RAI Manual v1.20.1Steps for Assessment
1. Ask the resident about their overall expectations and goals to be sure that they have
participated in the assessment process and have an understanding of their current situation
and the implications of choices such as returning home or moving to another appropriate
community setting such as an assisted living facility or an alternative healthcare setting.
2. Ask the resident to consider their current health status, expectations regarding improvement
or worsening, social supports and opportunities to obtain services and supports in the
community.
3. If goals have not already been stated directly by the resident and documented since
admission, ask the resident directly about what their expectation is regarding the outcome of
this nursing home admission and expectations about returning to the community.
4. The resident’s stated goals should be recorded here. The goals for the resident, as described
by the family, significant other, guardian, or legally authorized representative, may also be
recorded in the clinical record.
5. Because of a temporary (e.g., delirium) or permanent (e.g., profound dementia) condition,
some residents may be unable to provide a clear response. If the resident is unable to
communicate their preference either verbally or nonverbally, the information can be obtained
from the family or significant other, as designated by the individual. If family or the
significant other is not available, the information should be obtained from the guardian or
legally authorized representative.
6. Encourage the involvement of family or significant others in the discussion, if the resident
consents. While family, significant others, or the guardian or legally authorized
representative can be involved if the resident is uncertain about their goals, the response
selected must reflect the resident’s perspective if they are able to express it.
7. In some guardianship situations, the decision-making authority regarding the individual’s
care is vested in the guardian. But this should not create a presumption that the individual
resident is not able to comprehend and communicate their wishes.
DEFINITION
DISCHARGE
To release from nursing
home care. Can be to home,
another community setting,
or a healthcare setting.
Q0310: Resident’s Overall Goal (cont.)
Manual page Q-3RAI Manual v1.20.1Coding Instructions
for Q0310A, Resident’s overall goal for discharge
established during the assessment process
Record the resident’s expectations as expressed by them. It is important to document their
expectations.
•
Code 1, Discharge to the community: if the resident indicates an expectation to
return home, to assisted living, or to another community setting.
•
Code 2, Remain in this facility: if the resident indicates that they expect to remain
in the nursing home.
•
Code 3, Discharge to another facility/institution: if the resident expects to be
discharged to another nursing home, rehabilitation facility, or another institution.
•
Code 9, Unknown or uncertain: if the resident is uncertain or if the resident is not
able to participate in the discussion or indicate a goal, and family, significant other, or
guardian or legally authorized representative do not exist or are not available to
participate in the discussion.
Manual page Q-3RAI Manual v1.20.1Coding Tips
•
The response to this item should be individualized and
resident-driven rather than what the nursing home staff
judge to be in the best interest of the resident. This item
focuses on exploring the resident’s expectations, not
whether or not the staff considers them to be realistic.
Coding other than the resident’s stated expectation is a
violation of the resident’s civil rights.
•
Q0310A, Code 1 “Discharge to the community” may
include newly admitted residents with a facility-
arranged discharge plan or those residents with
adequate supports already in place that would not
require referral to a local contact agency (LCA). It may
also include residents who ask to talk to someone about
the possibility of leaving this facility and returning to
live and receive services in the community (Q0500B,
Code 1, Yes).
•
Avoid trying to guess what the resident might identify
as a goal or to judge the resident’s goal. Do not infer a
response based on a specific advance directive, e.g., “do not resuscitate” (DNR).
•
The resident should be provided options, as well as access to information that allows
them to make the decision and to be supported in directing their care planning.
DEFINITION
DESIGNATED LOCAL
CONTACT AGENCY
(LCA)
Each state has community
contact agencies that can
provide individuals with
information about community
living options and available
community-based supports
and services. These local
contact agencies may be a
single entry point agency, an
Aging and Disability
Resource Center (ADRC), an
Area Agency on Aging (AAA),
a Center for Independent
Living (CIL), or other state
designated entities.
Q0310: Resident’s Overall Goal (cont.)
•
If the resident is unable to communicate their preference either verbally or nonverbally,
or has been legally determined incompetent, the information can be obtained from the
family or significant other, as designated by the individual. Families, significant others or
legal guardians should be consulted as part of the assessment.
Coding Instructions for Q0310B, Indicate information source for
Q0310A
•
Code 1, Resident: if the resident is the source for completing this item.
•
Code 2, Family: if a family member is the source for completing this item because the
resident is unable to respond.
•
Code 3, Significant other: if a significant other of the resident is the source for
completing this item because the resident is unable to respond.
•
Code 4, Legal guardian: if a legal guardian of the resident is the source for
completing this item because the resident is unable to respond.
•
Code 5, Other legally authorized representative: if a legally authorized
representative of the resident is the source for completing this item because the resident is
unable to respond.
•
Code 9, None of the above: if the resident cannot respond and the family or
significant other, or guardian or legally authorized representative does not exist or cannot
be contacted or is unable to respond (Q0310A = 9).
Manual page Q-3 