Long-term care providers were intent on dismissing undesirable memories of the COVID-19 pandemic as much as possible in 2023, but the year’s top stories revealed there were still remnants of it to deal with — and plenty of other issues to fill the gaps.

From unprecedented, increased regulatory pressures to newly introduced legislation, ongoing workforce challenges, image problems and more, there was a lot to digest.

Here are the top stories that grabbed our readers’ attention in 2023, the top handful of them inevitably related to the staffing mandate and the sector’s ongoing workforce challenges.

Federal minimum staffing proposal dominates

By the time the Centers for Medicare & Medicaid Services finally issued its first-ever rule to set nursing home minimum staffing levels, the sector had experienced a roller-coaster of tense emotions. The Sept. 1 announcement put providers and their advocacy counterparts in labor and consumer groups in an uproar.

Operators called the proposal an impossible, unfunded mandate, if not because of the estimated $4 billion or greater price tag, then because there simply aren’t currently enough registered nurses to satisfy the tripling of current mandated levels.

‘Accidental’ early study release, Biden unloads on providers

President Biden added fuel to the fire when he unloaded on nursing operators just days after the staffing mandate was proposed.

The administration, however, was undercut a few days before the proposed rule’s release, when a “draft” of it was briefly posted online before being pulled down. That gave outsiders an early look at study findings saying it’s impossible to settle on a specific staffing level(s) that would serve the White House’s desired goal. Despite officials calling it a “draft” study report, it was nonetheless included in the same form when the proposal was released later that week.

The intrigue persists: Was it truly an accidental early posting, or was it the purposeful act of an insider sympathetic to providers’ year-long criticism that an unprecedented staffing mandate would be a bad idea?

Staffing mandate’s costs greatly underestimated: report

Three weeks after the staffing mandate was officially proposed, a respected third-party analyst hired by providers found that its cost would be nearly 60% higher than the $4 billion annual cost estimated by the Centers for Medicare & Medicaid Services.

Nursing homes would need to spend more than $6.8 billion annually and hire more than 102,000 new workers under its proposed form, said an updated analysis issued by accounting and consulting firm CliftonLarsonAllen.

Bills would block federal staffing mandate

Within five weeks of the staffing rule’s proposal, Republican House members proposed legislation to block it. A similar Senate bill, this one bipartisan, was proposed in December. 

The legislative efforts are being led by lawmakers in rural states, which figure to be most severely hurt by any new staffing standard.

CMS delivers 4% Medicare pay raise

Nursing homes received a higher-than-expected 4.0% increase to their Medicare Part A payments for fiscal 2024. The July 31 final rule from CMS added 0.3% — or $200 million — to the agency’s original April proposal. Inflationary costs were deemed responsible for the largest annual increase in recent memory.

In addition, most of the recommended vast changes to CMS’ quality reporting and value-based purchasing programs were retained in the final rule.

Biden plan would tie pay rates to staff turnover rates

In mid-April, President Biden signed a massive executive order that included several measures intended to improve access to long-term care and bolster job protections for skilled nursing workers. Among them were calls to expand on the then-undisclosed staffing mandate and to tie Medicare payments to staff retention.

The White House called the 50-plus elements the “most comprehensive set of executive actions any President has ever taken to improve care for hard-working families while supporting care workers and family caregivers.”

Nursing home ownership transparency pushed

Federal authorities made good on their promise to increase transparency from anyone owning a stake in nursing homes, or doing top business with them, with a rule finalized Nov. 15.

The rule imposes many of the ownership transparency measures outlined in a February proposal and defines both private equity and real estate investment trust owners. A coalition of 18 attorneys general fueled aspects of the rule with a plea for more ownership information.

Feds lift COVID-19 vaccine mandate that Supreme Court upheld

Regulators made big news in late spring when they announced they were acting to COVID-19 vaccination requirements for healthcare workers. The mandate had been upheld by the Supreme Court in a historic court decision in January of 2022.

Other vaccine requirements also were lifted with the end of the public health emergency on May 11. Booster shot rates have plummeted since.

Among the other big story lines

As the referring examples in this sentence indicate, the skilled nursing sector saw a growing number of providers shedding or closing facilities, or filing for bankruptcy as access worries mounted.

Meanwhile, as Medicare Advantage plans passed the 50% market share level for the first time, regulators made moves to impose more standards on them, with providers appealing for even more.

On Oct. 1, the largest overhaul to the Minimum Data Set in years became effective, capping a hectic year of planning and worrying.

Also on the federal regulatory front, authorities quietly put into place new, stricter measures regarding infection control and general vaccine immunization matters. They also continued to increase scrutiny of the use of antipsychotics and schizophrenia medications.

In other pandemic-related matters, a federal jury found that the nursing home that was the site of the first major COVID-19 outbreak in the US was not liable for the deaths of two residents. It signified one of a number of heartening court victories for providers accused of wrongdoing in the early days of the public health emergency.

