“How do you know if the nursing home is providing the necessary care to my loved one?”
This question gets asked repeatedly by families who have a relative in a nursing home. One of the first places to begin an investigation into whether the resident is getting the proper level of care in a nursing home is by looking at documents related to the Resident Assessment Instrument (RAI).
Within 14 days of admission, new nursing home residents must be evaluated by the nursing home staff for the purpose of conducting a RAI under the Nursing Home Reform Act of 1987 (contained in the Omnibus Budget Reconciliation Act, OBRA 1987) and specifically codified at 42 CFR 483.20 (b)(1)(i)-(F272).
The RAI has three elements: MDS- minimum data set, RAPS- resident assessment protocols and utilization guidelines. The acronyms are confusing, however each element of the assessment is intended to provide a customized care plan for each nursing home resident. Each area has specified criteria for the nursing home staff to address when making their assesment. It is up to the staff to address other areas that are relevant to individual resident– regardless of their omission from the RAI. Families of the new residents should actively participate in this process.
The first step in conducting the RAI is the MRS. The MDS (Minimum Date Set) is a set of screening items that forms the foundation of all long-term care residents at Medicare and Medicaid certified facilities. This is a standardized list to allow facilities a consistent ‘measuring stick’ to analyze resident improvement or deterioration while at the facility and to help new facilities or agencies get a quick analysis of the patient.
A completed MDS is an extremely valuable tool in determining whether the needs of a nursing home resident are met. An MDS is a legal document, which must be signed by all health care professionals who assist in completing it. The completed MDS is also significant in that it is used for Medicare and Medicaid billing. Its accuracy for both patient needs and for billing purposes is essential. The MDS items are detailed below:
- Identification and background information
- Cognitive patterns
- Communication / hearing patterns
- Vision patterns
- Mood and behavior patterns
- Psychological well being
- Physical functioning and structural problems
- Continence in the last 14 days
- Disease diagnoses
- Health Conditions
- Oral / nutritional status
- Oral / dental status
- Skin Condition
- Activity pursuit patterns
- Special treatments and procedures
- Discharge potential and overall status
- Signature and attestation
- State defined section
- Required for Medicare assessments
- Resident Assessment Protocol (RAP) study
The second step in conducting a RAI is the Resident Assessment Protocols (RAPS). The RAPS are intended to further identify the strengths and weaknesses of each resident by organizing the MDS into specific areas that may become problematic. The RAPS assist the staff with determining the importance of risk factors and those that require immediate attention. The RAPS in the Resident Assessment Instrument are:
- Cognitive loss / dementia
- ADL function / rehabilitation
- Urinary incontinence and catheter usage
- Psychological well-being
- Mood state
- Behavior symptoms
- Nutritional status
- Feeding tubes
- Dehydration / fluid maintenance
- Dental care
- Pressure ulcers
- Psychotropic drug use
- Physical restraints
The third component of the Resident Assessment Instrument (RAI) is the Utilization Guidelines. Utilization Guidelines are used to evaluate the problem and determine the course for the care plan.
Under the OBRA regulations, individual resident assessments must be done on admission, quarterly and annually. The assessments must be continued as long as the individual is at the facility.
Lastly, below you will find relevant websites for the following information: