1 mds essentials intro to rai and mds process fall 2019 updates … · 2020-01-14 · title:...

MDS ESSENTIALS

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Introduction to RAI and MDS Process


Faculty Disclosures

• I have no financial relationships to disclose• I have no conflicts of interests to disclose• I will not promote any commercial products or

services

All Planning Committee members, content reviewers, authors, and presenters have been evaluated for conflicts of interest and there are not any to disclose.

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Educational Activity Completion and CE Disclosure

Requirements for Successful Completion• 1.25 contact hours will be awarded for this continuing

nursing education activity.• Criteria for successful completion includes attendance for

at least 80% of the entire event. Partial credit may not be awarded.

• Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services.

American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

*AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC)

3Visit us at AANAC.org | Copyright © 2019

Learning Objectives1. Interpret the regulatory mandate for the

Minimum Data Set (MDS)2. Differentiate the various functions of the MDS

and their application in nursing homes3. Describe the components of the Resident

Assessment Instrument (RAI) process4. Demonstrate awareness of key aspects of RAI-

specific lingo5. Explain the process for accurate and timely

completion of the MDS6. Describe how the RAI process is linked to

resident care and positive outcomes

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The Minimum Data Set (MDS)Page numbers on the slides indicate

the related page number on the Comprehensive MDS item set or the

page(s) in the RAI User’s Manual when indicated by a chapter and

page number (e.g., 2-22). The exception to this is the item-by-item guide to the MDS located in chapter 3 using the section letter and page

number of that portion


Minimum Data Set

• Paper form or software version• Must be submitted electronically to national

MDS database known as QIES ASAP• Core set of resident-specific screening, clinical,

and functional status items• Complex completion instructions and

processes involved

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Minimum Data SetItem Set

• Set of MDS items required depending on the reason for doing the assessment– Nursing Home Comprehensive (NC) item set

• Contains the most items, used for clinical assessment

– Subsets of the NC items set• Quarterly clinical assessment• OBRA Discharge assessments• Medicare PPS Assessments • Entry and Death records


Minimum Data SetSections A – Z: Topics Mandated by Law

A. Identification InformationB. Hearing, Speech, and VisionC. Cognitive PatternsD. MoodE. BehaviorF. Preferences/ActivitiesG. Functional StatusGG. Functional Abilities and GoalsH. Bladder and BowelI. Active DiagnosesJ. Health Conditions

K. Swallowing/Nutritional Status

L. Oral/DentalM. Skin Conditions N. MedicationsO. Special TreatmentsP. Physical Restraints and

AlarmsQ. Participation/GoalsV. CAAs/SignaturesX. Correction RequestZ. Assessment Admin

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Minimum Data SetItems

• Each section is further divided into specific items– Example, Section E, Behavior (p. 11)– Item E0100, Potential Indicators of Psychosis

• Item E0200, Behavioral Symptoms• Item E0300, Overall Presence of Behavioral

Symptoms• Item E0500, Impact on Resident• Item E0600, Impact on Others• Item E0800, Rejection of Care


Minimum Data Set

• After each item label, list of answer options, such as:

OR…

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Minimum Data Set• Further subdivided into more questions

and the answer options:


Minimum Data SetAnswer Options

• Coding conventions– Check all that apply, such as E0100

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• Coding conventions– Check all that apply, such as E0100, or– Select code and enter it into box, such as A0310 (p. 1)

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• Coding conventions– Check all that apply, such as E0100, or– Select code and enter it into box, such as A0310 (p. 1),

or– Enter ID numbers, such as A0100 (p. 1) or A0600 (p. 2)

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• Coding conventions– Check all that apply, such as E0100, or– Select code and enter it into box, such as A0310

(p. 1), or– Enter ID numbers, such as A0100 (p. 1) or A0600

(p. 2)

Key Concept: Read coding instructions for each item


Resident Assessment Instrument (RAI)

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Resident Assessment Instrument (RAI)Regulatory Mandate

