This All Facilities Letter (AFL) is being sent to provide you with information concerning the POLST form and the MDS. Effective January 1, 2009, Assembly Bill 3000 (Chapter 266, Statutes of 2008) enabled the use of a POLST form (Sections 4780 – 4785 of the Probate Code).

The POLST is a voluntary form used to document a patient’s wishes for medical treatment as end-of-life approaches, giving patients more control over their end-of-life care. The POLST form is printed on brightly colored paper and signed by both a doctor and patient. The use of a POLST form is not mandatory. The POLST is not a California Department of Public Health (CDPH) form.

The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The Centers for Medicare and Medicaid Services (CMS) has updated the MDS to improve the reliability, accuracy, and usefulness of the assessment, which will include the resident in the assessment process and incorporate standard protocols used in other settings.

CMS allows each state to collect information of specific interest that can be used for various purposes, including statistical analysis. This state-defined portion of the MDS is called "Section S" and was not used in the MDS 2.0.

The implementation of the updated MDS 3.0 is scheduled for October 1, 2010. In the MDS 3.0, California will be utilizing "Section S" which will be mandatory for all MDS assessments. Any resident assessments scheduled with an assessment reference date on or after October 1, 2010 are to use the MDS 3.0. Any assessments with an assessment reference date scheduled on or before September 30, 2010 are to continue to use the MDS 2.0. A copy of the MDS 3.0 can be found on the CDPH website at:

Minimum Data Set Page

The MDS 3.0 "Section S" begins with a mandatory question that asks whether or not the patient has a POLST form. A POLST form is not mandatory; therefore if the answer is "NO", then there is no need to answer the remainder of the POLST questions in "Section S". However, if the answer is "YES," then the remainder of the POLST questions in "Section S" will need to be completed.

Additionally, to alleviate some confusion, the department provides guidance on the following frequently asked questions:

1. Question S9040C asks about POLST Section B, which allows two choices, but "Section S" only provides for one answer.
   Response:
   In the event that a resident’s POLST has both "Do Not Transfer to hospital" and "Limited Additional Interventions" marked, then chose option "3," do not transfer to hospital for medical intervention.
2. Question S9040G asks with whom the POLST was discussed. The POLST form offers an "Other" category, which is not included in "Section S."
   Response:
   If "Other" is chosen on the POLST, please mark "2," for Decision Maker.

If you have additional questions about the MDS 3.0 release and "Section S", please contact the MDS/OASIS Help Desk by email at mdsoasis@cdph.ca.gov or by phone at (916) 324-2362.

For additional information concerning POLST, please refer to AFL 08-29 and  AFL 09-27. The POLST form can be downloaded from the California Emergency Medical Services Authority publications website at:

POLST Form

Sincerely,

Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director