The National Department of Health and Human Services states that a resident nursing home assessment is one of the critical components of care for you or your loved one when they enter a nursing home facility. The Nursing Home Reform Act mandates that nursing homes use a clinical assessment tool known as the Resident Assessment Instrument (RAI) to identify their resident’s strengths, weaknesses, preferences, and needs in key areas of functioning.

1 - The RAI is supposed to be used to provide individual care.

Residents respond to individual care rather than being sorted and grouped with like-type conditions. Many facilities have discovered that when they create a personalized care plan for each resident, considering their specific problems and underlying causes, residents tend to achieve their goals more successfully. Additionally, their level of functioning either improves or declines at a slower pace.

2 - An RAI must be completed for any resident residing in the facility longer than 14 days .

If you or a loved one of yours will be living in a nursing home facility, especially if that facility is part of the Medicare system, then the Resident Assessment must be completed for that resident. This also includes residences for Hospice facilities. Short-term stay residents must have the assessment completed unless they will be staying less than 14 days.

3 - An RAI must be conducted OR coordinated by a Registered Nurse (RN)

Facilities have the flexibility to determine accurately who should participate in the assessment process. While many facilities have licensed health professionals complete the assessment, an RN must coordinate, certify, and sign off on the RAI. Sometimes, facilities may not have a Registered Nurse on staff, but it's important to know that they still must provide an RN to complete the RAI.

4 - The Minimum Data Set (MDS) must be compiled in specific intervals.

When a resident is admitted to a facility, they must be completely assessed within the first 14 days of admission. This means that the MDS is one of the components of the RAI. If a significant change occurs in the patient's mental or physical condition, a new MDS must also be compiled within a 14-day period. Each resident must also collect a yearly MDS according to the Quality of Care guidelines.

5 - The RAI should determine the Plan of Care for the patient.

Developing a comprehensive care plan is crucial to ensuring that every resident receives the best possible care. It helps prevent avoidable decline and focuses on building and enhancing their current strengths, ensuring that they lead a fulfilling rest of their lives. Creating a meaningful care plan requires taking into consideration the individual characteristics of each resident.

Terms that were discussed in this article:

CMS - Centers for Medicare and Medicaid Services
HHS - Department of Health and Human Services
RAI - Resident Assessment Instrument
RN - Registered Nurse
MDS - Minimum Data Set

This article referred to the Nursing Home Resident Assessment: Quality of Care (OEI-02-99-00040) and CMS's RAI Version 2.0 Manual.

NOTE: Subscribers to Safe Secure Seniors can find a printable checklist to use when going to evaluate a facility under the Resources tab in the top menu.