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

AFL 17-14
August 24, 2017

Nursing Facilities
Skilled Nursing Facilities
Intermediate Care Facilities
Swing Bed Hospitals

Update to MDS 3.0 California Section S, Effective October 1, 2017

All Facilities Letter (AFL) Summary

This AFL notifies all certified Medicare and/or Medicaid nursing facilities of the California Minimum Data Set (MDS) 3.0 Section S.

​The updated MDS California Section S form, effective October 1, 2017, reflects the changes on the California Physician Orders for Life Sustaining Treatment (CA POLST) form dated January 1, 2016. The CA POLST remains an option for residents to designate end-of-life choices with their health care provider. The current CA POLST form (effective January 1, 2016) is available at

The updated Section S form is available on the California Department of Public Health website at:

Nursing facilities submitting MDS 3.0 need to obtain the updated software specification for California Section S from Quality Improvement and Evaluation System Technical Support Office (QTSO) website at:

The changes in S9040A and S9040E are underlined on the table below:

MDS 3.0 Section S itemItem Question​Response Value​
​S9040A​Does resident have a California POLST form in chart? ​0. No
1. Yes
2. In Process
​S9040E​CA-POLST Section D- signature of Physician, Nurse Practitioner or Physician Assistant ​0. No
1. Yes

MDS Section S completion is required on MDS comprehensive assessments, quarterly assessments, discharge assessments, and tracking records. Facilities are not required to complete section S on Medicare Part A Prospective Payment System (PPS) assessments.

If you have additional questions, please contact the MDS/OASIS Help Desk by email at or by phone at (916) 324-2362.
Please distribute copies to MDS Coordinators, Directors of Nursing, and Facility Administrators.


Original signed by Jean Iacino

Jean Iacino
Deputy Director

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