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CMS Minimum Data Set (MDS) Cheat Sheet by

MDS 3.0 CMS Mandate for SNF
assessment     3-0     snf     healthcare     ltc     mds     caas

Introd­uction MDS 3.0

The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a compre­hensive assessment of each resident's functional capabi­lities and helps nursing home staff identify health problems. Care Area Assess­ments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formul­ated. MDS assess­ments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assess­ments are required for residents on admission to the nursing facility, period­ically, and on discharge. All assess­ments are completed within specific guidlines and time frames. In most cases, partic­ipants in the assessment process are licensed health care profes­sionals employed by the nursing home. MDS inform­ation is transm­itted electr­oni­cally by nursing homes to the national MDS database at CMS.

Main Objectives

MDS screens for possible problems in 20 care areas.
Care Area Triggers (CATs) alert to possible issues in the care needs.
Triggered care area must be thoroughly assessed.
There is no mandated specific tool for assess­ment.
Documentation must meet criteria.

CAAs: Problem Areas

1. Activities
2. ADL Supplement Attaining Maximum Possible Indepe­ndence
3. ADLs Functional Status­/Re­hab­ili­tation Potential
4. Behavioral Symptoms
5. Cognitive Loss/D­ementia
6. Commun­ication
7. Dehydr­ati­on/­Fluid Mainte­nance
8. Delirium
9. Dental Care
10. Documents
11. Feeding Tubes
12. Mood State
13. Nutrit­ional Status
14. Pain
15. Physical Restraints
16. Pressure Ulcer
17. Psycho­social Well-Being
18. Psycho­tropic Medication Use
19. Return to Community Referral
20. Urinary
21. Visual Function

CAA Process Framwork

Guides review of triggered areas
Clarifies functional status and related causes of impair­ments
Assessment of causes and contri­buting factors provides IDT additional inform­ation
Should help staff:
 ­ ­ ­ • Consider each resident as a whole
 ­ ­ ­ • Identify areas of concern
 ­ ­ ­ • Develop to extent possible, interv­entions to help improve, stabilize, or prevent declines
 ­ ­ ­ • Address need and desire for other consid­era­tions such as palliative care

No mandated forms

There are no mandated forms that must be used for the CAA process in MDS 3.0. The RAI Manual instructs “To identify and use tools that are current and grounded in current clinical standards of practice, such as eviden­ce-­based or expert­-en­dorsed research, clinical practice guidel­ines, and resour­ces.”

CMS does supply facilities with CAA Resources in Appendix C. The appendix includes care area specific tools that the assessor can use for each of the 20 care areas. Each tool is between three to five pages long, guides the interd­isc­ipl­inary decisi­on-­making, and provides a place to document the process. Using the tools provides a compre­hensive assessment of the problem area.

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