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MDS 3.0 article

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#1 penkay



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Posted 26 May 2010 - 11:24 AM

MDS 3.0 update


A Closer Look at the MDS 3.0:
News and Overview for Activity and Recreation Professionals
By Kimberly Grandal, CTRS, ACC/EDU
February 8, 2010

The MDS 3.0 implementation date is scheduled for October 1, 2010. CMS
highly recommends that everyone should hold back from training until
the "Train-the-Trainer" sessions have been completed. The
Train-The-Trainer sessions are scheduled for the spring of 2010.
it’s still too early to start training the staff on how to complete the
MDS 3.0, it’s important to keep abreast of any MDS 3.0 news. The RAI
Manual is available for download. It’s not too early to start reviewing
these materials and familiarize yourself with the new terminology, form
design and layout, and the process. This way you will be more prepared
ask questions when you are presented with specific training
I’ve begun reading various components of the RAI Version 3.0 Manual. The
following is a summary of what I have gathered to date.

Advantages of the MDS 3.0
A 5-year CMS Nursing Home MDS 3.0 Validation Study suggests that the MDS
3.0 has many advantages such as:
• Increased resident’s voice
• Increased clinical relevance for assessment
• Increased accuracy, both validity and reliability
• Increased clarity and efficiency
• 45% reduction in the average time for completion
• Supports the movement of items toward future electronic formats

• The CMS website has the MDS 3.0 materials, forms, timetables, RAI User
Manual, etc. available for download. Visit
To download the MDS 3.0 RAI user manual scroll down the page and click
MDS 3.0 RAI Manual Jan 2010. The section for Customary Routine and
Activities is called section F and is located in the Chapter 3 file
folder. The section which refers to Recreation Therapy can be found in
section 0, Special Treatments and Procedures.
• You can also download sections F and O at
• Other items to download on the CMS website include:
o MDS 3.0 Item Subsets – A file that contains the various subsets of the
MDS 3.0 assessment and tracking document such as admission, quarterly,
annual, significant change, discharge, etc.
o MDS 3.0 Item Matrix - This document identifies the items required for
each type of assessment along with how the item is used (e.g. QMs, QIs,
o MDS 3.0 Data Submission Specifications - Detailed data submission
specifications for MDS 3.0.
o MDS 3.0 CATs Specifications - This document provides Care Area Trigger
(CAT) specifications for the MDS 3.0 items used in triggering the Care
Area, the conditions for triggering, and Visual Basic code for
CMS provided a webcast, entitled, MDS 3.0: Part 1- An Introduction, on
December 17, 2009. You can view this archived webcast for free at
• This webcast was the first of a three part series focused on providing
information about the MDS 3.0. The other webcasts in the series include:
o 2nd Part: Coding the MDS 3.0 (late spring/early summer, 2010)
o 3rd Part: CMS Programs impacted by the MDS 3.0 (summer, 2010

Resident Assessment Instrument Overview
The Resident Assessment Instrument (RAI) version 3.0 is no different
the 2.0 version in that it is a structured, standardized approach for
applying a problem identification process in nursing homes. Completion
the RAI includes: assessment, decision making, care planning, care plan
implementation and evaluation.

Care Area Assessment
The Care Area Assessment (CAA) process provides guidance on how to focus
on problems, concerns or important issues that are identified in the
comprehensive and MDS assessment. There are 20 CAA-s which include:

01. Delirium
02. Cognitive Loss/Dementia
03. Visual Function
04. Communication
05. ADL Function/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

The MDS 3.0 identifies the actual or potential problem areas and the CAA
process provides for further assessment. Care Area Triggers (CATs)
replaced the MDS 2.0 Resident Assessment Protocol (RAPs). The triggers
identify those who have or are at risk for developing various functional
problems in any of the 20 CAAs and directs staff to evaluate further.
Care Area Resources is a list of resources that may be helpful in
performing the assessment of a triggered care area. The Care Area
(Section V of the MDS 3.0), provides a location for documentation of the
care areas that have triggered from the MDS and the decisions made
the CAA process regarding whether or not to proceed with care planning.

Just as with the MDS 2.0, further documentation for each triggered CAA
required. Documentation for each triggered CAA should describe:
• The nature of the issue, concern or condition
• Causes and contributing factors
• Complications related to the specific care area
• Risk factors
• Need for referral or further evaluation by appropriate health care
• What research, resources or assessment tools were utilized

There are four types of triggers which can change how the CAA is
• Potential Problems
• Broad Screening Triggers
• Prevention of Problems
• Rehabilitation Potential

In terms of activities, the purpose of the CAA is to identify strategies
to assist the resident in increasing their involvement in meaningful
activities that have been of interest to them in the past and to help
find new or adapted activities of interest to accommodate their current
level of functioning. The CAA for activities is triggered when there are
indications that the resident may have a decrease in involvement in
activities. The information from the assessment should be used to
residents who may be uneasy in social relationships and activities. In
addition, assessment information is to identify resident interests and
identify possible causes or risk factors.

Chapter 4 of the CMS RAI Version Manual also addresses care planning.
for care planning are provided. The manual indicates six general care
planning areas:
• Functional status
• Rehabilitation/Restorative Nursing
• Health Maintenance
• Discharge Potential
• Medications Daily Care Needed

When residents trigger for activities, the CMS RAI Version 3.0 manual
states that the focus of the care plan should be to address the
cause(s) and the development of the inclusion of activity programs
customized to the resident’s interests and his or her abilities.
Activities should focus on helping the resident fulfill his/her wishes,
use cognitive skills and provide enjoyment as well opportunities for
socialization with others.

