MDS Data Elements

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Sep 01 2025
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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 CMS has rescinded a few things that were anticipated and added a few things that may be a surprise. Post-acute care providers will want to make sure that staff are aware of the updates and have processes in place to ensure a smooth transition from September into October.   What Has CMS...
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Jul 01 2025
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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 assessment is a template that guides staff in determining what resources are necessary to care for residents competently during both day-to-day operations and in emergencies. Accurate data collected and recorded on the MDS can be used to generate helpful...
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Jun 01 2025
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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...
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Apr 01 2025
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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 “simple” process, but MDS corrections can be a multifaceted undertaking. When an MDS error is identified, the NAC must determine what type of error has occurred and if the MDS assessment has been submitted to iQIES (Internet Quality Improvement and...
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Mar 01 2025
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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 skilled nursing – from resident care plans to quality measures and reimbursement – which are governed through regulatory compliance. While adherence to these guidelines certainly falls to MDS Coordinators and Interdisciplinary Team (IDT) members, there...
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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 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...
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mds-consultants-what-is-an-mds-nurse-coordinator-part-1
Dec 01 2024
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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...
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From-the-MDS-to-RAI-System-Management
Nov 01 2024
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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...
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iQIES-a-new-age
Aug 01 2024
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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 and Roles Reports generated from MDS submissions (along with other reports) are available in the iQIES portal. Becoming familiar with what reports are available, who in the organization is responsible for “pulling” the reports, how often to pull the...
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SCSA
Jul 01 2024
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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...
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Interim-Payment-Assessment
Jun 01 2024
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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 the team at the facility. This team is not prescribed but identified by facility. The key question: does the 5-day PPS MDS completed on admission capture the current clinical picture being reimbursed (PDPM classification) or is an updated assessment...
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Resident-Interviews-Capturing-the-Data
May 01 2024
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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 in your path to creating a plan of care that puts each resident’s needs and preferences in focus and allows staff to support individual resident goals. Interviews in Sections C and D can affect PDPM scores and increase reimbursement based on...
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Section-GG
Apr 01 2024
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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 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...
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Social-Determinants-of Health-A-Global-Initiative
Mar 01 2024
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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 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...
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Trauma-and-the-MDS
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 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...
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New-Year-Same-MDS-Obstacle-Course
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 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...
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Schizophrenia Diagnosis Audits
Dec 01 2023
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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 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...
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PDPM-Or -OSA-A-State-Level-Decision
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 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...
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The Physician and I
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 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...
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Coding UTIs on the MDS 3.0
Oct 01 2023

Coding UTIs on the MDS 3.0

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...
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Recent Blogs in All Topics

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
Oct 01 2023

Coding UTIs on the MDS 3.0

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....
Keep Reading
Oct 01 2023
, ,

Achieving Accurate ADLs with the OSA

Section G of the MDS 3.0 was retired October 1, 2023, yet the MDS nurse may still need to use the knowledge of accurately coding ADLs with an assessment called the Optional State Assessment (OSA).  State-Optioned OSA Although the option to choose...
Keep Reading
Jul 05 2023

What Is an MDS Coordinator?

It’s a bit odd that when asked what you do for a living most MDS coordinators struggle to come up with an answer. Who struggles to explain what they do every day? The reality is that MDS Coordinators fully understand what this multifaceted job...
Keep Reading
May 13 2023
,

MDS 2023 Countdown Wrap-Up

This post is part of the MDS 2023 Countdown series.  Disclaimer: Current as of May 13, 2023.   What You Can Expect to See CMS released the first MDS draft item set (v1.18.11) in September 2022, which generated many questions for the long-term...
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May 13 2023
,

Rx Reconciliation – New SNF QRP and QMs

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See The reconciled medication list will have a new documentation requirement that will go into effect with the October 1, 2023...
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May 13 2023
,

Away with Q0300 and in with Q0310 – New Section Q Changes

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of May 13, 2023 What You Can Expect to See This new Section Q update presents a key change to the wording: GOAL vs expectation. The Cambridge American Dictionary defines...
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