The Resident Assessment Instrument (RAI) is the
assessment tool approved by the Department to provide a comprehensive,
accurate, standardized, reproducible assessment of each resident's functional
capacity. It is comprised of the Minimum Data Set (MDS) currently specified for
use by Centers for Medicare and Medicaid (CMS) and the Resident Assessment
Protocols (RAPs).
The MDS provides the basis for resident classification
into one (1) of forty-four (44) case mix classification groups. An additional
unclassified group is assigned when assessment data are determined to be
incomplete or in error. Resident assessment protocols (RAPs) are structured
frameworks for organizing MDS elements and gathering additional clinically
relevant information about a resident that contributes to care planning.
Per CMS guidelines, all residents admitted to a Nursing
Facility (NF), regardless of payment source, shall be assessed using the
MDS.
16.2.1
Schedule for MDS
submissions
(1) An Admission
Assessment (Comprehensive) must be completed and submitted (VB2) by the
fourteenth (14th) day of the resident's
stay.
(2) An Annual Reassessment
(Comprehensive) must be completed and submitted (VB2) within three
hundred-sixty-six (366) days of the most recent comprehensive
assessment.
(3) A Significant
Change in Status Reassessment (Comprehensive) must be completed and submitted
(VB2) by the end of the fourteenth (14th) calendar
day following determination that a significant change has occurred.
(4) A Quarterly Assessment must be completed
and submitted every ninety-two (92) days.
16.2.2
Electronic Submission of the MDS
Information(1)
Encoding
Data: A facility must encode the data on every assessment as listed in
Sec 16.2.1 within seven (7) days after a facility completes a resident's
assessment.
(2)
Transmitting
data: A facility must be capable of transmitting to the State
information for each resident contained in the MDS in a format that conforms to
standard record layouts and data dictionaries within seven (7) days after a
facility completes a resident's assessment.
Should extraordinary conditions arise whereby the nursing
facility is unable to submit electronically, a request to submit MDS
information via diskette shall be submitted to the Office of MaineCare
Services. This request must be made a minimum of five (5) days prior to the
required date of submission of the MDS assessment data. Transmission of MDS
information will be in accordance with standards and specifications established
under CMS guidelines.
16.2.3
Quality review of the MDS
process
16.2.3.1
Definitions(1)
MDS
Correction Form. The MDS correction form is a form specified by CMS that
allows for the correction of MDS assessment information previously submitted
and accepted into the MDS central data repository.
Facility staff identifies and determines the need for
data correction. The MDS clinical process must be maintained under CMS
requirements. Corrections take two (2) forms:
(a)
Modification: Information
contained in the MDS central repository is inaccurate for an assessment and
requires correction.
(b)
Deletion: The facility determines the MDS was submitted in error
and is wrong. The facility submits an MDS Correction Form requesting the
inaccurate record be deleted from the database.
(2)
"MDS assessment review" is a
review conducted at nursing facilities (NFs) by the Maine Department of Health
and Human Services, for review of assessments submitted in accordance with
Principle 16.2 to ensure that assessments accurately reflect the resident's
clinical condition.
(3)
"Effective date of the Rate" is established by the date on the
rate letter. A rate letter will be generated at least annually.
(4)
"Assessment review error
rate" is the percentage of unverified Case Mix Group Record in the drawn
sample. Samples shall be drawn from Case Mix Group Record completed for
residents who have MaineCare reimbursement. MDS Correction Forms received in
the central repository or included in the clinical record will be the basis for
review when completed before the day of the review and included as part of the
resident's clinical record.
(5)
"Verified Case Mix Group Record" is a NF's completed MDS
assessment form, which has been determined to accurately represent the
resident's clinical condition, during the MDS assessment review process.
Verification activities include reviewing resident assessment forms and
supporting documentation, conducting interviews, and observing
residents.
(6)
"Unverified
Case Mix Group Record" is one which, for reimbursement purposes, the
Department has determined does not accurately represent the resident's
condition, and therefore results in the resident's inaccurate classification
into a case mix group that increases the case mix weight assigned to the
resident. Records so identified will require facilities to submit the
appropriate MDS correction form and follow CMS clinical guidelines for MDS
completion. Correction forms received prior to calculating the rate setting
quarterly index will be used in the calculation of that index.
(7)
"Unverified MDS Record" is
one, which, for clinical purposes, does not accurately reflect the resident's
condition. Records so identified will require facilities to submit the
appropriate MDS correction form and follow the CMS clinical guidelines for MDS
completion.
