2.2 Required OBRA Assessments for the MDS

ADMISSION ASSESSMENTS

The Admission assessment is a comprehensive assessment for a new resident that must be completed within 14 calendar days of admission to the facility if:

• this is the resident’s first stay,

• the resident has just returned to the facility after being discharged prior to the completion of the initial assessment, or

• the resident has just returned to the facility after being discharged as return not anticipated.

The 14-day calculation includes weekends. When calculating when the RAI is due, the day of admission is counted as Day “1”. For example, if a resident is admitted at 8:30 a.m. on Wednesday

(Day 1), a completed RAI is required by the end of the day Tuesday (Day 14), 13 days after admission. If a resident dies or is discharged within 14 days of admission, then whatever portions of the RAI that have been completed must be maintained in the resident’s discharge record.1 In closing the record, the facility may wish to note why the RAI was not completed.

If a resident goes to the hospital and returns during the 14-day assessment period and most of the initial assessment was completed prior to the hospitalization, then the facility may wish to continue with the original assessment, provided the resident did not have a significant change in status. In this case, the Assessment Reference Date remains the same and the Admission comprehensive assessment must be completed by day 14 counting from the original date of admission. Otherwise the assessment should be re-initiated with a new Assessment Reference Date and completed within 14 days after readmission from the hospital. The portion of the resident’s assessment that was previously completed should be stored on the resident’s record with a notation that the assessment was re-initiated because the resident was hospitalized.

1The RAI is considered part of the resident’s clinical record and is treated as such by the RAI Utilization Guidelines, e.g., portions of the RAI that are “started” must be saved.

Assessment Management Tips: ADMISSION COMPREHENSIVE ASSESSMENT

The above chart summarizes how to count the days for various points within the admission assessment. As stated previously, the date of admission is Day 1 for determining when the assessment must be completed and for setting the Assessment Reference Date. Once the ARD has been established, then the ARD is day 1 whenever counting back for those items observed over a specific time period.

• Both the MDS Completion Date (R2b) and RAPs Completion Date (VB2) must be dated within 14 days of admission. R2b must always be earlier than or the same as VB2. If R2b is dated prior to day 14, VB2 may or may not be the same day, but can be no later than day 14.

• Care Plan Completion Date (VB4) must be dated by the end of the 7th calendar day following VB2 (VB2 + 7 days) and can be no later than day 21.

• Electronic submission is due within 31 days following VB4 (VB4 + 31 days).

ANNUAL REASSESSMENTS

The annual comprehensive assessment must be completed within 366 days of the completion date at VB2 of the most recent comprehensive assessment (could be the Admission assessment, an Annual assessment, a Significant Change in Status assessment or a Significant Correction of a Prior Full assessment). If a significant change reassessment is completed in the interim, the clock “restarts,” and the Annual assessment would be due within 366 days of the significant change reassessment. Routinely scheduled RAI assessments may be scheduled early if a facility wants to stagger due dates for assessments.

In managing the dates for the Annual assessment, the anticipated completion date of the assessment to be scheduled as well as the completion dates of the previous comprehensive and Quarterly assessments must be considered when setting the ARD. The completion date of the Annual assessment must meet two requirements: 1) a comprehensive assessment must be completed within 366 days of the RAPs Completion Date (VB2 ) of the previous comprehensive, and 2) there can be no more than 92 days since the (MDS Completion Date (R2b) of the last Quarterly assessment.

If a significant change in status is identified in the process of completing an Annual assessment, code the assessment as a Significant Change in Status assessment. Do not code it as an Annual assessment.

Assessment Management Tips: ANNUAL COMPREHENSIVE REASSESSMENT

• The Annual assessment must be completed no later than 14 days after the ARD. That is, R2b and VB2 can be no more than 14 days from the ARD (ARD + 14 days). Since the ARD is part of the observation period, it is considered day 0, and is not included in calculating the 14-day completion period. VB2 is not required to be the same day as R2b but can be no later than 14 days following the ARD.

• Once the ARD has been established, it is the last day of the observation period.

• Care Plan Completion Date (VB4) must be dated by the end of the 7th calendar day following VB2 (VB2 + 7 days) and can be no later than 21 days following the ARD.

• Electronic submission is due within 31 days following VB4 (VB4 + 31 days).

