MDS Data Elements

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 MDS. CMS states in its Participant Questions from the Skilled Nursing Facility MDS 3.0 RAI v1.18.11 Guidance Training Program (June 21, 2023 - current as of August 2023) that: While CMS does not impose specific documentation procedures on nursing...

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 everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and...

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 and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident” (p. 433, CMS, 2023). The State Operations Manual (SOM), Appendix PP, identifies the Substance Abuse and Mental Health Services Administration...

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 the full ramifications of the 2023 updates remain to be determined, let’s recap the major changes in 2023.   What Major Changes Occurred After October 1, 2023? The MDS 3.0 item sets v1.18.11 v6 was released along with an errata document with...

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 appropriate use of antipsychotic medications.  What does this mean for nursing facilities? CMS utilizes data regarding the use of antipsychotic medications in the Five-Star Quality Rating System. A diagnosis of schizophrenia excludes the residents...

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 optional MDS assessment that may be completed at the discretion of each state’s government. The OSA is used by State Medicaid Agencies to calculate a case-mix score. States have the option to utilize the OSA for the collection of RUGS data pertinent to the...

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 diagnoses. Only the verified diagnosis is to be used on the MDS. Once a diagnosis is verified, MDS Coordinators must then determine if the verified diagnosis is active within the 7-day look back of the assessment reference date (ARD) window...

Urinary Tract Infections (UTIs) are a commonly miscoded data element on the MDS. Are you over coding UTIs? Are you not coding them at all? Should you? Shouldn’t you? The MDS has historically left data collectors asking themselves these questions. What happens if I do not code it, what happens if I do. As MDS completion people, our number one priority should always be accuracy.  Let us look at the basics of coding a UTI on the MDS.    How to Code a UTI on the MDS  Per the RAI Manual, the...

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...

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...

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...

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...

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...

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...

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...

Urinary Tract Infections (UTIs) are a commonly miscoded data element on the MDS. Are you over coding UTIs? Are you not coding them at all? Should you? Shouldn’t you? The MDS has historically left data collectors asking themselves these questions....

Changes to Section I and Schizophrenia In July 2022, CMS released an erratum to the RAI (Resident Assessment Instrument) Manual that included more detailed guidance on the use of diagnoses for section I, including the schizophrenia diagnoses that...

Achieving Accurate ADLs The MDS nurse faces challenges when ADL documentation is sparse or even conflicting.  Everyone wants accurate ADL’s, but how often do we fall short?  How have pandemic staffing issues affected ADL accuracy? The “Rule of...