With the Minimum Data Set (MDS), the Centers for Medicare and Medicaid (CMS) created a standardized, reliable, reproducible framework for assessing long term care resident status. As a result, MDS data plays a significant role in myriad areas of skilled nursing – from resident care plans to quality measures and reimbursement – which are governed through regulatory compliance. While adherence to these guidelines certainly falls to MDS Coordinators and Interdisciplinary Team (IDT) members, there is yet another group just as important in stepping up to the regulatory compliance plate: facility administrators.
MDS Assists
MDS assessments allow a facility’s IDT to capture each resident’s cognitive, psychosocial, and physical functioning and specific health needs at designated points of time. Using this information, the IDT develops a plan of care that supports each resident’s goals for their highest practicable level of function. The IDT also has the ability to review successive MDS assessments to compare a resident’s current and prior status – adjusting the care plan to support any changes in their needs, preferences, and goals for care.
Information reported on the MDS similarly assists the facility administrator in developing an accurate facility assessment, evaluating the quality of care that is provided to the population in their facility, and comparing the facility quality of care metrics to other facilities in their state and across the nation. These metrics are reflected in resident and facility quality measure (QM) reports and on the publicly-reported CMS Care Compare website.
In addition to quality measures, CMS uses MDS data to project individual staffing thresholds it expects the facility will meet and shares it with surveyors. Surveyors in turn utilize this MDS-generated data to guide their completion of comprehensive and complaint surveys. This all ultimately impacts what many consider to be the most significant role of MDS data: the determination of Medicare reimbursement and – in many states – that of Medicaid reimbursement.
Change in CMS Fielding
Regulations that govern MDS timing, accuracy, completion, submission, and facility and surveyor guidance are in the State Operations Manual (SOM). In January 2025, CMS published an advanced release of upcoming SOM changes. With these updates, administrators and MDS staff can expect to see more streamlined and stringent oversight of MDS accuracy. Updated guidance in F641 – anticipated to be implemented in March 2025 – guides the survey team to determine not only the level of deficiency tag, but also any financial penalties that may be levied based on patterns of inaccurate or false MDS completion.
Civil monetary penalties (CMPs) can be levied up to $5,000 for each assessment found to have been certified with material and false statements.
In instances of inaccurate or incomplete provider documentation to support coding a new diagnosis, such as schizophrenia on three or more assessments, the surveyors are also directed to make a referral to the State Board of Nursing and potentially to the Office of the Inspector General.
Accuracy Umpires
CMS has several means of verifying that facilities are completing and submitting accurate MDS assessments. Surveyors review MDS information that has been accepted into iQIES prior to and during the survey process, and they utilize guidance from the Critical Elements Pathways in the SOM to evaluate the accuracy of the MDS as well as appropriateness of the care plans.
Additionally, CMS uses federal contractors to review the resident record and determine if the MDS was coded correctly. This resident record review comes in the form of Additional Documentation Requests (ADRs). These requests may be made within months of the submitted and accepted MDS, or up to 4 years later. Federal contractors include Medicare Administrative Contractors (MACs), Recovery Auditor Contractors (RACs), Unified Program Integrity Contractors (UPICs), Supplemental Medicare Review Contractors (SMRCs), and Targeted Probe and Educate programs (TPEs). Most recently, CMS has added validations covering MDS submissions that impact the Quality Reporting Program and the SNF Value Based Purchasing Program.
Administrator Grand Slam
Administrators have the opportunity to be a game changer at their facility when it comes to supporting RAI compliance and accurate MDS completion. To make that grand slam:
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- Ensure your vendors are providing the most up-to-date electronic health record forms available for staff to capture all required MDS data.
- If your facility is working with paper charts, verify that the most recent data collection tools have been implemented.
- Consider including competencies/training for resident interviews and MDS data collection as part of your annual evaluations for IDT members.
- Encourage and financially support education (when possible) for staff who capture data and code the MDS, especially when updates are occurring in the MDS process.
- Cross train staff in completing interviews to ensure data is being collected and recorded in a timely fashion, which supports MDS coding and allows your IDT members to take time off without missing data capture.
- Review MDS validations, assess QM reports, and participate in QAPI plans.
- If you receive an ADR, facilitate the review by ensuring all requested information is sent to the requesting entity in one organized submission by the deadline noted.
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