Resident Assessment Protocol, Care Area Assessment


Instead of Resident Assessment Protocols, MDS 3.0 will be using Care Area Assessments for more in-depth assessment. There are some similarities and some differences between RAPs and CAAs.

The Centers for Medicare & Medicaid Services (CMS) believes that the new MDS 3.0 will introduce advances in assessment measures, increase the clinical relevance of the assessment items, improve accuracy and validity, increase resident voice, and increase user satisfaction. MDS 2.0 used Resident Assessment Protocols (RAPs) for more comprehensive assessment of triggered areas. Instead of RAPs, MDS 3.0 will be using Care Area Assessments (CAAs) for more in-depth assessment. There are some similarities and some differences between RAPs and CAAs.

According to CMS, “The purpose of the Care Area Triggers and Care Area Assessments is development of a resident-specific care plan based on identified problems, needs, and strengths.” Since the MDS is a preliminary screening tool and not a comprehensive assessment, the CAAs provide for a more comprehensive assessment process. The goal of the comprehensive assessment is to promote the highest practicable level of functioning for the resident through an assessment of triggered care areas on the MDS. After these areas are triggered, a further assessment will allow an understanding of the causes and contributing factors and determine if there is a problem in each of these areas.

When completed, the MDS 3.0 Section V: Care Area Assessment (CAA) Summary lists which care areas were triggered and if further assessment determined the need for care planning. How is the assessment process in MDS 3.0 different from that in MDS 2.0? The following comparison can be made:

MDS 2.0

  • MDS screens for possible problems in 18 care areas.

  • Triggers alert to possible issues in the care needs.

  • Triggered care area must be thoroughly assessed.

  • RAPS must be the tool used for conducting the assessment.

  • Documentation must meet criteria.

MDS 3.0

  • MDS screens for possible problems in 20 care areas.

  • Care Area Triggers (CATs) alert to possible issues in the care needs.

  • Triggered care area must be thoroughly assessed.

  • There is no mandated specific tool for assessment.

  • Documentation must meet criteria.

Major difference

The two new CAAs that are part of MDS 3.0 are “Pain” and “Return to the Community.” The major difference between the old MDS 2.0 process and the MDS 3.0 process is that facilities must now use validated practice standards, not mandated forms, for their further assessment of the Care Area Triggers.

Chapter 4 of the MDS 3.0 Resident Assessment Instrument (RAI) manual provides very specific information on the care areas and the CAA process. The MDS is the starting point in development of the individualized care plan. The information gained after completing the MDS will identify actual or potential areas of concern. These areas become highlighted as Care Area Triggers. The CATs replace the MDS 2.0 triggers and identify potential problems, needs, or strengths. The CATs all come from the resident’s current MDS 3.0 except the two for “Delirium” and “Mood” that look back to the resident’s previous MDS. The CATs provide flags for the interdisciplinary team (IDT) and are the link between data and further assessment.

Depending on which MDS items are triggered by the CAT logic, the care areas needing further attention are determined. As the CAT is the link between the data and the assessment, the CAA is the link between the assessment and care planning. Further investigation will then identify whether these areas of concern are a problem or risk requiring interventions and care planning.

All triggered CAAs must be addressed in Section V but may or may not be addressed in a care plan. CMS states, “The RAI is not intended to provide diagnostic advice, nor is it intended to specify which areas may be related to one another or how those problems relate to underlying causes.” The IDT, along with the resident’s physician, needs to look at the assessment findings and determine these interconnections.

No mandated forms

Although MDS 2.0 demanded that the RAPs be used for this further investigation, there are no mandated forms that must be used for the CAA process in MDS 3.0. The facility is instructed in the RAI Manual, “To identify and use tools that are current and grounded in current clinical standards of practice, such as evidence-based or expert-endorsed research, clinical practice guidelines, and resources.”