SIGNIFICANT CHANGE IN STATUS ASSESSMENTS (SCSA)-Comprehensive Assessment

Facilities have an ongoing responsibility to assess resident status and intervene to assist the resident to meet his or her highest practicable level of physical, mental, and psycho-social well-being. If interdisciplinary team members identify a significant change (either improvement or decline) in a resident’s condition they should share this information with the resident’s physician, who they may consult about the permanency of the change. The facility’s medical director may also be consulted when differences of opinion about a resident’s status occur among team members.

Document the initial identification of a significant change in terms of the resident’s clinical status in the progress notes. A Significant Change in Status (SCSA) assessment is not required in a case where the resident’s condition is expected to return to baseline within a short period of time, such as one to two weeks. If the condition does not return to baseline, the assessment should be completed as soon as needed to provide appropriate care to the resident, but in no case later than 14 days after the determination was made that a significant change occurred.

An SCSA can be performed at any time after the completion of the Admission assessment. If a significant change in status is identified in the process of completing a Quarterly assessment, code the assessment as a SCSA and complete a comprehensive assessment. Do not code it as a Quarterly assessment. The SCSA restarts the schedule and the next Quarterly assessment would be due no more than 92 days from R2b of the SCSA. Similarly, if an SCSA is identified in the process of completing an Annual assessment, it should be coded as an SCSA.

A condition is defined as “self-limiting” when the condition will normally resolve itself without further intervention or by staff implementing standard disease related clinical interventions. For example, a 5% weight loss for a resident with the flu would not normally meet the requirements for a “significant change” reassessment. In general, a 5% weight loss may be an expected outcome for a resident with the flu who experienced nausea and diarrhea for a week. In this situation, staff should monitor the resident’s status and attempt various interventions to rectify the immediate weight loss. If the resident did not become dehydrated and started to regain weight after the symptoms subsided, a comprehensive assessment would not be required. The amount of time that would be appropriate for a facility to monitor a resident depends on the clinical situation and severity of symptoms experienced by the resident. Generally, if the condition has not resolved within approximately 2 weeks, staff should begin a comprehensive RAI assessment. This time frame is not meant to be prescriptive, but rather should be driven by clinical judgment and the resident’s needs.

An SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. In this example, a resident with a 5% weight loss in 30 days would not generally require a significant change reassessment, unless a second area of decline accompanies it. Note that this answer assumes that the care plan has already been modified to actively treat the weight loss as opposed to continuing with the original problem, “potential for weight loss.” This situation should be documented in the resident’s clinical record along with the plan for subsequent monitoring and if the problem persists or worsens, a comprehensive RAI reassessment may be clinically indicated.

If there is only one change, however, staff may still decide that the resident would benefit from an SCSA. It is important to remember that each resident’s situation is unique and the interdisciplinary treatment team must make the decision as to whether or not the resident will benefit from an RAI.

Other conditions may not be permanent but would have such an impact on the resident’s overall status that they would require a comprehensive assessment and care plan revision. For example, a hip fracture may be viewed as a transient condition but it would generally have a major impact on the resident’s functional status in more than one area (e.g., ambulation, toileting, elimination patterns, activity patterns). Changes in the resident’s condition that would affect the resident’s functional capacity and day-to-day routine should be investigated in a holistic manner through the RAI reassessment. Therefore, concepts associated with significant change are “major” or “appears to be permanent,” but a change does not necessarily need to be both major and permanent.

An SCSA is appropriate if there is a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). Any determination about whether or not a resident has experienced a significant change in status is a clinical decision. When a SCSA is completed, the facility must review all of the RAPs because they are interrelated. If there are no changes in a RAP, they can then document that there were no changes and bring that RAP forward and specify where the supporting documentation can be located in the medical record.

GUIDELINES FOR DETERMINING SIGNIFICANT CHANGE IN RESIDENT STATUS

(Please note this is not an exhaustive list.)

The final decision regarding what constitutes a significant change in status must be based upon the judgment of the clinical staff and the guidelines shown below.

Decline in two or more of the following:

• Resident’s decision-making changes from 0 or 1 to 2 or 3 for Item B4;

• Emergence of sad or anxious mood pattern as a problem that is not easily altered (Item E2);

• Increase in the number of areas where Behavioral Symptoms are coded as “not easily altered” (i.e., an increase in the number of code “1”s for Item E4B);

• Any decline in an ADL physical functioning area where a resident is newly coded as 3, 4, or 8 (Extensive assistance, Total dependency, Activity did not occur) for Item G1A;

• Resident’s incontinence pattern changes from 0 or 1 to 2, 3 or 4 (Item H1a or b), or there was placement of an indwelling catheter (Item H3d);

• Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days) (Item K3a);

• Emergence of a pressure ulcer at Stage II or higher, when no pressure ulcers were previously present at Stage II or higher (Item M2a);

• Resident begins to use trunk restraint or a chair that prevents rising when it was not used before (Items P4c and e);

• Overall deterioration of resident’s condition; resident receives more support (e.g., in ADLs or decision-making) (Item Q2 = 2);

• Emergence of a condition or disease in which a resident is judged to be unstable (Item J5a).

