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The MDS 3.0 Is About to be Served Are You Ready? 2010 Webinar August 25, 2010 Handouts prepared by: Jane Belt, MS, RN, RAC MT Plante & Moran Clinical Group 614 222 9020 jane.belt@ March 2, 2010 Objectives Describe the transition to the MDS 3.0 and the major changes from the MDS 2.0 to the 3.0 Identify those sections in the MDS 3.0 that impact dietary services, such as communication, cognition, mood, preferences, eating function, active diagnoses, nutritional approaches, and oral status Delineate the accurate coding of Section K: Swallowing/Nutritional Status Review the Care Assessment process and documentation requirements MDS 3.0 Update August 12, 2010: What's New: A new naming convention for the MDS 3.0 Manual. Any sections or chapters that have had revisions will now have an updated version number along with the month and year that the information was revised (e.g. MDS 3.0 Chapter 4 V1.03 August 2010). Subsequent revisions of any section or chapter of the manual will have updated version numbers (e.g. V1.04, V1.05, etc ) Any sections or chapters that have NOT been revised will have the same version number, month, and year that that version was last published (e.g. MDS 3.0 RAI Manual Chapter 3 Section A V1.02 July 2010). However, you will notice that the "day" has been dropped from the file name. Any changes from the previous version of all Chapter 3 Sections are now listed at the beginning of each respective section.
MDS 3.0 Update The following revised training materials are now available MDS 3.0 RAI Manual Chapter 4 has been reposted and is available for download below in the file labeled "MDS 3.0 RAI Manual August 2010. MDS 3.0 RAI Manual Chapter 3 Updates: V1.03 of the following sections - A, C, D, E, F, G, K, M, O, P, X, and Z. (Also J and Q) VIVE - Video on Interviewing Vulnerable Elders - Will be available for ordering from CMS beginning the week of August 16, 2010. Please visit http://productordering.cms.hhs.gov to order a copy of the DVD (CMS Product No. 11479-CD). Transition Schedule MDS 2.0 MDS 3.0 ARD of 9/30/2010 or earlier ARD of 10/01/2010 or later Based upon RAPs and/or MDS Completion Dates Based upon ARD* April 12, 2010: CMS has not determined the cut off date for when an MDS 2.0 record may not be modified or inactivated. *NEW 7/30/10 *1 st one will be based on previous MDS 2.0 completion R2b or Vb2 If most recent prior comprehensive MDS is a 2.0, then ARD of 3.0 must be within 366 days of Vb2 (located on MDS 2.0). If most recent annual or quarterly MDS is a 2.0, then ARD of next quarterly using 3.0 must be within 92 days of the date located on the MDS 2.0 at R2b. Visual Changes on the MDS 3.0 Forms Layout Font Numbering (section + 4 digits) Sections breaks logical Pages More definitions on form Items require resident interview
Changes on the MDS 3.0 MDS 3.0 Most Significant Changes Assessment types and when to use Multiple interviews with the resident Facility staff must be equipped to conduct effective interviews Look-back periods (when and where) Coding in Communication, Cognition, Mood, Behavior, ADLs, Skin, Preferences, Oral Status Expanded identification information and active diagnosis section Coding of therapy minutes Use of the Care Area Assessments Return to community (Section Q) Process Changes on the MDS 3.0 Adds self-reported (resident) interview items more resident/person focused hearing the resident s voice Scripted interviews - detailed instructions Huge quality of care and quality of life implications based on resident s values, needs and priorities promotes culture change now
Process Changes on the MDS 3.0 Specific timeframes to conduct interviews preferably the day before or the day of the Assessment Reference Date (ARD) places time constraints on staff It Interviews may give providers answers to questions they are not prepared to ask or address Emphasis on resident participation hearing aids, amplifiers, cue cards, interpreter, proper lighting, privacy, reduction of background noise Process Changes on the MDS 3.0 Revised look-back periods While a resident versus in the hospital MDSs must be transmitted to federal (QIES ASAP) database within 14 days of completion date A0310 Type of Assessment Identifies the information required to complete the type of assessment MDS assessments have 2 schedules (OBRA, PPS) MDS may meet more than one purpose MDS may meet more than one purpose Must meet the requirements for both OBRA (A0310A) and PPS (A0310B) assessments if being conducted for both reasons The item set used depends on the type of assessment that must be completed
