Catherine R. “Cat” Selman, BS
The Healthcare Communicators, Inc.
www.thehealthcarecommunicators.com
© 2014, The Healthcare Communicators, Inc. – All rights reserved.
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Federal regulations require that
(1) the assessment accurately reflects the
resident’s status,
(2) a registered nurse conducts or
coordinates each assessment with the
appropriate participation of health
professionals, and
(3) the assessment process includes direct
observation, as well as communication
with the resident and direct care staff on
all shifts.
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However, nursing homes are left to determine
(1) who should participate in the assessment
process,
(2) how the assessment process is completed,
and
(3) how the assessment information is
documented while remaining in
compliance with the requirements of the
Federal regulations and the instructions
contained within the RAI manual.
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Given the requirements of participation of
appropriate health professionals and direct care
staff, completion of the RAI is best accomplished
by an interdisciplinary team (IDT) that includes
nursing home staff with varied clinical
backgrounds, including nursing staff and the
resident’s physician.
Such a team brings their combined experience
and knowledge to the table in providing an
understanding of the strengths, needs and
preferences of a resident to ensure the best
possible quality of care and quality of life.
Care Area Assessment
 The MDS alone is not a comprehensive
assessment.
 It is used for preliminary screening to identify
potential resident issues/conditions,
strengths, and preferences.
 Facilities must ensure that residents improve
when possible and do not deteriorate unless
the resident’s clinical condition demonstrates
that the decline was unavoidable.
The goal of the CAA process is to
guide the IDT through a
comprehensive assessment of a
resident’s functional status.
 Functional status differs from medical
or clinical status in that the whole of a
person’s life is reviewed with the intent
of assisting that person to function at
his or her highest practicable level of
well-being.
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The CATs (Care Area Triggers) are specific
response options from the MDS that are
indicators of 20 particular care areas that
affect nursing home residents.
When a trigger is entered as the response on
a resident’s MDS, additional assessment and
review of the care area are required to
determine the status of the issue. Thus,
The CATs and CAAs form a critical link
between the MDS and care planning.
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Triggers identify residents who have or are at
risk for developing specific functional
issues/conditions and require further evaluation.
A CAT provides a starting point for care planning
and should be used in combination with other
assessment and care planning information.
A CAA may define several MDS items or sets of
items as triggers (CATs).
Only one of the trigger definitions must be
present for a CAA to be triggered, although for
many CAAs, each of the specific trigger items
that are present must be investigated
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The specific MDS response indicates that clinical
factors are present that may or may not
represent a condition that should be addressed
in the care plan.
CATs merely provide a “flag” for the IDT
members, indicating that the care area must be
assessed completely prior to making care
planning decisions.
When the resident’s status on a particular MDS
item(s) matches one of the CATs, the CAA is
triggered, requiring an in-depth assessment.
1. Potential Problems:
 Suggest the presence of a problem that
warrants additional assessment and
consideration of a care plan intervention.
 Usually include clinical factors commonly seen
as indicative of possible underlying problems
and well understood by nursing home staff.
 For example, whether underlying behavioral
symptoms can be minimized or eliminated by
treatment of the underlying cause (e.g., agitated
depression).
2. Broad Screening Triggers:
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Assist staff in identifying hard-to-diagnose problems.
Because some problems are often difficult to assess in
the elderly nursing home population, certain triggers
have been broadly defined and consequently may have a
fair number of false positives
Examples include factors related to delirium or
dehydration.
Experience, however, has shown that many residents
who have these problems were not identified prior to
having been triggered for review.
3. Prevention of Problems
These factors assist staff in identifying
residents at risk of developing particular
problems.
 Examples include risk factors for falling or
developing a pressure ulcer.
 “At risk” – will the resident decline or
deteriorate if this issue is not addressed on the
care plan
4. Rehabilitation Potential
 Attempts to identify candidates with rehabilitation
potential.
 Not all triggers identify deficits or problems. Some
triggers indicate areas of resident strengths.
 Gives consideration to programs that improve a
resident’s functioning or minimize decline.
 For example, MDS item responses indicating that
“resident believes he or she is capable of increased
independence in at least some ADLs” (Section G) may
focus the assessment and care plan on functional
areas most important to the resident or on the area
with the highest potential for improvement.
