MDS Notes

MDS ESSENTIALS
Faculty Disclosures
• I have no financial relationships to disclose

• I have no conflicts of interests to disclose
• I will not promote any commercial products or
services
Introduction to RAI and MDS Process

All Planning Committee members, content reviewers, authors, and presenters have
been evaluated for conflicts of interest and there are not any to disclose.
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Educational Activity Completion Learning Objectives

and CE Disclosure 1. Interpret the regulatory mandate for the
Requirements for Successful Completion Minimum Data Set (MDS)
• 1.25 contact hours will be awarded for this continuing 2. Differentiate the various functions of the MDS
nursing education activity. and their application in nursing homes
• Criteria for successful completion includes attendance for 3. Describe the components of the Resident
at least 80% of the entire event. Partial credit may not be Assessment Instrument (RAI) process
awarded. 4. Demonstrate awareness of key aspects of RAI-
• Approval of this continuing education activity does not specific lingo
imply endorsement by AANAC or ANCC (American Nurses 5. Explain the process for accurate and timely
Credential Center) of any commercial products or completion of the MDS
services. 6. Describe how the RAI process is linked to
American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education
by the American Nurses Credentialing Center’s Commission on Accreditation.
resident care and positive outcomes
*AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC)
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MDS ESSENTIALS
The Minimum Data Set (MDS) Minimum Data Set

Page numbers on the slides indicate • Paper form or software version
the related page number on the
Comprehensive MDS item set or the • Must be submitted electronically to national
page(s) in the RAI User’s Manual MDS database known as QIES ASAP
when indicated by a chapter and • Core set of resident-specific screening, clinical,
page number (e.g., 2-22). The and functional status items
exception to this is the item-by-item
guide to the MDS located in chapter • Complex completion instructions and
3 using the section letter and page processes involved
number of that portion
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Minimum Data Set Minimum Data Set

Sections A – Z: Topics Mandated by Law
Item Set
A. Identification Information K. Swallowing/Nutritional
• Set of MDS items required depending on the reason B. Hearing, Speech, and Vision Status
for doing the assessment C. Cognitive Patterns L. Oral/Dental
– Nursing Home Comprehensive (NC) item set D. Mood M. Skin Conditions
• Contains the most items, used for clinical E. Behavior N. Medications
assessment F. Preferences/Activities O. Special Treatments
– Subsets of the NC items set G. Functional Status P. Physical Restraints and
GG. Functional Abilities and Goals Alarms
• Quarterly clinical assessment
H. Bladder and Bowel Q. Participation/Goals
• OBRA Discharge assessments V. CAAs/Signatures
I. Active Diagnoses
• Medicare PPS Assessments X. Correction Request
J. Health Conditions
• Entry and Death records
Z. Assessment Admin
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MDS ESSENTIALS
Minimum Data Set

Items
Minimum Data Set
• Each section is further divided into specific items • After each item label, list of answer options,
– Example, Section E, Behavior (p. 11) such as:
– Item E0100, Potential Indicators of Psychosis
• Item E0200, Behavioral Symptoms
• Item E0300, Overall Presence of Behavioral
Symptoms
• Item E0500, Impact on Resident
• Item E0600, Impact on Others
• Item E0800, Rejection of Care OR…
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Minimum Data Set

Minimum Data Set Answer Options
• Further subdivided into more questions
and the answer options: • Coding conventions
– Check all that apply, such as E0100

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MDS ESSENTIALS
Minimum Data Set Minimum Data Set

Answer Options Answer Options
• Coding conventions
– Check all that apply, such as E0100, or
– Select code and enter it into box, such as A0310 (p. 1),
– Select code and enter it into box, such as A0310 (p. 1) or
– Enter ID numbers, such as A0100 (p. 1) or A0600 (p. 2)
0 1
1 2 3 4 5 6 7 8 9

