MDS 3.0 and the RAI Process
The MDS 3.0 and the RAI (Resident Assessment Instrument) is a comprehensive nurse assessment and care planning process used by the long-term and post-acute care field as a requirement for reimbursement under Medicare and Medicaid. AAPACN nurse experts help you stay up to date on changes to the MDS with breaking news, articles, and practical tools.
- Extended Q&A from the AAPACN May 18 Live Webinar on Upcoming MDS ChangesIn this podcast, Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, curriculum development specialist with AAPACN, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist with AAPACN, discuss some of the most pressing questions about …
- Q&A: Please clarify when a device would or would not be considered a restraint?Question: Can a winged versus a concave mattress be considered a restraint if it fits the definition? Can a tilt and space wheelchair be considered a restraint? It is being explained to me that it …
- MDS Data Specifications V3.01.1 (FINAL) and OSA Data Specifications V3.01.0 (FINAL) PostedThe MDS Data Specifications V3.01.1 (FINAL) and the OSA Data Specifications V3.01.0 (FINAL) are now available for download. These specifications will go into effect on October 1, 2023. There are both item and edit updates in …
- Final MDS 3.0 Item Sets v. 1.18.11 effective Oct. 1, 2023–UpdatedThe final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available. The NP, NPE, and SD Item Sets have been replaced with revised versions; the remaining item sets …
- CMS iQIES MDS FAQsTable of Contents 1. Launch/Help Questions 1.1 Will iQIES have the same spec version at launch as QIES (version 3.00.1 including Errata Version3.00.8)? _____________________________________________ 1.2 How do I register for iQIES? 1.3 Whom can I …
- MDS Issues From the iQIES Known Issues ReportCS1963652 Resolved Reports ALL iQIES Users are currently experiencing issues generating reports in HTML or downloading them in CSV/PDF format, presenting no data or limited data to users. Team is investigating and resolving actively 05/31/2023 …
- Q&A: What staff member in a skilled nursing facility (SNF) can complete data collection and entry for section GG items?Question: What staff member in a SNF can complete data collection and entry for section GG items? Answer from Melissa Brown, OTR/L, RAC-CT, CDP, CSRS: I think what may be causing confusion here is the …
- Q&A: If a Medicare Part A resident goes on a therapeutic leave of absence (LOA) of four days for a funeral, what MDS assessments/records, if any, are required?Question: If a Medicare Part A resident goes on a therapeutic leave of absence (LOA) of four days for a funeral, what MDS assessments/records, if any, are required? Answer from Jeff Taylor: No additional MDS …
- Q&A: Can a comprehensive MDS be completed before day 14, such as on day 9 or 10, as long as it is completed by day 14?Question: Can a comprehensive MDS be completed before day 14, such as on day 9 or 10, as long as it is completed by day 14? For example, we have a 5-Day combined with an …
- MDS Item O0110: Get Ready for Multiple Look-Back Periods on the Same MDSThis Oct. 1, 2023, MDS 3.0 item O0100 (Special Treatments, Procedures, and Programs) will be retired and replaced with O0110 (Special Treatments, Procedures, and Programs) as part of the transition to the v1.18.11 MDS item …
- MDS: State Section S Items Effective October 1, 2023 OverviewThe tables list the Section S items that will be active on MDS 3.0 records with a target date on or after October 1, 2023. The active item on each item subset code (ISC) is …
- Top Attendee Questions from the May 18 AAPACN Webinar on Upcoming RAI Manual ChangesThe Centers for Medicare & Medicaid Services (CMS) recently released the draft Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual v.1.18.11. With several changes coming this October, the American Association of Post-Acute Care …
- CMS MDS v1.18.11 Training Videos: Direct LinksDirect links: SNF Training Program Overview SNF Understanding Changes to the MDS 3.0 RAI Manual v1.18.11 Training Webinar SNF Social Determinants of Health and New Data Elements in Section A Training Webinar SNF Section C: …
- Q&A: Where can I obtain CMS training regarding the new MDS guidelines?Question: Where can I obtain CMS training regarding the new MDS guidelines? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP: The Centers for Medicare & Medicaid Services (CMS) has developed a two-part, training program …
- Updated CASPER MDS Census Reports for Nursing HomesUPDATED Certification and Survey Provider Enhanced Reports (CASPER) Daily Minimum Data Set (MDS) Census Reports for Nursing Homes The 1704D Daily MDS Census Detail and 1704S Daily MDS Census Summary reports in the Payroll-Based Journal …
