Changes to the December 2002 Rai Manual, Version 2
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CMS’s RAI Version Manual 2.0 June 2005 Revision Table CH. Sect. Pg. June 2005 Revision CH 1 1.11 1-16 NEWLY CERTIFIED NURSING HOMES FACILITIES Correction Nursing homes facilities must admit residents and operate in compliance with certification requirements before a survey can be conducted. The OBRA assessments are a condition of participation and should be performed as if the beds were already certified. Then, assuming a survey where the SNF has been determined to be in substantial compliance, the facility will be certified effective on the last day of the survey. If the facility completed the Admission assessment prior to the certification date, there is no need to do another Admission assessment. The facility simply continues the OBRA schedule using the actual admission date as Day 1. NOTE: Even in situations where the facility’s certification date is delayed due to the need for a resurvey, the facility must continue performing OBRA assessments according to the original schedule. CH 1 1.11 1-16 CHANGE IN OWNERSHIP Page change schedule for existing residents continues, and the facility continues to use the existing provider number. For example, if the Admission assessment was done 10 days prior to the change in [This text moved to page 1-16] CH 1 1.11 1-17 ADD: There are situations where the new owner does not assume the assets and liabilities of the previous owner. In Clarify these cases, the beds are no longer certified. Also, there are Change of no links to the prior provider, including sanctions, Ownership deficiencies, resident assessments, Quality Indicators, Quality Measures debts, etc. Compliance with OBRA regulations, including the MDS requirements, is expected at the time of survey for certification of the facility with a new owner. See page 1-16 for information regarding newly certified facilities. CH 1 1.11 1-17 Transfers of Residents DELETE: In instances where there has been a massive Clarify transfer of new residents to a nursing facility secondary to natural natural disasters (flood, earthquakes, fire), a new MDS must disaster be completed by the admitting facility. The admitting facility should try to complete the MDS within 14 days of transfer if at all possible. If the admitting facility is having problems meeting the requirement they should contact their State agency to discuss the situation and receive guidance about any extensions in the 14-day time factor. 1 CMS’s RAI Version Manual 2.0 June 2005 Revision Table ADD: When there has been a transfer of residents secondary to disasters (flood, earthquake, fire) with an anticipated return to the facility, the evacuating facility should contact their Regional Office, State agency, and Fiscal Intermediary for guidance. When the originating facility determines that the resident will not return to the evacuating facility, the provider will discharge the resident. The receiving facility will then admit the resident and the MDS cycle will begin as of the admission date. For questions related to this type of situation, providers should contact their State agency and their Regional Office. CH 1 1.18 1-27 DELETE: A hard copy of all MDS forms within the last 15 months, including the signatures of the facility staff attesting Clarify to the accuracy and completion of the records, must be electronic maintained in the resident’s clinical record. This applies to all signature nursing facilities. Until such time as CMS adopts an electronic signature standard that is compatible with pending Health Insurance Standards Accountability Act (HIPAA) requirements for electronic signature, all facilities are required to sign and retain hard copies of the MDS. We understand that the industry is eager to use electronic signatures, and we are just as eager to enable that capability. We plan to implement this as soon as CMS adopts an electronic signature standard, and the standard system is upgraded to enable compliance. There is no requirement to maintain two copies of the form in the resident’s record (the hand-written and computer- generated MDS). Either a hand written or a computer- generated form is equally acceptable. It is required that the record be completed, signed, and dated within the regulatory time frames, and maintained for 15 months in the resident’s active record. If changes are made after completion, those changes must be made to the MDS record, and indicated on the form using standard medical records procedure. It may also be appropriate to update the resident’s care plan, based on the revised assessment record. Resident assessment forms must accurately reflect the resident’s status, and agree with the record that is submitted to the CMS standard system at the state. Please see Chapter 5 for detailed instructions on correcting MDS data. 2 CMS’s RAI Version Manual 2.0 June 2005 Revision Table Facilities are required to maintain 15 months of assessment data in the resident’s active clinical record according to CMS policy. This includes all MDS forms, RAP Summary forms and Quarterly assessments as required during the previous 15- month period. After the 15-month period, RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested by clinical staff or State agency surveyors. The exception is that face sheet information (Section AB, AC, and AD) must be maintained in the active record until the resident is permanently discharged. The information must be kept in a centralized location, accessible to all professional staff members (including consultants) who need to review the information in order to provide care to the resident. The 15-month period for maintaining assessment data does not restart with each readmission to the facility. In some cases when a resident is out of the facility for a short period (i.e., hospitalization), the facility must close the record because of State bed hold policies. When the resident then returns to the facility and is “readmitted,” the facility must open a new record. The facility may copy the previous RAI and transfer a copy to the new record. In this case, the facility should also copy the previous 15 months of assessment data and place it on the new record. Facilities may develop their own specific policies regarding how to handle readmissions, but the 15-month requirement for maintenance of the RAI data does not restart with each new admission. ADD: Nursing homes may use electronic signatures for clinical record documentation, including the MDS, when permitted to do so by state and local law and when authorized by the long-term care facility’s policy. Facilities must have written policies in place to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to which the electronic signature belongs. While use of electronic signatures for the MDS does not require that the entire clinical record be maintained electronically, the guidance language for Clinical Records found in Appendix PP [42 CFR 483.75(1)(1)] notes that facilities have the option for an individual’s record to be maintained by computer rather than hard copy. In addition, proper security measures must be implemented via facility 3 CMS’s RAI Version Manual 2.0 June 2005 Revision Table policy to ensure the privacy and integrity of the record and to ensure that access to clinical records is made available to surveyors and others who are authorized by law. Long-term care facilities that are not capable of maintaining MDSs electronically must adhere to the current requirements that either a hand written copy or a computer-generated form must be maintained in the clinical record. All state licensure and state practice regulations continue to apply to certified long-term care facilities. Where state law is more restrictive than federal requirements, the provider needs to apply the state law standard. In the future, long-term care facilities may be required to conform to a CMS electronic signature standard should CMS adopt one. Unless the provider has exercised the option to maintain electronic MDSs, facilities are required to maintain hard copies of 15 months of assessment data in the resident’s active clinical record according to CMS policy. There is no requirement to maintain two copies of the form in the resident’s record (the hand-written and computer-generated MDS). Either a hand written or a computer-generated form is equally acceptable. This includes all MDS forms, RAP Summary forms and Quarterly assessments as required during the previous 15-month period. After the 15-month period, RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested by clinical staff or State agency surveyors. The exception is that face sheet information (Section AB,AC, and AD) must be maintained in the active record until the resident is permanently discharged. The information must be kept in a centralized location, accessible to all professional staff members (including consultants) who need to review the information in order to provide care to the resident. CH 1 1.18 1-28 ADD: The 15-month period for maintaining assessment data does not restart with each readmission to the facility. In some Clarify cases when a resident is out of the facility for a short period electronic (i.e., hospitalization), the facility must close the record signature & because of State bed hold policies. When the resident then move from returns to the facility and is “readmitted,” the facility must page 1-27 to open a new record. The facility may copy the previous RAI 1-28 and transfer a copy to the new record.