In recent months, federal and state regulators have demonstrated an increased attention on MDS practices. AHCA/NCAL wants to provide some reminders on key requirements for MDS roles and responsibilities as well as highlight resources we have for providers.
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:
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:
- and family, guardian, significant other and/or other legally authorized representative
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:
- 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:
- 2-4 registrations will receive $50 off each registration.
- 5 or more registrations will receive $100 off each registration.
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.