CAA & Care Plans

Browse our posts in this topic!

Mar 01 2026
, , ,

From Orders to Action: Aligning Care Plans and Psychotropic Medications

Critical Element Pathways (CEPs) are tools in the Long-Term Care State Operations Manual (SOM) that are developed by Centers for Medicare and Medicaid (CMS) and utilized by surveyors along with interpretive guidance to evaluate each facility’s adherence to specific Federal Tag (F-tag) requirements. To evaluate resident care, each CEP is formatted to explain the purpose of investigation, with directions about which records to review – including Minimum Data Set (MDS) and care plans. Each CEP...
Keep Reading
Jun 01 2025
,

MDS Nutrition – Not Limited to Section K

Often Section K on the MDS, associated CAAs, and care planning are relegated to the dietician to worry about. However, when we look at a comprehensive MDS, we can see that the information in Section K is only part of the resident's nutritional story, and the dietitian (or any other IDT member who is coding Section K, developing the CAAs, and creating effective care plans) cannot be successful without input from multiple sources. When the data is collected from a variety of sources in the...
Keep Reading
Feb 01 2025

Laying the Foundation – Care Area Assessments to Care Plans

Because Care Area Assessments (CAAs) are not submitted to CMS, and the Resident Assessment Instrument (RAI) manual offers little guidance on how to complete a CAA when compared to the Minimum Data Set (MDS) instructions, CAAs are a segment of the RAI that is easy to overlook and underutilize. With many other duties and concerns to manage on a daily basis, the Interdisciplinary Team (IDT) may view the CAA process as an inconvenience and tend to skimp on reviewing the components of the triggered...
Keep Reading
mds-consultants-what-is-an-mds-nurse-coordinator-part-1
Dec 01 2024
, ,

What is an MDS Coordinator?

"What do you do for a living?" It may not surprise you that when asked this question, most MDS Coordinators struggle to come up with an answer. The reality is that MDS Coordinators fully understand what this multifaceted job entails, but are at a loss of how to put it into words for someone who isn’t out there doing it every day. This refresher on the basics of MDS Coordination should help answer that basic question quickly, completely, and in such a way that is easy to grasp.   What Does...
Keep Reading
From-the-MDS-to-RAI-System-Management
Nov 01 2024
, ,

From the MDS to RAI System Management

With the introduction of the Minimum Data Set (MDS) through the Omnibus Budget Reconciliation Act (OBRA) of 1987, Centers for Medicare and Medicaid (CMS) implemented a method of standardized, comprehensive, and reproducible data collection for long term care residents that addressed medical conditions and functional status. This data collection tool has morphed into a means of reflecting long term care and rehab facility compliance with federal regulations, facility quality measures, resident...
Keep Reading
SCSA
Jul 01 2024
,

A Significant Change in Status Assessment – There are Options

The Resident Assessment Instrument (RAI) system includes a significant change in status assessment (SCSA). What might be forgotten is the State Operation Manual (SOM), Appendix PP, includes information that mirrors the RAI manual at 42 CFR §483.20(b)(2)(ii), F637 - Comprehensive Assess After Significant Change. Thus, regulatory oversight mirrors the RAI manual’s description of what constitutes a SCSA for a resident.   SCSA Definitions Chapter 2 of the RAI Manual covers SCSA. A...
Keep Reading
Nov 04 2021
,

Section F Drives Better Quality Care

Section F is critical to creating a patient-centered care plan. The RAI Manual states, “A lack of attention to lifestyle preferences can contribute to depressed mood and increased behavior symptoms.”  However, are we utilizing the interview for daily and activity preferences appropriately to ensure that we reduce depression and behavior symptoms? Remember that behavior does directly corelate with two quality measures: Percentage of long-stay residents who have symptoms of depression....
Keep Reading
Jul 22 2021
,

Can I interrupt? Understanding the Interrupted Stay Policy

According to the RAI Manual, chapter 6: "The interruption window is a 3-day period, starting with the calendar day of Part A discharge and including the two immediately following calendar days, ending at midnight. In other words, the resident must return to the same SNF by 11:59 p.m. at the end of the third calendar day. The interruption window begins on the first non-covered day following a Part A-covered stay and ends at 11:59 p.m. on the third consecutive non-covered day following a Part...
Keep Reading
May 30 2021
,

SNF QRP Changes are Coming

The Proposed Rule for Fiscal Year (FY) 2022 for the Skilled Nursing Facility Prospective Payment System was released early April 2021. Now that providers have had a chance to digest the proposed SNF payment updates and the PDPM parity adjustment, attention turns to the quality initiatives that have been updated. Just 1 NTA point can have an average worth of anywhere from $18 to $55 per day. (difference of NE-NF and NA-NB). The SNF QRP quality initiative is a pay-for-reporting program. SNFs...
Keep Reading
Jan 24 2019
,

