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Financial and Operating Review for
The Nathaniel Witherell
Final Report
Appendices
Appendix A: BPCI Advanced Participants Located near The Nathaniel Witherell
Appendix B: Primary Referral Sources
Appendix C: Provider Profiles
Appendix D: New Executive Director/DON Training and Orientation Checklists
Appendix E: Insurance Verification Form
Appendix F: Resident Trust Fund Authorization Form
Appendix G: Bad Debt Worksheet Form
Appendix H: Office of Inspector General (OIG) Vendor Verification Form
Appendix I: IDEAL Discharge Process Checklist (Example)
Appendix J: Paid Time Off (PTO) Policy (Example)
Appendix K: CMS 5-Star User Guide
Appendix L: Minimum Data Set (MDS) Forms
Appendix M: Glossary of Terms
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX A: BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI)
ADVANCED PARTICIPANTS LOCATED NEAR THE NATHANIEL
WITHERELL
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell
Source: Centers for Medicare & Medicaid Services
Organization DBA Name
Participa
nt Type
City Clinical Episode
BAY AREA INPATIENT GROUP PGP DARIEN ACUTE MYOCARDIAL INFARCTION
BAY AREA INPATIENT GROUP PGP DARIEN BACK & NECK EXCEPT SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC ARRHYTHMIA
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC DEFIBRILLATOR
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC VALVE
BAY AREA INPATIENT GROUP PGP DARIEN CELLULITIS
BAY AREA INPATIENT GROUP PGP DARIEN CERVICAL SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CHRONIC OBSTRUCTIVE PULMONARY DISEASE, BRONCHITIS, ASTHMA
BAY AREA INPATIENT GROUP PGP DARIEN COMBINED ANTERIOR POSTERIOR SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CONGESTIVE HEART FAILURE
BAY AREA INPATIENT GROUP PGP DARIEN CORONARY ARTERY BYPASS GRAFT
BAY AREA INPATIENT GROUP PGP DARIEN DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS
BAY AREA INPATIENT GROUP PGP DARIEN DOUBLE JOINT REPLACEMENT OF THE LOWER EXTREMITY
BAY AREA INPATIENT GROUP PGP DARIEN FRACTURES OF THE FEMUR AND HIP OR PELVIS
BAY AREA INPATIENT GROUP PGP DARIEN GASTROINTESTINAL HEMORRHAGE
BAY AREA INPATIENT GROUP PGP DARIEN GASTROINTESTINAL OBSTRUCTION
BAY AREA INPATIENT GROUP PGP DARIEN HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT
BAY AREA INPATIENT GROUP PGP DARIEN LOWER EXTREMITY AND HUMERUS PROCEDURE EXCEPT HIP, FOOT, FEMUR
BAY AREA INPATIENT GROUP PGP DARIEN MAJOR BOWEL PROCEDURE
BAY AREA INPATIENT GROUP PGP DARIEN MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY
BAY AREA INPATIENT GROUP PGP DARIEN MAJOR JOINT REPLACEMENT OF THE UPPER EXTREMITY
BAY AREA INPATIENT GROUP PGP DARIEN PACEMAKER
BAY AREA INPATIENT GROUP PGP DARIEN PERCUTANEOUS CORONARY INTERVENTION
BAY AREA INPATIENT GROUP PGP DARIEN RENAL FAILURE
BAY AREA INPATIENT GROUP PGP DARIEN SEPSIS
BAY AREA INPATIENT GROUP PGP DARIEN SIMPLE PNEUMONIA AND RESPIRATORY INFECTIONS
BAY AREA INPATIENT GROUP PGP DARIEN SPINAL FUSION (NON-CERVICAL)
BAY AREA INPATIENT GROUP PGP DARIEN STROKE
BAY AREA INPATIENT GROUP PGP DARIEN URINARY TRACT INFECTION
BAY AREA INPATIENT GROUP PGP DARIEN BACK & NECK EXCEPT SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC DEFIBRILLATOR
BAY AREA INPATIENT GROUP PGP DARIEN PERCUTANEOUS CORONARY INTERVENTION
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN ACUTE MYOCARDIAL INFARCTION
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN CARDIAC ARRHYTHMIA
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN CELLULITIS
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN CONGESTIVE HEART FAILURE
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN GASTROINTESTINAL HEMORRHAGE
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN PACEMAKER
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN RENAL FAILURE
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN SEPSIS
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN SIMPLE PNEUMONIA AND RESPIRATORY INFECTIONS
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN URINARY TRACT INFECTION
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name Inpatient / Outpatient MS-DRG
BAY AREA INPATIENT GROUP INPATIENT 280, 281, 282
BAY AREA INPATIENT GROUP INPATIENT 518, 519, 520
BAY AREA INPATIENT GROUP INPATIENT 308, 309, 310
BAY AREA INPATIENT GROUP INPATIENT 222, 223, 224, 225, 226, 227
BAY AREA INPATIENT GROUP INPATIENT 216, 217, 218, 219, 220, 221, 266, 267
BAY AREA INPATIENT GROUP INPATIENT 602, 603
BAY AREA INPATIENT GROUP INPATIENT 471, 472, 473
BAY AREA INPATIENT GROUP INPATIENT 190, 191, 192, 202, 203
BAY AREA INPATIENT GROUP INPATIENT 453, 454, 455
BAY AREA INPATIENT GROUP INPATIENT 291, 292, 293
BAY AREA INPATIENT GROUP INPATIENT 231, 232, 233, 234, 235, 236
BAY AREA INPATIENT GROUP INPATIENT 441, 442, 443
BAY AREA INPATIENT GROUP INPATIENT 461, 462
BAY AREA INPATIENT GROUP INPATIENT 533, 534, 535, 536
BAY AREA INPATIENT GROUP INPATIENT 377, 378, 379
BAY AREA INPATIENT GROUP INPATIENT 388, 389, 390
BAY AREA INPATIENT GROUP INPATIENT 480, 481, 482
BAY AREA INPATIENT GROUP INPATIENT 492, 493, 494
BAY AREA INPATIENT GROUP INPATIENT 329, 330, 331
BAY AREA INPATIENT GROUP INPATIENT 469, 470
BAY AREA INPATIENT GROUP INPATIENT 483
BAY AREA INPATIENT GROUP INPATIENT 242, 243, 244
BAY AREA INPATIENT GROUP INPATIENT 246, 247, 248, 249, 250, 251, 273, 274
BAY AREA INPATIENT GROUP INPATIENT 682, 683, 684
BAY AREA INPATIENT GROUP INPATIENT 870, 871, 872
BAY AREA INPATIENT GROUP INPATIENT 177, 178, 179, 193, 194, 195
BAY AREA INPATIENT GROUP INPATIENT 459, 460
BAY AREA INPATIENT GROUP INPATIENT 61, 62, 63, 64, 65, 66
BAY AREA INPATIENT GROUP INPATIENT 689, 690
BAY AREA INPATIENT GROUP OUTPATIENT
BAY AREA INPATIENT GROUP OUTPATIENT
BAY AREA INPATIENT GROUP OUTPATIENT
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 280, 281, 282
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 308, 309, 310
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 602, 603
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 291, 292, 293
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 377, 378, 379
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 469, 470
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 242, 243, 244
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 682, 683, 684
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 870, 871, 872
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 177, 178, 179, 193, 194, 195
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 689, 690
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Participa
nt Type
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name Inpatient / Outpatient MS-DRG
SAME INPATIENT 280, 281, 282
SAME INPATIENT 518, 519, 520
SAME INPATIENT 308, 309, 310
SAME INPATIENT 602, 603
SAME INPATIENT 471, 472, 473
SAME INPATIENT 190, 191, 192, 202, 203
SAME INPATIENT 291, 292, 293
SAME INPATIENT 533, 534, 535, 536
SAME INPATIENT 377, 378, 379
SAME INPATIENT 388, 389, 390
SAME INPATIENT 480, 481, 482
SAME INPATIENT 492, 493, 494
SAME INPATIENT 329, 330, 331
SAME INPATIENT 469, 470
SAME INPATIENT 483
SAME INPATIENT 242, 243, 244
SAME INPATIENT 246, 247, 248, 249, 250, 251, 273, 274
SAME INPATIENT 682, 683, 684
SAME INPATIENT 870, 871, 872
SAME INPATIENT 177, 178, 179, 193, 194, 195
SAME INPATIENT 459, 460
SAME INPATIENT 61, 62, 63, 64, 65, 66
SAME INPATIENT 689, 690
SAME OUTPATIENT
SAME OUTPATIENT
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 280, 281, 282
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 518, 519, 520
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 308, 309, 310
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 222, 223, 224, 225, 226, 227
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 216, 217, 218, 219, 220, 221, 266, 267
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 602, 603
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 471, 472, 473
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 190, 191, 192, 202, 203
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 453, 454, 455
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 291, 292, 293
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 231, 232, 233, 234, 235, 236
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 441, 442, 443
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 461, 462
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 533, 534, 535, 536
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 377, 378, 379
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 388, 389, 390
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 480, 481, 482
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 492, 493, 494
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 329, 330, 331
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 469, 470
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 483
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 242, 243, 244
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 246, 247, 248, 249, 250, 251, 273, 274
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 682, 683, 684
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 870, 871, 872
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 177, 178, 179, 193, 194, 195
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 459, 460
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 61, 62, 63, 64, 65, 66
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 689, 690
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC OUTPATIENT
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC OUTPATIENT
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC OUTPATIENT
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name
Participa
nt Type
City Clinical Episode
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC PGP GREENWICH MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC PGP GREENWICH MAJOR JOINT REPLACEMENT OF THE UPPER EXTREMITY
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD CARDIAC ARRHYTHMIA
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD GASTROINTESTINAL HEMORRHAGE
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD GASTROINTESTINAL OBSTRUCTION
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD RENAL FAILURE
STAMFORD HOSPITAL ACH STAMFORD ACUTE MYOCARDIAL INFARCTION
STAMFORD HOSPITAL ACH STAMFORD CARDIAC ARRHYTHMIA
STAMFORD HOSPITAL ACH STAMFORD CHRONIC OBSTRUCTIVE PULMONARY DISEASE, BRONCHITIS, ASTHMA
STAMFORD HOSPITAL ACH STAMFORD CONGESTIVE HEART FAILURE
STAMFORD HOSPITAL ACH STAMFORD CORONARY ARTERY BYPASS GRAFT
STAMFORD HOSPITAL ACH STAMFORD GASTROINTESTINAL HEMORRHAGE
STAMFORD HOSPITAL ACH STAMFORD GASTROINTESTINAL OBSTRUCTION
STAMFORD HOSPITAL ACH STAMFORD RENAL FAILURE
STAMFORD HOSPITAL ACH STAMFORD SIMPLE PNEUMONIA AND RESPIRATORY INFECTIONS
STAMFORD HOSPITAL ACH STAMFORD STROKE
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name Inpatient / Outpatient MS-DRG
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC INPATIENT 469, 470
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC INPATIENT 483
STAMFORD HEALTH MEDICAL GROUP INPATIENT 308, 309, 310
STAMFORD HEALTH MEDICAL GROUP INPATIENT 377, 378, 379
STAMFORD HEALTH MEDICAL GROUP INPATIENT 388, 389, 390
STAMFORD HEALTH MEDICAL GROUP INPATIENT 682, 683, 684
STAMFORD HOSPITAL INPATIENT 280, 281, 282
STAMFORD HOSPITAL INPATIENT 308, 309, 310
STAMFORD HOSPITAL INPATIENT 190, 191, 192, 202, 203
STAMFORD HOSPITAL INPATIENT 291, 292, 293
STAMFORD HOSPITAL INPATIENT 231, 232, 233, 234, 235, 236
STAMFORD HOSPITAL INPATIENT 377, 378, 379
STAMFORD HOSPITAL INPATIENT 388, 389, 390
STAMFORD HOSPITAL INPATIENT 682, 683, 684
STAMFORD HOSPITAL INPATIENT 177, 178, 179, 193, 194, 195
STAMFORD HOSPITAL INPATIENT 61, 62, 63, 64, 65, 66
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX B: PRIMARY REFERRAL SOURCES
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1B: Acute Neurologic
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF
Length of
Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as
2nd PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL
ASSOCIATION
32
21.5
17.5%
55.6%
STAMFORD HOSPITAL
29
22.5
19.0%
60.3%
TOTAL/AVERAGE
61
22.0
18.2%
57.9%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Table 2B: Elective Joint Replacement
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
231
12.6
3.0%
31.2%
STAMFORD HOSPITAL
44
14.9
4.5%
70.5%
TOTAL/AVERAGE
275
13.0
3.3%
37.5%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 3B: Major Joint Replacement/Spinal Surgery
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
71
19.6
6.4%
56.0%
STAMFORD HOSPITAL
18
23.0
22.9%
60.0%
TOTAL/AVERAGE
89
20.3
9.7%
56.8%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Table 4B: Medical Management
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
418
22.6
18.7%
59.0%
STAMFORD HOSPITAL
387
22.4
16.3%
61.6%
TOTAL/AVERAGE
805
22.5
17.5%
60.2%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 5B: Non-Orthopedic Surgery
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
67
20.6
18.7%
56.0%
STAMFORD HOSPITAL
112
23.0
18.8%
60.1%
TOTAL/AVERAGE
179
22.1
18.8%
58.5%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Table 6B: Other Orthopedic
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
143
28.1
8.4%
63.6%
STAMFORD HOSPITAL
97
30.9
13.0%
62.7%
TOTAL/AVERAGE
240
29.2
10.2%
63.3%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 7B: Total Discharges
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
962
20.6
12.4%
52.4%
STAMFORD HOSPITAL
687
23.2
15.8%
62.0%
TOTAL/AVERAGE
1,649
21.7
13.8%
56.4%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX C: HOSPITAL PROFILES
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1C: Hospital Profiles
Source: Definitive Healthcare
Greenwich Hospital Stamford Hospital
Location Greenwich, Connecticut Stamford, Connecticut
Hospital Type Short-Term Acute Care Hospital Short-Term Acute Care Hospital
Staffed Beds 184 279
Medicare-certified Beds 206 305
Total Discharges 10,701 13,888
Total Average Length of Stay 4.8 Days 4.3 Days
CMI 1.63 1.65
Affiliated Physicians (Primary) 405 652
Affiliated Physicians (Secondary) 371 249
ACO Affiliations Cigna - Northeast Medical Group ACO (Commercial) None
Readmission Reduction Adjustment Penalty Score -0.79% -0.20%
Readmission Reduction Revenue Adjustment ($356,673) ($99,738)
Value-Based Purchasing $45,158 ($230,900)
Hospital Acquired Conditions Reduction $0 $0
Medicare Spending per Patient $21,287 $21,950
Medicare Spend vs. National Median 1.04 1.04
Hospital Spend: Connecticut Average 1.00 1.00
Medicare Case-Mix Adjusted Cost Per Discharges $10,834 $13,096
State Average $10,513 $10,513
Medicare Overall Case Mix Index 1.6339 1.6498
Average Daily Census 123.2 146.8
% Medicare 41.0% 35.6%
% Medicaid 3.2% 20.8%
% Other 55.8% 43.6%
Network Yale New Haven Health System None
Hospital 9 0
Physician Group 7 0
Ambulatory Surgery Center 20 0
Imaging Center 24 0
Home Health Agency 1 0
Hospice 2 0
Skilled Nursing Facility 1 0
Ugent Care Clinic 9 0
Payor Mix
System Components
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX D: ORIENTATION AND TRAINING CHECKLISTS FOR NEW
EXECUTIVE DIRECTORS AND DIRECTORS OF NURSING
December 13, 2018
Page 1
Director of Nursing Training Completion Checklist
DON Name:
Hire Date:
Nurse Consultant Name:
HDG NURSING PROCESSES/SYSTEMS
Core Competency
Date
Completed
Initial
Trainer
Initial
DON
Anticoagulant Therapy
Diabetic Management
Pain Management
Dialysis
Change of Condition
Enteral Feeding
Tracheostomy Care
Hydration
Accidents/Incidents
Bowel & Bladder
Behavior Management
Nutrition at Risk
Medical Records
Skin/ Wound Care
Infection Control
QAPI/ Root Cause Analysis
Survey Readiness/Regulatory Compliance
Code Status System
Pharmacy Services
Investigations/Complaints/Grievances
Core Competency
Date
Completed
Initial
Trainer
Initial
DON
MDS
Medline University/Inservice/Education
Care Planning/ Quarterly Assessments
Admissions
December 13, 2018
Page 2
Discharges
Labor/ Staffing/ Performance Evals
802/672
INTERACT
Abaqis
PCC (Point Click Care)/ POC (Point of Care, if applicable)
Clinical Oversight- Daily, Weekly, Monthly, Quarterly
Quality Measures/ Casper Report
5 Star
Community Orientation
Date
Completed
Initial
Trainer
Initial
DON
Important Facility Information
Your Nursing Team
Staffing
Training Opportunities
Continuous Quality Improvement
Facility Manuals
Customer Satisfaction
Getting to Know your Role in your Community
Clinical Rounds
Infection Control
Communication Systems
Recruitment and Retention
Supplies and Ordering
Service Providers
RAI
Administrative Services
Business Office Services
Housekeeping Services
Laundry Services
Maintenance Services
Medical Director Services
December 13, 2018
Page 3
Medical Records Services
Nutritional Services
Activities and Recreation Services
Rehabilitation Services
Social Services
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Caring Above and Beyond / HDG Corporate
Review of HDG Values, Mission, Vision RDO/CEO
Review of Scope of Authority RDO
Explain role of company consultants (Clinical, MDS, HR, Billing, Safety, Marketing) RDO
Functional Policies, Procedures and Expectations. Each regional consultant meets with administrator and
discusses how they can be of help.
RDO
Discuss items used to measure success in each functional area. What are the measureable standards and
metrics for marketing, clinical, human resources, rehabilitation, etc.
RDO
Review of Caring Above and Beyond Values in Action VP of Quality Improvement
Review and explain Code of Conduct, Compliance Policies, OIG requirements Corporate Compliance Director
HIPAA Policies Corporate Compliance Director
Review of Scorecard process RDO
Emergency Contacts
Discuss emergency contacts and when to call (Regional Director of Operations, Nurse Consultant, HR
Consultant Business Office Consultant)
RDO
Trigger Event Process/VA/Investigative Events
Provides overview of reporting Process, Expectations, Who to call during State Survey/Complaint
Survey/OSHA Survey
RDO
Labor Management
Communicate Labor Expectations RDO
How to use Labor Reports: Includes explanation, demonstration on computer, coaching and feedback RDO
How to conduct a daily staffing meeting. Includes explanation, demonstration observation and feedback RDO
Daily Staffing RDO
Daily Profitability Report RDO
Labor Management
Employment Laws and procedure for reducing employee hours or pay, if needed HR Consultant /RDO
Smartlinx Overview Payroll Consultant
Block Scheduling Overview Payroll Consultant
Purchasing
WEEK ONE
EXECUTIVE DIRECTOR ONBOARDING CHECKLIST
-1
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
AP Director of AP/Insurance
Vendors, New Vendors W-9 forms Director of AP/Insurance
Purchasing Contracts/community Contracts and Agreements Director of AP/Insurance
People Policies
Provide an explanation of key manager polices in the Handbook/HR P&P Manual and answer questions. HR Consultant
Provide an explanation of key employee policies in the Employee Handbook and answer questions. HR Consultant
Small Group Policy Overview HR Consultant
Performance Review/Stay Interview Process HR Consultant
HDG Orientation/Mentorship Program 30/60/90 Check-ins HR Consultant
Explain HR Audit/Assessment. HR Consultant
Review employee survey and action plans HR Consultant
Review the Employee Handbook HR Consultant
Discuss Union Contracts/Labor Relations HR Consultant
Weekend Manager on Duty program RDO
Explain HDG Quality Compliance HotLine for employees and families VP Quality Improvement
Review last 90 days of Quality HotLine calls from employees and how to prepare a written response. VP Quality Improvement
Review Caring Above and Beyond and Family, Employee, and Resident QC committee's, QC committee
reporting calendar
VP Quality Improvement
Disciplinary Process and Termination
Provide an explanation of policies and procedures regarding the disciplinary process. HR Consultant
Provide an explanation of termination policies and procedures. HR Consultant
Compensation Process and Levels of Authorization
Explain the yearly compensation philosophy HR Consultant
Explain compensation process including levels of authorization, completion of form, hire bonus, shift bonus
and pay raises.
HR Consultant
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Financial Reports, Financial Documents, By-Weekly Labor Reports, and Budget
Provides overview of system and sets financial expectations RDO
How to understand and use Financial Reports, Financial Documents, Bi-weekly Labor Reports, Budget, and
Spend-Down Sheets to successfully run the business
RDO
Review Scorecard process RDO
Monthly Management Report and Monthly Variance Report RDO
FIRST MONTH
-2
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Processing travel expense - GL Account Coding RDO
Monthly Accrual Process RDO
Review ED Bonus Criteria RDO
Business Office Processes
Accounts Receivable process/reports, bad debt, collections, central billing office Business Office Consultant
Cash Receipting process (General depository, Lockbox) Business Office Consultant
Resident Trust Fund Business Office Consultant
PCC - Admin tab Business Office Consultant
Aging/Financial meeting, Triple Check, & payer verifications Business Office Consultant
Collection Agency Business Office Consultant
Administrator process & PCC - cash adjustments, ancillaries, census reconciliation Business Office Consultant
Private Statements Business Office Consultant
Pharmacy Statements Business Office Consultant
Ancillaries Bundled Pricing Business Office Consultant
Internal Audit Business Office Consultant
Consolidated Billing Business Office Consultant
Access and Use of Electronic Resources
Explanation and demonstration of how to use email, voicemail, telephone system, passwords and other
electronic resources.
RDO or as assigned
Explanation and demonstration of how information is organized and shared from HDG RDO
Email Encryption Corporate Compliance Director
PointClickCare and reports Business Office Consultant
Medicare Entitlement
Compliance: Pre-bill audit/ Triple check: Business Office Consultant
Beneficiary Notice and Electronic signatures Business Office Consultant
Regulatory
Standard Operations Policies RDO
Explain and communicate Survey History, Plan of Correction, Survey Readiness process, and PREP Survey
Nurse/Clinical Consultant
Explain and demonstrate Survey Readiness Nurse/Clinical Consultant
Review of community assessment Nurse/Clinical Consultant
Clinical Systems
Abuse Prevention Policy, DHS Reporting Nurse/Clinical Consultant
Additional Clinical Resources, e.g., door security, bed systems, memory unit, community layout, etc Nurse/Clinical Consultant
Review of clinical meetings (behavior, nutrition at risk, skin) Nurse/Clinical Consultant
-3
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Review of Elopment Guidelines Nurse/Clinical Consultant
Weekly Medicare Meeting RUGS Meeting
Provide overview of Weekly Medicare meeting, the purpose and the process.
Director of Clinical Reimbursement
and Therapy
How to conduct the Medicare meeting. Includes observation of Medicare Meeting, explanation of how to run
the meeting, practice running the meeting with observer and feedback.
Director of Clinical Reimbursement
and Therapy
Review the triple check process and how it affects billing.
Director of Clinical Reimbursement
and Therapy
Assessment Reference Date Planner (Daily Meeting)
Daily Standup RDO
ED Routines RDO
Safety
Explain culture of safety excellence; safety committees, lifts, Injury-Reducing Safety Report Program, Disaster
Drills, Safe Patient Handling Policy and Equipment and Root Cause Analysis
Director of Safety and Risk
Management
Customer Service
Explain the company customer service CAAB VP Quality Improvement
Explain customer satisfaction measurement process (MyInnerview Survey), and the Quality Hot Line program VP Quality Improvement
Customer Satisfaction Survey Committees (Employee, Residents, Family) VP Quality Improvement
Sales and Marketing
Explain the importance of the Medicare and Managed Care business line, strategy and philosophy. Explain the
strategy of the admitting of high acuity patients.
Director of Market Development &
Admissions
Explain the general key account integration strategy
Director of Market Development &
Admissions
Explain the sales and marketing business tools including the Annual Sales Plan (ASP), Marketing Action Plan,
Admission Director Month End Report, and marketing collaterals.
Director of Market Development &
Admissions
Explain the sales team concept. Explain the roles of key sales positions including the Admissions Director and
Business Development Director
Director of Market Development &
Admissions
Explain the 24/7, Holiday, and Fast Admissions Process
Director of Market Development &
Admissions
Explain the Referral Development Team
Director of Market Development &
Admissions
Review the Clinical Capabilities of the building and Admission process with required policy and procedures
Director of Market Development &
Admissions
Quality Council and Performance Improvement
-4
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
How to manage QAPI VP Quality Improvement
Sources of inputs VP Quality Improvement
Root cause analysis and how to develop an action plan VP Quality Improvement
Incident Reporting System VP Quality Improvement
Pharmacy Operations
Review and explain Rx Trend Reports, Omniview, and Pharmacy Operations Initiatives RDO
Review and explain basic pharmacy services procedures RDO
Review and explain how to escalate pharmacy issues. RDO
Omniview - Medication orders RDO
Medical Directors
Contracting for Medical Director/ Physicians RDO
Compensation Guidelines for Medical Directors and Physicians RDO
Rehabilitation
Responsibilities of the Director of Rehabilitation
Director of Clinical Reimbursement
& Therapy
Patient Scheduling
Director of Clinical Reimbursement
& Therapy
Non-billable service
Director of Clinical Reimbursement
& Therapy
Staffing Model
Director of Clinical Reimbursement
& Therapy
Rehabilitation Organization Chart
Director of Clinical Reimbursement
& Therapy
Life Safety
Review Life Safety expectations
Director of Safety & Risk
Management
Review Emergency Preparedness, Active Shooter/Workplace Violence policies, door security
Director of Safety & Risk
Management
Monthly Corporate Mandatory Reports
Monthly Management Report RDO
-5
EXAMPLE
1 | P a g e
Executive Director Routines
Instructions:
The purpose of this form is to outline the key leadership routines and cyclical processes of the Executive Director.
Documenting routines that occur on an annual, semi-annual, quarterly, monthly, weekly and bi-weekly basis help to
identify priorities within an organization and to streamline processes leading to improved efficiency and operational
outcomes across the care community. The document should include those activities that the Executive Director would
either provide primary leadership, secondary support or oversight. (i.e. What happens at the care community) The intent
of this document is to provide a general structure of framework for documentation. There could be other requirements based on the
specific needs of the community.
Annual Routines
Operational Area
Target
Completion
Date:
Back Up
HDG Resource
Quality
Operation plan development and
review: Quality Section
November
RDO
RDO
Conduct Resident Survey
Sept/Oct
RDO
VP Quality Improvement
Conduct Family Survey
Sept/Oct
RDO
VP Quality Improvement
Survey Preparedness
Determined by
survey cycle
DON
Clinical Consultant
Life Safety Audit
December
Plant Ops
Director of Safety & Risk
Management
Review Emergency Preparedness
Plan
January
Plant Ops/HR
Director of Safety & Risk
Management
OIG/Code of Conduct/Compliance
Policy Review by Employees
April
HR
Corporate Compliance
Officer
Review community and staff
licenses are up to date
July/August
HR/RDO
HR Consultant/RDO
Building License Review, CLIA
Waiver
July/August
RDO
RDO
Maintenance – Annual
Inspection/Plan
January
Plant Ops
Director of Safety & Risk
Management
Activities – Review Annual
Calendar/Community Involvement
January
Activity Director
RDO / Director of Market
Development
Community specific policy review /
approval on changes
December
RDO
RDO
QAPI review
October
DON
VP Quality Improvement
People
Operation plan development and
review: People Section
November
RDO
HR Consultant
Employee Survey
Sept/Oct
RDO
VP Quality Improvement
Employee Survey Communication,
Analysis and Identifications of
Action Plan
January
RDO
VP Quality Improvement
Employee Performance Reviews
Anniversary
Date or Annual
Date Set
HR
HR Consultant
EXAMPLE
2 | P a g e
HDG HR/Payroll Audit
November
HR
HR Consultant
Payroll Consultant
Compensation Planning
October
HR
Director of Total Rewards
Benefit Open Enrollment
October (for
Jan 1 renewals)
HR
Director of Total Rewards
Employee Handbook / P&P Review
December
HR
HR Consultant
Affirmative Action Plan Update, if
required
April
HR
HR Consultant
5500 401(k) or 403(b) Completion /
5500 Health & Welfare / 401(k)
Audit
July
HR
Director of Total Rewards
Review CBA / Contract
Negotiations, if required
As set by
contract
HR
VP Human Resources
Posting OSHA Log
By February 1
HR
Director of Safety & Risk
Management
Risk Management Audit / Claim
Review
October
HR
Director of Safety & Risk
Management
Operational Plan Review with
Employees & with Staff / Mission,
Vision, Values Review
January
RDO
RDO
Annual Required Trainings through
MedCom
December
HR
HR Consultant
W-2 Completion & Handout
January
HR
Payroll Consultant
Financial Performance
Operation plan development and
review: Financial Performance
Section
November
RDO
RDO
Budget planning
October
RDO
RDO
Capital Expenditure planning
October
RDO
RDO
Contract Review (payers and
vendors) and Renewal
July/August
RDO
RDO
EXAMPLE
3 | P a g e
Semi-Annual Routines
Operational Area
Target Completion
Date
Back Up
HDG Resource
Quality
Phase 1/Phase 2 Abaqis – Check-in
on all appropriate phased tasks
January & July
DON
Clinical Consultant
Prep Survey
As set by HDG
DON
VP Quality
Improvement
Quarterly Routines
Operational Area
Target Completion
Date
Back Up
HDG Resource
Quality
Quality/Regulatory compliance
operations plan review
January, April, July,
October
RDO
RDO
Review meal menus, quality, update
action plan
January, April, July,
October
Culinary Director
Dietitian
Clinical Consultant
Community maintenance and curb
appeal plan - review
By end of month
Plan Operations
Director
VP of Safety and Risk
Management
Review PBJ CMS Status
January, April, July
October
HR
Payroll Consultant
People
People operations plan review
January, April, July,
October
RDO
RDO
Small Group Meetings
January, April, July,
October
DON
HR Consultant
Provides or Coordinate Leadership
Training (example: Talent Management,
Policy Procedures as needed)
February, May,
August, November
HR
HR Consultant
Financial Performance
Approve marketing and sales plan
January, April, July,
October
RDO
Director of Market
Development
Financial operations plan review
January, April, July,
October
RDO
RDO
Vendor usage/spend review/meet
with vendors to discuss opportunities
January, April, July,
October
DON
RDO
EXAMPLE
4 | P a g e
Monthly Routines
Operational Area
Target Completion
Date:
Back-Up
HDG Resource
Quality
Quality/Regulatory compliance
operations plan review
By end of month
RDO
RDO
Review Casper Report / Take to
QAPI
By end of month
RDO
RDO
Prepare monthly operations report
Before 20
th
of month
RDO
RDO
Attend Scorecard Call
Last two weeks of
month
RDO
RDO
Ensures PBJ Timely Report
2
nd
week of month
HR
Payroll Consultant
Resident QI Action Plan - ensure
teams on track and making progress
By end of month
Team Facilitator
VP of Quality
Improvement
Family QI Action Plan - ensure
teams on track and making progress
By end of month
Team Facilitator
VP of Quality
Improvement
5 Star Rating data to ensure
accuracy, update action plans
By end of month
DON
Director of Corporate
Compliance
Behavioral/Psychotropic meeting
By end of month
DON
Clinical Consultant
Attend Nutrition at Risk Meeting
By end of month
DON
Clinical Consultant
Meet with Medical Director and
Nurse Practitioner
By end of month
RDO
RDO
People
Meet with Leadership Team (outside
of stand-up)
By end of month
RDO
RDO
Review Turnover Data & Exit
Interview Trends
By end of month
HR
HR Consultant
Sign off on Monthly Benefit
Reconciliation
By end of month
HR
Director of Total Rewards
Leadership Webinar participation
3
rd
Wednesday of
Month
HR
HR Consultant
Safety Committee Action Plan -
ensure teams on track and safety
activities completed
By end of month
HR
Director Safety and Risk
Management
Employee QI Action Plan - ensure
teams on track and making progress
By end of month
HR
HR Consultant
Financial Performance
Review financial statements, update
action plan
15
th
of month
RDO
RDO
Accounts Receivable call with HDG
As scheduled
Bus Office/Billing
RevGroup
Admissions/Marketing data
analysis, update marketing plan
By end of month
Admissions
Director
Admissions Consultant
Attend triple check meeting to
assure that all UB’s have been
checked vs PCC and therapy bills
By end of month
RDO
RevGroup
Case mix call / report review
By end of month
MDS Coordinator
RevGroup
EXAMPLE
5 | P a g e
Bi-Weekly Routines
Operational Area
Target Completion
Date:
Back-Up
HDG Resource
People
Sign off on payroll/401(k)
submission
Payroll week
HR
Payroll Consultant
Review business analytics in
Smartlinx
Payroll week
HR
Payroll Consultant
Financial Performance
Prepare and submit financial
projection
1
st
and 3
rd
week of
each month
RDO
RDO
Review marketing plan with
marketing team
1
st
and 3
rd
week of
each month
RDO
Director of Market
Development
Weekly Routines
Operational Area
Target
Completion Date:
Back-Up
HDG Resource
Quality
Medicare meeting
Weekly
RDO
RevGroup
1:1 Operations update with RDO
Weekly
N/A
RDO
Walk around with plant
operations director, update
action plan
Weekly
N/A
RDO
Curb appeal walk around
Weekly
Admissions/Marketing
Director
RDO
Wound program meeting review
and documentation check
Weekly
DON
Nurse Consultant
People
Oversee & Attends New
Employee Orientation
At each orientation
HR
HR Consultant
Reviews Staffing/Recruiting
Needs with HR and managers
Weekly
HR
HR Consultant or
Centralized Recruiter
HDG HR Call with HR
Consultant to discuss projects,
issues
As scheduled
HR
HR Consultant
Meet with each manager, address
issues, review operational plan
progress, update action plans,
employee issues, labor
management, punch detail
completions
Weekly
RDO
RDO
Financial Performance
Spend down review/adjust
expenses if expenses not trending
to meet budget
Weekly
RDO
RDO
EXAMPLE
6 | P a g e
Daily Routines
Operational Area
Target Completion
Time:
Back-Up
HDG Resource
Quality
Oversees Daily Values in Action
DON
RDO/VP of Quality
Improvement
Facilitates Daily Stand Up Meeting
(using HDG stand-up routines)
DON
RDO
Daily Rounding – twice per day at
least (using HDG rounding routine)
DON
RDO
Dining room meal monitoring
Culinary Director
VP of Quality
Improvement
Concern/grievance report review
DON
Clinical Consultant
Meet new admissions
Admissions
Director
Director of Market
Development
People
Oversees Employee
Relations/Investigations/Safety
Incidents
HR
RDO / HR Consultant
Address customer service issues with
families, residents and employees
DON/HR
RDO / HR Consultant
Follows up to resolution on payroll,
PTO, other compensation issues
HR
Payroll Consultant
Supports performance management
processes of community
HR
HR Consultant
Facilitates daily recognition
initiatives
HR
HR Consultant
Advises, consults, supports
Leadership
HR
RDO
Oversee completion of safety
activities
HR
Director of Safety & Risk
Management
Financial Performance
Daily Profitability Report Submission
RDO / HR
RDO
Directs Management to Review Daily
punch detail report (Reviews
compliance for
Attendance/Overtime/Meal Punches)
HR
HR Consultant
Review and approve labor variations
HR
HR Consultant
Review labor management/staffing
to census
DON
RDO
Reviews Projected
admissions/discharges
DON
Clinical Consultant
EXAMPLE
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX E: INSURANCE VERIFICATION FORM
June 2018
HDG 2018 Page 1
New Resident Insurance Information
Name of Resident: Date of Birth:
Date of Admit:
Medicare #: Medicaid #:
Insurance #:
Primary Insurance Secondary Insurance
Name of Insurance Company:
Claims Address:
Phone #: Fax #:
Prior Auth Phone #: Prior Auth Contact:
Policy ID #: Group ID #:
Insurance Effective Date: Auth. Number:
In Network Yes No Out of Network Yes No
3-day hospital stay needed? Yes No Deductible met? Yes No
Max out of pocket met? Yes No Out of pocket Max $
100 % paid for days? Co-insurance of after day ?
