Q&A: Do I need to complete discharge assessments for an emergency evacuation?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Do I need to complete discharge assessments for an emergency evacuation? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: You may not be required to complete the discharge MDS in this situation. Here is a link to the all-cause waiver information: https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Provider-Survey-and-Certification-Frequently-Asked-Questions.pdf. Review the SNF information and watch …

Q&A: What are the correct dates for flu season and pneumonia vaccines for MDS purposes to count if present during that time?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: What are the correct dates for flu season and pneumonia vaccines for MDS purposes to count if present during that time? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: The influenza vaccine question O0250 is asking if the vaccine was delivered in your facility during the current flu …

COVID-19 Vaccine “Up to Date” Guidance Tracker

MDS 3.0 and the RAI Process / NAC / Tool

The Centers for Disease Control and Prevention (CDC) has updated the “Staying Up to Date with COVID-19 Vaccines” guidance several times since requiring COVID-19 vaccinations to be coded on the MDS as of October 2024. Facility teams can track these changes by using AAPACN’s COVID-19 Vaccine “Up to Date” Guidance …

Sepsis: Nurse Documentation Training Aid

Clinical Care Solutions / MDS 3.0 and the RAI Process / NAC / Tool

Starting Oct. 1, 2024, additional supporting documentation is required to capture a diagnosis of sepsis at I2100, Septicemia on the MDS. Nurse assessment coordinators can use the AAPACN Sepsis: Nurse Documentation Training Aid to provide guidance to nurses on assessment and documentation needs when a resident is diagnosed with sepsis. …

Don’t Short-Change Significant Correction MDSs: Learn When and Why to Do Them

Article / MDS 3.0 and the RAI Process / NAC

Listen to this article Your browser does not support the audio element. The OBRA Significant Correction to Prior Assessment (SCPA), which includes the Significant Correction to Prior Quarterly Assessment and the Significant Correction to Prior Comprehensive Assessment, is one of the most misunderstood parts of the Resident Assessment Instrument (RAI) …

Q&A: Does every CAA trigger require a care plan intervention?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: I need clarification regarding the CAA notes: I was understanding that anything that triggers we would address in the care plan. Do we have to address every single CAA note even if it does not trigger? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, CRC: Not every item that triggers …

Q&A: How do I support MDS coding of a medication in N0415 when a surveyor disagrees with the classification?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: During our annual survey, I was questioned about coding methenamine as an antibiotic on the MDS. I had coded it based on information received from AAPACN and references discussed in this forum. The surveyor appreciated the reference but disagreed, stating that the medication is an anti-infective rather than an …

Q&A: Is a signed diagnosis list enough to support coding in section I?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Is a signed diagnosis list enough to support coding diagnoses in section I, or does the physician need to document the diagnosis as active in their notes? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, CRC: Just having a diagnosis list signed by a physician is not quite enough. There …

Falls MDS Coding: Why the DNS Should Get Involved—and How to Do It

Article / Clinical Care Solutions / DNS / IDT member / MDS 3.0 and the RAI Process / NAC

Listen to this article Your browser does not support the audio element. In September 2025, the Office of Inspector General (OIG) rang the alarm bell on MDS coding inaccuracies involving falls with major injury, and the Centers for Medicare & Medicaid Services (CMS) took actions that every director of nursing …

Leave of Absence versus Interrupted Stay: The Effect of EHR Census Decisions

Article / Billing and Reimbursement / MDS 3.0 and the RAI Process / NAC

Listen to this article Your browser does not support the audio element. Skilled nursing facilities (SNFs) frequently manage residents who temporarily leave the building or experience a break in Medicare Part A coverage. On the UB-04, these situations may look the same, often reflected as gaps in covered days or …