7 Baseline Care Plan Myths

By Caralyn Davis | Jan. 24, 2018 | Excerpted from: AANAC Baseline care plans have been required since late November 2017, but nurse assessment coordinators (NACs) and other interdisciplinary team (IDT) members are still navigating through a lot of misinformation to learn the rules of the road for F655 (Baseline Care Plans) as detailed in Appendix PP of the State Operations Manual. Here are seven common myths that need to be vanquished: Myth: The resident needs to sign the baseline care plan...
Keep Reading

Recent Blogs in All Topics

Mar 01 2026
, , ,

From Orders to Action: Aligning Care Plans and Psychotropic Medications

Critical Element Pathways (CEPs) are tools in the Long-Term Care State Operations Manual (SOM) that are developed by Centers for Medicare and Medicaid (CMS) and utilized by surveyors along with interpretive guidance to evaluate each facility’s...
Keep Reading
Feb 01 2026

F641 in Plain English – How Interview Accuracy Protects Your CMI

When surveyors look at MDS accuracy, they’re not just checking boxes – they’re looking at whether the assessment truly reflects the resident. F641 holds the interdisciplinary team and nursing leadership accountable for how the assessment is...
Keep Reading
Jan 01 2026
,

From Coding to Compliance: Avoiding Pitfalls in the 2026 MDS Landscape

With the numerous regulatory bodies that govern long term care (LTC) and skilled nursing facilities (SNF), it is easy to feel like there is no end to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) “rules.” There are Federal,...
Keep Reading
Dec 01 2025
,

Keeping Up with Quality Measures in 2026

Quality measures (QM) that are driven by MDS data are currently utilized for long term care (LTC) facilities and skilled nursing facilities (SNF) in several ways. These QMs are publicly reported via the Care Compare (CC) website and accompanying...
Keep Reading
Nov 01 2025
, , , ,

The Latest in the Lineup: The Skilled Nursing Facility Validation Program

The Centers for Medicare and Medicaid (CMS) audits of skilled nursing facility (SNF) Minimum Data Set (MDS) data are nothing new. The MDS 3.0 was implemented in 2010, and in 2014 CMS piloted MDS Focused Surveys in 5 states. The results of the pilot...
Keep Reading
Oct 01 2025
, ,

How the MDS is Utilized During the Survey Process

Have you ever wondered how the survey team determines which residents they will focus on during a standard survey in the skilled nursing facility/long term care facility (SNF/LTC)? The answers submitted to the Center for Medicare and Medicaid (CMS)...
Keep Reading
Sep 01 2025
,

Fall MDS Updates are Here!

October 1 is typically when the Centers for Medicare and Medicaid Services (CMS) institutes changes to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) – and this year is no exception. CMS has rescinded a few things that were...
Keep Reading
Aug 01 2025
,

Medicaid PDPM Is Coming: What Skilled Nursing Facilities Need to Know

Beginning October 1, 2025, many nursing homes will adopt a new reimbursement model for Medicaid residents: the Patient-Driven Payment Model, or Medicaid PDPM. While PDPM has been in place for Medicare since 2019, this is the first time it’s being...
Keep Reading
Jul 01 2025
,

The Facility Assessment and Emergency Management Planning: The MDS Plays a Big Role

  What is the MDS Role in the Facility Assessment? F838 in the State Operations Manual (SOM) provides specific information for developing a Facility Assessment that must be reviewed and updated at least annually. A well-developed facility...
Keep Reading
Jun 01 2025
,

MDS Nutrition – Not Limited to Section K

Often Section K on the MDS, associated CAAs, and care planning are relegated to the dietician to worry about. However, when we look at a comprehensive MDS, we can see that the information in Section K is only part of the resident's nutritional...
Keep Reading
May 01 2025
,

Celebrating Skilled Nursing

National Skilled Nursing Week is held annually in May to recognize long-term care professionals that care for our residents in Skilled Nursing Facilities. This year’s National Skilled Nursing Week is May 11 - 17 and the theme is “Tapestry of Life”...
Keep Reading
Apr 01 2025
,

MDS Errors: Steps for Correction

What does the NAC do when they identify an error on an MDS assessment? The answer is correct the identified error. Any error that incorrectly represents the resident's status needs to be corrected. One would think correcting an MDS error would be a...
Keep Reading
Mar 01 2025
, ,

RAI and MDS Compliance: The Importance of the Administrator in the Lineup

With the Minimum Data Set (MDS), the Centers for Medicare and Medicaid (CMS) created a standardized, reliable, reproducible framework for assessing long term care resident status. As a result, MDS data plays a significant role in myriad areas of...
Keep Reading
Feb 01 2025

Laying the Foundation – Care Area Assessments to Care Plans

Because Care Area Assessments (CAAs) are not submitted to CMS, and the Resident Assessment Instrument (RAI) manual offers little guidance on how to complete a CAA when compared to the Minimum Data Set (MDS) instructions, CAAs are a segment of the...
Keep Reading
Jan 01 2025

Navigating the 2025 Winds of Change: New Survey Guidance

The 2025 new year has begun with a whirlwind of changes in Long-Term Care – starting with New Surveyor Guidance. CMS released an advanced copy of these State Operations Manual Appendix PP (Guidance for Skilled Nursing Facilities) updates in a...
Keep Reading
Dec 01 2024
, ,

What is an MDS Coordinator?