Improvement in two or more of the following:

• Any improvement in an ADL physical functioning area where a resident is newly coded as 0, 1, or 2 when previously scored as a 3, 4, or 8 (Item G1A);

• Decrease in the number of areas where Behavioral Symptoms or Sad or Anxious Mood are coded as “not easily altered” (Items E2 and E4B);

• Resident’s decision-making changes from 2 or 3 to 0 or 1 (Item B4);

• Resident’s incontinence pattern changes from 2, 3, or 4 to 0 or 1 (Item H1a or b);

• Overall improvement of resident’s condition; resident receives fewer supports (Item Q2 = 1).

While a facility may choose to perform more frequent comprehensive assessments than mandated by CMS, reassessments are not required for minor or temporary variations in resident status. However, staff must note these transient changes in the resident’s status in the resident’s record and implement necessary clinical interventions, even though a reassessment is not required. In these cases the resident’s condition is expected to return to baseline within a short period of time, such as 1-2 weeks.

GUIDELINES FOR WHEN A CHANGE IN RESIDENT STATUS IS NOT SIGNIFICANT

(Please note this is not an exhaustive list)

• Discrete and easily reversible cause(s) documented in the resident’s record and for which the interdisciplinary team can initiate corrective action (e.g., an anticipated side effect of introducing a psychoactive medication while attempting to establish a clinically effective dose level. Tapering and monitoring of dosage would not require a significant change reassessment).

• Short-term acute illness, such as a mild fever secondary to a cold from which the interdisciplinary team expects the resident to fully recover.

• Well-established, predictable cyclical patterns of clinical signs and symptoms associated with previously diagnosed conditions (e.g., depressive symptoms in a resident previously diagnosed with bipolar disease would not precipitate a significant change assessment).

• Instances in which the resident continues to make steady progress under the current course of care. Reassessment is required only when the condition has stabilized.

• Instances in which the resident has stabilized but is expected to be discharged in the immediate future. The facility has engaged in discharge planning with the resident and family, and a comprehensive reassessment is not necessary to facilitate discharge planning.

GUIDELINES FOR DETERMINING THE NEED FOR AN SCSA FOR RESIDENTS WITH TERMINAL CONDITIONS

The key in determining if an SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration, an SCSA assessment is required. Similarly, if the resident enrolls in a hospice (Medicare Hospice program or other structured hospice program), but remains a resident at the facility, an SCSA should be performed if the terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration. The facility is responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

If a resident elects the Medicare Hospice program, it is important that the two separate entities (nursing facility and hospice program staff) coordinate their responsibilities and develop a care plan reflecting the interventions required by both entities. The need to complete an SCSA will depend upon the resident’s status at the time of election of hospice care, and whether or not the resident’s condition requires a new assessment. Because a Medicare-certified hospice must also conduct an assessment at the initiation of its services, this is an appropriate time for the nursing facility to evaluate the MDS information to determine if it reflects the current condition of the resident. The nursing facility and the hospice’s plans of care should be reflective of the current status of the resident.

• Complete an SCSA for a newly diagnosed resident with end-stage disease when:

• a change is reflected in more than one area of decline; and

• the resident’s status will not normally resolve itself; and

• the resident’s status requires interdisciplinary review and/or revision of the care plan.

• Complete subsequent SCSA’s based upon the degree of decline and the impact upon the comprehensive care plan. Consider the following criteria:

• completion date of the last MDS;

• clinical relevancy and accuracy of the MDS to the resident’s current status; and

• the need to change the resident’s care plan to reflect the current status.

Assessment Management Tips: SIGNIFICANT CHANGE IN STATUS ASSESSMENT

The Significant Change in Status assessment must be completed no later than the ARD + 14 days. That is, the MDS Completion Date (R2b) and the RAPs Completion Date (VB2) can be no more than 14 days following the ARD. However, the requirement that the assessment be completed by the end of the 14th day following the determination that a significant change has occurred overrides this.

• Once the ARD has been established, it is the last day of the observation period.