OBRA PPS Scheduled PPS Unscheduled Entry / Discharge A0310 Type of Assessment (Item Sets) Item Set All K All L Partial K Partial L Comprehensive X X Quarterly X X 5, 14, 30, 60, 90, return X X OMRA X OMRA Discharge X OMRA SOT OMRA SOT Discharge X Discharge (return anticipated or not) Tracking (Entry or Death in Facility) X Assessment Reference Date (ARD) A2300 Assessment Reference Date Timing the same (366 days for the annual and 92 days for the quarterly) But NOT using completion date (currently R2b), but based on the ARD Anything that happens after the ARD will not be reflected on the MDS Designates end of the lookback or observation period Comprehensive Assessments Significant change in status (SCSA) (A0310A = 04): ARD = no later than 14 th day after determination MDS completion date (Z0500B) and CAAs completion date (V0200B2) = no later than 14 th day after determination (ARD + 14 calendar days) Care plan completion date = CAAs completion date (V0200B2) + 7 calendar days Submission = care plan completion (V0200C2) + 14 calendar days
Significant Change Assessments Significant decline or improvement in resident s status; 1. Normally will not resolve without interventions not self-limiting 2. Impacts more than one area of health status 3. Requires interdisciplinary review and/or revision of POC May still take up to 14 days to determine if SCSA criteria met Document initial identification of the significant change in the progress notes Significant Change Assessment Decline in 2 or more of the following: Change in decision-making Mood item not previously reported by resident or staff and/or increase in symptom frequency; increase in the number of areas where behavioral symptoms are coded as being present and/or frequency of a symptom increases for items in Section E (behavior) Any decline in an ADL where newly coded 3, 4 or 8 Incontinence pattern changes or catheter placed Emergence of weight loss Emergence of a new Stage II or higher or worsening in ulcer status Begins to use trunk restraint or chair prevents rising Overall deterioration of condition Significant Change Assessment Improve in 2 or more of the following: Decision-making changes for the better Decrease in the number of areas where behavioral symptoms are coded as being present and/or frequency of a symptom decreases for items in Section E (behavior) Any improvement in an ADL where newly coded 0, 1, or 2 Incontinence pattern changes for the better Overall improvement of condition
Significant Change Assessments For terminally ill: A new onset of symptoms or condition that is not part of the expected course of deterioration and SCSA criteria met Enrolls in a hospice program (Medicare Hospice or other structured hospice) but remains in the facility regardless if an assessment was recently conducted SCSA required when resident decides to revoke hospice care. The ARD must be within 14 days of: decision to discontinue; or the expiration date of the certification of terminal illness; or date of physician s order stating the resident is no longer terminally ill Before the Interviews Section B CMS moved the positions of these items (Hearing, Speech and Vision) in the MDS 3.0 intentionally since so important to know for the interview process Identify communication skills to be assessed: speech clarity, ability to make self understood, d and ability to understand others B0200 to B0300 Hearing Look-back = 7 days Indicate whether the resident used a hearing appliance during the 7-day hearing assessment conducted for item B0200
B0600 to B0800 Speech Not assessing content but clarity Remember: verbal AND non-verbal. Includes writing, conversation, sign Spoken or written; sign language. Ability to process and understand language B1000 to B1200 Vision Indicate if resident uses corrective lenses or other visual aids before beginning vision assessment Consult with family, significant others, and staff Verify findings with a reading test (newspaper). If illiterate, use numbers or pictures Anchored to B1000 Does not document what the resident uses on a regular or daily basis. Does not include lens implants The Interviews Resident Centered Assessment Resident interviews (if resident unable to be interviewed then staff is interviewed) Staff interviews (only if resident unable) Section C D F J Q Topic Cognitive Patterns Mood Preferences for Customary Routines and Activities Health Conditions (Pain) Participation in Assessment and Goal Setting
The Interviews All residents capable of any communication should be asked to provide information regarding what they consider to be the most important facets of their lives Self-report is the single most reliable indicator of topics such as mood, preferences, pain Setting Privacy, quiet with no distractions, lighting, ability to hear, comfort, positioning, interpreter needed, explanation of why, rapport and respect essential Before each interview section, assessor determines if interview should be conducted More about the Interview Process Consider how to establish rapport BEFORE interview The staff the resident is most comfortable with should be doing the interviews. Who is that in your facility? It may not be the same staff person for every resident Where will the interviews be conducted? Learn the best time and way to interview residents time of day, locations Consider Interview Skills Practice! Interview each other fine tune NOW Consider additional needs different lighting and external amplifier systems Begin with proper introduction and explanation of the interview i and ask to come into their space Consider use of cue cards to help increase understanding Listen, pay attention, be non-judgmental, but stay focused. Might have to bring conversation back to the topic at hand
