regulations are copied from
https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf

GUIDANCE §483.10(g)(17)-(18)

Residents must be told in advance when changes will occur in their bills. Providers must fully inform the resident of services and related changes.

A Medicare beneficiary who requires services upon admission that are not covered under Medicare may be required to submit a deposit provided the notice provisions of §483.10(g)(17) if applicable, are met. Facility staff must notify residents of services or items that they may be charged for, if they are not required by the resident’s care plan, such as hair salon services beyond basic services or incontinence briefs the resident requests per personal preference in lieu of the briefs provided by the facility. See §483.10(f)(11) for those items and services that must be included in payment under skilled nursing and nursing facility benefits.

The facility’s responsibility regarding refunds applies to all residents for “any deposit or charges already paid” by a resident during their nursing home stay. For residents residing in a Continuing Care Retirement Community (CCRC), an exception can be considered for those residents who were admitted to the CCRC’s nursing home, had deposits and charges related to the CCRC separate from those incurred during the nursing home stay, and who were discharged/transferred from the nursing home back to the same CCRC’s independent or assisted living residences.

Beneficiary Notices

1. Notice of Medicare Non-Coverage (NOMNC)
The NOMNC, Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. See also 42 CFR 405.1200 and 422.624.

The NOMNC is not given if:

 

• The beneficiary exhausts the SNF benefits coverage (100 days), thus exhausting their Medicare Part A SNF benefit.
• The beneficiary initiates the discharge from the SNF.
• The beneficiary elects the hospice benefit or decides to revoke the hospice benefit andreturn to standard Medicare coverage.

2. Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN)

It is important to note that the SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility’s responsibility to inform the beneficiary about potential non- coverage and the option to continue services with the beneficiary accepting financial liability for those services.

Per Ch. 30, section 70.2 of the Medicare Claims Processing Manual (IOM Pub. 100-04), a SNFABN must be given to a beneficiary for the following triggering events:

• Initiation – In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNFABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary.
• Reduction – In the situation in which a SNF proposes to reduce a beneficiary’s extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNFABN to the beneficiary before it reduces items or services to the beneficiary.
• Termination – In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services.The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potentialfinancial liability and related standard claim appeal rights.The SNF:

• Files a claim when requested by the beneficiary (this claim is called a “demand bill”);and
• May not charge the beneficiary for Medicare covered Part A services during demand billprocess.

For detailed information refer to the Medicare Claims Processing Manual (IOM Pub. 100-04) athttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf. SNFABN is addressed in Ch. 30, section 70 of the manual and NOMNC is addressed in section 260.

NOTE: A facility’s requirement to notify and explain via the SNFABN that the individual is no longer receiving Medicare Part A services based on the SNF’s belief that Medicare Part A will not pay for the resident’s stay, is separate and unrelated to the admission and discharge requirements under 42 CFR §483.15, which outlines the notification and requirements under which an individual may be discharged from the facility or when the transfer or discharge is not initiated by the resident.

KEY ELEMENTS OF NONCOMPLIANCE §483.10(g)(17)-(18)

To cite deficient practice at F582, the surveyor’s investigation will generally show the facility failed to do one or more of the following:

• Notify each Medicaid- eligible resident in writing of the items and services which are/are not covered under Medicaid or by the facility’s per diem rate, including the cost of those items and services:
  o At the time of admission, oro When the resident became eligible for Medicaid, or
• Inform each Medicaid-eligible resident when changes were made to the items andservices covered by Medicaid; or
• Inform each resident of services available in the facility and the charges for those servicesnot covered under Medicare/Medicaid or by the facility’s per diem rate:
  o Before admission or at the time of admission, and periodically during the resident’sstay; or
  o As soon as reasonably possible when a change in coverage occurs; or
  o At least 60 days prior to implementation of changes made to charges for other itemsand services that the facility offers; or
• Refund the applicable funds to the resident, resident representative, or estate when aresident died, or was hospitalized, or was transferred and did not return to the facility; or
• Refund any and all funds due the resident:o Within 30 days from the date of discharge; oro To the resident or resident representative; or
• Included terms in the admission contract that conflicted with the requirements of theseregulations.F583

§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:

(i) Identification and demographic information (ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.

(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment

performed on the care areas triggered by the completion of the Minimum Data Set

(MDS).
(xviii) Documentation of participation in assessment. The assessment process must

include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.