Co Pay for Days to Co Pay for Days to
Co Pay for Days to Co Pay for Days to
Type of Service
Covered
Prior
Authorization
Needed
Description of Coverage
Skilled Room and Board
Medicare RUGs
Negotiated Rate
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Physical Therapy
Yes No
Yes No
Occupational Therapy
Yes No
Yes No
Speech Therapy
Yes No
Yes No
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX F: RESIDENT TRUST FUND AUTHORIZATION FORM
June 2018
HDG 2018 Page 1
Resident Trust Fund Authorization
Resident
By my signature below, I authorize the Care Community to hold my personal funds in
the Resident Trust Account. I understand my money will be held in an interest bearing
Bank account. Receipts will be kept for all expenditures, and the account will be
managed in accordance with all State and Federal codes. Quarterly statements will be
sent to the authorized person. I will have access to my account during the normal
business hours as posted at the office.
I
Do
Do Not
I authorize to have my income direct deposited into the Resident Trust Account as well
as my resident liability withdrawn for my room and board.
I
Do
Do Not
Authorize the Care Community to withdraw monies as needed for personal needs,
medical needs, and/or activity needs that I may have incurred, such as beautician,
barber, health insurance, clothing, etc., as such bills are presented to the care
community.
I authorize the following individuals to have access to the funds in my Resident Trust
Account in order to make purchases or payments on my behalf:
Authorized Person Relationship
Authorized Person Relationship
Resident Signature or Legally Authorized Representative
Witness Date
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX G: BAD DEBT WORKSHEET FORM
Billing and Collections Manual
June 2018
HDG 2018 Page 1
BAD DEBT WORKSHEET
Care Community Name:
Resident Name Resident Number
Payor Amount Service Dates
Explanation of uncollectible charges and collection efforts:
Steps taken to prevent this type of bad debit from recurring:
Prepared By: Date:
Business Office Consultant: Date:
Administrator: Date:
VP Finance: Date:
Admissions Coordinator (if applicable): Date:
Bad Debt Posted By: Date:
Posting Date: Adjustment Batch No:
Please Note: Please attach the following documentation: Current A/R Aging, Transaction
History Report, Collection Log; Collection Notes, Collections Letters & Copies of Statements,
and any other relevant documentation regarding collection attempts for this amount.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX H: OFFICE OF INSPECTOR GENERAL (OIG) VENDOR
VERIFICATION FORM
50.6.8 – OIG/GSA Exclusion
(Chapter 21 - Rev. 109, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07-20-12)
(Chapter 9 - Rev. 15, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07-20-12)
The Act §1862(e)(1)(B), 42 C.F.R. §§ 422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504(b)(4)(vi)(F),
423.752(a)(6), 1001.1901
This section provides guidance regarding sponsors’ implementation of FWA safeguards to identify
excluded providers and entities. Medicare payment may not be made for items or services furnished
or prescribed by an excluded provider or entity. Sponsors shall not use federal funds to pay for
services, equipment or drugs prescribed or provided by a provider, supplier, employee or FDR
excluded by the DHHS OIG or GSA.
Sponsors must review the DHHS OIG List of Excluded Individuals and Entities (LEIE list) and the
GSA Excluded Parties Lists System (EPLS) prior to the hiring or contracting of any new employee,
temporary employee, volunteer, consultant, governing body member, or FDR, and monthly
thereafter, to ensure that none of these persons or entities are excluded or become excluded from
participation in federal programs. Monthly screening is essential to prevent inappropriate payment to
providers, pharmacies, and other entities that have been added to exclusions lists since the last time
the list was checked. After entities are initially screened against the entire LEIE and EPLS at the time
of hire or contracting, sponsors need only review the LEIE supplement file provided each month,
which lists the entities added to the list that month, and review the EPLS updates provided during the
specified monthly time frame.
OIG’s LEIE includes all health care providers and suppliers that are excluded from participation in
federal health care programs, including those health care providers and suppliers that might also be
on the EPLS. In addition to health care providers (that are also included on the OIG LEIE), the EPLS
includes non-health care contractors.
Links to instructions for accessing this information are available in Appendix A: Resources.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX I: IDEAL DISCHARGE PROCESS (EXAMPLE)
Guide to Patient and Family Engagement :: 1
IDEAL Discharge Planning Overview, Process, and Checklist
Evidence for engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.
1,2
Research shows that
three-quarters of these could have been prevented
or ameliorated.
1
Common post-discharge complications
include adverse drug events, hospital-acquired infections,
and procedural complications.
1
Many of these
complications can be attributed to discharge planning
problems, such as:
• Changes or discrepancies in medications before and
after discharge
3,4
• Inadequa
te preparation for patient and family related
to medications, danger signs, or lifestyle changes
3,4,5
• Disconne
ct between clinician information-giving and
patient understanding
3
• Discontin
uity between inpatient and outpatient
providers
3
Involvin
g the patient and family in discharge planning can
improve patient outcomes, reduce unplanned
readmissions, and increase patient satisfaction.
6,7
More and more, hospitals are focusing on transitions in
care as a way to improve hospital quality and safety. As
one indicator of this, the Centers for Medicare and
Medicaid Services implemented new guidelines in 2012
that reduce payment to hospitals exceeding their
expected readmission rates.
To improve quality and reduce preventable readmissions,
[insert hospital name] will use the Agency for Healthcare
Research and Quality’s Care Transitions from Hospital to
Home: IDEAL Discharge Planning tools to engage
patients and families in preparing for discharge to home.
Key elements of IDEAL
Discharge Planning
Include the patient and family as full partners in the
discharge planning process.
Discuss with the patient and family five key areas to
prevent problems at home:
1. Describe what life at home will be like
2. Review medications
3. Highlight warning signs and problems
4. Explain test results
5. Make followup appointments
Educate the patient and family in plain language about
the patient’s condition, the discharge process, and
next steps throughout the hospital stay.
Assess how well doctors and nurses explain the
diagnosis, condition, and next steps in the patient’s
care to the patient and family and use teach back.
Listen to and honor the patient’s and family’s goals,
preferences, observations, and concerns.
This process will include at least one meeting to discuss
concerns
and questions with the patient, family of their
choice, and [identify staff].
What does this mean for clinicians?
We expect all clinicians to:
• Incorporate the IDEAL discharge elements in
their work
• Make themselves available to the [identify staff]
who will work closely with the patient and family
• Take part in trainings on the process
Guide to Patient and Family Engagement :: 2
How do you implement
IDEAL Discharge Planning?
Each part of IDEAL Discharge Planning has
multiple components:
I
nclude the patient and family as full partners in the
discharge planning process.
• Always include the patient and family in team
meetings about discharge. Remember that
discharge is not a one-time event but a process
that takes place throughout the hospital stay.
• Identify which family or friends will provide care
at home and include them in conversations.
Discuss with the patient and family five key areas to
prevent problems at home.
1. Describe what life at home will be like. Include
the home environment, support needed, what the
patient can or cannot eat, and activities to do or
avoid.
2. Review medications. Use a reconciled medication
list to discuss the purpose of each medicine, how
much to take, how to take it, and potential side
effects.
3. Highlight warning signs and problems. Identify
warning signs or potential problems. Write down the
name and contact information of someone to call if
there is a problem.
4. Explain test results. Explain test results to the
patient and family. If test results are not available at
discharge, let the patient and family know when
they should get the results and identify who they
should call if they have not gotten results by that
date.
5. Make followup appointments. Offer to make
followup appointments for the patient. Make sure
that the patient and family know what followup is
needed.
Educate the patient and family in plain language
about the patient’s condition, the discharge process,
and next steps at every opportunity throughout the
hospital stay.
Getting all the information on the day of discharge can be
overwhelming. Discharge planning should be an ongoing
process throughout the stay, not a one-time event. You
can:
• Elicit patient and family goals at admission and
note progress toward those goals each day
• Involve the patient and family in bedside shift
report or bedside rounds
• Share a written list of medicines every morning
• Go over medicines at each administration: What
it is for, how much to take, how to take it, and
side effects
• Encourage the patient and family to take part in
care practices to support their competence and
confidence in caregiving at home
Assess how well doctors and nurses explain the
diagnosis, condition, and next steps in the patient’s
care to the patient and family and use teach back.
• Provide information to the patient and family in
small chunks and repeat key pieces of
information throughout the hospital stay
• Ask the patient and family to repeat what you
said back to you in their own words to be sure
that you explained things well
Listen to and honor the patient and family’s goals,
preferences, observations, and concerns.
• Invite the patient and family to use the white
board in their room to write questions or
concerns
• Ask open-ended questions to elicit questions
and concerns.
• Use Be Prepared to Go Home Checklist and
Booklet (Tools 2a and 2b) to make sure the
patient and family feel prepared to go home
• Schedule at least one meeting specific to
discharge planning with the patient and family
caregivers
Guide to Patient and Family Engagement :: 3
IDEAL Discharge Planning Process
The elements of the IDEAL Discharge Planning process are incorporated into our current discharge. The information
below describes key elements of the IDEAL discharge from admission to discharge to home. Note that this process
includes at least one meeting between the patient, family, and discharge planner to help the patient and family feel
prepared to go home.
Initial nursing assessment
Daily
Identify the caregiver who will be at home
along with potential back-ups. These are the
individuals who need to understand instructions
for care at home. Do not assume that family in
the hospital will be caregivers at home.
Let the patient and family know that they can
use the white board in the room to write
questions or concerns.
Elicit the patient and family’s goals for when
and how they leave the hospital, as
appropriate. With input from their doctor, work
with the patient and family to set realistic goals
for their hospital stay.
Inform the patient and family about steps in
progress toward discharge. For common
procedures, create a patient handout, white
board, or poster that identifies the road map to
get home. This road map may include things like
“I can feed myself” or “I can walk 20 steps.”
Educate the patient and family about the
patient’s condition at every opportunity, such
as nurse bedside shift report, rounds, vital status
check, nurse calls, and other opportunities that
present themselves. Use teach back.
Who: All clinical staff
Explain medicines to the patient and family
(for example, print out a list every morning)
and at any time medicine is administered.
Explain what each medicine is for, describe
potential side effects, and make sure the patient
knows about any changes in the medicines they
are taking. Use teach back.
Who: All clinical staff
Discuss the patient, family, and clinician goals
and progress toward discharge. Once goals are
set at admission, revisit these goals to make
sure the patient and family understand how they
are progressing toward discharge.
Who: All clinical staff
Involve the patient and family in care practices
to improve confidence in caretaking after
discharge. Examples of care practices could
include changing the wound dressing, helping
the patient with feeding or going to the
bathroom, or assisting with rehabilitation
exercises.
Who: All clinical staff
Guide to Patient and Family Engagement :: 4
Prior to discharge planning meeting
When: 1 to 2 days before discharge planning meeting. For short stays, this meeting may occur at admission.
Give the patient and family Tools 2a and 2b: Be
Prepared to Go Home Checklist and Booklet.
Who: Hospital to identify staff person to distribute,
for example a nurse, patient advocate, or discharge
planner.
Schedule discharge planning meeting with the
patient, family, and hospital staff.
Who: Hospital to identify staff person to distribute,
for example a nurse, patient advocate, or discharge
planner.
Discharge planning meeting Day of discharge
When:
1 to 2 days before discharge, earlier for more
extended stays in the hospital
Use the Tools 2a and 2b: Be Prepared to Go
Home Checklist and Booklet as a starting
point to discuss questions, needs, and
concerns going home.
• If the patient or family did not read or fill out
the checklist, review it verbally. Make sure to
ask if they have questions or concerns other
than those listed. You can start the dialogue
by asking, “What will being back home look
like for you?”
• Repeat the patient’s concerns in your own
words to make sure you understand.
• Use teach back to check if the patient
understands the information given.
• If another clinician is needed to address
concerns (e.g., pharmacist, doctor, or
nurse), arrange for this conversation.
Who: Hospital to identify staff to be involved in
meeting, for example the nurse, doctor, patient
advocate, discharge planner, or a combination.
Patient identifies if family or friends need to be
involved.
Offer to make followup appointments. Ask if
the patient has a preferred day or time and if
the patient can get to the appointment.
Who: Hospital to identify staff person to do, such
as a patient advocate or discharge planner.
Review a reconciled medication list with the
patient and family. Go over the list of current
medicines. Use teach back (ask them to repeat
what the medicine is, when to take it, and
how to take it). Make sure that patients have an
easy-to-read, printed medication list to take
home.
Who: Hospital to identify staff person to review
the medication list with patient and family.
Because this involves medications, we assume it
would be a clinician — nurse, doctor, or
pharmacist.
Give the patient and family the patient’s
followup appointment times and include the
provider name, time, and location of
appointments in writing.
Who: Staff who scheduled appointment.
Give the patient and family the name,
position, and phone number of the person to
contact if there is a problem after discharge.
Make sure the contact person is aware of the
patient’s condition and situation (e.g., if the
primary care physician is the contact person,
make sure the primary care physician has a copy
of the discharge summary on the day of
discharge).
Who: Hospital to identify staff person to write
contact information, for example a nurse, patient
advocate, or discharge planner.
Guide to Patient and Family Engagement :: 5
IDEAL Discharge Planning Checklist
Fill in, initial, and date next to each task as completed.
Patient Name:
Initial Nursing Assessment
Prior to Discharge
Planning Meeting
During Discharge
Planning Meeting
Day of Discharge
Identified the caregiver
at home and backups
Told patient and family
about white board
Elicited patient and
family goals for hospital
stay
Informed patient and
family about steps to
discharge
Distributed checklist and
booklet to patient and
family with explanation
Scheduled discharge
planning meeting
Scheduled for
/ / at
[time]
Discussed patient
questions
Discussed family
questions
Reviewed discharge
instructions as needed
Used Teach Back
Offered to schedule
followup appointments
with providers.
Preferred dates / times
for:
PCP:
Other:
Medication
Reconciled medication list
Reviewed medication list with patient
and family and used teach back
Appointments and contact information
Scheduled followup appointments:
1) With
on
/ / at [time]
2) With
on
/ / at [time]
Arranged any home care needed
Wrote down and gave appointments to the
patient and family
Wrote down and gave contact information
for followup person after discharge
Guide to Patient and Family Engagement :: 6
IDEAL Discharge Planning Daily Checklist
Fill in, initial, and date next to each task as completed.
Patient Name:
Day 1 Day 2 Day 3 Day 4
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Notes
Guide to Patient and Family Engagement :: 7
References
1. Forster AJ, Murff HJ, Peterson JF, et al. The
incidence and severity of adverse events affecting
patients after discharge from the hospital. Ann
Intern Med 2003;138(3):161–7.
2. Jencks SF, Williams MV, Coleman EA.
Rehospitalizations among patients in the Medicare
fee-for-service program. N Engl J Med
2009;360(14):1418–28.
3. Kripalani S, Jackson AT, Schnipper JL, et al.
Promoting effective transitions of care at hospital
discharge: a review of key issues for hospitalists.
J Hosp Med 2007;2(5):314–23.
4. Anthony MK, Hudson-Barr D. A patient-centered
model of care for hospital discharge. Clin Nurs Res
2004;13(2):117–36.
5. Popejoy LL, Moylan K, Galambos C. A review of
discharge planning research of older adults 1990–
2008. West J Nurs Res 2009;31(7):923–47.
6. Bauer M, Fitzgerald L, Haesler E, et al. Hospital
discharge planning for frail older people and their
family. Are we delivering best practice? A review of
the evidence. J Clin Nurs 2009;18(18):2539–46.
7. Shepperd S, McClaran J, Phillips CO, et al.
Discharge planning from hospital to home.
Cochrane Database Syst Rev.
2010;20;(1):CD000313.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX J: PAID TIME OFF (PTO) POLICY (EXAMPLE)
Client Name
Paid Time Off & Paid Disability Leave
Paid Time-Off (PTO) Plan
Paid Time-Off (PTO) combines the traditional vacation, holiday and sick leave programs into
one paid time off plan. Full-time and part-time employees regularly scheduled for 40 hours per
two-week pay period are eligible for PTO benefits.
PTO accumulates from the first day of employment and is considered earned upon completion of
90 days of employment. Therefore, hourly-paid employees may use earned PTO starting on their
91
st
day of employment. Salaried employees may use accumulated PTO upon hire.
Holidays
Employees scheduled off an observed holiday will take the day off and use their PTO. PTO will
be automatically assigned for those employees taking the holiday off when it would otherwise be
normally scheduled. Employees working a holiday shall be paid at their normal rate and have
the ability to take additional PTO for holiday pay.
Employees not eligible for PTO benefits who work a holiday will be paid at time and a half (1.5)
times their base wage rate.
Observed Holidays include:
o New Year’s Day
o Memorial Day
o July 4 (Independence Day)
o Labor Day
o Thanksgiving Day
o Christmas Day
Granting time off:
Time off shall be granted to employees on a first come, first serve basis at the discretion
of management. Approvals for time off requests will be based on workloads and staffing
levels to ensure resident care needs are met. Changes to approved time off may be
granted at the discretion of the department director and Executive Director.
Any hours worked less than “regularly scheduled hours” require the use of PTO to make
the employee’s status/check “whole”. Exceptions may be made when the employer
temporarily reduces hours due to low census.
Unplanned time off (i.e. sick calls, weather absences, etc.) and planned time off requires
the use of PTO provided the employee is eligible and has an available balance of PTO
benefit.
Time off beyond the available PTO balance, will be considered and approved at the
discretion of the department director and Human Resources and in accordance with
community leave policies.
Paid Time-Off (PTO) Accrual
Regularly Scheduled Part-Time and Full-Time
Length
of
Service
PTO Accrual
Factor
Full Time
Annual Accrual
Maximum
Maximum
Annual
Balance
0 to < 3 years
.0654
17 days*
136 hours
3 to < 5 years
.0769
20 days*
160 hours
5 to < 10 years
.0962
25 days*
200 hours
10+ years
.1154
30 days*
200 hours
*These levels reflect the amount of hours accumulated by a full time employee that works 40 hours per week.
Years of continuous service are used to determine when an employee moves from one
accrual rate to the next.
PTO accrues each per pay period based upon the hours actually compensated, limited to
80 hours each pay period.
Non-exempt employees may use PTO in four (4) hour increments for planned time off
(i.e. vacation). PTO for unplanned absences (illness) will be taken in .25 hour
increments. Exempt employees must use PTO in four (4) hour increments.
Payment of PTO is limited to the available balance. Negative balances will not be
allowed. PTO balances are recorded on employee paychecks.
PTO may accrue to a maximum balance of 200 hours. Once the maximum is achieved,
no further accrual will occur until the balance falls below the accrual limit. Employees
will not be paid for hours in excess of the PTO balance.
Earned and unused PTO is paid out at termination provided a proper two (2) week
resignation notice is given to the employer for non-management employees and four (4)
week resignation notice for RN’s and management employees and the probationary
period has been completed. Involuntary termination will exclude an employee from
receiving any PTO payout.
Paid Disability Leave (PDL)
Paid Disability Leave (PDL) functions as a short term disability plan providing income for time
lost due to an illness/disability for oneself. Employees are required to notify Human Resources
and their director of absences or anticipated absences extending beyond three consecutive days.
PDL may be used after the employee has missed five (5) consecutive days of work. The first
three days of an illness/disability must be paid from the employee’s PTO account prior to
accessing PDL. PDL is accrued based upon compensated hours.
Waiting period:
An employee becomes eligible for PDL after an absence of more than five (5)
consecutive work days due to the illness/disability of oneself.
An employee is required to provide a “return-to- work” certification from a medical
provider when his/her illness/disability extends three (3) work days or longer.
Accrual limits:
Unused PDL accumulates to a maximum of 200 hours. Once the maximum accrual is
reached, no further accrual will occur. Employees are not compensated for hours in
excess of their PDL balance.
Should an employee exhaust their PDL account, he/she must use PTO for the remainder
of the absence or until PTO is also exhausted.
Earned and unused PDL are not paid out upon either voluntary or involuntary termination
of employment.
Paid Disability Leave Accrual
Full Time PDL
Accrual Per Year
Accrual
Rate
Maximum PDL
Accrual Hours
40 Hours (5 days)
.0308
200 hours
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX K: CMS 5-STAR USER GUIDE
Design for Nursing Home Compare
Five-Star Quality Rating System:
Technical Users’ Guide
July 2018
July 2018 Revisions
Beginning with the July 2018 update of the Nursing Home Compare website and the Five-Star Quality
Rating System, there are additional reasons why a nursing home may receive a one-star rating for
Staffing and RN Staffing. Additionally, the method of estimating the RUG-IV case-mix index, which is
used in the calculation of adjusted nurse staffing and adjusted RN staffing for assigning the star
ratings has changed slightly. These changes are described in the Staffing Domain section of this
document.
Additional text was added to the Health Inspection Domain section to explain how the health
inspection rating is being calculated for nursing homes with two or more health inspections occurring
on or after November 28, 2017.
May 2018 Revisions
Additional text was added to the staffing section to provide more detail about the resident census
calculation.
April 2018 Revisions
Beginning with the April 2018 update of the Nursing Home Compare website and the Five-Star
Quality Rating System, the Centers for Medicare and Medicaid Services (CMS) is replacing the
existing staffing measures (derived from the CMS-671 form and case-mix based on RUG-III) with
staffing reported through the payroll-based journal (PBJ) system, resident census derived from MDS
assessments, and case-mix based on RUG-IV.
These changes as they affect the Five-Star Quality Rating System are described in detail in the Staffing
Domain section of this document.
February 2018 Revisions
On November 28, 2017 the CMS instituted a new health inspection process along with an entirely new
set of “tags”. Beginning in February 2018, for a period of 12 months, CMS will not use deficiencies
cited on surveys conducted on or after November 28, 2017 in calculating the health inspection rating
for the Nursing Home Compare Five-Star Quality Rating System, to allow sufficient survey results to
accumulate from the new-process surveys. During that time, the health inspection rating will be based
on results from the two most recent standard surveys prior to November 28, 2017, as well as
deficiencies arising from complaint investigations during the two-year period prior to November 28,
2017.
Standard surveys and complaint surveys that occurred on or after November 28, 2017 (under the new
survey process) will be displayed on the Nursing Home Compare website, but will not be utilized to
calculate the health inspection rating during the twelve-month period beginning in February 2018.
These changes are described in more detail in the Health Inspection Domain section of this document.
1
Introduction
In December 2008, The Centers for Medicare & Medicaid Services (CMS) enhanced its Nursing Home
Compare public reporting site to include a set of quality ratings for each nursing home that participates in
Medicare or Medicaid. The ratings take the form of several “star” ratings for each nursing home. The
primary goal of this rating system is to provide residents and their families with an easy way to
understand assessment of nursing home quality, making meaningful distinctions between high and low
performing nursing homes.
This document provides a comprehensive description of the design for the Nursing Home Compare Five-
Star Quality Rating System. This design was developed by CMS with assistance from Abt Associates,
invaluable advice from leading researchers in the long-term care field who comprise the Technical Expert
Panel (TEP) for this project, and numerous ideas contributed by consumer and provider groups. All of
these organizations and groups have continued to contribute their input as the rating system has been
refined and updated to incorporate newly available data. We believe the Five-Star Quality Rating System
continues to offer valuable and comprehensible information to consumers based on the best data currently
available. The rating system features an Overall Quality Rating of one to five stars based on facility
performance for three types of measures, each of which has its own five-star rating:
• Health Inspections - Measures based on outcomes from State health inspections: Facility
ratings for the health inspection domain are based on the number, scope, and severity of
deficiencies identified during the two most recent annual inspection surveys occurring prior to
November 28, 2017, as well as substantiated findings from complaint investigations occurring in
the 24 months prior to November 28, 2017. All deficiency findings are weighted by scope and
severity. This measure also takes into account the number of revisits required to ensure that
deficiencies identified during the health inspection survey have been corrected.
• Staffing - Measures based on nursing home staffing levels: Facility ratings on the staffing
domain are based on two measures: 1) Registered nurse (RN) hours per resident day; and 2) total
staffing (RN+ licensed practical nurse (LPN) + nurse aide hours) hours per resident per day.
Other types of nursing home staff, such as clerical or housekeeping staff, are not included in the
staffing rating calculation. The staffing measures are derived from data submitted each quarter
through the Payroll-Based Journal System (PBJ), along with daily resident census derived from
Minimum Data Set, Version 3.0 (MDS 3.0) assessments, and are case-mix adjusted based on the
distribution of MDS 3.0 assessments by Resource Utilization Groups, version IV (RUG-IV
group).
• QMs - Measures based on MDS and claims-based quality measures (QMs): Facility ratings for
the quality measures are based on performance on 16 of the 24 QMs that are currently posted on
the Nursing Home Compare website, and that are based on MDS 3.0 assessments as well as
hospital and emergency department claims. These include nine long-stay measures and seven
short-stay measures.
In recognition of the multi-dimensional nature of nursing home quality, Nursing Home Compare displays
information on facility ratings for each of these domains alongside the overall performance rating. In
addition to the overall staffing rating mentioned above, a five-star rating for RN staffing is also displayed
separately on the Nursing Home Compare website, when users seek more information on the staffing
component.
2
An example of the rating information included on Nursing Home Compare is shown in the figure below.
Users of the website can drill down on each domain to obtain additional details on facility performance.
A compa
nion document to this Technical Users’ Guide (Nursing Home Compare – Five Star Quality
Rating System: Technical Users’ Guide – State-Level Cut Point Tables) provides the data for the state-
level cut points for the star ratings included in the health inspection. The data table in the companion
document will be updated monthly. Cut points for the QM and staffing ratings have been fixed and do not
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this Technical Users’ Guide. Table 7 provides the cut points for the QM ratings, and the cut points for the
individual QMs are in Appendix Table A-3.
Methodology for Constructing the Ratings
Health Inspection Domain
Nursing homes that participate in the Medicare and/or Medicaid programs have an onsite recertification
(standard) (“comprehensive”) inspection annually on average, with very rarely more than fifteen months
elapsing between inspections for any one particular nursing home. Inspections are unannounced and are
conducted by a team of health care professionals who spend several days in the nursing home to assess
whether the nursing home is in compliance with federal requirements. These inspections provide a
comprehensive assessment of the nursing home, reviewing facility practice and policies in such areas as
resident rights, quality of life, medication management, skin care, resident assessment, nursing home
administration, environment, and kitchen/food services. The methodology for constructing the health
inspection rating is based on the two most recent recertification surveys prior to November 28, 2017,
complaint deficiencies during the two-year period prior to November 28, 2017, and any repeat revisits
needed to verify that required corrections have brought the facility back into compliance. The Five-Star
Quality Rating System uses more than 200,000 records for the health inspection domain alone.
Scoring Rules
Beginning in February 2018, CMS calculates a health inspection score based on points assigned to
deficiencies identified in each active provider’s two most recent recertification health inspections prior to
November 28, 2017, as well as on deficiency findings from the most recent two years of complaint
inspections prior to November 28, 2017.
•
Health Inspection Results: Points are assigned to individual health deficiencies according to their
scope and severity –more serious, widespread deficiencies receive more points, with additional
points assigned for substandard quality of care (see Table 1). If the status of the deficiency is
“past non-compliance” and the severity is “immediate jeopardy” (i.e., J-, K- or L-level), then
points associated with a G- level deficiency are assigned. Deficiencies from Life Safety surveys
are not included in calculations for the Five-Star rating. Deficiencies from Federal Comparative
Surveys are not reported on Nursing Home Compare or included in Five Star calculations, though
the results of State Survey Agency determinations made during a Federal Oversight Survey are
included.
• Repeat Revisits - Number of repeat revisits required to confirm that correction of deficiencies
have restored compliance: No points are assigned for the first revisit; points are assigned only for
the second, third, and fourth revisits and are proportional to the health inspection score for the
survey cycle (Table 2). If a provider fails to correct deficiencies by the time of the first revisit,
then these additional revisit points are assigned up to 85 percent of the health inspection score for
the fourth revisit. CMS’ experience is that providers who fail to demonstrate restored compliance
with safety and quality of care requirements during the first revisit have lower quality of care than
other nursing homes. More revisits are associated with more serious quality problems.
4
Table 1
Health Inspection Score: Weights for Different Types of Deficiencies
Severity
Scope
Isolated
Pattern
Widespread
Immediate jeopardy to resident health or safety
J
50 points*
(75 points)
K
100 points*
(125 points)
L
150 points*
(175 points)
Actual harm that is not immediate jeopardy
G
20 points
H
35 points
(40 points)
I
45 points
(50 points)
No actual harm with potential for more than minimal
harm that is not immediate jeopardy
D
4 points
E
8 points
F
16 points
(20 points)
No actual harm with potential for minimal harm
A
0 point
B
0 points
C
0 points
Note: Figures in parentheses indicate points for deficiencies that are for substandard quality of care.
Shaded cells denote deficiency scope/severity levels that constitute substandard quality of care if the requirement
which is not met is one that falls under the following federal regulations: 42 CFR 483.13 resident behavior and
nursing home practices, 42 CFR 483.15 quality of life, 42 CFR 483.25 quality of care.
* If the status of the deficiency is “past non-compliance” and the severity is Immediate Jeopardy, then points
associated with a ‘G-level” deficiency (i.e., 20 points) are assigned.
