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CMS'sRAIVersionManual2.
0August2005RevisionTableCH.
Sect.
Pg.
August2005RevisionNANAReviseddatechangedTitlePageNANAiiiAddedSectionWTableofContentsCH3T1c3-216ClarifytimeperiodClarifyphysicianordersc.
ESTIMATEOFNUMBEROFDAYS(Throughday15)Clarifications:Donotcounttheevaluationdayintheestimatenumberofdaysunlesstreatmentisrendered.
Whenthephysicianordersalimitednumberofdaysoftherapy,thentheprojectionisbasedontheactualnumberofdaysoftherapyordered.
Forexample,ifthephysicianorderstherapyfor7days,theprojectednumberofdaysinT1cwillbe7.
CH3T1d3-216Deletesfromthewordclarifications.
DeletebulletfromT1dandmoveittoT1cClarifications:Donotcounttheevaluationdayintheestimatenumberofdaysunlesstreatmentisrendered.
CH3W3-240–3-246AddednewsectionSECTIONW.
SUPPLEMENTALITEMSAppendixPageAugust2005RevisionB1-6RAICoordinatorandRegionalOfficecontactsupdated1CentersForMedicare&MedicaidServicesRevisedLong-TermCareFacilityResidentAssessmentInstrumentUser'sManualVersion2.
0December2002RevisedAugust2005Non-CompliancewiththeAssessmentSchedule2-40EarlyAssessment.
2-40DefaultRate2-40LateorMissedAssessmentCriteria.
2-40ErrorsonaMedicareAssessment.
2-40Chapter3:Item-by-ItemGuidetotheMDS3.
1OverviewtotheItem-by-ItemGuidetoMDS.
3-1UsingThisChapter3-1StandardFormatUsedinThisChapter.
3-43.
2CodingConventions.
3-43.
3SectionAA.
IdentificationInformationforMDS.
3-6SECTIONAB.
DEMOGRAPHICINFORMATION3-12SECTIONAC.
CUSTOMARYROUTINE.
3-22SECTIONAD.
FACESHEETSIGNATURES3-27SECTIONA.
MDSIDENTIFICATIONANDBACKGROUNDNFORMATION.
.
.
.
3-283.
4ClinicalItemsfortheMDS.
3-41SECTIONB.
COGNITIVEPATTERNS.
3-41SECTIONC.
COMMUNICATION/HEARINGPATTERNS3-51SECTIOND.
VISIONPATTERNS.
3-58SECTIONE.
MOODANDBEHAVIORPATTERNS.
3-60SECTIONF.
PSYCHOSOCIALWELL-BEING.
3-71SECTIONG.
PHYSICALFUNCTIONINGANDSTRUCTURALPROBLEMS3-76SECTIONH.
CONTINENCEINLAST14DAYS.
3-119SECTIONI.
DISEASEDIAGNOSES3-127SECTIONJ.
HEALTHCONDITIONS.
3-138SECTIONK.
ORAL/NUTRITIONALSTATUS3-149SECTIONL.
ORAL/DENTALSTATUS3-158SECTIONM.
SKINCONDITION.
3-159SECTIONN.
ACTIVITYPURSUITPATTERNS.
3-169SECTIONO.
MEDICATIONS.
3-176SECTIONP.
SPECIALTREATMENTSANDPROCEDURES3-182SECTIONQ.
DISCHARGEPOTENTIALANDOVERALLSTATUS3-207SECTIONR.
ASSESSMENTINFORMATION.
3-210SECTIONS.
STATE-DEFINEDSECTION.
3-214SECTIONT.
THERAPYSUPPLEMENTFORMEDICAREPPS.
3-214SECTIONU.
MEDICATIONS.
3-223SECTIONV.
RESIDENTASSESSMENTPROTOCOLSUMMARY.
3-237SECTIONW.
SUPPLEMENTALITEMS3-240Chapter4:ProceduresforCompletingtheResidentAssessmentProtocols(RAPs)andLinkingtheAssessmenttotheCarePlan4.
1WhataretheResidentAssessmentProtocols(RAPs)4-14.
2HowaretheRAPsOrganized4-3Revised--August2005Revised--December2002PageiiiCMS'sRAIVersion2.
0ManualCH3:MDSItems[T]Revised--December2002Page3-216Completedandtherapytreatment(s)hasbeenscheduled.
Iftherapytreatment(s)willnotbescheduled,skiptoItemT3.
Iftheresidentisscheduledtoreceiveatleastoneofthetherapies,havethetherapist(s)calculatethetotalnumberofdaysthroughtheresident'sfifteenthdaysinceadmissiontoMedicarePartAwhenatleastonetherapyservicewillbedelivered.
Thenhavethetherapist(s)estimatethetotalPT,OT,andSPtreatmentminutesthatwillbedeliveredthroughthefifteenthdayofadmissiontoMedicarePartA.
c.
ESTIMATEOFNUMBEROFDAYS(Throughday15)Coding:EstimateofNumberofDays-Enterthenumber(#)ofdaysatleastonetherapyservicecanbeexpectedtohavebeendeliveredthroughtheresident'sfifteenthdayofadmission.
CountthedaysoftherapyalreadydeliveredfromItemP1a,b,andc.
Calculatetheexpectednumberordaysthroughday15,eveniftheresidentisdischargedpriortoday15.
Ifordersarereceivedformorethanonetherapydiscipline,enterthenumberofdaysatleastonetherapyserviceisperformed.
Forexample,ifPTisprovidedonMWF,andOTisprovidedonMWF,theMDSshouldbecodedas3days,not6days.
Clarifications:Donotcounttheevaluationdayintheestimatenumberofdaysunlesstreatmentisrendered.
Whenthephysicianordersalimitednumberofdaysoftherapy,thentheprojectionisbasedontheactualnumberofdaysoftherapyordered.
Forexample,ifthephysicianorderstherapyfor7days,theprojectednumberofdaysinT1cwillbe7.
d.
ESTIMATEOFNUMBEROFMINUTES(Throughday15)Coding:EstimateofNumberofMinutes-Entertheestimatedtotalnumberoftherapyminutes(acrossalltherapies)itisexpectedtheresidentwillreceivethroughtheresident'sfifteenthdayofadmission.
IncludethenumberofminutesalreadyprovidedfromMDSItemsP1ba(B),P1bb(B),andP1bc(B).
Calculatetheexpectednumberofminutesthroughday15,eveniftheresidentisdischargedpriortoday15.
Clarification:Donotincludeevaluationminutesintheestimateofnumberofminutes.
