CMS Aligns RAI Manual v1.15 with the Mega Rule

By Caralyn Davis, Staff Writer - September 06, 2017

Directors of nursing services (DNSs) sometimes think that the MDS and the Resident Assessment Instrument (RAI) process don’t need to be on their radar. However, the initial resident pool that surveyors will review in the new survey process effective Nov. 28, 2017, to determine the final sample for in-depth investigations will be 70 percent preselected offsite from MDS data, according to the New Long-term Care Survey Process—Slide Deck and Speaker Notes released by the Centers for Medicare & Medicaid Services (CMS) earlier this year. Since surveyors will have the ability to replace a resident selected offsite with a resident they identified onsite, testing showed that the offsite/onsite split of the final sample tends to be about 50/50. But whether it’s 50 percent or the full 70 percent, the MDS will play a starring role in residents chosen for investigation during survey going forward.

So DNSs shouldn’t be surprised that many of the updates to v1.15 of the Centers for Medicare & Medicaid Services’ Long-Term Care Facility Resident Assessment Instrument User’s Manual, which goes into effect Oct. 1, 2017, support CMS’ focus on person-centered care and better align the MDS with the Reform of Requirements for Long-term Care Facilities (aka the Mega-Rule) and the advance copy of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual.

This RAI Manual update includes 21 change tables detailing what’s been added to and deleted from the manual. Five change tables include what amount to housekeeping, e.g., changing internal references to other RAI Manual sections or external references to sections in the Code of Federal Regulations. The other 16 change tables include substantive changes that should be reviewed in full by nurse assessment coordinators and other interdisciplinary team (IDT) members involved in the RAI process. (See the breakdown, below.)

21 change tables decoded

Housekeeping updates

· Title page;

· Table of contents;

· Chapter 1

· Chapter 6

· Appendix C


Changes to read in their entirety:


· Chapter 2

· Chapter 3: Intro

· Chapter 3: Section A

· Chapter 3: Section G

· Chapter 3: Section GG

· Chapter 3: Section H

· Chapter 3: Section I

· Chapter 3: Section J

· Chapter 3: Section L

· Chapter 3: Section M

· Chapter 3: Section N

· Chapter 3: Section O

· Chapter 3: Section P

· Chapter 3: Section Q

· Chapter 4

· Appendix A


Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA, and Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, president/CEO of Celtic Consulting in Torrington, CT, recommend DNSs keep a particular eye on the following changes in Chapter 3, “Overview to the Item-by-Item Guide to the MDS 3.0”:

Section I

CMS has simplified the coding criteria for I2300 (Urinary Tract Infection (UTI) (Last 30 Days)). Effective Oct. 1, UTI should be coded only if both of the following criteria are met in the last 30 days:

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


2.      A physician-documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days. (pages I-8 – I-9)

Many facilities currently use some evidence-based tool to determine whether a resident has a UTI, notes McCarthy. However, the RAI Manual (page I-9) makes clear that providers must use a tool that is linked to their Infection Prevention and Control Program:

·         In accordance with requirements at §483.80(a) Infection Prevention and Control Program, 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. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident.

·         Example: if a facility chooses to use the Surveillance Definitions of Infections (updated McGeer criteria) as part of the facility’s Infection Prevention and Control Program, then the facility should also use the same criteria to determine whether or not a resident has a UTI.

At face value, cutting out signs or symptoms attributable to UTI and significant laboratory findings as part of the coding criteria would indicate the potential for increased reporting of UTIs, says McCarthy. However, it’s important to note that the resident would still need to have whatever signs/symptoms or laboratory findings that are required under the evidence-based criteria chosen for use by the facility.

On the survey side, the Infection Prevention, Control & Immunizations Facility Task Pathway (form CMS 20054) and the Urinary Catheter or Urinary Tract Infection Critical Element (CE) Pathway (form CMS 20068), as well as the interpretive guidance in F880 (Infection Prevention & Control) and F881 (Antibiotic Stewardship Program) in Appendix PP, tie in the evidence-based criteria requirements for UTI. Note: Access all pathways here.

Section N

Section N (Medications) includes several new items that correlate to issues that surveyors will review as appropriate for the final survey sample via two CE Pathways during the new survey process: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway (form CMS-20082) and/or Pain Recognition and Management Critical Element Pathway (form CMS–20076).