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Reviewing a triggered CAA means doing an in-depth,
resident-specific assessment of the triggered
condition in terms of the potential need for care plan
interventions.
Is used to glean information needed to fully
understand a resident’s condition.
After completing the assessment, analyzing the
information collected, and drawing conclusions about
the causes and factors contributing to the care area as
well as risk factors for this resident, the next step is to
develop a resident-specific care plan based directly on
these conclusions.
Care Area Assessment
 Each care area comprises:
(1) an introduction that provides general
information about the issue or condition and
(2) a list of items and responses from the MDS
that are considered CATs for the issue or
condition.
 Each triggered CAA must be assessed further to
facilitate care plan decision making, but it may or
may not represent a condition that should be
addressed in the care plan.
Care Area Assessment
 In previous versions of the RAI, Resident
Assessment Protocols (RAPs) were mandated as
the tools for completing the assessments of
the triggered care areas.
 For MDS 3.0, no specific tool is mandated as
long as the tools are current and founded on
evidence-based or expert-endorsed research,
clinical practice guidelines, and resources.
1. Delirium
2. Cognitive
Loss/Dementia
3. Visual Function
4. Communication
5. Activity of Daily Living
(ADL) Functional/
Rehabilitation Potential
6. Urinary Incontinence
and Indwelling Catheter
7. Psychosocial Well-Being
8. Mood
9. Behavioral Symptoms
10. Activities
CAAs
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Falls
Nutritional Status
Feeding Tubes
Dehydration/Fluid
Maintenance
Dental Care
Pressure Ulcer
Psychotropic
Medication Use
Physical Restraints
Pain (New)
Return to Community
Referral (New)
CAAs
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CAA documentation should include the
underlying causes, contributing factors, and
unique risk factors related to the care area
condition for the specific resident.
A risk factor increases the chance of having a
negative outcome or complication.
A CAA should provide nursing home staff
with comprehensive information for
evaluating factors that may cause, contribute
to, or exacerbate the triggered condition.
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If the condition is found to be a problem for
the resident, the CAA information should
assist the IDT in determining whether the
care area issue/condition can be eliminated
or reversed or, if not, whether special care
must be taken to maintain a resident’s
current level of functioning.
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The nature of the issue or condition (may include
presence or lack of objective data and subjective
complaints). In other words, what is the problem
for this resident?
Causes and contributing factors.
Complications affecting or caused by the care area
for this resident.
Risk factors that arise because of the presence of
the condition that affect the staff’s decision to
proceed to care planning.
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Factors that must be considered in developing
individualized care plan interventions, including
appropriate documentation to justify the decision to
plan care or not to plan care for the individual
resident.
Need for referrals or further evaluation by appropriate
health professionals.
What research, resource(s), or assessment tool(s) were
used in performing the CAA. A source(s) need only be
cited if it is not already cited as the standard source(s)
used for this CAA by facility policy.
Completion of Section V (CAA Summary; see Chapter 3
for coding instructions) of the MDS.
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Per regulatory mandate: the resident’s
assessment must be conducted or
coordinated by a registered nurse (RN) with
the appropriate participation of health
professionals.
It is common practice for facilities to assign
specific MDS items or portion(s) of items (and
subsequently CAAs associated with those
items) to those of various disciplines.
Normal communication involves related
activities, including:
 expressive communication (making oneself
understood to others, both verbally and via
non-verbal exchange) and
 receptive communication (comprehending or
understanding the verbal, written, or visual
communication of others).
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While behavior may sometimes be related to or
caused by illness, behavior itself is only a symptom
and not a disease.
Only identifies certain behaviors - is not intended to
determine the significance of behaviors, not whether
they are problematic and need an intervention.
Understanding the nature of the issue/condition and
addressing the underlying causes have the potential
to improve the quality of the resident’s life and the
quality of the lives of those with whom the resident
interacts.
Review of Indicators of Behavioral Symptoms
a
Seriousness of the behavioral
symptoms (E0300, E0800,
E0900, E1100)
r
• Resident is immediate threat to
self – IMMEDIATE INTERVENTION
REQUIRED
r
• Resident is immediate threat to
others – IMMEDIATE
INTERVENTION REQUIRED
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
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Sadness and anxiety are normal human emotions,
and fluctuations in mood are also normal.
