The Resident Assessment Instrument (RAI) process is a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life. The process helps nursing professionals and staff assess a resident’s strengths and needs to create an individualized care plan. This allows for a holistic approach to care for each resident. This assessment is completed initially and periodically and is comprehensive, accurate, and standardized. It is a reproducible assessment of each resident’s functional capacity.
The RAI process is also a federal requirement from the Centers of Medicare and Medicaid Services (CMS) as outlined in section §483. The regulations refer to and utilize the RAI’s standardized assessments known as the Minimum Data Item Sets (MDS) and include comprehensive, quarterly, and significant change of status assessments. These regulations apply to federally and state licensed facilities and allows states the option to utilize the MDS assessment (Section S) to collect state specific data if they choose.
Why is the Resident Assessment Instrument Important?
The RAI process sets the stage for the level of care and quality of life of all SNF residents. It is one of the most important facility systems and not doing it right could come with serious operational and financial complications, especially around compliance, quality, and reimbursement.
Compliance
The most recent ‘comprehensive’ assessment (initial or periodic assessment) is often referred to as the primary resident document and is the representation of the resident’s overall health status. A facility will be out of compliance on both a state and federal level if they cannot produce the documentation showing how the assessment outcomes are systematically applied to care and services as well as the RAI process requirements.
It is important to invest in quality RAI education for the team, not just for the resident assessment coordinator, but also for each assessor on the interdisciplinary team.
Quality
Your facility’s quality status is directly related to this process. Each MDS submission of completed assessments, used to report and benchmark your facility’s quality, is tracked on the CMS Care Compare website. Providers should keep in mind that private entities can access facility data at any time and is used in a variety of ways.
Reimbursement
The facility’s state Medicaid reimbursement is calculated using the MDS assessments produced from the RAI process. In addition the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program also uses data from the process to reimburse facilities.
What Does the RAI Process Include?
| F-TAG | REGULATORY FOCUS | REGULATION |
|---|---|---|
| F635 | Admission Physician Orders for Immediate Care | 483.20 |
| At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care, which is expected to include dietary needs, medications (if necessary), and routine care to maintain or improve the resident’s functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. |
| F636 | Comprehensive Assessments & Timing | 483.20(b)(1)(2)(i)(iii) |
| The facility must conduct initially and periodically a comprehensive, accurate, standardized, and reproducible assessment of each resident’s functional capacity to determine a resident’s needs, strengths, goals, life history, and preferences. This is all completed during required timeframes and must include summarized assessment findings and show resident participation efforts in the process. |
| F637 | Significant Change in Status Assessment (SCSA) | 483.20(b)(2)(ii) |
| A facility has 14 days to complete a SCSA, when they determine that there has been a significant change in a resident’s physical or mental condition. A “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status and requires interdisciplinary review, revision of the care plan, or both. |
| F638 | Quarterly Assessment At Least Every 3 Months | 483.20(c) |
| A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS once every 3 months (92 days). |
| F639 | Maintain 15 Months of Resident Assessments | 483.20(d) |
| A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review, and revise the resident’s comprehensive care plan. |
| F640 | Encoding/Transmitting Resident Assessment | 483.20(f)(1)-(4) |
| This is the automated data processing requirement which includes data encoding in the required format and transmitting a completed assessment within required timeframes. |
| F641 | Accuracy of Assessments | 483.20(g) |
| Requires that the assessment accurately reflects the resident’s status at the time of the assessment. “Accuracy of Assessment” means that the appropriate, qualified health professionals 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 type (i.e., comprehensive, quarterly, significant change in status). In October 2022, CMS updated to include the following note: CMS is aware of situations where practitioners have potentially misdiagnosed residents with a condition for which antipsychotics are an approved use (e.g., new diagnosis of schizophrenia) which would then exclude the resident from the long-stay antipsychotic quality measure. For these situations, determine if non-compliance exists for the facility’s completion of an accurate assessment. This practice may also require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing. |
| F642 | Coordination/Certification of Assessment | 483.20(h)-(j) |
| A registered nurse (RN) must conduct or coordinate each assessment with the appropriate participation of health professionals. An RN must sign and certify that the assessment is completed. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Encoding doesn’t constitute assessment. If the therapist assessed, then it’s that individual who should sign and certify the accuracy of the assessment portion they assessed. Also, under Medicare and Medicaid, an individual who willfully and knowingly— (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. Keep in mind that a clinical disagreement does not constitute a material and false statement. |
| F644 | Coordination of PASARR and Assessments | 483.20(e)(1)(2) |
| A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident’s assessment, care planning, and transitions of care. Referring all level II residents and all residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions for level II resident review upon a significant change in status assessment. |
| F645 | PASARR Screening for MD & ID | 483.20(k)(1)-(3) |
| Preadmission screening for individuals with a mental disorder and individuals with intellectual disability requirements along with admitting and restrictions for those with IDMD diagnoses. |
| F646 | MD/ID Significant Change Notification | 483.20(k)(4) |
| A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. |