(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary

***absence for hospitalization or therapeutic leave.)

(iii)Not less than once every 12 months. INTENT §483.20(b)(1)-(2)(i) & (iii)

To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident’s preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified.

DEFINITIONS §483.20(b)(1)-(2)(i) & (iii)
“Minimum Data Set”: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment.

“Care Area Assessment (CAA) Process” is a process outlined in Chapter 4 of the MDS manual designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a 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 CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident. This process has three components:

• Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment.
• Care Area Assessment (CAA) is the further investigation of triggered areas, to determine if the care area triggers require interventions and care planning.
• CAA Summary (Section V of the MDS) provides a location for documentation of the care area(s) that have triggered from the MDS, the decisions made during the CAA process regarding whether or not to proceed to care planning, and the location and date of the CAA documentation.“Comprehensive Assessment” includes the completion of the MDS as well as the CAA process, followed by the development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment.“Resident Assessment Instrument (RAI)” consists of three basic components: the Minimum Data Set (MDS) version 3.0, the Care Area Assessment (CAA) process and the RAI utilization guidelines. The utilization of these components of the RAI yields information about a resident’s functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified.“Utilization Guidelines” provide instructions for when and how to use the RAI. The Utilization Guidelines are also known as the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.GUIDANCE §483.20(b)(1)-(2(i) & (iii)

Each facility must use the RAI specified by CMS (which includes the MDS, utilization guidelines and the CAAs) to assess each resident. The facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or CAAs. The scope of the RAI does not limit the facility’s responsibility to assess and address all care needed by the resident.

The information required in §483.20(b)(1)(i-xviii) is incorporated into the MDS, which forms the core of the RAI process. Additional assessment information is also gathered using triggered Care Area Assessments (CAAs) after the completion of the comprehensive MDS.

The facility is expected to use resident observation and communication as the primary source of information when completing the RAI. In addition to record review, direct observation and communication with the resident, the facility must use a variety of other sources, including communication with licensed and non-licensed staff members on all shifts and may include discussions with the resident’s physician, the resident’s representative, family members, or outside consultants.

At a minimum, facilities are required to complete a comprehensive assessment of each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident’s status and not less than once every 12 months while a resident. For the purpose of this guidance, not less than once every 12 months means within 366 days.

For additional requirements regarding a Significant Change in Status Assessment, see §483.20(b)(2)(ii).

If a comprehensive assessment was completed, any time prior to a temporary absence for hospitalization or a leave of absence, and upon return to the facility, the resident does not meet the criteria for a Significant Change in Status Assessment (SCSA), as defined in §483.20(b)(2)(ii), a comprehensive assessment is not required. For example, a resident had a comprehensive assessment completed within 14 days of admission, four months later was hospitalized, then returned to the facility. Upon return to the facility, the resident’s status does not meet the criteria for a SCSA, therefore a comprehensive assessment is not required.

For additional information on assessment scheduling and completion requirements, see Chapter 2 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Link to the LTCF RAI User’s Manual: https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.

The facility must use the RAI process to develop a comprehensive care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident’s status.

PROBES §483.20(b)(1)-(2)(i) & (iii)

• Did the facility complete a comprehensive assessment, using the CMS-specified RAI process, within the regulatory timeframes (i.e. within 14 days after admission and at least annually) for each resident in the sample?

 

• Is there evidence in the clinical record that the facility gathered and analyzed supplemental information based on the triggered CAAs prior to developing the comprehensive care plan? For reference a list of CAAs is found in Section V of the MDS (Care Area Assessment Summary).
• Is there evidence of resident and/or resident representative participation in the assessment process? Examples include participating in the resident interviews, providing information about preferences or discharge goals.
• Ask licensed and non-licensed direct-care staff if they participate in the resident assessment process.
• Does the facility have a system in place to assure assessments are conducted in accordance with the specified timeframes for each resident?F637
  (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)§483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purpose of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.)INTENT §483.20(b)(2)(ii)To ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process.DEFINITIONS §483.20(b)(2)(ii)
  “Significant Change” is a major decline or improvement in a resident’s status that 1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered “self-limiting” (NOTE: Self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.); 2) impacts more than one area of the resident’s health status; and 3) requires interdisciplinary review and/or revision of the care plan. This does not change the facility’s requirement to immediately consult with a resident’s physician of changes as required under 42 CFR §483.10(i)(14), F580.“Significant Change in Status Assessment (SCSA)” is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline.“Assessment Reference Date (ARD)” is the specific end point for the look-back periods in the Minimum Data Set (MDS) assessment process. This look-back period is also called the observation or assessment period.