Although there are no mandated forms, CMS does supply facilities with CAA Resources in Appendix C. The appendix includes care area specific tools that the assessor can use for each of the 20 care areas. Each tool is between three to five pages long, guides the interdisciplinary decision-making, and provides a place to document the process. The benefit of using the tools in Appendix C is that it gives a comprehensive, reliable assessment that has good rater reliability.

Appendix C also includes a Care Area General Resource list. None of these tools or resources is mandated but according to CMS, “Nursing homes should ensure that whatever assessment and care planning resources are used are current, evidence-based, or expert-endorsed research, and clinical practice guidelines/resources.” The facility should also be able to provide surveyors with the resources that were used in the decision-making process.

Facility protocol

The decision as to who fills out the CAAs depends on facility protocol. Facilities must have input into the CAA process that results in good clinical decision-making. Make sure that further assessment in a particular area is within the scope of training or practice of the discipline filling out the section. If an evaluation which is beyond the assessor’s scope is needed, it must be obtained from the appropriate discipline.

CMS expects the CAA process to be interdisciplinary. The whole team, the resident, and/or the resident’s representative must have input into this process for the assessment to be reliable and valid. The concerns, observations, and suggestions of this entire team must go into the decision-making process. The IDT, the resident, and/or resident’s representative must look at how these findings affect the resident’s function and quality of life and then determine the areas that require care planning. From that point, the determination is made for further tests, consultations, and interventions.


Documentation of the CAA findings can be anywhere in the resident’s record. They can be part of discipline-specific flow sheets, progress notes, care plan summaries, a CAA narrative, etc. The only requirement is that the facility fill out the “Location and Date of CAA Documentation” column on the CAA Summary in Section V of the MDS 3.0. The documentation should show how the IDT came to the conclusion it did. That is: Why an intervention is required and why specific interventions were chosen.

Once the CAA identifies the causal or risk factors, then the care plan is completed. Since the goal of the care plan is to promote the resident’s highest practicable level of functioning, the interventions should work toward improvement where possible and the maintenance/prevention of any avoidable decline. The IDT must work together to make sure that they see the causal relationship between data, cause, and care plan, and that they are all on the same page, working toward the same goals.

Chapter 4 of the MDS 3.0 RAI manual also includes Table 2 which is the “Clinical Problem-Solving and Decision-Making Process Steps and Objectives.” This guide walks the assessor through the key tasks that are needed during each step of the assessment process. After gathering the needed information, a clear issue or problem statement can be made.

Assessors need to remember that an issue is different than a finding. It is the findings that need to be care-planned. CMS does not require that each care area triggered be care-planned separately. Goals and approaches for each problematic area may overlap or may stand alone. The care plan must be driven not only by the issues and conditions that were identified during the assessment process but also by the resident’s strengths, needs, and unique characteristics. The resident and/or representative must be a part of this important process.

CAAs are required for OBRA assessments but not Medicare PPS assessments. However, if a Medicare PPS assessment is combined with an OBRA assessment, the CAAs must be completed.

As stated earlier, the CAA process for MDS 3.0 is not that different from the RAP process of MDS 2.0. Since there are no specific forms required with MDS 3.0, the facility has greater freedom to use a wider range of resources when making CAA decisions. However, if facilities are using resources other than those provided by CMS in Appendix C, they must be able to show the resources that were used in this new decision-making process.

Susan Duda-Gardiner, BSN, RN, LNHA, is a clinical consultant for the Health Care Council of Illinois. Ms. Duda-Gardiner has 25 years experience as a nurse in long-term care, holding positions as DON, ADON, nurse educator, corporate nurse consultant, and director of clinical services. She has worked with the Illinois Department of Healthcare and Family Services on the development of the Medicaid Reimbursement System for Illinois. Ms. Duda-Gardiner has developed clinical protocols and presented seminars throughout the states on abuse prevention, pain management, resident attendant training, wound management, falls, DON training, language assistance, and cultural diversity Long-Term Living 2010 August;59(8):26-29

Topics: Articles , MDS/RAI