Please find a CMS memo below addressing onsite RAI requirements.
It is essential that healthcare professionals completing MDS assessments comply with licensure requirements in the state in which the facility is located, and they should contact the State Board for Nursing or other applicable board for professions for more information. Facilities 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.
The RAI process is governed by multiple regulatory requirements, as discussed in the MDS 3.0 RAI User’s Manual (see pgs. 1-5 and 1-6). Notably, federal regulations at 42 CFR §483.20 (b)(1)(xviii), (g), and (h) require that
1) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts,
2) the assessment accurately reflects the resident’s status; and
3) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals.
Given that the regulations require, “direct observation,” the assessment of a resident’s status cannot be conducted off site. Indeed, if an assessor were to complete an assessment without observing the resident and gathering data, it may be considered a material and false statement and subject to penalties under 42 CFR §483.20(j).
The regulations do not address whether the coding of an MDS assessment (based on the required tasks conducted on site) can be conducted off site. Offsite MDS response code selection decisions based on documented assessments and interdisciplinary team (IDT) collaboration may be allowable, as long as all requirements (42 CFR §483 subpart B) are met. Separately, we note that any time worked off site cannot be reported as hours in the Payroll-Based Journal (PBJ) system.
That said, in keeping with objectives set forth in the Institute of Medicine (IOM) study and report completed in 1986 (Committee on Nursing Home Regulation, IOM) that made recommendations to improve the quality of care in nursing homes, the RAI provides each resident with a standardized, comprehensive, accurate, and reproducible assessment, as well as individualized and holistic care planning.
An accurate assessment requires collecting information from multiple sources, which must include the resident and direct care staff on all shifts. Given the requirements of participation of appropriate health professionals and direct care staff, completion of the RAI is best accomplished by an IDT that includes nursing home staff with varied clinical backgrounds, including nursing staff, therapists, dietary professionals, and the resident’s physician. Such a team brings their combined experience and knowledge to the table in providing an understanding of the strengths, needs, and preferences of a resident to ensure the best possible quality of care and quality of life.
All levels of staff, including nursing assistants, have a stake in the RAI process, including the care plan. Knowledge gained from careful examination of possible causes and solutions of resident problems (i.e., from performing the CAAs) challenges staff to hone the professional skills of their discipline, focus on the resident’s individuality, and holistically consider how that individuality is accommodated in the care plan.
The key to successfully using the RAI process is to understand that its structure is designed to enhance resident care, increase a resident’s active participation in care, and promote the quality of a resident’s life. This occurs not only because it follows an interdisciplinary problem-solving model, but also because the staff (across all shifts), residents and families (and/or guardian or other legally authorized representatives), and physicians (or other authorized healthcare professionals as allowable under state law) are all involved in its “hands on” approach.
CMS recognizes that NH providers have different approaches to conducting and completing the RAI process. However, the expectation is that all residents are accurately assessed, receive quality care, and have individualized and holistic care plans to ensure they are able to attain and maintain their highest practicable well-being, which is best accomplished by an IDT, including but not limited to direct observation, resident/family interview, and involving staff from all shifts. Factors to address when considering offsite coding of MDS assessments may include the following:
- Are staff on site conducting the needed in-person assessments and properly/fully documenting to allow accurate coding of the MDS?
- Is the MDS reproducible, meaning a person coding the MDS on site would arrive at the same responses as a person coding the MDS off site?
- Will a person off site be able to engage with the resident, family, and staff adequately and appropriately as a staff person on site and obtain the same coding responses?
- Can a person who is 100% off site adequately participate in the care planning process and communicate effectively with the onsite staff?
- Is the offsite staff person able to ensure the resident is involved in the RAI process? Resident voice/interview is imperative for comprehensive assessment and accurate RAI process. The strengths, needs, preferences, and goals of the resident to ensure the best possible quality of care and quality of life.
- If an integral staff person is 100% off site, is the care planning process negatively impacted, or worse, the quality of care provided to the resident is not appropriate and/or a negative outcome?
CMS recommends that providers consider all aspects of the provision of resident care, completion of the RAI process, staff involvement, reporting of staff hours, resident outcomes, and quality of care when developing policy and procedures and assignment of work.
We value your interest and thank you for helping to optimize the health, safety, and quality of life for people living in nursing homes.
Who to Email for questions and assistance
If you have questions about defaults, excluded residents, corrections, modifications, an inactivation, or need a copy of the CMID report please contact MDSHelpdesk@dshs.wa.gov
Confidentiality
When emailing the MDSHelpdesk@dshs.wa.gov, please do not list the resident name or other identifying information unless you are using a Secure Email. Instead, please include only the “Resident ID” number found in the column on the right of the resident name on the CMID report. We are able to review your inquiries as we have access to your CMID reports. If we need to send you detailed information about a specific resident(s), we will send the information via Secure Email and you will need to log-in with a password to retrieve it.
If you have questions about how a CMID score affects your nursing home rate, please contact Bobbie Howard, Rates Analyst at 360-725-2474 or bobbie.howard@dshs.wa.gov
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