Source: Centers for Medicare & Medicaid Services
Table 2
Weights for Repeat Revisits
Revisit Number
Noncompliance Points
First
0
Second
50 percent of health inspection score
Third 70 percent of health inspection score
Fourth
85 percent of health inspection score
Note: The health inspection score includes points from deficiencies cited on the standard health inspection and
complaint inspections during a given survey cycle.
C
MS calculates a total health inspection score for each facility. The total score is calculated as the
facility’s weighted deficiency score (including any repeat revisit points). Note that a lower survey score
corresponds to fewer deficiencies and revisits, and thus better performance on the health inspection
domain. In calculating the total weighted score, more recent surveys are weighted more heavily than
earlier surveys with the most recent period (rating cycle 1) being assigned a weighting factor of 60
percent and the previous period (rating cycle 2) having a weighting factor of 40 percent. The individual
weighted scores for each cycle are then summed to create the total weighted survey score for each facility.
Complaint inspections are assigned to a time period based on the 12-month period in which the complaint
survey occurred. Complaint inspections that occurred between November 28, 2016 and November 27,
2017 receive a weighting factor of 60 percent; those occurring between November 28, 2015 and
November 27, 2016 have a weighting factor of 40 percent. There are some deficiencies that appear on
both standard and complaint inspections. To avoid potential double-counting, deficiencies that appear on
complaint inspections that are conducted within 15 days of a recertification inspection (either prior to or
5
after the recertification inspection) are counted only once. If the scope or severity differs between the two
inspections, the highest scope-severity combination is used. Points from complaint deficiencies from a
given period are added to the health inspection score before calculating revisit points, if applicable.
Facilities with only one standard health inspection prior to November 28, 2017 are considered to have
insufficient data to determine a health inspection rating and are reported as “Too New to Rate” for the
health inspection domain. For these facilities, no overall quality rating is assigned, and no ratings are
reported for the staffing or QM domains, even if data for these domains are available.
Facilities with two or more health inspections on or after November 28, 2017
Results (dates, counts and lists of citations) from the three most recent health inspections are displayed on
Nursing Home Compare, regardless of whether these surveys took place before or after November 28,
2017. For example:
• For facilities with one survey conducted on or after November 28, 2017, the posted results from
the three most recent health inspections would include:
o One survey conducted after November 28, 2017; and
o two surveys conducted prior to November 28, 2018
For nursing homes that have had two surveys on or after November 28, 2017, the rating will still be based
on the last two surveys conducted prior to November 28, 2017. However, since the results from the three
most recent surveys are posted, the results from the oldest survey will not be displayed on the main
website. For example:
• For facilities with two surveys conducted on or after November 28, 2017, the posted results from
the three most recent health inspections would include:
o Two surveys conducted after November 28, 2017; and
o one survey conducted prior to November 28, 2018.
In other words, the oldest survey will still be used to calculate a facility’s rating, but the results from that
survey will not be displayed on the main website. Interested users can find these earlier survey results in
the health inspection files that are available at https://data.medicare.gov/data/nursing-home-compare
.
Rating Methodology
Health inspections are based on federal regulations, which surveyors implement using national
interpretive guidance and a federally-specified survey process. Federal staff train State inspectors and
oversee State performance. The federal oversight includes quality checks based on a 5% sample of the
health inspections performed by States, in which Federal inspectors either accompany State inspectors or
replicate the inspection within 60 days of the State and then compare results. These control systems are
designed to improve consistency in the survey process. Nonetheless there remains variation among states
in both inspection process and outcomes. Such variation derives from many factors, including:
• Survey Management: Variation among states in the skill sets of inspectors, supervision of
inspectors, and the inspection processes;
• State Licensure: State licensing laws set forth different expectations for nursing homes and affect
the interaction between State enforcement and Federal enforcement (for example, a few states
conduct many complaint investigations based on State licensure, and issue citations based on
State licensure rather than on the Federal regulations);
6
• Medicaid Policy: Medicaid pays for the largest proportion of long term care in nursing homes.
Nursing home eligibility rules, payment, and other policies in the State-administered Medicaid
program may be associated with differences in survey outcome.
For the above reasons, CMS bases Five-Star quality ratings in the health inspection domain on the relative
performance of facilities within a state. This approach helps control for variation among states. CMS
determines facility ratings using these criteria:
• The top 10 percent (with the lowest health inspection weighted scores) in each state receive a
health inspection rating of five stars.
• The middle 70 percent of facilities receive a rating of two, three, or four stars, with an equal
number (approximately 23.33 percent) in each rating category.
• The bottom 20 percent receive a one-star rating.
Rating thresholds are re-calibrated each month so that the distribution of star ratings within states remains
relatively constant over time. However, the rating for a given facility is held constant until there is a
change in the weighted health inspection score for that facility, regardless of changes in the statewide
distribution. While changes to health inspection scores (and thus rating changes) during the time period
when surveys conducted under the new process will be rare, there are a few reasons why facilities may
have a change. Items that could change the health inspection score include the following:
• If a survey occurred prior to November 28, 2017 that has not yet entered the national database,
then it will result in a change to a provider’s health inspection score in the month following its
entry into the national database;
• A second, third, or fourth revisit occurs that is associated with a survey occurring prior to
November 28, 2017;
• Resolution of Informal Dispute Resolutions (IDR) or Independent Informal Dispute Resolutions
(IIDR) resulting in changes to the scope and/or severity of deficiencies for a survey that occurred
prior to November 28, 2017.
In the very rare case that a state or territory has fewer than five facilities upon which to generate the cut
points, the national distribution of health inspection scores is used. Cut points for the health inspection
ratings can be found in the Cut Point Table in the companion document to this Technical Users’ Guide:
Five Star Quality Rating System State-Level Cut Point Tables available in the ‘downloads’ section at:
https://www.cms.gov/medicare/provider-enrollment-and-
certification/certificationandcomplianc/fsqrs.html.
7
Staffing Domain
There is considerable evidence of a relationship between nursing home staffing levels and resident
outcomes. The CMS Staffing Study
1
, among other research, found a clear association between nurse
staffing ratios and nursing home quality of care.
The rating for staffing is based on two quarterly case-mix adjusted measures:
• Total nursing hours per resident day (RN + LPN + nurse aide hours)
• RN hours per resident day
The source for reported staffing hours is the Payroll-based Journal (PBJ) system
2
. These data are
submitted quarterly and are due 45 days after the end of each reporting period. Only data submitted and
accepted by the deadline are used by CMS for staffing calculations and the Five-Star Rating System. The
resident census is based on a daily resident census measure that is calculated by CMS using MDS
assessments.
The specific PBJ job codes that are used in the RN, LPN, and nurse aide hours calculations are:
• RN hours: Includes RN director of nursing (job code 5), registered nurses with administrative
duties (job code 6), and registered nurses (job code 7).
• LPN hours: Includes licensed practical/licensed vocational nurses with administrative duties (job
code 8) and licensed practical/vocational nurses (job code 9)
• Nurse aide hours: Includes certified nurse aides (job code 10), aides in training (job code 11), and
medication aides/technicians (job code 12)
Note that the PBJ staffing data include both facility employees (full-time and part-time) and individuals
under an organization (agency) contract or an individual contract. The PBJ staffing data do not include
“private duty” nursing staff reimbursed by a resident or his/her family. Also not included are hospice staff
and feeding assistants.
The daily resident census, used in the denominator of the reported nurse staffing ratios, is derived from
MDS resident assessments and is calculated as follows:
1) Identify the reporting period (quarter) for which the census will be calculated (e.g., CY 2017 Q4:
October 1 – December 31, 2017).
2) Extract MDS assessment data for all residents of a facility beginning one year prior to the
reporting period to identify all residents that may reside in the facility (i.e., any resident with an
MDS assessment may still reside in the facility). For example, for the CY 2017 Q4 reporting
period, extract MDS data from October 1, 2016 through December 31, 2017.
3) Identify discharged residents using the following criteria:
1
Kramer AM, Fish R. “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home
Care.” Chapter 2 in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final
Report. Abt Associates, Inc., Winter 2001.
2
More detailed information about the PBJ system is available at: https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html
8
a) If a resident has an MDS Discharge assessment, use the discharge date reported on that
assessment and assume that the resident no longer resides in the facility as of the date of
discharge on the last assessment. If there is a subsequent admission assessment, then assume
that the resident re-entered the nursing home on the entry date indicated on the admission
assessment.
b) For any resident with an interval of 150 days or more with NO assessments, assume the
resident no longer resides in the facility as of the 150th day from the last assessment. (This
assumption is based on the requirement for facilities to complete MDS assessments on all
residents at least quarterly). If no assessment is present, assume the resident was discharged,
but the facility did not transmit a Discharge assessment.
For any particular date, residents whose assessments do not meet the criteria in #3 above prior to that date
are assumed to reside in the facility. The count of these residents is the census for that particular day.
NOTE ON RESIDENT MATCHING: MDS assessments for a given resident are linked using the
Resident Internal ID. The Resident Internal ID is a unique number, assigned by the Quality Improvement
Evaluation System (QIES) Assessment Submission and Processing (ASAP) system, which identifies a
resident. The combination of State and Resident Internal ID uniquely identifies a resident in the national
repository. The process by which the Resident Internal ID is created is described by the MDS 3.0
Provider User’s Guide - Appendix B
(https://qtso.cms.gov/download/guides/MDS/mds_30/Prvdr_Users_AppB.pdf
). The following MDS items
are used to define the Resident Internal ID:
• State ID
• Facility Internal ID (QIES ASAP system number)
• Social Security Number (SSN)
• Last Name
• First Name
• Date of Birth
• Gender
Therefore, in order to achieve an accurate census, it is imperative that, in addition to having complete
assessment data for each resident including discharge assessment data, residents are assigned correct
Resident Internal IDs. To facilitate this, providers must ensure that MDS items, in particular the items
indicated above, are entered correctly on each assessment. Providers must also carefully monitor the Final
Validation Report, generated upon MDS submission, for any errors. Providers should work with their
State RAI Coordinator or State Automation Coordinator to correct any errors that arise during assessment
submission. In addition to using their Final Validation Report to validate the file structure and data
content of each successful MDS submission, providers can monitor their MDS data using additional
Certification and Survey Provider Enhanced Reports (CASPER) Reports. There are CASPER Reports for
Admissions, Discharges, Duplicate Residents, Errors, and daily Rosters, among others. Full descriptions
of these reports are available in Section 6 of the CASPER Reporting MDS Provider User’s Guide
available at the following link: https://qtso.cms.gov/download/guides/casper/cspr_sec6_mds_prvdr.pdf
.
Information about Final Validation Reports and error messages in the reports is available in Sections 4
and 5 of the MDS 3.0 Provider User's Guide available at the following link:
https://qtso.cms.gov/mdstrain.html.
9
The nurse staffing hours reported through PBJ and the daily MDS census are both aggregated (summed)
across the quarterly reporting period. The quarterly reported nurse staffing hours per resident per day
(HRD) are then calculated by dividing the aggregate reported hours by the aggregate resident census.
Only days that have at least some (>0) nurse staffing (for any job category 5-12) and at least one resident
are included in the calculations.
CMS uses a set of exclusion criteria to identify facilities with highly improbable PBJ staffing data and
neither staffing data nor a staffing rating are reported for these facilities (displaying “Data Not Available”
on the Nursing Home Compare website). These exclusion criteria are as follows:
• The nursing home has 5 or more days with at least one resident but no nurse (RN, LPN or nurse
aide) staffing hours reported. Because nurse aides in training cannot operate independently as
nurses, nurse aides in training (job code 11) are not included.
• Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with both nurses and
residents is excessively low (<1.5 HRD)
• Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with both nurses and
residents is excessively high (>12 HRD)
• Nurse aide staffing (job codes 10-12) aggregated over all days in the quarter with both nurses and
residents is excessively high (>5.25 HRD)
Case-Mix Adjustment
CMS adjusts the reported staffing ratios for case-mix, using the Resource Utilization Group (RUG-IV)
case-mix system. The CMS Staff Time Resource Intensity Verification (STRIVE) Study measured the
number of RN, LPN, and nurse aide minutes associated with each RUG-IV group (using the 66 group
version of RUG-IV). CMS calculates case-mix adjusted hours per resident day for each facility for each
staff type using this formula:
T
he “r
eported” hours are those reported by the facility through PBJ as described above. “National
average” hours for a given staff type represent the national mean of expected hours across all facilities
active on the last day of the quarter and that submitted valid nurse staffing data for the quarter (shown in
Table 3). The National Average Hours values shown in Table 3 will be updated each quarter (in January,
April, July and October).
The “expected” values for each nursing home are based on the daily distribution of residents by RUG-IV
group in the same quarter as that covered by the PBJ reported staffing and estimates of daily expected
RN, LPN, and nurse aide hours from the CMS STRIVE Study (see Table A1). Specifically, expected
nurse staffing hours per resident day for a given nursing home are calculated as follows:
1) The MDS is used to assign a RUG-IV group to each resident for each day in the quarter. The
method is similar to that used for calculating the daily MDS census and is described below.
2) This information is aggregated to generate a count of residents in each of the 66 RUG-IV groups
in the nursing home for each day in the quarter. RUG-IV groups that are not represented on a
given day are assigned a count of 0. Residents for whom there is insufficient MDS information to
assign a RUG-IV category are not included.
10
3) Based on the number of residents in each RUG-IV group, expected total nursing and RN hours
are calculated by multiplying by nursing time estimates for each RUG-IV group from the
STRIVE study (Table A1).
4) Aggregate expected nursing and RN hours for the quarter are calculated by summing across all
days and RUG-IV groups. These are the numerators in the calculations of expected total nursing
and RN hours per resident day. The denominator for these calculations is the count of the total
number of resident-days in the quarter for which there is a valid RUG-IV group.
5) Expected total nursing and RN hours per resident day for each nursing home are calculated by
dividing aggregate expected hours (total nursing or RN) by the number of resident-days.
To determine the number of residents in each RUG-IV grouping for each day of the quarter for each
facility, the same algorithm is used as that used to generate the daily MDS census (with slight adjustment
to count RUG-IV groupings specifically, instead of just counting residents):
1) Identify the reporting period (quarter) for which the RUG groupings will be collected (e.g., CY
2017 Q4: October 1 – December 31, 2017).
2) Extract MDS assessment data (including RUG-IV 66 Hierarchical group) for all residents of a
facility beginning one year prior to the reporting period to identify all residents that may reside in
the facility (i.e., any resident with an MDS assessment may still reside in the facility). For
example, for the CY 2017 Q4 reporting period, extract MDS data from October 1, 2016 through
December 31, 2017.
3) Identify discharged residents using the following criteria:
a) If a resident has an MDS Discharge assessment, use the discharge date reported on that
assessment and assume that the resident no longer resides in the facility as of the date of
discharge on the last assessment. If there is a subsequent admission assessment, then assume
that the resident re-entered the nursing home on the entry date indicated on the admission
assessment.
b) For any resident with an interval of 150 days or more with NO assessments, assume the
resident no longer resides in the facility as of the 150th day from the last assessment. (This
assumption is based on the requirement for facilities to complete MDS assessments on all
residents at least quarterly). If no assessment is present, assume the resident was discharged,
but the facility did not transmit a Discharge assessment.
For any particular date, residents whose assessments do not meet the criteria in #3 above prior to that date
are assumed to reside in the facility. The RUG IV 66 Hierarchical groupings assigned to those residents
on their most recent assessments as of that date are counted as the RUG groupings for that facility on that
date.
Table 3
National Average Hours per Resident Day Used To Calculate Adjusted Staffing (as of July 2018)
1
Type of staff
National average expected hours per resident
per day
Total nursing staff (Aides + LPNs + RNs) 3.2146
Registered nurses 0.3763
1
These values will be updated each quarter and will be available in the State Averages table at
(https://data.medicare.gov/data/nursing-home-compare
)
11
The calculations of “expected”, “reported”, and “national average” hours are performed separately for
RNs and for all staff delivering nursing care (RNs, LPNs, and nurse aides). Adjusted hours are also
calculated for both groups using the formula discussed earlier in this section.
A downloadable file that contains the “expected”, “reported” and “case-mix adjusted" hours used in the
staffing calculations is available at:
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/FSQRS.html. The file, referred to as the “Expected and Adjusted
Staff Time Values Data Set,” contains data for both RNs and total staff for each individual nursing home.
Scoring Rules
The two staffing measures (RN and total nursing staff) are given equal weight. For each of RN staffing and
total staffing, a 1 to 5 rating is assigned based on a percentile-based method (Table 4). For each facility, the
overall staffing rating is assigned based on the combination of the two staffing ratings (Table 5).
The percentile cut points (data boundaries between star categories) were determined using the data
available as of March 2018. This was the first update of the cut points since December 2011 and was
necessary because of changes in the expected staffing due to the transition to RUG-IV. The cut points
were set so that the changes in expected staffing due to RUG-IV would not impact the overall distribution
of the five-star ratings; that is, they were selected so that the proportion of nursing homes in each rating
category would initially (i.e., for April 2018) be the same as it was in March 2018. CMS will evaluate
whether further rebasing is needed on a quarterly basis.
Table 4
National Star Cut Points for Staffing Measures, Based on Case-Mix Adjusted Hours per Resident
Day (updated April 2018)
Staff type 1 star 2 stars 3 stars 4 stars 5 stars
RN
< 0.246 0.246 - 0.382 0.383 – 0.586 0.587 – 0.883 >0.884
Total
< 3.176 3.176 – 3.551 3.552 - 4.009 4.010 – 4.237 >4.238
Note: Adjusted staffing values are rounded to three decimal places before the cut points are applied.
Rating Methodology
Facility ratings for overall staffing are based on the combination of RN and total nurse (RNs, LPNs, and
nurse aides) staffing ratings as shown in Table 5. To receive an overall staffing rating of five stars,
facilities must achieve a rating of five stars for both RN and total staffing. To receive a four-star staffing
rating, facilities must receive at least a three-star rating on one (either the RN or total nurse staffing) and a
rating of four or five stars on the other.
12
Table 5
Staffing Hours and Rating (updated April 2018)
RN rating and hours Total nurse staffing rating and hours (RN, LPN and nurse aide)
1 2 3 4 5
< 3.176 3.176 – 3.551
3.552 – 4.009 4.010 – 4.237 >4.238
1
< 0.246
★
★ ★★ ★★ ★★★
2
0.246 - 0.382
★ ★★ ★★★ ★★★ ★★★
3
0.383 – 0.586
★★
★★★
★★★ ★★★★
★★★★
4
0.587 – 0.883
★★ ★★★ ★★★★ ★★★★ ★★★★
5
>0.884
★★★ ★★★ ★★★★ ★★★★ ★★★★★
Note: Adjusted staffing values are rounded to three decimal places before the cut points are applied.
Scoring Exceptions
As of July 2018, there are the following exceptions to the scoring rules described above for assigning the
staffing rating and RN staffing rating.
• Providers that fail to submit any staffing data by the required deadline will receive a one-star
rating for overall staffing and RN staffing for the quarter.
• Providers that submit staffing data indicating that there were seven or more days in the quarter
with no RN staffing (job codes 5-7) but on which there were one or more residents in the facility
will receive a one-star rating for overall staffing and RN staffing for the quarter.
• CMS conducts audits of nursing homes to verify the data submitted and to ensure accuracy.
Facilities that fail to respond to these audits and those for which the audit identifies significant
discrepancies between the hours reported and the hours verified will receive a one-star rating for
overall staffing and RN staffing for three months from the time at which the deadline to respond
to audit requests passes or discrepancies are identified.
Quality Measure Domain
A set of quality measures (QMs) has been developed from Minimum Data Set (MDS) and Medicare
claims data to describe the quality of care provided in nursing homes. These measures address a broad
range of function and health status indicators. The facility rating for the QM domain is based on its
performance on a subset of 13 (out of 24) of the MDS-based QMs and three MDS- and Medicare claims-
based measures currently posted on Nursing Home Compare. The measures were selected based on their
validity and reliability, the extent to which facility practice may affect the measure, statistical
performance, and importance.
Measures for Long-Stay residents (residents in the facility for greater than 100 days) that are derived from
MDS assessments:
• Percentage of residents whose need for help with activities of daily living has increased
• Percentage of residents whose ability to move independently worsened
13
• Percentage of high risk residents with pressure ulcers (sores)
• Percentage of residents who have/had a catheter inserted and left in their bladder
• Percentage of residents who were physically restrained
• Percentage of residents with a urinary tract infection
• Percentage of residents who self-report moderate to severe pain
• Percentage of residents experiencing one or more falls with major injury
• Percentage of residents who received an antipsychotic medication
Measures for Short-Stay residents that are derived from MDS assessments:
• Percentage of residents whose physical function improves from admission to discharge
• Percentage of residents with pressure ulcers (sores) that are new or worsened
• Percentage of residents who self-report moderate to severe pain
• Percentage of residents who newly received an antipsychotic medication
Measures for Short-Stay residents that are derived from claims data and MDS assessments:
• Percentage of residents who were re-hospitalized after a nursing home admission
• Percentage of residents who have had an outpatient emergency department visit
• Percentage of residents who were successfully discharged to the community
Table 6 contains more detailed information on these measures.
Technical specifications for the complete set of MDS-based QMs are available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V10.pdf
Technical specifications for the claims-based measures are available at:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT-
04-05-16-.pdf.
Values for five of the MDS-based QMs (mobility decline, catheter, long-stay pain, short-stay functional
improvement, and short-stay pressure ulcers) are risk adjusted, using resident-level covariates that adjust
for resident factors associated with differences in the performance on the QM. For example, the catheter
risk-adjustment model takes into account whether or not residents had bowel incontinence or pressure
sores on the prior assessment. Additionally, all three of the claims-based measures are also risk adjusted
using both items from Medicare Part A claims that preceded the start of the nursing home stay and
information from the first MDS assessment associated with the nursing home stay.
The risk-adjustment methodology is described in more detail in the technical specification documents
referenced above. The covariates and the coefficients used in the risk-adjustment models are reported in
Table A-2 in the Appendix.
14
CMS calculates ratings for the QM domain using the four most recent quarters for which data are
available. This time period specification was selected to increase the number of assessments available for
calculating the QM rating. This increases the stability of estimates and reduces the amount of missing
data. The adjusted four-quarter QM values for each of the MDS-based QMs used in the five-star
algorithm are computed as follows:
Where QM
Q1
, QM
Q2
, QM
Q3
, and QM
Q4
correspond to the adjusted QM values for the four most recent
quarters and D
Q1
, D
Q2
, and D
Q3
D
Q4
are the denominators (number of eligible residents for the particular
QM) for the same four quarters.
Values for the three claims-based measures are calculated in a similar manner, except that the data used to
calculate the measures use a full year of data rather than being broken out separately by quarter.
Table 6 Quality Measures Used in the Five-Star Quality Measure Rating Calculation
Measure Comments
MDS Long-Stay Measures
Percentage of residents
whose ability to move
independently worsened
This measure is a change measure that reports the percent of long-stay residents
who have demonstrated a decline in independence of locomotion when comparing
the target assessment to a prior assessment. Residents who lose mobility may also
lose the ability to perform other activities of daily living, like eating, dressing, or
getting to the bathroom.
Percentage of residents
whose need for help with
activities of daily living has
increased
1
This measure reports the percentage of long-stay residents whose need for help
with late-loss Activities of Daily Living (ADLs) has increased when compared to the
prior assessment. This is a change measure that reflects worsening performance
on at least two late loss ADLs by one functional level or on one late loss ADL by
more than one functional level compared to the prior assessment. The late loss
ADLs are bed mobility, transfer, eating, and toileting. Maintenance of ADLs is
related to an environment in which the resident is up and out of bed and engaged
in activities. The CMS Staffing Study found that higher staffing levels were
associated with lower rates of increasing dependence in ADLs.
Percentage of high-risk
residents with pressure
ulcers
This measure captures the percentage of long-stay, high-risk residents with Stage
II-IV pressure ulcers. Residents at high risk for pressure ulcers are those who are
impaired in bed mobility or transfer, who are comatose, or who suffer from
malnutrition.
Percentage of residents who
have/had a catheter inserted
and left in their bladder
This measure reports the percentage of residents who have had an indwelling
catheter in the last seven days. Indwelling catheter use may result in complications,
like urinary tract or blood infections, physical injury, skin problems, bladder stones,
or blood in the urine.
Percentage of residents who
were physically restrained
This measure reports the percentage of long-stay residents who are physically
restrained on a daily basis. A resident who is restrained daily can become weak,
lose his or her ability to go to the bathroom without help, and develop pressure
ulcers or other medical complications.
Percentage of residents with
a urinary tract infection
This measure reports the percentage of long-stay residents who have had a urinary
tract infection within the past 30 days. Urinary tract infections can often be
prevented through hygiene and drinking enough fluid. Urinary tract infections are
relatively minor but can lead to more serious problems and cause complications
like delirium if not treated.
Percentage of residents who
self-report moderate to
severe pain
This measure captures the percentage of long-stay residents who report either (1)
almost constant or frequent moderate to severe pain in the last five days or (2) any
very severe/horrible pain in the last 5 days.
15
Table 6 Quality Measures Used in the Five-Star Quality Measure Rating Calculation
Measure Comments
Percentage of residents
experiencing one or more
falls with major injury
This measure reports the percentage of long-stay residents who have experienced
one or more falls with major injury reported in the target period or look-back period
(one full calendar year).
Percentage of residents who
received an antipsychotic
medication
This measure reports the percentage of long-stay residents who are receiving
antipsychotic drugs in the target period. Reducing the rate of antipsychotic
medication use has been the focus of several CMS initiatives.
MDS Short-Stay Measures
Percentage of residents
whose physical function
improves from admission to
discharge
This measure assesses the percentage of short-stay residents whose
independence in three mobility functions (i.e., transfer, locomotion, and walking)
increases over the course of the nursing home care episode.
Percentage of residents with
pressure ulcers that are new
or worsened
This measure captures the percentage of short-stay residents with new or
worsening Stage II-IV pressure ulcers.
Percentage of residents who
self-report moderate to
severe pain
This measure captures the percentage of short-stay residents, with at least one
episode of moderate/severe pain or horrible/excruciating pain of any frequency, in
the last 5 days.
Percentage of residents who
newly received an
antipsychotic medication
This measure reports the percentage of short-stay residents who are receiving an
antipsychotic medication during the target period but not on their initial
assessment.
Claims-Based Short-Stay Measures
Percentage of residents who
were re-hospitalized after a
nursing home admission
This measure reports the percentage of all new admissions or readmissions to a
nursing home from a hospital where the resident was re-admitted to a hospital for
an inpatient or observation stay within 30 days of entry or reentry.
Percentage of short-stay
residents who have had an
outpatient emergency
department (ED) visit
This measure reports the percentage of all new admissions or readmissions to a
nursing home from a hospital where the resident had an outpatient ED visit (i.e., an
ED visit not resulting in an inpatient hospital admission) within 30 days of entry or
reentry.
Percentage of short-stay
residents who were
successfully discharged to
the community
This measure reports the percentage of all new admissions to a nursing home from
a hospital where the resident was discharged to the community within 100 calendar
days of entry and for 30 subsequent days, did not die, was not admitted to a
hospital for an unplanned inpatient stay, and was not readmitted to a nursing
home.
1
Indicates ADL QM as referenced in scoring rules
Sources: Based on information from the AHRQ Measures Clearinghouse and the NHVBP Draft Design Report and
the MDS 3.0 Quality Measures User’s Manual.
Missing Data and Imputation
Consistent with the specifications used for Nursing Home Compare, MDS-based measures are reported if
the measure can be calculated for at least 20 residents’ assessments (summed across four quarters of data
to enhance measurement stability) for both the long- and short-stay QMs. The claims-based measures are
reported if the measure can be calculated for at least 20 nursing home stays over the course of the year.
For facilities with missing data or an inadequate denominator size for one or more QMs, meeting the
criteria described below, all available data from the facility are used. The remaining assessments (or
stays) are imputed to get the facility to the minimum required sample size of 20. For example, if a facility
had actual data for 12 resident assessments, the data for those 12 assessments would be used and the
remaining eight assessments would be imputed using the state average to get to the minimum sample size
to include the measure in the scoring for the QM rating. Missing values are imputed based on the
16
statewide average for the measure. The imputation strategy for the missing values depends on the pattern
of missing data.
• For facilities that have an adequate denominator size for at least five of the nine long-stay QMs,
values are imputed for the long-stay measures with fewer than 20 assessments as described
above. Points are then assigned for all nine long-stay QMs according to the scoring rules
described below.
• For facilities that have an adequate denominator size for at least four of the seven short-stay QMs
(including at least one of the three claims-based measures), values are imputed for the short-stay
measures with smaller denominators as described above. Points are then assigned for all seven
short-stay QMs according to the scoring rules described below.
• For facilities with adequate denominator sizes on four or fewer long-stay QMs, the QM rating is
based on the short-stay measures only. Values for the missing long-stay QMs are not imputed,
and no long-stay measures are used in determining the QM rating.
• Similarly, for facilities with adequate denominator sizes for three or fewer short-stay QMs or no
claims-based QMs, the QM rating is based on the long-stay measures only. Values for the
missing short-stay QMs are not imputed, and no short-stay measures are used in determining the
QM rating. One exception to this is for a small number of nursing homes that have adequate
denominators for all four of the MDS-based short-stay measures but none of the claims-based
measures. For these nursing homes, values are not imputed for the claims-based measures;
however, the points assigned for the MDS-based short-stay measures are used in generating the
QM rating according to the scoring rules described below.
Note that while values are imputed according to the rules described above for the purposes of assigning
points for the QM score, imputed data for QMs is not reported on the Nursing Home Compare website
nor included in the downloadable databases available at Data.Medicare.gov. QM values are publicly
reported only for providers meeting the minimum denominator requirements prior to any imputation.
Scoring Rules for the Individual QMs
For each measure, 20 to 100 points are assigned based on facility performance relative to the national
distribution of the QM. Points are assigned after any needed imputation of individual QM values, with the
points determined in the following way:
• For long-stay ADL worsening, long-stay pressure ulcers, long-stay catheter, long-stay urinary
tract infections, long-stay pain, long-stay injurious falls, and short-stay pain: facilities are
grouped into quintiles based on the national distribution of the QM. The quintiles are assigned 20
points for the poorest performing quintile, 100 points for the best performing quintile, and 40, 60
or 80 points for the second, third and fourth quintiles respectively.
• The long-stay physical restraint and short-stay pressure ulcer QMs are treated slightly
differently because they have low prevalence – specifically, substantially more than 20 percent
(i.e. a quintile) of nursing homes have zero percent rates on these measures.
o For the long-stay physical restraint QM, facilities achieving the best possible score on
the QM (i.e. zero percent of residents triggering the QM) are assigned 100 points; this is
about 60 percent of facilities (or three quintiles). The remaining facilities are divided into
two evenly sized groups, (each with about 20 percent of nursing homes); the poorer
17
performing group is assigned 20 points, and the better performing group is assigned 60
points.
o The short-stay pressure ulcer QM is treated similarly: facilities achieving the best
possible score on the QM (i.e. zero percent of residents triggering the QM) are assigned
100 points; this is about one-third of nursing homes. The remaining facilities are divided
into three evenly sized groups, (each with about 23 percent of nursing homes) and
assigned 25, 50 or 75 points.
• For measures that were added to the QM rating beginning in February 2015, the following
scoring rules use used:
o For the long-stay antipsychotic medication, long-stay mobility decline, short-stay
functional improvement, and the three claims-based measures, facilities are divided
into five groups based on the national distribution of the measure. The top-performing 10
percent of facilities receive 100 points; the poorest performing 20 percent of facilities
receive 20 points; the middle 70 percent of facilities are divided into three equally sized
groups (each including approximately 23.3 percent of nursing homes) and receive 40, 60
or 80 points.
o The short-stay antipsychotic medication QM is treated similarly; however, because
approximately 20 percent of facilities achieve the best possible score on this QM (i.e.
zero percent of residents triggering the QM), these facilities all receive 100 points; the
poorest performing 20 percent of facilities receive 20 points; the remaining facilities are
divided into three equally sized groups (each including approximately 20 percent of
nursing homes) and receive 40, 60 or 80 points.
Note that, for all of the measures, the groupings are based on the national distribution of the QMs, prior to
any imputation. For each of the MDS-derived QMs, the cut points are based on the QM distributions
averaged across the four quarters of 2015. For the claims-based QMs, the cut points are based on the
national distribution of the measures calculated for the period of Quarter 3 of 2014 through Quarter 2 of
2015.
Rating Methodology
After any needed imputation for individual QMs, the points are summed across all QMs based upon the
scoring rules above to create a total score for each facility. The total possible score ranges between 325
and 1,600.
Facilities that receive a QM rating are in one of the following categories:
• They have points for all of the QMs.
• They have points for only the nine long-stay QMs (long-stay facilities).
