Current through Register Vol. 48, No. 38, September 20, 2024
a) A facility shall conduct and
electronically submit a Minimum Data Set (MDS) assessment that conforms with
the assessment schedule and guidance defined by Code of Federal Regulations,
Title 42, section 483.20, and in the RAI Manual, published by the United States
Department of Health and Human Services, Centers for Medicare and Medicaid
Services (federal CMS), and subsequent updates when issued by federal
CMS.
b) A facility shall complete
the MDS Comprehensive Item Set form that includes all items Section A-Z, for
each resident quarterly, regardless of the resident's payment source. The
Comprehensive Item Set refers to the MDS items that are active on a particular
assessment type or tracking form. While a Comprehensive Item Set is required
for all assessments including quarterlies, a comprehensive assessment is not
required on a quarterly basis. A comprehensive assessment is defined as both
the completion of a Comprehensive Item Set as well as completion of the Care
Area Assessment (CAA) process and care planning. When completing the
Comprehensive Item Set for the quarterly MDS, the CAA process is not required.
The federal regulatory requirements at
42 CFR
483.20(d) requires nursing
facilities to maintain all resident assessments completed within the previous
15 months in the resident's active clinical record.
c) A facility shall electronically transmit
to the federal CMS database the following MDS assessments in the timeframes
identified.
1) The Omnibus Budget
Reconciliation Act (OBRA) regulations require nursing facilities that are
Medicare or Medicaid certified to conduct initial and periodic assessments for
all their residents. The MDS 3.0 is part of that assessment process and is
required by federal CMS. The assessment that will be used for the purpose of
rate calculations shall be identified as an OBRA assessment on the MDS
following the guidance in the RAI Manual.
2) Admission, Annual, Significant Change in
Status, and Significant Correction to Prior Comprehensive Assessments shall be
completed and transmitted to the federal CMS database no later than 14 calendar
days after the care plan completion date. The quarterly assessment shall
identify the MDS was transmitted to the federal CMS database no later than 14
calendar days after the MDS completion date.
3) An MDS admission assessment and CAAs shall
be completed by the 14th calendar day from the
resident's admission date. This assessment shall include completion of the MDS
Comprehensive Item Set as well as completion of the CAA process and care
planning. Care plan completion date is 7 calendar days after the MDS/CAA
completion date. Transmission date is within 14 calendar days after the care
plan completion date.
4) An annual
assessment shall have an assessment reference date (ARD) within 366 calendar
days of the ARD identified on the last comprehensive assessment. This
assessment shall include completion of the MDS Comprehensive Item Set as well
as completion of the CAA process and care planning. The MDS/CAA completion date
is the ARD plus 14 calendar days. The care plan completion date is MDS/CAA
completion date plus 7 calendar days. Transmission date is care plan date plus
14 calendar days.
5) A significant
change assessment shall be completed within 14 calendar days after the
identification of a significant change. This assessment shall include
completion of the MDS Comprehensive Item Set as well as completion of the CAA
process and care planning. The MDS/CAA completion date is 14 calendar days
after the determination date plus 7 calendar days. Transmission date is care
plan date plus 14 calendar days.
6)
All quarterly assessments shall have an ARD within 92 calendar days after the
previous OBRA assessment. This assessment includes the completion of the MDS
Comprehensive Item Set, but does not include the completion of the CAA process
and care planning. MDS completion date is ARD plus 14 calendar days.
Transmission date is completion date plus 14 calendar days.
7) The significant correction to a prior
comprehensive assessment or significant correction to a prior quarterly
assessment shall be completed when the interdisciplinary team determines that a
resident's prior assessment contains a significant error that has not been
corrected by more recent assessments as required by the RAI Manual. Nursing
facilities shall document the initial identification of a significant error in
a prior assessment in the progress notes.
d) A facility shall comply with the
following:
1) All staff completing any portion
of the MDS shall enter their signatures, titles, section or portions of
sections they completed and the date completed.
2) The signature attests that the information
entered by them, to the best of their knowledge, most accurately reflects the
resident's status during the timeframes identified.
3) Federal regulations require the RN
assessment coordinator to sign and thereby certify that the assessment is
completed.
4) When the electronic
MDS record submitted to the state from the federal CMS database does not match
the facility's copy of the MDS, the items on the MDS submitted will be used for
purposes of validation.
5) It is
the facility's responsibility to create an electronic transmission file that
meets the requirements detailed in the current MDS Data Specification Manual.
The facility shall submit MDS assessments under the appropriate authority and
timely as defined in the RAI Manual. In addition, the facility is responsible
to access the federal CMS database to receive and review validation reports.
Records that are rejected or contain errors must be dealt with 30 days prior to
the rate period and appropriately to avoid default rate.