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Minimum Data Set

Answer Options
– Select code and enter it into box, such as A0310
Resident Assessment Instrument
(p. 1), or (RAI)
– Enter ID numbers, such as A0100 (p. 1) or A0600
(p. 2)
Key Concept:
Read coding instructions for each item
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MDS ESSENTIALS

Resident Assessment Instrument (RAI) Process of Investigation
Regulatory Mandate
• Parallels nursing process
• Nursing Home Reform Act of 1987 known as
“OBRA ’87” • Components
• Standardized, periodic functional status – Minimum Data Set (MDS)
assessments required for all nursing home • Core set of screening, clinical, and functional status
residents items
– Care Area Triggers (CATs)
• To improve quality of assessment
• MDS items that alert staff to possible problems,
– Spotlighting resident-specific problems
needs, strengths
– Targeting care planning
• Triggers need a complete assessment of the issue
Goal: Improving resident care and outcomes that meets standards of practice
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Resident Assessment Instrument Resident Assessment Instrument

Process of Investigation Assessment Requirement
• Care Area Assessments (CAAs)
• Comprehensive assessment
– 20 care areas (p. 47)
– MDS + CAAs
– Complete assessments of issues identified by the MDS
– Required at least every 366 days
– Identify causes, contributing factors, risk factors
related to the problem
• Quarterly assessment
– Subset of comprehensive assessment
• Care Plan
– Required at least every 92 days
– Working action plan that targets specific problems,
needs, strengths and preferences including those • Unscheduled comprehensive assessments
identified by the MDS and CAAs – Significant Change in Status Assessment
– Significant Correction of Prior Assessment
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MDS ESSENTIALS

Assessment Requirement
• OBRA-required clinical assessments

– Required for all residents of nursing home
facilities and units in facilities that are
Medicare and/or Medicaid certified
regardless of payer

(RAI) User’s Manual
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RAI User’s Manual RAI User’s Manual

CHAPTER 1: Excerpt (p. 1-7)
CHAPTER 1 • Monitoring the Quality of Care. MDS assessment data
are also used to monitor the quality of care in the
• Overview nation’s nursing homes. MDS-based quality measures
(QMs) were developed by researchers to assist:
• Components of the MDS 1. State Survey and Certification staff in identifying potential
care problems in a nursing home
• Layout of the RAI Manual 2. Nursing home providers with quality improvement
• Protecting the privacy of the MDS data activities/efforts
3. Nursing home consumers in understanding the quality of
care provided by a nursing home
4. CMS with long-term quality monitoring and program
planning. CMS continuously evaluates the usefulness of the
QMs, which may be modified in the future to enhance their
effectiveness
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MDS ESSENTIALS
RAI User’s Manual RAI User’s Manual – Chapter 2

Excerpt (pp. 2-6, 2-7)
CHAPTER 2
• Federal regulatory requirement [42 CFR
• RAI Requirements
483.20(d)] requires nursing homes to maintain
• Responsibility for Completing Assessments all assessments completed within previous 15
• Assessment Types and Definitions months in the active clinical record. Applies to
• Required OBRA Assessments all MDS assessment types regardless of the form
• Skilled Nursing Facility Medicare Prospective of storage (i.e., electronic or hard copy)
Payment System Assessments
– The 15-month period for maintaining assessment
• Combining Assessments data may not restart with each readmission to the
• Determining Item Set for an MDS Record facility
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RAI User’s Manual – Chapter 2 RAI User’s Manual

Excerpt (p. 2-22)
CHAPTER 3
SIGNIFICANT CHANGE = major decline or improvement
• Item-By-Item Guide to MDS 3.0
in resident’s status
– Sections A-Z
1. Will not normally resolve itself without intervention by
staff or by implementing standard disease-related clinical • Intent
interventions, the decline is not considered “self- • Rationale
limiting”;
• Coding instructions
2. Impacts more than one area of the resident’s health
status; and • Examples
3. Requires interdisciplinary review and/or revision of care • Tips and special population
plan
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MDS ESSENTIALS

