|(a) All coded items on minimum data set (MDS) assessments
must be accurate and supported by documentation in the recipient's
clinical record. Completion of the MDS assessment does not remove
the nursing facility provider's responsibility to document in the
clinical record a detailed assessment of all relevant issues that
affect the recipient.
(1) Clinical documentation must contain individualized
care plans and document pertinent facts, findings, and observations
about an individual's health history, including past and present illnesses,
treatments, and outcomes to support the assessment and the care provided.
(2) Sources of information, such as other health care
professionals and family members, utilized for the MDS assessment
must be identified in the clinical record.
(3) Clinical records must include the recipient's name
and the signatures, dates of signatures, and titles of individuals
providing care for the recipient.
(4) Documents, such as grids and flow sheets that include
entries by multiple staff members at different times, must include
complete dates with initials or signatures to clearly identify who
provided the care. For purposes of this paragraph, a signature may
be an original handwritten signature or an electronic signature as
set out in Texas Business and Commerce Code Chapter 322 (relating
to the Uniform Electronic Transactions Act).
(b) MDS items that are inaccurate or unsupported by
documentation in the recipient's clinical record may result in an
adjustment in the RUG classification of a recipient.
(c) A nursing facility provider that utilizes an electronic
clinical record system must maintain MDS assessments in the recipient's
clinical record in accordance with the Resident Assessment Instrument
(RAI) User's Manual.
(d) Nursing facility resident records must be maintained
in accordance with the nursing facility provider's contract with HHSC
and all applicable state and federal law, rules, and policy, including:
(1) 26 TAC Chapter 554 (relating to Nursing Facility
Requirements for Licensure and Medicaid Certification);
(2) 1 TAC §354.1004 (relating to Retention of
(3) 45 C.F.R. Parts 160 and 164; and
(4) the RAI User's Manual.