MDS Data Elements

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 November QSO Memo (QSO-25-07-NH Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process). Surveyors will start using the updated guidance on February 24, 2025.   What Are the...

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...

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...

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...

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...

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....