Thispagerevised--August2005,June2005,August2003CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]August2005Page3-240SECTIONW.
SUPPLEMENTALITEMSW1.
NationalProviderIDIntent:TorecordthefacilityNationalProviderIdentification(NPI).
Definition:TheNPIisasystemforuniquelyidentifyingallprovidersofhealthcareservices,supplies,andequipment.
TheSecretaryoftheDepartmentofHealthandHumanServices(HHS)hasestablishedastandardidentifierforhealthcareproviders.
Process:CMSassignsanNPItothenursingfacility.
TheNPIappliestoallresidentsofthatnursingfacility.
Coding:Whenavailable,onlyenterthe10digitNPIinthespacesprovided.
Donotenteranyembeddeddashesorspaces.
Recheckthenumbertoensureyouhaveenteredthe10digitscorrectly.
ThefacilityisencouragedtobeginusingthisnumberonceithasbeenassignedbyCMS.
W2.
InfluenzaImmunizationIntent:Todeterminetherateofvaccinationandcausesfornon-vaccination.
SectionW2mustbecompletedforallresidentsonallassessmenttypes(OBRAand/orPPS)withAssessmentReferenceDatesandalldischargetrackingformswithDischargeDatesfromOctober1throughJune30.
DischargetrackingformsareincludedinordertocapturefluvaccinesadministeredtoresidentswhosefluvaccineswerenotcapturedonanMDSassessment.
AlthoughfluseasoncurrentlyisdefinedasOctober1throughMarch31,assessmentswithanARDanddischargeswithadischargedatethroughJune30areincludedinordertocaptureanyrecordthatprovidestheonlyreportofavaccinationreceivedduringthefluseason.
Example:AfluvaccineisadministeredtoaresidentinMarch,notwithinthewindowofanMDSassessment.
ExtendingthedateforcompletingW2toJune30providesthefacilitytheabilitytocapturethatfluvaccineonthenextQuarterly,evenifitisnotdueforanother92daysoronadischargebeforetheQuarterlyisdue.
Process:Reviewtheresident'smedicalrecordandinterviewtheresidentorCMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]responsibleparty/legalguardiantodetermineInfluenzavaccinationstatusduringthisyear'sfluseason,definedasOctober1throughMarch31.
Usethefollowingsteps:Step1.
Reviewtheresident'smedicalrecordtodeterminewhetheranInfluenzavaccinationwasreceivedduringthefluseason.
Ifvaccinationstatusisunknown,proceedtothenextstep.
Step2.
Asktheresidentifhe/shereceivedadoseofInfluenzavaccineoutsideofthefacilityforthisyear'sfluseason.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Step3.
Iftheresidentisunabletoanswer,thenaskthesamequestionoftheresponsibleparty/legalguardian.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Step4.
Ifvaccinestatuscannotbedetermined,administerthevaccinationtotheresidentaccordingtostandardsofclinicalpractice.
TheCDChasevaluatedinactivatedInfluenzavaccineco-administrationwiththepneumococcalpolysaccharidevaccinesystematicallyamongadults.
Simultaneousvaccineadministrationissafewhenadministeredbyaseparateinjectionintheoppositearm2,3.
Iftheresidentisanamputeeorifintramuscularinjectionsarecontraindicatedintheupperextremities,administerthevaccine(s)accordingtostandardsofclinicalpractice.
Coding:W2aEnter"0"fora'No'responseandproceedtoitemW2bIftheresidentdidnotreceivetheInfluenzavaccineinthisfacilityfromOctober1–March31.
Example:Mrs.
J.
receivedtheInfluenzavaccineinJanuary2005.
TheARDofthisassessmentisOctober2005.
ThefacilityhasnotyetadministeredtheInfluenzavaccineforthecurrentfluseason.
W2awouldbecoded"0",No.
Enter"1"fora'Yes'responseandproceedtoitemW3IftheARDofthisassessmentorthedischargedateofthisdischargetrackingformisfromJanuary1throughJune30,includeInfluenzavaccineadministeredinthefacilityfromOctober1oflastyearthroughMarch31ofthecurrentyear.
Example:Mrs.
T.
receivedtheInfluenzavaccineinAugust2005Page3-241CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]November2004.
TheARDofthisassessmentisFebruary2005.
IncludetheNovember2004vaccinationonthisassessmentandcodeW2a"1",Yes.
IftheARDofthisassessmentorthedischargedateofthisdischargetrackingformisonorafterOctober1,includetheInfluenzavaccineadministeredinthefacilityonorafterOctober1ofthecurrentyear.
Example:Mr.
CreceivedtheInfluenzavaccineinOctober2005.
TheARDofthisassessmentisDecember2005.
IncludetheOctober2005vaccinationonthisassessmentandcodeW2a"1",Yes.
SkipitemW2andgotoitemW3IftheARDofthisassessmentorthedischargedateofthisdischargetrackingformisfromJuly1throughSeptember30.
Example:Mr.
P.
receivedtheInfluenzavaccineinFebruary2005.
TheARDofthisassessmentisinAugust2005.
SkipthisitemandgotoitemW3.
W2bIftheresidenthasnotreceivedtheInfluenzavaccineinthefacility,codethereasonfromthefollowinglist:1.
Notinfacilityduringthisyear'sfluseason-ResidentnotinthefacilityfromOctober1–March31.
2.
Receivedoutsideofthisfacility-IncludesInfluenzavaccinationsadministeredfromOctober1throughMarch31inanyothersetting(e.
g.
physicianoffice,healthfair,grocerystore,hospital,firestation).
3.
Noteligible–Duetocontraindicationsincluding:allergicreactiontoeggsorothervaccinecomponent(s)aphysicianordernottoimmunizeoranacutefebrileillnessispresent;however,theresidentshouldbevaccinatedifcontraindicationsend4.
Offeredanddeclined–Residentorresponsibleparty/legalguardianhasbeeninformedofwhatisbeingofferedandchoosesnottoacceptthevaccine.
Seepages3-36&37fortypesofAugust2005Page3-242CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]responsibility/legalguardian.
5.
Notoffered–Residentorresponsibleparty/legalguardiannotofferedthevaccine.
Seepages3-36&37fortypesofresponsibility/legalguardian.
6.
Inabilitytoobtainvaccine–Vaccineunavailableatthefacilityduetodeclaredvaccineshortage;however,theresidentshouldbevaccinatedoncethevaccineisreceived.
TheannualsupplyofinactivatedInfluenzavaccineandthetimingofitsdistributioncannotbeguaranteedinanyyear.
