Specification of a State RAI

4145.4 - Specification of a State RAI (Rev. 1, 05-21-04) The State must specify an RAI for use in long term care facilities that participate in Medicare and/or Medicaid. The State must either specify: • The RAI designated by CMS, which is comprised of the MDS with common definitions, the utilization guidelines, including CMS’ RAPs, triggers and a documentation format (see Appendix R), and quarterly review items; or • An alternate instrument for use in the State. An alternate instrument must be approved by CMS prior to the State specifying it to facilities. To receive approval, an alternate instrument must contain: a. The Utilization Guidelines for Completion of the RAI - See Appendix R, Part I. b. The MDS - See Appendix R, Part II. All data elements and corresponding coding categories specified in the MDS must be contained in the State’s instrument. A State agency may not alter the MDS definitions or the coding categories used with each MDS element. The State may not rearrange the sequence of core MDS items or introduce new items within the core set of MDS items specified by CMS. ● The State agency may add data elements additional to those in the MDS that are needed to meet unique State operational needs. Include these elements at the end of the core MDS in “Section S,” which is designated for State supplemental items. These additional items will be reviewed by CMS to assure there is no conflict with elements included in the MDS. However, CMS will not evaluate the merits of those elements. Under the SNF Prospective Payment System (PPS) requirement, for residents in a Medicare part A covered stay, Section T must be completed with each MDS that is required for payment purposes. In addition, States may specify MDS sections T and/or U as part of the State-specified RAI. ● Discharge Tracking - Includes section AA Items 1 - 9, (but only the three discharge codes from Item 8, Reasons for Assessment), Items AB1 - 2, A6, and R3 - 4. This form is completed when a resident dies or leaves the facility and is actually admitted to another health care facility, regardless of whether the long-term care facility formally discharges the resident. (Refer to Appendix R for additional detail regarding the Discharge Tracking form and its use.) ● Reentry Tracking - This form contains Section AA Items 1 - 9, (but only one Reentry code from Item 8, Reasons for Assessment), and Items A4 and 6. This form is completed whenever a resident reenters the nursing home following temporary admission to a hospital or other health care setting, even if the resident’s clinical record was not formally closed, and regardless of whether the resident was formally discharged from the facility. (Refer to Appendix R for additional detail regarding the Reentry Tracking form and its use.) c. Utilization Guidelines Pertaining to the RAPs – At a minimum, State’s RAI must include CMS’ RAPs. As CMS develops new RAPs or revises RAP triggers or guidelines, a State agency must develop comparable changes. To develop a new RAP, provide the following documentation to CMS when requesting approval to add the RAP to the State-specified RAI: • Assessment triggers, based on MDS elements or other information requirements that screen which residents are subject to additional assessment; • Guidelines, which provide a framework for additional assessment or structured investigation of issues to facilitate clinical decision-making for care planning; and • Supporting documentation for clinical validation of RAP content (e.g., literature citations, expert consensus, research studies, results of field testing). • States wishing to pursue RAP development are encouraged to seek consultation and assistance from CMS during the planning phase. Additionally, States are encouraged to volunteer to participate in CMS-sponsored RAP development/revision activities. d. RAP Summary Form - Information from Section V of the MDS is documented on the RAP Summary Form. Each State’s RAI must include CMS’ RAP Summary Form or another standardized format for documentation of the RAP assessment. States may request approval of an alternate format for inclusion in the State RAI which: • Identifies the location of information derived from RAPs about the resident’s status in the triggered area. As appropriate for the resident, information may include the nature of problems, complications and risk factors, the need for referral to appropriate health professionals, and the reasons for deciding to proceed or not to proceed with care planning specific to the triggered problems; • Provides a means for collecting data on triggered RAPs and care plan decisions; and • Provides a method for staff to certify the accuracy and completeness of the RAP assessment (i.e., signature and date). e. Quarterly Review – States must specify a Quarterly assessment form, for use by facilities that include at least the items on the CMS-designated form (See Section R). The Quarterly assessment form contains the mandated subset of MDS items from Section A (Identification and Background Information) through Section R (Assessment Information) that serve as the minimum requirement within each State’s RAI. Some States have mandated an expanded Optional Quarterly assessment form. The CMS has published two optional versions that States may require. A State may also require a full assessment on a quarterly basis. Contract your state RAI coordinator for State specifics. States have the following options for the Quarterly Assessment: ● Minimum Required MDS Quarterly Assessment; ● MDS Quarterly Assessment Form Optional Version for RIG-III; ● Full MDS Assessment; ● Medicare Prospective Payment Assessment Form (MPAF). The State may require facilities to use the full MDS or may add MDS elements to the quarterly review but may not omit or reorder any elements in CMS’ designated form. States may add items to their quarterly review form in one of two ways: ● Items that are part of CMS’ MDS should be added within the same area of the quarterly review form that it falls on the full MDS (e.g., the State would add item H4, Change in Urinary Continence, after item H3 on the quarterly review form); or ● Items that are part of the State supplement (i.e., MDS Section S) should be added at the end of the State quarterly review form.