[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR483.20]



[Page 517-519]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 483_REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES--Table 

of Contents

 

          Subpart B_Requirements for Long Term Care Facilities

 

Sec. 483.20  Resident assessment.



    The facility must conduct initially and periodically a 

comprehensive, accurate, standardized, reproducible assessment of each 

resident's functional capacity.

    (a) Admission orders. At the time each resident is admitted, the 

facility must have physician orders for the resident's immediate care.

    (b) Comprehensive assessments.

    (1) Resident assessment instrument. A facility must make a 

comprehensive assessment of a resident's needs, using the resident 

assessment instrument (RAI) specified by the State. The assessment must 

include at least the following:

    (i) Identification and demographic information.

    (ii) Customary routine.

    (iii) Cognitive patterns.

    (iv) Communication.

    (v) Vision.

    (vi) Mood and behavior patterns.

    (vii) Psychosocial well-being.

    (viii) Physical functioning and structural problems.

    (ix) Continence.

    (x) Disease diagnoses and health conditions.

    (xi) Dental and nutritional status.

    (xii) Skin condition.

    (xiii) Activity pursuit.

    (xiv) Medications.

    (xv) Special treatments and procedures.

    (xvi) Discharge potential.

    (xvii) Documentation of summary information regarding the additional 

assessment performed through the resident assessment protocols.

    (xviii) Documentation of participation in assessment.

    The assessment process must include direct observation and 

communication with the resident, as well as communication with licensed 

and nonlicensed direct care staff members on all shifts.

    (2) When required. Subject to the timeframes prescribed in Sec. 

413.343(b) of this chapter, a facility must conduct a comprehensive 

assessment of a resident in accordance with the timeframes specified in 

paragraphs (b)(2) (i) through (iii) of this section. The timeframes 

prescribed in Sec. 413.343(b) of this chapter do not apply to CAHs.

    (i) Within 14 calendar days after admission, excluding readmissions 

in which there is no significant change in the resident's physical or 

mental condition. (For purposes of this section, ``readmission'' means a 

return to the facility following a temporary absence for hospitalization 

or for therapeutic leave.)

    (ii) Within 14 calendar days after the facility determines, or 

should have determined, that there has been a significant change in the 

resident's physical or mental condition. (For purposes of this section, 

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 or 

revision of the care plan, or both.)

    (iii) Not less often than once every 12 months.

    (c) Quarterly review assessment. A facility must assess a resident 

using the quarterly review instrument specified



[[Page 518]]



by the State and approved by CMS not less frequently than once every 3 

months.

    (d) Use. 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 plan f care.

    (e) Coordination. A facility must coordinate assessments with the 

preadmission screening and resident review program under Medicaid in 

part 483, subpart C to the maximum extent practicable to avoid 

duplicative testing and effort.

    (f) Automated data processing requirement. (1) Encoding data. Within 

7 days after a facility completes a resident's assessment, a facility 

must encode the following information for each resident in the facility:

    (i) Admission assessment.

    (ii) Annual assessment updates.

    (iii) Significant change in status assessments.

    (iv) Quarterly review assessments.

    (v) A subset of items upon a resident's transfer, reentry, 

discharge, and death.

    (vi) Background (face-sheet) information, if there is no admission 

assessment.

    (2) Transmitting data. Within 7 days after a facility completes a 

resident's assessment, a facility must be capable of transmitting to the 

State information for each resident contained in the MDS in a format 

that conforms to standard record layouts and data dictionaries, and that 

passes standardized edits defined by CMS and the State.

    (3) Monthly transmittal requirements. A facility must electronically 

transmit, at least monthly, encoded, accurate, complete MDS data to the 

State for all assessments conducted during the previous month, including 

the following:

    (i) Admission assessment.

    (ii) Annual assessment.

    (iii) Significant change in status assessment.

    (iv) Significant correction of prior full assessment.

    (v) Significant correction of prior quarterly assessment.

    (vi) Quarterly review.

    (vii) A subset of items upon a resident's transfer, reentry, 

discharge, and death.

    (viii) Background (face-sheet) information, for an initial 

transmission of MDS data on a resident that does not have an admission 

assessment.

    (4) Data format. The facility must transmit data in the format 

specified by CMS or, for a State which has an alternate RAI approved by 

CMS, in the format specified by the State and approved by CMS.