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.

Hmm… I suppose individual perspective is the key to whether that is true.

I remember one time when I was a much younger inexperienced man, I mistakenly left my car in neutral on a slight hill after changing the oil. 

I went into the house to retrieve a grocery list and discovered, after hearing a loud bang, that my car had rolled down the hill into my neighbor’s barn. 

The changes that I faced then weren’t so beautiful. Thankfully no one was hurt, but my wallet and my pride suffered some serious loss. Lesson learned.

This fall has brought a cornucopia of changes to nursing homes. I’m sure you feel the weight.  Not all of them have been what we expected. The quality measure changes, for example, contain some surprising crossover from section G to GG “equivalent.”

Four weeks post implementation, the Centers for Medicare & Medicaid Services continues to make significant revisions to the MDS coding guidelines as well with the release of the sixth versions of the data set, an item set supplemental document and two errata documents. CMS had three-plus years to get this right. What happened that so many revisions are having to be made?

Whatever the reason, the most significant revision occurred with the release of these errata documents, in particular the coding guideline revisions to the depression interview, now the PHQ-2 to 9. 

Revisions related to the PHQ-2 to 9

Added

p. D-2: D0100 serves as a gateway item for the Resident Mood Interview (PHQ-2 to 9©) and D0500, Staff Assessment of Resident Mood (PHQ-9-OV©). The assessor will complete the Staff Assessment only when D0100 is coded 0, No. The assessor does not complete the Staff Assessment based on resident performance during the Resident Mood Interview.

p. D-3: Resident refusal or unwillingness to participate in the interview would result in Item D0100 being coded 1, Yes, and code 9, No response being entered in Column 1. Symptom Presence. Assessors should proceed to Item D0700, Social Isolation in the case of resident refusal or unwillingness to participate.

p. D-5: If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social Isolation.

p. D-6: If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social Isolation.

p. D-11: If only the PHQ-2© is completed because both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social Isolation.

p. D-11: If symptom frequency in items D0150A2 through D0150I2 is blank for 3 or more items, the interview is deemed NOT complete. Total Severity Score should be coded as “99,” do not complete the Staff Assessment of Mood, and skip to D0700, Social Isolation.

p. D-13: When staff determine the resident is not interviewable (i.e., D0100 = 0, No), scripted interviews with staff who know the resident well should provide critical information for understanding mood and making care planning decisions.

p. D-13: 1. Interview staff from all shifts who know the resident best. Conduct the staff interview in a location that protects resident privacy.

p. 6-37: Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the Special Care High category. Residents with signs and symptoms of depression are identified by the Patient Mood Interview (PHQ-2 to 9©) or the Staff Assessment of Patient Mood (PHQ-9-OV©). Instructions for completing the PHQ-2 to 9© are in Chapter 3, Section D. Item D0100 is a gateway question to determine when the Patient Mood Interview (D0100 is coded 1, Yes) or the Staff Assessment of Patient Mood is to be conducted (D0100 is coded 0, No). Refer to Appendix E for cases in which the PHQ-2 to 9© or PHQ-9-OV© is complete but all questions are not answered. For the PHQ-2 to 9©, if either D0150A2 or D0150B2 is coded 2 or 3, continue asking the questions below, otherwise end the PHQ interview. Assessors should proceed to D0700, Social Isolation in the case of resident refusal or unwillingness to participate. The following items comprise the PHQ-2 to 9© and PHQ-9-OV© for the Patient and Staff assessments, respectively:

Removed

p. D-13: PHQ-2 to 9© Resident Mood Interview is preferred as it improves the detection of a possible mood disorder. However, a small percentage of residents are unable or unwilling to complete the PHQ-2 to 9© Resident Mood Interview. Therefore, staff should complete the PHQ-9© Observational Version (PHQ-9-OV©) Staff Assessment of Mood in these instances so that any behaviors, signs, or symptoms of mood distress are identified.

p. D-13: Even if a resident was unable to complete the Resident Mood Interview, important insights may be gained from the responses that were obtained during the interview, as well as observations of the resident’s behaviors and affect during the interview.

Considerations

These guidelines are pretty straight forward. CMS has now unequivocally indicated that the PHQ-9 OV is only to be conducted in cases where B0700 (Makes self-understood) is coded 3, rarely or never understood. 

Until these revisions, the RAI manual guidance allowed the staff interview for depression to be conducted when a resident was unable or unwilling to complete the PHQ-9, and more recently the PHQ-2 to 9©, Resident Mood Interview.

It wasn’t until this year, FY 2024, after the PHQ data was labeled a SPADE, or Standardized Patient Assessment Data Element, that the guidance changes occurred, and not until well after the final RAI Manual was posted. Why now?