- Q&A: When coding section E (Behaviors), does this need to be supported by episode charting in the medical record for each behavior or does this require progress notes stating what behavior occurred?Question: When coding section E (Behaviors), does this need to be supported by episode charting in the medical record for each behavior or does this require progress notes stating what behavior occurred? Answer from Jeff …
- Deep Dive into ICD-10-CM: Misunderstood Coding GuidelinesDiagnosis accuracy, long a critical component of the MDS, is escalating in importance. With the recently released draft Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual version 1.18.11, which will become effective October …
- SNF MDS 3.0 RAI v1.18.11 Guidance Training Program: REGISTRATION OPEN for June 21 Live Event; Training Videos and Presentation Slide Decks Are Now AvailableThe Centers for Medicare & Medicaid Services (CMS) is offering a virtual training program that provides instruction on the updated guidance for the Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument …
- Substantive Changes to the Final MDS Nursing Home Item SetsOn April 3, 2023, the Centers for Medicare & Medicaid Services (CMS) released the final MDS Nursing Home Item Sets version 1.18.11. Nursing homes will be required to implement the new item sets—with their many …
- CAA Considerations with Oct. 1, 2023 MDS UpdatesThe draft Long-Term Care Resident Assessment Instrument (RAI) 3.0 User’s Manual v1.18.11, released in early April, presents revised care area triggers (CATs) in chapter 4 and care area assessment (CAA) worksheets in appendix C. To …
- MDS Section GG: Why It May Be Time to Bring in Restorative NursingEffective Oct. 1, 2023, section G (Functional Status) will officially be retired from the MDS 3.0 except in states that choose to implement the Optional State Assessment (OSA) with its limited four-item section G for …
- Submission to iQIES ChecklistAre your MDS assessments and tracking forms ready for submission to the national database? This checklist will prepare users to submit MDS item sets in the electronic health record (EHR) to the Centers for Medicare …
- What’s New with MDS Scripted Interview Questions for Oct. 1, 2023In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, curriculum development specialist for AAPACN, discuss the changes …
- Q&A: We have a resident who was in our facility in 2017 and then returned as a new admission this year. We noted her last name was misspelled on all assessments in 2017. Can I modify these assessments?Question: We have a resident who was in our facility in 2017 and then returned as a new admission this year. We noted her last name was misspelled on all assessments in 2017. Our billing …
- Q&A: The look-back period for J1800 is for falls since admission/entry or reentry or prior assessment (OBRA or scheduled PPS), whichever is more recent. For this look-back, is the Part A PPS Discharge assessment considered a “scheduled PPS” assessment?Question: The look-back period for J1800 is for falls since admission/entry or reentry or prior assessment (OBRA or scheduled PPS), whichever is more recent. For this look-back, is the Part A PPS Discharge assessment considered …
- Q&A: If a resident’s BIMS interview cannot be completed, when is it appropriate to code C0100, “Should the Brief Interview for Mental Status be Conducted?” as “No”? Question: If a resident’s BIMS interview cannot be completed, when is it appropriate to code C0100, “Should the Brief Interview for Mental Status be Conducted?” as “No”? Surveyors asked about our rationale for coding resident …
- Why Height and Weight Matter on the MDS and How to Get Them RightWhile many nurse assessment coordinators (NACs) are understandably focused on the changes in the draft v1.18.11 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, important MDS items that will remain as-is effective Oct. 1, …
- Optional State Assessment (OSA) Item Set and OSA Manual for Oct. 1, 2023 ImplementationThe Optional State Assessment (OSA) Item Set, OSA Manual, and OSA Change History table are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The OSA is …
- Sample iQIES MDS 3.0 ReportsWith the migration of Minimum Data Set (MDS) assessment submissions and reporting into iQIES, the Provider and Quality Measure reports that are currently available in the Certification and Survey Provider Enhanced Reporting (CASPER) system will …
- MDS Error Message User Guide From iQIESThis user guide addresses Minimum Data Set (MDS) error messages and troubleshooting. CMS iQIES MDS Error Message v1.0
- iQIES: MDS Upload an Assessment User Manual and How to Upload an Assessment for MDS Users Training VideoManual: CMS iQIES MDS Upload an Assessment v1.0 The How to Upload an Assessment for MDS Users training video provides steps for uploading MDS assessments to iQIES.