• They have points for the nine long-stay QMs and the 4 MDS-based short-stay QMs
• They have points for only the seven short-stay QMs (short-stay facilities)
• They have points for only the four MDS-based short-stay QMs
• No values are imputed for nursing homes with data on fewer than five long-stay QMs and fewer
than four short-stay QMs. No QM rating is generated for these nursing homes.
18
To ensure that all facilities are scored on the same scale, the total score is rescaled for long and short-stay
facilities:
• If the facility has data for only the nine long-stay measures, the average of these point values is
assigned for each of the seven (missing) short-stay measures and the total score is recalculated.
• If
the facility has data for the nine long-stay QMs and the four MDS-based short-stay QMs but
not the claims-based QMs, the average of the point values for the MDS-based short-stay QMs is
assigned for each of the three (missing) claims-based measures and the total score is recalculated.
• If the facility has data for only the seven short-stay measures, the average of these point values is
assigned for each of the nine (missing) long-stay measures and the total score is recalculated.
• I
f the facility has data for only the four MDS-based short stay QMs, but none of the long-stay
QMs or the claims-based QMs, the average of the point values for the MDS-based short-stay
QMs is assigned for each of the nine (missing) long-stay measures and each of the three (missing)
claims-based measures and the total score is recalculated.
O
nce the summary QM score is computed for each facility as described above, the five-star QM rating is
assigned, according to the point thresholds shown in Table 7. These thresholds were set so that the overall
proportion of nursing homes would be approximately 25 percent five-star, 20 percent for each of two-,
three-, and four-star and 15 percent one-star, which was the distribution in February 2015 (the previous
time that new measures were added and rebasing was required). The cut points associated with these star
ratings will be held constant for a period of at least one year (from January 2017), allowing the
distribution of the QM rating to change over time.
Table 7
Star Cut-points for Quality Measure Summary Score
QM Rating Point Range
★
325 – 789
★★
790 – 889
★★★
890 – 969
★★★★
970 – 1054
★★★★★
1055 – 1600
Overall Nursing Home Rating (Composite Measure)
Based on the star ratings for the health inspection domain, the staffing domain and the MDS quality
measure domain, CMS assigns the overall Five-Star rating in three steps:
Step 1: Start with the health inspection rating.
Step 2: Add one star to the Step 1 result if the staffing rating is four or five stars and greater than the
health inspection rating; subtract one star if the staffing rating is one star. The overall rating cannot be
more than five stars or less than one star.
19
Step 3: Add one star to the Step 2 result if the quality measure rating is five stars; subtract one star if
the quality measure rating is one star. The overall rating cannot be more than five stars or less than
one star.
Note: If the health inspection rating is one star, then the overall rating cannot be upgraded by more
than one star based on the staffing and quality measure ratings. If the nursing home is a Special Focus
Facility (SFF) that has not graduated, the maximum overall rating is three stars.
The rationale for upgrading facilities in Step 2 that receive a rating of four of five stars for staffing (rather
than limiting the upgrade to those with five stars) is that the criteria for the staffing rating is quite
stringent. However, requiring that the staffing rating be greater than the health inspection rating in order
for the score to be upgraded ensures that a facility with four stars on health inspections and four stars on
staffing (and more than one star on the quality measure rating) does not receive an overall rating of five
stars.
The rationale for limiting star rating upgrades is that two self-reported data domains should not
significantly outweigh the rating from actual onsite visits from trained surveyors who have found very
serious quality of care problems. Since the health inspection rating is heavily weighted toward the most
recent findings, a health inspection rating of one star reflects both a serious and recent finding.
The rationale for limiting the overall rating of a Special Focus Facility (SFF) is that the health inspection
rating is weighted toward more recent results and may not fully capture the long history of “yo-yo” or “in
and out” of compliance with federal safety and quality of care requirements that some nursing homes
exhibit. That type of history can be characteristic of the SFF nursing homes. The Nursing Home
Compare website should reflect the most recent data available so consumers can monitor facility
performance, however, the overall rating will be capped out of caution that the prior “yo-yo” pattern
could be repeated. Once a facility graduates from the SFF initiative by sustaining improved compliance
for about 12 months, the cap will be removed for the former SFF nursing home.
The method for determining the overall nursing home rating does not assign specific weights to the health
inspection, staffing, and QM domains. The health inspection rating is the most important dimension in
determining the overall rating, but, depending on the performance on the staffing and QM domains, the
overall rating for a facility may be increased or decreased by up to two stars.
If a facility has no health inspection rating, then no overall rating is assigned. If a facility has no health
inspection rating because it is too new to have two standard surveys, then no ratings for any domain are
displayed.
Change in Nursing Home Rating
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is
based on three individual domains, a change in any one of the domains can affect the overall rating.
Provided below are some potential reasons that a change in a domain could occur:
New Data for the Facility
Any new data for a facility could potentially change a star rating domain.
Events that could change the health inspection score include:
20
• A new health inspection (that occurred prior to November 28, 2017),
• New complaint deficiencies (that occurred prior to November 28, 2017),
• A second, third, or fourth revisit (for a survey that occurred before November 28, 2017),
• Resolution of Informal Dispute Resolutions (IDR) or Independent Informal Dispute Resolutions
(IIDR) resulting in changes to the scope and/or severity of deficiencies (for surveys prior to
November 28, 2017),
T
he data will be included as soon as they become part of the CMS database. The timing for this can vary
by state and depends on having the complete survey package for the State Survey Agency to upload to the
national database. Additional inspection data may be added to the database at any time because of
complaint investigations, outcomes of revisits, Informal Dispute Resolutions (IDR), or Independent
Informal Dispute Resolutions (IIDR). These data may not be added in the same cycle as the standard
inspection data.
PBJ staffing data are reported quarterly, so new staffing measures and ratings will be calculated and
posted quarterly. Changes in a facility’s staffing measure or rating may be due to differences in the
number of hours submitted for staff, changes in the daily census, or changes in risk adjustment from the
previous quarter.
Quality Measure data for the MDS-based QMs are updated on Nursing Home Compare on a quarterly
basis, and the nursing home QM rating is updated at the same time. The updates typically occur in
January, April, July, and October towards the end of these months. The claims-based QM data typically
update every six months (in April and October). Changes in the quality measures may change the star
rating.
Since the cut-points between star categories for the health inspection rating are based on percentile
distributions that are not fixed, those cut-points may vary slightly depending on the current facility
distribution in the database. However, while the cut-points for the health inspection ratings may change
from month to month, the rating for a given facility is held constant until there is a change in the weighted
health inspection score for that facility.
21
Appendix
Table A1
RUG-IV Based Case-Mix Adjusted Nurse and Aide Staffing Minute
1
Estimates
Major RUG
Group
RUG-IV
Code
STRIVE Study Average Times (Minutes)
1
RN LPN
Total
Licensed
Nurse Aide
Total Nurse
(RN+LPN+Aide)
Rehab Plus
Extensive
RUX
68.37
111.44
179.81
131.11
310.92
RUL
109.06
63.87
172.93
199.94
372.87
RVX
29.24
95.88
125.12
145.94
271.06
RVL
67.74
97.39
165.13
139.99
305.12
RHX
128.79
51.92
180.71
155.24
335.95
RHL
67.28
48.41
115.69
135.32
251.01
RMX
97.54
74.61
172.15
148.44
320.59
RML
133.82
84.01
217.83
153.24
371.07
RLX
133.82
84.01
217.83
153.24
371.07
Rehab
RUC
27.80
66.41
94.21
148.95
243.16
RUB
45.01
71.09
116.10
141.03
257.13
RUA
35.18
54.55
89.73
101.01
190.74
RVC
34.22
68.45
102.67
156.53
259.20
RVB
28.86
56.56
85.42
119.90
205.32
RVA
31.30
59.35
90.65
113.73
204.38
RHC
36.62
54.88
91.50
156.14
247.64
RHB
36.42
47.88
84.30
119.48
203.78
RHA
27.09
51.76
78.85
99.82
178.67
RMC
32.58
56.05
88.63
148.87
237.50
RMB
32.10
55.47
87.57
134.74
222.31
RMA
25.99
48.79
74.78
98.81
173.59
RLB
33.86
44.58
78.44
185.83
264.27
RLA
15.46
43.58
59.04
118.93
177.97
Extensive
Services
ES3
130.49
58.49
188.98
152.12
341.10
ES2
65.19
75.23
140.42
146.65
287.07
ES1
72.81
49.49
122.30
127.62
249.92
Special Care
High
HE2
21.25
67.93
89.18
190.47
279.65
HD2
41.89
70.63
112.52
153.76
266.28
HC2
35.13
53.63
88.76
154.72
243.48
HB2
60.64
67.91
128.55
133.86
262.41
HE1
19.20
67.73
86.93
149.47
236.40
HD1
16.89
54.54
71.43
141.80
213.23
HC1
22.43
54.17
76.60
135.33
211.93
HB1
21.65
50.50
72.15
106.77
178.92
22
Major RUG
Group
RUG-IV
Code
STRIVE Study Average Times (Minutes)
1
RN LPN
Total
Licensed
Nurse Aide
Total Nurse
(RN+LPN+Aide)
Special Care
Low
LE2
22.16
58.83
80.99
176.15
257.14
LD2
19.59
58.10
77.69
153.29
230.98
LC2
27.44
47.80
75.24
116.12
191.36
LB2
29.52
50.73
80.25
128.44
208.69
LE1
22.11
52.25
74.36
143.41
217.77
LD1
11.78
43.94
55.72
130.80
186.52
LC1
15.72
46.56
62.28
124.77
187.05
LB1
18.99
48.66
67.65
106.16
173.81
Clinically
Complex
CE2
21.05
44.13
65.18
162.70
227.88
CD2
20.01
45.17
65.18
175.51
240.69
CC2
19.77
36.95
56.72
132.92
189.64
CB2
23.50
36.46
59.96
114.97
174.93
CA2
20.69
44.63
65.32
80.92
146.24
CE1
21.26
33.75
55.01
159.10
214.11
CD1
15.31
41.90
57.21
151.40
208.61
CC1
16.00
35.10
51.10
126.91
178.01
CB1
16.17
34.99
51.16
118.45
169.61
CA1
22.39
40.22
62.61
72.76
135.37
Behavioral
Symptoms and
Cognitive
Performance
BB2
11.30
33.26
44.56
117.96
162.52
BA2
18.34
41.18
59.52
101.56
161.08
BB1
14.93
32.83
47.76
114.30
162.06
BA1
13.60
31.57
45.17
86.06
131.23
Reduced
Physical
Functioning
PE2
15.11
39.76
54.87
163.58
218.45
PD2
12.09
38.01
50.10
163.38
213.48
PC2
8.14
33.51
41.65
124.90
166.55
PB2
15.49
38.95
54.44
118.83
173.27
PA2
5.50
35.91
41.41
73.16
114.57
PE1
19.91
36.07
55.98
161.23
217.21
PD1
16.18
33.58
49.76
147.31
197.07
PC1
14.07
36.94
51.01
123.74
174.75
PB1
12.49
31.80
44.29
95.60
139.89
PA1
14.32
32.42
46.74
70.77
117.51
1
Note that time estimates in minutes are converted to hours (by dividing by 60) before being used in the calculations
for adjusted staffing.
23
Table A2
Coefficients for Risk-Adjustment Model
Quality Measure/Covariate
Constant
(Intercept)
Coefficient
Percentage of long-stay residents who had a catheter inserted and left in
their bladder
-3.645993
1. Indicator of frequent bowel incontinence on prior assessment 0.545108
2. Indicator of pressure sores at stages II, III, or IV on prior assessment 1.967017
Percentage of long-stay residents who self-report moderate to severe pain
-2.428281
1. Indicator of independence or modified independence in daily decision
making on the prior assessment 1.044019
Percentage of short-stay residents with pressure ulcers that are new or
worsened
-5.204646
1. Indicator of requiring limited or more assistance in bed mobility on the
initial assessment
1.013114
2. Indicator of bowel incontinence at least occasionally on initial
assessment
0.835473
3. Indicator of diabetes or peripheral vascular disease on the initial
assessment
0.412676
4. Indicator of low body mass index on the initial assessment
0.373643
Source: http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf
24
Table A3
Ranges for Point Values for Quality Measures, Using Four Quarter Average
Distributions
1
Quality measure
For QM values
Number of QM
points is…
between... and...
ADL Decline (long-stay) 0.00000000 0.10049021 100
0.10049022 0.13483145 80
0.13483146 0.16778523 60
0.16778524 0.20794393 40
0.20794394 1.00000000 20
Moderate to Severe Pain (long-stay) 0.00000000 0.02201134 100
0.02201135 0.04988420 80
0.04988421 0.08311380 60
0.08311381 0.13081113 40
0.13081114 1.00000000 20
High risk pressure Ulcers (long-stay) 0.00000000 0.02654868 100
0.02654869 0.04453437 80
0.04453438 0.06181819 60
0.06181820 0.08633095 40
0.08633096 1.00000000 20
Catheter (long-Stay) 0.00000000 0.01073927 100
0.01073928 0.02094371 80
0.02094372 0.03178361 60
0.03178362 0.04745521 40
0.04745522 1.00000000 20
Urinary Tract Infection (long-stay) 0.00000000 0.01851851 100
0.01851852 0.03423682 80
0.03423683 0.05128203 60
0.05128204 0.07598784 40
0.07598785 1.00000000 20
Physical Restraints (long-stay) 0.00000000 0.00000000 100
0.00000001 0.01424503 60
0.01424504 1.00000000 20
25
Quality measure
For QM values
Number of QM
points is…
between... and...
Injurious Falls (long-stay) 0.00000000 0.01315789 100
0.01315790 0.02403848 80
0.02403849 0.03511052 60
0.03511053 0.05035973 40
0.05035974 1.00000000 20
Antipsychotic Meds (long-stay) 0.00000000 0.06843265 100
0.06843266 0.12704916 80
0.12704917 0.17391305 60
0.17391306 0.23979592 40
0.23979593 1.00000000 20
Moderate to Severe Pain (short-stay) 0.00000000 0.07359305 100
0.07359306 0.13229570 80
0.13229571 0.18827161 60
0.18827162 0.26041665 40
0.26041666 1.00000000 20
New or Worsening Pressure Ulcers (short-stay) 0.00000000 0.00000000 100
0.00000001 0.00692691 75
0.00692692 0.01566247 50
0.01566248 1.00000000 25
Antipsychotic Meds (short-stay) 0.00000000 0.00000000 100
0.00000001 0.00999998 80
0.00999999 0.01912567 60
0.01912568 0.03486237 40
0.03486238 1.00000000 20
Mobility decline (long-stay)
0.00000000 0.08022493 100
0.08022494 0.14454544 80
0.14454545 0.19333225 60
0.19333226 0.24905966 40
0.24905967 1.00000000 20
26
Quality measure
For QM values
Number of QM
points is…
between... and...
Functional Improvement (short-stay)
0.81666872 1.00000000 100
0.70966590 0.81666871 80
0.62861965 0.70966589 60
0.52015014 0.62861964 40
0.00000000 0.52015013 20
Hospital readmission (short-stay)
0.00000000 0.13839278 100
0.13839279 0.18716279 80
0.18716280 0.21886203 60
0.21886204 0.25689121 40
0.25689122 1.00000000 20
ED Visits (short-stay)
0.00000000 0.05488714 100
0.05488715 0.08944665 80
0.08944666 0.11696705 60
0.11696706 0.15529003 40
0.15529004 1.00000000 20
Successful community discharge (short-stay)
0.66448731 1.00000000 100
0.59926791 0.66448730 80
0.54906047 0.59926790 60
0.47667646 0.54906046 40
0.00000000 0.47667645 20
1
For the claims-based measures (hospital readmission, ED visit, community discharge), points are based on data
from 2014Q3 – 2015Q2. For the MDS-based measures (all others), points are based on data from 2015Q1 –
2015Q4. A higher QM value corresponds to better performance for all measures except functional improvement and
successful community discharge where lower QM values correspond to better performance.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX L: MINIMUM DATA SET (MDS) FORMS
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 1 of 50
Resident Identifier Date
MINIMUM DATA SET (MDS) - Version 3.0.
RESIDENT ASSESSMENT AND CARE SCREENING.
Nursing Home Comprehensive (NC) Item Set.
Section A. Identification Information.
A0050. Type of Record.
1. Add new record Continue to A0100, Facility Provider Numbers.
2. Modify existing record Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record Skip to X0150, Type of Provider.
Enter Code
A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
C. State Provider Number:
A0200. Type of Provider.
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
A0310. Type of Assessment.
A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.
0. No.
1. Yes.
Enter Code
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
Enter Code
A0310 continued on next page.
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 2 of 50
Resident Identifier Date
Identification Information.Section A.
A0310. Type of Assessment - Continued.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
G. Type of discharge. - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
A0410. Unit Certification or Licensure Designation.
1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.
Enter Code
A0500. Legal Name of Resident.
A. First name: B. Middle initial:
C. Last name: D. Suffix:
A0600. Social Security and Medicare Numbers.
A. Social Security Number:
_ _
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.
A0800. Gender.
1. Male.
2. Female.
Enter Code
A0900. Birth Date.
Month
_
Day
_
Year
A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.
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Resident Identifier Date
Identification Information.Section A.
A1100. Language.
A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No Skip to A1200, Marital Status.
1. Yes Specify in A1100B, Preferred language.
9. Unable to determine. Skip to A1200, Marital Status.
Enter Code
B. Preferred language:
A1200. Marital Status.
1. Never married.
2. Married.
3. Widowed.
4. Separated.
5. Divorced.
Enter Code
A1300. Optional Resident Items.
A. Medical record number:
B. Room number:
C. Name by which resident prefers to be addressed:
D. Lifetime occupation(s) - put "/" between two occupations:
A1500. Preadmission Screening and Resident Review (PASRR).
Complete only if A0310A = 01, 03, 04, or 05
Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability
("mental retardation" in federal regulation) or a related condition?
0. No Skip to A1550, Conditions Related to ID/DD Status.
1. Yes Continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.
Skip to A1550, Conditions Related to ID/DD Status.9. Not a Medicaid-certified unit
Enter Code
A1510. Level II Preadmission Screening and Resident Review (PASRR) Conditions.
Complete only if A0310A = 01, 03, 04, or 05.
Check all that apply.
A. Serious mental illness.
B. Intellectual Disability ("mental retardation" in federal regulation).
C. Other related conditions.
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Resident Identifier Date
Identification Information.Section A.
A1550. Conditions Related to ID/DD Status.
If the resident is 22 years of age or older, complete only if A0310A = 01.
If the resident is 21 years of age or younger, complete only if A0310A = 01, 03, 04, or 05.
Check all conditions that are related to ID/DD status that were manifested before age 22, and are likely to continue indefinitely.
ID/DD With Organic Condition.
A. Down syndrome.
B. Autism.
C. Epilepsy.
D. Other organic condition related to ID/DD.
ID/DD Without Organic Condition.
E. ID/DD with no organic condition.
No ID/DD.
Z. None of the above.
Most Recent Admission/Entry or Reentry into this Facility.
A1600. Entry Date.
Month
_
Day
_
Year
A1700. Type of Entry.
1. Admission.
2. Reentry.
Enter Code
A1800. Entered From.
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A1900. Admission Date (Date this episode of care in this facility began).
Month
_
Day
_
Year
A2000. Discharge Date.
Complete only if A0310F = 10, 11, or 12
Month
_
Day
_
Year
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Resident Identifier Date
Identification Information.Section A.
A2100. Discharge Status.
Complete only if A0310F = 10, 11, or 12
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
08. Deceased.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A2200. Previous Assessment Reference Date for Significant Correction.
Complete only if A0310A = 05 or 06.
Month
_
Day
_
Year
A2300. Assessment Reference Date.
Observation end date:
Month
_
Day
_
Year
A2400. Medicare Stay.
A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No Skip to B0100, Comatose.
1. Yes Continue to A2400B, Start date of most recent Medicare stay.
Enter Code
B. Start date of most recent Medicare stay:
Month
_
Day
_
Year
C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:
Month
_
Day
_
Year
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Resident Identifier Date
Look back period for all items is 7 days unless another time frame is indicated.
Section B. Hearing, Speech, and Vision.
B0100. Comatose.
Persistent vegetative state/no discernible consciousness.
0. No Continue to B0200, Hearing.
1. Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.
Enter Code
B0200. Hearing.
Ability to hear (with hearing aid or hearing appliances if normally used).
0. Adequate - no difficulty in normal conversation, social interaction, listening to TV.
1. Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy).
2. Moderate difficulty - speaker has to increase volume and speak distinctly.
3. Highly impaired - absence of useful hearing.
Enter Code
B0300. Hearing Aid.
Hearing aid or other hearing appliance used in completing B0200, Hearing.
0. No...
1. Yes.
Enter Code
B0600. Speech Clarity.
Select best description of speech pattern.
0. Clear speech - distinct intelligible words.
1. Unclear speech - slurred or mumbled words.
2. No speech - absence of spoken words.
Enter Code
B0700. Makes Self Understood.
Ability to express ideas and wants, consider both verbal and non-verbal expression.
0. Understood.
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.
2. Sometimes understood - ability is limited to making concrete requests.
3. Rarely/never understood.
Enter Code
B0800. Ability To Understand Others.
Understanding verbal content, however able (with hearing aid or device if used).
0. Understands - clear comprehension.
1. Usually understands - misses some part/intent of message but comprehends most conversation.
2. Sometimes understands - responds adequately to simple, direct communication only.
3. Rarely/never understands.
Enter Code
B1000. Vision.
Ability to see in adequate light (with glasses or other visual appliances).
0. Adequate - sees fine detail, such as regular print in newspapers/books.
1. Impaired - sees large print, but not regular print in newspapers/books.
2. Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects.
3. Highly impaired - object identification in question, but eyes appear to follow objects.
4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects.
Enter Code
B1200. Corrective Lenses.
Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision.
0. No...
1. Yes.
Enter Code
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Resident Identifier Date
Section C. Cognitive Patterns.
C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents.
0. No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status.
1. Yes Continue to C0200, Repetition of Three Words.
Enter Code
Brief Interview for Mental Status (BIMS).
C0200. Repetition of Three Words.
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt.
0. None.
1. One.
2. Two.
3. Three.
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece
of furniture"). You may repeat the words up to two more times.
Enter Code
C0300. Temporal Orientation (orientation to year, month, and day).
Ask resident: "Please tell me what year it is right now."
A. Able to report correct year.
0. Missed by > 5 years or no answer.
1. Missed by 2-5 years.
2. Missed by 1 year.
3. Correct.
Enter Code
Ask resident: "What month are we in right now?"
B. Able to report correct month.
0. Missed by > 1 month or no answer.
1. Missed by 6 days to 1 month.
2. Accurate within 5 days.
Enter Code
Ask resident: "What day of the week is today?"
C. Able to report correct day of the week.
0. Incorrect or no answer.
1. Correct.
Enter Code
C0400. Recall.
Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall "sock".
0. No - could not recall.
1. Yes, after cueing ("something to wear").
2. Yes, no cue required.
Enter Code
B. Able to recall "blue".
0. No - could not recall.
1. Yes, after cueing ("a color").
2. Yes, no cue required.
Enter Code
C. Able to recall "bed".
0. No - could not recall.
1. Yes, after cueing ("a piece of furniture").
2. Yes, no cue required.
Enter Code
C0500. BIMS Summary Score.
Add scores for questions C0200-C0400 and fill in total score (00-15).
Enter 99 if the resident was unable to complete the interview.
Enter Score
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Resident Identifier Date
Section C. Cognitive Patterns.
C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
0. No (resident was able to complete Brief Interview for Mental Status ) Skip to C1310, Signs and Symptoms of Delirium.
1. Yes (resident was unable to complete Brief Interview for Mental Status) Continue to C0700, Short-term Memory OK.
Enter Code
Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.
C0700. Short-term Memory OK.
Seems or appears to recall after 5 minutes.
0. Memory OK.
1. Memory problem.
Enter Code
C0800. Long-term Memory OK.
Seems or appears to recall long past.
0. Memory OK.
1. Memory problem.
Enter Code
C0900. Memory/Recall Ability.
Check all that the resident was normally able to recall.
A. Current season.
B. Location of own room.
C. Staff names and faces.
D. That he or she is in a nursing home/hospital swing bed.
Z. None of the above were recalled.
C1000. Cognitive Skills for Daily Decision Making.
Made decisions regarding tasks of daily life.
0. Independent - decisions consistent/reasonable.
1. Modified independence - some difficulty in new situations only.
2. Moderately impaired - decisions poor; cues/supervision required.
3. Severely impaired - never/rarely made decisions.
Enter Code
Delirium.
C1310. Signs and Symptoms of Delirium (from CAM©).
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.
A. Acute Onset Mental Status Change.
Is there evidence of an acute change in mental status from the resident's baseline?
0. No.
1. Yes.
Enter Code
Coding:
0. Behavior not present .
1. Behavior continuously
present, does not
fluctuate.
2. Behavior present,
fluctuates (comes and
goes, changes in severity).
Enter Codes in Boxes.
B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or
having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by
any of the following criteria?
￭ vigilant - startled easily to any sound or touch.
￭ lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch.
￭ stuporous - very difficult to arouse and keep aroused for the interview.
￭ comatose - could not be aroused.
Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.
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Resident Identifier Date
Section D. Mood.
D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.
0. No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV).
1. Yes Continue to D0200, Resident Mood Interview (PHQ-9©).
Enter Code
D0200. Resident Mood Interview (PHQ-9©).
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
9. No response (leave column 2
blank).
2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).
1.
Symptom
Presence.
2.
Symptom
Frequency.
Enter Scores in Boxes
A. Little interest or pleasure in doing things.
B. Feeling down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family
down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people could have noticed. Or the opposite -
being so fidgety or restless that you have been moving around a lot more than usual.
I. Thoughts that you would be better off dead, or of hurting yourself in some way.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).
Enter Score
D0300. Total Severity Score.
D0350. Safety Notification - Complete only if D0200I1 = 1 indicating possibility of resident self harm.
Was responsible staff or provider informed that there is a potential for resident self harm?
0. No.
1. Yes.
Enter Code
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
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Resident Identifier Date
Section D. Mood.
D0500. Staff Assessment of Resident Mood (PHQ-9-OV*).
Do not conduct if Resident Mood Interview (D0200-D0300) was completed.
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).
1.
Symptom
Presence.
2.
Symptom
Frequency.
Enter Scores in Boxes
A. Little interest or pleasure in doing things.
B. Feeling or appearing down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety
or restless that s/he has been moving around a lot more than usual.
I. States that life isn't worth living, wishes for death, or attempts to harm self.
J. Being short-tempered, easily annoyed.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.
Enter Score
D0600. Total Severity Score.
D0650. Safety Notification - Complete only if D0500I1 = 1 indicating possibility of resident self harm.
Was responsible staff or provider informed that there is a potential for resident self harm?
0. No.
1. Yes.
Enter Code
* Copyright © Pfizer Inc. All rights reserved.
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Resident Identifier Date
Section E. Behavior.
E0100. Potential Indicators of Psychosis.
Check all that apply
A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Z. None of the above.
Behavioral Symptoms.
E0200. Behavioral Symptom - Presence & Frequency.
Note presence of symptoms and their frequency.
Coding:
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days,
but less than daily.
3. Behavior of this type occurred daily.
Enter Codes in Boxes.
A. Physical behavioral symptoms directed toward others (e.g., hitting,
kicking, pushing, scratching, grabbing, abusing others sexually).
B. Verbal behavioral symptoms directed toward others (e.g., threatening
others, screaming at others, cursing at others).
C. Other behavioral symptoms not directed toward others (e.g., physical
symptoms such as hitting or scratching self, pacing, rummaging, public
sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, disruptive sounds).
E0300. Overall Presence of Behavioral Symptoms.
Were any behavioral symptoms in questions E0200 coded 1, 2, or 3?
0. No Skip to E0800, Rejection of Care.
1. Yes Considering all of E0200, Behavioral Symptoms, answer E0500 and E0600 below.
Enter Code
E0500. Impact on Resident.
Did any of the identified symptom(s):
A. Put the resident at significant risk for physical illness or injury?
0. No...
1. Yes.
Enter Code
B. Significantly interfere with the resident's care?
0. No...
1. Yes.
Enter Code
C. Significantly interfere with the resident's participation in activities or social interactions?
0. No...
1. Yes.
Enter Code
E0600. Impact on Others.
Did any of the identified symptom(s):
A. Put others at significant risk for physical injury?
0. No...
1. Yes.
Enter Code
B. Significantly intrude on the privacy or activity of others?
0. No...
1. Yes.
Enter Code
C. Significantly disrupt care or living environment?
0. No...
1. Yes.
Enter Code
E0800. Rejection of Care - Presence & Frequency.
Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.
Enter Code
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Resident Identifier Date
Section E. Behavior.
E0900. Wandering - Presence & Frequency.
Has the resident wandered?
0. Behavior not exhibited
Skip to E1100, Change in Behavioral or Other Symptoms.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.
Enter Code
E1000. Wandering - Impact.
A. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the
facility)?
0. No...
1. Yes.
Enter Code
B. Does the wandering significantly intrude on the privacy or activities of others?
0. No...
1. Yes.
Enter Code
E1100. Change in Behavior or Other Symptoms.
Consider all of the symptoms assessed in items E0100 through E1000.
How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or Scheduled PPS)?
0. Same.
1. Improved.
2. Worse.
3. N/A because no prior MDS assessment.
Enter Code
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Resident Identifier Date
Section F. Preferences for Customary Routine and Activities.
F0300. Should Interview for Daily and Activity Preferences be Conducted? - Attempt to interview all residents able to communicate.
If resident is unable to complete, attempt to complete interview with family member or significant other.
0. No (resident is rarely/never understood and family/significant other not available) Skip to and complete F0800, Staff
Assessment of Daily and Activity Preferences.
1. Yes Continue to F0400, Interview for Daily Preferences.
Enter Code
F0400. Interview for Daily Preferences.
Show resident the response options and say: "While you are in this facility..."
Enter Codes in Boxes.
Coding:
1. Very important.
2. Somewhat important.
3. Not very important.
4. Not important at all.
5. Important, but can't do or no
choice.
9. No response or non-responsive.
A. how important is it to you to choose what clothes to wear?
B. how important is it to you to take care of your personal belongings or things?
C. how important is it to you to choose between a tub bath, shower, bed bath, or
sponge bath?
D. how important is it to you to have snacks available between meals?
E. how important is it to you to choose your own bedtime?
F. how important is it to you to have your family or a close friend involved in
discussions about your care?
G. how important is it to you to be able to use the phone in private?
H. how important is it to you to have a place to lock your things to keep them safe?
F0500. Interview for Activity Preferences.
Show resident the response options and say: "While you are in this facility..."
Enter Codes in Boxes
Coding:
1. Very important.
2. Somewhat important.
3. Not very important.
4. Not important at all.
5. Important, but can't do or no
choice.
9. No response or non-responsive.
A. how important is it to you to have books, newspapers, and magazines to read?
B. how important is it to you to listen to music you like?
C. how important is it to you to be around animals such as pets?
D. how important is it to you to keep up with the news?
E. how important is it to you to do things with groups of people?
F. how important is it to you to do your favorite activities?
G. how important is it to you to go outside to get fresh air when the weather is good?
H. how important is it to you to participate in religious services or practices?
F0600. Daily and Activity Preferences Primary Respondent.
Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500).
1. Resident.
2. Family or significant other (close friend or other representative).
9. Interview could not be completed by resident or family/significant other ("No response" to 3 or more items").
Enter Code
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Resident Identifier Date
Section F. Preferences for Customary Routine and Activities.
F0700. Should the Staff Assessment of Daily and Activity Preferences be Conducted?
0. No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant
other) Skip to and complete G0110, Activities of Daily Living (ADL) Assistance.
1. Yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident
or family/significant other) Continue to F0800, Staff Assessment of Daily and Activity Preferences.
Enter Code
F0800. Staff Assessment of Daily and Activity Preferences.
Do not conduct if Interview for Daily and Activity Preferences (F0400-F0500) was completed.
Resident Prefers:
Check all that apply.
A. Choosing clothes to wear.
B. Caring for personal belongings.
C. Receiving tub bath.
D. Receiving shower.
E. Receiving bed bath.
F. Receiving sponge bath.
G. Snacks between meals.
H. Staying up past 8:00 p.m.
I. Family or significant other involvement in care discussions.
J. Use of phone in private.
K. Place to lock personal belongings.
L. Reading books, newspapers, or magazines.
M. Listening to music.
N. Being around animals such as pets.
O. Keeping up with the news.
P. Doing things with groups of people.
Q. Participating in favorite activities.
R. Spending time away from the nursing home.
S. Spending time outdoors.
T. Participating in religious activities or practices.
Z. None of the above.
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Resident Identifier Date
Section G. Functional Status.
