Category: MDS

Skilled Nursing Facility Validation Program

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The SNF Validation Program is an audit-based program established to assess the accuracy of Minimum Data Set (MDS)-based quality measures used in the SNF Value Based Purchasing (VBP) and Quality Reporting Programs (QRPs). The SNF validation program audits are scheduled to begin in Fall 2025. SNFs selected for audit will be notified through their Internet Quality Improvement and Evaluation System (iQIES) MDS 3.0 Provider Preview Reports folder. The audit notification will contain instructions for documentation submission, the list of sampled residents for which medical charts are being requested and contact information for the contractor conducting the audit. For the FY2025 performance year/FY2027 program year, noncompliance may result in a 2% reduction of a SNF’s Annual Payment Update for the FY2027 SNF QRP program year.

CMS created a SNF Validation Program website which includes resources that can be found at SNF Validation Program.

Payroll-Based Journal (PBJ) Submission Deadline Reminder

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Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 4/1/25 through 6/30/25 is due August 14, 2025. Please submit PBJ data as soon as possible to avoid delays.

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

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SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on August 18, 2025:

  • MDS data for 1/1/25 through 3/31/25;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 1/1/25 through 3/31/25.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

Quality Reporting Program: Non-Compliance Letters for FY 2026 APU

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CMS is providing notifications to facilities that were determined to be out of compliance with Quality Reporting Program (QRP) requirements for CY 2024, which will affect their FY 2026 Annual Payment Update (APU). Non-compliance notifications are being distributed by the Medicare Administrative Contractors (MACs) and were placed into facilities’ Non-Compliance Notification folders in the Internet Quality Improvement and Evaluation System (iQIES) for SNFs on July 18, 2025. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 26, 2025.

If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notice of non-compliance and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

CMS Memo: QSO-25-19-ALL: Release of CMS-2567: Statement of Deficiencies and Plan of Correction

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Memorandum Summary

  • CMS is committed to the transparency of quality of care findings, so that patients, residents, and their families can make informed health care decisions.
  • The official Form CMS-2567: Statement of Deficiencies and Plan of Correction (CMS-2567) will be publicly releasable within 14 days after receipt by the provider, supplier, or lab. In other words, the CMS-2567 can be immediately released upon receipt by the provider/supplier.
  • This update aligns with the Nursing Home CMS-2567 process, which per regulation, are releasable within 14 days of transmission to the facility (See 42 CFR 488.325).
  • This guidance does not apply to Accrediting Organization (AO) survey findings, except those related to surveys of Hospice and Home Health Agencies.

Please see the full memo for details located at https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/policy-memos/policy-memos-states-and-cms-locations/release-cms-2567-statement-deficiencies-and-plan-correction.

SNF QRP CDC Data Submission Deadline Extended

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CMS is aware that access to the reporting of the annual National Healthcare Safety Network (NHSN) Influenza Vaccination among Healthcare Personnel data was not available for a short time on May 15th. In response to this circumstance CMS is extending the deadline for reporting this information to the Centers for Disease Control and Prevention NHSN to Friday, May 23, 2025, at 11:59 PM ET.

Note: This extension does NOT apply to Minimum Dat Set (MDS) data.

MDS Deadline Reminders

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Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 1/1/25 through 3/31/25 is due May 15, 2025. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on May 15, 2025:

  • MDS data for 10/1/24 through 12/31/24;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 10/1/24 through 12/31/24;
  • NHSN data for Influenza Vaccination Coverage Among Healthcare Personnel for 10/1/24 through 3/31/25.

 

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

MDS Deadline Reminders

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Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 10/1/24 through 12/31/24 is due February 14, 2025. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on February 18, 2025:

  • MDS data for 7/1/24 through 9/30/24.
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 7/1/24 through 9/30/24.