• Nursing Home Reform Act of 1987 known as “OBRA ’87”

• Standardized, periodic functional status assessments required for all nursing home residents

• To improve quality of assessment– Spotlighting resident-specific problems– Targeting care planning

Goal: Improving resident care and outcomes17


Resident Assessment InstrumentProcess of Investigation

• Parallels nursing process• Components

– Minimum Data Set (MDS)• Core set of screening, clinical, and functional status

items– Care Area Triggers (CATs)

• MDS items that alert staff to possible problems, needs, strengths

• Triggers need a complete assessment of the issue that meets standards of practice

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Resident Assessment InstrumentProcess of Investigation

• Care Area Assessments (CAAs)– 20 care areas (p. 47)– Complete assessments of issues identified by the MDS – Identify causes, contributing factors, risk factors

related to the problem

• Care Plan– Working action plan that targets specific problems,

needs, strengths and preferences including those identified by the MDS and CAAs


Resident Assessment InstrumentAssessment Requirement

• Comprehensive assessment – MDS + CAAs – Required at least every 366 days

• Quarterly assessment – Subset of comprehensive assessment– Required at least every 92 days

• Unscheduled comprehensive assessments– Significant Change in Status Assessment– Significant Correction of Prior Assessment

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Resident Assessment InstrumentAssessment Requirement

• OBRA-required clinical assessments– Required for all residents of nursing home

facilities and units in facilities that are Medicare and/or Medicaid certified regardless of payer


Resident Assessment Instrument (RAI) User’s Manual

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RAI User’s Manual

CHAPTER 1• Overview• Components of the MDS • Layout of the RAI Manual• Protecting the privacy of the MDS data


RAI User’s ManualCHAPTER 1: Excerpt (p. 1-7)• Monitoring the Quality of Care. MDS assessment data

are also used to monitor the quality of care in the nation’s nursing homes. MDS-based quality measures (QMs) were developed by researchers to assist: 1. State Survey and Certification staff in identifying potential

care problems in a nursing home 2. Nursing home providers with quality improvement

activities/efforts3. Nursing home consumers in understanding the quality of

care provided by a nursing home 4. CMS with long-term quality monitoring and program

planning. CMS continuously evaluates the usefulness of the QMs, which may be modified in the future to enhance their effectiveness

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RAI User’s ManualCHAPTER 2• RAI Requirements• Responsibility for Completing Assessments• Assessment Types and Definitions • Required OBRA Assessments• Skilled Nursing Facility Medicare Prospective

Payment System Assessments• Combining Assessments• Determining Item Set for an MDS Record


RAI User’s Manual – Chapter 2Excerpt (pp. 2-6, 2-7)

• Federal regulatory requirement [42 CFR 483.20(d)] requires nursing homes to maintain all assessments completed within previous 15 months in the active clinical record. Applies to all MDS assessment types regardless of the form of storage (i.e., electronic or hard copy)– The 15-month period for maintaining assessment

data may not restart with each readmission to the facility

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RAI User’s Manual – Chapter 2Excerpt (p. 2-22)

SIGNIFICANT CHANGE = major decline or improvement in resident’s status 1. Will not normally resolve itself without intervention by

staff or by implementing standard disease-related clinical interventions, the decline is not considered “self-limiting”;

2. Impacts more than one area of the resident’s health status; and

3. Requires interdisciplinary review and/or revision of care plan


RAI User’s ManualCHAPTER 3• Item-By-Item Guide to MDS 3.0

– Sections A-Z• Intent• Rationale• Coding instructions• Examples• Tips and special population

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RAI User’s ManualCHAPTER 3: Excerpt (p. L-1)


RAI User’s Manual

CHAPTER 4• Care Area Assessments (CAAs)

– Background and rationale – Other considerations regarding the use of

CAAs• When is the RAI not enough? • The RAI and care planning • The 20 care area assessments

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RAI User’s ManualCHAPTER 4: Excerpt (p. 4-4)