G0110. Activities of Daily Living (ADL) Assistance.
Refer to the ADL flow chart in the RAI manual to facilitate accurate coding.
1. ADL Self-Performance.
Code for resident's performance over all shifts - not including setup. If the ADL activity
occurred 3 or more times at various levels of assistance, code the most dependent - except for
total dependence, which requires full staff performance every time.
Coding:
Activity Occurred 3 or More Times.
0. Independent - no help or staff oversight at any time.
1. Supervision - oversight, encouragement or cueing.
2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering
of limbs or other non-weight-bearing assistance.
3. Extensive assistance - resident involved in activity, staff provide weight-bearing support.
4. Total dependence - full staff performance every time during entire 7-day period.
Activity Occurred 2 or Fewer Times.
7. Activity occurred only once or twice - activity did occur but only once or twice.
8. Activity did not occur - activity did not occur or family and/or non-facility staff provided
care 100% of the time for that activity over the entire 7-day period.
2. ADL Support Provided.
Code for most support provided over all
shifts; code regardless of resident's self-
performance classification.
Coding:
0. No setup or physical help from staff.
1. Setup help only.
2. One person physical assist.
3. Two+ persons physical assist.
8. ADL activity itself did not occur or family
and/or non-facility staff provided care
100% of the time for that activity over the
entire 7-day period.
1.
Self-Performance.
2.
Support.
Enter Codes in Boxes
A. Bed mobility - how resident moves to and from lying position, turns side to side, and
positions body while in bed or alternate sleep furniture.
B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair,
standing position (excludes to/from bath/toilet).
C. Walk in room - how resident walks between locations in his/her room.
D. Walk in corridor - how resident walks in corridor on unit.
E. Locomotion on unit - how resident moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair.
F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas
set aside for dining, activities or treatments). If facility has only one floor, how resident
moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair.
G. Dressing - how resident puts on, fastens and takes off all items of clothing, including
donning/removing a prosthesis or TED hose. Dressing includes putting on and changing
pajamas and housedresses.
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking
during medication pass. Includes intake of nourishment by other means (e.g., tube feeding,
total parenteral nutrition, IV fluids administered for nutrition or hydration).
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts
clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or
ostomy bag.
J. Personal hygiene - how resident maintains personal hygiene, including combing hair,
brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths
and showers).
Instructions for Rule of 3
￭ When an activity occurs three times at any one given level, code that level.
￭ When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist
every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited
assistance (2), code extensive assistance (3).
￭ When an activity occurs at various levels, but not three times at any given level, apply the following:
￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance.
￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).
If none of the above are met, code supervision.
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Resident Identifier Date
Section G. Functional Status.
G0120. Bathing.
How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most
dependent in self-performance and support.
A. Self-performance.
0. Independent - no help provided.
1. Supervision - oversight help only.
2. Physical help limited to transfer only.
3. Physical help in part of bathing activity.
4. Total dependence.
8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire
7-day period
Enter Code
B. Support provided.
(Bathing support codes are as defined in item G0110 column 2, ADL Support Provided, above).
Enter Code
G0300. Balance During Transitions and Walking.
After observing the resident, code the following walking and transition items for most dependent.
Coding:
0. Steady at all times.
1. Not steady, but able to stabilize without staff
assistance.
2. Not steady, only able to stabilize with staff
assistance.
8. Activity did not occur.
Enter Codes in Boxes.
A. Moving from seated to standing position.
B. Walking (with assistive device if used).
C. Turning around and facing the opposite direction while walking.
D. Moving on and off toilet.
E. Surface-to-surface transfer (transfer between bed and chair or
wheelchair).
G0400. Functional Limitation in Range of Motion.
Code for limitation that interfered with daily functions or placed resident at risk of injury.
Coding:
0. No impairment.
1. Impairment on one side.
2. Impairment on both sides.
Enter Codes in Boxes.
A. Upper extremity (shoulder, elbow, wrist, hand).
B. Lower extremity (hip, knee, ankle, foot).
G0600. Mobility Devices.
Check all that were normally used.
A. Cane/crutch.
B. Walker.
C. Wheelchair (manual or electric).
D. Limb prosthesis.
Z. None of the above were used.
G0900. Functional Rehabilitation Potential.
Complete only if A0310A = 01.
Enter Code
A. Resident believes he or she is capable of increased independence in at least some ADLs.
0. No...
1. Yes.
9. Unable to determine.
Enter Code
B. Direct care staff believe resident is capable of increased independence in at least some ADLs.
0. No...
1. Yes.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Coding:
3. Independent - Resident completed the
activities by him/herself, with or without an
assistive device, with no assistance from a
helper.
2. Needed Some Help - Resident needed partial
assistance from another person to complete
activities.
1. Dependent - A helper completed the activities
for the resident.
8. Unknown.
9. Not Applicable.
Enter Codes in Boxes.
A. Self-Care: Code the resident's need for assistance with bathing, dressing, using
the toilet, or eating prior to the current illness, exacerbation, or injury.
B. Indoor Mobility (Ambulation): Code the resident's need for assistance with
walking from room to room (with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or injury..
C. Stairs: Code the resident's need for assistance with internal or external stairs (with
or without a device such as cane, crutch, or walker) prior to the current illness,
exacerbation, or injury. .
D. Functional Cognition: Code the resident's need for assistance with planning
regular tasks, such as shopping or remembering to take medication prior to the
current illness, exacerbation, or injury.
GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair .
B. Motorized wheelchair and/or scooter .
C. Mechanical lift.
D. Walker.
E. Orthotics/Prosthetics.
Z. None of the above.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid
once the meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is
appropriate for safe mobility; including fasteners, if applicable.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the
bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with
feet flat on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) - Continued
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or
outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon,
from the floor.
Q1. Does the resident use a wheelchair and/or scooter?
0. No Skip to H0100, Appliances.
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns.
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make
two turns..
RR1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for
safe mobility; including fasteners, if applicable.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on
the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/
close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as
turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the
floor.
Q3. Does the resident use a wheelchair and/or scooter?
0. No Skip to H0100, Appliances
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns..
RR3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
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Resident Identifier Date
Section H. Bladder and Bowel.
H0100. Appliances.
Check all that apply.
A. Indwelling catheter (including suprapubic catheter and nephrostomy tube).
B. External catheter.
C. Ostomy (including urostomy, ileostomy, and colostomy).
D. Intermittent catheterization.
Z. None of the above.
H0200. Urinary Toileting Program.
A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on
admission/entry or reentry or since urinary incontinence was noted in this facility?
0. No Skip to H0300, Urinary Continence.
1. Yes Continue to H0200B, Response.
9. Unable to determine Skip to H0200C, Current toileting program or trial.
Enter Code
B. Response - What was the resident's response to the trial program?
0. No improvement.
1. Decreased wetness.
2. Completely dry (continent).
9. Unable to determine or trial in progress.
Enter Code
C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No...
1. Yes.
Enter Code
H0300. Urinary Continence.
Urinary continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (less than 7 episodes of incontinence).
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).
3. Always incontinent (no episodes of continent voiding).
9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.
Enter Code
H0400. Bowel Continence.
Bowel continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (one episode of bowel incontinence).
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement).
3. Always incontinent (no episodes of continent bowel movements).
9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.
Enter Code
H0500. Bowel Toileting Program.
Is a toileting program currently being used to manage the resident's bowel continence?
0. No...
1. Yes.
Enter Code
H0600. Bowel Patterns.
Constipation present?
0. No...
1. Yes.
Enter Code
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Resident Identifier Date
Section I. Active Diagnoses.
I0020. Indicate the resident’s primary medical condition category.
01. Stroke.
02. Non-Traumatic Brain Dysfunction.
03. Traumatic Brain Dysfunction.
04. Non-Traumatic Spinal Cord Dysfunction.
05. Traumatic Spinal Cord Dysfunction.
06. Progressive Neurological Conditions.
07. Other Neurological Conditions.
08. Amputation
09. Hip and Knee Replacement.
10. Fractures and Other Multiple Trauma.
11. Other Orthopedic Conditions.
12. Debility, Cardiorespiratory Conditions.
13. Medically Complex Conditions.
14. Other Medical Condition If “Other Medical Condition,” enter the ICD code in the boxes.
I0020A.
Indicate the resident's primary medical condition category that best describes the primary reason for admission
Complete only if A0310B = 01.
Enter Code
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Resident Identifier Date
Section I. Active Diagnoses.
Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Cancer.
I0100. Cancer (with or without metastasis).
Heart/Circulation.
I0200. Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell).
I0300. Atrial Fibrillation or Other Dysrhythmias (e.g., bradycardias and tachycardias).
I0400. Coronary Artery Disease (CAD) (e.g., angina, myocardial infarction, and atherosclerotic heart disease (ASHD)).
I0500. Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), or Pulmonary Thrombo-Embolism (PTE).
I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema).
I0700. Hypertension.
I0800. Orthostatic Hypotension.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Gastrointestinal.
I1100. Cirrhosis.
I1200. Gastroesophageal Reflux Disease (GERD) or Ulcer (e.g., esophageal, gastric, and peptic ulcers).
I1300. Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease.
Genitourinary.
I1400. Benign Prostatic Hyperplasia (BPH).
I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD).
I1550. Neurogenic Bladder.
I1650. Obstructive Uropathy.
Infections.
I1700. Multidrug-Resistant Organism (MDRO).
I2000. Pneumonia.
I2100. Septicemia.
I2200. Tuberculosis.
I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS).
I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E).
I2500. Wound Infection (other than foot).
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
I3100. Hyponatremia.
I3200. Hyperkalemia.
I3300. Hyperlipidemia (e.g., hypercholesterolemia).
I3400. Thyroid Disorder (e.g., hypothyroidism, hyperthyroidism, and Hashimoto's thyroiditis).
Musculoskeletal.
I3700. Arthritis (e.g., degenerative joint disease (DJD), osteoarthritis, and rheumatoid arthritis (RA)).
I3800. Osteoporosis.
I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and
fractures of the trochanter and femoral neck).
I4000. Other Fracture.
Neurological.
I4200. Alzheimer's Disease.
I4300. Aphasia.
I4400. Cerebral Palsy.
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke.
I4800. Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia
such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases).
Neurological Diagnoses continued on next page.
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Resident Identifier Date
Section I. Active Diagnoses.
Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Neurological - Continued.
I4900. Hemiplegia or Hemiparesis.
I5000. Paraplegia.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5250. Huntington's Disease.
I5300. Parkinson's Disease.
I5350. Tourette's Syndrome.
I5400. Seizure Disorder or Epilepsy.
I5500. Traumatic Brain Injury (TBI).
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.
Psychiatric/Mood Disorder.
I5700. Anxiety Disorder.
I5800. Depression (other than bipolar).
I5900. Manic Depression (bipolar disease).
I5950. Psychotic Disorder (other than schizophrenia).
I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders).
I6100. Post Traumatic Stress Disorder (PTSD).
Pulmonary.
I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis).
I6300. Respiratory Failure
Vision.
I6500. Cataracts, Glaucoma, or Macular Degeneration.
None of Above.
I7900. None of the above active diagnoses within the last 7 days.
Other.
I8000. Additional active diagnoses.
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
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Resident Identifier Date
Section J. Health Conditions.
J0100. Pain Management - Complete for all residents, regardless of current pain level.
At any time in the last 5 days, has the resident:
A. Received scheduled pain medication regimen?
0. No.
1. Yes.
Enter Code
B. Received PRN pain medications OR was offered and declined?
0. No.
1. Yes.
Enter Code
C. Received non-medication intervention for pain?
0. No.
1. Yes.
Enter Code
J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea).
0. No (resident is rarely/never understood) Skip to and complete J0800, Indicators of Pain or Possible Pain.
1. Yes Continue to J0300, Pain Presence.
Enter Code
Pain Assessment Interview.
J0300. Pain Presence.
Ask resident: "Have you had pain or hurting at any time in the last 5 days?"
0. No Skip to J1100, Shortness of Breath.
1. Yes Continue to J0400, Pain Frequency.
9. Unable to answer Skip to J0800, Indicators of Pain or Possible Pain.
Enter Code
J0400. Pain Frequency.
Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"
1. Almost constantly.
2. Frequently.
3. Occasionally.
4. Rarely.
9. Unable to answer.
Enter Code
J0500. Pain Effect on Function.
A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"
0. No.
1. Yes.
9. Unable to answer.
Enter Code
B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?"
0. No.
1. Yes.
9. Unable to answer.
Enter Code
J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B).
A. Numeric Rating Scale (00-10).
Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten
as the worst pain you can imagine." (Show resident 00 -10 pain scale)
Enter two-digit response. Enter 99 if unable to answer.
Enter Rating
B. Verbal Descriptor Scale.
Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)
1. Mild.
2. Moderate.
3. Severe.
4. Very severe, horrible.
9. Unable to answer.
Enter Code
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Resident Identifier Date
Section J. Health Conditions.
J0700. Should the Staff Assessment for Pain be Conducted?
0. No (J0400 = 1 thru 4) Skip to J1100, Shortness of Breath (dyspnea).
1. Yes (J0400 = 9) Continue to J0800, Indicators of Pain or Possible Pain.
Enter Code
Staff Assessment for Pain.
J0800. Indicators of Pain or Possible Pain in the last 5 days.
Check all that apply.
A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning).
B. Vocal complaints of pain (e.g., that hurts, ouch, stop).
C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw).
D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a
body part during movement).
Z. None of these signs observed or documented If checked, skip to J1100, Shortness of Breath (dyspnea).
J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days.
Frequency with which resident complains or shows evidence of pain or possible pain.
1. Indicators of pain or possible pain observed 1 to 2 days.
2. Indicators of pain or possible pain observed 3 to 4 days.
3. Indicators of pain or possible pain observed daily.
Enter Code
Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
B. Shortness of breath or trouble breathing when sitting at rest.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.
J1300. Current Tobacco Use.
Tobacco use.
0. No.
1. Yes.
Enter Code
J1400. Prognosis.
Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician
documentation).
0. No.
1. Yes.
Enter Code
J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.
C. Dehydrated.
D. Internal bleeding.
Z. None of the above.
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Resident Identifier Date
Section J. Health Conditions.
J1700. Fall History on Admission/Entry or Reentry.
Complete only if A0310A = 01 or A0310E = 1
A. Did the resident have a fall any time in the last month prior to admission/entry or reentry?
0. No.
1. Yes.
9. Unable to determine.
Enter Code
B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
Enter Code
C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
Enter Code
J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more
recent?
0. No Skip to K0100, Swallowing Disorder.
1. Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).
Enter Code
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Coding:
0. None
1. One
2. Two or more
Enter Codes in Boxes
A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the resident; no change in the resident's
behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.
Did the resident have major surgery during the 100 days prior to admission?
0. No.
1. Yes.
8. Unknown.
J2000. Prior Surgery.
Enter Code
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Resident Identifier Date
Section K. Swallowing/Nutritional Status.
K0100. Swallowing Disorder.
Signs and symptoms of possible swallowing disorder.
Check all that apply.
A. Loss of liquids/solids from mouth when eating or drinking.
B. Holding food in mouth/cheeks or residual food in mouth after meals.
C. Coughing or choking during meals or when swallowing medications.
D. Complaints of difficulty or pain with swallowing.
Z. None of the above.
K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry.
inches
B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).
pounds
K0300. Weight Loss.
Loss of 5% or more in the last month or loss of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-loss regimen.
2. Yes, not on physician-prescribed weight-loss regimen.
Enter Code
K0310. Weight Gain.
Gain of 5% or more in the last month or gain of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-gain regimen.
2. Yes, not on physician-prescribed weight-gain regimen.
Enter Code
K0510. Nutritional Approaches.
Check all of the following nutritional approaches that were performed during the last 7 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
1.
While NOT a
Resident.
2.
While a
Resident.
Check all that apply
A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids).
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) .
Z. None of the above.
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Resident Identifier Date
Section K. Swallowing/Nutritional Status.
Section L. Oral/Dental Status.
L0200. Dental
Check all that apply.
A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).
B. No natural teeth or tooth fragment(s) (edentulous).
C. Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn).
D. Obvious or likely cavity or broken natural teeth.
E. Inflamed or bleeding gums or loose natural teeth.
F. Mouth or facial pain, discomfort or difficulty with chewing.
G. Unable to examine.
Z. None of the above were present.
K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only enter a
code in column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If
resident last entered 7 or more days ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
3. During Entire 7 Days.
Performed during the entire last 7 days.
1.
While NOT a
Resident.
2.
While a
Resident.
3.
During Entire
7 Days.
Enter Codes
A. Proportion of total calories the resident received through parenteral or tube feeding.
1. 25% or less.
2. 26-50%.
3. 51% or more.
B. Average fluid intake per day by IV or tube feeding.
1. 500 cc/day or less.
2. 501 cc/day or more.
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Resident Identifier Date
Section M. Skin Conditions.
Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.
M0100. Determination of Pressure Ulcer/Injury Risk.
Check all that apply.
A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.
B. Formal assessment instrument/tool (e.g., Braden, Norton, or other).
C. Clinical assessment.
Z. None of the above.
M0150. Risk of Pressure Ulcers/Injuries.
Is this resident at risk of developing pressure ulcers/injuries?
0. No.
1. Yes.
Enter Code
M0210. Unhealed Pressure Ulcers/Injuries.
Does this resident have one or more unhealed pressure ulcers/injuries?
0. No Skip to M1030, Number of Venous and Arterial Ulcers.
1. Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Enter Code
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
Enter Number
1. Number of Stage 1 pressure injuries.
B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0 Skip to M0300C, Stage 3.
Enter Number
2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry.
Enter Number
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4.
Enter Number
2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry .
Enter Number
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device.
Enter Number
2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
M0300 continued on next page.
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Resident Identifier Date
Section M. Skin Conditions.
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F,
Unstageable - Slough and/or eschar.
Enter Number
2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
were noted at the time of admission/entry or reentry.
Enter Number
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0
Skip to M0300G,
Unstageable - Deep tissue injury.
Enter Number
2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
G. Unstageable - Deep tissue injury:
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0
Skip to M1030,
Number of Venous and Arterial Ulcers.
Enter Number
2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
M1030. Number of Venous and Arterial Ulcers.
Enter the total number of venous and arterial ulcers present.
Enter Number
M1040. Other Ulcers, Wounds and Skin Problems.
Check all that apply.
Foot Problems.
A. Infection of the foot (e.g., cellulitis, purulent drainage).
B. Diabetic foot ulcer(s).
C. Other open lesion(s) on the foot.
Other Problems.
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).
E. Surgical wound(s).
F. Burn(s) (second or third degree).
G. Skin tear(s).
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage).
None of the Above.
Z. None of the above were present.
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Resident Identifier Date
Section M. Skin Conditions.
M1200. Skin and Ulcer/Injury Treatments.
Check all that apply.
A. Pressure reducing device for chair.
B. Pressure reducing device for bed.
C. Turning/repositioning program.
D. Nutrition or hydration intervention to manage skin problems.
E. Pressure ulcer/injury care.
F. Surgical wound care.
G. Application of nonsurgical dressings (with or without topical medications) other than to feet.
H. Applications of ointments/medications other than to feet.
I. Application of dressings to feet (with or without topical medications).
Z. None of the above were provided.
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Resident Identifier Date
Section N. Medications.
N0300. Injections.
Enter Days
Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less
than 7 days. If 0 Skip to N0410, Medications Received.
N0350. Insulin.
A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry
or reentry if less than 7 days.
Enter Days
B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's
insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.
Enter Days
N0410. Medications Received.
Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the
last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days.
A. Antipsychotic.
Enter Days
B. Antianxiety.
Enter Days
C. Antidepressant.
Enter Days
D. Hypnotic.
Enter Days
E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin).
Enter Days
F. Antibiotic.
Enter Days
G. Diuretic.
Enter Days
H. Opioid.
Enter Days
N0450. Antipsychotic Medication Review.
A. Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is
more recent?
0. No - Antipsychotics were not received. Skip to O0100, Special Treatments, Procedures, and Programs .
1. Yes - Antipsychotics were received on a routine basis only.. Continue to N0450B, Has a GDR been attempted?
2. Yes - Antipsychotics were received on a PRN basis only. Continue to N0450B, Has a GDR been attempted?
3. Yes - Antipsychotics were received on a routine and PRN basis.. Continue to N0450B, Has a GDR been attempted?
Enter Code
B. Has a gradual dose reduction (GDR) been attempted?
0. No Skip to N0450D, Physician documented GDR as clinically contraindicated.
1. Yes Continue to N0450C, Date of last attempted GDR.
Enter Code
C. Date of last attempted GDR:
Month
_
Day
_
Year
N0450 continued on next page
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Resident Identifier Date
Medications.Section N.
N0450. Antipsychotic Medication Review - Continued.
D. Physician documented GDR as clinically contraindicated
0. No - GDR has not been documented by a physician as clinically contraindicated Skip to O0100, Special Treatments, Procedures, .
and Programs
1. Yes - GDR has been documented by a physician as clinically contraindicated Continue to N0450E, Date physician documented .
GDR as clinically contraindicated.
Enter Code
E. Date physician documented GDR as clinically contraindicated:
Month
_
Day
_
Year
N2001. Drug Regimen Review.
Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review Skip to O0100, Special Treatments, Procedures, and Programs.
1. Yes - Issues found during review Continue to N2003, Medication Follow-up.
9. NA - Resident is not taking any medications Skip to O0100, Special Treatments, Procedures, and Programs.
Enter Code
N2003. Medication Follow-up.
Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?
0. No.
1. Yes.
Enter Code
N2005. Medication Intervention.
Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No.
1. Yes.
9. NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any
medications.
Enter Code
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.
1.
While NOT a
Resident.
2.
While a
Resident.
Check all that apply
Cancer Treatments.
A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
D. Suctioning.
E. Tracheostomy care.
F. Invasive Mechanical Ventilator (ventilator or respirator).
G. Non-Invasive Mechanical Ventilator (BiPAP/CPAP).
None of the Above.
H. IV medications.
I. Transfusions.
J. Dialysis.
K. Hospice care.
L. Respite care.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).
Other.
Z. None of the above.
O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period.
A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes Continue to O0250B, Date influenza vaccine received.
Enter Code
B. Date influenza vaccine received
Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date?
Month
_
Day
_
Year
C. If influenza vaccine not received, state reason:
1. Resident not in this facility during this year's influenza vaccination season.
2. Received outside of this facility.
3. Not eligible - medical contraindication.
4. Offered and declined.
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage.
9. None of the above.
Enter Code
O0300. Pneumococcal Vaccine.
A. Is the resident's Pneumococcal vaccination up to date?
0. No Continue to O0300B, If Pneumococcal vaccine not received, state reason.
1. Yes Skip to O0400, Therapies.
Enter Code
B. If Pneumococcal vaccine not received, state reason:
1. Not eligible - medical contraindication.
2. Offered and declined.
3. Not offered.
Enter Code
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0400. Therapies.
A. Speech-Language Pathology and Audiology Services.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400A5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
B. Occupational Therapy.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400B5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
O0400 continued on next page
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0400. Therapies - Continued.
C. Physical Therapy.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400C5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
D. Respiratory Therapy.
1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days.
If zero,
skip to O0400E, Psychological Therapy.
Enter Number of Minutes
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
E. Psychological Therapy (by any licensed mental health professional).
1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days.
If zero,
skip to O0400F, Recreational Therapy.
Enter Number of Minutes
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
F. Recreational Therapy (includes recreational and music therapy).
1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days.
If zero,
skip to O0420, Distinct Calendar Days of Therapy.
Enter Number of Minutes
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
O0420. Distinct Calendar Days of Therapy.
Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days.
Enter Number of Days
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 41 of 50
Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0450. Resumption of Therapy - Complete only if A0310C = 2 or 3 and A0310F = 99.
A. Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of
Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline?
0. No Skip to O0500, Restorative Nursing Programs.
1. Yes
Enter Code
B. Date on which therapy regimen resumed:
Month
_
Day
_
Year
O0500. Restorative Nursing Programs.
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days
(enter 0 if none or less than 15 minutes daily).
Number
of Days.
Technique.
A. Range of motion (passive).
B. Range of motion (active).
C. Splint or brace assistance.
Number
of Days.
Training and Skill Practice In:
D. Bed mobility.
E. Transfer.
F. Walking.
G. Dressing and/or grooming.
H. Eating and/or swallowing.
I. Amputation/prostheses care.
J. Communication.
O0600. Physician Examinations.
Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident?
Enter Days
O0700. Physician Orders.
Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders?
Enter Days
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 42 of 50
Resident Identifier Date
Section P. Restraints and Alarms.
P0100. Physical Restraints.
Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that
the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.
Enter Codes in Boxes.
Used in Bed.
A. Bed rail.
B. Trunk restraint.
C. Limb restraint.
D. Other.
Used in Chair or Out of Bed.
E. Trunk restraint.
F. Limb restraint.
G. Chair prevents rising.
H. Other.
P0200. Alarms.
An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.
Enter Codes in Boxes.
A. Bed alarm.
B. Chair alarm.
C. Floor mat alarm.
D. Motion sensor alarm.
E. Wander/elopement alarm
F. Other alarm.
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 43 of 50
Resident Identifier Date
Section Q. Participation in Assessment and Goal Setting.
Q0100. Participation in Assessment.
A. Resident participated in assessment.
0. No.
1. Yes.
Enter Code
B. Family or significant other participated in assessment.
0. No.
1. Yes.
9. Resident has no family or significant other.
Enter Code
C. Guardian or legally authorized representative participated in assessment.
0. No.
1. Yes.
9. Resident has no guardian or legally authorized representative.
Enter Code
Q0300. Resident's Overall Expectation.
Complete only if A0310E = 1.
A. Select one for resident's overall goal established during assessment process.
1. Expects to be discharged to the community.
2. Expects to remain in this facility.
3. Expects to be discharged to another facility/institution.
9. Unknown or uncertain.
Enter Code
B. Indicate information source for Q0300A.
1. Resident.
2. If not resident, then family or significant other.
3. If not resident, family, or significant other, then guardian or legally authorized representative.
9. Unknown or uncertain.
Enter Code
Q0400. Discharge Plan.
A. Is active discharge planning already occurring for the resident to return to the community?
0. No.
1. Yes Skip to Q0600, Referral.
Enter Code
Q0490. Resident's Preference to Avoid Being Asked Question Q0500B.
Complete only if A0310A = 02, 06, or 99.
Enter Code
Does the resident's clinical record document a request that this question be asked only on comprehensive assessments?
0. No.
1. Yes Skip to Q0600, Referral.
Q0500. Return to Community.
B. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond):
"Do you want to talk to someone about the possibility of leaving this facility and returning to live and
receive services in the community?"
0. No.
1. Yes.
9. Unknown or uncertain.
Enter Code
Q0550. Resident's Preference to Avoid Being Asked Question Q0500B Again.
A. Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive
assessments.)
0. No - then document in resident's clinical record and ask again only on the next comprehensive assessment...
1. Yes.
8. Information not available.
Enter Code
B. Indicate information source for Q0550A.
1. Resident...
2. If not resident, then family or significant other.
3. If not resident, family or significant other, then guardian or legally authorized representative.
9. None of the above.
Enter Code
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 44 of 50
Resident Identifier Date
Section Q. Participation in Assessment and Goal Setting.
Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record).
0. No - referral not needed.
1. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20).
2. Yes - referral made.
Q0600. Referral.
Enter Code
Section V. Care Area Assessment (CAA) Summary.
V0100. Items From the Most Recent Prior OBRA or Scheduled PPS Assessment.
Complete only if A0310E = 0 and if the following is true for the prior assessment: A0310A = 01- 06 or A0310B = 01- 05
A. Prior Assessment Federal OBRA Reason for Assessment (A0310A value from prior assessment).
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. Prior Assessment PPS Reason for Assessment (A0310B value from prior assessment).
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
99. None of the above.
Enter Code
C. Prior Assessment Reference Date (A2300 value from prior assessment).
Month
_
Day
_
Year
D. Prior Assessment Brief Interview for Mental Status (BIMS) Summary Score (C0500 value from prior assessment).
Enter Score
E. Prior Assessment Resident Mood Interview (PHQ-9©) Total Severity Score (D0300 value from prior assessment).
Enter Score
F. Prior Assessment Staff Assessment of Resident Mood (PHQ-9-OV) Total Severity Score (D0600 value from prior assessment).
Enter Score
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Resident Identifier Date
Section V. Care Area Assessment (CAA) Summary.
V0200. CAAs and Care Planning.
1. Check column A if Care Area is triggered.
2. For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address
the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of
completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan.
3. Indicate in the Location and Date of CAA Documentation column where information related to the CAA can be found. CAA documentation
should include information on the complicating factors, risks, and any referrals for this resident for this care area.
A. CAA Results.
Care Area.
A.
Care Area
Triggered.
B.
Care Planning
Decision.
Location and Date of
CAA documentation.
Check all that apply
01. Delirium.
02. Cognitive Loss/Dementia.
03. Visual Function.
04. Communication.
05. ADL Functional/Rehabilitation Potential.
06. Urinary Incontinence and Indwelling
Catheter.
07. Psychosocial Well-Being.
08. Mood State.
09. Behavioral Symptoms.
10. Activities.
11. Falls.
12. Nutritional Status.
13. Feeding Tube.
14. Dehydration/Fluid Maintenance.
15. Dental Care.
16. Pressure Ulcer.
17. Psychotropic Drug Use.
18. Physical Restraints.
19. Pain.
20. Return to Community Referral.
B. Signature of RN Coordinator for CAA Process and Date Signed.
1. Signature.
2. Date.
Month
_
Day
_
Year
C. Signature of Person Completing Care Plan Decision and Date Signed.
1. Signature.
2. Date.
Month
_
Day
_
Year
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 46 of 50
Resident Identifier Date
Section X. Correction Request.
Complete Section X only if A0050 = 2 or 3.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated).
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
X0200. Name of Resident (A0500 on existing record to be modified/inactivated).
A. First name:
C. Last name:
X0300. Gender (A0800 on existing record to be modified/inactivated).
1. Male
2. Female
Enter Code
X0400. Birth Date (A0900 on existing record to be modified/inactivated).
Month
_
Day
_
Year
X0500. Social Security Number (A0600A on existing record to be modified/inactivated).
_ _
X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).
A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
X0600 continued on next page.
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 47 of 50
Resident Identifier Date
Section X. Correction Request.
X0600. Type of Assessment.- Continued.
D. Is this a Swing Bed clinical change assessment? Complete only if X0150 = 2.
0. No.
1. Yes.
Enter Code
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
X0700. Date on existing record to be modified/inactivated - Complete one only.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99.
Month
_
Day
_
Year
B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12.
Month
_
Day
_
Year
C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01.
Month
_
Day
_
Year
Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter the number of correction requests to modify/inactivate the existing record, including the present one.
Enter Number
X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
E. End of Therapy - Resumption (EOT-R) date.
Z. Other error requiring modification.
If "Other" checked, please specify:
X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:
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Resident Identifier Date
Section X. Correction Request.
X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:
B. Attesting individual's last name:
C. Attesting individual's title:
D. Signature.
E. Attestation date.
Month
_
Day
_
Year
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Resident Identifier Date
Section Z. Assessment Administration.
Z0100. Medicare Part A Billing.
A. Medicare Part A HIPPS code (RUG group followed by assessment type indicator):
B. RUG version code:
C. Is this a Medicare Short Stay assessment?
0. No.
1. Yes
Enter Code
Z0150. Medicare Part A Non-Therapy Billing.
A. Medicare Part A non-therapy HIPPS code (RUG group followed by assessment type indicator):
B. RUG version code:
Z0200. State Medicaid Billing (if required by the state).
A. RUG Case Mix group:
B. RUG version code:
Z0250. Alternate State Medicaid Billing (if required by the state).
A. RUG Case Mix group:
B. RUG version code:
Z0300. Insurance Billing.
A. RUG billing code:
B. RUG billing version:
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 50 of 50
Resident Identifier Date
Section Z. Assessment Administration.
Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Signature Title Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:
B. Date RN Assessment Coordinator signed
assessment as complete:
Month
_
Day
_
Year
Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the
copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted
permission to use these instruments in association with the MDS 3.0.
MDS 3.0 Nursing Home PPS (NP) Version 1.16.0 Effective 10/01/2018 DRAFT Page 1 of 42
Resident Identifier Date
Section A. Identification Information.
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home PPS (NP) Item Set
A0050. Type of Record.
1. Add new record Continue to A0100, Facility Provider Numbers.
2. Modify existing record Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record Skip to X0150, Type of Provider.
Enter Code
A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
C. State Provider Number:
A0200. Type of Provider.
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
A0310. Type of Assessment.
A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.
0. No.
1. Yes.
Enter Code
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
Enter Code
A0310 continued on next page.