 

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

MDS Documentation Requirements Refresher Training

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Myers and Stauffer conducted a MDS Documentation Requirements Refresher training on December 17, 2024, which can be found at https://myersandstauffer.com/client-portal/missouri/. Under “Helpful Downloads for Nursing Facilities MDS and Rate Setting” and “MDS Refresher Training – December 2024” you can find the training recording, slide deck, and FAQ document.

MDS Documentation Requirements Refresher

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Myers and Stauffer to conduct MDS Documentation Requirements Refresher

Please see the attached flier for the MDS Documentation Requirements Refresher scheduled for December 17, 2024 from 9:00 AM – 10:30 AM CST. Please click the link within the flier (or below) to register for the webinar. Registration is required.

Link to Register: https://mslc.webex.com/weblink/register/rc0eb002a1e79b4ee18d8f94400fe85b4

The training materials and recorded webinar will be available for download after the training should you be unable to attend the live session. Please direct any questions to MO_MDSINFO@mslc.com.

MDS INFO

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Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 7/1/24 through 9/30/24 is due November 14, 2024. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on November 18, 2024:

  • MDS data for 4/1/24 through 6/30/24;

  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 4/1/24 through 6/30/24;

 

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

Quality Reporting Program: Non-Compliance Letters for FY 2025 APU

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CMS is providing notifications to facilities that were determined to be out of compliance with Quality Reporting Program (QRP) requirements for CY 2023, which will affect their FY 2025 Annual Payment Update (APU). Non-compliance notifications are being distributed by the Medicare Administrative Contractors (MACs) and were placed into facilities’ My Reports folders in the Internet Quality Improvement and Evaluation System (iQIES) for SNFs on July 03, 2024. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 14, 2024.

If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notice of non-compliance and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

MDS Reminders

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Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 1/1/24 through 3/31/24 is due May 15, 2024. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on May 15, 2024:

  • MDS data for 10/1/23 through 12/31/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 10/1/23 through 12/31/23;
  • NHSN data for Influenza Vaccination Coverage Among Healthcare Personnel for 10/1/23 through 3/31/24.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

MDS Case Mix Review Training

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The Missouri Department of Social Services has contracted with Myers and Stauffer to conduct provider training. This webinar will be divided into two sessions. You may choose to participate in one or both sessions.

The Morning Session (9:00 am – 10:00 am CST) will include:

    • Case Mix Review Process
    • Web Portal Access and Submissions

The Afternoon Session (1:00 pm – 2:30 pm CST) will include:

    • Supportive Documentation Requirements

Please plan to join us during one or both of the scheduled sessions. Registration is required.

March 19, 2024
Morning Session: 9:00 am – 10:00 am CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2421 836 0727
Event Password: MOTraining

Afternoon Session: 1:00 pm – 2:30 pm CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2428 242 0685
Event Password: MOTraining

March 26, 2024
Morning Session: 9:00 am – 10:00 am CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2438 288 2508
Event Password: MOTraining

Afternoon Session: 1:00 pm – 2:30 pm CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2437 705 7018
Event Password: MOTraining

Payroll-Based Journal (PBJ) Submission Deadline Reminder

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Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 10/1/23 through 12/31/23 is due February 14, 2024.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

 

More information about PBJ can be found on the following webpages:

CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals
PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

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SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on February 15, 2024:

  • MDS data for 7/1/23 through 9/30/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 7/1/23 through 9/30/23;

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Internet Quality Improvement and Evaluation System (iQIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable MDS reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

 

More information about SNF QRP can be found on the following webpages:

CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines
CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help
CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information
CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

Medicare from Start to Finish

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January 9, 2024: Live Virtual Workshop
March 12, 2024: In-Seat Workshop
May 14, 2024: In-Seat Workshop
September 17, 2024: In-Seat Workshop
November 12, 2024: Live Virtual Workshop

This workshop will review the SNF QRP reports from CASPER that provides information about the Medicare Part A stays in your SNF. It will also explore factors impacting SNF PPS assessment schedule, PDPM basics, and consolidating billing that can impact the financial facet of the facility. It also explains Medicare eligibility, coverage, and skilling criteria. The completion of the MDS is becoming more difficult and confusing, this workshop will help clear up the confusion surrounding this process. This workshop is geared towards those individuals working in long‐term care who have a leadership role such as ADM, DON, ADON, or MDS Coordinator.