• Care Plan Completion Date (VB4) must be dated by the end of the 7th calendar day following RAPs Completion Date (VB2) (VB2 + 7 days) and can be no later than 21 days following the ARD.

• Electronic submission is due within 31 days following Care Plan Completion Date (VB4) (VB4 + 31 days).

• If the significant change has been identified in the course of completing either a Quarterly assessment or an Annual reassessment, then the SCSA must be completed no later than 92 days from the previous OBRA assessment and 366 days from the previous comprehensive assessment.

SIGNIFICANT CORRECTION OF A PRIOR FULL ASSESSMENT

A Significant Correction of Prior Full assessment (SCPA), including the full MDS form, RAPs and care plan review, is completed when an uncorrected major error is discovered in a prior comprehensive assessment. An error is major when the resident's overall clinical status has been mis-coded on the MDS and/or the care plan derived from the erroneous assessment does not suit the resident. A major error is uncorrected when there is no subsequent assessment that has resulted in an accurate view of the resident's overall clinical status and an appropriate care plan. A Significant Correction of a Prior Full assessment is appropriate after a comprehensive assessment has been accepted into the State MDS database, or when a major error has been identified in a comprehensive assessment that has been completed but is no longer in the editing and revision time period (later than 7 days following VB4). This could include an assessment containing a major error that has not yet been transmitted, or that has been submitted and rejected. It is not necessary to complete a new Significant Correction of Prior Full assessment if another, more current assessment has just been completed or is in progress and includes a correction to the item(s) in error.

A Significant Correction of a Prior Full assessment uses a new observation period (as defined by a new Assessment Reference Date). A significant correction assessment (not the original assessment that it corrects) drives the due date of the next assessment.

When the assessment in error has already been accepted by the MDS system at the state, the facility should also correct the assessment that was in error by completing and submitting a correction request for the erroneous assessment, in addition to completing a new assessment, the Significant Correction of a Prior Full assessment. See Chapter 5 for detailed information on processing corrections. It is necessary to correct the erroneous assessment that resides in the State MDS database in order to ensure that accurate information is available for reports that consider historic MDS information, such as incidence reporting for Quality Indicators.

The Significant Correction of a Prior Full assessment differs from a Significant Change in Status assessment, in which there has been an actual significant change in the resident’s health status. In any instance in which a resident experiences a significant change in status, regardless of whether or not there was also an error on the previous assessment, the primary reason for assessment should be coded as a significant change in status. In the event of a significant change in status where there are also errors in a prior assessment already accepted into the State MDS database, the facility should also correct the assessment that was in error by completing and submitting a correction request for that erroneous assessment, in addition to completing a Significant Change in Status assessment.

Assessment Management Tips: SIGNIFICANT CORRECTION OF A PRIOR FULL ASSESSMENT

• The Significant Correction of a Prior Full assessment must be completed no later than the ARD + 14 days. That is, the MDS Completion Date (R2b) and the RAPs Completion Date (VB2) can be no more than 14 days following the ARD. However, the requirement that the assessment be completed by the end of the 14th day following the determination that a major error in a prior full assessment has occurred overrides this.

• Once the ARD has been established, it is the last day of the observation period.

• Care Plan Completion Date (VB4) must be dated by the end of the 7th calendar day following RAPs Completion Date (VB2) (VB2 + 7 days) and can be no later than 21 days following the ARD.

• Electronic submission is due within 31 days following the Care Plan Completion Date (VB4) (VB4 + 31 days).

ASSESSMENTS UPON READMISSION/RETURN

If a facility has formally discharged a resident without the expectation that the resident would return, but later the resident does return (AA8a = 6, Discharged-Return Not Anticipated), this situation is considered a new admission. When this occurs, a new Admission assessment, including Sections AB (Demographic Information) and AC (Customary Routine), must be completed within 14 days of admission.

If a resident returns to a facility following a temporary absence for hospitalization or therapeutic leave, it is considered a readmission. Facilities should evaluate a resident upon readmission to determine if a significant change in the resident’s condition has occurred. In these situations, follow the procedures for Significant Change in Status assessments. It is not necessary to complete Sections AB (Demographic Information) or AC (Customary Routine) of the MDS if this information has previously been collected and entered into the resident’s record. If it is determined that a resident has not experienced a Significant Change in Status, the next OBRA assessment is completed within 92 days of the completion (R2b) of the last OBRA assessment prior to the resident leaving the facility.