MDS 3.0 Nursing Home PPS (NP) Version 1.16.0 Effective 10/01/2018 DRAFT Page 2 of 42
Resident Identifier Date
Section A. Identification Information.
A0310. Type of Assessment - Continued.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
G. Type of discharge. - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
A0410. Unit Certification or Licensure Designation.
1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.
Enter Code
A0500. Legal Name of Resident.
A. First name: B. Middle initial:
C. Last name: D. Suffix:
A0600. Social Security and Medicare Numbers.
A. Social Security Number:
_ _
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.
A0800. Gender.
1. Male.
2. Female.
Enter Code
A0900. Birth Date.
Month
_
Day
_
Year
A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.
MDS 3.0 Nursing Home PPS (NP) Version 1.16.0 Effective 10/01/2018 DRAFT Page 3 of 42
Resident Identifier Date
Section A. Identification Information.
A1100. Language.
A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No Skip to A1200, Marital Status.
1. Yes Specify in A1100B, Preferred language.
9. Unable to determine. Skip to A1200, Marital Status.
Enter Code
B. Preferred language:
A1200. Marital Status.
1. Never married.
2. Married.
3. Widowed.
4. Separated.
5. Divorced.
Enter Code
A1300. Optional Resident Items.
A. Medical record number:
B. Room number:
C. Name by which resident prefers to be addressed:
D. Lifetime occupation(s) - put "/" between two occupations:
Most Recent Admission/Entry or Reentry into this Facility.
A1600. Entry Date.
Month
_
Day
_
Year
A1700. Type of Entry.
1. Admission.
2. Reentry.
Enter Code
A1800. Entered From.
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A1900. Admission Date (Date this episode of care in this facility began).
Month
_
Day
_
Year
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Resident Identifier Date
Section A. Identification Information.
A2000. Discharge Date.
Complete only if A0310F = 10, 11, or 12.
Month
_
Day
_
Year
A2100. Discharge Status.
Complete only if A0310F = 10, 11, or 12.
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
08. Deceased.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A2200. Previous Assessment Reference Date for Significant Correction.
Complete only if A0310A = 05 or 06.
Month
_
Day
_
Year
A2300. Assessment Reference Date.
Observation end date:
Month
_
Day
_
Year
A2400. Medicare Stay.
A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No Skip to B0100, Comatose.
1. Yes Continue to A2400B, Start date of most recent Medicare stay.
Enter Code
B. Start date of most recent Medicare stay:
Month
_
Day
_
Year
C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:
Month
_
Day
_
Year
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Resident Identifier Date
Look back period for all items is 7 days unless another time frame is indicated.
Section B. Hearing, Speech, and Vision.
B0100. Comatose.
Persistent vegetative state/no discernible consciousness.
0. No Continue to B0200, Hearing.
1. Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.
Enter Code
B0200. Hearing.
Ability to hear (with hearing aid or hearing appliances if normally used).
0. Adequate - no difficulty in normal conversation, social interaction, listening to TV.
1. Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy).
2. Moderate difficulty - speaker has to increase volume and speak distinctly.
3. Highly impaired - absence of useful hearing.
Enter Code
B0300. Hearing Aid.
Hearing aid or other hearing appliance used in completing B0200, Hearing.
0. No.
1. Yes.
Enter Code
B0600. Speech Clarity.
Select best description of speech pattern.
0. Clear speech - distinct intelligible words.
1. Unclear speech - slurred or mumbled words.
2. No speech - absence of spoken words.
Enter Code
B0700. Makes Self Understood.
Ability to express ideas and wants, consider both verbal and non-verbal expression.
0. Understood.
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.
2. Sometimes understood - ability is limited to making concrete requests.
3. Rarely/never understood.
Enter Code
B0800. Ability To Understand Others.
Understanding verbal content, however able (with hearing aid or device if used).
0. Understands - clear comprehension.
1. Usually understands - misses some part/intent of message but comprehends most conversation.
2. Sometimes understands - responds adequately to simple, direct communication only.
3. Rarely/never understands.
Enter Code
B1000. Vision.
Ability to see in adequate light (with glasses or other visual appliances).
0. Adequate - sees fine detail, such as regular print in newspapers/books.
1. Impaired - sees large print, but not regular print in newspapers/books.
2. Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects.
3. Highly impaired - object identification in question, but eyes appear to follow objects.
4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects.
Enter Code
B1200. Corrective Lenses.
Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision.
0. No.
1. Yes.
Enter Code
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Resident Identifier Date
Section C. Cognitive Patterns.
Brief Interview for Mental Status (BIMS).
C0200. Repetition of Three Words.
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt.
0. None.
1. One.
2. Two.
3. Three.
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece
of furniture"). You may repeat the words up to two more times.
Enter Code
C0300. Temporal Orientation (orientation to year, month, and day).
Ask resident: "Please tell me what year it is right now."
A. Able to report correct year.
0. Missed by > 5 years or no answer.
1. Missed by 2-5 years.
2. Missed by 1 year.
3. Correct.
Enter Code
Ask resident: "What month are we in right now?"
B. Able to report correct month.
0. Missed by > 1 month or no answer.
1. Missed by 6 days to 1 month.
2. Accurate within 5 days.
Enter Code
Ask resident: "What day of the week is today?"
C. Able to report correct day of the week.
0. Incorrect or no answer.
1. Correct.
Enter Code
C0400. Recall.
Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall "sock".
0. No - could not recall.
1. Yes, after cueing ("something to wear").
2. Yes, no cue required.
Enter Code
B. Able to recall "blue".
0. No - could not recall.
1. Yes, after cueing ("a color").
2. Yes, no cue required.
Enter Code
C. Able to recall "bed".
0. No - could not recall.
1. Yes, after cueing ("a piece of furniture").
2. Yes, no cue required.
Enter Code
C0500. BIMS Summary Score.
Add scores for questions C0200-C0400 and fill in total score (00-15).
Enter 99 if the resident was unable to complete the interview.
Enter Score
C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents.
0. No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status.
1. Yes Continue to C0200, Repetition of Three Words.
Enter Code
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Resident Identifier Date
Section C. Cognitive Patterns.
C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
0. No (resident was able to complete Brief Interview for Mental Status ) Skip to C1310, Signs and Symptoms of Delirium.
1. Yes (resident was unable to complete Brief Interview for Mental Status) Continue to C0700, Short-term Memory OK.
Enter Code
Delirium.
C1310. Signs and Symptoms of Delirium (from CAM©).
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.
A. Acute Onset Mental Status Change.
Is there evidence of an acute change in mental status from the resident's baseline?
0. No.
1. Yes.
Enter Code
Coding:
0. Behavior not present.
1. Behavior continuously
present, does not
fluctuate.
2. Behavior present,
fluctuates (comes and
goes, changes in severity).
Enter Codes in Boxes.
B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or
having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by
any of the following criteria?
￭ vigilant - startled easily to any sound or touch.
￭ lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch.
￭ stuporous - very difficult to arouse and keep aroused for the interview.
￭ comatose - could not be aroused.
Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.
Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.
C0700. Short-term Memory OK.
Seems or appears to recall after 5 minutes.
0. Memory OK.
1. Memory problem.
Enter Code
C0800. Long-term Memory OK.
Seems or appears to recall long past.
0. Memory OK.
1. Memory problem.
Enter Code
C0900. Memory/Recall Ability.
Check all that the resident was normally able to recall.
A. Current season.
B. Location of own room.
C. Staff names and faces.
D. That he or she is in a nursing home/hospital swing bed.
Z. None of the above were recalled.
C1000. Cognitive Skills for Daily Decision Making.
Made decisions regarding tasks of daily life.
0. Independent - decisions consistent/reasonable.
1. Modified independence - some difficulty in new situations only.
2. Moderately impaired - decisions poor; cues/supervision required.
3. Severely impaired - never/rarely made decisions.
Enter Code
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Resident Identifier Date
Section D. Mood.
D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.
0. No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV).
1. Yes Continue to D0200, Resident Mood Interview (PHQ-9©).
Enter Code
D0200. Resident Mood Interview (PHQ-9©).
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
9. No response (leave column 2
blank).
2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).
1.
Symptom
Presence.
2.
Symptom
Frequency.
Enter Scores in Boxes
A. Little interest or pleasure in doing things.
B. Feeling down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family
down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people could have noticed. Or the opposite -
being so fidgety or restless that you have been moving around a lot more than usual.
I. Thoughts that you would be better off dead, or of hurting yourself in some way.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).
Enter Score
D0300. Total Severity Score.
D0350. Safety Notification - Complete only if D0200I1 = 1 indicating possibility of resident self harm.
Was responsible staff or provider informed that there is a potential for resident self harm?
0. No.
1. Yes.
Enter Code
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
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Resident Identifier Date
Section D. Mood.
D0500. Staff Assessment of Resident Mood (PHQ-9-OV*).
Do not conduct if Resident Mood Interview (D0200-D0300) was completed.
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).
1.
Symptom
Presence.
2.
Symptom
Frequency.
Enter Scores in Boxes
A. Little interest or pleasure in doing things.
B. Feeling or appearing down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety
or restless that s/he has been moving around a lot more than usual.
I. States that life isn't worth living, wishes for death, or attempts to harm self.
J. Being short-tempered, easily annoyed.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.
Enter Score
D0600. Total Severity Score.
D0650. Safety Notification - Complete only if D0500I1 = 1 indicating possibility of resident self harm.
Was responsible staff or provider informed that there is a potential for resident self harm?
0. No.
1. Yes.
Enter Code
* Copyright © Pfizer Inc. All rights reserved.
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Resident Identifier Date
Section E. Behavior.
E0100. Potential Indicators of Psychosis.
Check all that apply
A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Z. None of the above.
Behavioral Symptoms.
E0200. Behavioral Symptom - Presence & Frequency.
Note presence of symptoms and their frequency.
Coding:
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days,
but less than daily.
3. Behavior of this type occurred daily.
Enter Codes in Boxes.
A. Physical behavioral symptoms directed toward others (e.g., hitting,
kicking, pushing, scratching, grabbing, abusing others sexually).
B. Verbal behavioral symptoms directed toward others (e.g., threatening
others, screaming at others, cursing at others).
C. Other behavioral symptoms not directed toward others (e.g., physical
symptoms such as hitting or scratching self, pacing, rummaging, public
sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, disruptive sounds).
E0800. Rejection of Care - Presence & Frequency.
Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.
Enter Code
E0900. Wandering - Presence & Frequency.
Has the resident wandered?
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.
Enter Code
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Resident Identifier Date
Section G. Functional Status.
G0110. Activities of Daily Living (ADL) Assistance.
Refer to the ADL flow chart in the RAI manual to facilitate accurate coding.
1. ADL Self-Performance.
Code for resident's performance over all shifts - not including setup. If the ADL activity
occurred 3 or more times at various levels of assistance, code the most dependent - except for
total dependence, which requires full staff performance every time.
Coding:
Activity Occurred 3 or More Times.
0. Independent - no help or staff oversight at any time.
1. Supervision - oversight, encouragement or cueing.
2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering
of limbs or other non-weight-bearing assistance.
3. Extensive assistance - resident involved in activity, staff provide weight-bearing support.
4. Total dependence - full staff performance every time during entire 7-day period.
Activity Occurred 2 or Fewer Times.
7. Activity occurred only once or twice - activity did occur but only once or twice.
8. Activity did not occur - activity did not occur or family and/or non-facility staff provided
care 100% of the time for that activity over the entire 7-day period.
2. ADL Support Provided.
Code for most support provided over all
shifts; code regardless of resident's self-
performance classification.
Coding:
0. No setup or physical help from staff.
1. Setup help only.
2. One person physical assist.
3. Two+ persons physical assist.
8. ADL activity itself did not occur or family
and/or non-facility staff provided care
100% of the time for that activity over the
entire 7-day period.
1.
Self-Performance.
2.
Support.
Enter Codes in Boxes
A. Bed mobility - how resident moves to and from lying position, turns side to side, and
positions body while in bed or alternate sleep furniture.
B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair,
standing position (excludes to/from bath/toilet).
C. Walk in room - how resident walks between locations in his/her room.
D. Walk in corridor - how resident walks in corridor on unit.
E. Locomotion on unit - how resident moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair.
F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas
set aside for dining, activities or treatments). If facility has only one floor, how resident
moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair.
G. Dressing - how resident puts on, fastens and takes off all items of clothing, including
donning/removing a prosthesis or TED hose. Dressing includes putting on and changing
pajamas and housedresses.
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking
during medication pass. Includes intake of nourishment by other means (e.g., tube feeding,
total parenteral nutrition, IV fluids administered for nutrition or hydration).
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts
clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or
ostomy bag.
J. Personal hygiene - how resident maintains personal hygiene, including combing hair,
brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths
and showers).
Instructions for Rule of 3
￭ When an activity occurs three times at any one given level, code that level.
￭ When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist
every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited
assistance (2), code extensive assistance (3).
￭ When an activity occurs at various levels, but not three times at any given level, apply the following:
￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance.
￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).
If none of the above are met, code supervision.
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Resident Identifier Date
Section G. Functional Status.
G0120. Bathing.
How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most
dependent in self-performance and support.
A. Self-performance.
0. Independent - no help provided.
1. Supervision - oversight help only.
2. Physical help limited to transfer only.
3. Physical help in part of bathing activity.
4. Total dependence.
8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire
7-day period.
Enter Code
B. Support provided.
(Bathing support codes are as defined in item G0110 column 2, ADL Support Provided, above).
Enter Code
G0300. Balance During Transitions and Walking.
After observing the resident, code the following walking and transition items for most dependent.
Coding:
0. Steady at all times.
1. Not steady, but able to stabilize without staff
assistance.
2. Not steady, only able to stabilize with staff
assistance.
8. Activity did not occur.
Enter Codes in Boxes.
A. Moving from seated to standing position.
B. Walking (with assistive device if used).
C. Turning around and facing the opposite direction while walking.
D. Moving on and off toilet.
E. Surface-to-surface transfer (transfer between bed and chair or
wheelchair).
G0400. Functional Limitation in Range of Motion.
Code for limitation that interfered with daily functions or placed resident at risk of injury.
Coding:
0. No impairment.
1. Impairment on one side.
2. Impairment on both sides.
Enter Codes in Boxes.
A. Upper extremity (shoulder, elbow, wrist, hand).
B. Lower extremity (hip, knee, ankle, foot).
G0600. Mobility Devices.
Check all that were normally used.
A. Cane/crutch.
B. Walker.
C. Wheelchair (manual or electric).
D. Limb prosthesis.
Z. None of the above were used.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Coding:
3. Independent - Resident completed the
activities by him/herself, with or without an
assistive device, with no assistance from a
helper.
2. Needed Some Help - Resident needed partial
assistance from another person to complete
activities.
1. Dependent - A helper completed the activities
for the resident.
8. Unknown.
9. Not Applicable.
Enter Codes in Boxes.
A. Self-Care: Code the resident's need for assistance with bathing, dressing, using
the toilet, or eating prior to the current illness, exacerbation, or injury.
B. Indoor Mobility (Ambulation): Code the resident's need for assistance with
walking from room to room (with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or injury..
C. Stairs: Code the resident's need for assistance with internal or external stairs (with
or without a device such as cane, crutch, or walker) prior to the current illness,
exacerbation, or injury. .
D. Functional Cognition: Code the resident's need for assistance with planning
regular tasks, such as shopping or remembering to take medication prior to the
current illness, exacerbation, or injury.
GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair .
B. Motorized wheelchair and/or scooter .
C. Mechanical lift.
D. Walker.
E. Orthotics/Prosthetics.
Z. None of the above.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid
once the meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is
appropriate for safe mobility; including fasteners, if applicable.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the
bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with
feet flat on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) - Continued
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or
outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon,
from the floor.
Q1. Does the resident use a wheelchair and/or scooter?
0. No Skip to H0100, Appliances.
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns.
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make
two turns..
RR1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for
safe mobility; including fasteners, if applicable.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on
the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/
close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as
turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the
floor.
Q3. Does the resident use a wheelchair and/or scooter?
0. No Skip to H0100, Appliances
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns..
RR3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
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Resident Identifier Date
Section H. Bladder and Bowel.
H0100. Appliances.
Check all that apply.
A. Indwelling catheter (including suprapubic catheter and nephrostomy tube).
B. External catheter.
C. Ostomy (including urostomy, ileostomy, and colostomy).
D. Intermittent catheterization.
Z. None of the above.
H0200. Urinary Toileting Program.
A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on
admission/entry or reentry or since urinary incontinence was noted in this facility?
0. No Skip to H0300, Urinary Continence.
1. Yes Continue to H0200C, Current toileting program or trial.
9. Unable to determine Continue to H0200C, Current toileting program or trial.
Enter Code
C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No.
1. Yes.
Enter Code
H0300. Urinary Continence.
Urinary continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (less than 7 episodes of incontinence).
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).
3. Always incontinent (no episodes of continent voiding).
9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.
Enter Code
H0400. Bowel Continence.
Bowel continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (one episode of bowel incontinence).
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement).
3. Always incontinent (no episodes of continent bowel movements).
9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.
Enter Code
H0500. Bowel Toileting Program.
Is a toileting program currently being used to manage the resident's bowel continence?
0. No.
1. Yes.
Enter Code
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Resident Identifier Date
Section I. Active Diagnoses.
I0020. Indicate the resident’s primary medical condition category.
01. Stroke.
02. Non-Traumatic Brain Dysfunction.
03. Traumatic Brain Dysfunction.
04. Non-Traumatic Spinal Cord Dysfunction.
05. Traumatic Spinal Cord Dysfunction.
06. Progressive Neurological Conditions.
07. Other Neurological Conditions.
08. Amputation
09. Hip and Knee Replacement.
10. Fractures and Other Multiple Trauma.
11. Other Orthopedic Conditions.
12. Debility, Cardiorespiratory Conditions.
13. Medically Complex Conditions.
14. Other Medical Condition If “Other Medical Condition,” enter the ICD code in the boxes.
I0020A.
Indicate the resident's primary medical condition category that best describes the primary reason for admission
Complete only if A0310B = 01.
Enter Code
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Resident Identifier Date
Section I. Active Diagnoses.
Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Heart/Circulation.
I0200. Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell).
I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema).
I0700. Hypertension.
I0800. Orthostatic Hypotension.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Genitourinary.
I1550. Neurogenic Bladder.
I1650. Obstructive Uropathy.
Infections.
I1700. Multidrug-Resistant Organism (MDRO).
I2000. Pneumonia.
I2100. Septicemia.
I2200. Tuberculosis.
I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS).
I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E).
I2500. Wound Infection (other than foot).
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
I3100. Hyponatremia.
I3200. Hyperkalemia.
I3300. Hyperlipidemia (e.g., hypercholesterolemia).
Musculoskeletal.
I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and
fractures of the trochanter and femoral neck).
I4000. Other Fracture.
Neurological.
I4200. Alzheimer's Disease.
I4300. Aphasia.
I4400. Cerebral Palsy.
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke.
I4800. Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia
such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases).
I4900. Hemiplegia or Hemiparesis.
I5000. Paraplegia.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5250. Huntington's Disease.
I5300. Parkinson's Disease.
I5350. Tourette's Syndrome.
I5400. Seizure Disorder or Epilepsy.
I5500. Traumatic Brain Injury (TBI).
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.
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Resident Identifier Date
Section I. Active Diagnoses.
Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Psychiatric/Mood Disorder.
I5700. Anxiety Disorder.
I5800. Depression (other than bipolar).
I5900. Manic Depression (bipolar disease).
I5950. Psychotic Disorder (other than schizophrenia).
I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders).
I6100. Post Traumatic Stress Disorder (PTSD).
Pulmonary.
I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis).
I6300. Respiratory Failure
Other.
I8000. Additional active diagnoses.
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
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Resident Identifier Date
Section J. Health Conditions.
J0100. Pain Management - Complete for all residents, regardless of current pain level.
At any time in the last 5 days, has the resident:
A. Received scheduled pain medication regimen?
0. No.
1. Yes.
Enter Code
B. Received PRN pain medications OR was offered and declined?
0. No.
1. Yes.
Enter Code
C. Received non-medication intervention for pain?
0. No.
1. Yes.
Enter Code
Pain Assessment Interview.
J0300. Pain Presence.
Ask resident: "Have you had pain or hurting at any time in the last 5 days?"
0. No Skip to J1100, Shortness of Breath.
1. Yes Continue to J0400, Pain Frequency.
9. Unable to answer Skip to J0800, Indicators of Pain or Possible Pain.
Enter Code
J0400. Pain Frequency.
Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"
1. Almost constantly.
2. Frequently.
3. Occasionally.
4. Rarely.
9. Unable to answer.
Enter Code
J0500. Pain Effect on Function.
A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"
0. No.
1. Yes.
9. Unable to answer.
Enter Code
B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?"
0. No.
1. Yes.
9. Unable to answer.
Enter Code
J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B).
A. Numeric Rating Scale (00-10).
Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten
as the worst pain you can imagine." (Show resident 00 -10 pain scale)
Enter two-digit response. Enter 99 if unable to answer.
Enter Rating
B. Verbal Descriptor Scale.
Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)
1. Mild.
2. Moderate.
3. Severe.
4. Very severe, horrible.
9. Unable to answer.
Enter Code
J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea).
0. No (resident is rarely/never understood) Skip to and complete J0800, Indicators of Pain or Possible Pain.
1. Yes Continue to J0300, Pain Presence.
Enter Code
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Resident Identifier Date
Section J. Health Conditions.
J0700. Should the Staff Assessment for Pain be Conducted?
0. No (J0400 = 1 thru 4) Skip to J1100, Shortness of Breath (dyspnea).
1. Yes (J0400 = 9) Continue to J0800, Indicators of Pain or Possible Pain.
Enter Code
Staff Assessment for Pain.
J0800. Indicators of Pain or Possible Pain in the last 5 days.
Check all that apply.
A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning).
B. Vocal complaints of pain (e.g., that hurts, ouch, stop).
C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw).
D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a
body part during movement).
Z. None of these signs observed or documented If checked, skip to J1100, Shortness of Breath (dyspnea).
J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days.
Frequency with which resident complains or shows evidence of pain or possible pain.
1. Indicators of pain or possible pain observed 1 to 2 days.
2. Indicators of pain or possible pain observed 3 to 4 days.
3. Indicators of pain or possible pain observed daily.
Enter Code
Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
B. Shortness of breath or trouble breathing when sitting at rest.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.
J1400. Prognosis.
Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician
documentation).
0. No.
1. Yes.
Enter Code
J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.
C. Dehydrated.
D. Internal bleeding.
Z. None of the above.
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Resident Identifier Date
Section J. Health Conditions.
J1700. Fall History on Admission/Entry or Reentry.
Complete only if A0310A = 01 or A0310E = 1
A. Did the resident have a fall any time in the last month prior to admission/entry or reentry?
0. No.
1. Yes.
9. Unable to determine.
Enter Code
B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
Enter Code
C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
Enter Code
J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more
recent?
0. No Skip to K0100, Swallowing Disorder.
1. Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).
Enter Code
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Coding:
0. None
1. One
2. Two or more
Enter Codes in Boxes
A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the resident; no change in the resident's
behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.
Did the resident have major surgery during the 100 days prior to admission?
0. No.
1. Yes.
8. Unknown
J2000. Prior Surgery
Enter Code
Section K. Swallowing/Nutritional Status.
K0100. Swallowing Disorder.
Signs and symptoms of possible swallowing disorder.
Check all that apply.
A. Loss of liquids/solids from mouth when eating or drinking.
B. Holding food in mouth/cheeks or residual food in mouth after meals.
C. Coughing or choking during meals or when swallowing medications.
D. Complaints of difficulty or pain with swallowing.
Z. None of the above.
K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry.
inches
B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).
pounds
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Resident Identifier Date
Section K. Swallowing/Nutritional Status.
K0300. Weight Loss.
Loss of 5% or more in the last month or loss of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-loss regimen.
2. Yes, not on physician-prescribed weight-loss regimen.
Enter Code
K0310. Weight Gain.
Gain of 5% or more in the last month or gain of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-gain regimen.
2. Yes, not on physician-prescribed weight-gain regimen.
Enter Code
K0510. Nutritional Approaches.
Check all of the following nutritional approaches that were performed during the last 7 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
1.
While NOT a
Resident.
2.
While a
Resident.
Check all that apply
A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids).
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol).
Z. None of the above.
K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only enter a
code in column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If
resident last entered 7 or more days ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
3. During Entire 7 Days.
Performed during the entire last 7 days.
1.
While NOT a
Resident.
2.
While a
Resident.
3.
During Entire
7 Days.
Enter Codes
A. Proportion of total calories the resident received through parenteral or tube feeding.
1. 25% or less.
2. 26-50%.
3. 51% or more.
B. Average fluid intake per day by IV or tube feeding.
1. 500 cc/day or less.
2. 501 cc/day or more.
Section L. Oral/Dental Status.
L0200. Dental
Check all that apply.
A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).
F. Mouth or facial pain, discomfort or difficulty with chewing.
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Resident Identifier Date
Section M. Skin Conditions.
Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.
M0100. Determination of Pressure Ulcer/Injury Risk.
Check all that apply.
A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.
B. Formal assessment instrument/tool (e.g., Braden, Norton, or other).
C. Clinical assessment.
Z. None of the above.
M0150. Risk of Pressure Ulcers/Injuries.
Is this resident at risk of developing pressure ulcers/injuries?
0. No.
1. Yes.
Enter Code
M0210. Unhealed Pressure Ulcers/Injuries.
Does this resident have one or more unhealed pressure ulcers/injuries?
0. No Skip to M1030, Number of Venous and Arterial Ulcers.
1. Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Enter Code
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
Enter Number
1. Number of Stage 1 pressure injuries.
B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0 Skip to M0300C, Stage 3.
Enter Number
2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry.
Enter Number
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4.
Enter Number
2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry .
Enter Number
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers - If 0
Skip to M0300E, Unstageable - Non-removable dressing/device.
Enter Number
2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
M0300 continued on next page.
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Resident Identifier Date
Section M. Skin Conditions.
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F,
Unstageable - Slough and/or eschar.
Enter Number
2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
were noted at the time of admission/entry or reentry.
Enter Number
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0
Skip to M0300G,
Unstageable - Deep tissue injury.
Enter Number
2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
G. Unstageable - Deep tissue injury:
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0
Skip to M1030,
Number of Venous and Arterial Ulcers.
Enter Number
2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
M1030. Number of Venous and Arterial Ulcers.
Enter the total number of venous and arterial ulcers present.
Enter Number
M1040. Other Ulcers, Wounds and Skin Problems.
Check all that apply.
Foot Problems.
A. Infection of the foot (e.g., cellulitis, purulent drainage).
B. Diabetic foot ulcer(s).
C. Other open lesion(s) on the foot.
Other Problems.
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).
E. Surgical wound(s).
F. Burn(s) (second or third degree).
G. Skin tear(s).
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage).
None of the Above.
Z. None of the above were present.
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Resident Identifier Date
Section M. Skin Conditions.
M1200. Skin and Ulcer/Injury Treatments.
Check all that apply.
A. Pressure reducing device for chair.
B. Pressure reducing device for bed.
C. Turning/repositioning program.
D. Nutrition or hydration intervention to manage skin problems.
E. Pressure ulcer/injury care.
F. Surgical wound care.
G. Application of nonsurgical dressings (with or without topical medications) other than to feet.
H. Applications of ointments/medications other than to feet.
I. Application of dressings to feet (with or without topical medications).
Z. None of the above were provided.
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Resident Identifier Date
Section N. Medications.
N0300. Injections.
Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less
than 7 days. If 0 Skip to N0410, Medications Received.
Enter Days
N0350. Insulin.
A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry
or reentry if less than 7 days.
Enter Days
B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's
insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.
Enter Days
N0410. Medications Received.
Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the
last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days.
A. Antipsychotic.
Enter Days
B. Antianxiety.
Enter Days
C. Antidepressant.
Enter Days
D. Hypnotic.
Enter Days
E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin).
Enter Days
F. Antibiotic.
Enter Days
G. Diuretic.
Enter Days
H. Opioid.
Enter Days
N2001. Drug Regimen Review.
Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review Skip to O0100, Special Treatments, Procedures, and Programs.
1. Yes - Issues found during review Continue to N2003, Medication Follow-up.
9. NA - Resident is not taking any medications Skip to O0100, Special Treatments, Procedures, and Programs.
Enter Code
N2003. Medication Follow-up.
Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?
0. No.
1. Yes.
Enter Code
N2005. Medication Intervention.
Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No.
1. Yes.
9. NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any
medications.
Enter Code
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.
1.
While NOT a
Resident.
2.
While a
Resident.
Check all that apply
Cancer Treatments.
A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
D. Suctioning.
E. Tracheostomy care.
F. Invasive Mechanical Ventilator (ventilator or respirator).
H. IV medications.
I. Transfusions.
J. Dialysis.
K. Hospice care.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).
Other.
O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period.
A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes Continue to O0250B, Date influenza vaccine received.
Enter Code
B. Date influenza vaccine received
Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date?
Month
_
Day
_
Year
C. If influenza vaccine not received, state reason:
1. Resident not in this facility during this year's influenza vaccination season.
2. Received outside of this facility.
3. Not eligible - medical contraindication.
4. Offered and declined.
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage.
9. None of the above.
Enter Code
O0300. Pneumococcal Vaccine.
A. Is the resident's Pneumococcal vaccination up to date?
0. No Continue to O0300B, If Pneumococcal vaccine not received, state reason.
1. Yes Skip to O0400, Therapies.
Enter Code
B. If Pneumococcal vaccine not received, state reason:
1. Not eligible - medical contraindication.
2. Offered and declined.
3. Not offered.
Enter Code
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0400. Therapies.
A. Speech-Language Pathology and Audiology Services.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400A5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
B. Occupational Therapy.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400B5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
O0400 continued on next page
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0400. Therapies - Continued.
C. Physical Therapy.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400C5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
D. Respiratory Therapy.
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
E. Psychological Therapy (by any licensed mental health professional).
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
O0420. Distinct Calendar Days of Therapy.
Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days.
Enter Number of Days
O0450. Resumption of Therapy - Complete only if A0310C = 2 or 3 and A0310F = 99.
A. Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of
Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline?
0. No Skip to O0500, Restorative Nursing Programs.
1. Yes
Enter Code
B. Date on which therapy regimen resumed:
Month
_
Day
_
Year
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0500. Restorative Nursing Programs.
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days
(enter 0 if none or less than 15 minutes daily).
Number
of Days.
Technique.
A. Range of motion (passive).
B. Range of motion (active).
C. Splint or brace assistance.
Number
of Days.
Training and Skill Practice In:
D. Bed mobility.
E. Transfer.
F. Walking.
G. Dressing and/or grooming.
H. Eating and/or swallowing.
I. Amputation/prostheses care.
J. Communication.
O0600. Physician Examinations.
Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident?
Enter Days
O0700. Physician Orders.
Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders?
Enter Days
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Resident Identifier Date
Section P. Restraints and Alarms.
P0100. Physical Restraints.
Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that
the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.
Enter Codes in Boxes.
Used in Bed.
A. Bed rail.
B. Trunk restraint.
C. Limb restraint.
D. Other.
Used in Chair or Out of Bed.
E. Trunk restraint.
F. Limb restraint.
G. Chair prevents rising.
H. Other.
Section Q. Participation in Assessment and Goal Setting.
Q0100. Participation in Assessment.
A. Resident participated in assessment.
0. No.
1. Yes.
Enter Code
B. Family or significant other participated in assessment.
0. No.
1. Yes.
9. Resident has no family or significant other.
Enter Code
C. Guardian or legally authorized representative participated in assessment.
0. No.
1. Yes.
9. Resident has no guardian or legally authorized representative.
Enter Code
Q0300. Resident's Overall Expectation.
Complete only if A0310E = 1.
A. Select one for resident's overall goal established during assessment process.
1. Expects to be discharged to the community.
2. Expects to remain in this facility.
3. Expects to be discharged to another facility/institution.
9. Unknown or uncertain.
Enter Code
B. Indicate information source for Q0300A.
1. Resident.
2. If not resident, then family or significant other.
3. If not resident, family, or significant other, then guardian or legally authorized representative.
9. Unknown or uncertain.
Enter Code
Q0400. Discharge Plan.
A. Is active discharge planning already occurring for the resident to return to the community?
0. No.
1. Yes Skip to Q0600, Referral.
Enter Code
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Resident Identifier Date
Section Q. Participation in Assessment and Goal Setting.
Q0490. Resident's Preference to Avoid Being Asked Question Q0500B.
Complete only if A0310A = 02, 06, or 99.
Enter Code
Does the resident's clinical record document a request that this question be asked only on comprehensive assessments?
0. No.
1. Yes Skip to Q0600, Referral.
Q0500. Return to Community.
B. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond):
"Do you want to talk to someone about the possibility of leaving this facility and returning to live and
receive services in the community?"
