Submit Your MDS
Unless your Minimum Data Set (MDS) software vendor directs you otherwise, submit your MDS data to the Centers for Medicare and Medicaid Services (CMS) using the following steps:
- Connect to the CMS MDS website using the using the CMSNet Verizon (see "Set up software" for more information).
- If you see the "CMS Links" page, click on the "MDS" link (for nursing facilities) or "Swing Bed" link (for swing bed facilities).
- If you see the "Texas MDS Nurses' Station" page, read any announcements that are new to you, then click on the "Click here to go to submissions page" link.
- On the "CMS Welcome" page, scroll down to read any announcements that are new to you. Click on "MDS 3.0 Submissions" to submit MDS 3.0 assessments only or click on "MDS 2.0 Submissions" to submit MDS 2.0 assessments only.
- Log into the CMD MDS website and submit MDS data.
MDS 3.0 data submission instructions can be found in the MDS 3.0 Provider User's Guide, Section 3 on the QTSO MDS 3.0 page.
Validation reports confirm the acceptance or rejection of the data file and the acceptance or rejection of individual MDS assessments.
MDS 3.0 Errors and Warnings
After you successfully submit your data file, a validation report will be created and placed in CASPER. Your logon information (username and password) are the same for CASPER as they are for the CMS MDS website. Instructions for how to log into CASPER and read your MDS 3.0 validation report can be found in the MDS 3.0 Provider User—s Guide, Section 4 on the QTSO MDS 3.0 page.
If your data file is accepted, use the Validation Report to review errors and warnings in your MDS assessments. A description of error and warning messages, along with tips for correcting them, can be found in the MDS 3.0 Provider User—s Guide, Section 5 on the QTSO MDS 3.0 page. Fix incorrect data in MDS assessments that receive errors or warnings on the Validation Report and resend them, if necessary. Refer to Correct your data on the left menu when making corrections to your MDS assessments.
If your data file is rejected, contact your MDS software vendor.
Provider and Assessment Reports
Provider reports should be used for quality assurance purposes. MDS 3.0 provider reports are available in the CASPER provider reports folder. CASPER can be accessed by clicking the "CASPER Reporting" link located on the CMS MDS Welcome page. Just below the "CASPER Reporting" link is the "CASPER Reporting Users Manual" that can be used to learn more about navigating CASPER and reading CASPER reports, including the provider reports.
SimpleLTC users can run provider reports as follows: Click the "MDS" tab, click the "CMS Reports" tab and request a report.
Missing Assessment Report
The MDS 3.0 Missing Assessment report (MAR) is one of several methods for finding MDS errors that must be corrected. Using the MAR can help you avoid survey tags, payment issues, and incorrect reports (including quality measure reports). The following information will assist you on how to use the MAR to correct MDS errors.
The "MDS 3.0 Missing Assessment" report is located in the CASPER report tool under the MDS 3.0 NH Provider category. An example MAR can be found HERE (see page 27).
The MDS 3.0 Missing Assessment report should be run at least once a month. We recommend running it at the start and middle of each month. Any residents that appear on the report should be addressed immediately. If MDS are done correctly, there should be no residents listed on the report.
Residents are listed on the MAR because —
- They are missing an MDS assessment, or
- One or more accepted MDS records have incorrect data in Section A that need to be corrected.
The "Resident Identifiers" might not match the data you submitted in your records because it is the resident data included in the most recent record submitted by ANY long term care entity. The MDS record under "Last Record Identifiers" is NOT missing — but it might contain incorrect data.
Any of the following reasons could potentially cause a resident to appear on the MAR. Research to find which issues are affecting each resident:
- The discharge assessment must be submitted. Missing discharge assessments are the most common reason for residents to appear on the MAR. Discharge assessments (A0310F=10 or 11) are required MDS assessments that must be completed within, and not later than, 14 days after the date of discharge. Current guidelines allow skilled nursing facility/nursing facility (SNF/NF) and swing bed facility staff to set the Assessment Reference Date (ARD) in item A2300 for the same as the date of discharge in item A2000 on the MDS, as long as it is set within 14 days after the date of discharge. According to the MDS 3.0 RAI Manual, once more than 14 days have transpired since discharge, there is no provision to set an ARD for a discharge assessment and, therefore, no method of completing a discharge assessment. A missed discharge will have to remain on the MAR.