W3.
PneumococcalImmunizationIntent:Todeterminetherateofvaccinationandcausesfornon-vaccination.
SectionW3mustbecompletedforallresidentsonallassessmenttypes(OBRAand/orPPS)andalldischargetrackingforms.
TheCDChasevaluatedinactivatedInfluenzavaccineco-administrationwiththePneumococcalPolysaccharideVaccine(PPV)systematicallyamongadults.
Simultaneousvaccineadministrationissafewhenadministeredbyaseparateinjectionintheoppositearm2,3.
Iftheresidentisanamputeeorintramuscularinjectionsarecontraindicatedintheupperextremities,administerthevaccine(s)accordingtoclinicalstandardsofcare.
Personslessthan65yearsofagewhoarelivinginenvironmentsorsocialsettings(e.
g.
nursinghomesandotherlong-termcarefacilities)inwhichtheriskforinvasivepneumococcaldiseaseoritscomplicationsisincreasedshouldreceivethePPV2.
Alladults65yearsofageoroldershouldgetthePPV.
PPVisgivenonceinalifetime,withcertainexceptions1.
August2005Page3-243CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]Persons65yearsoroldershouldbeadministeredaseconddoseofvaccine(boostervaccine)iftheyreceivedthefirstdoseofvaccinemorethan5yearsearlierandwerelessthan65yearsoldatthetime1,2.
Note:PleaserefertothefollowingalgorithmforPPVadministrationONLYFigure1AdoptedfromtheCDCRecommendationsandReports.
PreventionofPneumococcalDisease:RecommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).
MMWRApril1997;46(RR-08);1-24.
FIGURE1.
Algorithmforvaccinatingimmunocompetentpersonsaged>65yearsNOorUnsureVaccinationindicatedYESYESNOYES*NOVaccinationnotindicatedHasthepersonbeenvaccinatedpreviouslyWasthepersonaged>65yearsatthetimeoflastvaccinationHave>5yearselapsedsincethefirstdose*Foranyimmunocompetentpersonwhohasreceivedadoseofpneumococcalpolysaccharidevaccineatage>65years,revaccinationisnotindicated.
1CDC.
PneumococcalPolysaccharideVaccine.
Whatyouneedtoknow.
PneumococcalVaccineInformationStatementJuly1997.
2CDC.
PreventionofPneumococcalDisease:RecommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).
MMWRApril1997;46(RR-08);1-24.
3RecommendationsandReports.
Preventionandcontrolofinfluenza.
RecommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).
MMWRMay28,2004/53(RR06);1-40.
August2005Page3-244CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]TheCDCrecommendsasecond(booster)doseforimmunocompromisedpersonsdueto1oAdamagedspleenornospleenoSickle-celldiseaseoHIVinfectionsorAIDSoCancer,leukemia,lymphoma,multiplemyelomaoKidneyfailureoNephroticsyndromeoHistoryofanorganorbonetransplantoMedicationregimensthatlowersimmunity(suchaschemotherapyorlong-termsteroids)Whenanyoftheaboveconditionsarepresent,personsolderthan10yearsold(includingthose65yearsofageandolder)shouldgetthesecond(booster)dose5yearsafterthefirstdose.
Children10yearsoldandyoungermaygetthissecond(booster)dose3yearsafterthefirstdose.
Process:Reviewtheresident'smedicalrecordandinterviewresidentorresponsibleparty/legalguardiantodeterminePPVstatus,usingthefollowingsteps.
Step1.
Reviewtheresident'smedicalrecordtodeterminewhetherPPVhasbeenreceived.
Ifvaccinationstatusisunknown,proceedtothenextstep.
Step2.
Asktheresidentifhe/shereceivedaPPV.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Step3.
Iftheresidentisunabletoanswer,askthesamequestionofaresponsibleparty/legalguardian.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Seepages3-36&37fortypesofresponsibility/legalguardian.
Step4.
Ifvaccinationstatuscannotbedetermined,administertheappropriatevaccinetotheresident,accordingtothestandardsofclinicalpractice.
Coding:W3aEnter"0"fora'No'responseandproceedtoitemW3bIftheresident'sPPVstatusisnotuptodateEnter"1"fora'Yes'responseandskipitemW3bIftheresident'sPPVstatusisuptodateAugust2005Page3-245CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]W3bIftheresidenthasnotreceivedaPPV,codethereasonfromthefollowinglist:1.
Noteligible–Duetocontraindicationsincluding:allergicreactiontovaccinecomponent(s)aphysicianordernottoimmunizeanacutefebrileillnessispresent;however,theresidentshouldbevaccinatedaftercontraindicationsend2.
Offeredanddeclined–Residentorresponsibleparty/legalguardianhasbeeninformedofwhatisbeingofferedandchoosesnottoacceptthevaccine.
Seepages3-36&37fortypesofresponsibility/legalguardian.
3.
Notoffered-Residentorresponsibleparty/legalguardianwerenotofferedthevaccine.
Seepages3-36&37fortypesofresponsibility/legalguardian.
August2005Page3-246CMS'sRAIVersion2.
0ManualAppendixBAPPENDIXBSTATEAGENCYCONTACTSRESPONSIBLEFORANSWERINGRAIQUESTIONSRevised—August2005PageB-1CMS'sRAIVersion2.
0ManualAppendixBSTATEAGENCYCONTACTS–MDSRAICOORDINATORSSTATEMDSRAICoordinatorPHONE#E-mailAddressAKDoreneLukas907-334-2491Dorene_Lukas@health.
state.
ak.
usALPamelaCarpenter334-206-7929pamelacarpenter@adph.
state.
al.
usARSueGaines501-682-8853Sue.
gaines@arkansas.
govARTwylaMoore,RN501-661-2201tmoore@healthyarkansas.
comAZSylviaBalistreri602-364-3878balists@azdhs.
govCAVirginiaE.
Aquino,RN916-324-2362Helpdeskmdsoasis@dhs.
ca.
gov.
HelpdeskCOBettyKeen,RN303-692-2894Betty.
Keen@state.
co.
usCTLoriGiffinAlternate:AngelaWhite860-509-7400Lori.