    (5) Resident-identifiable information. (i) A facility may not 

release information that is resident-identifiable to the public.

    (ii) The facility may release information that is resident-

identifiable to an agent only in accordance with a contract under which 

the agent agrees not to use or disclose the information except to the 

extent the facility itself is permitted to do so.

    (g) Accuracy of assessments. The assessment must accurately reflect 

the resident's status.

    (h) Coordination. A registered nurse must conduct or coordinate each 

assessment with the appropriate participation of health professionals.

    (i) Certification. (1) A registered nurse must sign and certify that 

the assessment is completed.

    (2) Each individual who completes a portion of the assessment must 

sign and certify the accuracy of that portion of the assessment.

    (j) Penalty for falsification. (1) 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 

of not more than $5,000 for each assessment.

    (2) Clinical disagreement does not constitute a material and false 

statement.

    (k) Comprehensive care plans. (1) The facility must develop a 

comprehensive care plan for each resident that includes measurable 

objectives and timetables to meet a resident's medical,



[[Page 519]]



nursing, and mental and psychosocial needs that are identified in the 

comprehensive assessment. The care plan must describe the following--

    (i) The services that are to be furnished to attain or maintain the 

resident's highest practicable physical, mental, and psychosocial well-

being as required under Sec. 483.25; and

    (ii) Any services that would otherwise be required under Sec. 

483.25 but are not provided due to the resident's exercise of rights 

under Sec. 483.10, including the right to refuse treatment under Sec. 

483.10(b)(4).

    (2) A comprehensive care plan must be--

    (i) Developed within 7 days after completion of the comprehensive 

assessment;

    (ii) Prepared by an interdisciplinary team, that includes the 

attending physician, a registered nurse with responsibility for the 

resident, and other appropriate staff in disciplines as determined by 

the resident's needs, and, to the extent practicable, the participation 

of the resident, the resident's family or the resident's legal 

representative; and

    (iii) Periodically reviewed and revised by a team of qualified 

persons after each assessment.

    (3) The services provided or arranged by the facility must--

    (i) Meet professional standards of quality; and

    (ii) Be provided by qualified persons in accordance with each 

resident's written plan of care.

    (l) Discharge summary. When the facility anticipates discharge a 

resident must have a discharge summary that includes--

    (1) A recapitulation of the resident's stay;

    (2) A final summary of the resident's status to include items in 

paragraph (b)(2) of this section, at the time of the discharge that is 

available for release to authorized persons and agencies, with the 

consent of the resident or legal representative; and

    (3) A post-discharge plan of care that is developed with the 

participation of the resident and his or her family, which will assist 

the resident to adjust to his or her new living environment.

    (m) Preadmission screening for mentally ill individuals and 

individuals with mental retardation. (1) A nursing facility must not 

admit, on or after January 1, 1989, any new resident with--

    (i) Mental illness as defined in paragraph (f)(2)(i) of this 

section, unless the State mental health authority has determined, based 

on an independent physical and mental evaluation performed by a person 

or entity other than the State mental health authority, prior to 

admission,

    (A) That, because of the physical and mental condition of the 

individual, the individual requires the level of services provided by a 

nursing facility; and

    (B) If the individual requires such level of services, whether the 

individual requires specialized services; or

    (ii) Mental retardation, as defined in paragraph (f)(2)(ii) of this 

section, unless the State mental retardation or developmental disability 

authority has determined prior to admission--

    (A) That, because of the physical and mental condition of the 

individual, the individual requires the level of services provided by a 

nursing facility; and

    (B) If the individual requires such level of services, whether the 

individual requires specialized services for mental retardation.

    (2) Definition. For purposes of this section--

    (i) An individual is considered to have mental illness if the 

individual has a serious mental illness as defined in Sec. 

483.102(b)(1).

    (ii) An individual is considered to be mentally retarded if the 

individual is mentally retarded as defined in Sec. 483.102(b)(3) or is 

a person with a related condition as described in 42 CFR 435.1009.



[56 FR 48871, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992; 

62 FR 67211, Dec. 23, 1997; 63 FR 53307, Oct. 5, 1998; 64 FR 41543, July 

30, 1999; 68 FR 46072, Aug. 4, 2003]