• CATs provide a “flag” for the IDT members, indicating that the triggered care area needs to be assessed more completely prior to making care planning decisions. Further assessment of a triggered care area may identify causes, risk factors, and complications associated with the care area condition. The plan of care then addresses these factors with the goal of promoting the resident’s highest practicable level of functioning: (1) improvement where possible or (2) maintenance and prevention of avoidable declines


RAI User’s ManualCHAPTER 5• Submission and Correction of the MDS

Assessment– Transmitting MDS Data – Validation Edits– MDS Correction Policy – Correcting MDS records that have not yet been

accepted into the QIES ASAP system– Correcting MDS records that have been accepted

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RAI User’s ManualCHAPTER 5: Excerpt (p. 5-7)• It is important to remember that the electronic

record submitted to and accepted into the QIES ASAP system is the legal assessment. Corrections made to the electronic record after QIES ASAP acceptance or to the paper copy maintained in the medical record are not recognized as proper corrections. It is the responsibility of the provider to ensure that any corrections made to a record are submitted to the QIES ASAP system in accordance with the MDS Correction Policy


RAI User’s ManualCHAPTER 6• Medicare Skilled Nursing Facility Prospective

Payment System (SNF PPS)– Patient-Driven Payment Model (PDPM)– Relationship between assessment and claim – SNF PPS Eligibility Criteria – PDPM Calculation Worksheet for SNFs– SNF PPS policies – Non-compliance with the SNF PPS schedule

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RAI User’s Manual CHAPTER 6: Excerpt (6-16)


RAI User’s Manual

APPENDIX A• Glossary • Common Acronyms

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RAI User’s ManualAPPENDIX A - Glossary – excerpts:


RAI User’s ManualAPPENDIX A• Common Acronyms - Excerpt

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RAI User’s ManualAPPENDIX B• State Agency and CMS Regional Office • State RAI contact information

– Located in the “Downloads” section on the CMS MDS 3.0 RAI Manual Web page: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html


RAI User’s ManualAPPENDIX C• Care Area Assessment Resources

– Provided as a courtesy– CMS does not endorse or mandate use of this

resource • Facilities must use resource(s) that are current,

evidenced-based or expert-endorsed research and clinical practice guidelines

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RAI User’s Manual

Appendix C• Example:


RAI User’s Manual

APPENDIX D• Interviewing to increase resident voice in MDS

Assessments – Approaches and techniques to make

interviews more effective

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RAI User’s ManualAPPENDIX D: Excerpt (p. D-1)

• Find a quiet, private area where you are not likely to be interrupted or overheard. This is important for several reasons: – Background noise should be minimized– Some items are personal, and the resident will

be more comfortable answering in private. The interviewer is in a better position to respond to issues that arise

– Decrease available distractions


RAI User’s Manual

APPENDIX E• PHQ-9© Scoring Rules

– Resident Mood Interview Total Severity Score: D0300

– Staff Assessment of Resident Mood Total Severity Score: D0600

• Instructions for BIMS (when administered in writing)– Sample cue cards that may be used for interviews

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RAI User’s ManualAPPENDIX E: Excerpt


RAI User’s Manual

APPENDIX F• MDS item Matrix

APPENDIX G• References

APPENDIX H• MDS Forms

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Skilled Nursing Facility Prospective Payment System (SNF PPS)


SNF Prospective Payment SystemRegulatory Mandate

• Federal law mandated switch from cost-based to case-mix reimbursement in 1998– Cost-based = pay facility whatever it spends on the

resident’s care– Case-mix prospective reimbursement = predict cost

of care using resident-specific information from MDS and pay facility based on that

• The Patient-Driven Payment Model (PDPM) replaced RUG-IV October 1, 2019

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SNF Prospective Payment SystemCalculating Payment

• Nursing Home PPS (NP) item set– Specific items reflecting resident’s acuity used to

help quantify the cost of care and services, such as• Functional status• Health conditions• Diagnoses• Certain treatments, procedures


