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 (SAMHSA) as a resource when discussing caring for residents with trauma. Also discussed in the guidance is a “direct correlation between trauma and physical health conditions” (p. 434, CMS,2023). The SOM, Appendix PP, provides further guidance on assessment, care planning, and monitoring delivery of care and services. The following is a peak into the Minimum Data Set (MDS) when assessing a resident with trauma.


MDS Sections Impact Trauma Informed Care


The Resident Assessment Instrument (RAI) is one of the screening and assessment tools mentioned in FTag 699, Trauma Informed Care, to be used when assessing residents. This tool may be used with other screening and assessment tools specific to trauma mentioned in the guidance. As part of the RAI, a MDS is completed on all residents living in the nursing home on admission and at routine intervals. We therefore must ask ourselves: Have we correlated sections of the MDS that may require further investigation when completing the section and data element as it relates to trauma and trauma-informed care?

      • For example, Section A, Identification Information, addresses social determinants of health (SDOH), race/ethnicity, and preferred language to be considered when setting a resident’s care plan. A resident may request no care givers as a cultural preference or prevention of re-traumatization.
      • Another example: if a resident is responding yes to data elements in Section D, Mood, have we further explored why? Is there a known traumatic history? Is there a concern that a resident with a traumatic history needs additional care and resources to address the mood indicators in this section? Is the resident socially isolating due to a history of trauma events?
      • Looking further, we find Section E, Behavior. If someone is having behaviors noted in section E have, have we looked to understand if there is a history of trauma in the resident’s background and ensure our care planning has addressed triggers and potential behaviors?
      • Section F, Preferences, begins reviewing the important daily activities of a resident.
      • Accuracy of Section I, Active Diagnoses, stimulates involvement of the resident’s physician in care and attends specifically to psychiatric/mood disorders – including post-traumatic stress disorder (PTSD).

These examples highlight a few sections of the MDS that can assist care givers when caring for residents with trauma.


What Should We Be Doing Now?


Each team of care givers must review the MDS, CAA, and care planning practices in relation to trauma-informed care so they can provide training and guidance on how the RAI system strengthens care practices of residents with a history of trauma. We recommend facilities:


        • Ensure protocols and processes are in place for the MDS team to review for trauma informed care
        • Monitor residents’ assessments for trauma
        • Incorporate areas for improvement in QAA/QAPI related to trauma informed care

Ultimately, the RAI system (MDS section/data element completion; care area assessment (CAA) process; care planning development, implementation, and evaluation) provides an opportunity to take a closer look at residents with a history of trauma and enhance established care practices.


    More Resources

    Explore More Posts from MDS Consultants

    Get ready for October 1

    Transportation – New Item A1250

    This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See An additional item we will see in the upcoming MDS 3.0 v.1.18.11 in October 2023 is A1250 - Transportation. This is included in a new subset of...

    New 3-day Lookbacks | Assessment Periods

    This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of March 24, 2023 What You Can Expect to See New 3-day lookback/assessment periods are coming to the MDS world. There are different sections of the MDS that the Nurse Assessment Coordinators...

    New Pain Interview in Section J

    This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of February 22, 2023 What You Can Expect to See The most noticeable changes to Section J are evident in the pain interview, specifically questions J0510, J0520 and J0530. The RAI Manual has...

    Section B – Hearing, Speech and Vision Changes

    This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See Section B on the MDS is a component of the Standardized Patient Assessment Data Elements (SPADEs), which is utilized across post-acute care...

    Race and Ethnicity – Changes in Section A

    This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See Section A, Identification Information for Race/Ethnicity has expanded. One of the major changes is the deletion of section A1000 Race/Ethnicity....

    Read more on Toolbox Essentials

    Focused Infection Control Surveys and Directed Plan of Correction

    It's a dreary Monday morning, and the state surveyors walk into your facility to conduct a Focused Infection Control survey. You and your team have been trying your hardest to comply with infection control procedures throughout the pandemic. At the end of the survey,...

    New Advanced Beneficiary Notice

    Is your facility using the proper ABN form? The Centers for Medicare & Medicaid Services (CMS) recently updated the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. The new ABN will be mandatory for use on 1/1/2021, but the new form can be...

    Covid-19 and Skilled Status

    In late June, CMS addressed two issues and posted MDS 3.0 Final Item Sets (V1.17.2).  The two edits were changes to facilitate the calculation of Patient-Driven Payment Model payment codes on OBRA assessments for states that wish to have this calculation performed. ...

    Mind Your PHQs

    Some skilled nursing facilities (SNFs) are concerned about accurate payment when a resident unexpectedly discharges and the Brief Interview for Mental Status (BIMS) has not yet been completed.However, they should be just as concerned about the PHQ-9. The PHQ-9...

    MDS in the Emergency Preparedness Plan

    The COVID-19 pandemic has highlighted the need for skilled nursing facilities to have an effective Emergency Preparedness Plan - one that includes sheltering-in-place. The Centers for Medicare and Medicaid Final Rule requires that participating providers have an...

    MORE from MDS Experts

    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...

    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...

    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...

    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...

    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 an OSA from the...

    Webinars & Training

    Grow your knowledge with our MDS education

    MDS Guides & Forms

    Exclusive resources & tools we use every day

    Ask an Expert Forum

    Members can get 1:1 advice from our MDS experts

    Let's Meet in Person

    Get more info on our training & conference schedule

    News for MDS Experts

    Browse our blog & get news alerts on MDS changes

    MDS Completion

    Get your MDS' done ASAP with short-term, expert help

    Remote Floater

    Fill gaps on your team when & where you need

    Case Mix Index

    Improve your complex case mix calculations

    MDS System Mgt

    Best practices for MDS schedules & workflow

    + More Services

    Get help on PDPM, ICD-10, quality, schizoph. audits ++