The RAI process has multiple Federal regulatory requirements at 42 CFR 483.20. The following applies for F-Tag 636 in particular:

  • The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity.
  • A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS.
  • The facility must conduct a comprehensive assessment of a resident in accordance with the time frames specified in paragraphs (b)(2)(i) through (iii) of this section.
    • Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. Not less than once every 12 months.
  • The facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or CAAs.

During this process, the facility is expected to use resident observation and communication as the primary source of information when completing the RAI. This means the resident is involved not only in the assessment but in expressing their goals for care plan, if capable. In addition to record review, direct observation and communication with the resident, the facility must use a variety of other sources, including communication with licensed and non-licensed staff members on all shifts. During recent RAI process audits conducted by LW Consulting, Inc., it has been noted that residents and some critical interdisciplinary team members are not involved in the care plan process. Surveyors are taught to identify if regulations are being followed. CMS has developed tools for surveyors in an effort to expedite the survey process. The tools are called Critical Element Pathways. These pathways provide the surveyor with questions to ask staff during the survey process. Below are a few examples of critical pathway questions related to the resident assessment:

  • Does information in the MDS correspond with information obtained during observations and interviews with the resident, facility staff, and resident’s family or representative?
  • Have appropriate health professionals assessed the resident? For example, has the resident’s nutritional status been assessed by someone who is knowledgeable in nutrition and capable of assessing the resident?
  • Was the assessment completed and submitted timely? If not, why not?
  • Did the facility complete a comprehensive assessment, using the CMS-specified RAI process, within the regulatory time frames (i.e., within 14 days after admission and at least annually) for each resident?
  • Did the facility assess residents, using the CMS-specified quarterly review assessment, no less than once every three months, between comprehensive assessments?
  • Did the facility ensure no one willfully and knowingly coded MDS assessment information inaccurately or falsely?

Common Coding Inaccuracies

Due to the focus on the RAI process, it is imperative that the MDS Coordinator and interdisciplinary team understand all MDS completion regulations as well as timelines. Too often during facility audits, LW Consulting, Inc. has identified multiple areas of coding inaccuracy without supportive documentation:

  • CAAs not worked or those that do not include location and the date of supporting documentation,
  • Sections of the MDS are not signed for as complete at Z0400,
  • Interviews are not conducted timely or per the RAI regulations, and
  • When reviewing the MDS validation reports, it is identified that assessments are completed and/or submitted late.
All the above stated items are deficiencies waiting to be cited. The Critical Element Pathways instruct the surveyor to cite specific F-Tags if non-compliance is identified.

As part of professional education, clinicians are taught a problem identification process. The completion of the RAI process can be conceptualized in the nursing process as follows:

  • Assessment: know the resident, involve the resident and representative
  • Decision Making: Determine with the involvement of the resident and representative the severity, functional impact and scope of the resident’s clinical needs and conditions. Know the resident’s diagnosis and comorbidities. Understand the causes and the whys of the clinical needs and issues. Incorporate the resident’s lifestyle, goals and needs.
  • Identification of Outcomes: Form specific resident goals and outcomes. Knowing the resident goals and outcomes helps to identify what staff members need to be involved to meet the outcomes. Involving the resident reinforces individualized care and a happier informed resident and representative.
  • Care Planning: Establish a course of action by involving the resident, physician and interdisciplinary team to move toward goals and individualized outcomes.
  • Implementation: Put the course in motion.
  • Evaluation: Review the goals and interventions to identify if goals and outcomes are being achieved or if the goal and/or interventions need to be changed.

RAI Process Success

The key to success for the RAI process is for facility staff to understand the structure of the process. The process is designed to enhance resident care and promote quality of life.

Besides the RAI manual which provides guidance for completing the MDS and time frames, the Requirements for Participation (RoP) also provides Federal Tags that govern the RAI process. Some of the F-Tags that come from §483.20 Resident Assessment in the State Operations Manual, Appendix PP are listed below. It is imperative that facilities know both RAI Manual and State Operations regulations.

  • F637 Comprehensive Assessment After Significant Change
  • F638 Quarterly Assessment
  • F639 Maintaining Resident Assessments
  • F640 Encoding/Transmitting Resident Assessments
  • F641 Accuracy of Assessments
  • F642 Coordination and Certification of Assessments
  • F644 Coordination of PASARR Screening and Assessments
  • F645 PASARR Screening for MD/ID
  • F646 MD/ID Significant Change Notification
The above stated Federal Regulations are just the tip of the iceberg when it comes to regulations and F-Tags that could be cited.

Resources:

MDS 3.0 RAI Manual v1.17.1 October 2019
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual

Long-Term Care Survey Pathways
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes

State Operations Manual, Appendix PP
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf



If your facility is looking for assistance in the RAI process, directed in-services or mock surveys, LW Consulting is ready to assist you. 

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