Interview Considerations Is it social services that needs to become familiar with the Brief Interview for Mental Status (BIMS) and other scripted interviews such as for Mood (PHQ-9); Activities could start using the scripted interviews for Daily Activity Preferences to become familiar with the information; OR does one staff do interview all at same time? All disciplines need to review current assessment forms to determine the support/non-support of information needed for the MDS 3.0 Brief Interview for Mental Status (BIMS) Attempt with all residents except those who are rarely or never understood (B0700) Consists of three components: Repetition of 3 words (sock, blue, and bed) Temporal orientation ti (year, month, day) Recall with or without cues Results are compiled into a Summary Score Summary Score used also to determine RUG group in Behavioral Symptoms and Cognitive Performance The Mood Interview D0100 Mood attempt with all residents except those who are rarely or never understood (B0700) Most residents are able to attempt the interview Attempt to conduct the interview with all residents if at all possible The interview (PHQ-9 ) has been translated into over 80 languages check online for availability as needed
The Mood Interview D0200 Resident Mood Interview (PHQ-9 ) A validated interview ask items as on MDS Screens for symptoms of depression Provides standardized severity score Assess for both presence and frequency of each symptom Consider setting/interview guidelines Explain reason for interview Explain the choices Show responses in large font (cue card) The Mood Interview D0200 Resident Mood Interview (PHQ-9 ) 2 week look-back period interview must be completed preferably day before or day of ARD Remember to provide interpreter if needed or wanted by resident Start by asking the resident if he or she has been bothered by any of the problems over the last 2 weeks (time frame tied to DSM-IV) Reviews 9 symptoms with the resident if answers yes then interviewer must determine frequency for each item Code higher frequency if resident has difficulty selecting between 2 choices Do NOT define for resident Code 9 for any nonsensical response
Section F Preferences for Customary Routines and Activities Lack of attention to preferences and activities can result in: Boredom Depressed mood Behavior disturbances Resident responses can provide clues: Understanding pain Perceived functional limitations Perceived environmental barriers Serves as a guide for individualized daily care and activity planning a portion of the assessment not meant to be all-inclusive Section F Preferences for Customary Routines and Activities Skip pattern different in that family member or significant other can provide information about routines and preferences If no family or significant other then go to staff interview only talk to staff if interview not possible No look-back period is set Conduct before the ARD Resident is being asked about CURRENT preferences Section F required only for comprehensive assessments Section F Preferences for Customary Routines and Activities Sequence: Resident Family or significant other Staff interview only if resident and/or family / significant other unable to answer (or gives nonsensical response) to 3 or more of the 16 items in F0400 thru F0500. Indicate respondent in F0600
The Interview Section F F0400 Interview for Daily Preferences While you are in this facility How important is it to you to Choose clothes to wear Take care of personal belongings Choose between a bath, shower, bed or sponge bath Have snacks available between meals Choose your own bedtime Have family or close friend involved in discussions about your care Be able to use the phone in private Have a place to lock your things to keep them safe Daily Preferences Responses based on importance to resident: 1. Very important 2. Somewhat important 3. Not very important 4. Not important at all 5. Important, but can t do or no choice 9. No response or non-responsive Section J Pain Assessment Consists of an interview with the resident Conduct a staff interview only if resident is unable to participate in the interview Pain items assess: Presence of pain Frequency of pain Effect on function Intensity Management Control Challenge is to find the etiology of the pain