"What do you do for a living?" It may not surprise you that when asked this question, most MDS Coordinators struggle to come up with an answer. The reality is that MDS Coordinators fully understand what this multifaceted job entails, but are at a...
Keep Reading
Nov 01 2024
, ,

From the MDS to RAI System Management

With the introduction of the Minimum Data Set (MDS) through the Omnibus Budget Reconciliation Act (OBRA) of 1987, Centers for Medicare and Medicaid (CMS) implemented a method of standardized, comprehensive, and reproducible data collection for long...
Keep Reading
Oct 01 2024

Maximizing Case Mix with Special Programs: Respiratory Therapy and Restorative Nursing

Case mix is essential in skilled nursing facilities as it impacts both reimbursement and the care provided. Two key programs that significantly impact case mix scores when properly implemented and documented are Respiratory Therapy and Restorative...
Keep Reading
Sep 01 2024

Strategic Admissions: The Path to Optimized Medicaid Reimbursement

Medicaid reimbursement plays a significant role in the financial health of long-term care facilities, particularly those serving a high percentage of Medicaid residents. While it may not be the sole source of revenue, it is an important component...
Keep Reading
Aug 01 2024
, ,

Internet Quality Improvement and Evaluation System (iQIES): A New Age

Just when we thought we had a handle on QIES (Quality Improvement and Evaluation System), the Centers for Medicare & Medicaid Services (CMS) transitioned to the Internet Quality Improvement and Evaluation System (iQIES) in 2023.   Reports...
Keep Reading
Jul 01 2024
,

A Significant Change in Status Assessment – There are Options

The Resident Assessment Instrument (RAI) system includes a significant change in status assessment (SCSA). What might be forgotten is the State Operation Manual (SOM), Appendix PP, includes information that mirrors the RAI manual at 42 CFR...
Keep Reading
Jun 01 2024
,

Interim Payment Assessment (IPA) – To do or not to do?

The Patient-Driven Payment Model took effect in October of 2019. Along with this change came the optional IPA. We are now five years into this change and questions still arise on when to complete an IPA. The decision of when to complete lies with...
Keep Reading
May 01 2024
,

Resident Interviews – What are you doing to capture the data?

Effective October 1, 2023, several resident interviews were added to or updated on the MDS. Interview items in Section A and changes to the interviews in Section D, J, and Q have been implemented. Each of the interviews can be a great steppingstone...
Keep Reading
Apr 01 2024
,

Section GG Documentation – Questions Still Abound

Section GG remains a popular discussion topic among the Nurse Assessment Coordinator (NAC) and other members of the interdisciplinary team (IDT). Many have questioned their own practices and processes, designed to support coding this section of the...
Keep Reading
Mar 01 2024
, ,

Social Determinants of Health (SDOH) – A Global Initiative Important to Skilled Nursing Providers

The Centers for Medicare & Medicaid Services’ (CMS) Office of Mental Health report CMS Framework for Health Equity 2022 and 2032 states that health equity is defined by the attainment of the highest level of health for all people, where...
Keep Reading
Feb 01 2024

Trauma and the MDS – A Sneak Peak

Trauma informed care has become an area of focus for Post Acute Care providers and survey agencies. Organizations are required to provide trauma-informed care that meets “professional standards of practice and accounting for residents’ experiences...
Keep Reading
Jan 01 2024

New Year….Same MDS Obstacle Course

As we ring in 2024, long term care professionals are still struggling to implement the October 2023 updates to the MDS. CMS is already talking about more changes in 2024, and the anticipation continues to create anxiety amongst PAC members. While...
Keep Reading
Dec 01 2023
,

Schizophrenia Diagnosis Audits

On January 18th, 2023, CMS announced they will be conducting off-site audits in nursing homes for assessment accuracy and coding of residents with a diagnosis of Schizophrenia. Along with auditing for appropriate diagnosis, the audits will review...
Keep Reading
Nov 01 2023
,

OSA or PDPM? A State-Level Decision

As of Oct. 1, 2023, the Centers for Medicare & Medicaid Services (CMS) has retired the A0300 Optional State Assessment (OSA) from the federally required MDS 3.0 v1.18.11 that is submitted by nursing facilities. The OSA is now a separate...
Keep Reading
Oct 02 2023

The Physician and “I”

The physician’s role in the nursing facility is essential to delivering skilled, quality care for Skilled and Long-Term Care residents. Physicians are our lead in providing clinical decision making and properly defining, clarifying, and verifying...
Keep Reading