Chapter 21 Federal Regulations

plan in order for residents to achieve their highest prac- ticable level of well-being.

Federal regulations at 42 CFR 483.20 (b)(l)(xvii), (g), and (h) require that

1. The assessment accurately reflects the resident’s status.

2. A registered nurse (RN) conducts or coordinates each assessment with the appropriate participa- tion of health professionals.

3. The assessment process includes direct observa- tion and communication with the resident and all shifts of direct care staff.

The facility can decide who participates in the assessment process, how the assessment process is completed, and how the information is documented, as long as it is within the federal requirements and the requirements of the RAI user’s manual. Usual participants in this process include resident care managers, registered nurses, direct care staff, RDNs, NDTRs, social services, activity staff, dietary staff, rehabilitation staff, and any other care personnel who have knowledge of the resident. Even though not mandated, the RDN should play an active role in the process based on knowledge of the science of nutrition, ability to use critical thinking skills during the assessment process, and knowledge of reimbursement based solely on MDS scores.

Federal requirements codified at 42 CFR 483.20 (b) (l) and 483.20(c) stipulate the use of an RAI tool specified by the state and approved by CMS. It also mandates the MDS data is encoded and electronically transmitted.

The Resident Assessment Instrument Process

The RAI consists of three basic components:

1. MDS version 3.0, 2. Care Area Assessment (CAA) 3. RAI utilization guidelines

The use of all three RAI components yields informa- tion about the resident’s functional status, strengths, weaknesses, and preferences and offers guidance once problems have been identified. Clinicians in the health care arena are educated on the problem identification process as a part of the curriculum. The RAI easily fits into this model, providing structure and standardized approaches for problem identification. The steps gener- ally include the following:

1. assessment: using all available sources for information

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2. decision-making: including the resident/family, the physician, and the IDT in the process while putting the resident at the center of the care

3. care planning: identifying specific resident- directed goals that use the resident’s strengths and the IDT’s expertise

4. identification of outcomes: determining the expected outcomes helps in the evaluation of the resident-specific goals and needed interventions for achieving those goal

5. implementation: putting into action the specific interventions

6. evaluation: critically reviewing the above process to determine the outcomes and to determine if revisions are necessary due to resident status change or goals

Minimum Data Set

The MDS 3.0 is a set of screening, clinical, and func- tional elements that form the basis for the assessment of the resident (1). This establishes the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. However, the MDS does not provide a comprehensive assessment for all aspects of resident care. It is used for preliminary screening—to identify potential resident problems, strengths, and/or preferences. Each section of the MDS includes spe- cific guidance on how the section should be com- pleted based on specific data, observations, interviews, and time frames. It does not include detailed descriptions of all factors necessary for care planning and evaluation. CMS has a series of YouTube videos (www.youtube.com/user/ CMSHHSgov) that give instructions on how each section of the MDS should be completed, in addition to the information provided in the RAI Manual (7). RDNs who complete any section of the MDS must sign, date, and indicate the sections of the assessment completed. It is the facility’s responsibility to ensure that every participant who completes the MDS has the requisite knowledge to complete an accurate compre- hensive assessment and abide by any state licensure laws that define scope of practice or designate qualifi- cations for those assessing residents. The RN coordina- tor is required to sign the MDS, certifying that this part of the process is complete.

Data collected from MDS assessments are also used for the Medicare reimbursement system and for many state Medicaid reimbursement systems (see Table 21.1 on page 304). These data reflect the acuity level of the resident, including diagnosis, treatments, and an evaluation of the resident’s functional status. The RDN can aid in making sure that all data involving