Griffin@po.
state.
ct.
usAngela.
white@po.
state.
ct.
usDCMarySklencar202-442-4759Mary.
sklencar@dc.
govDEKimPaugh302-424-6377Kim.
paugh@state.
de.
usFLClaireHoagland727-552-1133x179hoaglanc@fdhc.
state.
fl.
usGABarbaraChuven404-657-5854bechuven@dhr.
state.
ga.
usHIJaniceNakama,RNAlternate:SharonMatsubara808-692-7420jpnakama@mail.
health.
state.
hi.
usskmatsub@mail.
health.
state.
hi.
usIAKarenZaabel515-242-5991Kzaabel@dia.
state.
ia.
usIDLorettaTodd208-334-6626Toddl@idhw.
state.
id.
usILRhondaImhoff,RN217-785-5132rimhoff@idph.
state.
il.
usINKimberlyHoneycutt,RN317-233-4719khoneycu@isdh.
state.
in.
usKSLynnSearlesVeraVanBruggen,RN785-291-3552785-296-1246Lsearles@kdhe.
state.
ks.
usveravanbruggen@aging.
state.
ks.
usKYDebbieDicken859-246-2301Debbie.
dicken@ky.
govLAEvelynEnclarde,RN225-342-4855eenclarde@dhh.
la.
govMAPaulDiNatale617-753-8222Paul.
dinatale@state.
ma.
usMDLynneCondon410-402-8102Lcondon@dhmh.
state.
md.
usRevised—August2005PageB-2CMS'sRAIVersion2.
0ManualAppendixBSTATEMDSRAICoordinatorPHONE#E-mailAddressMELouisT.
DorogiCaroleKus,RN207-287-9300207-287-3933Lou.
dorogi@maine.
govcarole.
kus@maine.
govMIMaryHess989-732-8837hessm@michigan.
govMNSusanPedro651-215-8749Susan.
pedro@health.
state.
mn.
usMOMikeDeClue,RN-C573-751-6308Michael.
DeClue@dhss.
mo.
govMSLynnCox601-576-7316Lynn.
cox@msdh.
state.
ms.
usMTKathleenMoran406-444-3459kmoran@mt.
govNCCindyDeporterDeniceDavis(Back-up)919-733-7461919-733-7461Cindy.
DePorter@ncmail.
netdenice.
davis@ncmail.
netNDPatriciaRotenberger701-328-2364Protenbe@state.
nd.
usNEDanTaylor402-471-0535Daniel.
taylor@hhss.
ne.
govNHSusanGrimes603-271-3024sgrimes@dhhs.
state.
nh.
usNJBethBell,RN609-633-8981Beth.
Bell@doh.
state.
nj.
usNMSandraColeConnieArmijo505-476-9037505-476-9056Sandra.
cole@doh.
state.
nm.
usConnie.
armijo@doh.
state.
nm.
usNVJuanitaBall,RN775-687-4475x235JBall@blc.
state.
nv.
usNYKristinArmstrong-Ross518-478-1124KMA07@health.
state.
ny.
usOHPatsyStrouse614-955-0774pstrouse@odh.
ohio.
govOKSharonWarlick405-271-5278Sharonlw@health.
state.
ok.
usORMaryB.
Borts503-691-6587Mary.
B.
Borts@state.
or.
usPASusanWilliamsonChrisKelly717-787-1816suswilliam@state.
pa.
usChkelly@state.
pa.
usPRLourdesCruz787-782-0553x2252lcruz@salud.
gov.
prRIMadelineVincent,RN401-277-2566madeline.
vincent@health.
ri.
govSCSaraS.
Granger803-545-4205Grangerss@dhec.
sc.
govSDDollyHanson605-773-7070Carol.
hanson@state.
sd.
usTNLeatriceCoffin615-741-8002Leatrice.
coffin@state.
tn.
usTXMargaretEvans,RN806-249-5579x27Margaret.
evans@dads.
state.
tx.
usRevised—August2005PageB-3CMS'sRAIVersion2.
0ManualAppendixBSTATEMDSRAICoordinatorPHONE#E-mailAddressUTCarolynReese,RN801-538-6599carolynreese@utah.
govVAJudyWilhide804-367-2103Judy.
wilhide@vdh.
virginia.
govVTLaineLucenti802-241-2345Laine.
lucenti@dail.
state.
vt.
usWAMarjorieRay360-725-2487RayMa@dshs.
wa.
govWIChrisBenesh608-266-1718Benesce@dhfs.
state.
wi.
usWVEmilyKeeferBeverlyHissom304-558-1740304-558-4145emilykeefer@wvdhhr.
orgbeverlyhissom@wvdhhr.
orgWYLindaBrown307-777-7123lbrown@state.
wy.
usNOTE:NotincludedinthismanualisalistoftheStateMDSAutomationCoordinatorsandtheStateMedicaidMDSCoordinators.
TheselistswillbepostedontheCMSwebsiteat:http://www.
cms.
hhs.
gov/medicaid/mds20Revised—August2005PageB-4CMS'sRAIVersion2.
0ManualAppendixBREGIONALOFFICECONTACTSRegionISharonRobersonCMS/DHSQ,Room2275JFKFederalBuildingBoston,MA02203-0003(617)565-1300RegionIINormaJ.
BirkettCMS/DHSQ26FederalPlaza,Room3800NewYork,NY10278-0063(212)616-2460RegionIIIMicheleClintonCMS/DHSQP.
O.
Box7760Philadelphia,PA19101-7760(215)861-4290CynthiaMcWilliams(215)861-4765RegionIVJillHartlineCMS/DHSQSuite4T20,SamNunnAtlantaFederalCenterAtlanta,GA30303(404)562-7477RegionVWandahHardyCMS/DHSQ105W.
AdamsStreet,15thFloorChicago,IL60603-6201(312)353-3337RegionVIJacquelynDouglasCMS/SCRB1301YoungStreet,Room833Dallas,TX75202-4348(214)767-4436Revised—August2005PageB-5CMS'sRAIVersion2.
0ManualAppendixBRegionVIIMaryaliceFutrellHealthQualityReviewSpecialistSurvey&CertificationBranchII601East12thStreet,Room235KansasCity,MO64106-2808(816)426-6474(ContactforMO&NE)IreneWeizirl(816)426-2011(ContactforKS&IA)RegionVIIINancyWalkerCMS/DHSQFederalOfficeBldg.
,Room11851961StoutSt.
Denver,CO80294-3538(303)844-7037RegionIXRenieSoriaCMS/DHSQ75HawthorneSt.
,4thFloorSanFrancisco,CA94105-3903(415)744-3692RegionXJoanneRokoskyCMS/DHSQBlanchardPlazaBldg.
2201SixthAve.
,MailStopRX-42Seattle,WA98121-2500(206)615-2091Revised—August2005PageB-6
0August2005RevisionTableCH.
Sect.
Pg.