CHAPTER 3: Excerpt (p. L-1)
CHAPTER 4
• Care Area Assessments (CAAs)
– Background and rationale
– Other considerations regarding the use of
CAAs
• When is the RAI not enough?
• The RAI and care planning
• The 20 care area assessments
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CHAPTER 4: Excerpt (p. 4-4) CHAPTER 5
• CATs provide a “flag” for the IDT members, indicating • Submission and Correction of the MDS
that the triggered care area needs to be assessed Assessment
more completely prior to making care planning
decisions. Further assessment of a triggered care – Transmitting MDS Data
area may identify causes, risk factors, and – Validation Edits
complications associated with the care area – MDS Correction Policy
condition. The plan of care then addresses these
factors with the goal of promoting the resident’s – Correcting MDS records that have not yet been
highest practicable level of functioning: (1) accepted into the QIES ASAP system
improvement where possible or (2) maintenance and – Correcting MDS records that have been accepted
prevention of avoidable declines into the QIES ASAP System
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MDS ESSENTIALS

CHAPTER 5: Excerpt (p. 5-7)
CHAPTER 6
• It is important to remember that the electronic
record submitted to and accepted into the QIES • Medicare Skilled Nursing Facility Prospective
ASAP system is the legal assessment. Corrections Payment System (SNF PPS)
made to the electronic record after QIES ASAP – Patient-Driven Payment Model (PDPM)
acceptance or to the paper copy maintained in – Relationship between assessment and claim
the medical record are not recognized as proper – SNF PPS Eligibility Criteria
corrections. It is the responsibility of the provider – PDPM Calculation Worksheet for SNFs
to ensure that any corrections made to a record – SNF PPS policies
are submitted to the QIES ASAP system in
– Non-compliance with the SNF PPS schedule
accordance with the MDS Correction Policy
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RAI User’s Manual

CHAPTER 6: Excerpt (6-16) RAI User’s Manual
APPENDIX A
• Glossary
• Common Acronyms

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MDS ESSENTIALS

APPENDIX A - Glossary – excerpts: APPENDIX A
• Common Acronyms - Excerpt

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APPENDIX B APPENDIX C
• State Agency and CMS Regional Office • Care Area Assessment Resources
• State RAI contact information – Provided as a courtesy
– CMS does not endorse or mandate use of this
– Located in the “Downloads” section on the CMS resource
MDS 3.0 RAI Manual Web page:
http://www.cms.gov/Medicare/Quality-Initiatives- • Facilities must use resource(s) that are current,
Patient-Assessment- evidenced-based or expert-endorsed research
Instruments/NursingHomeQualityInits/MDS30RAI and clinical practice guidelines
Manual.html
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MDS ESSENTIALS

Appendix C APPENDIX D
• Example: • Interviewing to increase resident voice in MDS
Assessments
– Approaches and techniques to make
interviews more effective

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APPENDIX D: Excerpt (p. D-1)
APPENDIX E
• Find a quiet, private area where you are not • PHQ-9© Scoring Rules
likely to be interrupted or overheard. This is
– Resident Mood Interview Total Severity Score:
important for several reasons:
D0300
– Background noise should be minimized – Staff Assessment of Resident Mood Total Severity
– Some items are personal, and the resident will Score: D0600
be more comfortable answering in private. The • Instructions for BIMS (when administered in
interviewer is in a better position to respond
writing)
to issues that arise
– Sample cue cards that may be used for interviews
– Decrease available distractions
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MDS ESSENTIALS

APPENDIX E: Excerpt
APPENDIX F
• MDS item Matrix
APPENDIX G
• References
APPENDIX H
• MDS Forms
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SNF Prospective Payment System

Regulatory Mandate
• Federal law mandated switch from cost-based to
Skilled Nursing Facility Prospective case-mix reimbursement in 1998
– Cost-based = pay facility whatever it spends on the
Payment System (SNF PPS) resident’s care
– Case-mix prospective reimbursement = predict cost
of care using resident-specific information from MDS
and pay facility based on that
• The Patient-Driven Payment Model (PDPM)
replaced RUG-IV October 1, 2019

