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Use of the MDS is Waived for CAH Swing-Bed Patients

PDF Version of BQA 02-007 (PDF, 9 KB)

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Date: February 14, 2002 DSL-BQA 02-007

To: Hospitals HOSP 02, Critical Access Hospitals (CAH) CAH 01

From: Jan Eakins, Chief, PRQI, Bureau of Quality Assurance

cc: Susan Schroeder, Director, Bureau of Quality Assurance

On February 1, 2002 the Centers for Medicare and Medicaid Services (CMS) issued a memo that waived the requirement at 42 CFR, section 485.645 that required the use of the long term care Minimum Data Set (MDS) for patients receiving post hospital skilled nursing facility (SNF) care. A copy of the CMS letter announcing this change is attached to this memo. Facilities should note that the CMS action does NOT eliminate the requirement that CAHs complete an assessment and a comprehensive care plan for each SNF patient, only the requirements that the MDS instrument be completed as part of the assessment.

The effective date of this change in enforcement policy is February 1, 2002. Should you have questions, please contact Billie March, RAI Education Coordinator, at the above address [Bureau of Quality Assurance, PO Box 2969, Madison, WI  53701-2969] or via email at

Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Ref: S&C-02-17

DATE: February 1, 2002

FROM: Director, Office of Clinical Standards and Quality

Director, Survey and Certification Group, Center for Medicaid and State Operations

SUBJECT: Completion of Minimum Data Set (MDS) in Critical Access Hospitals (CAHs)

TO: Associate Regional Administrators, DMSO; State Survey Agency Directors

The purpose of this memorandum is to notify states and regional offices of a change in enforcing the Minimum Data Set (MDS) requirement for CAHs with swing-beds. The regulations at 42 CFR, section 485.645 provide that in order for a CAH to use its beds to provide post-hospital skilled nursing facility (SNF) care, it must be in "substantial compliance" with nine SNF requirements contained in 42 CFR, section 483, subpart B. Included in those regulations are requirements for CAHs to complete the full MDS as part of their assessment of patients in CAH swing-beds.

We have analyzed the current significance of this requirement and concluded that the MDS compliance burden on these small facilities can be reduced without jeopardizing patient health and safety. CMS will consider CAH facilities that meet all but the MDS SNF requirements to be in substantial compliance with the CAH swing-bed regulations.

We will still require CAHs to complete a resident assessment and a comprehensive care plan for each SNF patient and document the assessment in the medical record. However, we will not require CAHs to use the MDS instrument for the resident assessments.

Effective Date: This enforcement policy change is effective immediately.

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