August2005RevisionNANAReviseddatechangedTitlePageNANAiiiAddedSectionWTableofContentsCH3T1c3-216ClarifytimeperiodClarifyphysicianordersc.
ESTIMATEOFNUMBEROFDAYS(Throughday15)Clarifications:Donotcounttheevaluationdayintheestimatenumberofdaysunlesstreatmentisrendered.
Whenthephysicianordersalimitednumberofdaysoftherapy,thentheprojectionisbasedontheactualnumberofdaysoftherapyordered.
Forexample,ifthephysicianorderstherapyfor7days,theprojectednumberofdaysinT1cwillbe7.
CH3T1d3-216Deletesfromthewordclarifications.
DeletebulletfromT1dandmoveittoT1cClarifications:Donotcounttheevaluationdayintheestimatenumberofdaysunlesstreatmentisrendered.
CH3W3-240–3-246AddednewsectionSECTIONW.
SUPPLEMENTALITEMSAppendixPageAugust2005RevisionB1-6RAICoordinatorandRegionalOfficecontactsupdated1CentersForMedicare&MedicaidServicesRevisedLong-TermCareFacilityResidentAssessmentInstrumentUser'sManualVersion2.
0December2002RevisedAugust2005Non-CompliancewiththeAssessmentSchedule2-40EarlyAssessment.
2-40DefaultRate2-40LateorMissedAssessmentCriteria.
2-40ErrorsonaMedicareAssessment.
2-40Chapter3:Item-by-ItemGuidetotheMDS3.
1OverviewtotheItem-by-ItemGuidetoMDS.
3-1UsingThisChapter3-1StandardFormatUsedinThisChapter.
3-43.
2CodingConventions.
3-43.
3SectionAA.
IdentificationInformationforMDS.
3-6SECTIONAB.
DEMOGRAPHICINFORMATION3-12SECTIONAC.
CUSTOMARYROUTINE.
3-22SECTIONAD.
FACESHEETSIGNATURES3-27SECTIONA.
MDSIDENTIFICATIONANDBACKGROUNDNFORMATION.
.
.
.
3-283.
4ClinicalItemsfortheMDS.
3-41SECTIONB.
COGNITIVEPATTERNS.
3-41SECTIONC.
COMMUNICATION/HEARINGPATTERNS3-51SECTIOND.
VISIONPATTERNS.
3-58SECTIONE.
MOODANDBEHAVIORPATTERNS.
3-60SECTIONF.
PSYCHOSOCIALWELL-BEING.
3-71SECTIONG.
PHYSICALFUNCTIONINGANDSTRUCTURALPROBLEMS3-76SECTIONH.
CONTINENCEINLAST14DAYS.
3-119SECTIONI.
DISEASEDIAGNOSES3-127SECTIONJ.
HEALTHCONDITIONS.
3-138SECTIONK.
ORAL/NUTRITIONALSTATUS3-149SECTIONL.
ORAL/DENTALSTATUS3-158SECTIONM.
SKINCONDITION.
3-159SECTIONN.
ACTIVITYPURSUITPATTERNS.
3-169SECTIONO.
MEDICATIONS.
3-176SECTIONP.
SPECIALTREATMENTSANDPROCEDURES3-182SECTIONQ.
DISCHARGEPOTENTIALANDOVERALLSTATUS3-207SECTIONR.
ASSESSMENTINFORMATION.
3-210SECTIONS.
STATE-DEFINEDSECTION.
3-214SECTIONT.
THERAPYSUPPLEMENTFORMEDICAREPPS.
3-214SECTIONU.
MEDICATIONS.
3-223SECTIONV.
RESIDENTASSESSMENTPROTOCOLSUMMARY.
3-237SECTIONW.
SUPPLEMENTALITEMS3-240Chapter4:ProceduresforCompletingtheResidentAssessmentProtocols(RAPs)andLinkingtheAssessmenttotheCarePlan4.
1WhataretheResidentAssessmentProtocols(RAPs)4-14.
2HowaretheRAPsOrganized4-3Revised--August2005Revised--December2002PageiiiCMS'sRAIVersion2.
0ManualCH3:MDSItems[T]Revised--December2002Page3-216Completedandtherapytreatment(s)hasbeenscheduled.
Iftherapytreatment(s)willnotbescheduled,skiptoItemT3.
Iftheresidentisscheduledtoreceiveatleastoneofthetherapies,havethetherapist(s)calculatethetotalnumberofdaysthroughtheresident'sfifteenthdaysinceadmissiontoMedicarePartAwhenatleastonetherapyservicewillbedelivered.
Thenhavethetherapist(s)estimatethetotalPT,OT,andSPtreatmentminutesthatwillbedeliveredthroughthefifteenthdayofadmissiontoMedicarePartA.
c.
ESTIMATEOFNUMBEROFDAYS(Throughday15)Coding:EstimateofNumberofDays-Enterthenumber(#)ofdaysatleastonetherapyservicecanbeexpectedtohavebeendeliveredthroughtheresident'sfifteenthdayofadmission.
CountthedaysoftherapyalreadydeliveredfromItemP1a,b,andc.
Calculatetheexpectednumberordaysthroughday15,eveniftheresidentisdischargedpriortoday15.
Ifordersarereceivedformorethanonetherapydiscipline,enterthenumberofdaysatleastonetherapyserviceisperformed.
Forexample,ifPTisprovidedonMWF,andOTisprovidedonMWF,theMDSshouldbecodedas3days,not6days.
Clarifications:Donotcounttheevaluationdayintheestimatenumberofdaysunlesstreatmentisrendered.
Whenthephysicianordersalimitednumberofdaysoftherapy,thentheprojectionisbasedontheactualnumberofdaysoftherapyordered.
Forexample,ifthephysicianorderstherapyfor7days,theprojectednumberofdaysinT1cwillbe7.
d.
ESTIMATEOFNUMBEROFMINUTES(Throughday15)Coding:EstimateofNumberofMinutes-Entertheestimatedtotalnumberoftherapyminutes(acrossalltherapies)itisexpectedtheresidentwillreceivethroughtheresident'sfifteenthdayofadmission.
IncludethenumberofminutesalreadyprovidedfromMDSItemsP1ba(B),P1bb(B),andP1bc(B).
Calculatetheexpectednumberofminutesthroughday15,eveniftheresidentisdischargedpriortoday15.
Clarification:Donotincludeevaluationminutesintheestimateofnumberofminutes.
Thispagerevised--August2005,June2005,August2003CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]August2005Page3-240SECTIONW.
SUPPLEMENTALITEMSW1.