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MDS ESSENTIALS
SNF Prospective Payment System SNF Prospective Payment System

Calculating Payment Calculating Payment
• Nursing Home PPS (NP) item set • Completed PPS 5-Day or Interim Payment
– Specific items reflecting resident’s acuity used to
Assessment (IPA) classifies resident case-mix
groups for PT, OT, SLP, nursing, and non-therapy
help quantify the cost of care and services, such
ancillary components
as
• A daily payment rate is assigned to each case-mix
• Functional status
group and combined with a non-case-mix flat rate
• Health conditions to establish the total rate
• Diagnoses • A variable per diem (VPD) adjustment schedule is
• Certain treatments, procedures applied to the PT, OT, and non-therapy ancillary
components
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SNF Prospective Payment System

Assessment Requirement
• SNF PPS required the 5-Day assessment to set the
daily rate for the entire Medicare Part A stay
– The optional IPA may be used to change the rate
during the Medicare Part A stay
• SNF PPS Discharge Assessment is required
– Not used for determining daily rate, used for reporting MDS 3.0 Quality Measures (QMs)
• The PPS schedule is in addition to the OBRA-
required clinical assessments

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MDS ESSENTIALS
MDS 3.0 Quality Measures MDS 3.0 Quality Measures
• Intended to reflect quality of care in the • Long list of QMs, scores periodically updated
nursing home
• CMS pulls data specific to particular • Complex formulas and calculations involved
conditions and problems from a national • Quality Measures info and User’s Manual:
database - examples https://www.cms.gov/Medicare/Quality-Initiatives-
– Rate of UTIs in a facility comes from I2300 Patient-Assessment-
– Decline in ADLs computed from comparing G0110 instruments/NursingHomeQualityInits/NHQIQuality
data on successive assessments Measures.html

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MDS 3.0 Quality Measures Quality Measures

Publicly Reported QMs CASPER Reporting System
• Takes facility-specific resident care • Certification and Survey Provider Enhanced

information directly to consumers Reporting (CASPER) system
• To publicize the differences in quality to assist • Produces QM reports for facility to use in
consumers in selection of a facility quality improvement efforts
• Five-Star Rating System • Surveyors use the MDS Indicator Facility Rate
– Nursing Home Compare website report
www.medicare.gov/nursinghomecompare/
search.html
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MDS ESSENTIALS
SNF QRP
• SNF Quality Reporting Program (QRP)
– Requirement of the IMPACT Act (2014)
– Requires SNF to report 100% of the data MDS and Survey Outcomes
required to calculate all SNF QRP Measures
on at least 80% of all assessments
• 5-Day MDS
• Part A PPS Discharge Assessment

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Survey Outcomes 483.20 RESIDENT ASSESSMENTS (12 TAGS)

New Tag Tag Title CFR
• All nursing facilities participating in Medicare 483.20(f)(5)
F842 Resident Records – Identifiable Information
and/or Medicaid program are required to have 483.70(i)(1)-(5)
F635 Admission Physician Orders for Immediate Care 483.20(a)
a Life Safety and Standard Annual Survey F636 Comprehensive Assessments & Timing 483.20(b)(1)(2)(i)(iii)
– Additional surveys F637 Comprehensive Assmt After Significant Change 483.20(b)(2)(ii)
F638 Quarterly Assessment At Least Every 3 Months 483.20(c)
• Dementia Focus Survey F639 Use, Maintain 15 Months of Resident Assessments 483.20(d)
• Complaint Survey F640 Encoding/Transmitting Resident Assessment 483.20(f)(1)-(4)
F641 Accuracy of Assessments 483.20(g)
F642 Coordination/Certification of Assessment 483.20(h)-(j)
– Must apply RAI guidelines and understand the F644 Coordination of PASARR and Assessments 483.20(e)(1)(2)
guidelines found in the State Operations Manual F645 PASARR Screening for MD & ID 483.20(k)(1)-(3)
(SOM Appendix PP) F646 MD/ID Significant Change Notification 483.20(k)(4)
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MDS ESSENTIALS
Survey Outcome Guidelines