QUARTERLY ASSESSMENTS

Each State’s RAI includes, at a minimum, CMS’s required Quarterly assessment items. Not all MDS items appear on the Quarterly assessment form. However, states may add items from the core MDS on their Section S, and require completion of Sections T and/or U. If you are unsure of your State’s Quarterly assessment requirements, check with your State RAI Coordinator (listed in Appendix B of the User’s Manual) to determine what is required in your state.

The Quarterly assessment is used to track the resident’s status between comprehensive assessments, and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status. At a minimum, three Quarterly assessments and one comprehensive assessment are required in each 12-month period. Federal requirement CFR 483.20(c) specifies that a Quarterly assessment must be conducted “not less frequently than once every three months.” Timing edits in the MDS standard system count 92-day intervals because there are never more than 92 days in any consecutive three-month intervals. These 92 days are measured from the date at MDS Item R2b of one assessment to Item R2b of the next assessment.

The resident’s status must be assessed for each of the key mandated items of the Quarterly assessment using the State-specified form. For information on State requirements, contact your State RAI Coordinator. In conducting Quarterly assessments, facilities must also assess any additional items required for use by the State. Based on the Quarterly assessment, the resident’s care plan is revised if necessary. If a Significant Change in Status assessment was completed replacing the Quarterly, the next assessment that is required is a Quarterly assessment. The Quarterly must be completed within 92 days of Item R2b on the Significant Change in Status assessment. In other words, there can be no more than 92 days between the dates recorded at MDS Item R2b of the last to the next clinical assessment.

Assessment Management Tips: QUARTERLY ASSESSMENT

• When setting the ARD for the Quarterly assessment, the anticipated completion date of the assessment to be scheduled as well as the MDS Completion Date (R2b) of the previous OBRA assessment must be considered. The completion date of the Quarterly assessment must be within 92 days of the MDS Completion Date (R2b) of the last OBRA assessment.

• If, in the course of completing the Quarterly assessment, it is determined that a significant change in status has occurred, the comprehensive Significant Change assessment must be completed instead of the Quarterly. The next Quarterly assessment would be due no more than 92 days of the R2b date of the SCSA.

• The Quarterly assessment must be completed no later than 14 days after the ARD. That is, R2b can be no more than 14 days from the ARD (ARD + 14 days).

• Once the ARD has been established, it is the last day of the observation period.

• Electronic submission is due within 31 days following the MDS Completion Date (R2b) (R2b + 31 days).

SIGNIFICANT CORRECTION OF A PRIOR QUARTERLY ASSESSMENT

Significant Correction of a Prior Quarterly assessment is completed when an uncorrected major error is discovered in a Quarterly assessment. An error is major when the resident’s overall clinical status has been mis-coded on the MDS and/or the care plan derived from the erroneous assessment does not suit the resident. A major error is uncorrected when there is no subsequent assessment that has resulted in an accurate view of the resident’s overall clinical status and an appropriate care plan. A Significant Correction of a Prior Quarterly assessment is appropriate when an uncorrected major error is identified in a Quarterly assessment that has been accepted into the State MDS database, or in a Quarterly assessment that has been completed and is no longer in the editing and revision time period (later than 7 days from R2b). This could include an assessment containing a major error that has not yet been transmitted, or that has been submitted and rejected. It is not necessary to complete a new Significant Correction of Prior Quarterly assessment if another, more current assessment is already due or in progress that contains and will correct the item(s) in error.

A Significant Correction of a Prior Quarterly assessment uses a new observation period (as defined by a new Assessment Reference Date). A Significant Correction of a Prior Quarterly assessment (not the original assessment that it corrects) drives the due date of the next assessment.

When the assessment in error has already been accepted by the MDS system at the State, the facility should also correct the assessment that was in error by completing and submitting a correction request for the erroneous assessment, in addition to completing a new assessment, the Significant Correction of a Prior Quarterly assessment. Refer to Chapter 5 for details regarding the CMS correction process. It is necessary to correct the erroneous assessment that resides in the State MDS database in order to ensure that accurate information is available for reports that consider historic MDS information, such as incidence reporting for Quality Indicators.

Assessment Management Tips: SIGNIFICANT CORRECTION OF A PRIOR QUARTERLY ASSESSMENT

The Significant Correction of a Prior Quarterly assessment must be completed no later than the ARD + 14 days. That is, the MDS Completion Date (R2b) can be no more than 14 days following the ARD. However, the requirement that the assessment be completed by the end of the 14th day following the determination that a significant error in a prior Quarterly assessment has occurred overrides this.

• Once the ARD has been established, it is the last day of the observation period.