1. (a) Under 40 TAC §19.801 (relating to Resident Assessment), a nursing facility must conduct initially and periodically thereafter a comprehensive, accurate, standardized, reproducible assessment of each nursing facility recipient's functional capacity that describes the recipient's ability to perform daily life functions and significant impairments in functional capacity. The nursing facility must conduct the assessment using a Minimum Data Set (MDS) Resident Assessment Instrument (RAI) based on the MDS RAI Resource Utilization Group (RUG-III) 34-group case mix classification system selected by the state and established by the Centers for Medicare and Medicaid Services (CMS).

   1. (1) Requirements for completing the MDS are derived from the RAI, including the MDS, specified by the Department of Aging and Disability Services (DADS). The nursing facility must adhere to any updates released by CMS in addition to the state specific mandates. To the extent such CMS updates conflict with DADS specific mandates, the CMS updates shall control.
   2. (2) Completion of the MDS does not remove the nursing facility's responsibility to document in a clinical record a detailed assessment of all relevant issues that affect the recipient. All clinical record documentation must chronicle, support, and be consistent with the findings of, rather than conflict with, each MDS assessment. Documentation in the clinical record must contain pertinent facts, findings, and observations about an individual's health history including past and present illnesses, treatments, and outcomes to support the care the recipients are receiving. Inconsistent and unsupported findings will not be validated and may result in an adjustment in the RUG-III classification.
   3. (3) All coded items on MDS assessments submitted for Medicaid reimbursement must be supported by documentation in the recipient's clinical record. Sources of information (e.g., other health care professionals, family members) utilized for the MDS assessment must be identified and must be supported by the clinical record.

   4. (4) Nursing facility resident records must be maintained in accordance with:

      1. (A) 40 TAC §19.1910 (relating to Clinical Records);
      2. (B) 40 TAC §19.1912 (relating to Additional Clinical Record Service Requirements);
      3. (C) 40 TAC §19.1210 (relating to Certification and Recertification Requirements in Medicaid-Certified Facilities);
      4. (D) 40 TAC §19.1924 (relating to Financial Records), including supporting documents and other records necessary to fully document the services and supplies provided and delivered to the resident, the medical necessity of those services and supplies, and records or documents necessary to determine whether payment for those items or services was due and was properly made;
      5. (E) Section 354.1004 of this title (relating to Retention of Records) which requires a facility to maintain all records necessary to fully disclose the services provided and to retain these records for a period of five years from the date of the service, or until all audit questions are resolved, whichever is longer;
      6. (F) the Health Insurance and Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 United States Code §§1320d-1320d-8;
      7. (G) 45 Code of Federal Regulations Parts 160 and 164 (relating to Health Insurance Reform: Security Standards); and
      8. (H) accepted professional health information management standards and practices.
   5. (5) Documentation must have the recipient's name, and the signatures, dates of signatures, and titles of individuals providing care for the recipient. 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 subchapter, a signature may be an original handwritten, electronic, photocopier, or facsimile transmitted signature or an electronic signature submitted in compliance with HHSC policy unless the authenticity of the signature is in doubt.

2. (b) An admission comprehensive assessment must be completed by day 14 and include the Basic Assessment Tracking form and MDS Sections AA, AB-AD, A-R, Sections V and W. The annual assessment must be completed no later than the 366th day from the last comprehensive assessment and no later than 92 days from the previous assessment.

   1. (1) The MDS Long-Term Care Medicaid Information Section and Section W must be completed on all MDS assessments submitted for Medicaid.
   2. (2) An admission assessment or quarterly assessment will establish RUG-III classification. Medical necessity is evaluated each time an MDS assessment is completed, until permanent medical necessity (PMN) is established by the Texas Medicaid claims administrator (MCA), as set out in 40 TAC §19.2403 (relating to Medical Necessity Determination).
   3. (3) A significant-change assessment must be completed as soon as needed to provide appropriate care to the resident, but in no case later than 14 calendar days after the determination was made that a significant change occurred. The nursing facility must document the significant change in condition. The documentation must include a completed comprehensive MDS assessment with Resident Assessment Protocols (RAPS). A significant change assessment resets the schedule for the next annual assessment.
   4. (4) A quarterly assessment following an admission assessment, an annual assessment, or a significant change-in-status assessment must be completed within 92 days of the previous assessment.
   5. (5) An MDS assessment is considered complete on the date the registered nurse (RN) assessment coordinator signs and dates the MDS assessment as complete. That date may not be prior to dates for all sections completed.
   6. (6) The MDS assessment is considered timely if it is submitted in accordance with the federal MDS submission schedule and is received by the state MCA within 31 days after the completion date.
   7. (7) Each MDS assessment submitted must indicate the reason for the assessment.
   8. (8) Assessment time frames are based on the assessment reference date (ARD), which is the specific end-point for a common observation period (look back period) in the MDS assessment process.

