A series of struggles around assessment began in fall, with the most extensive updates in years to the Minimum Data Set, which captures patients’ clinical needs and also serves as the basis for much of a provider’s state and federal reimbursement.

“It’s not news to anybody that this rollout was not smooth,” said Alicia Cantinieri, senior vice president of Clinical Policy and Education for Zimmet Healthcare Services Group. “There were a lot of technical issues with coding, with skip patterns, with Section GG, with HIPPS code calculation being incorrect.”

Despite the Centers for Medicare & Medicaid Service issuing corrections and technical clarifications in the weeks after the Oct. 1 launch of the updated MDS, some providers still may face long-term consequences of coding errors or delays forced on them by incomplete early guidance from regulators. That was just one of the cautions shared by Cantinieri and two of her Zimmet colleagues during a webinar titled, “Fasten Your Seatbelts: It Might be a Bumpy Ride.”

Cantinieri said the lasting implications of some software and coding issues in the first week of the launch were going to especially affect providers in states that used the Patient Driven Payment Mode to determine a Medicaid case-mix before the changeover.

In the case of providers who needed to code patients receiving respiratory therapy, for example, many found the section blocked out and were unable to capture payment for related services. Some went back and modified submission; others waited to submit until they had clarification on how to correct the problem.

“Facilities have been left with questions about when to modify, when to resubmit,” she added. “And we haven’t heard any guidance from CMS that they would waive or forgive the submission timing requirement, so there’s the potential that facility could be cited.”

Chief Innovation Officer Steven Littlehale said that regardless of the complication or system error, it is critical that providers keep related records for a few years “so that ultimately you’re not left holding the bag for this sort of failed launch.”

Duplication of efforts

The removal of Section G to measure a patient’s functional status also continues to wreak havoc on payment, especially at the state level. Many states used G to determine payments, and without it, complications have continued to crop up, said Melanie Tribe-Scott, vice president of Quality and Regulatory Compliance.

For providers in many states not using the PDPM yet, the workload has increased significantly, with many requiring that MDS coordinators record information in the replacement Section GG and capture details for all patients on an optional state assessment, too.

The advent of MDS also has led to frozen pay in some states, while upcoming quality measure changes will lead to freezing quality measures as well, the speakers noted. That may discourage providers from being diligent in some areas, thinking they are temporarily less important.

But that couldn’t be farther from the truth for payment, Tribe-Scott added. She said some states would undoubtedly be using codes captured in the frozen period to see how provider behavior and patient needs would shape spending under a system more aligned with PDPM.

And those frozen metrics, which lock in April to give regulators more time to collect full data before publishing new calculations, also could come back to haunt if not given enough attention. Most are connected to new quality measures, which will be used later to inform quality measure ratings on the Care Compare website.

“Eventually, it will be thawed and you’ll see those new measures,” Littlehale said. “It’s important to not turn your back, for quality improvement reasons, on those very outcomes. You need to get a little old school with how you’ve tracking performance in those areas.”

Stay ahead of problems, and no blanking out

Another critical change is coming Jan. 1: Providers will need to submit a higher percentage of MDS data than in years past to remain eligible for a value-based purchasing payment bump. It’s critical they not leave boxes blank, especially new ones, simply because staff don’t understand how or when to complete them, Cantinieri said.

Providers can stay ahead of some of the challenges by taking a few steps as 2024 gets underway, the presenters said.

Cantinieri recommended auditing MDS forms to make sure information is being collected and submitted correctly; a standard size nursing home could make it a quality improvement goal to review 10 charts per month and include charts from a variety of patients involving a range of interdisciplinary staff. An external audit also could benefit providers who want to ensure they’re capturing everything possible in line with the Oct. 1 changes.

The team also suggested reaching out to any MDS-involved software vendors to ensure updates have been made and that any incorrect data caused by early adoption kinks has been retroactively corrected, if appropriate.

 I remember one Christmas, I was probably 7 years old, I wanted a child’s toolbox full of working tools like a kid-sized hand saw, screwdriver, wrench and a hammer. They all came in a metal toolbox that had a latch and a handle so you could carry it around.