0. No.
1. Yes.
9. Unknown or uncertain.
Enter Code
Q0550. Resident's Preference to Avoid Being Asked Question Q0500B Again.
A. Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive
assessments.)
0. No - then document in resident's clinical record and ask again only on the next comprehensive assessment...
1. Yes.
8. Information not available.
Enter Code
B. Indicate information source for Q0550A.
1. Resident...
2. If not resident, then family or significant other.
3. If not resident, family or significant other, then guardian or legally authorized representative.
9. None of the above.
Enter Code
Q0600. Referral.
Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record)
0. No - referral not needed.
1. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20).
2. Yes - referral made.
Enter Code
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Resident Identifier Date
Section X. Correction Request.
Complete Section X only if A0050 = 2 or 3.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated).
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
X0200. Name of Resident (A0500 on existing record to be modified/inactivated).
A. First name:
C. Last name:
X0300. Gender (A0800 on existing record to be modified/inactivated).
1. Male
2. Female
Enter Code
X0400. Birth Date (A0900 on existing record to be modified/inactivated).
Month
_
Day
_
Year
X0500. Social Security Number (A0600A on existing record to be modified/inactivated).
_ _
X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).
A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
X0600 continued on next page.
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Resident Identifier Date
Section X. Correction Request.
X0600. Type of Assessment.- Continued.
D. Is this a Swing Bed clinical change assessment? Complete only if X0150 = 2.
0. No.
1. Yes.
Enter Code
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
X0700. Date on existing record to be modified/inactivated - Complete one only.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99.
Month
_
Day
_
Year
B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12.
Month
_
Day
_
Year
C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01.
Month
_
Day
_
Year
Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter the number of correction requests to modify/inactivate the existing record, including the present one.
Enter Number
X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
E. End of Therapy - Resumption (EOT-R) date.
Z. Other error requiring modification.
If "Other" checked, please specify:
X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:
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Resident Identifier Date
Section X. Correction Request.
X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:
B. Attesting individual's last name:
C. Attesting individual's title:
D. Signature.
E. Attestation date.
Month
_
Day
_
Year
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Resident Identifier Date
Section Z. Assessment Administration.
Z0100. Medicare Part A Billing.
A. Medicare Part A HIPPS code (RUG group followed by assessment type indicator):
B. RUG version code:
C. Is this a Medicare Short Stay assessment?
0. No.
1. Yes
Enter Code
Z0150. Medicare Part A Non-Therapy Billing.
A. Medicare Part A non-therapy HIPPS code (RUG group followed by assessment type indicator):
B. RUG version code:
Z0200. State Medicaid Billing (if required by the state).
A. RUG Case Mix group:
B. RUG version code:
Z0250. Alternate State Medicaid Billing (if required by the state).
A. RUG Case Mix group:
B. RUG version code:
Z0300. Insurance Billing.
A. RUG billing code:
B. RUG billing version:
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Resident Identifier Date
Section Z. Assessment Administration.
Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Signature Title Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:
B. Date RN Assessment Coordinator signed
assessment as complete:
Month
_
Day
_
Year
Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the
copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted
permission to use these instruments in association with the MDS 3.0.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 1 of 14
Resident Identifier Date
Section A. Identification Information.
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home Part A PPS Discharge (NPE) Item Set
A0050. Type of Record.
1. Add new record Continue to A0100, Facility Provider Numbers.
2. Modify existing record Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record Skip to X0150, Type of Provider.
Enter Code
A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
C. State Provider Number:
A0200. Type of Provider.
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
A0310. Type of Assessment.
A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.
0. No.
1. Yes.
Enter Code
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
Enter Code
A0310 continued on next page.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 2 of 14
Resident Identifier Date
Section A. Identification Information.
A0310. Type of Assessment - Continued.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
G. Type of discharge. - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
A0410. Unit Certification or Licensure Designation.
1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.
Enter Code
A0500. Legal Name of Resident.
A. First name: B. Middle initial:
C. Last name: D. Suffix:
A0600. Social Security and Medicare Numbers.
A. Social Security Number:
_ _
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.
A0800. Gender.
1. Male.
2. Female.
Enter Code
A0900. Birth Date.
Month
_
Day
_
Year
A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 3 of 14
Resident Identifier Date
Section A. Identification Information.
A1100. Language.
A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No Skip to A1200, Marital Status.
1. Yes Specify in A1100B, Preferred language.
9. Unable to determine. Skip to A1200, Marital Status.
Enter Code
B. Preferred language:
A1200. Marital Status.
1. Never married.
2. Married.
3. Widowed.
4. Separated.
5. Divorced.
Enter Code
A1300. Optional Resident Items.
A. Medical record number:
B. Room number:
C. Name by which resident prefers to be addressed:
D. Lifetime occupation(s) - put "/" between two occupations:
Most Recent Admission/Entry or Reentry into this Facility.
A1600. Entry Date.
Month
_
Day
_
Year
A1700. Type of Entry.
1. Admission.
2. Reentry.
Enter Code
A1800. Entered From.
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 4 of 14
Resident Identifier Date
Identification Information.Section A.
A1900. Admission Date (Date this episode of care in this facility began).
Month
_
Day
_
Year
A2000. Discharge Date.
Complete only if A0310F = 10, 11, or 12
Month
_
Day
_
Year
A2100. Discharge Status.
Complete only if A0310F = 10, 11, or 12
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
08. Deceased.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A2300. Assessment Reference Date.
Observation end date:
Month
_
Day
_
Year
A2400. Medicare Stay.
A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No Skip to GG0130, Self-Care.
1. Yes Continue to A2400B, Start date of most recent Medicare stay.
Enter Code
B. Start date of most recent Medicare stay:
Month
_
Day
_
Year
C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:
Month
_
Day
_
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 5 of 14
Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for
safe mobility; including fasteners, if applicable.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 6 of 14
Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on
the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/
close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 7 of 14
Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as
turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the
floor.
Q3. Does the resident use a wheelchair and/or scooter?
0. No Skip to H0100, Appliances
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns..
RR3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 8 of 14
Resident Identifier Date
Section J. Health Conditions.
J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more
recent?
0. No Skip to M0210, Unhealed Pressure Ulcer(s).
1. Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).
Enter Code
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Coding:
0. None
1. One
2. Two or more
Enter Codes in Boxes
A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the resident; no change in the resident's
behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 9 of 14
Resident Identifier Date
Section M. Skin Conditions.
Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries.
Does this resident have one or more unhealed pressure ulcers/injuries?
0. No Skip to M1030, Number of Venous and Arterial Ulcers.
1. Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Enter Code
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0 Skip to M0300C, Stage 3.
Enter Number
2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at
the time of admission/entry or reentry.
Enter Number
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4.
Enter Number
2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at
the time of admission/entry or reentry.
Enter Number
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device.
Enter Number
2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at
the time of admission/entry or reentry.
Enter Number
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F,
Unstageable - Slough and/or eschar.
Enter Number
2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
were noted at the time of admission/entry or reentry.
Enter Number
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0 Skip to M0300G,
Unstageable - Deep tissue injury.
Enter Number
2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
G. Unstageable - Deep tissue injury:
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0 Skip to M1030,
Number of Venous and Arterial Ulcers.
Enter Number
2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 10 of 14
Resident Identifier Date
Medications.Section N.
N2005. Medication Intervention.
Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No.
1. Yes.
9. NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any
medications.
Enter Code
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 11 of 14
Resident Identifier Date
Section X. Correction Request.
Complete Section X only if A0050 = 2 or 3.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated).
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
X0200. Name of Resident (A0500 on existing record to be modified/inactivated).
A. First name:
C. Last name:
X0300. Gender (A0800 on existing record to be modified/inactivated).
1. Male
2. Female
Enter Code
X0400. Birth Date (A0900 on existing record to be modified/inactivated).
Month
_
Day
_
Year
X0500. Social Security Number (A0600A on existing record to be modified/inactivated).
_ _
X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).
A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
X0600 continued on next page.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 12 of 14
Resident Identifier Date
Section X. Correction Request.
X0600. Type of Assessment.- Continued.
D. Is this a Swing Bed clinical change assessment? Complete only if X0150 = 2.
0. No.
1. Yes.
Enter Code
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
X0700. Date on existing record to be modified/inactivated - Complete one only.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99.
Month
_
Day
_
Year
B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12.
Month
_
Day
_
Year
C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01.
Month
_
Day
_
Year
Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter the number of correction requests to modify/inactivate the existing record, including the present one.
Enter Number
X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
E. End of Therapy - Resumption (EOT-R) date.
Z. Other error requiring modification.
If "Other" checked, please specify:
X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 13 of 14
Resident Identifier Date
Section X. Correction Request.
X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:
B. Attesting individual's last name:
C. Attesting individual's title:
D. Signature.
E. Attestation date.
Month
_
Day
_
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.16.0 Effective 10/01/2018 DRAFT Page 14 of 14
Resident Identifier Date
Section Z. Assessment Administration.
Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Signature Title Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:
B. Date RN Assessment Coordinator signed
assessment as complete:
Month
_
Day
_
Year
Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the
copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted
permission to use these instruments in association with the MDS 3.0.
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 1 of 44
Resident Identifier Date
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home Quarterly (NQ) Item Set
Section A. Identification Information.
A0050. Type of Record.
1. Add new record Continue to A0100, Facility Provider Numbers.
2. Modify existing record Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record Skip to X0150, Type of Provider.
Enter Code
A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
C. State Provider Number:
A0200. Type of Provider.
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
A0310. Type of Assessment.
A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.
0. No.
1. Yes.
Enter Code
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
Enter Code
A0310 continued on next page.
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Resident Identifier Date
Section A. Identification Information.
A0310. Type of Assessment - Continued.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
G. Type of discharge. - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
A0410. Unit Certification or Licensure Designation.
1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.
Enter Code
A0500. Legal Name of Resident.
A. First name: B. Middle initial:
C. Last name: D. Suffix:
A0600. Social Security and Medicare Numbers.
A. Social Security Number:
_ _
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.
A0800. Gender.
1. Male.
2. Female.
Enter Code
A0900. Birth Date.
Month
_
Day
_
Year
A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.
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Resident Identifier Date
Section A. Identification Information.
A1100. Language.
A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No Skip to A1200, Marital Status.
1. Yes Specify in A1100B, Preferred language.
9. Unable to determine. Skip to A1200, Marital Status.
Enter Code
B. Preferred language:
A1200. Marital Status.
1. Never married.
2. Married.
3. Widowed.
4. Separated.
5. Divorced.
Enter Code
A1300. Optional Resident Items.
A. Medical record number:
B. Room number:
C. Name by which resident prefers to be addressed:
D. Lifetime occupation(s) - put "/" between two occupations:
Most Recent Admission/Entry or Reentry into this Facility.
A1600. Entry Date.
Month
_
Day
_
Year
A1700. Type of Entry.
1. Admission.
2. Reentry.
Enter Code
A1800. Entered From.
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A1900. Admission Date (Date this episode of care in this facility began).
Month
_
Day
_
Year
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Resident Identifier Date
Section A. Identification Information.
A2000. Discharge Date.
Complete only if A0310F = 10, 11, or 12
Month
_
Day
_
Year
A2100. Discharge Status.
Complete only if A0310F = 10, 11, or 12
01. Community (private home/apt., board/care, assisted living, group home).
02. Another nursing home or swing bed.
03. Acute hospital.
04. Psychiatric hospital.
05. Inpatient rehabilitation facility.
06. ID/DD facility.
07. Hospice.
08. Deceased.
09. Long Term Care Hospital (LTCH).
99. Other.
Enter Code
A2200. Previous Assessment Reference Date for Significant Correction.
Complete only if A0310A = 05 or 06.
Month
_
Day
_
Year
A2300. Assessment Reference Date.
Observation end date:
Month
_
Day
_
Year
A2400. Medicare Stay.
A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No Skip to B0100, Comatose.
1. Yes Continue to A2400B, Start date of most recent Medicare stay.
Enter Code
B. Start date of most recent Medicare stay:
Month
_
Day
_
Year
C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:
Month
_
Day
_
Year
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Resident Identifier Date
Look back period for all items is 7 days unless another time frame is indicated.
Section B. Hearing, Speech, and Vision.
B0100. Comatose.
Persistent vegetative state/no discernible consciousness.
0. No Continue to B0200, Hearing.
1. Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.
Enter Code
B0200. Hearing.
Ability to hear (with hearing aid or hearing appliances if normally used).
0. Adequate - no difficulty in normal conversation, social interaction, listening to TV.
1. Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy).
2. Moderate difficulty - speaker has to increase volume and speak distinctly.
3. Highly impaired - absence of useful hearing.
Enter Code
B0300. Hearing Aid.
Hearing aid or other hearing appliance used in completing B0200, Hearing.
0. No.
1. Yes.
Enter Code
B0600. Speech Clarity.
Select best description of speech pattern.
0. Clear speech - distinct intelligible words.
1. Unclear speech - slurred or mumbled words.
2. No speech - absence of spoken words.
Enter Code
B0700. Makes Self Understood.
Ability to express ideas and wants, consider both verbal and non-verbal expression.
0. Understood.
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.
2. Sometimes understood - ability is limited to making concrete requests.
3. Rarely/never understood.
Enter Code
B0800. Ability To Understand Others.
Understanding verbal content, however able (with hearing aid or device if used).
0. Understands - clear comprehension.
1. Usually understands - misses some part/intent of message but comprehends most conversation.
2. Sometimes understands - responds adequately to simple, direct communication only.
3. Rarely/never understands.
Enter Code
B1000. Vision.
Ability to see in adequate light (with glasses or other visual appliances).
0. Adequate - sees fine detail, such as regular print in newspapers/books.
1. Impaired - sees large print, but not regular print in newspapers/books.
2. Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects.
3. Highly impaired - object identification in question, but eyes appear to follow objects.
4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects.
Enter Code
B1200. Corrective Lenses.
Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision.
0. No.
1. Yes.
Enter Code
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Resident Identifier Date
Section C. Cognitive Patterns.
Brief Interview for Mental Status (BIMS).
C0200. Repetition of Three Words.
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt.
0. None.
1. One.
2. Two.
3. Three.
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece
of furniture"). You may repeat the words up to two more times.
Enter Code
C0300. Temporal Orientation (orientation to year, month, and day).
Ask resident: "Please tell me what year it is right now."
A. Able to report correct year.
0. Missed by > 5 years or no answer.
1. Missed by 2-5 years.
2. Missed by 1 year.
3. Correct.
Enter Code
Ask resident: "What month are we in right now?"
B. Able to report correct month.
0. Missed by > 1 month or no answer.
1. Missed by 6 days to 1 month.
2. Accurate within 5 days.
Enter Code
Ask resident: "What day of the week is today?"
C. Able to report correct day of the week.
0. Incorrect or no answer.
1. Correct.
Enter Code
C0400. Recall.
Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall "sock".
0. No - could not recall.
1. Yes, after cueing ("something to wear").
2. Yes, no cue required.
Enter Code
B. Able to recall "blue".
0. No - could not recall.
1. Yes, after cueing ("a color").
2. Yes, no cue required.
Enter Code
C. Able to recall "bed".
0. No - could not recall.
1. Yes, after cueing ("a piece of furniture").
2. Yes, no cue required.
Enter Code
C0500. BIMS Summary Score.
Add scores for questions C0200-C0400 and fill in total score (00-15).
Enter 99 if the resident was unable to complete the interview.
Enter Score
C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents.
0. No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status.
1. Yes Continue to C0200, Repetition of Three Words.
Enter Code
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Resident Identifier Date
Section C. Cognitive Patterns.
C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
0. No (resident was able to complete Brief Interview for Mental Status ) Skip to C1310, Signs and Symptoms of Delirium.
1. Yes (resident was unable to complete Brief Interview for Mental Status) Continue to C0700, Short-term Memory OK.
Enter Code
Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.
C0700. Short-term Memory OK.
Seems or appears to recall after 5 minutes.
0. Memory OK.
1. Memory problem.
Enter Code
C0800. Long-term Memory OK.
Seems or appears to recall long past.
0. Memory OK.
1. Memory problem.
Enter Code
C0900. Memory/Recall Ability.
Check all that the resident was normally able to recall.
A. Current season.
B. Location of own room.
C. Staff names and faces.
D. That he or she is in a nursing home/hospital swing bed.
Z. None of the above were recalled.
C1000. Cognitive Skills for Daily Decision Making.
Made decisions regarding tasks of daily life.
0. Independent - decisions consistent/reasonable.
1. Modified independence - some difficulty in new situations only.
2. Moderately impaired - decisions poor; cues/supervision required.
3. Severely impaired - never/rarely made decisions.
Enter Code
Delirium.
C1310. Signs and Symptoms of Delirium (from CAM©).
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.
A. Acute Onset Mental Status Change.
Is there evidence of an acute change in mental status from the resident's baseline?
0. No.
1. Yes.
Enter Code
Coding:
0. Behavior not present .
1. Behavior continuously
present, does not
fluctuate.
2. Behavior present,
fluctuates (comes and
goes, changes in severity).
Enter Codes in Boxes.
B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or
having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by
any of the following criteria?
￭ vigilant - startled easily to any sound or touch.
￭ lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch.
￭ stuporous - very difficult to arouse and keep aroused for the interview.
￭ comatose - could not be aroused.
Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 8 of 44
Resident Identifier Date
Section D. Mood.
D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.
0. No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV).
1. Yes Continue to D0200, Resident Mood Interview (PHQ-9©).
Enter Code
D0200. Resident Mood Interview (PHQ-9©).
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
9. No response (leave column 2
blank).
2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).
1.
Symptom
Presence.
2.
Symptom
Frequency.
Enter Scores in Boxes
A. Little interest or pleasure in doing things.
B. Feeling down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family
down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people could have noticed. Or the opposite -
being so fidgety or restless that you have been moving around a lot more than usual.
I. Thoughts that you would be better off dead, or of hurting yourself in some way.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).
Enter Score
D0300. Total Severity Score.
D0350. Safety Notification - Complete only if D0200I1 = 1 indicating possibility of resident self harm.
Was responsible staff or provider informed that there is a potential for resident self harm?
0. No.
1. Yes.
Enter Code
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
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Resident Identifier Date
Section D. Mood.
D0500. Staff Assessment of Resident Mood (PHQ-9-OV*).
Do not conduct if Resident Mood Interview (D0200-D0300) was completed.
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).
1.
Symptom
Presence.
2.
Symptom
Frequency.
Enter Scores in Boxes
A. Little interest or pleasure in doing things.
B. Feeling or appearing down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety
or restless that s/he has been moving around a lot more than usual.
I. States that life isn't worth living, wishes for death, or attempts to harm self.
J. Being short-tempered, easily annoyed.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.
Enter Score
D0600. Total Severity Score.
D0650. Safety Notification - Complete only if D0500I1 = 1 indicating possibility of resident self harm.
Was responsible staff or provider informed that there is a potential for resident self harm?
0. No.
1. Yes.
Enter Code
* Copyright © Pfizer Inc. All rights reserved.
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Resident Identifier Date
Section E. Behavior.
E0100. Potential Indicators of Psychosis.
Check all that apply
A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Z. None of the above.
Behavioral Symptoms.
E0200. Behavioral Symptom - Presence & Frequency.
Note presence of symptoms and their frequency.
Coding:
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days,
but less than daily.
3. Behavior of this type occurred daily.
Enter Codes in Boxes.
A. Physical behavioral symptoms directed toward others (e.g., hitting,
kicking, pushing, scratching, grabbing, abusing others sexually).
B. Verbal behavioral symptoms directed toward others (e.g., threatening
others, screaming at others, cursing at others).
C. Other behavioral symptoms not directed toward others (e.g., physical
symptoms such as hitting or scratching self, pacing, rummaging, public
sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, disruptive sounds).
E0800. Rejection of Care - Presence & Frequency.
Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.
Enter Code
E0900. Wandering - Presence & Frequency.
Has the resident wandered?
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.
Enter Code
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Resident Identifier Date
Section G. Functional Status.
G0110. Activities of Daily Living (ADL) Assistance.
Refer to the ADL flow chart in the RAI manual to facilitate accurate coding.
1. ADL Self-Performance.
Code for resident's performance over all shifts - not including setup. If the ADL activity
occurred 3 or more times at various levels of assistance, code the most dependent - except for
total dependence, which requires full staff performance every time.
Coding:
Activity Occurred 3 or More Times.
0. Independent - no help or staff oversight at any time.
1. Supervision - oversight, encouragement or cueing.
2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering
of limbs or other non-weight-bearing assistance.
3. Extensive assistance - resident involved in activity, staff provide weight-bearing support.
4. Total dependence - full staff performance every time during entire 7-day period.
Activity Occurred 2 or Fewer Times.
7. Activity occurred only once or twice - activity did occur but only once or twice.
8. Activity did not occur - activity did not occur or family and/or non-facility staff provided
care 100% of the time for that activity over the entire 7-day period.
2. ADL Support Provided.
Code for most support provided over all
shifts; code regardless of resident's self-
performance classification.
Coding:
0. No setup or physical help from staff.
1. Setup help only.
2. One person physical assist.
3. Two+ persons physical assist.
8. ADL activity itself did not occur or family
and/or non-facility staff provided care
100% of the time for that activity over the
entire 7-day period.
1.
Self-Performance.
2.
Support.
Enter Codes in Boxes
A. Bed mobility - how resident moves to and from lying position, turns side to side, and
positions body while in bed or alternate sleep furniture.
B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair,
standing position (excludes to/from bath/toilet).
C. Walk in room - how resident walks between locations in his/her room.
D. Walk in corridor - how resident walks in corridor on unit.
E. Locomotion on unit - how resident moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair.
F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas
set aside for dining, activities or treatments). If facility has only one floor, how resident
moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair.
G. Dressing - how resident puts on, fastens and takes off all items of clothing, including
donning/removing a prosthesis or TED hose. Dressing includes putting on and changing
pajamas and housedresses.
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking
during medication pass. Includes intake of nourishment by other means (e.g., tube feeding,
total parenteral nutrition, IV fluids administered for nutrition or hydration).
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts
clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or
ostomy bag.
J. Personal hygiene - how resident maintains personal hygiene, including combing hair,
brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths
and showers).
Instructions for Rule of 3
￭ When an activity occurs three times at any one given level, code that level.
￭ When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist
every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited
assistance (2), code extensive assistance (3).
￭ When an activity occurs at various levels, but not three times at any given level, apply the following:
￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance.
￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).
If none of the above are met, code supervision.
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Resident Identifier Date
Section G. Functional Status.
G0120. Bathing.
How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most
dependent in self-performance and support.
A. Self-performance.
0. Independent - no help provided.
1. Supervision - oversight help only.
2. Physical help limited to transfer only.
3. Physical help in part of bathing activity.
4. Total dependence.
8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire
7-day period.
Enter Code
B. Support provided.
(Bathing support codes are as defined in item G0110 column 2, ADL Support Provided, above).
Enter Code
G0300. Balance During Transitions and Walking.
After observing the resident, code the following walking and transition items for most dependent.
Coding:
0. Steady at all times.
1. Not steady, but able to stabilize without staff
assistance.
2. Not steady, only able to stabilize with staff
assistance.
8. Activity did not occur.
Enter Codes in Boxes.
A. Moving from seated to standing position.
B. Walking (with assistive device if used).
C. Turning around and facing the opposite direction while walking.
D. Moving on and off toilet.
E. Surface-to-surface transfer (transfer between bed and chair or
wheelchair).
G0400. Functional Limitation in Range of Motion.
Code for limitation that interfered with daily functions or placed resident at risk of injury.
Coding:
0. No impairment.
1. Impairment on one side.
2. Impairment on both sides.
Enter Codes in Boxes.
A. Upper extremity (shoulder, elbow, wrist, hand).
B. Lower extremity (hip, knee, ankle, foot).
G0600. Mobility Devices.
Check all that were normally used.
A. Cane/crutch.
B. Walker.
C. Wheelchair (manual or electric).
D. Limb prosthesis.
Z. None of the above were used.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Coding:
3. Independent - Resident completed the
activities by him/herself, with or without an
assistive device, with no assistance from a
helper.
2. Needed Some Help - Resident needed partial
assistance from another person to complete
activities.
1. Dependent - A helper completed the activities
for the resident.
8. Unknown.
9. Not Applicable.
Enter Codes in Boxes.
A. Self-Care: Code the resident's need for assistance with bathing, dressing, using
the toilet, or eating prior to the current illness, exacerbation, or injury.
B. Indoor Mobility (Ambulation): Code the resident's need for assistance with
walking from room to room (with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or injury..
C. Stairs: Code the resident's need for assistance with internal or external stairs (with
or without a device such as cane, crutch, or walker) prior to the current illness,
exacerbation, or injury. .
D. Functional Cognition: Code the resident's need for assistance with planning
regular tasks, such as shopping or remembering to take medication prior to the
current illness, exacerbation, or injury.
GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair .
B. Motorized wheelchair and/or scooter .
C. Mechanical lift.
D. Walker.
E. Orthotics/Prosthetics.
Z. None of the above.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid
once the meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is
appropriate for safe mobility; including fasteners, if applicable.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the
bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with
feet flat on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay).
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) - Continued
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
Admission
Performance.
2.
Discharge
Goal.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or
outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon,
from the floor.
Q1. Does the resident use a wheelchair and/or scooter?
0. No Skip to GG0130, Self Care (Discharge).
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns.
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make
two turns..
RR1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for
safe mobility; including fasteners, if applicable.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on
the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/
close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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Resident Identifier Date
Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay).
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as
turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the
floor.
Q3. Does the resident use a wheelchair and/or scooter?
0. No Skip to H0100, Appliances
1. Yes. Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns..
RR3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
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Resident Identifier Date
Section H. Bladder and Bowel.
H0100. Appliances.
Check all that apply.
A. Indwelling catheter (including suprapubic catheter and nephrostomy tube).
B. External catheter.
C. Ostomy (including urostomy, ileostomy, and colostomy).
D. Intermittent catheterization.
Z. None of the above.
H0200. Urinary Toileting Program.
A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on
admission/entry or reentry or since urinary incontinence was noted in this facility?
0. No Skip to H0300, Urinary Continence.
1. Yes Continue to H0200C, Current toileting program or trial.
9. Unable to determine Continue to H0200C, Current toileting program or trial.
Enter Code
C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No.
1. Yes.
Enter Code
H0300. Urinary Continence.
Urinary continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (less than 7 episodes of incontinence).
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).
3. Always incontinent (no episodes of continent voiding).
9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.
Enter Code
H0400. Bowel Continence.
Bowel continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (one episode of bowel incontinence).
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement).
3. Always incontinent (no episodes of continent bowel movements).
9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.
Enter Code
H0500. Bowel Toileting Program.
Is a toileting program currently being used to manage the resident's bowel continence?
0. No.
1. Yes.
Enter Code
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Resident Identifier Date
Section I. Active Diagnoses.
I0020. Indicate the resident’s primary medical condition category.
01. Stroke.
02. Non-Traumatic Brain Dysfunction.
03. Traumatic Brain Dysfunction.
04. Non-Traumatic Spinal Cord Dysfunction.
05. Traumatic Spinal Cord Dysfunction.
06. Progressive Neurological Conditions.
07. Other Neurological Conditions.
08. Amputation
09. Hip and Knee Replacement.
10. Fractures and Other Multiple Trauma.
11. Other Orthopedic Conditions.
12. Debility, Cardiorespiratory Conditions.
13. Medically Complex Conditions.
14. Other Medical Condition If “Other Medical Condition,” enter the ICD code in the boxes.
I0020A.
Indicate the resident's primary medical condition category that best describes the primary reason for admission
Complete only if A0310B = 01.
Enter Code
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Resident Identifier Date
Section I. Active Diagnoses.
Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Heart/Circulation.
I0200. Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell).
I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema).
I0700. Hypertension.
I0800. Orthostatic Hypotension.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Genitourinary.
I1550. Neurogenic Bladder.
I1650. Obstructive Uropathy.
Infections.
I1700. Multidrug-Resistant Organism (MDRO).
I2000. Pneumonia.
I2100. Septicemia.
I2200. Tuberculosis.
I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS).
I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E).
I2500. Wound Infection (other than foot).
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
I3100. Hyponatremia.
I3200. Hyperkalemia.
I3300. Hyperlipidemia (e.g., hypercholesterolemia).
Musculoskeletal.
I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and
fractures of the trochanter and femoral neck).
I4000. Other Fracture.
Neurological.
I4200. Alzheimer's Disease.
I4300. Aphasia.
I4400. Cerebral Palsy.
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke.
I4800. Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia
such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases).
I4900. Hemiplegia or Hemiparesis.
I5000. Paraplegia.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5250. Huntington's Disease.
I5300. Parkinson's Disease.
I5350. Tourette's Syndrome.
I5500. Traumatic Brain Injury (TBI).
I5400. Seizure Disorder or Epilepsy.
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.
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Resident Identifier Date
Section I. Active Diagnoses.
Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Psychiatric/Mood Disorder.
I5700. Anxiety Disorder.
I5800. Depression (other than bipolar).
I5900. Manic Depression (bipolar disease).
I5950. Psychotic Disorder (other than schizophrenia).
I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders).
I6100. Post Traumatic Stress Disorder (PTSD).
Pulmonary.
I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis).
I6300. Respiratory Failure
Other.
I8000. Additional active diagnoses.
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 24 of 44
Resident Identifier Date
Section J. Health Conditions.
J0100. Pain Management - Complete for all residents, regardless of current pain level.
At any time in the last 5 days, has the resident:
A. Received scheduled pain medication regimen?
0. No.
1. Yes.
Enter Code
B. Received PRN pain medications OR was offered and declined?
0. No.
1. Yes.
Enter Code
C. Received non-medication intervention for pain?
0. No.
1. Yes.
Enter Code
Pain Assessment Interview.
J0300. Pain Presence.
Ask resident: "Have you had pain or hurting at any time in the last 5 days?"
0. No Skip to J1100, Shortness of Breath.
1. Yes Continue to J0400, Pain Frequency.
9. Unable to answer Skip to J0800, Indicators of Pain or Possible Pain.
Enter Code
J0400. Pain Frequency.
Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"
1. Almost constantly.
2. Frequently.
3. Occasionally.
4. Rarely.
9. Unable to answer.
Enter Code
J0500. Pain Effect on Function.
A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"
0. No.
1. Yes.
9. Unable to answer.
Enter Code
B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?"
0. No.
1. Yes.
9. Unable to answer.
Enter Code
J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B).
A. Numeric Rating Scale (00-10).
Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten
as the worst pain you can imagine." (Show resident 00 -10 pain scale)
Enter two-digit response. Enter 99 if unable to answer.
Enter Rating
B. Verbal Descriptor Scale.
Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)
1. Mild.
2. Moderate.
3. Severe.
4. Very severe, horrible.
9. Unable to answer.
Enter Code
J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea) .
0. No (resident is rarely/never understood) Skip to and complete J0800, Indicators of Pain or Possible Pain.
1. Yes Continue to J0300, Pain Presence.
Enter Code
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Resident Identifier Date
Section J. Health Conditions.
J0700. Should the Staff Assessment for Pain be Conducted?
0. No (J0400 = 1 thru 4) Skip to J1100, Shortness of Breath (dyspnea).
1. Yes (J0400 = 9) Continue to J0800, Indicators of Pain or Possible Pain.
Enter Code
Staff Assessment for Pain.
J0800. Indicators of Pain or Possible Pain in the last 5 days.
Check all that apply.
A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning).
B. Vocal complaints of pain (e.g., that hurts, ouch, stop).
C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw).
D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a
body part during movement).
Z. None of these signs observed or documented If checked, skip to J1100, Shortness of Breath (dyspnea).
J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days.
Frequency with which resident complains or shows evidence of pain or possible pain.
1. Indicators of pain or possible pain observed 1 to 2 days.
2. Indicators of pain or possible pain observed 3 to 4 days.
3. Indicators of pain or possible pain observed daily.
Enter Code
Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
B. Shortness of breath or trouble breathing when sitting at rest.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.
J1400. Prognosis.
Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician
documentation).
0. No.
1. Yes.
Enter Code
J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.
C. Dehydrated.
D. Internal bleeding.
Z. None of the above.
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Resident Identifier Date
Section J. Health Conditions.
J1700. Fall History on Admission/Entry or Reentry.
Complete only if A0310A = 01 or A0310E = 1
A. Did the resident have a fall any time in the last month prior to admission/entry or reentry?
0. No.
1. Yes.
9. Unable to determine.
Enter Code
B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
Enter Code
C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
Enter Code
J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more
recent?
0. No Skip to K0100, Swallowing Disorder.
1. Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).
Enter Code
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Coding:
0. None
1. One
2. Two or more
Enter Codes in Boxes
A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the resident; no change in the resident's
behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.