Mood states (which reflect more enduring patterns of
emotions) may be become as extreme or
overwhelming as to impair personal and psychosocial
function.
Mood disorders such as depression reflect a
problematic extreme and should not be confused
with normal sadness or mood fluctuation.
The mood section of the MDS screens for—but is not
intended to definitively diagnose—any mood
disorder, including depression.
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Involvement in social relationships is a vital
aspect of life -most adults have meaningful
relationships with family, friends, and
neighbors.
When relationships are challenged, it can cloud
other aspects of life.
Decreases in a person’s social relationships may
affect psychological well-being and have an
impact on mood, behavior, and physical activity.
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Declines in physical functioning or cognition or
a new onset or worsening of pain or other health
or mental health issues/conditions may affect
both social relationships and mood.
Psychosocial well-being may also be negatively
impacted when a person has significant life
changes such as the death of a loved one.
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In the right column the facility can provide a
summary of supporting documentation
regarding the basis or reason for checking a
particular item. This could include the
location and date of that information,
symptoms, possible causal and contributing
factor(s) for item(s) checked.
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Step 6: Analyze the findings in the context of
their relationship to the care area and
standards of practice. This should include a
review of indicators and supporting
documentation, including symptoms and
causal and contributing factors, related to
this care area. Draw conclusions about the
causal/contributing factors and effect(s) on
the resident, and document these conclusions
in the Analysis of Findings section.
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Step 8: In the Care Plan Considerations
section, document whether a care plan for the
triggered care area will be developed and the
reason(s) why or why not.
NOTE: An optional Signature/Date line has
been added to each checklist. This was added
if the facility wants to document the staff
member who completed the checklist and
date completed.
Triggering Conditions (any of the following):
1. Resident has little interest or pleasure in
doing things as indicated by:
D0200A1 = 1
2. Staff assessment of resident mood suggests
resident states little interest or pleasure in
doing things as indicated by:
D0500A1 = 1
Triggering Conditions (any of the following):
3. Any 6 items for interview for activity
preferences has the value of 4 (not important
at all) or 5 (important, but cannot do or no
choice) as indicated by:
Any 6 of F0500A through F0500H = 4 or 5
4. Any 6 items for staff assessment of activity
preference item L through T are not checked
as indicated by:
Any 6 of F0800L through F0800T = not
checked
Review of Indicators of Activities
a
Activity preferences prior
to admission (from
interviews and record)
r
• Passive
r
• Active
r
• Outside the home
r
• Inside the home
r
• Centered almost entirely on
family activities
r
• Centered almost entirely on
non-family activities
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Activity preferences prior
to admission (from
interviews and record)
r
• Group (F0500E) activities
r
• Solitary activities
r
• Involved in community service,
volunteer activities
r
• Athletic
r
• Non-athletic
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Current activity pursuits
(from interviews and
record)
r
• Resident identifies leisure
activities that interest this
resident
r
• Self-directed or done with
others and/or planned by
others
r
• Activities resident pursues
when visitors are present
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Current activity pursuits
(from interviews and
record)
r
• Scheduled programs in
which resident participates
r
• Activities of interest not
currently available or
offered to the resident
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Health issues that result
in reduced activity
participation
r
• Indicators of depression or
anxiety (D0200, D0500)
r
• Use of psychoactive
medications (N0400A-D)
r
• Functional/mobility (G0110) or
balance (G0300) problems;
physical disability
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Health issues that result
in reduced activity
participation
r
• Cognitive deficits (C0500, C0700C1000), including stamina, ability
to express self (B0700),
understand others (B0800), make
decisions C1000)
r
• Unstable acute/chronic health
problem (from record) (O0100)
r
• Chronic health conditions, such
as incontinence (H0300, H0400)
or pain (J0300)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Health issues that result
in reduced activity
participation
r
• Embarrassment or unease due to
presence of equipment, such as
tubes, oxygen tank, or colostomy
bag (H0100) (from observation,
record)
r
• Receives numerous
treatments(O0100) that limit
available time/energy (from
record)
r
• Performs tasks slowly due to
reduced energy reserves
