August 29, 2013
ALTSA: NH #2013-015
MINIMUM DATA SET (MDS) 3.0 DISCHARGE ASSESSMENTS
THAT HAVE NOT BEEN COMPLETED AND/OR SUBMITTED
Dear Nursing Facility/Home Administrator
The purpose of this letter is to inform you that CMS is providing an opportunity to rectify the current situation related to missing and incomplete discharge assessments. Facilities must complete steps to address the completion and submission of discharge assessments as soon as possible, but no later than September 30, 2013. Beginning October 1, 2013, MDS assessments older than 3 years will no longer be accepted. View memo S&C-13-56-NH in full
The failure to submit or complete MDS 3.0 discharge assessment records leads to inaccurate MDS 3.0 Quality Measures (QMs) data, potentially affecting the resident, the facility's payment, and facility liabilities. Failure to submit or complete MDS 3.0 discharge assessment records can also lead to citation of a facility under 42 CFR §483.20(f) and 42 CFR §483.20(g). Inaccurate MDS 3.0 Quality Measures (QMs) data affects the 5 Star Rating that appears on Nursing Home Compare.
Effective immediately:
CMS is requiring facilities to take the following steps when facilities have not completed discharge assessments and/or have not submitted discharge assessments prior to September 30, 2013:
- Identify any residents appearing on the facility's current MDS 3.0 Roster report who are no longer active residents.
- If the resident was discharged prior to October 1, 2012, a discharge assessment must be completed for the resident indicating the actual date of discharge in Item A2000, Discharge Date. This assessment must have demographic information completed in Section A. Clinical information in Sections B through Z must be dash-filled. Items Z0400, Signatures of Persons Completing the Assessment or Entry/Death Reporting, and Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, must reflect the actual completion date of this assessment.
- If the resident was discharged on or after October 1, 2012, a discharge assessment must be completed for the resident indicating the actual date of discharge in Item A2000, Discharge Date. This assessment must have demographic information completed in Section A. Clinical information in Sections B through Z must be completed as much as possible to reflect the actual status of the resident at the time of discharge. The following coding instruction is applicable for coding BIMS, PHQ-9 and Pain interviews for these late discharge assessments: In lieu of the interviews, the staff assessments should be completed if appropriate based on the clinical record information that is available. In this case the gateway questions (Items C0100, D0100 and/or J0200) should be coded No (0) and the staff assessment should be completed. Z0400, Signatures of Persons Completing the Assessment or Entry/Death Reporting, and Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, must reflect the actual completion date of this assessment.
Please direct any additional questions or concerns regarding this topic to Judy Bennett, CPA, Washington State MDS Automation Coordinator, at (360) 725-2620 or e-mail bennej@dshs.wa.gov or Sandy Kerrigan, RN, Washington State RAI Coordinator, at (360) 725-2487 or e-mailSandy.Kerrigan@dshs.wa.gov
Sincerely,
E. Irene Owens, Interim Director
Residential Care Services