Preferences for Customary Routine and Activities (Section F)
A section with significant revisions is the “Preferences for Customary
Routine and Activities”. The customary routine staff assessment is
replaced by the MDS 3.0 Preference Assessment Tool. Residents are to be
interviewed for their activity interests and routine preferences. The
Version 3.0 Manual suggests various ways for the interviewer to phrase
questions, probe for clarification of residents’ responses and to
adaptive techniques such as cue cards, an interpreter, opportunity to
write out answers, etc. The residents are to rate the level of
by using the following codes:
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can’t do or no choice (meaning the resident finds it
important but feel he/she cannot do that at this time because of health
because of nursing home resources or scheduling.
9. No response or non-responsive (resident, family or significant other
refuses to answer or doesn’t know, if the resident does not respond to
question, or provides a nonsensical response. A nonsensical response is
defined as, “any unrelated, incomprehensible or incoherent response that
is not informative with respect to the item being rated”.
When coding the activity preferences interview, no look back is
The resident is to respond to their current preferences while in the
facility. Family members and significant others may be the primary
respondent to the interview questions if the resident is unable to do
In this case, the family member or significant other may have to
past preferences if they are unsure of current preferences and the
resident is unable to communicate.
There is a series of questions that relates to the resident’s
for daily routine such as bathing, bedtime, clothing, etc. The questions
relating to activities include:
• How important is it to you to have books, newspapers, and magazines to
• How important is it to you to listen to music you like?
• How important is it to you to be around animals such as pets?
• How important is it to you to keep up with the news?
• How important is it to you to do things with groups of people?
• How important is it to you to do your favorite activities?
• How important is it to you to go outside to get fresh air when the
weather is good?
• How important is it to you to participate in religious services or
For residents who cannot answer the questions and a family member or
significant other is not available to answer on behalf of the resident,
staff assessment of activities and daily preferences is conducted. Staff
is instructed to observe the resident’s response during activity
A variety of routine and activity preferences are listed and staff is to
check off each item as it applies in the last 7 days. The items listed
as follows:
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 of significant other involvement in care discussions
J. Use of phone in private
K. Place to lock personal belongings L. Reading books, newspapers, or
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

In a sample of individuals that completed the revised Preferences for
Customary Routine and Activities (Section F), findings indicated that:
• 81% rated the interview items as more useful for care planning
• 80% found that the interview changed their impression of resident’s
• 1% felt that some residents who responded didn’t really understand the
• More likely to report that post-acute residents appreciated being
Special Treatments and Therapies (Section O)
The RAI Version 3.0 Manual states that recreational therapy is not a
skilled service according to the Social Security Act however, for
of the MDS, providers should record services for recreational therapy
the conditions for the provision of recreation therapy are as follows:
• The physician orders recreation therapy that provides therapeutic
stimulation beyond the general activity program;
• The physicians order must include a statement of frequency, duration
scope of treatment;
• The services must be directly and specifically related to an active
written treatment plan that is based on an initial evaluation performed
a therapeutic recreation specialist;
• The services are required and provided by a state licensed or
certified therapeutic recreation specialist or therapeutic recreation
assistant who is under the direct supervision of a therapeutic
specialist; and
• The services must be reasonable and necessary for the resident’s
The assessor records the number of days and the minutes that recreation
therapy was administered over the 7 day look back period. Sessions must
at least 15 minutes in length. The RAI Version 3.0 Manual states that
therapy logs are not a MDS requirement but is standard of good clinical
practice by all therapy professionals.
It’s also important to note that when two clinicians work together,
may be common with a recreational therapist and an occupational
the clinicians must split the time between the two disciplines.
Music Therapy is included under Recreational Therapy as well.
• Visit the CMS website regularly using the link I provided above.
• Download and print the items that are available on the CMS website and
put it in a binder.
• Read the RAI User Manual and review all MDS 3.0 materials.
• Write down your questions as you read the manual. Have these questions
available during formal training sessions.
• Please share what you have learned with others. You can email me and I
will post news and information at
http://www.recreativeresources.com/MDS3.0.htm as I receive it. I will
address MDS 3.0 issues on my Facebook group page at

Kim Grandal ACC/EDU, is the Executive Director of Re-Creative Resources,
Inc (www.recreativeresources.com), and serves as a government relations
liason to NCCAP. Kim has given her permission for Activity Directors Network to post this
article and we thank her.

#2 bigchris


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Posted 28 June 2010 - 08:43 AM

I saw this article as I was doing research on my own article, specific for activity directors. As I was writing, the Nursing Home association was condicting a class and they had to cancel a good portion of it. Why? CMS is still changing the MDS 3.0 documents and overall program. Needless to say, I put a pause on my article!

I have calls in to CMS now but all they say id that yes, we are still making changes that will alter the final draft......so stay tuned folks.

#3 bigchris


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Posted 23 July 2010 - 07:05 AM

It should be noted that CMS has finally "finished" MDS 3.0 and has information on thier web site. As I collect it , I will relay it to you all.


I saw this article as I was doing research on my own article, specific for activity directors. As I was writing, the Nursing Home association was condicting a class and they had to cancel a good portion of it. Why? CMS is still changing the MDS 3.0 documents and overall program. Needless to say, I put a pause on my article!

I have calls in to CMS now but all they say id that yes, we are still making changes that will alter the final draft......so stay tuned folks.