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5 Major MDS Changes and How to Operationalize What’s Coming October 1, 2023

Significant changes are coming with the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, version 1.18.11, which will become effective October 1, 2023. Facilities that prepare ahead of time will integrate the updates into their processes more smoothly and move ahead with confidence that their team can ensure MDS accuracy and limit revenue loss.

“There’s going to be multiple opportunities for operational roles in skilled nursing facilities to take a look at the way they are doing things now, the data they are collecting now, and the systems they are using to collect the data now and see what is going to need to change come October 1,” says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA, president/CEO of Celtic Consulting, LLC and founder and president of MDSRescue, LLC in Torrington, CT.

McCarthy will help nurse leaders, NACs, and IDT members strategize how to effectively operationalize the MDS changes coming this October during her session, “Operationalizing Oct. 1, 2023, MDS Changes” at the April 19 – 21 AAPACN 2023 Conference in Las Vegas, NV. This session will address at least 15 significant changes to the MDS 3.0, version 1.18.11, examine interdisciplinary processes required to capture the new MDS items, and outline the potential impact these MDS changes will have on Five-Star ratings and Quality Measures.

Five of the major changes McCarthy plans to cover during her session include:

  1. Removal of section G and transition to GG

“The merging of sections G (Functional Status) and GG (Functional Abilities and Goals) will come with significant changes to the activities of daily living (ADLs) and tracking for functional or reporting purposes,” says McCarthy. “In the 90s, we developed ADL flow sheets that the CNAs completed. Now, when section G goes away from the MDS and section GG replaces section G, these flow sheets are going to be nonfunctional or will no longer align with the MDS when we move over to version 1.18.11.”

“We haven’t generally relied on CNA documentation for section GG since we got it in 2016, so it will be relatively new for the CNAs,” adds McCarthy. “If you decide CNAs are going to collect section GG data and then have it assessed by the NAC—you are going to need training. There’s going to be a learning curve, and from a Medicaid case-mix perspective, it may impact revenue.”

“I think the same thing is going to happen for the Care Area Assessments (CAAs) of the MDS,” notes McCarthy. “Many of the CAAs are determined or triggered by section G. When that goes away, what will the CAAs be triggered by now? How will we do an Activities of Daily Living CAA? Or will there be a potential Functional Abilities CAA? What about pressure ulcers and falls? How will all the CAAs be impacted now that we no longer have a section G that’s looking at activities of daily living, but we have section GG that’s looking at a resident’s function score or their functional abilities?”

McCarthy also notes how the removal of section G could affect Five-Star: “A lot of the Quality Measures in the Five-Star program have a part of section G in the measure itself, or section G information risk-adjusts the resident for certain measures.”

MDS 3.0 Quality Measures that Currently Use Section G ADLs
• Percent of Residents Who Make Improvement in Function (SS)
• Percent of High-Risk Residents with Pressure Ulcers (LS)
• Percent of Low-Risk Residents Who Lose Control of Their Bowel or Bladder (LS)
• Percent of Residents Whose Need for Help with ADLs has Increased (LS)
• Percent of Residents Whose Ability to Move Independently Worsened (LS)

Claims-Based Measures that Currently Use Section G ADLs
• Short-Stay Residents Who Were Re-hospitalized after a Nursing Home Admission
• Number of Hospitalizations per 1,000 Long-Stay Resident Days
• Short-Stay Residents Who Have had an Outpatient Emergency Department Visit
• Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days

“Not all of section G is going to go away,” reminds McCarthy. “There are some items that the Centers for Medicare & Medicaid Services (CMS) is keeping that are going to go into section GG. As CMS crosswalks from section GG now instead of G,” she emphasizes, “there could be changes to Five-Star reporting.”

As CMS applies different data sources to calculate the Quality Measures, facilities could see impacts to their Five-Star ratings. Facility leaders therefore need to watch closely to see how CMS will adjust these calculations, stresses McCarthy.

2. Sections A, B, D, Social determinants of health – new data capture and increased workload

“There’s going to be a significant number of social determinants of health that will be added into the MDS—questions regarding ethnicity, race, language (resident’s preferred language and desire for an interpreter), transportation, health literacy, and social isolation,” says McCarthy. “To determine what the impact is for any specific social determinant, you need to collect the information on which residents have those social determinants and look at their outcomes.”

“To collect the information on who is impacted by social determinants of health, CMS is adding those areas into the new MDS,” says McCarthy. “It’s not an area of data that is collected currently. Facilities are going to need to think about: Who is going to collect it? How are they going to collect it? When are they going to collect it? And where will it be stored when they do collect it so that others can retrieve it if they are looking to complete any MDS sections with this additional information?”

“The social determinants of health will be a significant change, particularly for social services, who will probably be tasked with collecting this information,” says McCarthy. Nurse leaders need to understand the burden of data collection being added and how the new task will impact their staff’s workload—from the increased documentation needs and care planning for the social determinants of health, to the discharge planning process.