GUIDANCE §483.20(b)(2)(ii)

A SCSA including Care Area Assessments (CAAs) must be completed within 14 days after a determination has been made that a significant change in the resident’s status from baseline occurred. This may be determined by comparison of the resident’s current status to the most recent comprehensive assessment and most recent Quarterly assessment, and the resident’s condition is not expected to return to baseline within 2 weeks. A SCSA is appropriate if there are either two or more MDS areas of decline or two or more MDS areas of improvement or if the IDT determines that the resident would benefit from the SCSA assessment and subsequent care plan revision. The facility should document in the medical record when the determination is made that the resident meets the criteria for a Significant Change in Status Assessment.

A Significant Change in Status MDS is required when:
• A resident enrolls in a hospice program; or
• A resident changes hospice providers and remains in the facility; or
• A resident receiving hospice services discontinues those services; or
• A resident experiences a consistent pattern of changes, with either two or more areas of

decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident’s current status to the most recent CMS-required MDS).

Examples of Decline include, but are not limited to:
• Resident’s decision-making ability has changed;
• Presence of a resident mood item not previously reported by the resident or staff and/or

an increase in the symptom frequency, e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E Behavior;

• Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since last assessment;

• Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual’s functioning;

• Resident’s incontinence pattern changes or there was placement of an indwelling catheter;

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

• Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status;
• Resident begins to use a restraint of any type, when it was not used before;

• Emergence of a condition/disease in which a resident is judged to be unstable.

Examples of Improvement include, but are not limited to:

• Any improvement in ADL physical functioning area (at least 1) where a resident is newlycoded as Independent, Supervision, or Limited assistance since last assessment and doesnot reflect normal fluctuations in that individual’s functioning;
• Decrease in the number of areas where behavioral symptoms are coded as being presentand/or the frequency of a symptom decreases;

• Resident’s decision making ability improves;
• Resident’s incontinence pattern improves;If there is only one change, the resident may still benefit from a SCSA as determined by the IDT or as initiated by the resident based on changes in the care plan. It is important to remember that each resident’s situation is unique. The facility must document a rationale, in the resident’s medical record, for completing a SCSA that does not meet the criteria for completion.The facility may not complete a SCSA until after a Comprehensive Admission assessment has been completed.A Significant Change in Status MDS is considered timely when:

• The RN Assessment Coordinator signs the MDS as complete at section Z0500B &

V0200B2 by the 14th calendar day after the determination that a significant change has occurred (determination date + 14 calendar days).

If a SCSA MDS is completed, the next annual assessment is not due until 366 days after the ARD of the significant change in status assessment.

NOTE: For information on assessment scheduling for the MDS, see Chapter 2 of the Long- Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Link to the LTCF RAI User’s Manual: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursinghomeQualityInits/MDS30RAIManual.html.

Circumstances when a change in resident status is not significant include, but are not limited to:

• Short-term acute illness, such as a mild fever secondary to a cold from which the IDTexpects the resident to fully recover.
• Well-established, predictable cyclical patterns of clinical signs and symptoms associatedwith previously diagnosed conditions (e.g., depressive symptoms in a resident previouslydiagnosed with bipolar disease would not precipitate a Significant Change Assessment).
• Instances in which the resident continues to make steady progress under the currentcourse 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 theimmediate future. The facility has engaged in discharge planning with the resident and family, and a comprehensive reassessment is not necessary to facilitate discharge planning.PROBES §483.20(b)(2)(ii)

• Did the facility identify, in a timely manner, those residents who experienced a significant change in status?
• Is there documentation in the medical record when the determination was made that the resident met the criteria for a Significant Change in Status Assessment?
• Did the facility reassess residents who had a significant change in status, using the CMS- specified RAI, within 14 days after determining the change was significant?

 

F638
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

INTENT §483.20(c)

To assure each resident is assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments.

DEFINITIONS §483.20(c)
“Quarterly Review Assessment” is an OBRA ‘87-required, non-comprehensive assessment that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident’s status between comprehensive assessments to ensure critical indicators of gradual change in a resident’s status are monitored. As such, not all Minimum Data Set (MDS) items appear on the Quarterly assessment.

GUIDANCE §483.20(c)

At least every 92 days, the facility shall review each resident with respect to those MDS items specified in the CMS quarterly assessment (MDS).