- The date of discharge must be correct. Check for data entry errors. If the date of discharge is incorrect on a discharge or death in facility record then you will need to inactivate that record and, if it is still 14 days or less from the date of discharge, you must resubmit the record with the correct information.
- The next MDS with a target date later than a discharge assessment target date must be an entry tracking form.
- Example 1: If a 14-day PPS record assessment reference date (ARD) was originally set on January 12 but the resident discharged on January 10 then the 14-day PPS ARD must be moved back to January 10, otherwise there will be a non-entry MDS following a discharge assessment.
- Example 2: An assessment was incorrectly completed over 14 days after the date of discharge in order to attach a TMHP Portal Purpose Code E. Just like example 1, the ARD of an MDS cannot be later than the discharge date.
- Resident information must be correct. If a key field (name, SSN, DOB, or gender) is different from past records then a new "resident profile" is created and is considered a different person. Facilities always get a warning on their validation reports when they change key resident information or add residents who have never before been in a nursing facility. If this is not the resident's first MDS in Texas, and the facility sees a warning related to new or changed resident information, then the facility should confirm the resident's information. To fix the MAR, the facility must investigate which MDS records have incorrect resident information and correct them.
- An MDS record must be accepted into the CMS database. If an MDS record was rejected, check the appropriate validation report for errors and warnings, fix outstanding issues, and submit the MDS record. Remember that rejected MDS records are fixed and resent (as if for the first time) without performing a modification or inactivation.
Current nursing facility staff must correct data errors made by past employees. Keep in mind, when reviewing the assessments in MDS software, just because the facility's MDS software says an assessment was sent or accepted does not mean that it was properly submitted or that it was accepted. Check the validation reports to confirm that a record is accepted by CMS.
After analyzing the MDS Missing Assessment Report, if there are residents with missing or incorrect assessments that cannot be tracked down, contact the state MDS Automation Coordinator for assistance.
Quality Measure Reports
MDS 3.0 Quality Measure (QM) reports can be found in CASPER and include reports such as the Facility Quality Measure Report and the Resident Level Quality Measure Report. CASPER can be accessed by clicking the "CASPER Reporting" link located on the CMS MDS Welcome page. Just below the "CASPER Reporting" link is the "CASPER Reporting Users Manual" that can be used to learn more about navigating CASPER and reading CASPER reports.
Information regarding MDS 3.0 QM reports can be accessed on the CMS Quality Measures webpage. The MDS 3.0 QM User's Manual (found in the Download section of the CMS Quality Measures webpage) details how QMs are calculated and which MDS 3.0 items contribute to QMs. Contact the MDS Automation Coordinator with questions concerning the material in the MDS 3.0 QM User's Manual.
The accuracy of MDS items that contribute to the MDS 3.0 QMs can be verified in the MDS 3.0 RAI Manual. Contact the MDS Clinical Coordinator with questions about how to properly collect and encode specific MDS items if the MDS 3.0 RAI Manual does not sufficiently answer your questions.
If the day, or month and day, of the resident birth date are left blank, then they are defaulted by CMS after they are submitted and accepted.
In MDS 2.0, the month defaults to 1 and the day was defaults to 1 if left blank. The MDS 2.0 database cannot identify when the day, or month and day, of the birth date have been defaulted.
In MDS 3.0, the birth date defaults as follows:
If the entire birth date is submitted, the entire birth date will be stored.
02/29/1972 = 02/29/1972
If the day of birth is left blank, birth day = 15.
02/ /1972 = 02/15/1972
If the month and day are left blank, birth month = 7 and birth day = 2.
/ /1972 = 07/02/1972
The MDS 3.0 database can identify when the day, or month and day, of the birth date have been defaulted.