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Chapter 8: Documentation for Certified Nursing Homes

INTRODUCTION

OBJECTIVES

Following completion of this chapter, the reader will be able to:

  • Understand who is responsible for completing the Minimum Data Set (MDS).

  • Describe the role of the Minimum Data Set (MDS) in patient care in a Skilled Nursing Facility (SNF).

  • Explain how each of the 20 Care Area Assessment (CAA) areas is related to physical therapy.

  • Describe the Resident Assessment Instrument (RAI) processes and the relationship to the Minimum Data Set (MDS).

  • Explain the theory of the Patient-Driven Payment Model (PDPM).

DOCUMENTATION FOR CERTIFIED NURSING HOMES (MINIMUM DATA SET)

The Skilled Nursing Facility (SNF) Patient-Driven Payment Model (PDPM) began October 1, 2019 (the start of Medicare’s fiscal year 2020), marking a significant difference in the SNF payment system. PDPM replaced the Resource Utilization Group (RUG) reimbursement model.

RESIDENT ASSESSMENT INSTRUMENT

The Resident Assessment Instrument (RAI) consists of three basic components: the Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process, and the RAI Utilization Guidelines.

The MDS (see Figure 8-1) is used for an important set of processes beyond the Prospective Payment System (PPS).1 The MDS is a data collection tool designed to cue facilities to develop care plans that will affect critical components of a resident’s health and quality of life. MDS data is also used to assist state agencies in monitoring the quality and safety of skilled nursing facilities.

Figure 8-1

MDS 3.0. (Reproduced from MDS 3.0. Centers for Medicare & Medicaid Services; Baltimore, MD. Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-SECTIONS-A-AND-GG-DOCUMENT.pdf. Accessed July 20, 2020.)