16.2.3.2
Criteria for Assessment Review
NFs may be selected for a MDS assessment review by the
Department based upon but not limited to any of the following:
(1) The findings of a licensing and
certification survey conducted by the Department indicate that the facility is
not accurately assessing residents.
(2) An analysis of the case mix profile of
NFs included but not limited to changes in the frequency distribution of their
residents in the major categories or a change in the facility Average case mix
score.
(3) Prior resident
assessment performance of the provider, including, but not limited to, ongoing
problems with assessments submission deadlines, error rates, high percentages
of MDS corrections or deletions, and incorrect assessment
dates.
16.2.3.3
Assessment Review Process
(1)
Assessment reviews shall be conducted by staff or designated agents of the
Department.
(2) Facilities selected
for assessment reviews must provide reviewers with reasonable access to
residents, professional and non-licensed direct care staff, the facility
assessors, clinical records, and completed resident assessment instruments as
well as other documentation regarding the residents' care needs and
treatments.
(3) Samples shall be
drawn from MDS assessments completed for residents who have MaineCare
reimbursement. The sample size is determined following the CMS State
Operations Manual (SOM) Transmittal 274, Table 1 "Resident Sample
Selection".
(4) At the conclusion
of the on-site portion of the review process, the Department's reviewers shall
hold an exit conference with facility representatives. Reviewers will share
written findings for reviewed records.
16.2.3.4
Sanctions
The following sanctions shall be applied to the total
allowable inflated direct care cost per day for a three month period subsequent
to the quality review date. The sanction will apply to all MaineCare resident
days billed by the facility during the three month sanction period. Such
sanctions shall be a percentage of the total allowable inflated direct care
rate per day after the application of the wage index and upper limit. Upon
notification of the error rates as determined by the reviewers (in 16.2.3.3.),
the staff of the rate setting unit of the Department will implement the
appropriate sanction by issuing a rate letter with the start and end dates of
the three month sanction period. At the completion of the three month sanction
period, the staff of rate setting unit will issue a rate letter reinstating the
total allowable inflated direct care cost per day.
(1) A two percent (2%) decrease in the total
allowable inflated direct care rate per day after the application of the wage
index and upper limit will be imposed when the NF assessment review results in
an error rate of thirty-four percent (34%) or greater, but is less than
thirty-seven percent (37%).
(2) A
five percent (5%) decrease in the total allowable inflated direct care rate per
day after the application of the wage index and upper limit will be imposed
when the NF assessment review results in an error rate of thirty-seven percent
(37%) or greater, but is less than forty-one percent (41%).
(3) A seven percent (7%) decrease in the
total allowable inflated direct care rate per day after the application of the
wage index and upper limit will be imposed when NF assessment review results in
an error rate of forty-one percent (41%) or greater, but is less than
forty-five percent (45%).
(4) A ten
percent (10%) decrease in the total allowable inflated direct care rate per day
after the application of the wage index and upper limit will be imposed when
the NF assessment review results in an error rate of forty-five percent (45%)
or greater.
16.2.3.5
Failure to complete MDS corrections by the nursing facility staff within
fourteen (14) days of a written request by staff of the Office of MaineCare
Services may result in the imposition of the deficiency per diem as specified
in Principle 37 of these Principles of Reimbursement. Completed MDS corrections
and assessments, as defined in Principle 16.2, shall be submitted to the
Department or its designee according to CMS guidelines.
16.2.3.6
Appeal Procedures: A
facility may administratively appeal an Office of MaineCare Services rate
determination for the direct care cost component. An administrative appeal will
proceed in the following manner:
(1) Within
thirty (30) days of receipt of rate determination, the facility must request,
in writing, an informal review before the Director of the Office of MaineCare
Services or his/her designee. The facility must forward, with the request, any
and all specific information it has relative to the issues in dispute. Only
issues presented in this manner and time frame will be considered at an
informal review or at a subsequent administrative hearing.
(2) The Director or his/her designee shall
notify the facility in writing of the decision made as a result of the informal
review. If the facility disagrees with the results of the informal review, the
facility may request an administrative hearing before the Commissioner or a
presiding officer designated by the Commissioner. Only issues presented in the
informal review will be considered at the administrative hearing. A request for
an administrative hearing must be made, in writing, within thirty (30) days of
receipt of the decision made as a result of the informal review.
(3) To the extent the Department rules in
favor of the facility, the rate will be corrected.
(4) To the extent the Department upholds the
original determination of the Office of MaineCare Services, review of the
results of the administrative hearing is available in conformity with the
Administrative Procedure Act,
5 M.R.S.A.
§11001
et
seq.