SNF Prospective Payment SystemCalculating Payment

• Completed PPS 5-Day or Interim Payment Assessment (IPA) classifies resident case-mix groups for PT, OT, SLP, nursing, and non-therapy ancillary components

• A daily payment rate is assigned to each case-mix group and combined with a non-case-mix flat rate to establish the total rate

• A variable per diem (VPD) adjustment schedule is applied to the PT, OT, and non-therapy ancillary components

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SNF Prospective Payment SystemAssessment Requirement

• SNF PPS required the 5-Day assessment to set the daily rate for the entire Medicare Part A stay– The optional IPA may be used to change the rate

during the Medicare Part A stay

• SNF PPS Discharge Assessment is required– Not used for determining daily rate, used for reporting

• The PPS schedule is in addition to the OBRA-required clinical assessments


MDS 3.0 Quality Measures (QMs)

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MDS 3.0 Quality Measures

• Intended to reflect quality of care in the nursing home

• CMS pulls data specific to particular conditions and problems from a national database - examples– Rate of UTIs in a facility comes from I2300– Decline in ADLs computed from comparing G0110

data on successive assessments


MDS 3.0 Quality Measures

• Long list of QMs, scores periodically updated• Complex formulas and calculations involved• Quality Measures info and User’s Manual:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/NursingHomeQualityInits/NHQIQualityMeasures.html

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MDS 3.0 Quality MeasuresPublicly Reported QMs

• Takes facility-specific resident care information directly to consumers

• To publicize the differences in quality to assist consumers in selection of a facility

• Five-Star Rating System– Nursing Home Compare website

www.medicare.gov/nursinghomecompare/ search.html


Quality MeasuresCASPER Reporting System

• Certification and Survey Provider Enhanced Reporting (CASPER) system

• Produces QM reports for facility to use in quality improvement efforts

• Surveyors use the MDS Indicator Facility Rate report

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SNF QRP

• SNF Quality Reporting Program (QRP) – Requirement of the IMPACT Act (2014) – Requires SNF to report 100% of the data

required to calculate all SNF QRP Measures on at least 80% of all assessments • 5-Day MDS • Part A PPS Discharge Assessment


MDS and Survey Outcomes

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Survey Outcomes• All nursing facilities participating in Medicare

and/or Medicaid program are required to have a Life Safety and Standard Annual Survey– Additional surveys

• Dementia Focus Survey • Complaint Survey

– Must apply RAI guidelines and understand the guidelines found in the State Operations Manual (SOM Appendix PP)


483.20 RESIDENT ASSESSMENTS (12 TAGS)New Tag Tag Title CFR

F842 Resident Records – Identifiable Information483.20(f)(5)483.70(i)(1)-(5)

F635 Admission Physician Orders for Immediate Care 483.20(a)F636 Comprehensive Assessments & Timing 483.20(b)(1)(2)(i)(iii)F637 Comprehensive Assmt After Significant Change 483.20(b)(2)(ii)F638 Quarterly Assessment At Least Every 3 Months 483.20(c) F639 Use, Maintain 15 Months of Resident Assessments 483.20(d)F640 Encoding/Transmitting Resident Assessment 483.20(f)(1)-(4)F641 Accuracy of Assessments 483.20(g)F642 Coordination/Certification of Assessment 483.20(h)-(j)F644 Coordination of PASARR and Assessments 483.20(e)(1)(2)F645 PASARR Screening for MD & ID 483.20(k)(1)-(3)F646 MD/ID Significant Change Notification 483.20(k)(4)

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Survey Outcome GuidelinesF641 §483.20(g) Accuracy of Assessment The assessment must accurately reflect the resident’s status Intent §483.20(g) To assure that each resident receives an accurate assessment, reflective of the resident’s status at the time of the assessment, by staff that are qualified to assess relevant care areas and knowledgeable about the resident’s status, needs, strengths, and areas of decline

Guidelines §483.20(g) “Accuracy of assessment” means that the appropriate, qualified health professional correctly document the resident’s medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e., comprehensive, quarterly, SCSA)


