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State of California—Health and Human Services Agency
California Department of Public Health

AFL 13-22
September 13, 2013

Certified Skilled Nursing Facilities
Certified Nursing Facilities

Minimum Data Set (MDS) 3.0 Discharge Assessments That Have Not Been Completed and/or Submitted

AUTHORITY:      Title 42 Code of Federal Regulations (CFR) Section 483.20

​Please distribute copies to the MDS Coordinator, Director of Nursing, and Administrator.

This All Facility Letter (AFL) outlines Survey and Certification (S&C) Letter 13-56-NH, issued by the Centers for Medicare and Medicaid Services (CMS) on August 23, 2013, which provided clarifying steps required to address MDS 3.0 discharge assessments that have not been completed and/or submitted as required under 42 CFR Section 483.20. This information is provided in order to promote skilled nursing facility (SNF) and nursing facility (NF) completion of discharge assessments for inactive residents by September 30, 2013.

CMS regulations at 42 CFR Section 483.20(g) require that certified SNFs and NFs provide assessments that "accurately reflect the resident’s status." Further, 42 CFR Section 483.20(f) requires facilities to encode specified information for each resident in the facility within seven (7) days after completing a resident’s assessment, including "a subset of items upon…discharge…," meaning a discharge assessment. Within 14 days after a facility completes a resident’s assessment, it must electronically transmit encoded, accurate, and complete MDS data to the CMS system.

The failure to submit or complete MDS 3.0 discharge assessment records leads to inaccurate MDS 3.0 Quality Measures (QM) data, potentially affecting the resident, the facility’s payment, and facility liabilities. For example, failure to submit or complete MDS 3.0 discharge assessment records can lead to the citation of a facility under 42 CFR Sections 483.20(f) and 483.20(g).

CMS is providing this opportunity for facilities to rectify any missing and/or incomplete discharge assessments. Beginning October 1, 2013, MDS assessments older than 3 years will no longer be accepted by CMS. To minimize impact on QM data, CMS has also selected a reference date of October 1, 2012.

S&C Letter 13-56-NH outlines the facility procedures required to address the completion and submission of discharge assessments that have not yet been completed and/or submitted. These assessments for inactive residents must be completed and submitted as soon as possible, but no later than September 30, 2013.

The complete S&C Letter containing the facility procedures may be accessed at the following link:

CMS Survey and Certification Letter 13-56

Details about timing requirements for Discharge Assessments are available in Chapter 2 of the Long Term Care Facility Resident Assessment Instrument User’s Manual, Version 3.0.

If you have any questions, please contact Susana Belda, Residential Assessment Instrument Educational Coordinator at:

California Department of Public Health
Licensing & Certification Program
P.O. Box 997377, MS 3201
Sacramento, CA 95899-7377
Phone: (916) 324-2362 or 1-800-236-9747



Original signed by Debby Rogers

Debby Rogers, RN, MS, FAEN
Deputy Director 

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