I must have seen it in a store and asked for it, like Ralphie did with his Red Ryder BB gun. Lo and behold, on Christmas morning, there it was. I can still feel the elation of that moment. I also remember that in short order I was in the garage sawing up old cardboard boxes and making stuff that I proudly showed my parents. 

I hope you have memories like that. Just a few months before my mom passed away a few years ago, we all got out the photo albums and 8 mm films and reminisced about those days. It was a precious time I’ll never forget. Remember Clark Griswold in the attic. 

2023 has been a difficult year. The regulatory onslaught was brutal. But we are surviving. These challenges have also made me nostalgic. I often think about the day I made what I thought would be a temporary switch from acute care to long-term care. I became an MDS coordinator. A competent ICU step down nurse, I quickly realized I was out of my element in this new role.

In 2001, the MDS nurse was something new. PPS had just been initiated a few years earlier and the industry was still reeling. The MDS became electronic with that change and was required to be submitted to the state, via a modem. Do you remember the sound those things made? 

Quality Indicators, now quality measures, were new as well. No one really knew what was going on. Someone had to oversee it all. And so, the MDS coordinator position was born. 

Today there are a litany of resources available for the MDS nurse to rely on for advice and support. It is a wonderful thing to watch online communities take root and grow into vibrant discussions. Organizations like the American Association of Post-Acute Care Nursing (AAPACN), and others, have become the gold standard for educational opportunities and certifications. 

In those days, however, unless you knew someone who was also an MDS coordinator, there were relatively few resources available to answer questions and offer guidance. My paperback MDS manual was only a few hundred pages long and was scant on coding tips and clarifications. But those were the good old, “less complicated” days, remember? 

I also remember through the years those who helped me grow, many of whom have become career long friends. I remember my first administrator who had confidence that I could do the job. 

I remember several others I respected who came along, offered guidance, helped me gain confidence, and shed light on previously unrealized abilities. My initial nursing career plans did not include long-term care and these incredible people are the reasons I now do what I do. 

I came to understand through their compassion and care for this patient population, that the MDS and all it represents, is a powerful tool for good, that when a community of caregivers surround it and it is properly utilized, our residents are the beneficiary. What a joy!

As I think back, I am grateful for Randy Lewis, Joy Powers, Sandy Deakins, Mary Marshall, Diane Brown, Mendee Rock, Linda Estes, Manning McGraw, Sumit Malhotra and the many others who carried me along like a leaf on the river of this unexpected career.

Thank you also to McKnight’s Kimberly Marselas for reminding us of what it was like to have good friends by sharing this year’s Amazon ad, “Joy is shared,” in a recent article. I have a lump in my throat every time I watch it.

The RAI process is a wonderfully formidable task that cannot be accomplished alone. I hope that you have a circle of friends who help you grow and care about the MDS tasks you accomplish each day. Their support is indispensable. The outcome of those relationships will produce remarkable results, especially for the residents you care for.

Gracing our residents with those outcomes is the reason most of us do what we do in long term care.  Clarence the angel said it best to George Bailey in “It’s a Wonderful Life”: “No man is a failure who has friends.” 

I feel that intensely as I reminisce. How about you? 

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Their mission: Performing routine completion and submission using the new Minimum Data Set (MDS) 3.0 assessment version 1.18.11. 

The challenge: electronic medical record (EMR) software vendor glitches. With every click of an MDS, providers were unsure. Had they selected the right combination to unlock and proceed, or would they reach another locked door? The sheer volume of EMR errors made an already challenging transition exponentially more difficult for SNFs to navigate.

Providers were left with a difficult decision: to delay their MDS submission until system edits were issued or to submit MDSs with incorrect codes. During a Centers for Medicare & Medicaid Services Open Door Forum on Oct. 12, when questioned by callers, officials discussed the ramifications of not submitting an MDS: claims submitted without an MDS submission will not be paid. 

CMS officials were unable to provide specific remedies for software errors, or estimated timelines for correction, instead directing providers to work directly with their vendors, Medicare Administrative Contractors (MACs), or contact the Internet Quality Improvement & Evaluation System (iQIES) help desk.

EMR errors were not specific to any one vendor; CMS said all EMR vendors experienced problems. To illustrate the magnitude and complexity of errors providers encountered, one-month post-implementation of the MDS 3.0 version 1.18.11, one of the most prominent EMR software in the U.S. continues to investigate unresolved errors, releasing a multi-page document detailing the status of resolutions. 