J0200 Conduct Interview?? Most residents capable of communication can answer questions about how they feel Resident is the most reliable source Use staff observations for pain behavior only if a resident cannot communicate (verbally, with gestures, or in writing) Time frame = 5 days Everyone s Favorite: ADL Coding Section G Definitions: ADL Aspects = components of the task and listed next to the activity in the item set ADL Self-Performance = what the resident actually did over 7 days based on the performance scale ADL Support = highest level of support provided by staff over 7 days even once Section G Functional Status G0110 Activities for Daily Living Assistance Column 1 = Self-Performance Make sure to evaluate every component of task R d t l lf f Record actual self-performance Performance may vary from shift to shift Consider performance with adaptive devices Do NOT include assistance provided by family or other visitors (in either Column 1 or 2) Column 2 = ADL Support Provided
Everyone s Favorite ADL Coding Rule of Three Instructions When an activity occurs three times at any given level, code that level When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity did not occur (8). EXAMPLE: 3 times at extensive assistance and 3 times limited assistance: code = extensive assistance it When an activity occurs at various levels, but not for 3 or more times at any one level apply the following: Combination of full staff performance and extensive assistance = extensive assist Combination of full staff performance weight bearing and/or non-weight bearing assistance = limited assistance If none of the above are met, code supervision Rule of Three Not necessary to know how many times the activity occurred BUT know whether or not activity occurred 3 or more times within the last 7 days
Know the ADL Definitions MDS Independent Supervision Limited Assistance Extensive Assistance Total Dependence Therapy Independent Stand By Assist Contact Guard Min Mod Max Assist Dependent ADLs Values for Eating RUGs IV Support Performance None (0)/ Setup (1) None (8) 1-person (2) 2-person (3) Independent(0)/ Supervision (1) Limited Assistance (2) 1 or 2 times (7) None (8) Extensive Assistance (3) 0 2 Total Dependence (4) 4 2 3 No automatic score for tube feeding and parenteral/ivs ADL Cheat Sheet
Section I Active Diagnoses Step 1 = include ONLY diagnoses identified in the last 60 days Step 2 = active or inactive (7-day look-back) Transfer documents Nursing care plans Physician progress notes Medication sheets Recent History & Physical Doctor s orders Recent discharge summaries Consults Nursing assessments Official diagnostic reports Physician order sheets Indicators of Active Diagnosis Specific documentation of active diagnosis in medical record Recent onset or acute exacerbation indicated by a positive study, test, or procedure, hospitalization for acute symptoms and/or recent change in therapy Symptoms and abnormal signs indicating ongoing or decompensated disease Symptoms must be specifically attributable to a disease Ongoing therapy with medications or other interventions to manage a condition that requires monitoring for therapeutic efficacy or to monitor potential adverse effects J1550 Problem Conditions 2 or more indicators needed: Takes in less than 1500 cc Has one or more signs of dehydration dry mucous membranes, poor skin turgor, cracked lips, dark urine, sunken eyes, increased confusion Fluid loss exceeds fluid intake
Section K Swallowing/Nutritional Status Intent Assess the many conditions that could affect resident s ability to maintain adequate nutrition and hydration Items cover Swallowing disorders Height and weight Weight change Nutritional approaches Section K Swallowing/Nutritional Status Planning for Care Include provisions for monitoring resident during mealtimes and during functions/activities that include consumption of food and liquids When needed, resident should be evaluated by physician, ST and/or OT to assess any need for therapy Assess for S/S that suggest swallowing disorder that has not been successfully treated or managed with diet modifications or other interventions Care plan should be developed to assist residents maintain safe and effective swallow using compensatory techniques, alteration in diet consistency, and/or positioning during meals K0100 Assessment K0100 Swallowing Disorder Ask resident about any difficulty swallowing during the look-back period Ask about each symptom Observe resident to identify any symptoms During meals At times resident is eating, drinking, or swallowing Interview staff members across all shifts Review medical record nursing, physician, dietician, ST notes, dental history or problems