It is interesting to note that the OASIS, LCDS and IRF-PAI all contain the PHQ-2 to 9 but no staff assessment for depression. Ostensibly this is why these revisions have occurred, to make the reporting of depression data among post-acute providers as standardized as possible. 

The fact remains, however, that CMS has noticed that the incidents of depression indicators have been an outlier under PDPM compared to the RUG 66 grouper. That means money. Parity happened for a reason. It is difficult not to think that limiting the times that the depression end split is in play was a subtext impetus for these revisions.

I am perplexed, though, as to why only the PHQ-2 to 9 has been singled out.

I find it interesting that the BIMs has not undergone the same scrutiny. Considered a SPADE as well, the BIMS also has a staff assessment component that continues to be allowed to be utilized in specific situations where the BIMs is stopped, and when there is an unanticipated discharge for a Part A resident. 

While the BIMs is also a standardized assessment embedded in the OASIS, LCDS and IRF-PAI, there is no standardized staff assessment for cognitive status in these tools either. Could it be that since cognitive performance, being only one fifth of SLP considerations under PDPM, doesn’t rise to the level of the PHQ in its financial impact on the rate?

In the end, the CAA and care plan requirements remain for residents with depressive symptoms, even if they are unable or unwilling to communicate them. Page D-13 of the RAI Manual continues to indicate, “Alternate means of assessing mood must be used for residents who cannot communicate or refuse or are unable to participate in the PHQ-2 to 9© Resident Mood Interview. This ensures that information about their mood is not overlooked.” 

Until this revision, that alternate means was PHQ-9 OV. Now, providers are left wondering what CMS means by “alternate means.” At least one thing is clear, if these residents are identified by whatever, “alternate means” is used to identify depression symptoms, the added acuity that these residents represent will not be reflected in the PDPM rate.  

Thank goodness the leaves have finally changed and, for goodness sakes, let’s hope that the leaves of the RAI manual have finally fallen into place so we can get busy with the task of implementation without hesitating for the next errata. It’s hard to be thankful for these late surprises.

Autumn is beautiful here in eastern Tennessee. The colorful foliage and cooler weather are certainly a wonder. I like sitting out by the fire pit, seeing my breath in the air, smelling the first hearth fire smoke, listening to the geese fly noisily overhead, watching the squirrels collect their winter stores, and anticipating the holidays. I am thankful for this change.

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.

Martin Allen, senior vice president of reimbursement policy for the American Health Care Association, cautioned providers Tuesday to advocate for themselves as states tackle routine rate rebasing, convert from therapy-based payment systems to case-mix versions more in line with Medicare, and also look to adjust to new federal regulatory requirements.

“We have to be very careful about the dollars associated with the next rate cycle and case-mix indexes associated with that as well,” Allen told providers at an educational session at the AHCA/NCAL annual meeting Tuesday.

“The general theme is acuity levels are still high and people coming into our buildings are still sicker, even though we’re not dealing with [significant] COVID diganoses anymore,” he added. “From a Medicaid perspective, we want to make sure those themes get built into  any rebasing process.”

Nearly half of states rebase per-diem rates annually, and the recent MDS transition will throw an extra wrench into the process for many states in 2023 and 2024. Gone with the old MDS system is Section G, which many states used to calculate clinical reimbursement on the Medicaid side. As of 2019, 34 states were still using a RUGS-based system to capture acuity, according to MACPAC data cited by Allen. 

Some states that were unable to transition to their own Patient Driven Payment Model-like models in time for that have frozen case mix while they develop a new standard. Others are using an Optional State Assessment that can be used to convert to old RUGS-based scores, but they will still need to work toward a permanent replacement.

“We have to be engaged in the process of revision,” Allen said, noting that AHCA is offering states feedback in addition to audits typically being led by accounting firm Myers & Stauffer.

One key will be for states to add measures that accurately reflect the needs and conditions of Medicaid long-stay residents, since PDPM is geared toward short-stay patients.

“We want to have adequate time to make the changes both from a cost standpoint and a rate standpoint,” Allen added. “With a hard transition … your risk of winners and losers can be very great.”

A phase-in would instead allow state Medicaid systems to catch problematic factors. So far, in states working on transitions, providers are asking for “hold harmless” provisions. Those can limit deep cuts, but they also limit higher payments to providers who would pick up significant acuity-based payment increases, Allen explained.

It’s important that states recognize a technical conversion shouldn’t be used to clawback money from providers, especially if cost-reporting information might be used simultaneously to adjust rate methodology or rates.

He said that states tackling both efforts at the same time could “muddy the water” and threaten providers’ livelihoods, and in turn, force providers to reconsider their approach to Medicaid patients or close units or buildings. That could be worsened by cost data that is skewed by COVID-era government support that temporarily helped providers counter higher costs.