- MDS 3.0 Vendor Call Minutes and Q&As – 03/29/2023Information primarily on the Oct. 1, 2023 transition:
- CMS iQIES Reports User Manual v2.3: MDS ReportsThis user manual provides information for CMS, Providers, Vendors, Accrediting Organizations, Contractors, and State Agencies to effectively perform Reports functions and the processes necessary to request, view, download, and save reports in iQIES. CMS iQIES …
- MDS 3.0 Care Area Trigger (CAT) Specifications V1.06.0 for Implementation on Oct. 1, 2023The MDS 3.0 CAT specifications (V1.06.0) are now available. The specifications currently consist of the PDF documentation files, which describe the logic changes and provide pseudocode. Note that many of the CAT triggers are changing …
- Draft FY 2024 PDPM ICD-10 Mapping ToolIncludes tables with proposed changes. FY 2024 DRAFT PDPM ICD-10 Mapping (ZIP) (see FY 2024 SNF PPS Proposed Rule) From https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM
- FY 2024 SNF PPS Proposed Rule and Fact SheetProposed rule: https://www.federalregister.gov/public-inspection/2023-07137/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities Fact Sheet: On April 4, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities under the …
- Q&A: Five days after a fall, a resident had an x-ray completed showing a fracture of the second cervical vertebra. Would the fall injury be considered a major injury due to these findings?Question: A resident fell in the facility and hit the back of her head. She was evaluated in the emergency room and had a CAT scan completed the same day, but showed no injuries. Five …
- Q&A: The RAI User’s Manual states that respiratory therapy must be performed by a “respiratory therapist” or a “respiratory nurse.” What is a “respiratory nurse”?Question: The RAI User’s Manual states that respiratory therapy must be performed by a “respiratory therapist” or a “respiratory nurse.” What is a “respiratory nurse”? Answer from Jeff Taylor:Appendix A of the RAI User’s Manual provides …
- Q&A: If an interim payment assessment (IPA) is determined to have a new primary diagnosis, does therapy need to re-evaluate the resident or can they continue treatment based on the 5-Day diagnosis?Question: If an interim payment assessment (IPA) is determined to have a new primary diagnosis, does therapy need to re-evaluate the resident or can they continue treatment based on the 5-Day diagnosis? Answer from Carol …
- Back to the Basics: Preparing for MDS Submission to the Federal RepositoryIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist with AAPACN, discuss the …
- Draft MDS 3.0 RAI User’s Manual version 1.18.11 effective Oct. 1, 2023NOW AVAILABLE: Draft MDS 3.0 RAI User’s Manual version 1.18.11 The draft Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v)1.18.11 is now available. The MDS 3.0 RAI User’s Manual v1.18.11 …
- MDS 3.0 Quality Measures (QM) User’s Manual and AppendicesMeasure specifications and calculations are detailed in this manual. March 2023 updates APPENDIX – Claims-based Measures Technical Specifications Updates 03-20-23.pdf and Nursing Home Compare Claims-based Measures Tech Specs 2023 From https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures
- Culturally Competent Care Planning: What It Takes to Get It RightEffective with the Oct. 1, 2023, implementation of MDS v1.18.11, items A1005 (Ethnicity), A1010 (Race), A1110 (Language), and B1300 (Health Literacy) will provide nurse assessment coordinators (NACs) and other interdisciplinary team members with a starting …
- TIP: CMS Answers iQIES Question on Change in OwnershipThe Centers for Medicare & Medicaid Services (CMS) officials answered a question regarding the ability to submit MDS assessments in the Internet Quality Improvement and Evaluation System (iQIES) if a change in ownership occurs after …
- Q&A: What is required if a resident passes away the day after the ARD for a Significant Change in Status Assessment (SCSA) due to hospice initiation?Question: What is required if a resident passes away the day after the ARD for a Significant Change in Status Assessment (SCSA) due to hospice initiation? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, …
