2017 RAI User’s Manual updates: The new survey era

With the MDS driving so much in long-term care—from survey success to reimbursement, from Quality Measures to Nursing Home Compare reports and from Five-Star ratings to the SNF Quality Reporting Program measures—the pressure for MDS accuracy is more intense than ever. The updated RAI User’s Manual, effective October 1, 2017, clearly synchronizes the MDS with the upcoming federal Requirements of Participation and the new survey process, signaling commitment to person-centered, resident-driven care. Here is a review of the updates.

Significant Change of Status

Significant change of status took on new meaning, as CMS added the word major to the definition, stating that a SCSA must be completed “when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline” (p. 2-22). So, when considering whether the resident has had two areas of decline or improvement, be sure to consider “changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment” (p. 2-25) and “a new unstageable pressure ulcer/injury, a new deep tissue injury” (p. 2-26).

Coding Activities of Daily Living

If you thought capturing Section G activities of daily living (ADL) using the Rule of 3 was challenging, there is good news! CMS updated the ADL Self-Performance Rule of 3 Algorithm (p. G-8). It is now easier to follow and should help assessors in an area famously vulnerable to errors.

Another change sure to be a surprise for most MDS nurses is what is coded in G0600C: Mobility Devices. For coding option Wheelchair (manual or electric), clarification was added: “Do not include geri-chairs, reclining chairs with wheels, positioning chairs, scooters, and other types of specialty chairs” (p. G-40).

Capturing Section GG: Usual Performance in Functional Abilities and Goals

CMS clarified this section, which was introduced last October and has raised many concerns among providers. Numerous clarifications, examples, and guidelines elucidate the concepts of admission/discharge functional assessment performance coding, usual performance, helper’s effort and eating (includes food and liquids).

For example, for the timing of the admission assessment:

The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission. If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment.… A provider may need to use the entire 3-day assessment period to obtain the resident’s usual performance. (p. GG-3)

CMS clarified that the discharge functional assessment “must be completed within the last three calendar days of the resident’s Medicare Part A stay, which includes the day of discharge from Medicare Part A and the two days prior to the day of discharge from Medicare Part A.”

One key instruction to note is that when conducting discharge goal planning, be sure to involve the resident and family concerning goals and anticipated length of stay (p. GG-14).

Urinary tract infection redefined

Coding criteria for I2300 (Urinary Tract Infection) were changed and connected to the upcoming changes in the State Operations Manual (§483.80[a] Infection Prevention and Control Program). The item look-back remains 30 days, but specific resources for evidence-based criteria must be used to determine the presence of a UTI; the choice of criteria must involve the medical director, director of nursing, and the Quality Assessment and Assurance lead.

Code only if all both of the following are met in the last 30 days:

1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, National Healthcare Safety Network (NHSN), or Loeb in the last 30 days,

AND

2. A physician documented UTI diagnosis (or by nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.

The link between this change and the SOM requirements is made explicit: “The facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility’s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria” (p. I-9).

Opioids and Antipsychotic GDRs

New items have been added to correlate with the new survey process and regulations, especially with the Critical Element Pathways, which will guide surveyors in assessing compliance with unnecessary/psychotropic medication regulations.

The new MDS items are:

N0410H, Opioid — the number of days the resident received an opioid during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Much information is provided about pain management and the effectiveness/adverse consequences of opioids, and CMS references the upcoming new regulations.

• Also in N0410, melatonin is specified in relation to herbal and alternative medicine; considered a dietary supplement, it is not coded as a hypnotic.

N0450 (Antipsychotic Medication Review)

• N0450A (Did the Resident Receive Antipsychotic Medications Since Admission/Entry or Re-entry or the Prior OBRA Assessment, Whichever Is More Recent)
• N0450B (Has a Gradual Dose Reduction [GDR] Been Attempted)
• N0450C (Date of Last Attempted GDR)
• N0450D (Physician Documented GDR as Clinically Contraindicated)
• N0450E (Date Physician Documented GDR as Clinically Contraindicated)

If the resident received an antipsychotic medication, the assessor must determine (1) whether a gradual dose reduction (GDR) has been attempted and on what date; if not, (2) whether the physician documented that GDR is clinically contraindicated. Time frames for attempted reductions link to the upcoming Requirements of Participation.

Pneumococcal Vaccines

“Up to date” in O0300A, Pneumococcal Vaccine, means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations, referring to the 2017 Adult Immunization Schedule, which addresses both the PCV-13 and PPSV23 (https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf).

Movement alarms

The big news is the addition of personal alarms.

P0200: Alarms. CMS provides this definition of an alarm:

Any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident’s clothing, motion sensors, door alarms, or elopement/wandering devices. (p. P-8)

CMS notes that alarms have not been proven effective in preventing falls, adding that alarms neither eliminate the need for supervision nor replace individualized, person-centered care planning.

At times, an alarm may meet the definition of a restraint. The assessor must:

Evaluate whether the alarm affects the resident’s freedom of movement when the alarm/device is in place. For example, does the resident avoid standing up or repositioning himself/herself due to fear of setting off the alarm? [p. P-9] . . . If an alarm meets the criteria as a restraint, code the alarm use in both P0100, Physical Restraints, and P0200, Alarms. (p. P-10)

Resident choice in housing

CMS clarified that the choice to explore a home-based or community-based setting must be driven by the resident rather than the facility staff. Coding other than the resident’s stated expectation is a violation of the resident’s civil rights.

Summary

Understanding the 2017 RAI updates will help improve MDS accuracy and compliance with the new regulations taking effect in November. Long-term care providers face challenges but, as always, will figure it out, and our residents will be better for it.

Jane Belt, RN, MS, RAC-MT, RAC-CT, QCP, is a Curriculum Development Specialist at the American Association of Nurse Assessment Coordination.