CHAPTER 22 | Federal Regulations 345


use by noncritical access hospitals with a swing bed agreement. (A swing bed is a service provided by rural hospitals and critical access hospitals with a Medi- care provider agreement, which allows an individual to transition from acute care to SNF care without leaving the hospital.) Noncritical access hospitals with swing beds are required to complete the MDS for reimbursement under the SNF PPS. Additional uses for MDS data are explained next.


Medicare and Medicaid payment systems The MDS contains data elements that reflect the resident’s acuity level, including diagnoses, treatments, and evaluation of the resident’s functional status. The MDS is used as a data collection instrument to classify residents receiving Medicare into Patient Driven Payment Model (PDPM) components. The PDPM classification system is used in the SNF PPS for SNFs and noncrit- ical access hospital swing bed programs. States may use the PDPM, a Resource Utilization Group–based system, or an alternate system to group residents into similar resource use categories for the purposes of Medicaid reimbursement. Refer to the Medicare internet-only manuals, including the Medicare Bene- fit Policy Manual, for comprehensive information on SNF PPS, including (but not limited to) SNF cover- age, SNF policies, and claims processing.7


Monitoring the quality of care MDS assessment data are also used to monitor the quality of care in nurs- ing homes. MDS-based quality measures, which are derived from data collected on the MDS, were devel- oped by researchers to assist (1) state survey and cer- tification staff in identifying potential care problems in a nursing home, (2) nursing home providers with quality improvement activities and efforts, (3) nurs- ing home consumers in understanding the quality of care provided by a nursing home, and (4) CMS with long-term quality monitoring and program planning. CMS continuously evaluates the quality measures for opportunities to improve their effectiveness, reliabil- ity, and validity.


Consumer access to nursing home information Consumers are also able to access information about every Medicare- or Medicaid-certified nursing home in the United States. The Medicare Care Compare tool provides public access to information on a vari- ety of health care facilities, including nursing homes.


Information available includes characteristics, staffing data, and quality of care measures for certified nurs- ing homes (www. medicare . gov / care - compare).


Interdisciplinary Care Plan


After completing the MDS and CAA process, the res- ident (or family, guardian, or other legally authorized representative), the resident’s physician, and the IDT meet to determine the severity, functional impact, and scope of a resident’s clinical issues and needs that will shape the development of the care plan. Decision-making should be guided by a review of the assessment information, in-depth understanding of the resident’s diagnoses and comorbidities, and care- ful consideration of the triggered areas in the CAA process. Understanding the causes and relationships between a resident’s clinical issues and needs, dis- covering the whats and whys, and incorporating the resident’s needs, interests, and lifestyle choices into care delivery is key to this step in the process. With implementation of the revised Medicare and Medicaid requirements for participation for long-term care facilities in 2016, CMS made changes regarding individuals needing to be involved in the development of the resident’s care plan. The rules now dictate that the IDT be made up of the resident and the resident’s representative, the resident’s physi- cian, a registered nurse, a certified nursing assistant, and a member of the nutrition services team, along with other staff or professionals as appropriate for the resident’s needs. OBRA regulation 42 CFR §483.25 directs the IDT to use the comprehensive care plan developed by this team as a communication tool. The care plan identifies measurable objectives and time frames and describes the services that should be provided to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being. Services pro- vided to the resident need to be consistent with the care plan, and the care plan must be reviewed and revised based on the resident’s needs.3


With this in


mind, the development of an effective nutrition plan of care for a resident requires the RDN to be cogni- zant of all aspects of the resident’s physiological, psy- chological, and sociological status. The MDS data, the CAAs, and a comprehensive nutrition assessment are


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