- CMS Section GG Training Videos: GG0130A, GG0110, GG0170C, GG0130B, Decision Tree for GG0130/GG0170Video Tutorials Available to Assist with Coding Specific Section GG Items The Centers for Medicare & Medicaid Services is releasing a series of short videos to assist providers with coding select Section GG items on …
- What Role Should the NAC Sign Up for in iQIES?The Centers for Medicare & Medicaid Services (CMS) recently announced that MDS assessment submissions and reporting will transition to the Internet Quality Improvement and Evaluation System (iQIES) on April 17, 2023. To prepare for this …
- 5 Major MDS Changes and How to Operationalize What’s Coming October 1, 2023Significant changes are coming with the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, version 1.18.11, which will become effective October 1, 2023. Facilities that prepare ahead of time will integrate the updates into …
- TIP: CMS Announces MDS Submission Transition to iQIES April 2023CMS announced that the transition of MDS assessment submission and reporting to the Internet Quality Improvement and Evaluation System (iQIES) will occur on Monday, April 17, 2023. Nursing facilities currently use the QIES Assessment Submission …
- New MDS Items Series: Transfer of Health InformationIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jessie McGill, RN, RAC-MT, RAC-MTA, AAPACN curriculum development specialist, continue the New MDS Items …
- Q&A: How does the new CMS memo, QSO-23-05-NH, for the schizophrenia diagnosis apply to OBRA assessments for residents who have been in the facility long-term?Question: How does the new CMS memo, QSO-23-05-NH, for the schizophrenia diagnosis apply to OBRA assessments for residents who have been in the facility long-term? Answer from Jeff Taylor: I would say that memo, the …
- Q&A: When a resident is admitted with a diagnosis of UTI from the hospital, and has physician documentation and a lab from the hospital in the medical record, do we code UTI at I2300 on the MDS?Question: When a resident is admitted with a diagnosis of UTI from the hospital, and has physician documentation and a lab from the hospital in the medical record, do we code UTI at I2300 on …
- Q&A: If the dietitian documents a resident is at risk of malnutrition, can I code this diagnosis on the MDS at item I5600? Question: If the dietitian documents a resident is at risk of malnutrition, can I code this diagnosis on the MDS at item I5600? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: I would …
- MDS 3.0 v1.18.11 Provider Burden Data From CMSSUPPORTING STATEMENT-PART A REVISION OF THE MINIMUM DATA SET (MDS) 3.0 (v1.18.11) NURSING HOME AND SWING BED PROSPECTIVE PAYMENT SYSTEM (PPS) FOR THE COLLECTION OF DATA PERTAINING TO THE PATIENT DRIVEN PAYMENT MODEL (PDPM) & …
- iQIES Resources SiteiQIES is the Internet Quality Improvement and Evaluation System, which is the system that the MDS submissions system is being transferred to. The QIES Technical Support Office maintains a website with iQIES reference materials, including …
- Ethnicity, Race, Language, Health Literacy: New MDS Items Are a Cultural Starting PointEffective Oct. 1, 2023, seven social determinants of health (SDOH) standardized patient assessment data elements (SPADEs) will be added to the MDS v1.18.11 item sets as follows: SDOH Items on the MDS v1.18.11 Draft Item …
- How NACs Can Support Administrative Level of Care Presumption During Medical ReviewWhen a Medicare beneficiary is admitted to a skilled nursing facility (SNF), there are specific requirements that the resident must meet for the facility to bill Medicare for the services provided. The physician must certify …
- Schizophrenia Care Planning Checklist by Federal SourceThe Centers for Medicare & Medicaid Services (CMS) recently announced they would be conducting audits on MDS coding of residents with a diagnosis of schizophrenia. With the increased scrutiny of this diagnosis, nurse assessment coordinators …
- Q&A: Would padded upper bedrails that are raised for a resident who experiences seizures be coded as a restraint?Question:Would padded upper bedrails that are raised for a resident who experiences seizures be coded as a restraint? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC:You must assess the effect the padded rails …
