The MDS is more than a data collection tool, says Sabrena McCarley, MBA-SL, OTR/L, CLIPP, RAC-CT, QCP, FAOTA, RAC-CTA, vice president of clinical reimbursement and regulatory affairs for Transitional Care Management in Lisle, IL. McCarley will present the April 23 session “From Data Collection to Impact: The MDS as a Starting Point, Not the Finish Line” at the AAPACN 2025 Conference, which will take place April 22 – 25 in Louisville, KY.
“The MDS is the story of the resident’s life,” explains McCarley. “With the revisions to the surveyor guidance in Appendix PP of the State Operations Manual that are currently slated for implementation in the survey process on March 24, 2025, the Centers for Medicare & Medicaid Services (CMS) is driving home just how important that story is. CMS is more clearly tying MDS accuracy together with the care area assessments (CAAs), the care plan, and the care that each resident actually receives on the floor.”
Note: Find the draft Appendix PP revisions in the Jan. 15, 2025 Quality, Safety, and Oversight (QSO) memo QSO-25-12-NH. This memo replaces the Nov. 18, 2024 memo QSO-25-07-NH.
The MDS doesn’t occur in isolation, continues McCarley. “For example, if you capture schizophrenia in MDS item I6000 for a resident who previously didn’t have that diagnosis, there has to be supporting documentation in the medical record that shows how that diagnosis came about.”
In addition, the CAAs, the care plan, and the documentation of the care being provided to that resident need to flow from that coded diagnosis, says McCarley. “These components of the medical record should collectively answer the question, ‘How has the interdisciplinary team (IDT) collaborated to provide this resident with individualized care that meets the requirements in the revised Appendix PP?’ But, it all starts with MDS accuracy.”
The following AAPACN graphic illustrates the multiple impact levels of MDS accuracy:
Note: For more information, review the AAPACN Trickle-Down Effect tool.
This alignment around MDS accuracy gives the nurse assessment coordinator (NAC) an opportunity to step up and own a vital role driving compliance, suggests McCarley. “You can serve as your organization’s ‘guardrails,’ using an accurate MDS to provide checks and balances that safeguard your facility’s regulatory health in addition to its reimbursement. For example, you can alert the interdisciplinary team if a resident’s new diagnosis of schizophrenia lacks adequate supporting documentation in the medical record—and you also can promote IDT collaboration that gets everyone on the same page regarding what care and services that resident needs.”
Steps that the NAC can take to work with the director of nursing services (DNS) and the rest of the IDT to improve MDS accuracy and create positive impacts for the residents and the facility include the following, according to McCarley:
Take an honest look at the current MDS picture
“It’s important to review your basic MDS processes and identify, for example, everyone’s roles and responsibilities, current workflows, and current meetings,” says McCarley. “However, you want to do this with a fresh set of eyes and be really honest.”
Two key factors should be considered in this assessment of MDS processes:
- Reliability. The key question is not whether these processes exist in theory but whether they consistently work well in practice, explains McCarley. “You must have reliable processes in place. For example, a regular meeting should have a set time, place, and communication process, as well as identified participants who know exactly what’s expected of them. And if this meeting is reliable, it will occur regardless of anything else that is happening—even if state surveyors have walked in the door. Executive leadership has to be ready to enforce staff compliance with their roles and responsibilities toward the MDS.”
- Backup support. “Do you have true processes in place and working effectively, or do your processes rely on a single person with no backup plan?” asks McCarley. “A person is not a process, and a process is not a person. As soon as you rely solely on one person—and you don’t have a backup plan in place—those processes will fail. So when you are talking about the MDS, your processes must truly be interdisciplinary, and each team member has to understand their role. Everything can’t rely just on the NAC.” Note: To assist the NAC’s backup, find the MDS Daily Startup for the NAC Backup tool from AAPACN.
Hold a weekly interdisciplinary meeting
This meeting goes by many different names, notes McCarley. “Some facilities call it the weekly MDS meeting, Medicare meeting, or even clinical meeting. At my organization, we call it the weekly care coordination meeting.”