A Quarterly assessment is considered timely if:

• The Assessment Reference Date (ARD) of the Quarterly MDS is within 92 days (ARDof most recent OBRA assessment +92 days) after the ARD of the previous OBRA assessment (Quarterly, Admission, Annual, Significant Change in Status, Significant Correction to Prior Comprehensive or Quarterly assessment) AND
• The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days).If the resident has experienced a significant change in status, the next quarterly review is due no later than3 months after the ARD of the Significant Change in Status Assessment.For information on assessment scheduling for the MDS, see Chapter 2 of the Long-Term Care FacilityResident Assessment Instrument 3.0 User’s Manual.Link to the LTCF RAI User’s Manual: https://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.NOTE: The Quarterly MDS does not require the completion of Care Area Assessments (CAAs). However, the resident’s care plan must be reviewed and revised by the interdisciplinary team after each assessment as required at §483.21(b)(2)(iii).PROBES §483.20(c)

• Does the facility assess residents, using the CMS-specified quarterly review assessment, no less than once every 3 months, between comprehensive assessments?

 

• Is there evidence of resident and/or resident representative participation in the assessment process? Examples include participating in the resident interviews and providing information about preferences or discharge goals.

F639
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.20(d) Use
A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan.

INTENT §483.20(d)

Facilities are required to maintain 15 months of assessment data in each resident’s active clinical record.

GUIDANCE §483.20(d)

The requirement to maintain 15 months of data in the resident’s active clinical record applies regardless of form of storage to all Minimum Data Set (MDS) records, including the Care Area Assessment (CAA) Summary, Quarterly Assessment records, Identification Information and Entry, Discharge and ReentryTracking Records and MDS Correction Requests (including signed attestation). MDS assessments must be kept in the resident’s active clinical record for 15 months following the final completion date for all assessments and correction requests. Other assessment types require maintaining them inthe resident’s active clinical record for 15 months following:

• The entry date for tracking records including re-entry; and
• The date of discharge or death for discharge and death in facility records.Facilities may maintain MDS data electronically regardless of whether the entire clinical record is maintained electronically and regardless of whether the facility has an electronic signature process in place. This is in accordance with state and local law, and when this is authorized by the long- term care facility’s policy.Facilities that maintain their MDS data electronically and do not utilize an electronic signature process must ensure that hard copies of the MDS assessment signature pages are maintained for every MDS assessment conducted in the resident’s active clinical record for 15 months. (This includes enough information to identify the resident and type and date of assessment linked with the particular assessment’s signature pages),The information, regardless of form of storage (i.e., hard copy or electronic), must be kept ina centralized location and must be readily and easily accessible. This information must be available to all professional staff members (including consultants) who need to review the information in order to provide care to the resident. (This information must also be made readily andeasilyaccessibleforreviewbytheStateSurveyagencyandCMS.) Residentspecific information must also be available to the individual resident; if there are concerns, please refer to F573.

After the 15-month period, 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, the State agency, or CMS. NOTE: States may have more stringent requirements for this process.

If there are concerns about how the results of the resident assessment are used to develop, review and revise the resident’s comprehensive care plan – See §483.21(b)(2)(iii), F657.

F640
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident’s assessment, a facility must encode the following information for each resident in the facility:

(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident’s transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident’s assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident’s assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:

(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident’s transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on

resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

INTENT §483.20(f)(1-4)

To ensure that facilities have provided resident specific information for payment and quality measure purposes.

To enable a facility to better monitor each resident’s decline and progress over time. Computer- aided data analysis facilitates a more efficient, comprehensive and sophisticated review of health data.

DEFINITIONS §483.20(f)(1-4)
“Accurate” means that the encoded MDS data matches the MDS form in the clinical record. Also refer to guidance regarding accuracy at §483.20(g), and the information accurately reflects the resident’s status as of the Assessment Reference Date (ARD).

“Background (face-sheet) information” refers to the MDS Entry tracking record

“Capable of transmitting” means that the facility has encoded and edited according to CMS specifications, the record accurately reflects the resident’s overall clinical status as of the assessment reference date, and the record is ready for transmission.

“Complete” means that all items required according to the record type, and in accordance with CMS’ record specifications and State required edits are in effect at the time the record is completed.

“Discharge subset of items” refers to the MDS Discharge assessment.

“Encoding” means entering information into the facility MDS software in the computer.