(observation, record)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Environmental or staffing
issues that hinder
participation
r
• Physical barriers that prevent
the resident from gaining
access to the space where the
activity is held (observation)
r
• Need for additional staff
responsible for social activities
(observation)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Environmental or staffing
issues that hinder
participation
r
• Lack of staff time to involve
residents in current activity
programs (observation)
r
• Resident’s fragile nature
results in feelings of
intimidation by staff
responsible for the activity
(from observation, interviews
and record)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Unique skills or knowledge
the resident has that he or
she could pass on to others
(from interviews and record)
r
• Games
r
• Complex tasks such as
knitting, or computer skills
r
• Topic that might interest
others
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Issues that result in
reduced activity
participation
r
• Resident is new to facility or has
been in facility long enough to
become bored with status quo
(from interview, record)
r
• Psychosocial well-being issues,
such as shyness, initiative, and
social involvement
r
• Socially inappropriate behavior
(E0200)
r
• Indicators of psychosis (E0100AC)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Issues that result in
reduced activity
participation
r
• Feelings of being unwelcome, due
to issues such as those already
involved in an activity drawing
boundaries that are difficult to
cross (from observation,
interview, record)
r
• Limited opportunities for resident
to get to know others through
activities such as shared dining,
afternoon refreshments, monthly
birthday parties, reminiscence
groups (from observation, facility
activity calendar)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Review of Indicators of Activities
a
Issues that result in
reduced activity
participation
r
• Available activities do not
correspond to resident’s
values, attitudes,
expectations (from
interview, record)
r
• Long history of unease in
joining with others (from
interview, record)
Supporting Documentation
(Basis/reason for checking the
item, including the location,
date, and source (if applicable)
of that information)
Input from resident and/or
family/representative regarding the care
area. (Questions/Comments/
Concerns/Preferences/Suggestions)
Analysis of Findings
Review indicators and
supporting documentation, and
draw conclusions. Document:
• Description of the problem;
• Causes and contributing
factors; and
• Risk factors related to the
care area.
Care Plan
Considerations
Care Document reason(s) care plan
Plan will/ will not be developed.
Y/N
Referral(s) to another discipline(s) is warranted (to
whom and why):
______________________ _______________________________________________
______________________________________________________________________
Information regarding the CAA transferred to the
CAA Summary (Section V of the MDS):
r Yes r No
Information from the assessment should be used
to:
 identify residents who have either withdrawn
from recreational activities, or
 who are uneasy entering into activities and
social relationships,
 to identify the resident’s interests, and
 to identify any related possible contributing
and/or risk factors.
The next step is to develop an individualized care
plan based directly on these conclusions. The
care plan should focus on:
 addressing the underlying cause(s) of activity
limitations, and
 the development or inclusion of activity
programs tailored to the resident’s interests
and to his or her cognitive, physical/functional,
and social abilities and improve quality of life.
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Written documentation of the CAA findings and
decision-making process may appear anywhere
in a resident’s record.
It can be written in discipline-specific flow
sheets, progress notes, the care plan summary
notes, a CAA summary narrative, etc.
Nursing homes should use a format that provides
the information as outlined in the RAI manual
and the State Operations Manual (SOM).
If it is not clear that a facility’s documentation
provides this information, surveyors will ask
facility staff to provide such evidence.
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No matter where the information is recorded,
use the “Location and Date of CAA
Documentation” column on the CAA Summary
(Section V of the MDS 3.0) to note where the
CAA information and decision-making
documentation can be found in the resident’s
record.
Also indicate in the column “Care Plan
Decision” whether the triggered care area is
addressed in the care plan.
Assessment
Decision-Making
(MDS)
(CAA)
Care Plan
Development
Care Plan
Implementation
Evaluation
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The care plan is driven not only by identified
resident issues and/or conditions but also by
a resident’s unique characteristics, strengths,
and needs.
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The IDT uses clinical problem solving and
decision making steps to make decisions. The
team may find during their discussions that
several problematic issues and/or conditions
have a related cause.