NationalProviderIDIntent:TorecordthefacilityNationalProviderIdentification(NPI).
Definition:TheNPIisasystemforuniquelyidentifyingallprovidersofhealthcareservices,supplies,andequipment.
TheSecretaryoftheDepartmentofHealthandHumanServices(HHS)hasestablishedastandardidentifierforhealthcareproviders.
Process:CMSassignsanNPItothenursingfacility.
TheNPIappliestoallresidentsofthatnursingfacility.
Coding:Whenavailable,onlyenterthe10digitNPIinthespacesprovided.
Donotenteranyembeddeddashesorspaces.
Recheckthenumbertoensureyouhaveenteredthe10digitscorrectly.
ThefacilityisencouragedtobeginusingthisnumberonceithasbeenassignedbyCMS.
W2.
InfluenzaImmunizationIntent:Todeterminetherateofvaccinationandcausesfornon-vaccination.
SectionW2mustbecompletedforallresidentsonallassessmenttypes(OBRAand/orPPS)withAssessmentReferenceDatesandalldischargetrackingformswithDischargeDatesfromOctober1throughJune30.
DischargetrackingformsareincludedinordertocapturefluvaccinesadministeredtoresidentswhosefluvaccineswerenotcapturedonanMDSassessment.
AlthoughfluseasoncurrentlyisdefinedasOctober1throughMarch31,assessmentswithanARDanddischargeswithadischargedatethroughJune30areincludedinordertocaptureanyrecordthatprovidestheonlyreportofavaccinationreceivedduringthefluseason.
Example:AfluvaccineisadministeredtoaresidentinMarch,notwithinthewindowofanMDSassessment.
ExtendingthedateforcompletingW2toJune30providesthefacilitytheabilitytocapturethatfluvaccineonthenextQuarterly,evenifitisnotdueforanother92daysoronadischargebeforetheQuarterlyisdue.
Process:Reviewtheresident'smedicalrecordandinterviewtheresidentorCMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]responsibleparty/legalguardiantodetermineInfluenzavaccinationstatusduringthisyear'sfluseason,definedasOctober1throughMarch31.
Usethefollowingsteps:Step1.
Reviewtheresident'smedicalrecordtodeterminewhetheranInfluenzavaccinationwasreceivedduringthefluseason.
Ifvaccinationstatusisunknown,proceedtothenextstep.
Step2.
Asktheresidentifhe/shereceivedadoseofInfluenzavaccineoutsideofthefacilityforthisyear'sfluseason.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Step3.
Iftheresidentisunabletoanswer,thenaskthesamequestionoftheresponsibleparty/legalguardian.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Step4.
Ifvaccinestatuscannotbedetermined,administerthevaccinationtotheresidentaccordingtostandardsofclinicalpractice.
TheCDChasevaluatedinactivatedInfluenzavaccineco-administrationwiththepneumococcalpolysaccharidevaccinesystematicallyamongadults.
Simultaneousvaccineadministrationissafewhenadministeredbyaseparateinjectionintheoppositearm2,3.
Iftheresidentisanamputeeorifintramuscularinjectionsarecontraindicatedintheupperextremities,administerthevaccine(s)accordingtostandardsofclinicalpractice.
Coding:W2aEnter"0"fora'No'responseandproceedtoitemW2bIftheresidentdidnotreceivetheInfluenzavaccineinthisfacilityfromOctober1–March31.
Example:Mrs.
J.
receivedtheInfluenzavaccineinJanuary2005.
TheARDofthisassessmentisOctober2005.
ThefacilityhasnotyetadministeredtheInfluenzavaccineforthecurrentfluseason.
W2awouldbecoded"0",No.
Enter"1"fora'Yes'responseandproceedtoitemW3IftheARDofthisassessmentorthedischargedateofthisdischargetrackingformisfromJanuary1throughJune30,includeInfluenzavaccineadministeredinthefacilityfromOctober1oflastyearthroughMarch31ofthecurrentyear.
Example:Mrs.
T.
receivedtheInfluenzavaccineinAugust2005Page3-241CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]November2004.
TheARDofthisassessmentisFebruary2005.
IncludetheNovember2004vaccinationonthisassessmentandcodeW2a"1",Yes.
IftheARDofthisassessmentorthedischargedateofthisdischargetrackingformisonorafterOctober1,includetheInfluenzavaccineadministeredinthefacilityonorafterOctober1ofthecurrentyear.
Example:Mr.
CreceivedtheInfluenzavaccineinOctober2005.
TheARDofthisassessmentisDecember2005.
IncludetheOctober2005vaccinationonthisassessmentandcodeW2a"1",Yes.
SkipitemW2andgotoitemW3IftheARDofthisassessmentorthedischargedateofthisdischargetrackingformisfromJuly1throughSeptember30.
Example:Mr.
P.
receivedtheInfluenzavaccineinFebruary2005.
TheARDofthisassessmentisinAugust2005.
SkipthisitemandgotoitemW3.
W2bIftheresidenthasnotreceivedtheInfluenzavaccineinthefacility,codethereasonfromthefollowinglist:1.
Notinfacilityduringthisyear'sfluseason-ResidentnotinthefacilityfromOctober1–March31.
2.
Receivedoutsideofthisfacility-IncludesInfluenzavaccinationsadministeredfromOctober1throughMarch31inanyothersetting(e.
g.
physicianoffice,healthfair,grocerystore,hospital,firestation).
3.
Noteligible–Duetocontraindicationsincluding:allergicreactiontoeggsorothervaccinecomponent(s)aphysicianordernottoimmunizeoranacutefebrileillnessispresent;however,theresidentshouldbevaccinatedifcontraindicationsend4.
Offeredanddeclined–Residentorresponsibleparty/legalguardianhasbeeninformedofwhatisbeingofferedandchoosesnottoacceptthevaccine.
Seepages3-36&37fortypesofAugust2005Page3-242CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]responsibility/legalguardian.
5.
Notoffered–Residentorresponsibleparty/legalguardiannotofferedthevaccine.
Seepages3-36&37fortypesofresponsibility/legalguardian.
6.
Inabilitytoobtainvaccine–Vaccineunavailableatthefacilityduetodeclaredvaccineshortage;however,theresidentshouldbevaccinatedoncethevaccineisreceived.
TheannualsupplyofinactivatedInfluenzavaccineandthetimingofitsdistributioncannotbeguaranteedinanyyear.
W3.
PneumococcalImmunizationIntent:Todeterminetherateofvaccinationandcausesfornon-vaccination.