F641 §483.20(g) Accuracy of Assessment
The assessment must accurately reflect the resident’s status
Intent §483.20(g)
To assure that each resident receives an accurate assessment,
reflective of the resident’s status at the time of the assessment, by
staff that are qualified to assess relevant care areas and
knowledgeable about the resident’s status, needs, strengths, and
Achieving MDS Accuracy
areas of decline
Guidelines §483.20(g)
“Accuracy of assessment” means that the appropriate, qualified health
professional correctly document the resident’s medical, functional, and
psychosocial problems and identify resident strengths to maintain or
improve medical status, functional abilities, and psychosocial status using
the appropriate Resident Assessment Instrument (RAI) (i.e.,
comprehensive, quarterly, SCSA)
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Achieving MDS Accuracy Achieving MDS Accuracy

• RAI User’s Manual: THE authoritative resource for all
official instructions and information • Download RAI User’s Manual from CMS
• Chapters website
– 1: Overview http://www.cms.gov/Medicare/Quality-Initiatives-
– 2: Timing and scheduling of assessments Patient-Assessment-
– 3: Item-by-item coding instructions Instruments/NursingHomeQualityInits/MDS30RAIMan
ual.html
– 4: Care Area Assessments and care planning
– 5: MDS correction policy and transmission
– 6: SNF PPS calculations
• 8 Appendices
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MDS ESSENTIALS
AANAC’s RAI User’s Manual Web Page Achieving MDS Accuracy

https://www.aanac.org/Information/Government-
Chapter 3
Source-Documents
• Process based on the standard format for the
instructions for each item
• Background included for each item
– Intent/reason for including item on MDS
– Rationale/purpose for assessing the topic
– How the topic of the item affects quality of life
– How assessment of the topic can contribute to
appropriate care planning
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Achieving MDS Accuracy B0700. Makes Self Understood

Chapter 3
• Item-specific coding instructions
– Steps for assessment: sources for information and
methods for determining the correct code Item Rationale
– Specific coding instructions with explanation of Health-related Quality of Life
individual response options • Problems making self understood can be very
– Coding tips/clarifications, issues of note, frustrating for the resident and can contribute to
conditions to be considered social isolation and mood and behavior disorders
• Unaddressed communication problems can be
– Case examples
inappropriately mistaken for confusion or cognitive
impairment
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MDS ESSENTIALS
B0700. Makes Self Understood B0700. Makes Self Understood

Planning for Care Steps for Assessment
• Ability to make self understood 1. Assess using the resident’s preferred language or
can be optimized by not rushing method of communication
the resident, breaking longer
2. Interact with resident. Be sure he/she can hear you or
questions into parts and waiting
have access to his or her preferred method for
for reply, and maintaining eye
communication. If the resident seems unable to
contact (if appropriate)
communicate, offer alternatives such as writing,
• If a resident has difficulty making pointing, sign language, or using cue cards
self understood:
— Identify the underlying cause 3. Observe his/her interactions with others in different
or causes
settings and circumstances
— Identify the best methods to 4. Consult with the primary nurse assistants (over all
facilitate communication for shifts) and if available, the resident’s family, and speech-
that resident language pathologist
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B0700. Makes Self Understood Achieving MDS Accuracy

Timeframe for Data Collection
Coding Instructions
• Code 0, understood: if the resident expresses requests • Based on Assessment Reference Date (ARD), item
and ideas clearly A2300 (p. 5)
• Code 1, usually understood: if the resident has difficulty – Last date for collecting data for the particular MDS
communicating some words or finishing thoughts but is able if
prompted or given time. He or she may have delayed item
responses or may require some prompting to make self – Most items look-back 7 days: ARD plus the 6 days
understood
• Code 2, sometimes understood: if the resident has preceding it (example next slide)
limited ability but is able to express concrete requests – This is the observation period or look-back period
regarding at least basic needs (e.g., food, drink, sleep, toilet)
(these terms are synonymous)
• Code 3, rarely or never understood: if, at best, the
resident’s understanding is limited to staff interpretation of – Using the wrong dates or not using every day in the
highly individual, resident-specific sounds or body language look-back is likely to result in accuracy problems
(e.g., indicated presence of pain or need to toilet)
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MDS ESSENTIALS