“This shouldn’t be an opportunity for the states to pull money out of the Medicaid program,” he added. “Budget neutral or better. We need to hold states accountable to make sure there are no changes.”

In a LinkedIn post Tuesday, reimbursement expert Marc Zimmet cautioned providers against that “better” standard.

“Operators anticipate significant rate increases per pre-transition modeling, but without additional funds, we  end up exactly where we were under the old system,” the Zimmet Healthcare Services Group president and CEO wrote. “Invariably, the same operators with high scores in one system have the highest scores in the new one because CMI is often as much about reimbursement management as it is patient acuity.”

“When all is said and done, the state wasted valuable resources, providers wasted valuable resources, all to rearrange the same deck furniture,” he noted. “I asked this question when CMS effectuated the PDPM recalibration: What was the point?“

The new MDS 3.0 v1.18.11 makes more demands of staff time, and quicker action in many cases. Despite months of preparation, however, it is clear many hurdles still remain, experts told McKnight’s Long-Term Care News.

“[Electronic medical record] configuration issues are rearing their ugly head,” Celtic Consulting CEO Maureen McCarthy said. “Things that providers thought were all set to populate [in forms] have glitches.”

Other high-problem areas being reported early after the Oct. 1 transition include new interview sections regarding race and ethnicity questions, she added. Providers may no longer enter information about these and other social determinants without actually consulting patients.

“Folks were not aware that is needed to be completed prior to the assessment reference date, or within the first seven days of entry,” McCarthy added.

Perhaps a foreboding sign, she said that such lapses were occurring despite the fact that “there was plenty of education and guidance from CMS on that.”

Of the many changes, she thinks provisions of the new Section GG represent “the biggest change globally.”

“It impacts more people in the building than any of the other changes do,” McCarthy explained. “So they’re always looking for what the other guy is doing, rather than looking for the best solution for their own situation. It amazes me that there are so many people here looking at how they’re going to manage GG and it’s already Oct. 1. It adds more stress to the entire process.”

Amy Stewart, chief nursing officer for the American Association of Post Acute Care Nursing, which specializes in nurse assessment education and coordination, said Tuesday that members were not reporting much about the new MDS. But problems seem “pretty widespread.”

“People are getting ‘fatal’ errors when trying to submit assessments,” she told McKnight’s. “There is also the issue of the deaths in facility requiring race and ethnicity (designations). That’s what we’re hearing. Those are resident-asked questions, and if the resident is dead, we can’t ask it again.”

Bigger MDS workloads

McCarthy was called on to provide a critical MDS update session at the American Health Care Association annual conference here. Among other points of emphasis, she planned to warn providers in her Tuesday afternoon session that more interdisciplinary team coordination will be needed, and that rehab, for example, should not be considered the sole lead in gathering data and making decisions.

Stewart, another multi-session speaker at the AHCA meeting, told McKnight’s that she feared many providers were not fully aware of the “workload issues” that the new MDS provisions created for nurse assessment coordinators and others such as as social workers and admissions, to name just a few..

“It might be surprising to some operators,” she said.

McCarthy noted that any changeover is bound to cause some problems, but she was concerned about the level of inactivity among some providers.

“It’s like they’re watching water go under the bridge so they can make changes after that,” she said with a shake of her head. “There’s uncertainty about how to put processes in place. Some are always looking for what the other guy is doing rather than doing it on their own.”

The risk in that, of course, is lost revenue, especially with a narrower, three-day lookback period that could already be biting some providers today if they weren’t primed to act given Sunday’s switchover. Later, there could be problems when regulatory reviews take place, she warned.

“So many people have an incomplete process,” for contending with new provisions, McCarthy said. 

Three tips for success

She made three recommendations to providers still working to catch up:

• Look at your intake documentation and forms. Make sure the intake forms have the information you need to support the new MDS. Get rid of old ones.
• Nursing departments must be sure they’re aware there is a process that goes along with the transfer of health information. “The expectation is we’re having a conversation with the resident, because I don’t think the [staff] are understanding that piece. It’s not just giving a piece of paper to the person. We really need to have the explanation about the medications they’re taking.” It has to be explained to the patient [or patient representative] or the next provider downstream. That all takes extra time. “I think it’s a great opportunity to improve care throughout the continuum,” she conceded.
• Have all three pieces necessary to support Section GG documentation, and have it reproducible: The data collection, the assessment and then the coding itself. 

“That’s probably the lowest hanging fruit, I would say, and probably one of the first things that auditors would come after to try and reduce your revenue,” McCarthy warned.

“The majority [of providers] don’t have a full plan,” she reflected Monday. “Smaller facilities, and moms-and-pops are limping along. They face potential regulatory noncompliance problems — and the potential financial impact will hurt.”

McCarthy and other experts believe providers will be better off in the long term under the new system. But providers need to get new processes in place, as soon as possible.