3. (c) All MDS items shall be coded in accordance with 42 Code of Federal Regulations §483.20 (relating to Resident Assessment); the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument User's Manual (RAI User's Manual); and state specific requirements. Coding for items described in this subsection must be based on observations over the look back period specified. If the observation did not occur during the look back period, it is not coded on the MDS.

   1. (1) Cognitive Patterns. The look back period for items described in this paragraph is seven days.

      1. (A) Comatose Code One is claimed only when the recipient's clinical record includes a documented neurological diagnosis of coma or persistent vegetative state. The clinical record must include physician documentation of a diagnosis of coma or persistent vegetative state.
      2. (B) Short-Term Memory Code One is claimed when it is determined that the recipient lacks the functional capacity to recall recent events. Documentation in the clinical record must support the resident's capacity to remember short-term events.
      3. (C) For Cognitive Skills for Daily Decision Making, code the correct response between zero and three that supports the recipient's level of ability based on the clinical record. The recipient's clinical record must include documentation describing the recipient's actual performance in making everyday decisions about tasks or activities of daily living.
   2. (2) Communication/Hearing Patterns. For Making Self Understood, code the correct response between zero and three that supports the recipient's level of ability to make himself or herself understood. The recipient's clinical record must support the resident's level of ability to express or communicate requests, needs, opinions, urgent problems, and social conversation, whether in speech, writing, sign language, or a combination of these. The look back period is seven days.

   3. (3) Mood and Behavior Patterns.

      1. (A) For Indicators of Depression, Anxiety and Sad mood, code between zero and two based on documented interactions and observations of the recipient. The recipient's clinical record must support the frequency of the indicators of depression, anxiety, and/or sad mood. The look back period is 30 days.
      2. (B) For Behavioral Symptoms, code between zero and three the frequency of behavioral symptoms manifested by the resident across all three shifts as it occurred during the look back period. The look back period is seven days. Record the frequency of behavioral symptoms manifested by the resident across all three shifts.

   4. (4) Physical Functioning and Structural Problems. The look back period for items described in this paragraph is seven days.

      1. (A) For Self Performance, code between zero and four or eight for self performance by the recipient in bed mobility, transfer, eating, and toilet use during the look back period. The clinical record must capture the total picture of the recipient's actual self care performance for each activity of daily living (ADL) over the seven day period, 24 hours a day.
      2. (B) For ADL Support Provided, code from zero and three or eight to support assistance provided by staff in bed mobility, transfer, and toilet use. The clinical record must reflect the support provided by staff, for each ADL, over a 24-hour period, during the look back period.

   5. (5) Continence Appliances and Programs. The look back period for items described in this paragraph is 14 days.

      1. (A) For Scheduled Toileting Plan, check if recipient is on any scheduled toileting program. The documentation must include a plan for bowel and/or bladder elimination whereby staff members at scheduled times each day either take the recipient to the toilet, give the recipient a urinal, or remind the recipient to go to the toilet. This includes bowel habit training and/or prompted voiding, but does not include changing wet garments. A "program" refers to a specific approach that is organized, planned, documented, monitored and evaluated. The recipient's toileting schedule must be in a place where it is clearly communicated, available to and easily accessible to all staff. The care plan must indicate the recipient is on a routine toileting schedule.
      2. (B) For Bladder Retraining Program, check if recipient is on any bladder retraining program that is a retraining program to teach the recipient to consciously delay urinating or to resist the urge to urinate. The care plan must include individualized goals and approaches that is organized, planned, documented, monitored, and evaluated.

   6. (6) Disease Diagnosis. The disease conditions described in this paragraph require a physician-documented diagnosis in the clinical record. The look back period is seven days.

      1. (A) For Diseases, code diabetes, aphasia, cerebral palsy, hemiplegia/hemiparesis, multiple sclerosis and/or quadriplegia if there is a documented physician diagnosis in the clinical record. Include active diagnoses only; do not include conditions that have been resolved or have not affected the recipient's functioning, medical treatment, or care plan.
      2. (B) For Infections, code pneumonia and/or septicemia, if the infection was present with a documented relationship to the recipient's current functioning, medical treatment, or care plan. A physician documented diagnosis in the clinical record is required to code this item.