3. Section N, indication of use for medications, schizophrenia diagnoses, and survey and Five-Star ramifications

“The change in section N (Medications)—where CMS is looking at not just whether the resident is taking a medication but whether there is an indication of use for that medication—will have an impact,” says McCarthy. “I think there are not only Quality components that could be impacted by that, but I also think that it could be a survey issue. If we are giving residents medications and they don’t have indications for use—they always should—but if surveyors see that a facility is giving medications that don’t have an indication for use, it would be something they would look at when they come into the building.”

“Particularly, I think antipsychotic medications are going to be a focus for CMS,” warns McCarthy. “CMS issued changes to surveyor guidance in the June 29, 2022, Quality, Safety, & Oversight (QSO) memo QSO-22-19-NH and also stated they will be conducting offsite audits to check for evidence of documentation, assessment, and MDS coding accuracy of residents with a diagnosis of schizophrenia in QSO-23-05-NH, issued January 18, 2023. If they find when they review the medical record that the diagnosis that the facility has for schizophrenia doesn’t have the supporting documentation to back up that an assessment was done of that specific diagnosis, then it needs to be removed, or we are not allowed to utilize that diagnosis in the MDS, per the instructions in the MDS 3.0 RAI User’s Manual (v1.17.1R) Errata (v2).

“Therefore, it’s going to impact the coding of section N when you are looking at antipsychotics,” says McCarthy. “For example, a resident has a diagnosis of schizophrenia: formerly, facilities had been documenting that they were taking an antipsychotic and that we thought they had an indication for use—schizophrenia. Now, when we look at the documentation, if it’s no longer supported because CMS is looking for specific supporting diagnostic information, we may have to report that that medication no longer has an indication for use, because the diagnosis that we thought we had approved can no longer be approved in the MDS. CMS asked us to do our own self-audit and make modifications to the MDS when that is the case.”

“The ability to code or not code schizophrenia by having the supportive documentation will impact Quality Measures,” warns McCarthy. “If you are found to have a diagnosis of schizophrenia that does not have supportive documentation, then CMS will drop your star rating to a one star for Quality Measures for six months. You lose a star from both your long-term and your short-term measures, and you lose an overall rating star.”

To emphasize the impact this may have on revenue, McCarthy elaborates, “So, your Quality Measures are down to a one star for six months—that is a long period of time. If you are just barely hanging on to three stars for your overall star rating, and then your Quality Measures go down to a one star, and your facility is now a two star overall, you may no longer be welcome in some of the preferred provider networks because you are a below-three-star-rated facility. So, you could lose referrals and revenue generated from belonging to those networks.”

“Section N and the indication of use will also impact the Nursing Home Quality Indicators (NHQI) program,” adds McCarthy. “A facility’s antipsychotic measure will be suppressed for twelve months if they don’t have the supportive documentation for the schizophrenia diagnosis.”

4. Section A and the Optional State Assessment (removed or not removed?)

“CMS didn’t release the Optional State Assessment (OSA), currently item A0300 in section A of the MDS, with the latest draft MDS 3.0 Item Set v.1.17.2; however, it is possible they will add it back in before the final draft,” says McCarthy. “But even if CMS does release it, the OBRA assessment will not have both the RUG information and the PDPM information. Facilities are collecting PDPM information for OBRA now, per CMS, but if your state still wants RUG information for Medicaid case-mix payment, there’s no other option but to do two separate assessments. This is going to increase workload, at a time when we are already short staffed.”

“Facilities will need time to complete the additional sections of the MDS v1.18.11, but they also need to factor in time to complete the OSA, or this additional assessment, as well,” says McCarthy. “Facilities need to look at what the workload will be for their organization. If they are going to need to do two separate MDSs every quarter for every patient that they have on caseload, what is the number of Medicaid qualifiers that they have in the building? If they have 100 patients in the building, and 70 patients are Medicaid, that’s going to add a significant amount of time to the NAC who is already doing the OBRA assessment.”

To help ensure the NAC has time to complete these assessments, McCarthy suggests, “Facilities need to look at their census, their processes, and look at what else they have their NAC doing. What is the NAC doing in the building that they can take away and give to someone else? Is she passing trays at lunchtime, and can that task go to someone else? Is she answering the phone for the receptionist when she goes on her break? Is she covering a unit at a certain period of time? Are there other places where staff other than the NAC can perform some of the duties and keep the NAC completing MDS-directed duties?”

“Because the NAC’s job is such a specialized position, you need that specially trained person in the seat and completing all the components that impact not only the reimbursement, but also the quality rating system and compliance,” says McCarthy. “If you put another nurse in that chair who isn’t a NAC and who hasn’t done that job, they won’t understand the deadlines, the signature requirements, and the nuances of the MDS process. So, keep the NAC in the chair, and send another nurse, or another staff member if it doesn’t need to be a nurse, to perform the other duties. Look at the NAC’s job description, look at the duties that the person is performing, and make sure you are giving them enough time to be successful in their position.”

