With the numerous regulatory bodies that govern long term care (LTC) and skilled nursing facilities (SNF), it is easy to feel like there is no end to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) “rules.” There are Federal, State, and sometimes local regulations. There are facility policies that may be in place (in response to a survey deficiency, as an extension of a corporate requirements, or simply “because we have always done it this way”). There is the internet and AI. And finally, there is “helpful” prepopulated data that certain Electronic Health Records (EHR) can push into the MDS – causing more damage than the interdisciplinary team (IDT) and untrained or new staff may understand.
Every member of the interdisciplinary team (IDT) would benefit from at least annual training on changes/updates to the MDS that happen each October. Periodic reviews of government regulations and routine audits of the work the IDT does that gets coded into the MDS are important to ensure the MDS is completed correctly. Poorly or undertrained members of the IDT who are responsible for data collection and/or coding of the MDS can quickly cost a facility in multiple, painful ways. Negative outcomes are reflected in loss of revenue due to incorrectly timed MDS and/or missing data; inaccurate or incomplete care plans that can result in detriment to resident care and quality of life; sub-standard performance on comprehensive and complaint surveys; and poor or incorrectly reported performance in the Centers for Medicare and Medicaid (CMS) standardized Quality Measures (QMs). Additionally, CMS has instituted various MDS audit processes that can result in financial penalties and possible “claw backs” of payments when incorrect coding of MDS items has resulted in over-payment. When CMS has sufficient concerns about improper MDS coding, facilities can face additional layers of government oversight and possible financial penalties to encourage correction of insufficient and/or improper practice, and compliance with federal regulations.
The Resident Assessment Instrument – Instructions
Every item on the MDS comes with specific information and instructions to support accurate coding. CMS covers everything – actual scheduling of the MDS, how each MDS item relates to resident quality of life, planning for great resident care, steps for assessing each MDS item, coding instructions, coding tips, and examples in the RAI manual. Untrained or poorly trained staff can easily miss nuances when attempting to code the MDS correctly. On October 1 of every year CMS updates portions of the MDS, and unaware or unprepared staff can miss immediate opportunities to capture data in the health record that is needed to support correct coding. Each MDS contains at least 500 data item choices; such an enormous data collection can present an opportunity to showcase great care or result in serious mistakes that can lead to loss of reimbursement, improper care planning, and miscalculation and misreporting of QMs.
The State Operations Manual – Regulations
Current federal regulations that CMS has implemented related to the MDS can be found in the State Operations Manual (SOM). Appendix PP of the SOM contains each MDS regulation listed by the regulatory tag number. This section of the SOM also contains the intent of each regulatory tag related to the MDS along with interpretive guidance for surveyors that support the survey process. Interpretive guidance contains information such as definitions that pertain to each tag, investigative protocols which may include Critical Elements Pathways (CEP), and summary of investigative procedure to help a surveyor determine the scope and severity of a possible deficient practice. The SOM with interpretive guidance and CEP can be an invaluable resource for the IDT. These criteria can be utilized as guidelines to establish or revise facility policies and processes that ensure (a) every MDS is scheduled and completed correctly and (b) care plans are reviewed and updated timely. The MDS is regulated by the following federal regulatory tags:
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- F636 The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity.
- F637 A significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition.
- F638 A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
- F639 A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review, and revise the resident’s comprehensive care plan.
- F641 Accuracy of assessments – the assessment must accurately reflect the resident’s status. Also addresses coordination and certification of completion of the MDS by a Registered Nurse, accuracy of assessment by each individual who completes a portion of the MDS, and establishes financial penalties for falsification.
- F644, F645, and F646 address requirements for coordination of assessments with the pre-admission screening and resident review (PASARR) program.
- F655 Establishes requirements for baseline care plans.
- F656 Addresses development and implementation of comprehensive care plans.
- F657 Addresses care plan timing and revisions.
Compliance and Quality at the Corporate Level
With F895, CMS has established regulatory guidance to support facility participation in a Compliance and Ethics program with the goal to design, implement, and enforce written facility compliance and ethics standards. This includes implementing policies and procedures designed to prevent and detect criminal, civil, and administrative violations while promoting quality of care. An effective Compliance and Ethics program is a reflection of the QAPI process, with guidance also found in the SOM. F865 directs facilities to develop, implement, and maintain a QAPI program; this includes written policies and procedures for QAPI program feedback, data systems, and monitoring per F867. The oversite of the QAPI committee is addressed in F868. Once a QAPI process of MDS auditing, tracking, and improvement plans to correct errors that may reflect criminal, civil, and/or administrative violations has been implemented, this information should be referred to the Compliance and Ethics committee for review and follow up if needed, which ensures facilities are following CMS requirements for Regulatory Compliance with the MDS.
Successful Regulatory Compliance
The MDS is not a simple form and should not be delegated to staff who have not been trained in how to schedule and complete the assessments correctly; a quick review of the list of potential survey tags related to the MDS makes this evident. Likewise, social media and AI are not ideal resources for coding the MDS. Each member of the IDT benefits from training that covers the RAI requirements for the section(s) they are responsible for, including the implications of incorrect timing of data collection, inaccurate coding, missing information, and deadlines related to the ARD. All the requirements for successful and accurate completion of the MDS can be found in the RAI and the SOM. Due to the complexity of the MDS, however, untrained staff can flounder and fail. There are various safeguards that any facility can implement to support regulatory compliance for MDS completion.
- Require IDT training to ensure MDS information and interview data is collected per the RAI instructions and coding requirements, during the lookback period for each assessment.
- Ensure data and interviews collected after the ARD is not utilized on the MDS.
- Review facility policies and procedures related to MDS at least annually to ensure that October updates to the RAI are being addressed, and obsolete data collection is phased out.
- Train alternate staff to complete interviews and collect MDS data so IDT members can take time off without causing MDS complications.
- Audit MDS completion regularly – compare what is coded on the MDS to what is found in the health record to ensure supporting documentation is available, and the MDS is reproducible. Compare what is coded on the MDS to the RAI instructions to ensure compliance with CMS expectations.
- Utilize audit findings to create Performance Improvement Plans (PIP) and employee evaluations.
- Review the SOM F tags, interpretive guidance, and critical element pathways related to MDS annually with the IDT. Utilize the CEP to audit facility performance.
- Utilize MDS audit findings to identify and initiate Quality Assurance and Process Improvement (QAPI) projects and evaluate progress toward QAPI goals.
- Examples of common MDS inaccuracies that could be referred to the QAPI committee and considered for QAPI projects might include findings of incorrect scheduling/completion of assessments; inaccurate and delayed updates of care plans; inaccurate and missing data in the health records; incorrect ICD10 coding and capture on the MDS; and incorrect timing and completion of MDS interviews per the instructions in the RAI manual.
- Additionally, referrals to the Compliance and Ethics committee may be needed if there are concerns related to fraud, waste, and abuse, which may reflect criminal, civil, and/or administrative concerns.
- New MDS staff could use a mentor – a seasoned MDS staff, consultant, or access to a professional organization that specializes in the RAI process and MDS completion.
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