   7. (7) Health Conditions. The look back period for items described in this paragraph is seven days. As applicable, review the clinical records (including the current nursing care plan) and consult with facility staff members and resident's family if the resident is unable to respond.

      1. (A) For Problem Conditions, code documented problems or symptoms that affect or could affect the recipient's health or functional status and to identify risk factors for illness, accident, and functional decline, as they occurred during the look back period.

      2. (B) For Dehydrated; Output Exceeds Intake Code only if the recipient has at least two of the following indicators:

         1. (i) Receives less than 1500ml fluids daily;
         2. (ii) One or more clinical signs or symptoms of dehydration; or
         3. (iii) Fluid loss exceeds daily intake.
      3. (C) For Delusions, the recipient's clinical record must support that the recipient holds fixed, false beliefs not shared by others based on observation during the look back period.
      4. (D) For Fever, include documentation that the recorded temperature of 2.4 degrees Fahrenheit or greater than the documented established baseline for that recipient was observed during the look back period.
      5. (E) For Hallucinations, the recipient's clinical record must support the recipient's false sensory perceptions that occur in the absence of any real stimuli as observed and documented during the look back period.
      6. (F) For Internal bleeding, the clinical record must support frank or occult bleeding in the clinical record based on observations during the look back period, excluding simple nosebleeds that are easily controlled.
      7. (G) For Vomiting, the clinical record must support that regurgitation of stomach contents occurred during the look back period.
   8. (8) Oral/Nutritional Status. For Weight Change, code zero or one for weight loss. Code one if there is documented evidence of weight loss of 5% as observed during a 30-day look back period, or 10% or more as observed during a 180-day look back period. Do not round the actual weight. If a recipient cannot be weighed, the facility must use the standard no-information code.

   9. (9) Nutritional Approaches. The look back period for items described in this paragraph is seven days.

      1. (A) For Parenteral/Intravenous, check if there is documentation that the recipient received parenteral and/or intravenous fluids administered for nutrition or hydration during the look back period. This item can only be coded if there is supporting documentation that reflects an identified need for additional fluid intake for nutrition and/or hydration.
      2. (B) For Feeding Tube, check if there is documentation that supports the presence of any type of tube that can deliver food, nutritional substances, fluids, and/or medications directly into the gastrointestinal system.

      3. (C) Parenteral or Enteral Intake. The look back period for items described in this paragraph is seven days.

         1. (i) For Total Calories, code between zero and four for the documented proportion of total calories actually received by the recipient via parenteral or tube feeding as observed during the look back period.
         2. (ii) Average Fluid Intake: Code between zero and five for the average documented fluid intake by intravenous or tube feeding received by the recipient each day as observed in the look back period. The actual amount of fluid the recipient received each day by this mode must be recorded.

   10. (10) Skin Condition. The look back period for items described in this paragraph is seven days.

       1. (A) For Ulcers, code between zero and nine, corresponding to the number of skin ulcers at each stage, due to circulatory problems or pressure, as observed during the look back period. A description of the wound must be documented in the clinical record during the look back period.
       2. (B) For Type of Ulcer, code between zero and four to indicate the highest staged pressure ulcer present as observed during the look back period. The staging of the pressure ulcer(s) must be coded as assessed, described and documented during the look back period.

   11. (11) Other Skin Problems or Lesions present. The look back period for items described in this paragraph is seven days.

       1. (A) For Burns (Second or Third Degree), check for the presence of burns, from any cause (e.g., heat, chemicals) and document in the clinical record. This category does not include first-degree burns.
       2. (B) For Open Lesions/Sores, check if documentation supports the presence of open skin lesion(s) that are not coded elsewhere. Do not code skin tears or cuts. A description of the lesions/sores must be documented in the clinical record during the look back period.
       3. (C) For Surgical Wounds, check if documentation supports the presence of healing and non-healing, open or closed surgical incisions, skin grafts or drainage sites, on any part of the body. This category does not include healed surgical sites, stomas, or lacerations that required suturing or butterfly closure. Peripherally inserted central venous catheters (PICC) sites, central line sites, and peripheral intravenous sites are not coded as surgical wounds. A description of the wound must be documented in the clinical record during the look back period.

   12. (12) Skin Treatments. Check all of the following provided and documented as observed during a look back period of seven days.