“I would absolutely say it’s a chaotic time,” McCarthy said. “It reminds me of when we went from the MDS 2.0 to 3.0 in 2010. It reminds me very much of that. The one good thing we have in this system that we didn’t have in 2010 is we don’t need to do a new MDS for every single patient beginning Oct. 1.”

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.

Have a column idea? See our submission guidelines here.

It’s been widely billed as the biggest change to the Minimum Data Set in more than a decade, and on Sunday, version 1.18.11 of the MDS 3.0 finally kicks in.

But potential trouble spots already exist for the unprepared provider.

After stalling an update during the pandemic, the Centers for Medicare & Medicaid Services dropped its long-awaited draft revisions just over a year ago. Since then, providers have waited anxiously as various changes to MDS sections, the RAI user’s manual, interview scripts and other tools have been rolled out in piecemeal fashion.

Now, it’s go-time. With so many major changes — the elimination of Section G, replacement of the PHQ-9 with a potentially shorter test, the addition of SPADES and new data points for quality reporting purposes — it might be easy to overlook some less obvious updates in coding practices and processes.

There are plenty of items that drew less concern in much of the public conversation but nonetheless merit attention now to ensure solid documentation, coding and reimbursement processes are in place during and after the transition. 

Just the increase in the number of required reportable items alone is staggering, jumping from 99 data elements to 230 in v1.18.11, noted Joel VanEaton, master teacher and executive vice president of PAC Regulatory Affairs and Education for Broad River Rehab. 

And it’s more important than ever that providers not skip or leave blank sections for which they’re unprepared or untrained. The final SNF PPS rule for fiscal 2024 requires nursing homes to submit 100% of Quality Reporting Program data on 90% of the MDS assessments submitted, up from 80%. 

“From the SNF QRP perspective, a single misplaced dash is all it will take to lose 2% off next year’s market basket update,” VanEaton said. “These items include all items required to calculate the SNF QRP quality measures as well as the additional Standardized Patient Data Elements (SPADEs), like race and ethnicity and social determinants of health.”

McKnight’s Long-Term Care News asked Van Eaton and other assessment and coding experts for their take on areas that should be high on the radar heading into the weekend.

Prep for the changeover

From now until a few days after the switch, there could be significant confusion when admitting and discharging patients, experts noted. 

“Providers need to be prepared to complete supporting documentation based on the assessment reference date (ARD), not the admission date,” said Jessiie McGill, curriculum development specialist for AAPACN. “The ARD of the assessment determines what item set is used. If the ARD is Sept. 30, 2023, or earlier, the facility will use the 1.17.2 item set. If the ARD is Oct. 1, 2023, or later, the facility will use the 1.18.11 item set.”

For instance, if a resident was admitted on Sept. 25, but the ARD is set for Oct. 1, the 1.18.11 item set will be used.

“If facilities are not prepared, this could result in missing supporting documentation in many areas of the MDS,” McGill warned. “For example, if the facility had not previously been collecting GG data on OBRA admission, they may miss that GG data is required for the first three days of the stay. Likewise, they may not have supporting documentation for the MDS items with new ‘on admission’ categories that will be required for K0520, Nutritional Approaches and O0110, Special Treatments, Procedures, and Programs.”

Facilities also need to ensure they have new processes in place to facilitate completion of the scripted interview and resident voice items for all assessments with an ARD Oct. 1 or later. Such items must be completed within the seven-day look-back period.

For patients discharged after Oct. 1, new MDS items affect the Part A PPS discharge assessment if the assessment reference is Oct. 1 or later.

In states where payment systems haven’t been updated to reflect new federal assessment and payment changes, things could be even more complicated — making for an especially busy Friday.

“Those states where case mix will be frozen as of Sept. 30 will need to be keenly aware of the cut-off date and identify those residents who may need an MDS prior to that cut-off,” said  Maureen McCarthy, president and CEO of Celtic Consulting. “Optimizing the current case mix index system, prior to the transition, should be considered. A side-by-side analysis should have been performed to determine the new CMI levels for those moving to a Medicaid PDPM payment model, rather than a freeze.”

Be ready to reconcile meds

One of the major new discharge provisions requires providers to share and document the transfer of medication information to the patient, family member or next-level caregiver.

“Educate floor nurses regarding documentation of the medication reconciliation and the methods used to educate the resident or provider,” advised Amy Stewart, chief nursing officer for AAPACN. “The facility will need documentation in the medical record that includes how and when this was done for it to be captured on the MDS. Also, if it is not done, documentation should include why it wasn’t completed.”

Also important at discharge, noted Stewart, is collection of health literacy information by the clinical or nursing department for use in the discharge care plan.

The resident voice items for ethnicity, race, transportation barriers, health literacy, and social isolation must also be asked during the look-back period for the assessment.