Section K0100 Swallowing Code a symptom even if it only occurred once during the 7-day look back Do NOT code a swallowing problem if interventions have been successful in treating the problem the intervention is successful Section K0200A Height Measure and record height in inches on admission Measure and record height again if last measurement is more than one year old (standard of practice) Record height to the nearest whole inch Use mathematical rounding A height of 62.5 inches is recorded as 63 inches A height of 62.4 inches is recorded as 62 inches Section K0200B Weight Weigh resident on admission For subsequent assessments: Check the medical record Enter the weight taken within 30 days of the ARD if 2 weights within 30 days, use the one closest to the ARD Weigh resident again if: Last recorded weight was taken more than 30 days prior to the ARD Previous weight is not available
Section K0200B Weight Measure weight consistently over time in accordance with the facility policy and procedure, which should reflect current standards of practice Use mathematical rounding: A weight of 152.5 pounds is recorded as 153 pounds A weight of 152.4 pounds is recorded as 152 pounds Use the no information code (-) if the resident cannot be weighed and document rationale Section K0300 Weight Loss New admission ask the resident, family, or significant other about weight loss over past 30 and 180 days For new admission compare the admission weight to any previous recorded weight (transfer documentation, consult resident s physician) Calculate the percentage of weight loss if admission weight is less than previous weight: Compare to weight 30 days ago Compare to weight 180 days ago Section K0300 Weight Loss Subsequent assessments Compare current weight to weight 30 days ago Calculate the percentage of weight loss if weight is less than previous weight Compare current weight to weight 180 days ago Calculate the percentage of weight loss if current weight is less Do not consider weight fluctuations outside of these two time points Does not have to meet criteria for both 5% and 10%
Calculate Percentages of Weight Loss Use mathematical rounding before calculation Multiply previous weight by 0.95 to determine resident weight after 5% weight loss Example: 160 pounds X 0.95 = 152 pounds. A resident whose weight drops from 160 to 152 pounds or less has experienced 5% or more weight loss Multiply previous weight by 0.90 to determine resident weight after 10% weight loss Example: 160 pounds X 0.90 = 144 pounds. A resident whose weight drops from 160 to 144 pounds or less has experienced 10% or more weight loss Coding Code weight loss based on whether it was planned/managed or unplanned/unmanaged Physician-prescribed weight-loss regimen = a weight reduction plan ordered by the resident s physician with the care plan goal of weight reduction. May employ a calorie-restricted diet or other weight loss diets and exercise, Also includes planned diuresis. It is important that weight loss is intentional K0500 Nutritional Approaches Includes any and all nutrition and hydration received by the NH resident in the last 7 days either at the NH, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration These 2 are reimbursement items Enteral feeding formulas NOT coded in C. Therapeutic (D.) only if managing problematic condition, such as diabetes
K0500A Parenteral/IV Feeding Code the following fluids when there is supporting documentation that reflects the need for additional fluid intake specifically addressing nutrition or hydration need: IV fluids or hyperalimentation, including TPN administered continuously or intermittently IV fluids running at Keep Vein Open (KVO) IV fluids contained in IV piggybacks Hypodermoclysis and subcutaneous ports in hydration therapy K0500A Parenteral/IV Feeding Do NOT code the following in K0500A: IV medications IV fluids administered solely for the purpose of prevention of dehydration. Active diagnosis of dehydration must be present in order to code this fluid in K0500A IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay IV fluids administered solely as flushes IV fluids administered in conjunction with chemotherapy or dialysis K0700 Percent Intake by Artificial Route Look-back period = 7 days Calories via tube or IV divided by total calories consumed times 100 = % intake Total fluid intake by tube or IV divided by 7 days - divide by 7 even if the resident did not receive IV fluids or tube feeding on each of the 7 days