- Q&A: Therapy is discharging a Medicare Part A resident, but he will continue to be skilled for daily nursing services. Do I need to complete any MDS assessments to reflect this change?Question:Therapy is discharging a Medicare Part A resident, but he will continue to be skilled for daily nursing services. Do I need to complete any MDS assessments to reflect this change? Answer from Janine Cortesa, …
- Q&A: Which role should the MDS coordinator request to be able to submit assessments when signing up for the new iQIES?Question:Which role should the MDS coordinator request to be able to submit assessments when signing up for the new iQIES? Answer from Sandy Baker, RN, RAC-CT, RAC-CTA: Looking at page 11 of the “Provider User …
- Q&A: Can we code respiratory therapy in section O for incentive spirometry with documentation of 15 minutes a day?Question: Can we code respiratory therapy in section O for incentive spirometry with documentation of 15 minutes a day? Answer from Karen White, LPN, RAC-CT: Read through the RAI manual carefully, page 0-18. The therapy must …
- Q&A: If I have a resident who had a Stage 4 pressure ulcer to his coccyx that healed and then six months later it reopened and appears to be a Stage 2, is it still coded as a Stage 4?Question: If I have a resident who had a Stage 4 pressure ulcer to his coccyx that healed and then six months later it reopened and appears to be a Stage 2, is it still …
- Q&A: Is there an interrupted stay policy quick guide for billers that I can use as a reference?Question: Is there an interrupted stay policy quick guide for billers that I can use as a reference? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: AAPACN has a lot of great resources on …
- New MDS Item Podcast Series: Social Determinants of HealthIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jessie McGill, RN, RAC-MT, RAC-MTA, AAPACN curriculum development specialist, continue the podcast series on …
- TPE Medical Review Prep: Revive These MDS Best PracticesThe general consensus is that Medicare Administrative Contractors (MACs) are targeting—more than ever before—skilled nursing facility (SNF) fee-for-service Medicare Part A claims for Targeted Probe and Educate (TPE) prepayment medical review. SNFs that undergo TPE audits …
- April 1, 2023 Release of Revised ICD-10-CM Code Files and Coding Guidelines–UpdatedIn an effort to better enable the collection of health-related social needs (HRSNs), defined as individual-level, adverse social conditions that negatively impact a person’s health or healthcare, are significant risk factors associated with worse health …
- Q&A: Does AAPACN have any webinars on the changes coming this year with the elimination of G to GG for CNA documentation?Question: Does AAPACN have any webinars on the changes coming this year with the elimination of G to GG for CNA documentation? Answered by Jessie McGill, RN, RAC-MT AAPACN offers an on-demand workshop for section GG, …
- Q&A: Where can I find information about iQIES?Question: Where can I find information about iQIES? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT: The Centers for Medicare & Medicaid Services (CMS) recently released the new iQIES Reports User Manual. This manual …
- TIP: CMS Releases QSO Memo with Updates to Care Compare and Quality Measure RatingsThe Centers for Medicare & Medicaid Services (CMS) released a memo last week containing updates to Care Compare and Quality Measure ratings. These changes include: CMS will consider a lesser action to the star ratings …
- How the DNS Can Lead Risk Mitigation for Schizophrenia Diagnoses2015—the year that the Centers for Medicare & Medicaid Services (CMS) added antipsychotic medication use quality measures (QMs) to the Five-Star Quality Rating System—marked the beginning of some difficult trends in the potentially inappropriate diagnosis …
- Q&A: If a resident has a chronic urinary tract infection (UTI) and the physician ordered a prophylactic antibiotic, do I code UTI on the MDS as an active diagnosis?Question: If a resident has a chronic urinary tract infection (UTI) and the physician ordered a prophylactic antibiotic, do I code UTI on the MDS as an active diagnosis? Answer from Carol Maher, RN-BC, RAC-MTA, …