Whatever it is called, the goal of this meeting should be to make sure the appropriate support systems are in place regardless of the resident’s payer source (e.g., fee-for-service Medicare Part A, Medicare Advantage, or Medicaid), says McCarley. “You also don’t want to focus only on residents who are in an assessment reference date (ARD) window.”
For example, skilled residents who are not in an ARD window still need daily documentation to support their continued skilled stay, says McCarley. “This meeting is an opportunity to check on that supporting documentation, as well as to ensure that their physician certifications are on schedule and that their physician orders are timely.”
The meeting needs to be interdisciplinary, adds McCarley. “Everyone who touches the MDS should participate so that you can double-check that they are all aware of what they need to do and what time frame they have to complete their responsibilities.”
Consistently educate staff to obtain strong data
“Your focus should be on ensuring that the MDS contains accurate and inclusive data,” says McCarley. “What is important about that is training. The individuals who are inputting data need to have education and competencies. You should have a system in place to train new staff and backup staff. This system should include competency checks and annual trainings to refresh staff knowledge.”
MDS education should address the “why” behind the coding requirements in addition to the actual coding instructions, recommends McCarley. “For example, activities staff may not know why they have to code section F (Preferences for Customary Routine and Activities). They may think, ‘Why does it matter if everyone understands the resident’s daily preferences and what activities they like to do?’ So, you want to make sure that activities staff—and any other IDT members who touch the MDS—understand that their contribution to the MDS is just as important as, for example, nursing’s contribution. Everyone on the IDT plays a vital role.”
In addition, IDT members who code MDS items that are based on the resident’s voice should be educated on how to ask the questions, says McCarley. “These assessors need to avoid making assumptions so that they get the true picture of how the resident is feeling or what the resident is saying. If staff members who complete resident interviews don’t understand that piece of it, the MDS may include inaccurate information, which could lead to an inaccurate care plan and even survey issues.”
‘Cite your sources’ for staff education
“One way to achieve buy-in with staff is to take them back to the source documents during education,” suggests McCarley. “When CMS makes changes, staff can easily become overwhelmed, and they may respond by deciding that you as the NAC are creating those requirements because you want things done a certain way. So, you need to cite your sources when you educate staff.”
Taking staff back to the source documents also allows the NAC to leverage available resources, says McCarley. “Education should be rooted in the most recent versions of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual), Appendix PP, and the MDS trainings that CMS has posted at the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Training website.”
Strengthen IDT collaboration
IDT collaboration is an important component of expanding MDS impacts, says McCarley. “Within that IDT collaboration, there must be a process in place for communicating information all the way down to frontline staff—beyond department heads—when an issue is identified during resident interviews or data collection.”
McCarley gives the example of MDS item A1110 (Language). “If the resident’s preferred language is perhaps Farsi or Spanish, that information needs to be conveyed to the rest of the IDT, especially if they specifically request an interpreter for discussing healthcare information,” she explains. “If that doesn’t occur, then you are not doing right by that resident, and you may not be in compliance.”
Strong IDT communication also will help the team deliver care based on care plans that are truly comprehensive, culturally competent, and individualized, says McCarley. “The MDS captures so much information—from active diagnoses to the resident’s voice—that you can use to individualize the resident’s care modeling the guidance in the revised Appendix PP. But, you need to have communication processes that ensure the entire team is working collaboratively to make decisions based on the same information.”
The following AAPACN graphic illustrates this need:
What to expect at the conference session
“At my upcoming conference session, we will delve into strategies for providing resident-centered care that is MDS-driven,” says McCarley. “For example, we will look at how to train staff and provide you with some practical tools and resources.”
Attendees will also go on a deep dive into some MDS components that impact all IDT members, such as the pain assessment items and the social determinants of health (SDOH) items, says McCarley. “We will look at these items that may not go beyond data collection in some nursing homes and demonstrate how IDT members can work together to create care plan interventions that are individualized to each resident—and have greater impact across all departments.”
In addition, the session will focus on outcomes, says McCarley. “We will examine how to take that MDS data and utilize it as more than data point. Attendees should leave the session ready to use MDS data to launch conversations about individualized plans of care.”
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