Section L Oral/Dental Status Revised in collaboration with the American Dental Association and the Special Care Dentistry Association to enhance the evaluation of any oral and dental issues a resident may be experiencing Screening for dental and oral problems Ask resident about chewing problems or mouth or facial pain or discomfort Ask the resident or responsible party: Does the resident have or recently had dentures or partials If yes, but the resident does not have them at the NH, ask for a reason Examine dentures/partials for a loose fit Section L Oral/Dental Status Ask resident to remove dentures or partials and examine for chips, cracks, and cleanliness Conduct exam of resident s lips and oral cavity (gums, tongue, palate, mouth floor, cheek lining) with dentures/partials removed Check for the following: Abnormal mouth tissue Abnormal teeth Inflamed or bleeding gums Use gloved fingers to adequately feel for masses or loose teeth Determine if chewing problems or mouth pain is present ADAPTED NPUAP Pressure Ulcer Definitions CMS has adapted the NPUAP 2007 definition of a pressure ulcer as well as categories/staging. The definitions do not perfectly correlate with each stage as described by NPUAP. Facility must code the MDS according to the instructions in the RAI Manual A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction
Pressure Ulcer Stages Stage 1 = An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness Stage 2 = Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister Pressure Ulcer Stages Stage 3 = Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is NOT exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling and undermining Stage 4 = Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes tunneling and undermining More M0300 Guidelines Do not reverse stage. Review the history of the pressure ulcer if the ulcer has ever been classified at a deeper stage than now, it should continue to be classified as the deeper stage For the purposes of coding, determine that the lesion being assessed is PRIMARILY related to pressure and that other conditions have been ruled out, If pressure is NOT the primary cause, do NOT code here
Stage 2 Pressure Ulcer Partial thickness loss of dermis presenting as: Shallow open ulcer Most Stage 2 pressure ulcers Red or pink wound bed should heal in a reasonable Without slough time frame (e.g., 60 days) May also present as an intact or open/ruptured blister Examine area adjacent to or surrounding an intact t blister for evidence of tissue damage. If other conditions are ruled out and the tissue adjacent to, or surrounding the blister demonstrates signs of tissue damage (e.g., color change, tenderness, bogginess, or firmness, warmth or coolness), these characteristics suggest a suspected deep tissue injury rather than a Stage 2 pressure ulcer M0700 Most Severe Tissue Type for any Pressure Ulcer Epithelial (all Stage 2 pressure ulcers should be coded as 1) and should NOT be coded with 2, 3, or 4 tissue type Granulation (cobblestone-type tissue) Slough Necrotic tissue (eschar) If two types of tissue code to the higher Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA, PPS, or Discharge) Compare to prior MDS assessment new ulcer or ulcer now at a higher (deeper) stage
Care Assessment Area (CAA) Process The CATs ate the RAPs Removing the phrase The resident assessment protocols (RAPs) and triggers and replace it with Care Area Triggers (CATs) The 18 domains for the RAPs remain plus 2 new for the CATs Pain Discharge Planning CAA Process Not a prescribed CMS protocol for performing a CAA, the IDT members should determine which current clinical protocols, tools, resources, research, and standards of practice they will use for assessment and care planning approaches IDT should be able to identify these resources upon request Appendix C contains one type of Care Area Specific Resources CAA Process Documentation focus on key issues: Why or why not will you address the specific conditions in the care plan What about the condition may affect the resident s daily functioning Why did you decide the resident is at risk, that improvement is possible or the decline can be minimized How could the resident benefit from consultation with an expert in a particular area
Example of CAA Resource Appendix C Example of CAA Resource Appendix C Questions??
Plante & Moran Clinical Group Jane Belt 614 222 9020 jane.belt@ Alicia Richey 614 222 9134 alicia.richey@ Melanie Nabozny 616 643 4058 melanie.nabozny@ Brenda Sowash 419 842 6204 brenda.sowash@ Bobbi Reed 216 274 6544 bobbi.reed@ Judy Vogel 513 744 4768 judy.vogel@
CERTIFICATE OF COMPLETION - CDR The MDS 3.0 is About to Be Served Are you Ready? 25 August 2010 Date of Completion Dietetics in Health Care Communities - DHCC Commission on Dietetic Registration CPE Accredited Provider AM003 CPE Provider Accreditation Number CPE Accredited Provider Participant s Name Has successfully completed 2 CPEUs (Level II) DHCC DPG #31, Brenda Richardson, MA, RD, LD, CD Chair Signature of CDR CPE Accredited Provider, Date 25 August 2010 CERTIFICATE OF COMPLETION - State The MDS 3.0 is About to Be Served Are you Ready? 25 August 2010 Date of Completion Dietetics in Health Care Communities - DHCC Commission on Dietetic Registration CPE Accredited Provider AM003 CPE Provider Accreditation Number CPE Accredited Provider Participant s Name Has successfully completed 2 CPEUs (Level II) DHCC DPG #31, Brenda Richardson, MA, RD, LD, CD Chair Signature of CDR CPE Accredited Provider, Date 25 August 2010