Regulations
require nursing homes to initially and periodically conduct a
comprehensive, accurate, standardized, reproducible assessment of each
resident's functional capacity. This process utilizes the Resident
Assessment Instrument (RAI) which consists of the Minimum Data Set (MDS)
and Care Assessment Areas (CAAs), and are used to develop a
person-centered care plan for each resident.
What You Need To Know:
The RAI process is governed by multiple regulatory requirements, as discussed in Appendix PP of the State Operations Manual and the MDS 3.0 RAI User’s Manual (pages 1-5 and 1-6).
Notably, federal regulations at 42 CFR §483.20 (b)(1)(xviii), (g), and (h) require that:
the assessment accurately reflects the resident’s status
a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and
the
assessment process includes direct observation, as well as
communication with the resident and direct care staff on all shifts.
All
members of the interdisciplinary team (IDT) have a stake in the RAI
process, from the RN to therapy teams to nursing assistants.
An
accurate assessment requires collecting information from multiple
sources, which is specified by regulation and outlined in guidance.
Those sources must include the resident and direct care staff on all
shifts, and should also include the resident’s:
Nursing homes are responsible for ensuring that all participants
in the assessment process have the requisite knowledge to complete an
accurate assessment. Additionally, the facility must comply with all
applicable state and Federal requirements for conducting resident
assessments, care planning, resident rights, professional scope of
practice, and health information privacy and confidentiality.
It
is also essential that healthcare professionals completing MDSs comply
with licensure requirements in the state in which the facility is
located. For example, the RN who coordinates and signs the assessment as
“complete” in Z0500 would need to be licensed in the applicable state.
Facilities may contact the State Board of Nursing or other applicable
board for professionals for more information.
Resources:
AHCA has comprehensive education for all members of the IDT who participate in the RAI process titled Learning the Minimum Data Set: Basic Training for the Interdisciplinary Team.
This program can be incorporated into facility orientation programs,
used for performance improvement, or continuing education. Upon
successful completion of the entire program, participants will:
Understand the role of the RAI in nursing homes,
Explain the process for completing the MDS, and
Complete an MDS assessment.
Note: This
training will be updated periodically to incorporate annual and
intermittent changes to the RAI Manual so that learners will have the
most current guidance.
Participants
can earn 13.25 nurse credits through IBON or 13.25 NAB credits. Group
purchase is available for groups of 2 or more.
AHCA offers the following discount structure for groups:
To qualify for group discounts on registrations, advance email requests to educate@ahca.org and invoice payments are required. Questions about regulatory and education requirements for the MDS may be directed to regulatory@ahca.org.