So what’s going on? Across multiple software vendors, providers reported significant complications:

• Health Insurance Prospective Payment System (HIPPS) scores were not calculating for OBRA assessments 
• Incorrect HIPPS scores were calculated for MDS assessments for Medicare 
• Erroneous skip patterns resulting from both CMS technical errors and EMR technical errors
• Not able to obtain Resource Utilization Groups (RUGs) scores
• Received inaccurate Patient Driven Payment Model (PDPM) scores
• Section GG calculation errors
• Unable to submit MDS assessments
• Software patches were issued after the fact, and are not consistently updated

What can providers do? Prepare for intensive Triple Check meetings. These meetings will be both critically important and technically challenging. 

The Triple Check process ensures billing accuracy and conformance with regulatory requirements prior to the submission of claims for payment and involves interdisciplinary team (IDT) review of admissions, billing, and MDS for Medicare/Managed Care residents. 

Typically, IDT members use reports created by their EMR to guide Triple Check. With the current situation surrounding EMR errors post- MDS v 1.18.11 implementation, these reports should be considered unreliable. 

SNF IDT members participating in a Triple Check meeting should use their acute understanding of how each case mix adjusted component under PDPM – Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), Non-Therapy Ancillary (NTA), and Nursing – is calculated, to verify accuracy of claims for payment. Moreover, SNF IDTs will need to recognize errors caused by both EMR glitches and human error. 

The MDS 3.0 version 1.18.11 included significant changes to the MDS process impacting documentation sourced from multiple disciplines, creating the perfect environment for additional errors caused by misinterpretation of MDS changes.  

Providers should plan to suspend use of EMR reports for Triple Check meetings for October 2023 and November 2023 claims. 

Three tips for Triple Check meetings

• For MDS’s completed before Oct. 1, download prior period reports from EMR software. Unless a new Interim Payment Assessment (IPA) MDS was completed, providers can use prior period reports to verify that the HIPPS score or Patient Driven Payment Model (PDPM) score remains the same. 
• For MDS assessments completed on or after Oct. 1, confirm the accuracy of each case mix group.
• SNFs located in states approaching a case mix freeze should review and optimize Medicaid case mix index (CMI) scores; determine if any residents need an MDS completed prior to the cutoff date.

Maureen McCarthy,  RN, BS, RAC-MT, QCP-MT, DNS-MT, RAC-MTA, is the President and CEO of Celtic Consulting, a post-acute advisory firm which provides assistance to skilled nursing providers across the nation.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

“National Lampoon’s Christmas Vacation” has so many funny one-liners. Remember when Clark finally gets the house lit up and each family member comments on the spectacle? When it finally gets around to Clark’s father, he is at a loss for words and all he can get out is, “It’s a beaut Clark, it’s a beaut!” Just then, Cousin Eddie shows up, and, well, you know the rest.

It’s been kind of like that this year, hasn’t it? We finally got the new MDS in all its glory and then things started to go downhill — kind of like Cousin Eddie showing up. The challenges we’ve faced with this implementation have been unprecedented and many. 

All of the prep work and long training hours hit a snag when we all began to realize that there were, and still are, issues to get used to and some that still need to be talked about. I’m thinking specifically about the unfolding changes to the quality measures and Five-Star rating now that section G has been officially retired. 

There are five quality measures that will be affected by these changes. The table below crosswalks these five measures to their GG equivalent measures. Note that measures one through four affect the Five-Star rating. 

Recently, the Centers for Medicare & Medicaid Services released QSO-23-21-NH in which it spelled out the effect that removal of section G would have on the four quality measures that will impact the Five-Star rating. 

Specifically, CMS indicated that, “Starting in April 2024, CMS will freeze (hold constant) these four measures on Nursing Home Care Compare. In October 2024, CMS will replace the short-stay functionality QM with the new cross-setting functionality QM, which is used in the SNF Quality Reporting Program (QRP). The remaining three measures will continue to be frozen until January 2025 while the data for the equivalent measures are collected.”

CMS also posted an announcement in November addressing two important impacts that this Section G to GG transition will have on the reporting of all five quality measures on the IQIES MDS 3.0 Facility-Level Quality Measure (QM) Report. 

