Minimum Data Set (MDS)
Click here for MDS Resources
Click here for MDS Training
- Patient Driven Payment Model (PDPM) Q&A
- MDS 3.0 RAI Manual (v1.16R) Errata
- CMS Based trainings
For questions, contact John Kane
•Transition to Payroll-Based Journal (PBJ) Data – Starting in April, 2018, CMS will use PBJ data to determine each facility’s staffing measure on the Nursing Home Compare tool on Medicare.gov website, and calculate the staffing rating used in the Nursing Home Five Star Quality Rating System
.•Staffing data audits - We are providing lessons-learned from audits conducted, and guidance to facilities for improving their accuracy. Nursing homes whose audit identifies significant inaccuracies between the hours reported and the hours verified, or facilities who fail to submit any data by the required deadline will be presumed to have low levels of staff. This will result in a one-star rating in the staffing domain, which will drop their overall (composite) star rating by one star for a quarter.
•Requirement for registered nurse (RN) staffing – We are reminding nursing homes of the importance of RN staffing and the requirement to have an RN onsite 8 hours a day, 7 days a week. Nursing homes reporting 7 or more days in a quarter with no RN hours will receive a one-star rating in the staffing domain, which will drop their overall (composite) star rating by one star for a quarter. This action will be implemented in July 2018, after the May 15, 2018 submission deadline for data for 2018 Calendar Quarter 1, 2018 (January –March, 2018) data.
•Technical assistance – CMS is continuing its efforts to help nursing homes submit accurate data, and there are a variety of ways described below in which facilities can seek support
•Future Actions – As of June 1, 2018, we will no longer collect facility staffing data through the CMS-671 form, and we will announce other future activities.
Payroll Based Journal (PBJ) Fiscal Quarter 1 2018 Deadline:
Fiscal Quarter 1 2018 Deadline
The deadline for data submission for Fiscal Quarter 1 2018 (October 1 – December 31) is February 14, 2018, 11:59 PM EST. Data submission for this quarter will be temporarily unavailable beginning at 12:01 AM EST February 15, 2018. CMS will re-open for late data submission for this quarter within approximately 24 hours. A message will be added to the Updates and Alerts section when this quarter is available again for submission. Data submission for Fiscal Quarter 2 2018 (January 1 - March 31) will be available during this time.
To all MDS Coordinators and Administrators:
The updated RAI User’s Manual files have been posted to the CMS MDS 3.0 RAI Manual webpage at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.
The RAI User’s Manual files, including the single PDF electronic version, located in the Related Links section of the webpage, have been updated to include the revised Sections I, N and P, per the Errata released on December 15, 2017. Updated manual pages are marked with the footer “October 2017 (R).”
- MDS 3.0 RAI Manual v1.15R October 1, 2017 (R)
- MDS 3.0 RAI Manual v1.15R and Change Tables October 1, 2017 (R)
The Errata file released December 15, 2017 is still located in the Downloads section of the Webpage for reference and contains the associated replacement pages.
Effective December 19, 2017:
Two new user-requested Quality Measure reports will be available in the SNF Quality Reporting Program report category in the CASPER Reporting application. The two new reports are as follows:
• SNF QRP Facility-Level Quality Measure Report
This report provides facility-level quality measure values for a select 12-month period. SNF quality measure values for this report are compiled from the following sources:
- MDS 3.0 assessment data - Medicare Fee-For-Service (FFS) claims - and Eligibility Files
• SNF QRP Resident-Level Quality Measure Report
This report identifies each resident with a qualifying MDS 3.0 Medicare Part A Stay (SNF Stay) used to calculate the facility-level quality measure values for a select 12-month period.
Elizabeth Ayello has published an article on the MDS 3.0 Section M in Advances in Skin & Wound Care, September 2017 – Volume 30 – Issue 9. This is a free access article, which means anyone can read the article free of charge. There is also an option for CEUs. Elizabeth’s article is available on the Advances in Skin & Wound Care website at http://journals.lww.com/aswcjournal/Pages/currenttoc.aspx, in the Clinical Management Section, and is titled: CMS MDS 3.0 Section M Skin Conditions in Long-term Care: Pressure Ulcers, Skin Tears, and Moisture-Associated Skin Damage Data Update
The Data Specifications for the PBJ Administration Submission File have been added to V3.00.00 of the PBJ Data Submission Specs and are now available in the download section at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html. This file should be used if an Employee has changed Employee IDs within a facility. This file is used strictly to link or delink Employee ID information already present in the PBJ system. An Employee ID can only be linked to one other Employee ID per XML file. For more information about the PBJ Administration Submission File please see “Linking Methodology” in the download section at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.
An Excel template and XSD will be provided for the PBJ Administration Submission File. These items will be available on November 20, 2017.