The new MDS items are as follows:

·         N0410H (Opioid Medications Received); and

·         N0450 (Antipsychotic Medication Review):

o   N0450A (Did the Resident Receive Antipsychotic Medications Since Admission/Entry or Re-entry or the Prior OBRA Assessment, Whichever Is More Recent?);

o   N0540B (Has a Gradual Dose Reduction (GDR) Been Attempted?);

o   N0450C (Date of Last Attempted GDR);

o   N0450D (Physician Documented GDR as Clinically Contraindicated); and

o   N0450E (Date Physician Documented GDR as Clinically Contraindicated).

For N0410H, “now that we are reporting the use of opioids for the seven-day look-back period, this classification of meds will likely be monitored more closely,” notes McCarthy. Indeed, both CE Pathways CMS-20082 and CMS-20076 address opioid use. For example, the Pain Recognition and Management CE Pathway includes the following questions under Nurse, DON, Hospice Nurse, Attending Practitioner, Pharmacist, Medical Director Interviews and Record Review, respectively:

·         How do you monitor for the emergence or presence of adverse events related to opioid medications or the consequences of interventions?

·         What indicators and characteristics of the resident’s pain, including causes and contributing factors related to pain, have been identified, and addressed in the care plan?

Similarly, the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review CE Pathway instructs surveyors to determine, for “all medications currently ordered or discontinued going back to the most recent signed recapitulation,” whether the facility demonstrates monitoring for opioids (“assess pain, implement bowel program”) as appropriate due to the high risk for adverse consequences.

These probes all link directly to the new RAI Manual instruction under Coding Tips and Special Populations for N0410 (Medications Received):

Opioid medications can be an effective intervention in a resident’s pain management plan, but also carry risks such as overuse and constipation. A thorough assessment and root-cause analysis of the resident’s pain should be conducted prior to initiation of an opioid medication and re-evaluation of the resident’s pain, side effects, and medication use and plan should be ongoing. (page N-10)

For N0450, “these items report whether residents who have received any antipsychotic medications have had a gradual dose reduction (GDR),” points out Maher. “If a GDR has been attempted, the assessor must enter the date of the latest GDR. If the physician/nonphysician practitioner has documented that GDR was not clinically appropriate, the assessor must enter the date the physician/NPP documented in the clinical record the determination that the GDR was not clinically indicated.”

While the steps for assessment and coding instructions (pages N-12 – N13) are relatively straightforward, the IDT should pay special attention to the Coding Tips and Special Populations section for N0450 (page N-13):

·         Any medication that has a pharmacological classification or therapeutic category as an antipsychotic medication must be recorded in this section, regardless of why the medication is being used.

·         In this section, the term physician also includes physician assistant, nurse practitioner, or clinical nurse specialist.

·         Do not include Gradual Dose Reductions that occurred prior to admission to the facility (e.g., GDRs attempted during the resident’s acute care stay prior to admission to the facility).

·         Physician documentation indicating dose reduction attempts are clinically contraindicated must include the clinical rationale for why an attempted dose reduction is inadvisable. This decision should be based on the fact that tapering of the medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the resident’s function, well-being, safety, and quality of life.

·         Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless physician documentation is present in the medical record indicating a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated.

·         Do not count an antipsychotic medication taper performed for the purpose of switching the resident from one antipsychotic medication to another as a GDR in this section.

·         In cases where a resident is or was receiving multiple antipsychotic medications on a routine basis, and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C, Date of last attempted GDR.

·         If multiple dose reductions have been attempted since admission/entry or reentry or the prior OBRA assessment, record the date of the most recent reduction attempt in N0450C, Date of last attempted GDR.

·         Federal requirements regarding GDRs are found at 42 CFR §483.45(d) Unnecessary drugs and 483.45(e) Psychotropic drugs.

The GDR timing requirements noted in this section link to the GDR probe in the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review CE Pathway, which instructs surveyors to ensure the facility does the following:

ü  Demonstrates a system for and documents gradual dose reduction (GDR) for psychotropic medications, unless contraindicated.

