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MDS 3.0 article

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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.


its still too early to start training the staff on how to complete the

MDS 3.0, its important to keep abreast of any MDS 3.0 news. The RAI


Manual is available for download. Its 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


Ive 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 residents 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 residents 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 cant 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 doesnt 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 residents


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 residents 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 residents


1% felt that some residents who responded didnt 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 residents


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.

Its 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.

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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.

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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.

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