A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening. The minimum data set version 3.0. resident assessment and care screening reads, Section A: Identification Information. A0050. Type of Record. Enter code: 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. A0100. Facility Provider Numbers. A. National Provider Identifier (NPI): B. CMS Certification Number (CCN): C. State Provider Number: A0200. Type of Provider. Enter Code for Type of provider. 1. Nursing home (SNF/NF). 2. Swing Bed. 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. PPS Scheduled Assessments for a Medicare Part A Stay. Enter Code B. PPS 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. 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 equals 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 10 or 11. 1. Planned. 2. Unplanned. Enter Code H. Is this a SNF PPS Part A Discharge (End of Stay) 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 open quotes plus closed quotes if pending, open quotes N closed quotes 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 open quotes / closed quotes between two occupations: A1500. Preadmission Screening and Resident Review (PASRR). Complete only if A0310A equals 01, 03, 04, or 05 Is the resident currently considered by the state level 2 PASRR process to have serious mental illness and/or intellectual disability (open quotes mental retardation closed quotes in federal regulation) or a related condition? 0. No Skip to A1550, Conditions Related to ID/DD Status. 1. Yes Continue to A1510, Level 2 Preadmission Screening and Resident Review (PASRR) Conditions. 9. Not a Medicaid-certified unit Skip to A1550, Conditions Related to ID/DD Status. Enter Code A1510. Level 2 Preadmission Screening and Resident Review (PASRR) Conditions. Complete only if A0310A equals 01, 03, 04, or 05. Check all that apply. A. Serious mental illness. B. Intellectual Disability (open quotes mental retardation closed quotes in federal regulation). C. Other related conditions. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, Section A. Identification Information. A1550. Conditions Related to ID/DD Status. If the resident is 22 years of age or older, complete only if A0310A equals 01. If the resident is 21 years of age or younger, complete only if A0310A equals 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 equals 10, 11, or 12 Month, Day, Year. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, Section A. Identification Information. A2100. Discharge Status. Complete only if A0310F equals 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 equals 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. 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 or TOUCHING/STEADYING 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 e ort. 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. 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 to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency. B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 1. Admission Performance. 2. Discharge Goal. Enter Codes in Boxes 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 safely 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 safely come to a standing position from sitting in a chair or on the side of the bed. E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair). F. Toilet transfer: The ability to safely get on and o a toilet or commode. H1. Does the resident walk? 0. No, and walking goal is not clinically indicated. Skip to GG0170Q1, Does the resident use a wheelchair/scooter? 1. No, and walking goal is clinically indicated Code the resident's discharge goal(s) for items GG0170J and GG0170K. 2. Yes Continue to GG0170J, Walk 50 feet with two turns. 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. Q1. Does the resident use a wheelchair/scooter? 0. No Skip to GG0130, Self Care. 1. Yes. Continue to GG0170R, Wheel 50 feet with two turns. R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, can wheel at least 50 feet and make two turns. RR1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space. SS1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equal to 2 and A0310H equals 1 and A2400C minus A2400B is greater than 2 and A2100 is not equal to 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 3. Discharge Performance. A. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/ tray. Includes modified food consistency. Enter Code B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] Enter Code C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equal to 2 and A0310H equal to 1 and A2400C minus A2400B is greater than 2 and A2100 is not equal to 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 3. Discharge Performance. Enter Codes in Boxes 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 safely 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 safely come to a standing position from sitting in a chair or on the side of the bed. E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair). F. Toilet transfer: The ability to safely get on and off a toilet or commode. H3. Does the resident walk? 0. No Skip to GG0170Q3, Does the resident use a wheelchair/scooter? 2. Yes Continue to GG0170J, Walk 50 feet with two turns 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. Q3. Does the resident use a wheelchair/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, can wheel at least 50 feet and make two turns.RR3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space. SS3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.
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A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening. The minimum data set version 3.0. resident assessment and care screening reads, Section A: Identification Information. A0050. Type of Record. Enter code: 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. A0100. Facility Provider Numbers. A. National Provider Identifier (NPI): B. CMS Certification Number (CCN): C. State Provider Number: A0200. Type of Provider. Enter Code for Type of provider. 1. Nursing home (SNF/NF). 2. Swing Bed. 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. PPS Scheduled Assessments for a Medicare Part A Stay. Enter Code B. PPS 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. 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 equals 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 10 or 11. 1. Planned. 2. Unplanned. Enter Code H. Is this a SNF PPS Part A Discharge (End of Stay) 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 open quotes plus closed quotes if pending, open quotes N closed quotes 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 open quotes / closed quotes between two occupations: A1500. Preadmission Screening and Resident Review (PASRR). Complete only if A0310A equals 01, 03, 04, or 05 Is the resident currently considered by the state level 2 PASRR process to have serious mental illness and/or intellectual disability (open quotes mental retardation closed quotes in federal regulation) or a related condition? 0. No Skip to A1550, Conditions Related to ID/DD Status. 1. Yes Continue to A1510, Level 2 Preadmission Screening and Resident Review (PASRR) Conditions. 9. Not a Medicaid-certified unit Skip to A1550, Conditions Related to ID/DD Status. Enter Code A1510. Level 2 Preadmission Screening and Resident Review (PASRR) Conditions. Complete only if A0310A equals 01, 03, 04, or 05. Check all that apply. A. Serious mental illness. B. Intellectual Disability (open quotes mental retardation closed quotes in federal regulation). C. Other related conditions. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, Section A. Identification Information. A1550. Conditions Related to ID/DD Status. If the resident is 22 years of age or older, complete only if A0310A equals 01. If the resident is 21 years of age or younger, complete only if A0310A equals 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 equals 10, 11, or 12 Month, Day, Year. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, Section A. Identification Information. A2100. Discharge Status. Complete only if A0310F equals 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 equals 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. 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 or TOUCHING/STEADYING 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 e ort. 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. 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 to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency. B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 1. Admission Performance. 2. Discharge Goal. Enter Codes in Boxes 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 safely 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 safely come to a standing position from sitting in a chair or on the side of the bed. E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair). F. Toilet transfer: The ability to safely get on and o a toilet or commode. H1. Does the resident walk? 0. No, and walking goal is not clinically indicated. Skip to GG0170Q1, Does the resident use a wheelchair/scooter? 1. No, and walking goal is clinically indicated Code the resident's discharge goal(s) for items GG0170J and GG0170K. 2. Yes Continue to GG0170J, Walk 50 feet with two turns. 