2026 RAI Updates: A Leadership Perspective

The Centers for Medicare and Medicaid Services (CMS) has released the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual), version 1.20.11, effective Oct. 1, 2026. At first glance, nursing home leaders may be relieved to learn that the Minimum Data Set (MDS) item sets remain the same. However, unchanged forms can still mean new expectations or an unexpected impact.

The updated manual clarifies how staff assess residents, interpret MDS coding rules, support Patient-Driven Payment Model (PDPM) classifications, and prepare for audits and medical reviews. For administrators, directors of nursing, regional leaders, and other operational decision-makers, these updates deserve attention because they reach well beyond the desk of the nurse assessment coordinator (NAC).

RAI guidance takes priority

Many of the Oct. 1 updates address areas where facilities have historically struggled with ambiguous interpretations. Recently there has been an increase in state case-mix documentation guidelines or Medicare Advantage (MA) plan documentation expectations that extend well beyond RAI guidance. This practice could potentially skew national data because all OBRA assessments are used for quality measurement and other data analyses. CMS clarified that although states can add items to section S and require additional assessments beyond the federal schedule, they cannot change the underlying coding guidance. CMS added this statement as a reminder: “State or other payer requirements do not replace, modify, or add to the item definitions, coding instructions, coding tips, or response options specified in this manual.”

This clarification holds states accountable for following the RAI User’s Manual instructions rather than relying on additional documentation guidelines for MDS coding. However, one important caveat: if states wish to continue using stricter requirements, they may require additional documentation, but any resulting adjustments must be made on the billing side, not on the MDS.

Bottom line: The RAI User’s Manual is the authoritative source for MDS coding. When team members sign at Z0400, they are attesting to the accuracy of their coding based on the applicable RAI guidance.

New clinical criteria to capture respiratory therapy

The respiratory therapy changes in section O may be among the most critical updates for nursing home leaders because they directly affect how facilities identify and support skilled respiratory services. CMS now distinguishes its definition of respiratory therapy to include only skilled therapy as opposed to routine maintenance or prophylactic treatments. Time spent on a nebulizer treatment, maintenance-level incentive spirometry, or other modalities does not automatically qualify simply because staff assisted the resident or the service lasted 15 minutes. To be captured on the MDS, the service must be clinically indicated or medically necessary, and it should definitively require the skills, knowledge, and judgment of a respiratory therapist or respiratory nurse.

This clarification has operational and financial implications. Respiratory therapy can affect PDPM classification, including qualification for the Special Care High nursing category when applicable. Leaders should ensure that nursing, respiratory therapy, MDS, and billing teams are aligned on what constitutes a skilled service and that their documentation clearly supports the clinical need. Existing respiratory protocols, staff education, and audit processes must also be reviewed so routine treatments are not inadvertently coded as skilled respiratory therapy.

Bottom line: Nursing home leaders should ensure respiratory therapy is captured only when the service is truly skilled, clinically necessary, and supported by documentation because inaccurate coding can affect both compliance and reimbursement.

Some changes may affect audits and appeals

Chapter 6 also merits leadership attention because CMS clarified several PDPM references that can affect reimbursement and medical review. The updated manual changes the general reference from “Depression” to “Depression Signs and Symptoms,” reinforcing that this nursing component end-split is based on the Patient Health Questionnaire (PHQ) interview findings rather than requiring an active depression diagnosis. CMS also clarified that the Special Care High qualifier tied to I6200 applies to the full item description of asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease. In addition, the manual distinguishes bowel and bladder training from other restorative nursing programs by stating that these programs don’t have to meet the same days-and-minutes requirements.

Bottom line: These changes can reduce inconsistent interpretations during audits and medical reviews. They also reinforce the need for MDS, nursing, billing, and clinical leadership to use the same current guidance when supporting PDPM classifications.

What leaders should do now

Facilities do not need to redesign the MDS process simply because a new manual has been released. But they should not assume that no action is required because the item sets stayed the same.

Leadership should work with the NAC and interdisciplinary team to take these initiatives:

• Review the major changes in version 1.20.11.

• Identify policies and workflows affected by the new guidance.

• Target education to high-risk areas such as wounds, respiratory therapy, interviews, falls, and PDPM classification.

• Confirm that audit tools reflect the updated coding rules.

• Monitor for inconsistencies between nursing, therapy, MDS, billing, and other departments.

Conclusion

The 2026 RAI updates haven’t changed the MDS item sets, but they do alter how facilities must interpret and apply key areas of guidance. For nursing home leaders, the priority is ensuring those clarifications are translated into consistent policies, documentation, education, and interdisciplinary practice.

Strong leadership oversight can help reduce coding variation, support accurate reimbursement, strengthen audit readiness, and ultimately ensure the MDS continues to reflect each resident’s needs accurately.

Jessie McGill, RN, BSN, RAC-MT, RAC-MT, is a regular contributor to Park Place, and is the curriculum development specialist for the American Association of Post-Acute Care Nursing.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.