·         Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication:

o   GDR attempts in two separate quarters with at least one month between the attempts.

o   The GDR must be attempted annually thereafter unless clinically contraindicated.

o   Non-pharmacological approaches must be attempted and documented instead of using psychotropic medications, along with use of psychotropic medications, and while GDR is attempted.

“With the implementation of N0450, facilities will need to start thinking about systems for tracking their GDRs,” suggests McCarthy. “Beginning Oct. 1, these dates will need to be reported in the MDS, so to avoid slowdowns, it’s probably a good idea to collect those dates before Sept. 30.”

Section P

New item P0200 (Alarms) includes the following subitems:

·         P0200A (Bed Alarm);

·         P0200B (Chair Alarm);

·         P0200C (Floor Mat Alarm);

·         P0200D (Motion Sensor Alarm);

·         P0200E (Wander/Elopement Alarm); and

·         P0200F (Other Alarm).

The RAI Manual (page P-8) defines an alarm as “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.”

“The instructions (pages P-8 – P-11) tell us to code any position change alarms (audible or inaudible) used during the seven-day look-back period in P0200, but goes further by instructing the assessor to determine whether those position change alarms are being used as restraints,” stresses Maher. “The RAI Manual instructs us that if an alarm meets the criteria as a restraint, we should code the alarm use in both P0100 (Physical Restraints) and P0200 (Alarms.)”

Accurately capturing position change alarms in P0200 and P0100 (as appropriate) is critical because position change alarms come under significant scrutiny in the new survey process. The new interpretive guidance in Appendix PP discusses position change alarms both in the context of accidents (F689) and physical restraints (F604). As a result, they are incorporated into investigations via the following survey tools:

·         Physical Restraints Critical Element Pathway (Form CMS-20077);

·         Accidents Critical Element Pathway (form CMS-20127); and

·         Sufficient and Competent Nurse Staffing Review (form CMS-20062)

Section Q

CMS revised the Intent statement (page Q-1) for Section Q (Participation in Assessment and Goal Planning) to clarify that having “the opportunity to learn about home- and community-based services and to receive long term care in the least restrictive setting possible” is “a civil right for all residents.” The agency then updated the coding instructions for individual items in Section Q to further address resident rights, including the following revised instructions:

Q0300 (Resident’s Overall Expectation): This item is individualized and resident-driven rather than what the nursing home staff judge to be in the best interest of the resident. This item focuses on exploring the resident’s expectations, not whether or not the staff considers them to be realistic. Coding other than the resident’s stated expectation is a violation of the resident’s civil rights. (page Q-5)

Q0400 (Discharge Plan): Important progress has been made so that individuals have more choices, care options, and available supports to meet care preferences and needs in the least restrictive setting possible. This progress resulted from the 1999 U.S. Supreme Court decision in Olmstead v. L.C., which states that residents needing long term services and supports have a civil right to receive services in the least restrictive and most integrated setting appropriate to their needs. … Should a planned relocation not occur, it might create stress and disappointment for the resident and family that will require support and nursing home care planning interventions. However, a referral should not be avoided based upon facility staff judgment of potential discharge success or failure. It is the resident’s right to be provided information if requested and to receive care in the most integrated setting. (pages Q-9 and Q-10)

Q0490 (Resident’s Preference to Avoid Being Asked Question Q0500B): Note: Let the resident know that they can change their mind about requesting information regarding possible return to the community at any time and should be referred to the LCA if they voice this request, regardless of schedule of MDS assessment(s). (page Q-12)

Q0500 (Return to Community): This item identifies the resident’s desire to speak with someone about returning to community living. Based on the Americans with Disabilities Act and the 1999 U.S. Supreme Court decision in Olmstead v. L.C., residents needing long-term care services have a civil right to receive services in the least restrictive and most integrated setting. Steps for Assessment: … 5. Ask the resident if he or she wants information about different kinds of supports that may be available for community living. Responding yes will be a way for the individual—and his or her family, significant other, or guardian or legally authorized representative—to obtain additional information about services and supports that would be available to support community living. It is simply a request for information, not a request for discharge. (page Q-14 and Q-15)

On the survey side, this ties into the Discharge Critical Element Pathway (form CMS-

 20132), as well as the interpretive guidance in F660 (Discharge Planning Process) in Appendix PP.

Note: Stay tuned for more highlights from the RAI Manual update.


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