Achieving MDS Accuracy

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Achieving MDS Accuracy• RAI User’s Manual: THE authoritative resource for all

official instructions and information• Chapters

– 1: Overview– 2: Timing and scheduling of assessments– 3: Item-by-item coding instructions– 4: Care Area Assessments and care planning– 5: MDS correction policy and transmission– 6: SNF PPS calculations

• 8 Appendices63


Achieving MDS Accuracy

• Download RAI User’s Manual from CMS website

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

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AANAC’s RAI User’s Manual Web Pagehttps://www.aanac.org/Information/Government-Source-Documents


Achieving MDS AccuracyChapter 3

• Process based on the standard format for the instructions for each item

• Background included for each item– Intent/reason for including item on MDS– Rationale/purpose for assessing the topic– How the topic of the item affects quality of life– How assessment of the topic can contribute to

appropriate care planning

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Achieving MDS AccuracyChapter 3

• Item-specific coding instructions– Steps for assessment: sources for information and

methods for determining the correct code– Specific coding instructions with explanation of

individual response options– Coding tips/clarifications, issues of note,

conditions to be considered– Case examples


B0700. Makes Self Understood

Item Rationale Health-related Quality of Life • Problems making self understood can be very

frustrating for the resident and can contribute to social isolation and mood and behavior disorders

• Unaddressed communication problems can be inappropriately mistaken for confusion or cognitive impairment

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B0700. Makes Self UnderstoodPlanning for Care • Ability to make self understood

can be optimized by not rushing the resident, breaking longer questions into parts and waiting for reply, and maintaining eye contact (if appropriate)

• If a resident has difficulty making self understood: — Identify the underlying cause

or causes — Identify the best methods to

facilitate communication for that resident


Steps for Assessment 1. Assess using the resident’s preferred language or

method of communication2. Interact with resident. Be sure he/she can hear you or

have access to his or her preferred method for communication. If the resident seems unable to communicate, offer alternatives such as writing, pointing, sign language, or using cue cards

3. Observe his/her interactions with others in different settings and circumstances

4. Consult with the primary nurse assistants (over all shifts) and if available, the resident’s family, and speech-language pathologist


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Coding Instructions• Code 0, understood: if the resident expresses requests

and ideas clearly • Code 1, usually understood: if the resident has difficulty

communicating some words or finishing thoughts but is able if prompted or given time. He or she may have delayed responses or may require some prompting to make self understood

• Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet)

• Code 3, rarely or never understood: if, at best, the resident’s understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet)



Achieving MDS AccuracyTimeframe for Data Collection

• Based on Assessment Reference Date (ARD), item A2300 (p. 5)– Last date for collecting data for the particular MDS

item– Most items look-back 7 days: ARD plus the 6 days

preceding it (example next slide)– This is the observation period or look-back period

(these terms are synonymous)– Using the wrong dates or not using every day in the

look-back is likely to result in accuracy problems72

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Achieving MDS AccuracyTimeframe for Data Collection

• Look-back period – ARD + 6 previous calendar days

1 2 3 4 5 6ARD


Achieving MDS AccuracyWho Takes Part in MDS Process?

• “A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals” (42CFR483.20[h])

• It must be an RN who signs item Z0500A certifying completion of all of the MDS items (483.20([I])– This is not verifying accuracy of the items

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Achieving MDS AccuracyWho Takes Part in MDS Process?

• “The determination of appropriate participation of health professionals must be based on the physical, mental and psychosocial condition of each resident. This includes an appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs ” (SOM guidelines, F641)


Achieving MDS AccuracyHow is Accuracy Validated?

• Chart documentation that supports the MDS coding

• Resident voice is incorporated into the assessment through MDS scripted interviews

• Any surveyor or auditor reading the chart should come to the same coding decision that the person coding the MDS did (except interviews)

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Please continue with MDS Essentials: Sections A, B, C, H and I

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QuestionsPlease submit questions to:

The New to MDS Community

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