Section K. Swallowing/Nutritional Status.
K0100. Swallowing Disorder.
Signs and symptoms of possible swallowing disorder.
Check all that apply.
A. Loss of liquids/solids from mouth when eating or drinking.
B. Holding food in mouth/cheeks or residual food in mouth after meals.
C. Coughing or choking during meals or when swallowing medications.
D. Complaints of difficulty or pain with swallowing.
Z. None of the above.
K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry.
inches
B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).
pounds
Did the resident have major surgery during the 100 days prior to admission?
0. No.
1. Yes.
8. Unknown.
J2000. Prior Surgery - Complete only if A0310B = 01.
Enter Code
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Resident Identifier Date
Section K. Swallowing/Nutritional Status.
K0300. Weight Loss.
Loss of 5% or more in the last month or loss of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-loss regimen.
2. Yes, not on physician-prescribed weight-loss regimen.
Enter Code
K0310. Weight Gain.
Gain of 5% or more in the last month or gain of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-gain regimen.
2. Yes, not on physician-prescribed weight-gain regimen.
Enter Code
K0510. Nutritional Approaches.
Check all of the following nutritional approaches that were performed during the last 7 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
1.
While NOT a
Resident.
2.
While a
Resident.
Check all that apply
A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids).
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol).
Z. None of the above.
K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only enter a
code in column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If
resident last entered 7 or more days ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
3. During Entire 7 Days.
Performed during the entire last 7 days.
1.
While NOT a
Resident.
2.
While a
Resident.
3.
During Entire
7 Days.
Enter Codes
A. Proportion of total calories the resident received through parenteral or tube feeding.
1. 25% or less.
2. 26-50%.
3. 51% or more.
B. Average fluid intake per day by IV or tube feeding.
1. 500 cc/day or less.
2. 501 cc/day or more.
Section L. Oral/Dental Status.
Check all that apply.
A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).
F. Mouth or facial pain, discomfort or difficulty with chewing.
L0200. Dental
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Resident Identifier Date
Section M. Skin Conditions.
Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.
M0100. Determination of Pressure Ulcer/Injury Risk.
Check all that apply.
A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.
B. Formal assessment instrument/tool (e.g., Braden, Norton, or other).
C. Clinical assessment.
Z. None of the above.
M0150. Risk of Pressure Ulcers/Injuries.
Is this resident at risk of developing pressure ulcers/injuries?
0. No.
1. Yes.
Enter Code
M0210. Unhealed Pressure Ulcers/Injuries.
Does this resident have one or more unhealed pressure ulcers/injuries?
0. No Skip to M1030, Number of Venous and Arterial Ulcers.
1. Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Enter Code
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
Enter Number
1. Number of Stage 1 pressure injuries.
B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0 Skip to M0300C, Stage 3.
Enter Number
2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry.
Enter Number
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4.
Enter Number
2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry .
Enter Number
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device.
Enter Number
2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
M0300 continued on next page.
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Resident Identifier Date
Section M. Skin Conditions.
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F,
Unstageable - Slough and/or eschar.
Enter Number
2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
were noted at the time of admission/entry or reentry.
Enter Number
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0
Skip to M0300G,
Unstageable - Deep tissue injury.
Enter Number
2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
G. Unstageable - Deep tissue injury:
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0
Skip to M1030,
Number of Venous and Arterial Ulcers.
Enter Number
2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
Enter Number
M1030. Number of Venous and Arterial Ulcers.
Enter the total number of venous and arterial ulcers present.
Enter Number
M1040. Other Ulcers, Wounds and Skin Problems.
Check all that apply.
Foot Problems.
A. Infection of the foot (e.g., cellulitis, purulent drainage).
B. Diabetic foot ulcer(s).
C. Other open lesion(s) on the foot.
Other Problems.
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).
E. Surgical wound(s).
F. Burn(s) (second or third degree).
G. Skin tear(s).
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage).
None of the Above.
Z. None of the above were present.
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Resident Identifier Date
Section M. Skin Conditions.
M1200. Skin and Ulcer/Injury Treatments.
Check all that apply.
A. Pressure reducing device for chair.
B. Pressure reducing device for bed.
C. Turning/repositioning program.
D. Nutrition or hydration intervention to manage skin problems.
E. Pressure ulcer/injury care.
F. Surgical wound care.
G. Application of nonsurgical dressings (with or without topical medications) other than to feet.
H. Applications of ointments/medications other than to feet.
I. Application of dressings to feet (with or without topical medications).
Z. None of the above were provided.
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Resident Identifier Date
Section N. Medications.
N0300. Injections.
Enter Days
Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less
than 7 days. If 0 Skip to N0410, Medications Received.
N0350. Insulin.
A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry
or reentry if less than 7 days.
Enter Days
B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's
insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.
Enter Days
N0410. Medications Received.
Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the
last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days.
A. Antipsychotic.
Enter Days
B. Antianxiety.
Enter Days
C. Antidepressant.
Enter Days
D. Hypnotic.
Enter Days
E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin).
Enter Days
F. Antibiotic.
Enter Days
G. Diuretic.
Enter Days
H. Opioid.
Enter Days
N0450. Antipsychotic Medication Review.
A. Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is
more recent?
0. No - Antipsychotics were not received. Skip N0450B, N0450C, N0450D, and N0450E.
1. Yes - Antipsychotics were received on a routine basis only.. Continue to N0450B, Has a GDR been attempted?
2. Yes - Antipsychotics were received on a PRN basis only. Continue to N0450B, Has a GDR been attempted?
3. Yes - Antipsychotics were received on a routine and PRN basis.. Continue to N0450B, Has a GDR been attempted?
Enter Code
B. Has a gradual dose reduction (GDR) been attempted?
0. No Skip to N0450D, Physician documented GDR as clinically contraindicated.
1. Yes Continue to N0450C, Date of last attempted GDR.
Enter Code
C. Date of last attempted GDR:
Month
_
Day
_
Year
N0450 continued on next page
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Resident Identifier Date
Section N. Medications.
N0450. Antipsychotic Medication Review - Continued.
D. Physician documented GDR as clinically contraindicated
0. No - GDR has not been documented by a physician as clinically contraindicated Skip N0450E Date physician documented
GDR as clinically contraindicated.
1. Yes - GDR has been documented by a physician as clinically contraindicated Continue to N0450E, Date physician documented .
GDR as clinically contraindicated.
Enter Code
E. Date physician documented GDR as clinically contraindicated:
Month
_
Day
_
Year
N2001. Drug Regimen Review - Complete only if A0310B = 01.
Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review.
1. Yes - Issues found during review.
9. NA - Resident is not taking any medications.
Enter Code
N2003. Medication Follow-up - Complete only if N2001 =1.
Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?
0. No.
1. Yes.
Enter Code
N2005. Medication Intervention - Complete only if A0310H = 1.
Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No.
1. Yes.
9. NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any
medications.
Enter Code
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.
1.
While NOT a
Resident.
2.
While a
Resident.
Check all that apply
Cancer Treatments.
A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
D. Suctioning.
E. Tracheostomy care.
F. Invasive Mechanical Ventilator (ventilator or respirator).
H. IV medications.
I. Transfusions.
J. Dialysis.
K. Hospice care.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).
Other.
O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period.
A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes Continue to O0250B, Date influenza vaccine received.
Enter Code
B. Date influenza vaccine received
Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date?
Month
_
Day
_
Year
C. If influenza vaccine not received, state reason:
1. Resident not in this facility during this year's influenza vaccination season.
2. Received outside of this facility.
3. Not eligible - medical contraindication.
4. Offered and declined.
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage.
9. None of the above.
Enter Code
O0300. Pneumococcal Vaccine.
A. Is the resident's Pneumococcal vaccination up to date?
0. No Continue to O0300B, If Pneumococcal vaccine not received, state reason.
1. Yes Skip to O0400, Therapies.
Enter Code
B. If Pneumococcal vaccine not received, state reason:
1. Not eligible - medical contraindication.
2. Offered and declined.
3. Not offered.
Enter Code
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0400. Therapies.
A. Speech-Language Pathology and Audiology Services.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400A5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
B. Occupational Therapy.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400B5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
O0400 continued on next page
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0400. Therapies - Continued.
C. Physical Therapy.
Enter Number of Minutes
1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.
Enter Number of Minutes
2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.
Enter Number of Minutes
3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero, skip to O0400C5, Therapy start date
Enter Number of Minutes
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
Enter Number of Days
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.
Month
_
Day
_
Year
6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.
Month
_
Day
_
Year
D. Respiratory Therapy.
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
E. Psychological Therapy (by any licensed mental health professional).
2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
Enter Number of Days
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Resident Identifier Date
Section O. Special Treatments, Procedures, and Programs.
O0420. Distinct Calendar Days of Therapy.
Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days.
Enter Number of Days
O0450. Resumption of Therapy - Complete only if A0310C = 2 or 3 and A0310F = 99.
A. Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of
Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline?
0. No Skip to O0500, Restorative Nursing Programs.
1. Yes
Enter Code
B. Date on which therapy regimen resumed:
Month
_
Day
_
Year
O0500. Restorative Nursing Programs.
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days
(enter 0 if none or less than 15 minutes daily).
Number
of Days.
Technique.
A. Range of motion (passive).
B. Range of motion (active).
C. Splint or brace assistance.
Number
of Days.
Training and Skill Practice In:
D. Bed mobility.
E. Transfer.
F. Walking.
G. Dressing and/or grooming.
H. Eating and/or swallowing.
I. Amputation/prostheses care.
J. Communication.
O0600. Physician Examinations.
Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident?
Enter Days
O0700. Physician Orders.
Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders?
Enter Days
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Resident Identifier Date
Section P. Restraints and Alarms.
P0100. Physical Restraints.
Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that
the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.
Enter Codes in Boxes.
Used in Bed.
A. Bed rail.
B. Trunk restraint.
C. Limb restraint.
D. Other.
Used in Chair or Out of Bed.
E. Trunk restraint.
F. Limb restraint.
G. Chair prevents rising.
H. Other.
P0200. Alarms.
An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.
Enter Codes in Boxes.
A. Bed alarm.
B. Chair alarm.
C. Floor mat alarm.
D. Motion sensor alarm.
E. Wander/elopement alarm
F. Other alarm.
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 38 of 44
Resident Identifier Date
Section Q. Participation in Assessment and Goal Setting.
Q0100. Participation in Assessment.
A. Resident participated in assessment.
0. No.
1. Yes.
Enter Code
B. Family or significant other participated in assessment.
0. No.
1. Yes.
9. Resident has no family or significant other.
Enter Code
C. Guardian or legally authorized representative participated in assessment.
0. No.
1. Yes.
9. Resident has no guardian or legally authorized representative.
Enter Code
Q0300. Resident's Overall Expectation.
Complete only if A0310E = 1.
A. Select one for resident's overall goal established during assessment process.
1. Expects to be discharged to the community.
2. Expects to remain in this facility.
3. Expects to be discharged to another facility/institution.
9. Unknown or uncertain.
Enter Code
B. Indicate information source for Q0300A.
1. Resident.
2. If not resident, then family or significant other.
3. If not resident, family, or significant other, then guardian or legally authorized representative.
9. Unknown or uncertain.
Enter Code
Q0400. Discharge Plan.
A. Is active discharge planning already occurring for the resident to return to the community?
0. No.
1. Yes Skip to Q0600, Referral.
Enter Code
Q0490. Resident's Preference to Avoid Being Asked Question Q0500B.
Complete only if A0310A = 02, 06, or 99.
Enter Code
Does the resident's clinical record document a request that this question be asked only on comprehensive assessments?
0. No.
1. Yes Skip to Q0600, Referral.
Q0500. Return to Community.
B. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond):
"Do you want to talk to someone about the possibility of leaving this facility and returning to live and
receive services in the community?"
0. No.
1. Yes.
9. Unknown or uncertain.
Enter Code
Q0550. Resident's Preference to Avoid Being Asked Question Q0500B Again.
A. Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive
assessments.)
0. No - then document in resident's clinical record and ask again only on the next comprehensive assessment...
1. Yes.
8. Information not available.
Enter Code
B. Indicate information source for Q0550A.
1. Resident...
2. If not resident, then family or significant other.
3. If not resident, family or significant other, then guardian or legally authorized representative.
9. None of the above.
Enter Code
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 39 of 44
Resident Identifier Date
Section Q. Participation in Assessment and Goal Setting.
Q0600. Referral.
Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record)
0. No - referral not needed.
1. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20).
2. Yes - referral made.
Enter Code
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 40 of 44
Resident Identifier Date
Section X. Correction Request.
Complete Section X only if A0050 = 2 or 3.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated).
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
X0200. Name of Resident (A0500 on existing record to be modified/inactivated).
A. First name:
C. Last name:
X0300. Gender (A0800 on existing record to be modified/inactivated).
1. Male
2. Female
Enter Code
X0400. Birth Date (A0900 on existing record to be modified/inactivated).
Month
_
Day
_
Year
X0500. Social Security Number (A0600A on existing record to be modified/inactivated).
_ _
X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).
A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
X0600 continued on next page.
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 41 of 44
Resident Identifier Date
Section X. Correction Request.
X0600. Type of Assessment.- Continued.
D. Is this a Swing Bed clinical change assessment? Complete only if X0150 = 2.
0. No.
1. Yes.
Enter Code
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
X0700. Date on existing record to be modified/inactivated - Complete one only.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99.
Month
_
Day
_
Year
B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12.
Month
_
Day
_
Year
C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01.
Month
_
Day
_
Year
Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter the number of correction requests to modify/inactivate the existing record, including the present one.
Enter Number
X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
E. End of Therapy - Resumption (EOT-R) date.
Z. Other error requiring modification.
If "Other" checked, please specify:
X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 42 of 44
Resident Identifier Date
Section X. Correction Request.
X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:
B. Attesting individual's last name:
C. Attesting individual's title:
D. Signature.
E. Attestation date.
Month
_
Day
_
Year
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 43 of 44
Resident Identifier Date
Section Z. Assessment Administration.
Z0100. Medicare Part A Billing.
A. Medicare Part A HIPPS code (RUG group followed by assessment type indicator):
B. RUG version code:
C. Is this a Medicare Short Stay assessment?
0. No.
1. Yes
Enter Code
Z0150. Medicare Part A Non-Therapy Billing.
A. Medicare Part A non-therapy HIPPS code (RUG group followed by assessment type indicator):
B. RUG version code:
Z0200. State Medicaid Billing (if required by the state).
A. RUG Case Mix group:
B. RUG version code:
Z0250. Alternate State Medicaid Billing (if required by the state).
A. RUG Case Mix group:
B. RUG version code:
Z0300. Insurance Billing.
A. RUG billing code:
B. RUG billing version:
MDS 3.0 Nursing Home Quarterly (NQ) Version 1.16.1 Effective 10/01/2018 Page 44 of 44
Resident Identifier Date
Section Z. Assessment Administration.
Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Signature Title Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:
B. Date RN Assessment Coordinator signed
assessment as complete:
Month
_
Day
_
Year
Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the
copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted
permission to use these instruments in association with the MDS 3.0.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX M: GLOSSARY OF TERMS
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Final Report
Glossary of Terms
Page 1
GLOSSARY OF TERMS
ACH – Acute Care Hospital. An inpatient medical facility providing therapy for severe illness
or injury; average length of stay 30 days or fewer.
ACO – Accountable Care Organization. A network of medical providers, consisting of
hospitals, doctors, home health agencies, and others, that agrees to coordinate and share
the costs associated with the delivery of health care to Medicare patients.
Acute Care – Hospital care given to patients who generally require a stay of several days
that focuses on a physical or mental condition requiring immediate intervention and constant
medical attention, equipment, and personnel.
ADC – Average Daily Census. The average number of inpatients per day. Calculated by
dividing the total number of days patients stayed in a medical care environment during a
certain period by the total number of calendar days in that same period.
ADL – Activities of Daily Living. A measure of independent-living ability based on capacity of
an individual to bathe, dress, use the toilet, eat, and move across a small room without
assistance and used to determine the need for nursing home and other care.
Admission – The formal acceptance of a patient into a hospital or other service setting for
the purpose of providing care.
ADON – Assistant/Associate Director of Nursing. Responsible for helping the director of
nursing with various tasks as well as managing the flow of work around a specific ward;
e.g., speaking with families, handling complaints.
AL – Assisted Living. A living arrangement in which personal care services (e.g., meals,
housekeeping, transportation, assistance with activities of daily living) are available as
needed to people living on their own in a residential facility.
ALOS – Average Length of Stay. A standard hospital statistic used to determine the average
amount of time between admission and departure for patients in a diagnosis-related group
(DRG), an age group, a specific hospital, or other factors.
Ancillary – A term used to describe additional services performed related to care.
A/P – Accounts Payable. Current liabilities incurred in the normal course of business as a
firm purchases goods or services with the understanding that payment is due at a later date.
APM – Alternative Payment Model. A payment approach that rewards providers for delivering
high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care
episode, or a population.
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Final Report
Glossary of Terms
Page 2
A/R – Accounts Receivable. The balance of money due to a firm for goods or services
delivered or used but not yet paid for by customers.
ARD – Assessment Reference Date. This date is the last day of the MDS observation period.
This date refers to a specific endpoint in the MDS assessment process. Almost all MDS items
refer to the resident’s status over a designated time period, most frequently the seven-day
period ending on this date.
Benchmark – A standard by which something can be measured, compared, or judged.
Benchmarking involves measuring another organization’s or person’s product or service by
specific standards and comparing it with one’s own product or service.
BOM – Business Office Manager. An individual who is responsible in part or in whole for
directing and planning a company’s administrative services.
BPCI – Bundled Payments for Care Improvement. The BPCI initiative comprises four broadly
defined models of care, which link payments for multiple services beneficiaries receive during
an episode of care. Under the initiative, organizations enter into payment arrangements that
include financial and performance accountability for episodes of care. These models may
lead to higher quality and more coordinated care at a lower cost to Medicare.
BPCI-A – Bundled Payments for Care Improvement Advanced. BPCI-A is similar to original
BPCI, with some significant differences. Under traditional fee-for-service payment, Medicare
pays providers for each individual service they perform. Under this bundled payment model,
participants can earn additional payment if all expenditures for a beneficiary’s episode of care
are under a spending target that factors in quality.
Bundled Payments – The practice of combining all of the medical expenses for a certain
procedure into one charge.
CAA – Care Area Assessment. Triggered care areas form a critical link between minimum
data set (MDS) and care planning decisions. CAAs cover the majority of problem areas
known to be problematic for nursing home residents.
CBA – Collective Bargaining Agreement. The contractual agreement between an employer
and a Labor Union that governs wages, hours, and working conditions for employees and
which can be enforced against both the employer and the union for failure to comply with its
terms.
CBSA – Core-Based Statistical Area. A U.S. geographic area defined by the Office of
Management and Budget (OMB) that consists of one or more counties (or equivalents)
anchored by an urban center of at least 10,000 people plus adjacent counties that are
socioeconomically tied to the urban center by commuting.
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Final Report
Glossary of Terms
Page 3
CCNH – Chronic and Convalescent Nursing Home. A convalescent home is primarily
designed to provide a home-like environment while patients recover from long-term illnesses
or medical procedures.
CCP – Coordinated Care Plan. A plan that includes a network of providers that are under
contract or arrangement with the Medicare Advantage plan organization to deliver the benefit
package approved by Centers for Medicare & Medicaid Services (CMS).
Census – The number of patients receiving care each day during a reporting period.
CFO – Chief Financial Officer. Person responsible for the financial operations of the
organization.
CJR – Comprehensive Care for Joint Replacement. On November 16, 2018, CMS issued the
final rule for the Comprehensive Care for Joint Replacement (CJR, formerly known as CCJR)
payment model. Under CJR, participation will be mandatory for 791 hospitals in 67
geographic areas. These hospitals will be held accountable for the quality and total Medicare
cost of care provided to Medicare fee-for-service beneficiaries for lower extremity joint
replacement procedures and recovery, including all hip and knee replacement surgeries—
some of the most common inpatient surgeries for Medicare beneficiaries. The hospitals will
be held accountable for CMS defined episode target prices for all Medicare FFS Part A and B
costs of care during the hospital stay as well as Medicare costs for 90 days post-hospital
discharge, including all SNF care; e.g., the episode of care. (42 CFR Part 510).
CMI – Case Mix Index. A relative value assigned to a diagnosis-related group
(DRG/MSDRG) of patients in a medical care environment. The CMI value is used in
determining the allocation of resources to care for and/or treat the patients in the group.
CMP – Civil Money Penalty. A monetary penalty the Centers for Medicare & Medicaid
Services (CMS) may impose against nursing homes for either the number of days or for each
instance a nursing home is not in substantial compliance with one or more Medicare and
Medicaid participation requirements for long-term care facilities.
CMS – Centers for Medicare & Medicaid Services. An agency within the U.S. Department of
Health and Human Services (HHS) that is responsible for the administration of the Medicare
and Medicaid programs.
CNA – Certified Nursing Assistant. An individual who helps patients or clients with health
care needs under the supervision of a registered nurse or a licensed practical nurse.
Coding – A mechanism for identifying and defining physician or medical services.
COPD – Chronic Obstructive Pulmonary Disease. A chronic inflammatory lung disease that
causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough,
mucus (sputum) production and wheezing.
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Final Report
Glossary of Terms
Page 4
Cost Report – The report required from providers on an annual basis in order to make a
proper determination of amounts payable under the Medicare program.
Differential – The out-of-pocket (or payroll deduction) difference that an eligible individual
may be required to pay.
DON – Director of Nursing. A director of nursing has special training beyond the training of a
staff nurse for the position that pertains to health care management and, in some places, a
director of nursing must hold a special license in order to be employed in that capacity.
DRG/MSDRG – Diagnosis Related Group/Medicare-Severity Diagnosis Related Group. A
prospective payment system used by Medicare and other insurers to classify illnesses
according to diagnosis and treatment; DRGs are used to group all charges for hospital
inpatient services into a single ‘bundle’ for payment purposes.
Dual-Eligible – A Medicare beneficiary who also receives the full range of Medicaid benefits
offered in his or her state.
EEOC – Equal Employment Opportunity Commission. The EEOC was created by the Civil
Rights Act of 1964.
Episode of Care – A term used to describe and measure the various health care services
and encounters rendered in connection with identified injury or period of illness.
ESCO – ESRD Seamless Care Organization. An accountable care organization (ACO)
comprised of providers and suppliers who voluntarily come together to form a legal entity that
offers coordinated care to beneficiaries with end-stage renal disease (ESRD) through the
comprehensive ESRD care model.
ESRD – End-Stage Renal Disease. A medical condition in which a person’s kidneys cease
functioning on a permanent basis leading to the need for a regular course of long-term
dialysis or a kidney transplant to maintain life.
Fee-for-Service – A method in which physicians and other health care providers receive a
fee for services performed.
FICA – Federal Insurance Contributions Act.
FLSA – Fair Labor Standards Act.
GPO – Group Purchasing Organization. A GPO leverages the collective buying power of its
members to obtain bulk discounts from retailers.
HC1 – Special Care High 1, ADL score of C, nursing RUG in the RUG-IV 66 payment model
Financial and Operating Review for
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Final Report
Glossary of Terms
Page 5
HDG – Health Dimensions Group. A privately held, for-profit Minnesota corporation that
provides consultation to senior health care settings, hospitals, and health systems. HDG
currently manages over 60 care communities and home health entities throughout the United
States.
HHA – Home health agency. An organization that provides medical, therapeutic, or other
health services in patients’ homes.
HMO – Health Maintenance Organization. Any of a variety of health care delivery systems
with structures ranging from group practice through independent practice models or
independent practice associations (IPAs). They provide alternatives to the fee-for-service
private practice of medicine and other allied health professions.
HMO-POS – Health Maintenance Organization Point-of-Service. A Medicare Advantage plan
that is an HMO with a more flexible network, allowing Plan Members to seek care outside of
the traditional HMO network under certain situations or for certain treatment.
HPPD – Hours per Patient Day. Calculated by taking the total number of nursing staff
providing care divided by the total number of patients in a given day. This number helps to
reflect the actual number of patients on a unit and determine staffing levels.
ICD-10 – International Classification of Diseases (Tenth Revision). A classification of
diseases and health problems in the medical field.
IDEAL Discharge Planning – A guideline and toolkit developed by the Agency for
Healthcare Research and Quality to help nurses and other clinicians involve patients in
discharge planning.
IDT – Interdisciplinary Team. A group of health care professionals from diverse fields who
work in a coordinated fashion toward a common goal for the patient.
IL – Independent Living. Independent and congregate living apartments typically include one
or more meals per day, utilities, activities, scheduled transportation, and light housekeeping
services. Additional services, such as laundry and linen services or extra meals, may be
available for an extra charge.
IPA – Independent Provider Association. An association of independent health care providers
(IPA members) that provide services to managed care, Medicare, managed Medicaid, or
accountable care organization patients on a fee-for-service or negotiated risk-bearing
contractual arrangement while respecting and preserving the individual autonomy of the IPA
members.
LDS – Limited Data Set. A limited data set eliminates certain identifying data so it can be
used for one of several purposes.
Financial and Operating Review for
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Final Report
Glossary of Terms
Page 6
LOS – Length of Stay. The number of days a patient stays in a hospital or other health care
facility.
Long-Term Care – Care given to patients with chronic illnesses who usually require a length
of stay longer than 30 days.
LPN – Licensed Practical Nurse. A nurse who has completed a practical nursing education
program and is licensed by a state to provide routine care under the direction of a registered
nurse or physician.
LTACH – Long-Term Acute Care Hospital. A hospital that specializes in treating patients with
serious and often complex medical conditions requiring a longer length of stay than
customarily provided by a traditional acute care hospital. LTACHs provide care for such
conditions as respiratory failure, non-healing wounds, and other diseases that are medically
complex. Also referred to as a long-term care hospital (LTCH).
Managed Care – A system of health care delivery that influences utilization and cost of
services, and often includes a capitated payment structure and a limited choice of health care
providers.
Market Penetration – The part of the total health care market that a managed care company
has captured.
MCAL – Memory Care Assisted Living. Memory care is a distinct form of long-term skilled
nursing that specifically caters to patients with Alzheimer’s disease, dementia, and other
types of memory problems who are otherwise moderately independent and require
supervised living.
MDS – Minimum Data Set. Part of the U.S. federally mandated process for clinical
assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical
access hospitals with Medicare swing bed agreements.
MDSC – Minimum Data Set (MDS) Coordinator. MDS coordinators oversee and facilitate the
completion of resident assessments at nursing facilities. Throughout the assessment and
while planning care, they ensure compliance with federal and state regulations.
MEC – Minimum Essential Coverage. Any insurance plan that meets the Affordable Care Act
requirement for having health coverage.
Medicaid – A state-administered health insurance program funded partly by the federal
government that provides health care services for certain low-income persons and certain
aged, blind, or disabled individuals.
Medicare – A federal program that provides health insurance benefits primarily to individuals
over the age of 65 and others eligible for Social Security benefits.
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Final Report
Glossary of Terms
Page 7
Medicare Advantage – A type of health insurance plan that provides coverage within
Medicare Part C. Medicare Advantage health plans pay for managed health care based on a
monthly fee per enrollee, rather than on the basis of billing a fee for each medical service
provided (fee-for-service), which is the way original Medicare Parts A and B work.
Medicare Part A – One of two parts of the Medicare program that covers inpatient hospital
services and services furnished by other health care providers such as nursing homes, home
health agencies, and hospices. Part A coverage is automatically provided for individuals
entitled to Medicare.
Medicare Part B – One of two parts of the Medicare program that covers outpatient,
physician, and medical supplier services. Part B coverage is optional and must be paid for
separately through monthly premium payments.
MFFS – Medicare Fee-for-Service. A program that provides hospital insurance (Part A) and
supplementary medical insurance (Part B) to eligible citizens. In general, Part A (hospital
insurance) covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery,
and home health care.
MSA – Metropolitan Statistical Area. A geographical region in the United States with a
relatively high population density at its core and close economic ties throughout the area.
MSS – Medicare Secondary Screening Form.
MSSP – Medicare Shared Savings Program. A voluntary program that encourages groups of
doctors, hospitals, and other health care providers to come together as an ACO to give
coordinated, high quality care to their Medicare beneficiaries.
NTA – Non-therapeutic ancillary payment component of the Patient-driven Payment Model
(PDPM).
OIG – Office of Inspector General. The enforcement arm within the U.S. Department of
Health and Human Services that oversees investigations of alleged violations of Medicare
and Medicaid laws and rules.
PAC – Post-Acute Care. A program introduced to improve the transition from hospital to the
community. PAC facilities provide services to patients needing additional support to assist
them to recuperate following discharge from an acute care hospital.
PASRR – Preadmission Screening and Resident Review. A screening process for mental
disabilities which assures that patients get the proper placement and access to services.
Payor Mix – A type of financial payment received by a medical practice, including Medicare,
Medicaid, indemnity insurance, managed care, and individual payments. It is the percentage
Financial and Operating Review for
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Final Report
Glossary of Terms
Page 8
of income that a medical facility receives from private and government insurance sources
versus self-payments from patients.
PCC – PointClickCare. Cloud-based electronic health records software designed to help
long-term post-acute care providers streamline and manage the complete lifecycle of resident
care.
PCCs – Patient Care Coordinators.
PDPM – Patient-Driven Payment Model. CMS’s new case-mix classification model that,
effective October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective
Payment System (PPS) for classifying SNF patients in a covered Part A stay.
PGP – Physician Group Practice.
PPD – Per Patient Day. Nursing hours per patient day is calculated by taking the total
number of nursing staff providing care divided by the total number of patients in a given day.
This helps to reflect the actual number of patients on a unit and determine staffing levels.
PPO – Preferred Provider Organization. Just like an HMO, a PPO plan offers a network of
health care providers you can use for your medical care.
PPS – Prospective Payment System. A method of financing health care that mandates
payments in advance for the provision of services and is based on diagnostic-related groups.
PRN – Pro Re Nata (as the situation demands/as needed).
PTO – Paid Time Off.
QAPI – Quality Assurance and Performance Improvement. QAPI is the coordinated
application of two mutually-reinforcing aspects of a quality management system: Quality
Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic,
comprehensive, and data-driven approach to maintaining and improving safety and quality in
nursing homes while involving all nursing home caregivers in practical and creative problem
solving.
RHNS – Rest Homes with Nursing Services. A nursing home that provides residential care
for elderly or disabled people that often includes around-the-clock nursing care.
RN – Registered Nurse. A person qualified by an approved post-secondary program or
baccalaureate in nursing and licensed by the state to practice nursing.
RTA – Resident Trust Account. A trust that is held by a long-term care facility that helps
residents manage their finances and pay for expenses within the nursing home, such as care
provided, treatments at the in-house beauty shop, or outings.
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Final Report
Glossary of Terms
Page 9
RU/RV – Rehab Ultra-High/Rehab Very High. Rehabilitation categories used for coding
therapy minutes on the MDS.
RUC – Rehab Ultra-High, ADL score C, rehab RUG in the RUG-IV 66 payment model.
RUG – Resource Utilization Group. A patient classification system for nursing home patients
used by the federal government and some states to determine reimbursement levels for
nursing home care.
SNF – Skilled Nursing Facility. A type of nursing home recognized by the Medicare and
Medicaid systems as meeting long-term health care needs for individuals who have the
potential to function independently after a limited period of care.
SNP – Special Needs Plan. A Medicare Advantage coordinated care plan specifically
designed to provide targeted care and limit enrollment to special needs individuals.
C-SNP – Chronic Condition Special Needs Plan. This plan serves beneficiaries with
certain severe or disabling chronic health conditions.
D-SNP – Dual-Eligible Special Needs Plan. D-SNPs enroll individuals who are entitled to
both Medicare and medical assistance from a state plan under Medicaid. States cover
some Medicare costs, depending on the state and the individual’s eligibility.
I-SNP – Institutional Special Needs Plan. I-SNPs restrict enrollment to Medicare
Advantage eligible individuals who, for 90 days or longer, require or are expected to
need the level of services provided in a long-term care skilled nursing facility, a long-
term care nursing facility, a SNF/NF, an intermediate care facility for the developmentally
disabled, an inpatient psychiatric facility, or an assisted living facility.
TNW – The Nathaniel Witherell. A short-term rehabilitation and skilled nursing center located
two miles from the Town of Greenwich, Connecticut.
Triple Check – An internal audit process to ensure billing accuracy and compliance with
regulatory guidelines prior to submission of claims to Medicare/Managed Care providers for
review and payment. It is a multi-level process requiring a group effort of interdisciplinary
team (IDT) members while providing a check and balance to the entire admission process for
new Medicare A/Managed Care residents.
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Appendices Appendix A: BPCI Advanced Participants Located near (Town of Greenwich)

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Completed 23 January 2021

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