• “… these five measures were frozen (held constant) in the iQIES MDS 3.0 Facility-Level and Resident-Level QM Reports on 10/1/2023. Starting on the first Monday of November, iQIES will process any qualifying records submitted on or after 10/1/2023 that had a target date prior to 10/1/2023 in order to provide updated measure data based on newer submissions. 
• “… MDS records with a target date on or after 10/1/2023 will not be included in these impacted measures. As a result, if the requested report period (i.e., Begin Date Range and End Date Range) in the MDS 3.0 QM Reports includes dates on or after 10/1/2023, then there would be expected decreases in the numerator and denominator due to the MDS G-GG transition.”

In addition to these notifications, CMS also released MDS 3.0 Quality Measures USER’S MANUAL (v16.0) which contains the technical specification changes to the quality measures noted above. Providers should become familiar with the revised specifications. All five measures contain striking differences that we will need to understand and get used to. 

One example of this is the current measure, “Percent of Residents Whose Ability to Move Independently Worsened,” which measured the change over time of MDS item G0110E Locomotion on unit. This MDS item was defined as, “How a resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair.” 

The GG Equivalent Measure, “Percent of Residents Whose Ability to Walk Independently Worsened,” measures only MDS item GG0170I Walk 10 feet defined as, “Once standing, the ability to walk at least 10 feet in a room, or similar space.”  The GG equivalent measure eliminates measuring a large portion of the long-term care community who use wheelchairs for locomotion. This is not an equivalent measure and begs the question, “Is this really a useful measure for the long-term care population?” 

Another example is the current measure, “Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased.” This measure used the four late loss ADLs, Bed Mobility, Transfer, Eating and Toilet Use as proxies for declines in function over time. 

While the measure title and description has not changed for the GG equivalent measure, the MDS items it measures, again, are significantly different from what the section G items measured in the current measure. The revised QM measures the following items out of section GG, Sit to Lying, Sit to Stand, Eating, and Toilet Transfer.

You are probably as surprised as I was when I first saw this new measure. Take toilet use vs. toilet transfer for example. In section G, toilet use was defined, “…as how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag.”

The GG equivalent toilet transfer only represents the resident’s, “…ability to get on and off a toilet of commode.” This too is not an equivalent measure and again begs the question, “Is this really a useful measure for the long-term care population?” 

These are huge changes. Keep in mind that all, but the discharge function score measure, are long-stay measures. It is relevant to remember that Section GG was developed as a standardized way to measure functional ability across post-acute care, not long-term care. It seems as if CMS is trying to pound square pegs into round holes here and it’s a bit bewildering as to why, the IMPACT Act notwithstanding. Nonetheless, preparation will be key as these new measures are phased in over the next year.

When Cousin Eddie showed up at the Griswolds to a surprised and befuddled Clark, Eddie askes “Clark, are you surprised?” To which Clark responds, “Surprised, Eddie … if I woke up tomorrow with my head sewn to the carpet, I wouldn’t be more surprised than I am right now.”

These G to GG equivalent measures are no less surprising and puzzling. Perhaps if CMS had engaged the provider community to some degree before they finalized these changes, we may not be having this conversation. But here we are. The innocence of the MDS is that it started out as a standardized way to assess residents, create care plans, and measure quality. The fundamental idea is a “beaut” — it’s the nursing process for goodness’ sake. 

These new complexities, in my opinion, take away some of the original intent. It doesn’t have to be this hard. Like the arrival of Cousin Eddie, we will have to accommodate these measures. Part of that may mean we will need to press CMS to make continued adjustments to these long stay measures affected by the G to GG transition so that they better reflect the long-term population in our communities. I hope there may be opportunities here. 

In the end, despite Cousin Eddie’s unanticipated appearance and Clark’s Christmas bonus debacle, the Griswolds were able to give Christmas to Eddie’s kids. Christmas really does embody the idea of hope. 

Amid all the changes we have had to assimilate this year, let’s encourage each other not to lose sight of the gifts we bring each day to the residents we serve. A little hope goes a long way. 

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Countless MDS training sessions, manuals, tip cards and software updates have filled our inboxes and daily industry news. However, if the arbiter of success isn’t making it past the Oct. 1 start date, then what is?