SectionW3mustbecompletedforallresidentsonallassessmenttypes(OBRAand/orPPS)andalldischargetrackingforms.
TheCDChasevaluatedinactivatedInfluenzavaccineco-administrationwiththePneumococcalPolysaccharideVaccine(PPV)systematicallyamongadults.
Simultaneousvaccineadministrationissafewhenadministeredbyaseparateinjectionintheoppositearm2,3.
Iftheresidentisanamputeeorintramuscularinjectionsarecontraindicatedintheupperextremities,administerthevaccine(s)accordingtoclinicalstandardsofcare.
Personslessthan65yearsofagewhoarelivinginenvironmentsorsocialsettings(e.
g.
nursinghomesandotherlong-termcarefacilities)inwhichtheriskforinvasivepneumococcaldiseaseoritscomplicationsisincreasedshouldreceivethePPV2.
Alladults65yearsofageoroldershouldgetthePPV.
PPVisgivenonceinalifetime,withcertainexceptions1.
August2005Page3-243CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]Persons65yearsoroldershouldbeadministeredaseconddoseofvaccine(boostervaccine)iftheyreceivedthefirstdoseofvaccinemorethan5yearsearlierandwerelessthan65yearsoldatthetime1,2.
Note:PleaserefertothefollowingalgorithmforPPVadministrationONLYFigure1AdoptedfromtheCDCRecommendationsandReports.
PreventionofPneumococcalDisease:RecommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).
MMWRApril1997;46(RR-08);1-24.
FIGURE1.
Algorithmforvaccinatingimmunocompetentpersonsaged>65yearsNOorUnsureVaccinationindicatedYESYESNOYES*NOVaccinationnotindicatedHasthepersonbeenvaccinatedpreviouslyWasthepersonaged>65yearsatthetimeoflastvaccinationHave>5yearselapsedsincethefirstdose*Foranyimmunocompetentpersonwhohasreceivedadoseofpneumococcalpolysaccharidevaccineatage>65years,revaccinationisnotindicated.
1CDC.
PneumococcalPolysaccharideVaccine.
Whatyouneedtoknow.
PneumococcalVaccineInformationStatementJuly1997.
2CDC.
PreventionofPneumococcalDisease:RecommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).
MMWRApril1997;46(RR-08);1-24.
3RecommendationsandReports.
Preventionandcontrolofinfluenza.
RecommendationsoftheAdvisoryCommitteeonImmunizationPractices(ACIP).
MMWRMay28,2004/53(RR06);1-40.
August2005Page3-244CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]TheCDCrecommendsasecond(booster)doseforimmunocompromisedpersonsdueto1oAdamagedspleenornospleenoSickle-celldiseaseoHIVinfectionsorAIDSoCancer,leukemia,lymphoma,multiplemyelomaoKidneyfailureoNephroticsyndromeoHistoryofanorganorbonetransplantoMedicationregimensthatlowersimmunity(suchaschemotherapyorlong-termsteroids)Whenanyoftheaboveconditionsarepresent,personsolderthan10yearsold(includingthose65yearsofageandolder)shouldgetthesecond(booster)dose5yearsafterthefirstdose.
Children10yearsoldandyoungermaygetthissecond(booster)dose3yearsafterthefirstdose.
Process:Reviewtheresident'smedicalrecordandinterviewresidentorresponsibleparty/legalguardiantodeterminePPVstatus,usingthefollowingsteps.
Step1.
Reviewtheresident'smedicalrecordtodeterminewhetherPPVhasbeenreceived.
Ifvaccinationstatusisunknown,proceedtothenextstep.
Step2.
Asktheresidentifhe/shereceivedaPPV.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Step3.
Iftheresidentisunabletoanswer,askthesamequestionofaresponsibleparty/legalguardian.
Ifvaccinationstatusisstillunknown,proceedtothenextstep.
Seepages3-36&37fortypesofresponsibility/legalguardian.
Step4.
Ifvaccinationstatuscannotbedetermined,administertheappropriatevaccinetotheresident,accordingtothestandardsofclinicalpractice.
Coding:W3aEnter"0"fora'No'responseandproceedtoitemW3bIftheresident'sPPVstatusisnotuptodateEnter"1"fora'Yes'responseandskipitemW3bIftheresident'sPPVstatusisuptodateAugust2005Page3-245CMS'sRAIVersion2.
0ManualCH3:SupplementalItems[W]W3bIftheresidenthasnotreceivedaPPV,codethereasonfromthefollowinglist:1.
Noteligible–Duetocontraindicationsincluding:allergicreactiontovaccinecomponent(s)aphysicianordernottoimmunizeanacutefebrileillnessispresent;however,theresidentshouldbevaccinatedaftercontraindicationsend2.
Offeredanddeclined–Residentorresponsibleparty/legalguardianhasbeeninformedofwhatisbeingofferedandchoosesnottoacceptthevaccine.
Seepages3-36&37fortypesofresponsibility/legalguardian.
3.
Notoffered-Residentorresponsibleparty/legalguardianwerenotofferedthevaccine.
Seepages3-36&37fortypesofresponsibility/legalguardian.
August2005Page3-246CMS'sRAIVersion2.
0ManualAppendixBAPPENDIXBSTATEAGENCYCONTACTSRESPONSIBLEFORANSWERINGRAIQUESTIONSRevised—August2005PageB-1CMS'sRAIVersion2.
0ManualAppendixBSTATEAGENCYCONTACTS–MDSRAICOORDINATORSSTATEMDSRAICoordinatorPHONE#E-mailAddressAKDoreneLukas907-334-2491Dorene_Lukas@health.
state.
ak.
usALPamelaCarpenter334-206-7929pamelacarpenter@adph.
state.
al.
usARSueGaines501-682-8853Sue.
gaines@arkansas.
govARTwylaMoore,RN501-661-2201tmoore@healthyarkansas.
comAZSylviaBalistreri602-364-3878balists@azdhs.
govCAVirginiaE.
Aquino,RN916-324-2362Helpdeskmdsoasis@dhs.
ca.
gov.
HelpdeskCOBettyKeen,RN303-692-2894Betty.
Keen@state.
co.
usCTLoriGiffinAlternate:AngelaWhite860-509-7400Lori.