Or, they might find that they stand alone and are
unrelated.
Goals and approaches for each problematic issue
and/or condition may overlap, and consequently
the IDT may decide to address the problematic
issues and/or conditions collectively in the care
plan.
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After assessing the resident, staff may decide
that a triggered condition does not affect the
resident’s functioning or well-being and
therefore should not be addressed on the
care plan.
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The existence of a care planning issue (i.e., a
problematic issue and/or condition, need, or
strength) should be documented as part of
the CAA review documentation.
There are various options for documentation;
for example, it may be done by individual
staff members who have completed
assessments or have participated in care
planning, or as a summary note by members
of the IDT.
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In some cases, a resident may decline
particular services or treatments that the IDT
believes may assist him or her to attain the
highest practicable level of well-being.
In such cases, the resident’s wishes should be
honored and documented in the clinical
record and alternatives should be offered
before the care plan is finalized.
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The IDT should identify and document the
functional and behavioral implications of
identified problematic issues and/or
conditions, limitations, maintenance levels,
improvement possibilities, and so forth (e.g.,
how the condition is a problem for the
resident, how the condition limits or
jeopardizes the resident’s ability to complete
activities of daily living, or how the condition
somehow affects the resident’s well-being).
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The IDT agrees on intermediate goal(s) that
will lead to outcome objectives.
The intermediate goal(s) and objectives must
be pertinent to the resident’s condition and
situation (i.e., not just automatically applied
without regard for their individual relevance),
measurable, and have a time frame for
completion or evaluation.
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The IDT, with input from the resident, family
and/or resident representative, identifies
specific, individualized steps or approaches that
will be taken to help the resident achieve his or
her goal(s).
These approaches serve as instructions for
resident care and provide for continuity of care
by all staff.
Precise and concise instructions help staff
understand and implement interventions by
consistently.
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The goals and their accompanying
approaches should be communicated to other
direct care staffs who were not directly
involved in developing the care plan.
The effectiveness of the care plan must be
evaluated from its initiation and modified as
necessary.
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Changes to the care plan should occur as
needed in accordance with professional
standards of practice and documentation
(e.g., signing and dating entries to the care
plan).
IDT members should communicate as needed
about care plan changes.
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A separate care plan is not necessarily
required for each area that triggers a CAA.
For example, if impaired ADL function, mood
state, falls and altered nutritional status are
all determined to be caused by an infection
and medication-related adverse
consequences, it may be appropriate to have
a single care plan that addresses these issues
in relation to the common causes.
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Quality of life can be greatly enhanced when
care respects the resident’s choice regarding
anything that is important to the resident.
Interviews allow the resident’s voice to be
reflected in the care plan.
Information about preferences that comes
directly from the resident provides specific
information for individualized daily care and
activity planning.
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Care planning should be individualized and
based on the resident’s preferences.
Care planning and care practices that are
based on resident preferences can lead to
• improved mood,
• enhanced dignity, and
• increased involvement in daily routines and
activities.
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Because residents may adjust their
preferences in response to events and
changes in status, the preference assessment
tool is intended as a first step in an ongoing
dialogue between care providers and the
residents.
Care plans should be updated as residents’
preferences change, paying special attention
to preferences that residents state are
important.
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These questions will be useful for designing
individualized care plans that facilitate residents’
participation in activities they find meaningful.
Preferences may change over time and extend
beyond those included here. Therefore, the
assessment of activity preferences is intended as
a first step in an ongoing informal dialogue
between the care provider and resident.
As with daily routines, responses may provide
insights into perceived functional, emotional, and
sensory support needs.

Caregiving staff should use observations of
resident behaviors to understand resident
likes and dislikes in cases where the resident,
family, or significant other cannot report the
resident’s preferences. This allows care plans
to be individualized to each resident.
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CMS MDS 3.0 Web Site
www.cms.hhs.gov/NursingHomeQualityInits/
25_NHQIMDS30.asp
You may submit questions regarding the MDS
3.0 directly to CMS:
[email protected]
Catherine R. “Cat” Selman, BS
The Healthcare Communicators, Inc.
601.497.9837
E-mail: [email protected]
www.thehealthcarecommunicators.com
www.catselman.com