Nutrition Connection: RAPs De-mystified! • Fall 2006

RAPs, or Resident Assessment Protocols, can be a source of confusion for dietary managers working in longterm care facilities. Required nationwide, RAPs fall into a model for clinical care of residents outlined by the Centers for Medicare & Medicaid Services (CMS). Below are some common questions and answers about RAPs.

RAPs, RAI, MDS — How do they fit together?

These three acronyms are closely related, and are all part of the system developed by CMS for managing and documenting clinical care in the longterm care environment. RAPs are part of the overall Resident Assessment Instrument, as shown on the table below.

Name of Tool:	Used For:
Resident Assessment Instrument (RAI)	Assessing residents to ensure that all needs are identified and addressed
...has 2 parts:
Minimum Data Set (MDS)	> Data collection & documentation > Screening for problems
Resident Assessment Protocols (RAPs)	> Assessing the resident when certain data on the MDS signal a need for assessment > Investigation of possible problems

In the Resident Assessment Instrument, the Minimum Data Set (MDS) is the first step. CDMs working in longterm care are familiar with the MDS form, which includes nutritional information, primarily in Section K, Oral/Nutritional Status. The entire RAI is an interdisciplinary tool. This means that all caregivers review information recorded on all sections of the form. Data that will relate to a nutrition care plan may show up in Section K and/or other sections of the MDS. For example, a description of skin conditions (decubitus ulcers), or hydration status, or ability to eat/self-feed may relate to nutritional care.

In many facilities, there is a staff member who serves as the MDS coordinator, who helps to ensure that the team meets timetables and requirements for RAI documentation and coordinates the efforts of healthcare team members to ensure full-circle assessment, planning, and care.

What is the real purpose of RAPs?

To make sense of RAPs, it helps to focus on the word “protocol”. A protocol is a set of guides and standards that help us carry out the same task repeatedly – and with consistent, predictable results. RAPs are protocols for assessing residents in longterm care. They are designed to help caregivers throughout the nation consistently evaluate conditions that may require intervention.

The CMS guidelines for documentation tell us that once particular areas of concern are flagged or “triggered” through the MDS, the next step is to complete further assessment, answering specific questions. Based on the assessment, caregivers decide whether a plan of care is warranted to address the concern. Thus, completing RAPs is completing a highly specialized type of assessment process for longterm care residents.

In all, the purpose of RAPs is to find clinical problems and ensure that they are addressed. This way, each resident receives the care he/she needs for individual conditions. If implemented correctly, RAPs should ensure that no key problem “slips through the cracks” in a longterm care facility.

Typically, after a RAP is completed, the team is responsible for documenting and implementing a care plan to address each problem identified. Occasionally, completion of a RAP will reveal that no intervention is necessary. Nonetheless, the assessment process is important, because it helps to assure the resident is receiving any and all needed interventions.

What types of problems do RAPs reveal?

RAPs target 18 problem areas, called triggers:

1.	Delirium	10.	Activities
2.	Cognitive Loss	11.	Falls
3.	Visual Function	12.	Nutritional Status*
4.	Communication	13.	Feeding Tubes*
5.	Urinary Incontinence and Indwelling Catheter	14.	Dehydration/Fluid Maintenance*
6.	ADL Functional/Rehabilitation Potential	15.	Dental Care*
7.	Psychosocial Well-Being	16.	Pressure Ulcers*
8.	Mood State	17.	Psychotropic Drug Use
9.	Behavioral Symptoms	18.	Physical Restraints
* RAPS directly related to nutritional status

A majority of longterm care facilities have computerized the entire RAI to ensure compliance with CMS regulations, and to transmit required information electronically. A typical RAI software package allows users to input MDS data. Next, the software identifies the RAP triggers for each resident. For each trigger, the healthcare team must complete the RAP.

Do the MDS and RAPs substitute for a medical record or care plan?

No, they do not. Exact documentation procedures vary by facility, but many dietary managers first collect data on their own forms, and then transfer needed information into the MDS. The two parts of the Resident Assessment Instrument require specialized documentation for CMS compliance, but they do NOT duplicate a full medical record.

Are requirements the same in all states?

Not exactly. According to Survival Skills for Nutrition Services (CD-HCF/DMA, 2006), “Completion of the RAI process is a federal requirement for skilled nursing facilities that accept payment for care provided to Medicare and Medicaid residents. States also use the information generated by this process, but may have requirements for additional information or completion of assessments at additional times. Some states ask for further information with completion of quarterly assessments.”

What is the role of the dietary manager?

Roles and responsibilities of CDM, CFPPs and Registered Dietitians are defined in each facility. If you are new to a job in a longterm care facility, it is important to discuss your responsibilities with the administrator, dietitian, and/or MDS coordinator. Procedures for who collects and documents information, who signs which documents, and many other aspects of the RAI process vary.

State by state, scope of clinical practice and levels of authority are often driven by licensure legislation. In any state where dietitians are licensed, legislation may in essence say that only a licensed dietitian can perform certain tasks. According to Survival Skills for Nutrition Services (CD-HCF/DMA, 2006), “Practice laws vary from state to state and may determine whether it is the RD or CDM who performs certain nutrition care tasks. Licensure laws may state specific duties that are part of dietetic practice [i.e., must be completed by a qualified dietitian] within a state. Examples include but are not limited to: completion of nutrition assessments, interpretation and education regarding therapeutic diets, and development of a plan of care….In states where this is the case…if they are completed by others, it may be considered a violation of the practice law.”

The specifics of such legislation are unique to each state. To check on licensure legislation for your own state, you can contact the appropriate agency. Visit the State Licensure Agency List on the DMA website for contact information.

Regardless of the exact role a CDM plays in completing the RAI for longterm care residents, one thing is true everywhere: As a member of the healthcare team, the CDM’s efforts are very valuable in contributing to complete assessment of residents, to ensure that needs are met, and that residents receive high quality of care.

 

By Sue Grossbauer