Griffin@po.
state.
ct.
usAngela.
white@po.
state.
ct.
usDCMarySklencar202-442-4759Mary.
sklencar@dc.
govDEKimPaugh302-424-6377Kim.
paugh@state.
de.
usFLClaireHoagland727-552-1133x179hoaglanc@fdhc.
state.
fl.
usGABarbaraChuven404-657-5854bechuven@dhr.
state.
ga.
usHIJaniceNakama,RNAlternate:SharonMatsubara808-692-7420jpnakama@mail.
health.
state.
hi.
usskmatsub@mail.
health.
state.
hi.
usIAKarenZaabel515-242-5991Kzaabel@dia.
state.
ia.
usIDLorettaTodd208-334-6626Toddl@idhw.
state.
id.
usILRhondaImhoff,RN217-785-5132rimhoff@idph.
state.
il.
usINKimberlyHoneycutt,RN317-233-4719khoneycu@isdh.
state.
in.
usKSLynnSearlesVeraVanBruggen,RN785-291-3552785-296-1246Lsearles@kdhe.
state.
ks.
usveravanbruggen@aging.
state.
ks.
usKYDebbieDicken859-246-2301Debbie.
dicken@ky.
govLAEvelynEnclarde,RN225-342-4855eenclarde@dhh.
la.
govMAPaulDiNatale617-753-8222Paul.
dinatale@state.
ma.
usMDLynneCondon410-402-8102Lcondon@dhmh.
state.
md.
usRevised—August2005PageB-2CMS'sRAIVersion2.
0ManualAppendixBSTATEMDSRAICoordinatorPHONE#E-mailAddressMELouisT.
DorogiCaroleKus,RN207-287-9300207-287-3933Lou.
dorogi@maine.
govcarole.
kus@maine.
govMIMaryHess989-732-8837hessm@michigan.
govMNSusanPedro651-215-8749Susan.
pedro@health.
state.
mn.
usMOMikeDeClue,RN-C573-751-6308Michael.
DeClue@dhss.
mo.
govMSLynnCox601-576-7316Lynn.
cox@msdh.
state.
ms.
usMTKathleenMoran406-444-3459kmoran@mt.
govNCCindyDeporterDeniceDavis(Back-up)919-733-7461919-733-7461Cindy.
DePorter@ncmail.
netdenice.
davis@ncmail.
netNDPatriciaRotenberger701-328-2364Protenbe@state.
nd.
usNEDanTaylor402-471-0535Daniel.
taylor@hhss.
ne.
govNHSusanGrimes603-271-3024sgrimes@dhhs.
state.
nh.
usNJBethBell,RN609-633-8981Beth.
Bell@doh.
state.
nj.
usNMSandraColeConnieArmijo505-476-9037505-476-9056Sandra.
cole@doh.
state.
nm.
usConnie.
armijo@doh.
state.
nm.
usNVJuanitaBall,RN775-687-4475x235JBall@blc.
state.
nv.
usNYKristinArmstrong-Ross518-478-1124KMA07@health.
state.
ny.
usOHPatsyStrouse614-955-0774pstrouse@odh.
ohio.
govOKSharonWarlick405-271-5278Sharonlw@health.
state.
ok.
usORMaryB.
Borts503-691-6587Mary.
B.
Borts@state.
or.
usPASusanWilliamsonChrisKelly717-787-1816suswilliam@state.
pa.
usChkelly@state.
pa.
usPRLourdesCruz787-782-0553x2252lcruz@salud.
gov.
prRIMadelineVincent,RN401-277-2566madeline.
vincent@health.
ri.
govSCSaraS.
Granger803-545-4205Grangerss@dhec.
sc.
govSDDollyHanson605-773-7070Carol.
hanson@state.
sd.
usTNLeatriceCoffin615-741-8002Leatrice.
coffin@state.
tn.
usTXMargaretEvans,RN806-249-5579x27Margaret.
evans@dads.
state.
tx.
usRevised—August2005PageB-3CMS'sRAIVersion2.
0ManualAppendixBSTATEMDSRAICoordinatorPHONE#E-mailAddressUTCarolynReese,RN801-538-6599carolynreese@utah.
govVAJudyWilhide804-367-2103Judy.
wilhide@vdh.
virginia.
govVTLaineLucenti802-241-2345Laine.
lucenti@dail.
state.
vt.
usWAMarjorieRay360-725-2487RayMa@dshs.
wa.
govWIChrisBenesh608-266-1718Benesce@dhfs.
state.
wi.
usWVEmilyKeeferBeverlyHissom304-558-1740304-558-4145emilykeefer@wvdhhr.
orgbeverlyhissom@wvdhhr.
orgWYLindaBrown307-777-7123lbrown@state.
wy.
usNOTE:NotincludedinthismanualisalistoftheStateMDSAutomationCoordinatorsandtheStateMedicaidMDSCoordinators.
TheselistswillbepostedontheCMSwebsiteat:http://www.
cms.
hhs.
gov/medicaid/mds20Revised—August2005PageB-4CMS'sRAIVersion2.
0ManualAppendixBREGIONALOFFICECONTACTSRegionISharonRobersonCMS/DHSQ,Room2275JFKFederalBuildingBoston,MA02203-0003(617)565-1300RegionIINormaJ.
BirkettCMS/DHSQ26FederalPlaza,Room3800NewYork,NY10278-0063(212)616-2460RegionIIIMicheleClintonCMS/DHSQP.
O.
Box7760Philadelphia,PA19101-7760(215)861-4290CynthiaMcWilliams(215)861-4765RegionIVJillHartlineCMS/DHSQSuite4T20,SamNunnAtlantaFederalCenterAtlanta,GA30303(404)562-7477RegionVWandahHardyCMS/DHSQ105W.
AdamsStreet,15thFloorChicago,IL60603-6201(312)353-3337RegionVIJacquelynDouglasCMS/SCRB1301YoungStreet,Room833Dallas,TX75202-4348(214)767-4436Revised—August2005PageB-5CMS'sRAIVersion2.
0ManualAppendixBRegionVIIMaryaliceFutrellHealthQualityReviewSpecialistSurvey&CertificationBranchII601East12thStreet,Room235KansasCity,MO64106-2808(816)426-6474(ContactforMO&NE)IreneWeizirl(816)426-2011(ContactforKS&IA)RegionVIIINancyWalkerCMS/DHSQFederalOfficeBldg.
,Room11851961StoutSt.
Denver,CO80294-3538(303)844-7037RegionIXRenieSoriaCMS/DHSQ75HawthorneSt.
,4thFloorSanFrancisco,CA94105-3903(415)744-3692RegionXJoanneRokoskyCMS/DHSQBlanchardPlazaBldg.
2201SixthAve.
,MailStopRX-42Seattle,WA98121-2500(206)615-2091Revised—August2005PageB-6
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