The finer points of the RAI: how effective leadership can deliver quality care and proper reimbursement.

Accurate and effective use of the Resident Assessment Instrument (RAI) in skilled nursing facilities has many significant benefits, including providing proper reimbursement, improving quality of care, increasing survey compliance, and decreasing potential liability. This much you know.

But certain decisions made by the administrative team--such as those pertaining to key personnel and the allocation of resources for training--greatly affect the interdisciplinary care team's success with the RAI, including the Minimum Data Set (MDS) and the resident assessment protocols (RAP). Even if frontline staff are skilled in the particulars of the MDS, do they have the guidance they need to make sure the RAI process is working to the facility's advantage?

There are several things you can do to ensure successful RAI management, including the following:

Stay up to date with procedural changes

It is important to establish with your MDS coordinator the expectation that he or she remain current with regulatory changes, CMS updates, and other information concerning the RAI. A key question to ask a potential MDS coordinator or your current coordinator is, "How will you remain up to date on changes affecting the RAI?" If your coordinator can't effectively answer that question, there are problems at square one.

Recently, while reviewing records during a consulting engagement, I noted that the resident whose chart I was reviewing was having his stay covered by Medicare; however, I was unable to determine the reason for coverage.

When I asked the MDS coordinator the reason for coverage, she informed me that the resident had a stage one pressure ulcer for which the resident received a daily nursing treatment. After I told her that to be considered a skilled nursing service according to Medicare guidelines a pressure ulcer needed to be a stage three or greater, or be a widespread disorder, she adamantly disagreed, citing her Medicare manual as the source of her information.

Do your staff know how to stay current with MDS changes?

I asked her to share the reference with me. The nurse returned with a manual published by the Health Care Financing Administration (HCFA). HCFA, of course, was renamed CMS in June 2001--meaning the manual that the MDS coordinator was using was more than five years old!

Ensure complete policies and procedures 

Policies and procedures related to the RAI need to address several key areas, including the following:

* Scheduling

* Staff accountability for specific parts of the process

* How to ensure involvement of residents and families

* Expectations for how staff collect, document, and communicate data to all other staff involved in the care of the resident

When I work with staff charged with scheduling the RAI, they often exhibit a poor understanding of the scheduling requirements. Upon auditing resident records, I often find facilities that have either done too many assessments for short-stay residents or find instances of lacking or inappropriately used grace days.

For instance, successful MDS coordinators generally do not schedule an entire 100-day prospective payment system schedule of assessments at once. Rather, they consider the scheduling of each assessment as an individual task. By doing so, the MDS coordinator is able to evaluate the resident's status, including attendance in scheduled therapy, and determine which schedule is best to capture appropriate reimbursement.

Stress that it's a team effort--and get your team educated

The Office of Inspector General's February 2006 report A Review of Nursing Facility Resource Utilization Groups highlighted the problems that nursing homes continue to face with MDS inaccuracy. The report concluded that 26% of all claims were incorrect, and the most frequent errors were miscounting physical and occupational therapy minutes and miscoding activities of daily living (ADL).

Improperly undercoding even one ADL can have significant financial implications. Here's an example of the financial impact of miscoding based on Nassau/Suffolk, NY, rates for 2007: For a resident who fell into the rehabilitation high category with an ADL score of 7, the facility would be reimbursed $380.45 per day. For the same resident whose ADL score was 8, the facility would receive $410.41. Over 10 days of Medicare coverage, the loss from one ADL point would be nearly $300.

A frequently problematic area regarding ADLs is the direct care staff's understanding of the terms used to describe those activities--especially when they code bed mobility. When providing education, be sure to target the night shift regarding this ADL.

The administrative team's role in the RAI process is a vital one--it must guide the frontline staff to ensure the best possible outcomes. By leading the staff to correctly use MDS data to identify problem or potential problem areas, the administrative team will ensure that the facility's continuous quality improvement plan focuses on appropriate areas of concern and ultimately improves the quality of care for the residents of the nursing home.

BY JENNIFER PETTIS, RN, RAC-C

RELATED ARTICLE: Watch your QM/QI reports.

Your initial task when investigating any elevated quality measures/quality indicators (QM/QI) is to ensure the accuracy of the data entered on the Minimum Data Set (MDS). By routinely monitoring MDS data through the use of QM/QI reports, the care team can identify emerging problems and promptly address them.

You can also use QM/QI reports to track the progress of resident outcomes in relation to the facility's continuous quality improvement (CQI) program. Because information regarding quality measures is available to the public on the Nursing Home Compare Web site, inaccurate MDS data can also cause potential litigation and public relations problems. (Go to www.Medicare.gov/NHCompare/Home.asp to check out what the public can see about your nursing home.)

Consider this example: MDS item 12j, urinary tract infection (UTI), has very specific coding instructions in the Resident Assessment Instrument (RAI) Users Manual, including the requirement for significant laboratory findings to be in the resident's record.

If staff code this item inaccurately without the supporting laboratory findings, the QM/QI will be inaccurately elevated. The first step in investigating residents who flag the facility's QM/QI reports for UTI is to confirm that the coding is accurate. This way, staff can detect any inaccuracies, such as this inaccurate coding, and correct them through the use of modification/correction request forms.

The CQI program should also include routine monitoring of RAI issues including scheduling practices, MDS coding, timeliness of completion and submission, and appropriateness of communications to the billing staff regarding those residents whose stays are covered by Medicare.--Jennifer Pettis, RN, RAC-C

Jennifer Pettis, RN, RAC-C, is a policy analyst and consultant for the New York Association of Homes and Services for the Aging. She began working in long-term care as a nurse assistant in 1988 and is a skilled nurse manager. Paris also provides training on the RAI through the State of New York at Albany's School of Public Health and is a master trainer for the American Association of Nurse Assesment Coordinators. E-mail her at [e-mail].