“Although the [Health Literacy] item is only asked of Medicare Part A beneficiaries, the organization may want to consider asking all residents that may be discharged to the community,” Stewart suggested. “Discharged residents who lack an understanding of discharge instructions, including follow up with their physician and medications, may end up back in the hospital or have an emergency room visit.”

Approach Section GG with staff in mind

“Providers are waiting to get direction on GG data collection,” McCarthy said about the new section for coding self-care and mobility needs. “No two providers are the same. Some are having CNAs document and then having nursing do the assessment. Some are having the nurses document.”

If you’re still feeling your way through this new process, McCarthy says it may be smart to allow staffing to dictate your final plan.

“If you are agency-heavy in CNA, then that’s probably not the discipline to have completing such crucial documentation,” she said. “If aides are fairly stable and nursing is agency heavy, then having your regular CNAs is probably safer. Then MDS can do the assessment portion. We always have the option of including the therapists as well, but many would not be on caseload under Medicaid, therefore, we need to have a solid plan on how to address the functional assessment of each resident, not just those on rehab caseload.”

The team also should keep in mind the GG data is now based on a three-day lookback rather than seven days.

Don’t forget Care Area Assessments

“The CAAs have been overlooked by and large in the haste to prepare for the updated MDS,” VanEaton said. “Facility interdisciplinary teams need to pay attention to the revisions to Chapter 4 and Appendix C.”

Among the most prominent changes, in addition to the new PHQ and Section GG, are:

• Three new line items for delirium, pain and limits to participation in rehabilitation therapy, which VanEaton said will require the team to analyze concepts they have not encountered before in CAAs.
• Item J1900, falls with major injury, has been added to several areas as an expanded approach to further analyzing the impact of falls.
• Item J1400, terminal condition, has been added to several CAAs to further consider the impact on resident care plan needs.
• Social isolation now shows up specifically in CAA7, psychosocial wellbeing, as it relates to loneliness. “Considering this as a social determinant of health within the CAA resources will be a new concept for IDTs that will need to assimilate it into care planning,” VanEaton said.

The phrase “Cat’s in the cradle” is often used to refer to situations in which one person has neglected another, or there is a total breakdown of communication. It’s the theme of this song.

I have been keenly aware of the risk of leaving the cat in the cradle as I have been preparing and providing training related to MDS 3.0 v1.18.11 — there is so much new to get used to. I’ve often expressed that this feels more like MDS 4.0. 

The final version of the RAI Manual was released by the Centers for Medicare & Medicaid Services just a few weeks ago. One area with significant revisions that seems to have been somewhat overlooked in all the hubbub is Chapter 4 and Appendix C of the RAI Manual. 

Have you taken a close look at the changes? Your interdisciplinary team should, before Oct. 1. Here are a few of the key revisions:

CATs

The following CAT Specifications include changes. 

• CATs for CAA 5: ADL Functional/Rehabilitation Potential
• CATs for CAA 6: Urinary Incontinence and Indwelling Catheter
• CATs for 16: Pressure Ulcer/Injury
• CATs for CAA 11: Falls

CATs for CAAs 5, 6 and 16 were revised to remove references to section G and add section GG 0130 and GG0170 items. The section G balance items were removed from the CATs for CAA 11. However, references to balance remain in CAA 5.

• CATs for CAA 20: The triggering condition changed, not only from the current trigger, but from the DRAFT Manual. Now the trigger is, “Resident wants to or may want to talk to someone about returning to community as indicated by: Q0500B = 1 or 9”.

CAAs

There have been many revisions to the CAA Resources. Here are some prominent ones that will require IDT attention.

• Section GG0130 and GG0170 have replaced section G items throughout the CAA resources. Special attention needs to be paid to the breadth of section GG evaluation vs section G.
• Reference to the PHQ 2-9 now populates specific CAA resources. It will be important to consider the resident responses to MDS items D0150A and D0150B regardless of whether the remaining seven questions are considered.
• Three distinctly new line items have been added, one to CAA1 Delirium (Terminal condition (J1400) and two to CAA 19 Pain (Venous or arterial ulcers (M1030) and Limits participation in rehabilitation therapy (J0520)). These will require the IDT to analyze concepts they have not encountered before in these CAAs.
• In multiple CAAs, Item J1900, falls with major injury, has been added as an expanded approach to further analyzing the impact of falls.
• Item J1400, Terminal Condition has been added to several CAAs as well to further consider the impact that end of life/hospice services has on the resident’ care plan needs.
• While the term “social isolation” is peppered throughout the current CAA resources, with the implementation of v1.18.11, new MDS item D0700, Social Isolation, now shows up specifically in CAA7, Psychosocial wellbeing as it relates to loneliness. Considering this as a social determinant of health within the CAA resources will be a new concept for IDTs that will need to assimilate it into care planning.
• Now that section K0520 and section O0110 items have additional columns and time frames to consider, teams will need to recognize how these additions potentially change their CAA analysis.
• The pain interview has expanded into three specific instances when pain might interrupt things like sleep, therapy and day-to-day activities. This expansion has been added to several CAA resources and teams will need to consider the implications in analysis and care planning.

