[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: 42CFR483.315]



[Page 551-553]

 

                         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 F_Requirements That Must be Met by States and State Agencies, 

                           Resident Assessment

 

Sec. 483.315  Specification of resident assessment instrument.





    (a) Statutory basis. Sections 1819(e)(5) and 1919(e)(5) of the Act 

require that a State specify the resident assessment instrument (RAI) to 

be used by long term care facilities in the State when conducting 

initial and periodic assessments of each resident's functional capacity, 

in accordance with Sec. 483.20.

    (b) State options in specifying an RAI. The RAI that the State 

specifies must be one of the following:

    (1) The instrument designated by CMS.

    (2) An alternate instrument specified by the State and approved by 

CMS, using the criteria specified in the State Operations Manual issued 

by CMS (CMS Pub. 7) which is available for purchase through the National 

Technical Information Service, 5285 Port Royal Rd., Springfield, VA 

22151.

    (c) State requirements in specifying an RAI.

    (1) Within 30 days after CMS notifies the State of the CMS-

designated RAI or changes to it, the State must do one of the following:

    (i) Specify the CMS-designated RAI.

    (ii) Notify CMS of its intent to specify an alternate instrument.

    (2) Within 60 days after receiving CMS approval of an alternate RAI, 

the State must specify the RAI for use by all long term care facilities 

participating in the Medicare and Medicaid programs.

    (3) After specifying an instrument, the State must provide periodic 

educational programs for facility staff to assist with implementation of 

the RAI.

    (4) A State must audit implementation of the RAI through the survey 

process.



[[Page 552]]



    (5) A State must obtain approval from CMS before making any 

modifications to its RAI.

    (6) A State must adopt revisions to the RAI that are specified by 

CMS.

    (d) CMS-designated RAI. The CMS-designated RAI is published in the 

State Operations Manual issued by CMS (CMS Pub. 7), as updated 

periodically, and consists of the following:

    (1) The minimum data set (MDS) and common definitions.

    (2) The resident assessment protocols (RAPs) and triggers that are 

necessary to accurately assess residents, established by CMS.

    (3) The quarterly review, based on a subset of the MDS specified by 

CMS.

    (4) The requirements for use of the RAI that appear at Sec. 483.20.

    (e) Minimum data set (MDS). The MDS includes assessment in the 

following areas:

    (1) Identification and demographic information, which includes 

information to identify the resident and facility, the resident's 

residential history, education, the reason for the assessment, 

guardianship status and information regarding advance directives, and 

information regarding mental health history.

    (2) Customary routine, which includes the resident's lifestyle prior 

to admission to the facility.

    (3) Cognitive patterns, which include memory, decision making, 

consciousness, behavioral measures of delirium, and stability of 

condition.

    (4) Communication, which includes scales for measuring hearing and 

communication skills, information on how the resident expresses himself 

or herself, and stability of communicative ability.

    (5) Vision pattern, which includes a scale for measuring vision and 

vision problems.

    (6) Mood and behavior patterns, which include scales for measuring 

behavioral indicators and symptoms, and stability of condition.

    (7) Psychosocial well-being, which includes the resident's 

interpersonal relationships and adjustment factors.

    (8) Physical functioning and structural problems, which contains 

scales for measuring activities of daily living, mobility, potential for 

improvement, and stability of functioning.

    (9) Continence, which includes assessment scales for bowel and 

bladder incontinence, continence patterns, interventions, and stability 

of continence status.

    (10) Disease diagnoses and health conditions, which includes active 

medical diagnoses, physical problems, pain assessment, and stability of 

condition.

    (11) Dental and nutritional status, which includes information on 

height and weight, nutritional problems and accommodations, oral care 

and problems, and measure of nutritional intake.

    (12) Skin condition, which includes current and historical 

assessment of skin problems, treatments, and information regarding foot 

care.

    (13) Activity pursuit, which gathers information on the resident's 

activity preferences and the amount of time spent participating in 

activities.

    (14) Medications, which contains information on the types and 

numbers of medications the resident receives.

    (15) Special treatments and procedures, which includes measurements 

of therapies, assessment of rehabilitation/restorative care, special 

programs and interventions, and information on hospital visits and 

physician involvement.

    (16) Discharge potential, which assesses the possibility of 

discharging the resident and discharge status.

    (17) Documentation of summary information regarding the additional 

assessment performed through the resident assessment protocols.

    (18) Documentation of participation in assessment.

    (f) Resident assessment protocols (RAPs). At a minimum, the RAPs 

address the following domains:

    (1) Delirium.

    (2) Cognitive loss.

    (3) Visual function.

    (4) Communication.

    (5) ADL functional/rehabilitation potential.

    (6) Urinary incontinence and indwelling catheter.

    (7) Psychosocial well-being.

    (8) Mood state.

    (9) Behavioral symptoms.

    (10) Activities.

    (11) Falls.



[[Page 553]]



    (12) Nutritional status.

    (13) Feeding tubes.

    (14) Dehydration/fluid maintenance.

    (15) Dental care.

    (16) Pressure ulcers.

    (17) Psychotropic drug use.

    (18) Physical restraints.

    (g) Criteria for CMS approval of alternate instrument. To receive 

CMS approval, a State's alternate instrument must use the standardized 

format, organization, item labels and definitions, and instructions 

specified by CMS in the latest issuance of the State Operations Manual 

issued by CMS (CMS Pub. 7).

    (h) State MDS collection and data base requirements. (1) As part of 

facility survey responsibilities, the State must establish and maintain 

an MDS Database, and must do the following:

    (i) Use a system to collect, store, and analyze data that is 

developed or approved by CMS.

    (ii) Obtain CMS approval before modifying any parts of the CMS 

standard system other than those listed in paragraph (h)(2) of this 

section (which may not be modified).

    (iii) Specify to a facility the method of transmission of data to 

the State, and instruct the facility on this method.

    (iv) Upon receipt of data from a facility, edit the data, as 

specified by CMS, and ensure that a facility resolves errors.

    (v) At least monthly, transmit to CMS all edited MDS records 

received during that period, according to formats specified by CMS, and 

correct and retransmit rejected data as needed.

    (vi) Analyze data and generate reports, as specified by CMS.

    (2) The State may not modify any aspect of the standard system that 

pertains to the following:

    (i) Standard approvable RAI criteria specified in the State 

Operations Manual issued by CMS (CMS Pub. 7) (MDS item labels and 

definitions, RAPs and utilization guidelines).

    (ii) Standardized record formats and validation edits specified in 

the State Operations Manual issued by CMS (CMS Pub. 7).

    (iii) Standard facility encoding and transmission methods specified 

in the State Operations Manual issued by CMS (CMS Pub. 7).

    (i) State identification of agency that collects RAI data. The State 

must identify the component agency that collects RAI data, and ensure 

that this agency restricts access to the data except for the following:

    (1) Reports that contain no resident-identifiable data.

    (2) Transmission of data and reports to CMS.

    (3) Transmission of data and reports to the State agency that 

conducts surveys to ensure compliance with Medicare and Medicaid 

participation requirements, for purposes related to this function.

    (4) Transmission of data and reports to the State Medicaid agency 

for purposes directly related to the administration of the State 

Medicaid plan.

    (5) Transmission of data and reports to other entities only when 

authorized as a routine use by CMS.

    (j) Resident-identifiable data. (1) The State may not release 

information that is resident-identifiable to the public.

    (2) The State may not release RAI data that is resident-identifiable 

except in accordance with a written agreement under which the recipient 

agrees to be bound by the restrictions described in paragraph (i) of 

this section.



[62 FR 67212, Dec. 23, 1997]