Timeframe for Data Collection Who Takes Part in MDS Process?
• Look-back period
• “A registered nurse conducts or coordinates
– ARD + 6 previous calendar days
each assessment with the appropriate
1 2 3 4 5 6 participation of health professionals”
ARD (42CFR483.20[h])
• It must be an RN who signs item Z0500A
certifying completion of all of the MDS items
(483.20([I])
– This is not verifying accuracy of the items
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Who Takes Part in MDS Process? How is Accuracy Validated?
• “The determination of appropriate participation
of health professionals must be based on the • Chart documentation that supports the MDS
physical, mental and psychosocial condition of
each resident. This includes an appropriate level coding
of involvement of physicians, nurses, • Resident voice is incorporated into the
rehabilitation therapists, activities professionals, assessment through MDS scripted interviews
medical social workers, dietitians, and other
professionals, such as developmental disabilities • Any surveyor or auditor reading the chart
specialists, in assessing the resident, and in should come to the same coding decision that
correcting resident assessments. Involvement of the person coding the MDS did (except
other disciplines is dependent upon resident interviews)
status and needs ” (SOM guidelines, F641)
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MDS ESSENTIALS
Please continue with MDS Essentials:

Sections A, B, C, H and I

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Questions
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MDS ESSENTIALS

• I have no financial relationships to disclose

Introduction to RAI and MDS Process

Visit us at AANAC.org | Copyright © 2019 Visit us at AANAC.org | Copyright © 2019

Educational Activity Completion Learning Objectives

The Minimum Data Set (MDS) Minimum Data Set

Minimum Data Set Minimum Data Set

Minimum Data Set

Minimum Data Set

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Minimum Data Set Minimum Data Set

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Minimum Data Set

Resident Assessment Instrument

Resident Assessment Instrument Resident Assessment Instrument

Resident Assessment Instrument

• OBRA-required clinical assessments

Resident Assessment Instrument

RAI User’s Manual RAI User’s Manual

RAI User’s Manual RAI User’s Manual – Chapter 2

RAI User’s Manual – Chapter 2 RAI User’s Manual

RAI User’s Manual RAI User’s Manual

RAI User’s Manual RAI User’s Manual

RAI User’s Manual RAI User’s Manual

RAI User’s Manual

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RAI User’s Manual RAI User’s Manual

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RAI User’s Manual RAI User’s Manual

RAI User’s Manual RAI User’s Manual

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RAI User’s Manual RAI User’s Manual

RAI User’s Manual RAI User’s Manual

SNF Prospective Payment System

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SNF Prospective Payment System SNF Prospective Payment System

SNF Prospective Payment System

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MDS 3.0 Quality Measures MDS 3.0 Quality Measures

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MDS 3.0 Quality Measures Quality Measures

• Takes facility-specific resident care • Certification and Survey Provider Enhanced

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Survey Outcomes 483.20 RESIDENT ASSESSMENTS (12 TAGS)

Survey Outcome Guidelines

Achieving MDS Accuracy Achieving MDS Accuracy

AANAC’s RAI User’s Manual Web Page Achieving MDS Accuracy

Achieving MDS Accuracy B0700. Makes Self Understood

B0700. Makes Self Understood B0700. Makes Self Understood

B0700. Makes Self Understood Achieving MDS Accuracy

Achieving MDS Accuracy Achieving MDS Accuracy

Achieving MDS Accuracy Achieving MDS Accuracy

Please continue with MDS Essentials:

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