While this is not an exhaustive list, it is fodder for considering that while the number of CAAs has not grown, the new and revised MDS items have expanded the IDT’s responsibility to integrate these changes into the RAI process.

There should be a sense of urgency to get this right. The data that will be produced by a completed MDS 3.0 v1.18.11 will be different in many significant ways than an MDS completed prior to Oct. 1 with residual impact to care plan details. 

Adapting to these changes is no small task and will require attention to detail, not to mention staying alert to the fact that on the SNF/LTC Open Door Forum CMS admitted that there are two CATs (6 and 16) in error, and that a forthcoming errata document or some other type of correction is in the works. More to learn.

The chorus to “Cat’s in the Cradle” goes like this:

And the cat’s in the cradle and the silver spoon,

Little boy blue and the man in the moon.

“When you coming home, Dad?” “I don’t know when,”

But we’ll get together then

You know we’ll have a good time then.

This song makes me nostalgic, partly because it was written during the time of my childhood and hearing that style takes me back to fond memories. However, more powerfully, it reminds me of my own dad and how important time is now. He will be 90 this year.

I called him up just the other day. I wanted to hear his voice, see what he had to say. I plan to spend time with him later this fall. I wish it were today. 

Now is the time to get together around the new CATs and CAAs — not then. Don’t neglect these important changes. Begin now to talk about them and how your IDT will work them into your RAI process before Oct. 1.

Waiting could cause a total breakdown of communication. You won’t have a good time then.

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.

The call’s moderator pre-empted any would-be questioners about the staffing rule at the very start, advising that the topic would not be addressed and questions about it would not be entertained.

What followed was an exhaustive, general review of previously announced CMS rules and actions for the minority of attendees who might not have already known of them, and a lengthy Q&A session, centering mostly on MDS details.

If nothing else, the call illustrated that the nation’s providers still have plenty of questions about the Oct. 1 rollout of the biggest overhaul to the MDS in years.

But not a word was shared about the White House’s staffing mandate, which moved closer to being released Thursday, when it was discovered that the Office of Management and Budget website had marked its review of the proposals as “concluded.”

That was preceded on Tuesday by the accidental temporary release of a CMS study report on the issue. The anticipatory pump on the most intensely watched nursing home issue of 2023 was further primed Wednesday, when it was revealed regulator meetings on the staffing mandate scheduled for September had disappeared from the OMB website, ostensibly canceled.

So Thursday’s Open Door conference had an undeniable buzz of expectation well before it began. A CMS moderator, however, quickly doused any hopes of talk about the looming staffing mandate, which providers have estimated could cost up to $11.7 billion extra annually.

“We know that many of you may have questions about the forthcoming minimum nursing home staffing standards,” the moderator informed the crowd both verbally and in writing before starting the main program. “CMS is committed to improving safety and quality of care for nursing home residents and looks forward to sharing the proposal with you soon. Please hold all questions related to the proposal as we will not be addressing the topic today.”

Although there is nothing to stop regulators from holding the proposed rule back for days or even weeks, on Thursday policy experts widely expected it to be released Friday. It would cap an 18-month process that began with the announcement of a sweeping nursing home reform package the day before President Biden’s first State of the Union Address in 2022.

Back to the future with MDS

Six CMS subject matter experts spoke during the hourlong call. Much of their time was devoted to nuances of the MDS 1.18.11, the overhauled version of the resident assessment tool that will go live Oct. 1.

Recordings of the Open Door Forum calls  can be found on the CMS website.

Providers need to continue educating their staff members on the significant changes that are coming, emphasized Ellen Berry, deputy director of the Division for Quality Systems for Assessments and Surveys in CMS’s Center for Clinical Standards and Quality.

Crossover training and execution regarding Oct. 1 is especially important, she said.

“The two versions of the MDS (the current and post-Oct. 1 formats) are extremely different and are not interchangeable,” Berry said. “This is similar to October 2019. We will, therefore, handle the same way with the crossover rules.”

This means, Berry explained, that providers may not modify the target date of an assessment completed prior to Oct. 1 to a target date on or after Oct. 1, and vice versa. 

“For example, if a provider submitted an MDS assessment with a target date of Sept. 29, and determined that the target date should have been Oct. 2, you may not modify the MDS,” she noted. “You must code and complete a new MDS, which in this example, would be 1.18.11.” 

Information for this has been included in Chapter 5 of the RAI manual, she added.

