Resident Assessment Instrument (RAI)

Resident Assessment and Care Plan 

Standard 
This facility is committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life. Recognizing each resident as an individual, we identify and meet those needs in a resident-centered environment. To this end, assessments and care plans are oriented toward preventing avoidable decline in clinical and functional levels, and reflect resident preferences and the right to refuse certain services or treatments. 

Policy 
It is the policy of this facility to conduct comprehensive assessments as required by the Federal Government for all residents in a Medicare/Medicaid-certified facility, as well as any other assessments that are clinically warranted. The assessment process begins with a pre-admission screening to include significant information relevant to care and services provided prior to admission. 

Procedure 

Comprehensive Assessment: 

1. Initial and Ongoing Assessments: 

• Comprehensive assessments are mandated to be performed on admission, annually, and/or with a significant change in status or significant correction of a prior full assessment. 

• Quarterly assessments are also mandated by the Federal Government. 

2. Components of Comprehensive Assessment: 

• Data concerning the resident obtained from the physician. 

• Clinical records such as the hospital discharge summary. 

• Assessments done by professional and other disciplines. 

• The resident and/or family goals for treatment. 

3. Resident Assessment Instrument (RAI): 

• The comprehensive assessment is the Resident Assessment Instrument (RAI), which consists of the Minimum Data Set (MDS), Triggers, and the Care Area Assessments (CAAs). 

• Assessments are completed per the CMS Resident Assessment Manual (RAI). 

4. Interdisciplinary Team (IDT) Participation: 

• Based on the RAI, the Interdisciplinary Team (IDT) develops a comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing, and psychosocial needs identified in the RAI and IDT. 

Care Plan: 

1. Development and Implementation: 

• The Care Plan is developed based on the comprehensive assessment and involves appropriate participation by a broad base of health professionals. 

• The designated registered nurse, Resident Care Coordinator (RCC), monitors the comprehensive assessment process. 

2. Team Members: 

• The Interdisciplinary Team includes, but is not limited to: 

• Nursing Services 

• Nutritional Services 

• Activities Services 

• Social Services 

• Rehabilitation Services 

• Attending Physician 

3. Evaluation and Revision: 

• The Care Plan is evaluated and revised as needed, but at least quarterly. 

4. Documentation: 

• The assessments and Care Plan are retained in the resident's Clinical Record. 

• Non-EMR Facility: The most recent comprehensive MDS is kept in the medical record. The previous 15 months of MDS are kept available at the nurse’s station. 

• EMR Facility: MDS are maintained in the resident’s electronic medical record. 

Additional Requirements for Specific Programs: 

1. Medicare, VA Contracts, Managed Care, and State Specifications: 

• Additional assessments for residents on Part A Medicare, VA Contracts, Managed Care, and State-specified programs may be required. This coverage is outlined in the Federal Register under the Prospective Payment System (PPS). 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• CMS Resident Assessment Instrument (RAI) Manual 

• Federal Register, Prospective Payment System (PPS) Guidelines