As you know, §483.20 (h) Coordination, otherwise referred to as F-tag 642, states: “A registered nurse (RN) must conduct or coordinate each assessment with the appropriate participation of health professionals.” The RN’s signature serves as the certification that the assessment is complete, but does not certify the accuracy of the assessment.¹ 

The language of this requirement has enabled the NH industry to define specific processes used in each facility or corporation to demonstrate compliance. Operationally, this has allowed for such practices as (1) having RNACs signing Minimum Data Set documents even if the RN is not present in the facility or even the country and (2) having licensed vocational or practical nurses (LVN/LPNs) conduct assessments, regardless of the relatively narrow scope of practice related to clinical assessment that the California Department of Consumer affairs, and other states, authorize for LVNs or LPNs.²

These practices persist despite stakeholders’ sustained advocacy for the comprehensive clinical assessment as the linchpin to NH quality. For example, accurate assessment and coding of the MDS are of practical importance because MDS data are used for Patient-Driven Payment Model (PDPM) reimbursement, Quality Measures, federal and state surveys, research, and AI-based applications.³

The Minimum Data Set (MDS) 3.0 Resident Assessment Instrument User’s Manual v1.201, effective October 1, 2025, is 1,000 pages. This manual has been revised many times since it was first published as MDS 1.0, 2.0, and now 3.0³ The once relatively straightforward comprehensive person-centered assessment and care planning process has become increasingly complex. Meanwhile, conscientious directors of nursing (DON) and RNs working in NHs find themselves practicing in facilities and corporations in which improvements in RN staffing levels have been delayed for 10 years.⁴ The majority of DONs and RNs have an associate degree or a diploma in nursing.⁵

Given these constraints, it may be time to consider advocating for certification of RNACs in California as a modest strategy to improve nursing and interprofessional clinical assessments and care provided to NH residents. The American Association of Post-Acute Care Nursing (AAPACN) has an excellent MDS certification and re-certification program.6 However, the certification and re-certification require financial investment in RNs. It is noteworthy that, while McKnight's Long-Term Care News routinely supports AAPACN nursing experts in their publications, neither it nor the American Health Care Association, has advocated for (AHCA) federal RNAC certification as a practical strategy to promote NH quality.

Trade-offs are inherent in politics and public policy. If we want to improve NH quality, we need to find modest ways to invest in improvements, or continue to be immobilized by the actual complexity of the issues we confront.

References

1. https://cms.gov/medicare/regulations-guidance/manuals
2. Dellefield ME. Implementation of the RAI/MDS in the nursing home as organization: implications for quality improvement in RN clinical assessment. Geriatric Nursing. 2007; 28(6):377-86.
3. https://cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual
4. Berklan JM. Judge rejects RN hourly staff rules. McKnights Long-Term Care News. 46(4). July/August 2025.
5. National Academies of Sciences, Engineering, and Medicine. 2022. The national imperative to improve nursing home quality: Honoring our commitment to residents, families, and staff. Washington, DC: The National Academies Press. https://doi.org/10.17226/26526.
6. https://www.aapacn.org