August has seen a flurry of activity to get MDS-related training and informational materials in the hands of nursing home personnel. On Aug. 2, CMS posted key training materials, including recordings of training webinars and workshops. Last week, on successive days, the agency posted the final MDS 3.0 v1.18.11 users manual, a post-event QA document with responses to questions received through the agency’s training campaign, and the final MDS 3.0 item sets.

Providers can send questions to CMS information experts at SNF_LTCODF-L@cms.hhs.gov.

Clinicians should remain vigilant for missed diagnoses — and the potential for reduced Medicare payment rates as the switch takes place, industry experts said.

The change is part of an update to the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, version 1.18.11, which will become effective on Oct. 1. At that time, the Patient Health Questionnaire-9 (PHQ-9), a set of nine questions that help clinicians identify signs and symptoms of depression, will transition to the PHQ-2 to 9. This sets a gateway at which residents must affirm high-frequency mood problems in an initial set of two questions before clinicians can proceed to seven remaining questions.

Capturing signs and symptoms

It is on those remaining questions that providers often capture conditions or concerns for which they might be able to earn additional reimbursement. For some, the switch could mean a major hit to daily rates.

The change creates a push-pull effect at a time when the Centers for Medicare & Medicaid Services is encouraging SNFs to accept and treat residents who present with mental and behavioral health needs and substance abuse disorders, said Jessie McGill, RN, RAC-MT, curriculum development specialist at American Association of Post-Acute Care Nurses (APACN).

“When we have residents that have the signs and symptoms of mood disorder and possible depression, we want to be able to put interventions in place and we want to be able to reimburse for additional interventions that those residents need,” McGill said.

That’s where a somewhat contradictory force comes into play, she said.

“We have a really strong initiative from CMS with the federal Center for Excellence for Behavioral Health in Nursing Facilities and they’re providing a lot of information and resources for skilled nursing facilities. At the same time, we’re seeing this change,” she said, adding that this may hinder reimbursements when residents’ signs and symptoms are not severe enough.

The validity of both the PHQ-9, which has been in use since 2010 and the PHQ-2 are well-supported by research, McGill noted, but there is a risk that facility staff may simply stop at the PHQ-2 mood disorder screening, even though there are many reasons a resident with undiagnosed depression may not demonstrate symptoms in response to those two threshold questions, she said. 

Undertreatment risks

“I think one of the main concerns I have is that symptoms of depression can be under-recognized and then undertreated if we don’t have strong systems in our facility to recognize those,” McGill said.

The PHQ screenings require direct resident interviews, and in order to lower the risk for missed diagnoses during the transition, McGill recommends that SNF clinicians lean on good interviewing techniques when administering the PHQ-2 questions. 

“We need to use all the resources that CMS gives us,” for successful resident interviews, including Appendix D in the Resident Assessment Instrument (RAI) Manual, and CMS’ Video for Interviewing Vulnerable Residents, she said.

Clinicians may also wish to implement more, or other, screening tools that detect depression as needed, she added. They will be able to proceed with staff assessment of mood, for example, in cases where the resident cannot answer the two questions for reasons such as language barrier or noncompliance, she noted.

“There should always be assessment and observation and treatment above and beyond the MDS. And so, not letting the PHQ-2 limit what you can do for possible mood disorder, but really keep that open dialogue and close communication with the primary care physician,” she said. 

“There are other avenues that the facility can use to help identify the symptoms, especially if they feel that a resident may have slipped through the cracks with the PHQ-2,” she added.

Impact on reimbursement

The depression questionnaire transition may also impact scoring in the PDPM methodology that determines provider reimbursement, observers added. 

The screening tool transition will have “critical payment implications for the Nursing component of the Patient Driven Payment Model (PDPM),” Nelia Sakai Adaci, RNC, BSN, COO of The CHARTS Group in Lakewood, NJ, wrote in a blog post by the AAPACN.

Without completing the full interview in the PHQ-9 or the D0500 (Staff Assessment of Resident Mood (PHQ-9-OV)), “there is no chance to obtain a Total Severity Score that is 10 points or higher,” Sakai Adaci said.

“Without the 10-point Total Severity Score add-on for residents who would have gotten it using the full resident mood interview, that could reduce payment rates an average of $50 to $55 per resident per day for the Clinically Complex, Special Care Low, or Special Care High categories of the Nursing component,” she wrote.

“Even though there’s a lot of research that supports the PHQ-2 as a valid tool, that doesn’t mean we’re not going to see an impact on the reimbursement,” McGill said. 

“If the facility is starting to identify that they’re not getting reimbursed for residents in cases where the physician is agreeing with them that there is a mood disorder,” McGill added, “then that’s evidence that CMS may need to revisit how the PHQ-2 to 9 impacts PDPM reimbursements.”

CMS’s SNF MDS 3.0 RAI v1.18.11 Guidance Training Program is available for use as preparation for the Oct. 1 implementation of MDS 3.0 version 1.18.11.