With this in mind, I turned to some of the best and brightest at Zimmet Healthcare: Alicia Cantinieri, Melanie Tribe-Scott and Amy Greer. In total, the three of them have completed dozens of public and private training sessions on the new MDS. But what I wanted to learn from them were any early warning signs that the transition wasn’t going well. Their response made me sound the alarm: “Fasten your seatbelts: It MIGHT be a bumpy ride.” However, they also offered several sage tips that should help you avoid unnecessary potholes.

Bumps related to Medicaid reimbursement 

States that are already using or converting to a Patient Driven Payment (PDPM) methodology for CMI are primarily using the Nursing component. Accurate documentation and coding of the resident’s “usual performance” in MDS Section GG is crucial, as well as the capture of diagnoses and other higher-acuity items. 

In states that are continuing to use the Optional State Assessment (OSA) or have rates frozen while the state adopts a PDPM system, MDS coding on OBRA assessment is also important as the OBRA assessments after Oct. 1 may be used in rate development or rate setting. 

As always, it’s crucial for the MDS and supporting documentation to be accurate. 

Therefore, three months out, do the following:

1. Self-audit or have a third party audit a random sample of OBRA assessments; the size of the sample depends on the number of assessments completed. Does the MDS coding have support in the medical record? Would another MDS assessor code the items the same way from the available documentation?

2. Review your facility’s process for collecting Section GG data. Is data gathered from all shifts? Is there evidence of multidisciplinary collaboration?

3. Review diagnoses coded on the MDS. Does the documentation support for diagnoses follow the RAI Manual guidelines? 

Bumps related to Medicare reimbursement

Double down on triple-check for Med A residents coding in Section K and Section O. Both of these sections added a new column that is required for PPS assessments at the start of the Medicare stay. The PDPM group will still pull from the “while a resident” column, as always. However, the extra column may cause some confusion. If the dietitian or MDS coordinator doesn’t fully understand the coding instructions, then reimbursement may be missed. For example, oxygen during the first three days of the Med A stay needs to be coded at both O0110C1a on admission and O0110C1b while a resident.

The same situation may occur in Section K. If the resident received tube feeding during the first three days of the Medicare stay, this must be coded at both K05201a and K05201b.

Regarding the PHQ-2 to 9, the facility should expect to see a decline in residents with a depression end-split, but not necessarily on the quality measure (QM). However, that decline in the end-split should not be extreme. A facility that was reporting a PDPM depression rate of 30% should not drop to 0%. If there IS an extreme decline, additional training may be required to ensure social services, or whoever is completing the assessment, understands the interview process for the PHQ-2 to 9. 

Therefore, three months out, do the following:

1. Monitor your PHQ-2 to 9 scores by pulling a report from your software.

2. Pay close attention to PDPM Section GG function scores.

3. Pay close attention to SLP and Nursing component scores dependent on Section K.

Bumps related to quality reporting

Although the Discharge Function Measure has a complicated formula and risk adjustment, if status on discharge indicates no improvement or minimal improvement from admission to discharge for many residents receiving rehab, it’s likely to be a red flag. This could indicate a lack of carryover from the rehab gym to performance back on the floor. With a focus on successful discharge to the community and rehospitalizations, ensuring the resident can translate performance in the gym to the unit and ultimately to their home as appropriate is key. 

Also remember that the data reporting threshold for QRP items will increase from 80% of the assessments to 90% for FY 2026. This affects MDS assessments beginning with CY 2024. A low data reporting percentage is related to “dashing” (—) the required data elements. Education or system changes may be needed to ensure the data reporting is at 90% or higher. With the additional assessment items on the new MDS, hitting 90% may be more of a challenge. Not only are there new QRP items, such as B1300 Health Literacy and transfer of health information, but we are also not well practiced in capturing these items. How have you operationalized their data capture?

Therefore, four months out, do the following:

1. Review the QRP Threshold Report in CASPER. If the facility is significantly below 90% after one complete quarter of data, it is critical to determine the reason why and make corrections if possible. 

2. Review the process for the UR meetings and discharge planning. Are the functional gains made by the resident in rehab translating to the rest of the day on the unit prior to discharge? 

