A facility must conduct, initially and periodically, a comprehensive,
accurate, standardized, reproducible assessment of a resident's functional
capacity. The facility must electronically transmit to CMS resident-entry-and-death-in-facility
tracking records required by the RAI; and OBRA assessments, including
admission, annual, quarterly, significant change, significant correction,
and discharge assessments.
(1) Admission orders. At the time a resident is admitted,
the facility must have physician orders for the resident's immediate
care.
(2) Comprehensive assessments.
(A) A facility must make a comprehensive assessment
of a resident's needs, strengths, goals, life history, and preferences,
using the current RAI process, including the MDS, Care Area Assessment
process, and the Utilization Guidelines specified by HHSC and approved
by CMS. The current RAI process is found in the MDS 3.0 manual posted
by CMS on http://www.cms.gov.
(B) A facility must conduct an additional assessment
and document the summary information if the MDS indicates an additional
assessment on a care area is required.
(C) A facility must conduct a comprehensive assessment
of a resident as follows:
(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 for therapeutic leave;
(ii) within 14 calendar 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 purposes 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 comprehensive care plan, or both; and
(iii) not less often than once every 12 months.
(3) Quarterly review assessment. A facility must assess
a resident using the quarterly review instrument specified by HHSC
and approved by CMS not less frequently than once every three months.
(4) 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 as specified in §19.802
of this subchapter (relating to Comprehensive Person-Centered Care
Planning).
(5) PASRR. A Medicaid-certified facility must:
(A) coordinate assessments with the PASRR process in
42 CFR, Part 483, Subpart C to the maximum extent practicable to
avoid duplicative testing and effort, including:
(i) incorporating the recommendations from the PASRR
level II determination and the PASRR evaluation report into a resident's
assessment, care planning, and transitions of care; and
(ii) referring a level II resident and a resident suspected
of having mental illness, an intellectual disability, or a developmental
disability for level II resident review upon a significant change
in status assessment; and
(B) promptly report a significant change in the mental
or physical condition of a resident by submitting an MDS Significant
Change in Status Assessment Form in the LTC Online Portal, in accordance
with §19.2704(i)(12) of this chapter (Nursing Facility Responsibilities
Related to PASRR).
(6) Automated data processing requirement.
(A) A facility must complete an MDS for a resident.
The facility must enter MDS data into the facility's assessment software
within 7 days after completing the MDS and electronically transmit
the MDS data to CMS within 14 days after completing the MDS.
(B) A facility must complete the Long Term Care Medicaid
Information form on an OBRA assessment that is submitted to the state
Medicaid claims system for a Medicaid recipient or Medicaid applicant
according to HHSC instructions located on the Texas Medicaid Healthcare
Partnership Long Term Care Portal at http://www.tmhp.com.
(C) Data format. The facility must transmit MDS data
to CMS in the format specified by CMS and HHSC.
(D) Information concerning a resident is confidential
and a facility must not release information concerning a resident
except as allowed by this chapter, including §19.407 of this
chapter (relating to Privacy and Confidentiality) and §19.1910(d)
of this chapter (relating to Clinical Records).
(7) Accuracy of assessments. The assessment must accurately
reflect the resident's status.
(8) Coordination. A registered nurse must conduct or
coordinate each assessment with the appropriate participation of health
professionals.
(9) Certification.
(A) A registered nurse must sign and certify that
the assessment is completed.
(B) Each individual who completes a portion of the
assessment must sign and certify the accuracy of that portion of the
assessment.
(10) Penalty for falsification under Medicare and Medicaid.
(A) 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 of not more than $5,000 for each assessment.
(B) Clinical disagreement does not constitute a material
and false statement.
(11) Use of independent assessors in Medicaid-certified
facilities and dually certified facilities. If HHSC determines, under
a certification survey or otherwise, that there has been a knowing
and willful certification of false statements under paragraph (10)
of this section, HHSC may require (for a period specified by HHSC)
individuals who are independent of the facility and who are approved
by HHSC to conduct and certify the resident assessments under this
section.
(12) Pediatric resident assessment.
(A) A facility must ensure that a pediatric assessment:
(i) is performed by a licensed health professional
experienced in the care and assessment of children;
(ii) includes parents or guardians in the assessment
process; and
(iii) includes a discussion with a parent or guardian
about the potential for community transition.
(B) The clinical record of a child must include a record
of immunizations, blood screening for lead, and developmental assessment.
The local school district's developmental assessment may be used if
available.
(C) A licensed health professional must assess a child's
functional status in relation to pediatric developmental levels, rather
than adult developmental levels.
(D) A facility must ensure pediatric residents receive
services in accordance with the guidelines established by the Department
of State Health Services' Texas Health Steps (THSteps). For Medicaid-eligible
pediatric residents between the ages of six months and six years,
blood screening for lead must be done in accordance with THSteps guidelines.
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| Source Note: The provisions of this §554.801 adopted to be effective October 1, 1999, 24 TexReg 7767; amended to be effective January 1, 2000, 24 TexReg 11522; amended to be effective May 1, 2002, 27 TexReg 2834; amended to be effective June 1, 2006, 31 TexReg 4457; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
