Long-Term Care Survey Alert

Published on Wed Apr 27, 2005 PDF

RAI update clarifies requirement to maintain hard copies for surveyors.

Facilities that maintain their MDSs electronically will find themselves out of the paper chase come May 1.

As of that date, facilities with electronic MDSs don't have to maintain 15 months' worth of MDSs in the resident's active clinical record, according to a Resident Assessment Instrument manual update.

The clarification makes sense given that the Bush Administration endorses an initiative to have all health records electronic within a decade. "The Centers for Medicare & Medicaid Services would have been inconsistent, if not disingenuous, to continue to insist facilities [with electronic MDSs] keep 15 months of hard copy MDSs on the unit," says Marie Infante, an attorney with Mintz Levin in Washington, DC.

But providers that haven't gone electronic with their MDSs must keep 15 months' worth of hard copies of the assessment information in residents' active clinical records. This includes all MDS forms, RAP summary forms and quarterly assessments as required during the previous 15-month period. But either a hand-written or computer-generated form will suffice, says the update.

Facilities don't have to keep the resident's RAI information in the actual chart - for example, they could maintain it in a folder on the unit and readily accessible to clinicians and surveyors.

When can you thin? After the 15-month period, facilities may remove the RAI information from the clinical record and store it in the medical records department. But make sure the information is readily available if surveyors ask for it. Keep the face sheet information (Section AB, AC, and AD) in the active record until the facility discharges the resident permanently.

Readmissions Don't Restart the Clock

The 15-month period for maintaining assessment data does not restart with each readmission to the facility, states the manual update. "In some cases when a resident is out of the facility for a short period (i.e., hospitalization), the facility must close the record because of state bed hold policies," CMS acknowledges.

When the resident then returns to the facility and is "readmitted," the facility must open a new record. The facility may copy the previous RAI and transfer a copy to the new record. But unless the facility maintains electronic MDSs, it should place a copy of the previous 15 months of assessment data in the new record.

If the resident returns to the facility after a long break in care (for example, 14.5 months), "staff may want to review the older records" to get up to speed on the resident's history and care needs, says CMS. But facility policy rather than CMS requirements would dictate whether the facility maintains the resident's prior stay record in the current chart.

Facilities may develop their own specific policies regarding how to handle readmissions, including linking the prior electronic MDS to the new admission record, the manual states.

What About Shorter Breaks in Care?

The RAI manual update doesn't address instances in which the resident is discharged permanently but returns unexpectedly within several months. The RAI manual clarification doesn't tie the directions for maintaining the RAI information to the type of discharge (discharge with return anticipated versus a permanent discharge), says Judy Wilhide, RN, BA, RAC-C, the RAI manager for Virginia.

Thus, pending further CMS clarification, Wilhide advises providers in Virginia to focus on the length of time the resident has been out of the facility rather than the type of discharge. (Wilhide notes her advice applies to Virginia, as that state is her purview.)

In such cases, facilities should err on the side of caution by maintaining the 15 months of required RAI information in the active clinical record, Wilhide advises. "The information helps provide more history about that patient, which can improve care," she says.