5. Sections A, B, and D and the transfer of health information SNF QRP measures

“CMS is going to add several items in section A (A2121, A2122, A2123, and A2124) that are going to ask us questions about, at discharge, if and how we transferred health information to the resident (or the responsible party), as well as the subsequent provider, which is the healthcare entity that your resident will be going to next,” says McCarthy. “Sometimes this subsequent provider is home with home health, an assisted living facility, a boarding home, or an intermediate care facility. Depending on where the resident goes, we will give this information to that next provider so that they are aware of certain health information regarding the resident we’ll be sending to them.”

“CMS is looking for us to transfer a reconciled medication list to the resident and/or the subsequent provider if they are using one post-discharge,” says McCarthy. “These are new items to the MDS, but it’s also a new process for the facility. Facility staff have to think about: Who will do the data collection? Who will be reporting and transferring this health information back to the family? What format will we use? We have the option of utilizing electronic health records, a health information exchange, a verbal method, a paper-based method, or others, such as texting, email, or CDs; how we get the information to the resident needs to be determined.”

“However, before we give that resident the information, it’s going to be in the facility’s best interest that we look at how the resident communicates,” notes McCarthy. “If the resident has an issue with health literacy, and you’re giving them a piece of paper to read and expecting them to understand what they are reading, that will be an issue. Not all residents can receive and understand information in the same way.”

“To understand how the resident will best receive information, we have to look at section B (Hearing, Speech, Vision) and section D (Mood), including the area of depression,” suggests McCarthy. “I think we need to look at how the patient learns new information before we jump to the conclusion that exchanging a piece of paper will be fine.”

McCarthy offers an example of a similar process on which facilities can model their response. “Facilities should look at the way we do the baseline care plan now. That was a new process that we had to implement in the facility to make sure that we got the resident or responsible party a copy of an interpretation or summary of the baseline care plan. I think the transfer of health information will be similar to this process.”

Collaborate across roles and departments

How can the NAC best collaborate with others for success? “The NAC is likely going to be the person who has to educate the team,” says McCarthy. The NAC is “generally the person with the most knowledge about the changes—they are going to come to the AAPACN conference and attend many different sessions about the changes. I think that starts the process.”

That process will require nurse leaders to confront the coming MDS revisions and their impacts, too. “The director of nursing services (DNS) needs to understand what changes that the nursing department and CNA staff will be facing,” says McCarthy. “They need to think about data collection processes, where that data is housed, as well as potentially making changes on the data collection tools that they use.”

“The interdisciplinary team (IDT) can help by all being prepared, attending the education, and providing input into any changes that happen within their departments and data collection tools,” adds McCarthy. “And then, they need to work as a team to make sure the data is collected and entered timely so the facility can maintain compliance.”

Implementation success – preparation of system processes, education, and lead time

“Preparation is going to be the key to success here,” says McCarthy. “You don’t want to wait until the end of the summer to decide what you are going to do about data collection. You want enough lead time so that you can roll out a system, determine whether it works or not, and have enough time to be able to make corrections and reevaluate whether that’s the way that you want to proceed or not. I think that’s going to be a key factor – having enough lead time to make corrections to the process that you will be using.”

“The other piece about the lead time is that you need to educate the team not just on what they are collecting, but why they are collecting the information,” says McCarthy. “You want to explain how the data is going to be used so that staff understand CMS’s intent for collecting this information. People in general like to know the answer to ‘Why are we doing this?’”

“I think that education—as well as the system process changes of who, how, when, and where that need to be determined for data collection—will probably be two of the biggest pieces for facilities to be successful,” says McCarthy.


“Understanding the impact of the culmination of multiple changes is going to be the difficult part for facilities,” says McCarthy. “If we are ready for section G to be replaced with GG, we trained all of the CNAs and want them to do the data collection, and the NAC is involved, but we didn’t think about the impact to our Five-Star, then we could be in trouble.”

“There are going to be a lot of sessions at the AAPACN Conference that will talk about the changes, the intent, and how to code the MDS. My session is a little bit different, because it’s going to be looking at operationally, how do we make these changes with the rest of the staff that’s in the building? This session comes more from an operations perspective, so corporate nurses, administrators, directors of nursing services, directors of operations, roles that have responsibility for departments other than nursing will also have some prep work that they’ll need to do for these changes. They need to understand what those are so that they factor in enough time to make the changes and ensure that the system that they put in place is functioning effectively before October 1.”

For a deeper dive into this topic, join McCarthy on Thursday, April 20, 10 – 11:30 am PT at the AAPACN 2023 Conference in Las Vegas. To find more information on McCarthy’s session on the conference schedule and make plans to attend, download the conference brochure here.

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