- TIP: Audit for Accurate Schizophrenia Diagnosis CodingCMS recently released a memo stating they will begin conducting an off-site audit of MDS coding of residents with a diagnosis of schizophrenia to ensure accuracy, and based upon the results, the quality measure (QM) …
- Prepare for iQIES to Avoid MDS Submission FailuresThe Centers for Medicare & Medicaid Services (CMS) is on target to transition MDS submissions from the current Quality Improvement and Evaluation System (QIES) to the cloud-based Internet Quality Improvement and Evaluation System (iQIES). “While …
- NACs Empowered: Tips to Optimize the Resident Interview for MDS CodingThe nurse assessment coordinator (NAC) is responsible for coordinating the completion of the MDS assessment, a process which depends on the interdisciplinary team (IDT) supplying documentation to support MDS coding. While the IDT’s role in …
- CMS QSO Memo 23-05-NH: Schizophrenia MDS Audits Are ComingUpdates to the Nursing Home Care Compare Website and Five Star Quality Rating System: Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding, and Posting Citations Under Dispute Summary • Adjusting Quality Measure Ratings: CMS …
- Person-Centered Care Planning – Nursing In-service EducationParticipants will learn to identify requirements of a person-centered care plan, identify ways to develop a relationship with a resident that facilitates care planning, and define person-centered care according to the Centers for Medicare & …
- MDS 3.0 v1.18.11 Draft Item Sets: PPS Discharge (NPE) Item Set Will See Big ChangesOn Dec. 23, 2022, the Centers for Medicare & Medicaid Services (CMS) released the nine revised MDS 3.0 v1.18.11 draft item sets so that nurse assessment coordinators (NACs) and other interdisciplinary team members can begin …
- Medical Review Audits and Regulatory Compliance: It Takes a VillageLong-term care is one of the most regulated settings in this country. The interpretive guidance in Appendix PP of the State Operations Manual, which surveyors apply during an onsite survey, is 856 pages long—and that …
- TIP: ICD-10 Coding Convention “with”When using the Alphabetical Index in the ICD-10-CM Official Guidelines for Coding and Reporting, generally the main terms and subterms are alphabetical. However, when the word “with” is immediately after a main term or subterm, …
- Medical Record Alert SheetWhile completing MDS assessments, nurse assessment coordinators can monitor for regulatory compliance during the chart review. If compliance issues arise, leadership should be notified to correct them. NACs can utilize AAPACN’s Medical Record Alert Sheet …
- New MDS Items Series: Changes to Ethnicity and RaceIn this new podcast series, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jessie McGill, RN, RAC-MT, RAC-MTA, AAPACN curriculum development specialist, discuss upcoming changes …
- Q&A: We have a resident on Medicare Part A that had a planned discharge return not anticipated to another facility. The resident came back to our facility after 24 hours. What assessments are required?Question: We have a resident on Medicare Part A that had a planned discharge return not anticipated to another facility. The resident came back to our facility after 24 hours. What assessments are required? Answer …
- Q&A: What is a reasonable amount of time to skill a resident on Medicare Part A for being COVID-19 positive?Question: What is a reasonable amount of time to skill a resident on Medicare Part A for being COVID-19 positive? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: I would refer you …
- Q&A: I have heard different rules on completing OBRA discharge assessments – that an assessment is required if the resident’s head isn’t in the bed at midnight and if the resident is out less than 24 hours, it isn’t necessary. Which is correct?Question: I have heard different rules on completing OBRA discharge assessments. Some say an assessment is required if the resident’s head isn’t in the bed at midnight, others say if the resident is out less …