RAI Process from Start to Finish

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April 9-10, 2024: In-Seat Workshop
June 18-19, 2024: In-Seat Workshop
August 13-14, 2024: In-Seat Workshop
October 29-30, 2024: In-Seat Workshop
December 10-11, 2024: Live Virtual Workshop

This workshop will look at the RAI process from beginning to end and at each item of the MDS. The MDS is used for both a clinical and a financial assessment and will discuss the rules on scheduling these assessments and meeting the clinical & financial requirements. This includes a basic understanding of PDPM and how it correlates within the RAI process. This virtual workshop reviews how to gain access to and read the MDS reports from CASPER to self-audit your RAI process and look at your QMs. This workshop is designed for the MDS Coordinator and Care Plan Coordinator, or for the DON or ADM who needs a better understanding of the complexity of the RAI Process.

Payroll-Based Journal (PBJ) Submission Deadline Reminder

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Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 7/1/23 through 9/30/23 is due November 14, 2023.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

More information about PBJ can be found on the following webpages:

CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ

PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals

PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

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SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on November 15, 2023:

  • MDS data for 4/1/23 through 6/30/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 4/1/23 through 6/30/23;

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Internet Quality Improvement and Evaluation System (iQIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable MDS reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

More information about SNF QRP can be found on the following webpages:

CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines

CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help

CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information

CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

MDS 3.0 RAI Manual version (v)1.18.11R Errata

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The PDF file labeled “MDS3.0RAIManualv1.18.11R.Errata.v2.October.20.2023” is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The errata document contains revisions to the MDS 3.0 RAI Manual version (v)1.18.11R to provide clarity and additional guidance in Section D and Chapter 6 to support item D0100, Should Resident Mood Interview be Conducted? serving as a gateway item for the Resident Mood Interview (PHQ-2 to 9©) and D0500, Staff Assessment of Resident Mood (PHQ-9-OV©). Minor revisions also included are corrections to language in Section Q to provide proper guidance on Care Area Assessment (CAA) requirements, corrections to language in Chapter 2 to provide proper guidance on combining Omnibus Budget Reconciliation Act (OBRA) discharge assessments, an updated Internet Quality Improvement & Evaluation System (iQIES) warning error message in Chapter 5, updated screenshots in Section A and Section O, and an updated MDS Item Matrix. The errata document also includes all issues from previous MDS 3.0 RAI Manual v1.18.11R errata releases.

Changed manual pages are marked with the footer “October 2023 (R).”

The errata document begins with a table that lists all identified revisions and the pages to which they have been applied. Following the table are the actual corrected replacement pages for insertion into the printed manual.

UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v6

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The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Changes in this version (listed below) align the item sets with the Errata V3.01.3 for MDS Data Specifications V3.01.1 (FINAL) posted September 21, 2023, on the Minimum Data Set (MDS) 3.0 Technical Information page. For a full list of changes to the final posted item sets since v1, see the Item Set Change Table Supplement that accompanies the posting. The MDS Item Sets v1.18.11 were effective beginning October 01, 2023.

M0300G1 on NPE

Replaced erroneous skip pattern <Skip to N2005, Medication Intervention> with the correct one: <Skip to N0415, High-Risk Drug Classes: Use and Indication>.

O0300A on NP and NQ

Corrected transposition of verbs in skip patterns (changed <Skip> to <Continue> in choice 0 and <Continue> to <Skip> in choice 1).

O0400 on NC and NQ

Removed completion language <Complete only when A0310B = 1 (complete O0400D2 when required by state)>.

O0400 on NP and SP

Removed completion language <Complete only when A0310B = 1>.

O0420 on NC, NP, and NQ

Removed completion language <Complete only when A0310B = 1>.