       1. (A) Pressure relieving device(s) for chair, to include pressure relieving, pressure reducing, and pressure redistributing devices utilized in the recipient's chair or wheelchair, excluding egg crate cushions;
       2. (B) Pressure relieving device(s) for bed, to include pressure relieving, pressure reducing and pressure redistributing devices, utilized in the recipient's bed, excluding egg crate mattresses;
       3. (C) Turning/repositioning program, to include a continuous, consistent program for changing the recipient's position and realigning the body. There must be a specific approach that is organized, planned, documented, monitored, and evaluated;
       4. (D) Nutrition or hydration intervention to manage skin problems, to include dietary measures received by the recipient and ordered for the purpose of preventing or treating specific skin conditions;
       5. (E) Ulcer care, to include any intervention for treating ulcers due to circulatory problems and/or pressure and/or open lesions;
       6. (F) Surgical wound care, to include any intervention for treating or protecting any type of surgical wound;
       7. (G) Application of dressings (with or without topical medications) other than to feet; and
       8. (H) Applications of ointments/medications (other than to feet), to include ointments or medications used to treat a skin condition.
   13. (13) Foot Problems and Care. Check for the presence of foot problems and care to the feet supported by documentation in the clinical record. The foot problem(s) and the care provided, including signs and symptoms of infection, description of the open lesion(s), and application of dressing, must be documented as observed during a seven-day look back period.
   14. (14) Activity Pursuit Patterns. Check all appropriate periods when recipient was awake all or most of the time with no more than a total of a one-hour nap during any such period. The clinical record must support the period(s) of a typical day when the recipient was awake all or most of the time as observed during a seven-day look back period.
   15. (15) Medications. For injections, code from zero to seven the number of days that the recipient received any type of medication, antigen, or vaccine, by subcutaneous, intramuscular or intradermal injection. Do not include medications ordered but not given. This category does not include intravenous (IV) fluids or IV medications. The look back period for this item is seven days.

   16. (16) Special Treatments and Procedures.

       1. (A) For Special Treatments, check any treatments provided during the look back period. The clinical record must have documentation of administration of any treatment(s) the recipient received during the look back period, as it occurred. Do not code services that were provided solely in conjunction with a surgical or diagnostic procedure and the immediate post-operative or post-procedure recovery period. If the treatment was administered outside the facility during the look back period, documentation of the treatment administered must be documented and included in the clinical record. The look back period is 14 days.
       2. (B) For Therapies, code the total number of days and the total number of minutes (for at least 15 minutes a day) that therapy was administered to a resident during the look back period. Code the total number of actual minutes the particular therapy was provided. Record therapies that occurred after admission/readmission to the nursing facility, were ordered by a physician, and were performed by a qualified therapist, who meets state credentialing requirements (i.e., qualified therapists or their assistants as contemplated by RAI Chapter P.3.b) or, in some instances, under such person's direct supervision. Include only medically necessary therapies furnished after admission to the nursing facility. The time should include the actual treatment time, not the time waiting or writing reports. The therapist's initial evaluation time may not be counted, but subsequent evaluations conducted as part of the treatment process may be counted. Therapy evaluations, treatments, sessions, and minutes must be documented in the clinical record, each day, as they occur. The look back period is seven days.

       3. (C) For Nursing Rehabilitation/Restorative Care, code between zero and seven the number of days on which the technique, procedure, or activity was practiced for a total of at least 15 minutes during each 24-hour period during the look back period. This includes nursing interventions that assist or promote the recipient's ability to attain his or her maximum functional potential, but does not include procedures or techniques carried out by or under the direction of a qualified therapist(s), as identified in the Special Treatments, Procedures, and Programs section of the MDS. The nursing rehabilitation and/or restorative care must meet all of the following additional criteria. The look back period for items described in this subparagraph is seven days.

          1. (i) Measurable objectives and interventions must be documented in the care plan and in the clinical record as observed during the look back period.
          2. (ii) Evidence of periodic evaluation by licensed nurse must be present in the clinical record.
          3. (iii) Nurse assistants/aides must be trained in the techniques that promote recipient involvement in the activity.
          4. (iv) The activities must be carried out or supervised by identified members of the nursing staff. There must be documentation, including minutes, in the clinical record for the nursing rehabilitation and/or restorative care program as observed during the look back period. This does not include groups with more than four recipients per identified supervising helper or caregiver. There must be documented evidence that services provided in a group setting were provided to a group of four or less.
       4. (D) For Physician visits, code the number of days the physician examined the recipient over a 14-day look back period (or since admission if less than 14 days ago). Documentation of the physician's evaluation must be included in the clinical record.
       5. (E) For Physician Orders, code the numbers of days on which physician orders were changed. Include written, telephone, fax, or consultation orders for new or altered treatment. Do not include order renewals without change. If no order changes exist, code zero.

Source Note:The provisions of this §371.212 adopted to be effective October 9, 2008, 33 TexReg 8311.