3. Again, self-audit or have a third-party audit MDS assessments for accuracy. 

Bumps related to Five-Star 

The new MDS will affect Five-Star ratings, especially the QMs domain. With the elimination of Section G, four of the QMs will be affected (Increased ADLs, Pressure Ulcers, Improvement in Function, and Move Independently Worsened). These measures historically were calculated using data from Section G, but they will now use data from Section GG. In April 2024, these four measures will be “frozen” on Nursing Home Compare for three months to allow CMS to “catch up.” 

Once the QMs are unfrozen, they will be based upon MDS data from Q3 2023. You don’t want this to be the point where you realize your facility has been missing documentation opportunities from Oct. 1 and onward. After Oct. 1, carefully review all MDS assessments on a weekly basis for coding accuracy. Don’t do this review monthly; accumulated errors will be time-consuming to correct, and possibly lower QM scores can impact your QMs star rating and possibly even your overall star rating. 

Therefore, one month out, do the following:

1. Go “old school.” Frozen QM CASPER reports will not suffice your QAPI or auditing needs. “Back of the envelope” is often as good as a dense analytical report. Manually track, audit and analyze those negative outcomes 

2. Ensure your clinical staff are educated on the changes. Are your CNAs coding accurately? Is your MDS coordinator updated and supported? 

3. Begin a QAPI for any issues that might arise during the transition (e.g., complete, accurate CNA coding; nursing documentation in ADL decline).

Bumps related to care planning

We’ve discussed how a facility might see a decline in residents triggering depression. It’s essential to ensure you’re properly identifying residents with depression, regardless of payer type or QM definition. Once you’ve done so, creating an appropriate care plan and evaluating its effectiveness is key to success. 

An exact cross-over between Section G and Section GG cannot be made. However, the facility should not see a significant difference in coding. For example, a resident typically coded extensive to total for ADLs in Section G should not be coded as independent to set up functional abilities in Section GG. Review and monitor for such differences prior to submission, as they may impact the care plan and Medicaid reimbursement in some states. Significant differences may indicate a need for additional CNA training or an update to the documentation system.

The facility should update verbiage in care plan templates to reflect the functional abilities in Section GG as opposed to Section G. Be sure to include new items in care plans such as social isolation, health literacy and indications for medications.

Therefore, immediately do the following if you haven’t already:

1. Provide follow-up education to CNAs on GG coding now and then two to three weeks after implementation of the new coding.

2. Supply additional education on interview techniques for the BIMS and PHQ-2 to 9.

3. Review GG coding prior to MDS submission for the first three or four weeks on all payer sources to ensure accuracy. 

Bumps related to survey

Surveyors will likely focus on Section GG and the newer items. If your facility lacks supporting documentation or has no process to gather the data to make a functional assessment, there will be a problem. Facilities that choose not to have CNAs document Section GG items still need a system for daily documentation to indicate the resident’s status and care provided, provide support for rehab referrals due to a change in function, and track significant changes. Lacking these items can be detrimental to the accuracy of assessment and care planning. 

Regarding missing indications in Section N, if the assessors are checking off “no” to indications for high-risk meds, that might signal an issue with documentation. Clinical support is required from the prescriber and not simply a diagnosis with no further support or rationale in the clinical record. The SOM requires physician’s visits to include an evaluation of the resident’s condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident’s current medical regimen, which is in line with the indication for high-risk medications in MDS Section N. 

Therefore, three months out, do the following:

1. Self-audit or have a third-party audit documentation to support change in function in ADLs and rehab referrals. 

2. Conduct a monthly review of CNA ADL documentation and ensure their involvement in the care plan meetings. 

3. Self-audit or have a third-party audit high-risk medications and clinical rationale. Pharmacy partners would be great for this. 

One final potential bump 

Have you updated your facility assessment, policy and procedures to reflect the new MDS changes? Is your interdisciplinary team comfortable with these changes? Specifically, are your nurses educated on medication reconciliation at discharge? Do they understand indication vs. diagnosis? Who will be responsible for ensuring that this requirement is completed, accurate and documented? 

Therefore, one month out, do the following:

1. Have conversations with members of your clinical team to gauge their adjustment to the changes. Do they have any ideas that may help improve your documentation?

