MDS – Flashcard

The minimum data set Care Area Assessment Process and RAI utilization Guidelines.

A core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid.

This process is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once they care area has been triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether or not to care plan for it.

The utilization guidelines provide instructions for when how to use the RAI. These include instructions for completion of the R a I as well as structured frameworks for synthesizing MDS and other clinic information.

Primary purpose is an assessment tool to identify resident care problems that are addressed in an individualized care plan, data collected from MDS assessment is also used for the skilled nursing facility prospective payment system Medicare reimbursement system, many state Medicaid reimbursement system, and monitoring the quality of care provided to nursing home residents.

These requirements for the RAI are applicable to all residents in Medicare and or Medicaid certified long term care facilities and must be completed for any resident residing in the facility including all residents of Medicare or Medicaid, hospice residence, short-term or respite care residence with stay of more than 14 days on the unit, special population residence, and swing bed facility resident.

If more than 14 days an OBRA admission assessment is not required however a discharge assessment is required

The 15 month period for maintaining assessment data may not restart with each readmission to the facility

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, state agency surveyors, CMS, or others authorized by law.

Refers to the last day of the observation or Lookback period that the assessment covers for the residents. Since a day begins at 12:00 AM and ends at 11:59 PM, the ARD must also cover this time period. the facility is required to set the ARD on the MDS item set or in the facility software within the required time frame of the assessment type being completed.

OBRA required comprehensive assessment ecru the completion of both the MDS and CAA process as well as care planning