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CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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CAAs and Care Planning
Item Rationale
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Use this item when the facility is completing content tied to Section V and needs to stay anchored to v1.20.1.
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- Current source status: Published.
- Item locator: Manual page V-4
- CMS exact locator: Manual page V-4
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Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page V-4
CMS exact locator
Manual page V-4
Full CMS Text
Item Rationale
Items V0200A 01 through 20 document which triggered care areas require further assessment, decision as to whether or not a triggered care area is addressed in the resident care plan, and the location and date of CAA documentation. The CAA Summary documents the interdisciplinary team’s and the resident, resident’s family or representative’s final decision(s) on which triggered care areas will be addressed in the care plan.
Coding Instructions for V0200A, CAAs
Facility staff are to use the RAI triggering mechanism to determine which care areas require review and additional assessment. The triggered care areas are checked in Column A “Care Area Triggered” in the CAAs section. For each triggered care area, use the CAA process and current standard of practice, evidence-based or expert-endorsed clinical guidelines and resources to conduct further assessment of the care area. Document relevant assessment information regarding the resident’s status. Chapter 4 of this manual provides detailed instructions on the CAA process, care planning, and documentation. For each triggered care area, Column B “Care Planning Decision” is checked to indicate that a new care plan, care plan revision, or continuation of the current care plan is necessary to address the issue(s) identified in the assessment of that care area. The “Care Planning Decision” column must be completed within 7 days of completing the RAI, as indicated by the date in V0200C2, which is the date that the care planning decision(s) were completed and that the resident’s care plan was completed. For each triggered care area, indicate the date and location of the CAA documentation in the “Location and Date of CAA Documentation” column. Chapter 4 of this manual provides detailed instructions on the CAA process, care planning, and documentation. Coding Instructions for V0200B, Signature of RN Coordinator for CAA Process and Date Signed V0200B1, Signature Signature of the RN coordinating the CAA process. V0200B2, Date Date that the RN coordinating the CAA process certifies that the CAAs have been completed. The CAA review must be completed no later than the 14th day of admission (admission date + 13 calendar days) for an Admission assessment and within 14 days of the Assessment Reference Date (A2300) for an Annual assessment, Significant Change in Status Assessment, or a Significant Correction to Prior Comprehensive Assessment. This date is considered the date of completion for the RAI. Coding Instructions for V0200C, Signature of Person Completing Care Plan Decision and Date Signed V0200C1, Signature Signature of the staff person facilitating the care planning decision-making. Person signing does not have to be an RN. V0200C2, Date The date on which a staff member completes the Care Planning Decision column (V0200A, Column B), which is done after the care plan is completed. The care plan must be completed within 7 days of the completion of the comprehensive assessment (MDS and CAAs), as indicated by the date in V0200B2. Following completion of the MDS, CAAs (V0200A, Columns A and B) and the care plan, the MDS 3.0 comprehensive assessment record must be transmitted to iQIES within 14 days of the V0200C2 date. Clarifications The signatures at V0200B1 and V0200C1 can be provided by the same person, if the person actually completed both functions. However, it is not a requirement that the same person complete both functions. If a resident is discharged prior to the completion of Section V, a comprehensive assessment may be in progress when a resident is discharged. Although the resident has been discharged, the facility may complete and submit the assessment. The following guidelines apply to completing a comprehensive assessment* when the resident has been discharged:
1. Complete all required MDS items from Section A through Section Z and
indicate the date of completion in Z0500B. Encode and verify these items.
2. Complete the care area triggering process by checking all triggered care areas
in V0200A, Column A.
3. Sign and enter the date the CAAs were completed at V0200B1 and V0200B2.
4. Dash fill all of the “Care Planning Decision” items in V0200A, Column B,
which indicates that the decisions are unknown.
5. Sign and enter the date that care planning decisions were completed at
V0200C1 and V0200C2. Use the same date used in V0200B2.
6. Submit the record.
*Please see Chapter 2 for additional detailed instructions regarding options for when residents are discharged prior to completion of the RAI. Intent: The purpose of Section X is to identify an MDS record to be modified or inactivated. The following items identify the existing assessment record that is in error. Section X is only completed if Item A0050, Type of Record, is coded a 2 (Modify existing record) or a 3 (Inactivate existing record). In Section X, the facility must reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect. This information is necessary to locate the existing record in the Internet Quality Improvement and Evaluation System (iQIES). A modification request is used to correct an iQIES record containing incorrect MDS item values due to: transcription errors, data entry errors, software product errors, item coding errors, and/or other error requiring modification The modification request record contains correct values for all MDS items (not just the values previously in error), including the Section X items. The corrected record will replace the prior erroneous record in iQIES. In some cases, an incorrect MDS record requires a completely new assessment of the resident in addition to a modification request for that incorrect record. Please refer to Chapter 5 of this manual, Submission and Correction of the MDS Assessments, to determine if a new assessment is required in addition to a modification request. An inactivation request is used to move an existing record in iQIES from the active file to an archive (history file) so that it will not be used for reporting purposes. Inactivations should be used when the event did not occur (e.g., a discharge was submitted when the resident was not discharged). The inactivation request only includes Item A0050 and the Section X items. All other MDS sections are skipped. The modification and inactivation processes do not remove the prior erroneous record from iQIES. The erroneous record is archived in a history file. In certain cases, it is necessary to delete or change a record and not retain any information about the record in iQIES. This requires the facility to complete an MDS 3.0 Individual Correction Request or MDS 3.0 Individual Deletion Request in iQIES. Additionally, in situations in which the state-assigned facility submission ID (FAC_ID) or state code (STATE_CD) is incorrect, an MDS 3.0 Manual Assessment Move Facility Request is required. The policy and procedures for these special requests are provided in Chapter 5 of this Manual. These special requests are required only in the following four cases:
1. Item A0410 Submission Requirement is incorrect. Submission of MDS assessment
records to iQIES constitutes a release of private information and must conform to privacy laws. Only records required by the State and/or the Federal governments may be stored in the iQIES. If a record has been submitted with the incorrect Submission Requirement value in Item A0410, then the facility must request correction of A0410 via an MDS 3.0 Individual Deletion Request or MDS 3.0 Individual Correction Request in iQIES. Item A0410 cannot be corrected by modification or inactivation. See Chapter 5 of this Manual and the iQIES Assessment Management: Assessment Submitter Manual for details.
2. Record was submitted with the incorrect state-assigned facility submission ID
(FAC_ID) or state code (STATE_CD). If a record was submitted to iQIES for an incorrect facility or with an incorrect state code, the record must be manually corrected by the State Agency. In these situations, the facility must complete an MDS 3.0 Manual Assessment Move Facility Request and send the request via certified mail to the State Agency.
3. Record submitted was not for OBRA or Medicare Part A purposes. When a facility
erroneously submits a record that was not for OBRA or Medicare Part A purposes, CMS does not have the authority to collect the data included in the record, and deletion via an MDS 3.0 Individual Deletion Request in iQIES is required to remove it from the CMS database. For erroneous PPS assessments combined with OBRA-required assessments, if the item set code changes, the assessment must be manually deleted, and a new, stand- alone OBRA assessment must be submitted. If the item set code does not change, then a modification can be completed.
4. Inappropriate submission of a test record as a production record. Removal of a test
record from iQIES requires record deletion via an MDS 3.0 Individual Deletion Request in iQIES. Otherwise, information for a “bogus” resident will be retained in the database and this resident will appear on some reports to the facility.
Matrix Applicability
Matrix values will appear here after they are imported into the governed matrix tables.