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. Q1. Does the resident use a wheelchair/scooter? 0. No Skip to GG0130, Self Care. 1. Yes. Continue to GG0170R, Wheel 50 feet with two turns. R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, can wheel at least 50 feet and make two turns. RR1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space. SS1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equal to 2 and A0310H equals 1 and A2400C minus A2400B is greater than 2 and A2100 is not equal to 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 3. Discharge Performance. A. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/ tray. Includes modified food consistency. Enter Code B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] Enter Code C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equal to 2 and A0310H equal to 1 and A2400C minus A2400B is greater than 2 and A2100 is not equal to 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 3. Discharge Performance. Enter Codes in Boxes 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 safely 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 safely come to a standing position from sitting in a chair or on the side of the bed. E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair). F. Toilet transfer: The ability to safely get on and off a toilet or commode. H3. Does the resident walk? 0. No Skip to GG0170Q3, Does the resident use a wheelchair/scooter? 2. Yes Continue to GG0170J, Walk 50 feet with two turns 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. Q3. Does the resident use a wheelchair/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, can wheel at least 50 feet and make two turns.RR3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space. SS3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.
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A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening. The minimum data set version 3.0. resident assessment and care screening reads, Section A: Identification Information. A0050. Type of Record. Enter code: 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. A0100. Facility Provider Numbers. A. National Provider Identifier (NPI): B. CMS Certification Number (CCN): C. State Provider Number: A0200. Type of Provider. Enter Code for Type of provider. 1. Nursing home (SNF/NF). 2. Swing Bed. 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. PPS Scheduled Assessments for a Medicare Part A Stay. Enter Code B. PPS 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. 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 equals 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 10 or 11. 1. Planned. 2. Unplanned. Enter Code H. Is this a SNF PPS Part A Discharge (End of Stay) 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 open quotes plus closed quotes if pending, open quotes N closed quotes 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 open quotes / closed quotes between two occupations: A1500. Preadmission Screening and Resident Review (PASRR). Complete only if A0310A equals 01, 03, 04, or 05 Is the resident currently considered by the state level 2 PASRR process to have serious mental illness and/or intellectual disability (open quotes mental retardation closed quotes in federal regulation) or a related condition? 0. No Skip to A1550, Conditions Related to ID/DD Status. 1. Yes Continue to A1510, Level 2 Preadmission Screening and Resident Review (PASRR) Conditions. 9. Not a Medicaid-certified unit Skip to A1550, Conditions Related to ID/DD Status. Enter Code A1510. Level 2 Preadmission Screening and Resident Review (PASRR) Conditions. Complete only if A0310A equals 01, 03, 04, or 05. Check all that apply. A. Serious mental illness. B. Intellectual Disability (open quotes mental retardation closed quotes in federal regulation). C. Other related conditions. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, Section A. Identification Information. A1550. Conditions Related to ID/DD Status. If the resident is 22 years of age or older, complete only if A0310A equals 01. If the resident is 21 years of age or younger, complete only if A0310A equals 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 equals 10, 11, or 12 Month, Day, Year. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, Section A. Identification Information. A2100. Discharge Status. Complete only if A0310F equals 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 equals 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. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. 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 or TOUCHING/STEADYING 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 e ort. 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. 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 to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency. B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equals 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 1. Admission Performance. 2. Discharge Goal. Enter Codes in Boxes 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 safely 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 safely come to a standing position from sitting in a chair or on the side of the bed. E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair). F. Toilet transfer: The ability to safely get on and o a toilet or commode. H1. Does the resident walk? 0. No, and walking goal is not clinically indicated. Skip to GG0170Q1, Does the resident use a wheelchair/scooter? 1. No, and walking goal is clinically indicated Code the resident's discharge goal(s) for items GG0170J and GG0170K. 2. Yes Continue to GG0170J, Walk 50 feet with two turns. 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. Q1. Does the resident use a wheelchair/scooter? 0. No Skip to GG0130, Self Care. 1. Yes. Continue to GG0170R, Wheel 50 feet with two turns. R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, can wheel at least 50 feet and make two turns. RR1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space. SS1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equal to 2 and A0310H equals 1 and A2400C minus A2400B is greater than 2 and A2100 is not equal to 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 3. Discharge Performance. A. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/ tray. Includes modified food consistency. Enter Code B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.] Enter Code C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. A screenshot shows minimum data set (mds) - version 3.0. resident assessment and care screening continued from the previous page. The minimum data set version 3.0. resident assessment and care screening continued from the previous page reads, 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 equal to 2 and A0310H equal to 1 and A2400C minus A2400B is greater than 2 and A2100 is not equal to 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 or TOUCHING/STEADYING 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. 88. Not attempted due to medical condition or safety concerns. 3. Discharge Performance. Enter Codes in Boxes 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 safely 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 safely come to a standing position from sitting in a chair or on the side of the bed. E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair). F. Toilet transfer: The ability to safely get on and off a toilet or commode. H3. Does the resident walk? 0. No Skip to GG0170Q3, Does the resident use a wheelchair/scooter? 2. Yes Continue to GG0170J, Walk 50 feet with two turns 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. Q3. Does the resident use a wheelchair/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, can wheel at least 50 feet and make two turns.RR3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized. S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space. SS3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.
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Under the PDPM (effective October 1, 2019), there are three SNF PPS assessments: the 5-day assessment, the Interim Payment Assessment (IPA), and the PPS Discharge Assessment. The 5-day assessment and the PPS Discharge Assessment are required. The IPA is optional and will be completed when providers determine that the patient has undergone a clinical change that would require a new PPS assessment. The goal of this change was to improve payments by focusing on the patient rather than the volume of services provided.4

The schedule of PPS assessments under PDPM may be found in Table 8-1.

Table 8-1Schedule of PPS assessments under PDPM
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Table 8-1 Schedule of PPS assessments under PDPM

MEDICARE MIDS ASSESSMENT SCHEDULE TYPE

ASSESSMENT REFERENCE DATE

APPLICABLE STANDARD MEDICARE PAYMENT DAYS

5-day PPS Assessment

Days 1–8

All covered Part A days until Part A discharge (unless an IPA is completed).

Interim Payment Assessment (PA)

The date the facility chooses to complete the IPA relative to the triggering event that causes the facility ...

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