The October 1st effective date of the revised MDS 3.0 item set (v1.18.11) is fast approaching. This updated version of the MDS brings with it many significant changes. The implications of these changes affect not just the completion of the MDS, but also will have a significant impact on the facility assessment and documentation practices, person centered care planning process, discharge planning, SNF QRP and other facility Quality Measures.

Facilities need to develop and implement action plans now to be ready for these changes. Include these important steps on your implementation action plan…

Consider taking the following steps when developing and implementing your action plan:

      • Familiarize yourself and the members of the IDT with the new, revised, and expanded data elements to be collected on the MDS.
      • Download the draft RAI Manual from the CMS website using the following link MDS 3.0 RAI Manual v1.18.11 October 2023 ( and review the coding guidance, tips and examples provided.  NOTE: The final version of this manual is expected to be posted by CMS in August and will likely contain additional clarifications and updates that will be important to review as you plan for the upcoming changes.
      • Assess current processes, policies, and procedures to determine whether you currently have a process in place for the collection of data to support the new and revised MDS data elements. For example, does your facility currently have a process in place for the transfer of health information, including a reconciled medication list, at the time of discharge? How is this process documented to support the accurate coding of the MDS?
      • For any processes, policies and procedures should be identified that will require updates, revisions or new workflows. Work with the team to determine who will be responsible for new process development and implementation and how each required element will be documented to support MDS coding.
      • With the addition of SPADEs and social determinates of health data elements, facilities must determine how this new data will be collected, documented and who will be responsible for collecting this information. It is also important to consider how this information will impact the resident focused care plan and discharge planning process within your facility.
      • Conduct a gap analysis to identify any changes needed to the current documentation tools utilized in your facility to support MDS coding. For facilities that utilize an Electronic Health Record (EHR), it is important to stay on top of your vendor’s preparedness for the upcoming changes not just related to the MDS, but also to the assessments and documentation with the medical record that support the MDS. In addition, for any User Defined Assessments that are customized by the facility,  it is important to consider what changes are needed and who will be responsible for making these changes.

Educate, Educate, Educate! Education is critical to successful implementation of the changes. The MDSC and the entire interdisciplinary team responsible for MDS completion need to receive education related to the MDS changes and their impact on the CAAs and care planning process, as well as other areas of impact. The clinical and direct care staff will also need to be educated on the changes to processes and documentation collection that are impacted by the MDS  For example, it is essential that training includes accurate coding of Section GG, especially if there will be changes in the staff responsible for this documentation due to the removal of Section G.

Contact Proactive for more information on MDS support services including training and education, new MDS orientation and mentoring, consultation for process improvement, and remote or hybrid-remote interim MDS coverage.

Written By: Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

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