- TIP: CMS Releases Draft Minimum Data Set 3.0 Item SetsThe Centers for Medicare & Medicaid Services (CMS) released an updated draft of the new MDS 3.0 Item Sets on Dec. 23, 2022. This newest draft includes changes to the following: Because there are multiple …
- Draft MDS 3.0 Item Sets v1.18.11 and Change Document AvailableThe draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. CMS plans to release the final …
- TIP: OBRA Scheduling Tools Updated for 2023AAPACN offers two great tools to assist nurse assessment coordinators (NACs) in scheduling OBRA assessments:• The Static OBRA Scheduling Tool is a 4-page tool that counts out day 92 for every calendar day – know when that …
- Schizophrenia: Keys to Coding I6000 and Supporting This Critical DiagnosisFrom 2015 – 2019, the number of long-stay residents who were coded in MDS item I6000 (Schizophrenia (e.g., Schizoaffective and Schizophreniform Disorders)) jumped by 35 percent, according to the November 2022 report Long-Term Trends of …
- Final Step of MDS Management: The Final Validation ReportWhen an MDS has been signed as complete, grouped into a batch, and submitted to the national repository, the nurse assessment coordinator (NAC) still is not yet done with managing that assessment. The last crucial …
- Preparing for the Retirement of Section GIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jessie McGill, RN, RAC-MT, RAC-MTA, a curriculum development specialist with AAPACN, talk about how …
- Preparing for Section G Retirement: Care Plan UpdatesCMS has announced the retirement of section G, activities of daily living with the MDS item set version 1.18.11, which goes into effect Oct. 1, 2023. To prepare for this change, nurse assessment coordinators can …
- MDS 3.0 Final Validation Reports Quick Facts and ResourcesNurse assessment coordinators (NACs) are responsible for the coordination and completion of the MDS assessments, however, to ensure these assessments are accepted without error into the National Submissions Database the Final Validation Report must also …
- Q&A: What assessments are required when a resident ends skilled care under a Managed Care plan and remains in long-term care?Question: What assessments are required when a resident ends skilled care under a Managed Care plan and remains in long-term care? Answer from Janine Cortesa RN, BSN: Typically, there are no MDS assessments to complete …
- Q&A: How is weight loss in the last six months assessed if the resident has only been in the facility for 14 days?Question: How is weight loss in the last six months assessed if the resident has only been in the facility for 14 days? Answer from Jeff Taylor: Looking at the steps for assessment on page …
- Q&A: We missed a first recertification (due by day 14), and we had the physician sign a delayed certification form. When is the next certification due?Question: We missed a first recertification (due by day 14), and we had the physician sign a delayed certification form. When is the next certification due? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, …
- Strengthen Care Plans to Reflect the Residents’ Needsby Michele Mummert, RN, RAC-CT, RAC-CTA, DNS-CT, Director of Research and Development, The Compliance Store Care planning is the foundation of resident care in the long-term care setting. Everything done to care for the resident …
- Action Required: Register ASAP for an iQIES Account for Early 2023 MDS SubmissionsAs previously announced, CMS is preparing to release the Internet-facing, cloud-based system, referred to as the Internet Quality Improvement and Evaluation System (iQIES) for Minimum Data Set (MDS) submission, in early 2023. Although the MDS …
- Back to Basics: Daily and Weekly Tasks of a Nurse Assessment CoordinatorNurse assessment coordinators (NACs) new to the job often receive guidance from a mentor during their first two weeks in the role. That mentor might lead the new NAC step by step through all the …
- Decision Support Software: How to Get the Benefits and Limit the RisksAccuracy, efficiency, consistency—these are all work process gains that nurse assessment coordinators (NACs) can reap from decision support software, such as MDS “scrubbers” and automated care plan interventions, and they can help lead to improved …