2. Review all policies, procedures, facility assessments and census and condition reports to ensure that they are updated and that they accurately and compliantly reflect changes to the MDS. Incorrect or outdated data can also have repercussions for your health inspection survey. 

3. Audit your medication reconciliation and discharge documentation monthly.

This “new MDS” doesn’t carry the title MDS 4.0 but maybe it should. The amount of change is significant. Do fasten your seatbelts because we will experience bumps. However, a seatbelt constructed of audits, education and QAPI will keep you safe. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

A: Failure to meet the requirements of the Skilled Nursing Facility Quality Reporting Program will result in a 2 percentage point reduction in the Annual Payment Update (APU). This can happen when the provider does not achieve an 80% threshold on the MDS reporting requirement. 

Essentially, no less than 80% of the MDS assessments for a given data submission period must have 100% completion of the required SNF QRP standardized data elements. 

To your point, a non-compliance letter will let you know that the threshold has not been met but does not describe the specific MDS data elements that were not submitted or “dashed.”  The data elements used for reporting assessment-based Quality Measures affecting FY 2024 APU determination include Section GG discharge goal, bowel continence, certain diagnoses, height, weight, falls with major injury, pressure ulcers/injuries and drug regimen review. 

Keep an eye on your SNF QRP QM reports. These are refreshed monthly and include facility-level and resident-level information for a single reporting period. Providers also have access to the SNF QRP Review and Correct report prior to each quarterly data submission deadline and the provided data should be reviewed for accuracy. Keep in mind that “triggering” for some measures is desirable while “triggering” for others is not. Erroneous records can be corrected as long as the deadline for corrections has not passed. 

Identifying which data elements are incomplete is necessary to review processes and avoid future situations where data may not be submitted. 

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.

My absolute enjoyment of changing into a different character each year for a few hours was probably a harbinger of things to come later in life.  Although professionally I am a nurse specializing in post-acute care regulatory affairs and education, on the side I am an amateur thespian.

You can routinely find me on the streets of Jonesborough, TN, dressed as an early 20^th century baseball player leading a town tour, on stage at the Jonesborough Repertory Theater, or bringing a long passed on Jonesborough citizen to life in our annual cemetery play, “A Spot on the Hill.”

If you have been paying attention, you recognize that what the MDS has changed into this go round is significant. Item sets and RAI Manual revisions, now staffing calculations and quality measures specifications, have taken front and center. No clowning around here. However, the reason for this change is something to which we should also pay attention.

You are probably aware that the changes we are now acclimating to are the result of a piece of legislation that was signed into law back in 2014 called the Improving Medicare Post Acute Care Transformation Act, or IMPACT act.

In a nutshell, this legislation requires the reporting of standardized, interoperable patient assessment data with regard to quality measures and standardized patient assessment data elements (SPADEs), to allow for the exchange of data among post-acute and other providers, in order to improve Medicare beneficiary outcomes through shared decision making, care coordination and enhanced discharge planning. That’s a descriptive mouthful. 

Unlike a mouthful of Halloween candy though, this delicious description is important to our understanding of the revised MDS data that we are now collecting. The SNF Quality Reporting Program (SNF QRP) relies on this standardized data to fulfill its responsibility to the IMPACT act. In other words, the SNF QRP creates the quality reporting requirement to which we owe MDS 3.0 v1.18.11. 

Annually, the Centers for Medicare & Medicaid Services posts documents that indicate which items on the MDS contribute to this reporting requirement.  With the implementation of v1.18.11 of MDS 3.0, the number of these data elements increased from 99 pre MDS 3.0 v1.18.11, to 230 in the revised data set. That’s 131 more MDS data elements that are required to be reported because of the SNF QRP. 

Also, the FY 2024 SNF PPS final rule finalized a new reporting standard. Starting with MDS data collected in CY 2024, facilities will be required to submit 100% of the QRP required data on 90% of the MDS assessments submitted to IQIES. 

This requirement carries with it some potentially hefty financial implications for SNFs that are non-compliant to the tune of a 2% reduction to the annual payment update or APU (adjusted market basket update). For FY 2024, that would mean a 6.4% update would be reduced to 4.4% that would then be further adversely affected by a 2.3% parity adjustment. Combined with Skilled Nursing Facility Value Based Purchasing (SNF VBP), sequestration and wage index adjustments, that’s not small potatoes. 