“Passing standard edits” means that the encoded responses to MDS items are consistent and within range, in accordance with CMS-specified standards. In general, inconsistent responses are either not plausible or ignore a skip pattern on the MDS. An example of inconsistency would be if one or more MDS items on a list were checked as present, and the “None of the Above” response was also checked for the same list. Out of range responses are invalid responses, such as using a response code of 2 for an MDS item for which the valid responses are zero or 1.

“Transmitted” means electronically transmitting to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, an MDS record that passes CMS’ standard edits and is accepted into the system, within 14 days of the final completion date, or event date in the case of Entry and Death in Facility situations, of the record.

“Transmitting data” refers to electronically sending encoded MDS information, from the facility to the QIES ASAP System.

GUIDANCE §483.20(f)(1-4)

Facilities are required to encode MDS data for each resident in the facility.

Facilities are required to electronically transmit MDS data to the CMS System for each resident in the facility. The CMS System for MDS data is named the QIES ASAP System.

Facilities are responsible to edit the encoded MDS data to ensure that it meets the standard edit specifications.

For §483.20(f)(1)(v), the subset of items required upon a resident’s entry, transfer, discharge and death are contained in the Entry and Death in Facility Tracking records and Discharge assessments. Refer to Chapter 2 of the Long-Term Care Resident Assessment Instrument User’s Manual for further information about these records.

All nursing homes must computerize MDS information. The facility must edit MDS information using standard CMS-specified edits, revise the information to conform to the edits and to be accurate, and be capable of transmitting that data to the QIES ASAP system within 7 days:

• For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), encoding must occur within 7 days after the Care Plan Completion Date (V0200C2 + 7 days).
• For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date (Z0500B + 7 days).
• For a tracking record, encoding should occur within 7 days of the Event Date (A1600 + 7 days for Entry records and A2000 + 7 days for Death in Facility records).Submission must be according to State and Federal time frames. Therefore the facility must:

• Encode the MDS and CAAs Summary (where applicable) in machine readable format;

and
o Edit the MDS and CAA Summary (where applicable) according to edits specified by

CMS. Within the 7 day time period specified above for editing, the facility must revise any information on the encoded MDS and CAA Summary (if applicable) that does not pass CMS-specified edits, revise any otherwise inaccurate information, and make the information ready for submission. The MDS Vendor software used at the facility should have an automated editing process that alerts the user to entries in an MDS record that do not conform to the CMS-specified edits and that prompts the facility to complete revisions within the 7-day editing and revision period. After editing and revision, MDS information and CAA summary information (if applicable) must always accurately reflect the resident’s overall clinical status as of the original ARD for an assessment or the original event date for a discharge or entry.

Electronically submit MDS information to the QIES ASAP system within 14 days:
• Assessment Transmission: Comprehensive assessments must be transmitted electronically

within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

• Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records).

Only CMS-required MDS assessments (e.g., OBRA and Medicare Part A PPS) are permitted to be transmitted into the QIES ASAP System. Assessments completed to meet third party payer (i.e. private insurance or managed care) requirements cannot be transmitted to CMS. OBRA MDS assessments completed anytime a facility is NOT certified to participate in Medicare/Medicaid cannot be transmitted.

PROCEDURES §483.20(f)(1-4)

If the surveyor suspects the facility is not encoding and submitting assessments as required, the surveyor should review the facility’s MDS 3.0 NH Final Validation Report to verify assessment submission into the QIES ASAP System.

F641

(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident’s status.

INTENT §483.20(g)

To assure that each resident receives an accurate assessment, reflective of the resident’s status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident’s status, needs, strengths, and areas of decline.

GUIDANCE §483.20(g)

“Accuracy of Assessment” means that the appropriate, qualified health professionals correctly document the resident’s medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status).

Facilities are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

The determination of appropriate participation of health professionals must be based on the physical, mental and psychosocial condition of each resident. This includes an appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs.

The assessment must represent an accurate picture of the resident’s status during the observation period of the MDS. The Observation Period (also known as the Look-back period) is the time period over which the resident’s condition or status is captured by the MDS

assessment and ends at 11:59 p.m. on the day of the Assessment Reference Date (ARD). Be aware that different items on the MDS have different Observation Periods.

When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. In other words, if it did not occur during the observation period, it is not coded on the MDS.

Note: CMS is aware of situations where practitioners have potentially misdiagnosed residents with a condition for which antipsychotics are an approved use (e.g., new diagnosis of schizophrenia) which would then exclude the resident from the long-stay antipsychotic quality measure. For these situations, determine if non-compliance exists for the facility’s completion of an accurate assessment. This practice may also require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing.

