Federal regulators sent nursing home operators and their MDS personnel scurrying for favorite reading spots Monday after they released finalized item sets and 450 pages of heavily updated draft Resident Assessment Instrument (RAI) manual changes.

While experts said their initial checks did not reveal major surprises, they added that the enormity of what is changing represents an extremely serious undertaking to prepare for. Changes will take effect Oct. 1.

At almost 400 pages longer than the previous manual, Monday’s release has not only new item coding instructions but additional definitional and coding instructions for current items. 

“This is just the beginning of a complex and large educational and procedural change for all facilities,” explained Leah Klusch, the executive director of the Alliance Training Center. “Planning will be very important as well as delegation of resources to plan for this important transition. This is an enormous document that will need considerable study and focus.”

Providers would do well to embrace the changes, said Veronica James, vice president, clinical reimbursement for Health Dimensions Group.

“While many of the changes were not a surprise, the biggest takeaway is that, clearly, CMS wants resident voices to shine ─ and, as a profession, we need to step up our game,” James told McKnight’s Long-Term Care News Monday. “Now that we have some much-needed clarification, we can finally act, prepare and train so we are ready come October 1. To ensure a smooth transition and accurate coding, providers should focus on educating team members, especially in rural communities where the MDS coordinator may hold two or three job titles.”

It’s “important” that operators realize the voluminous changes “are not just a burden to the MDS process or nurse assessment coordinators but are an overall burden on the provider,” said Jessie McGill, curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).

“Take, for example, the transfer of health information measure items,” she told McKnight’s. “This October, the MDS will be coded for transfer of health information, but it is the responsibility of the clinical team to complete the process for medication reconciliation at discharge.”

The revisions to the RAI users manual are “very extensive,” McGill said.

“Some of the changes will not have a huge impact on providers, such as the change in wording to gender neutral language,” she explained. “But many of the other changes will have a significant impact.”

Key sections get fresh treatment

Most of the changes were expected, including the retirement of section G, the new standardized patient assessment data elements (SPADEs) items, and the data elements for the transfer of health information measures. They will have a substantial impact on policy, procedures and workflow for providers.

The retirement of section G will be especially felt in states that have incorporated section G (activities of daily living) into their state Medicaid payment models or performance models. Numerous states are currently transitioning their Medicaid payment models to components of the Patient Driven Payment Model, which makes transitioning to other RAI manual changes that much more complicated.

Providers should count on brushing up on the medication reconciliation process required at discharge from a Medicare stay, McGill advised. The draft RAI User’s Manual v1.18.11 provides guidance of what is often included in a reconciled medication list.

In addition to fairly standard information about diagnoses, dosages and any patient allergies or drug sensitivities, basic notes about administration timing, patient weight and expected duration of usage are expected.

“It is important to note that indication of use of the medication is not only included as part of the medication reconciliation, but it is also a new requirement in section N,” McGill said. “Providers with a system or process in place to ensure all medications have an appropriate indication of use documented in the medical record will be better prepared for these changes this October.”

Nurse assessment coordinators, who comprise a large percentage of McGill’s membership, also will be pleased to see tips added to some common coding questions, she said.

For example, in section K, CMS clarifies that a therapeutic diet must be prescribed by a physician or non-physician practitioner and that a trial of a mechanically altered diet should not be captured on the MDS. Another tip notes, for example, that Kennedy Terminal Ulcers are not coded in section M.

Social determinants rise

One of the SPADEs, Social Determinants of Health (SDOH), requires expanded ethnicity and race items at A1005 and A1010, noted expert Joel Van Eaton, master teacher and executive vice president of PAC Regulatory Affairs and Education at Broad River Rehab.

“In the FY 2023 Final Rule there was an RFI for Health equity,” he explained Monday. “The revised RAI manual addresses this initially with these expanded items. ‘The ability to improve understanding of and address ethnic disparities in health care outcomes requires the availability of better data related to social determinants of health, including race and ethnicity.’ Providers have not had to address these issues in the past. This will be an ongoing discussion.”

Other social determinants of health SPADEs include Preferred Language and Interpreter Services, Health Literacy, Transportation and Social Isolation. 

“SDOH is a new concept to the MDS,” Van Eaton observed. “It is being considered by CMS for quality reporting and Value Based Purchasing. These items will give providers expanded insight into their resident’s needs that they have not had to address as fully before. If used as CMS intends, addressing these correctly will help residents achieve the outcomes they desire.”

Providers also need to be aware that new coding considerations for many of the social determinants of health items are self-reported by residents.

“This means that regardless of medical record documentation or reports from family members or the resident’s representative, this information must come from the resident,” McGill emphasized. “For some of the items, if the resident is unable to respond, only then may the assessor proceed to ask a family member or the resident’s representative for the needed information.”

Staff can only use medical record documentation if the resident is unable to respond and no family member or representative provides a response. The coding must reflect that the resident is unable to respond. Exceptions to the requirement include the health literacy and social isolation items, which should only reflect the resident’s response, regardless of information provided by the resident’s family, their representative, or documentation in the medical record.

McGill also cautioned that there could be confusion generated by the look-back period for “A1250. Transportation,” which asks about lack of transportation “in the past six months to a year.”

“This question appears to be asking about the tasks that would have occurred prior to admission to the skilled nursing facility, such as lack of transportation keeping the resident from medical appointments, getting medication, other appointments or work,” she observed. “However, the instructions in the draft manual do not exclude the time spent in the SNF.”

‘Devastating’ depression link

Van Eaton said CMS gives a good example on page N-11 about what it is looking for specifically related to indication. 

“Indication for use may be a challenging item for some providers. It will also shed a brother light on inappropriate diagnosing for schizophrenia,” he said. 

“It is now clear that the new PHQ 2-9 could have a devastating impact on the way that depression represents in PDPM,” he added. “Guidelines are specific in both chapter 3 and chapter 6 that If the first two item symptom frequency are coded 0 or 1, the interview is to be stopped. The depression end split still requires a PHQ 2-9 score of 10 or greater. That will be impossible if the first two items are scored 0 or 1,  regardless of how the remaining 7 items would have been answered.”

Like other experts consulted for this article, Van Eaton praised Monday’s releases for bringing greater clarity, more examples and consistency so that reporting can better answer mandates in the IMPACT Act, among other needs.

“There are expanded, helpful definitions in Appendix A,” he added. “Providers will not want to overlook this.”

While the Optional State assessment (OSA) and the instructions for completing it will be released as separate packages later this month or in early May, he added, the final version of RAI Manual v1.18.11 can be expected later this summer.