And while the SNF QRP is the primary impetus for the MDS changes this year, some of the standardized data will also impact CMS’ other quality reporting efforts like the SNF VBP and Five-Star Quality Rating System. The SNF VBP shares the following measures with the SNF QRP: discharge function Score, healthcare associated infections that require hospitalization, falls with major injury, and discharge to community. The revised Five-Star rating will share the following: skin integrity post-acute pressure ulcer injury measure, discharge function score, and discharge to community. 

One time my brother and I foolishly decided that we would pull a Halloween prank on a friend by soaping the windows on his car late at night. “Boy,” we thought, “will he be surprised.” We wore Halloween masks, just in case. A bit older at this point, I was now the werewolf. 

As we were completing our mischief in the apartment complex parking lot, we noticed a young woman, apparently another tenant, walking toward us and realized that she was writing down our license plate number. Not to be discovered by our friend, we thought it would be helpful to explain to her what we were doing and that this was a friend’s car. 

Forgetting our Halloween attire, as we ran after her to try to explain, we watched in dismay as she quickly disappeared into her apartment. Suddenly realizing that law enforcement may be our next surprise, we left in haste. A humorous, but real, lesson learned.

And so, here we are. It’s October 2023. All the hype is now reality.  As we grapple with successful implementation of the revised MDS over the next several months, let’s be sure that we aren’t soaping any windows. 

From the SNF QRP perspective, a single misplaced dash is all it will take to wake up in FY 2025 with an APU that is 2% less than everyone else’s. Nothing funny about that lesson.  

The changes to the MDS are in the bag. It’s time for trick-or-treat. Are you prepared?

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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A: Providing a reconciled medication list to subsequent providers or the resident/caregiver improves care coordination and decreases adverse events. Beginning with fiscal year 2024 (Oct. 1, 2023), the MDS-collected current reconciled medication list will inform the SNF QRP Transfer of Health Information quality measures. 

When preparing for this change, first consider who will provide the list at the time of discharge. Educate these individuals on how to deliver and document this information. The MDS offers several options for route of delivery, including electronic health record, health information exchange, paper-based, text or email.

It can be verbal, in writing, or both, but the person providing the reconciled medication list must know how to deliver it. If the information is going to the subsequent provider, clarify the provider’s preferences for receipt. If the information is going to residents or caregivers, consider how they learn best. Health literacy may affect routes of transmission. When communicating, use language that the resident or caregiver understands. 

Some residents may not be on any medications, prescribed or over-the-counter. If so, document this in the medical record and code the MDS as yes, the current medication list was provided. If the facility does not give a current reconciled medication list, the discharging nurse should document the reason.

In summary, it is critical that you review your current process, revise policies, educate on new processes, and document delivery of current reconciled medications upon discharge. 

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

A:There are no changes to the Patient Driven Payment Model calculations planned for Oct. 1. But updates to some data elements and your facility processes could theoretically impact reimbursement. 

Currently, the Patient Health Questionnaire (PHQ-9) or Resident Mood Interview in Section D of the MDS can contribute to increased reimbursement under the Nursing Component of PDPM if the total severity score for the interview equals 10 or greater. This depression “end-split” affects the Nursing Case-Mix Groups of Special Care High, Special Care Low, and Clinically Complex. The total severity score is the sum of the frequency responses for symptoms present. 

As of Oct. 1, the PHQ-9 will be revised to the PHQ-2 to 9. This will allow the mood interview to be stopped after the first two questions, depending on the resident’s responses. The positive here is that this may shorten the time the appointed staff member spends completing the Resident Mood Interviews. The question that remains is whether this shortened interview may lead to fewer residents with a total severity score of 10 or greater, and thus a dip in reimbursement. 

For example, one may not be bothered by “little interest or pleasure in doing things,” or “feeling down, depressed, or hopeless,” — the two questions posed in the PHQ-2. But, if one was bothered by “feeling tired or having little energy,” or “poor appetite or overeating,” these questions will not be asked if the interview is concluded early. 

Also, with the removal of Section G from federally required assessments, Section GG will stand as the assessment of functional abilities, and facilities should refocus efforts on GG assessment practices. 

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.