The initial comprehensive assessment provides starting point data for ongoing assessment of resident progress.

PROBES §483.20(g)

• Based on your total review of the resident, observations, interviews and record reviews, does each portion of the MDS assessment accurately reflect the resident’s status as of the Assessment Reference Date?
• Is there evidence that the health professionals who assessed the resident had the skills and qualifications to conduct the assessment? For example, has the resident’s nutritional status been assessed by someone who is knowledgeable in nutrition and capable of correctly assessing a resident?F642
  (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)§483.20(h) Coordination.
  A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.§483.20(i) Certification.
  §483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.§483.20(j) Penalty for Falsification.
  §483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly—(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or

(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.

§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

INTENT §483.20(h)-(i)

Each resident’s assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed.

GUIDANCE §483.20(h)-(j)

Whether Minimum Data Set (MDS) assessments are manually completed, or computer-generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident’s condition and discharge or entry status. Manually completed forms are signed and dated by each individual assessor the day they complete their portion(s) of the assessment.

Electronic Signatures

When MDS forms are completed directly on the facility’s computer (i.e., no paper form has been manually completed), then each individual assessor signs and dates a computer-generated hard copy, or provides an electronic signature, after they review it for accuracy of the portion(s) they completed.

Facilities may use electronic signatures on the MDS when permitted to do so by state and local law and when this is authorized by the facility’s policy. Additionally, the facility must have written policies in place to ensure proper security measures are in place to protect use of an electronic signature by anyone other than the person to which the electronic signature belongs. The policy must also ensure access to a hard copy of clinical records is made available to surveyors and others who are authorized access to clinical records by law, including the resident and/or resident representative.

Facilities that are not capable of maintaining the MDS signatures electronically must adhere to the current federal requirements at §483.20(d) addressing the need for either a hand-written copy or a computer-generated form. All state licensure and state practice regulations continue to apply to certified facilities.

NOTE: Where state law or regulations are more restrictive than federal requirements, the provider needs to apply the state law standard.

Backdating Completion Dates – Backdating completion dates is not acceptable – note that recording the actual date of completion is not considered backdating. For example, if an MDS was completed electronically and a hard copy was printed two days later, writing the date the MDS was completed on the hard copy is not considered backdating.

Patterns of MDS Assessment and Submissions

MDS information serves as the clinical basis for care planning and care delivery and provides information for Medicare and Medicaid payment systems, quality monitoring and public reporting. MDS information as it is reported impacts a nursing home’s payment rate and standing in terms of the quality monitoring process. A willfully and knowingly-provided false assessment may be indicative of payment fraud or attempts to avoid reporting negative quality measures.

All information recorded within the MDS Assessment must reflect the resident’s status at the time of the Assessment Reference Date (ARD).

A pattern within a nursing home of clinical documentation or of MDS assessment or reporting practices that result in higher Resource Utilization Group (RUG) scores, untriggering Care Area Assessments (CAAs) or unflagging Quality Measures (QMs), where the information does not accurately reflect the resident’s status, may be indicative of payment fraud or attempts to avoid reporting negative quality measures. Such practices may include, but are not limited to, a pattern or high prevalence of the following:

• Submitting MDS Assessments (including any reason(s) for assessment, routine ornon routine) or tracking records, where the information does not accurately reflect the resident’s status as of ARD, or the Discharge or Entry date, as applicable;
• Submitting correction(s) to information in the Quality Improvement Evaluation System Assessment Submission and Processing (QIES ASAP) where the corrected information does not accurately reflect the resident’s status as of the original ARD,or the original Discharge or Entry date, as applicable, or where the record it claims to correct does not appear to have been in error;
• Submitting Significant Correction Assessments where the assessment it claims to correct does not appear to have been in error;
• Submitting Significant Change in Status Assessments where the criteria forsignificant change in the resident’s status do not appear to be met;
• Delaying or withholding MDS Assessments (including any reason(s) for assessment, routine or non-routine), Discharge or Entry Tracking information, or correction(s) to information in the QIES ASAP system.PROCEDURES AND PROBES §483.20(h)-(j)

• When such patterns or practices are noticed, they should be reported by the State Agency to the Regional Office and Medicaid Fraud Control Unit.
• Are the appropriate certifications in place, including the RN Coordinator’s certification of completion of an MDS assessment or Correction Request, and the certification of individual assessors of the accuracy and completion of the portion(s) of the assessment or tracking record completed?

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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