CMS Changes to the Minimum Data Set October 2023 Implementation Challenges

Long-term care providers spent much of the past year preparing for the October 1, 2023, changes to the Minimum Data Set (MDS).  Staff training, software changes, and communications with stakeholders (including, but not limited to, residents, families, and referral partners) were just the tip of the iceberg with implementation.  Providers have experienced many technical issues with submitting data to Centers for Medicare & Medicaid Services (CMS) with uncertainties about the impact on Care Compare data which will start to be released in April 2024.  Proactive measures such as continuing education of staff and ongoing documentation audits will ensure compliance with the new requirements.


CMS’s Long-Term Care Facility Resident Assessment Instrument (RAI) v1.18.1 “helps nursing home staff gather definitive information on a resident’s strengths and needs, which must be addressed in an individualized care plan.”  The RAI is comprised of the MDS, the Care Area Assessment Process, and Utilization Guidelines.  The MDS is a “core set of screening, clinical, and functional status data elements… which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid.”  These data elements standardize communication within and between nursing homes and outside agencies.  This assessment is required for Medicare reimbursement and compliance, State Medicaid reimbursement, clinical assessment processes, state surveys, and quality of care monitoring and public reporting.

The goals of CMS in the MDS 3.0 revision included advancing assessment measures, increasing the clinical relevance of data elements, improving the accuracy and validity of the assessment instrument, increasing user satisfaction, and increasing the resident’s voice.

Overview of Changes

CMS posted a draft of the updated MDS specifications in September 2022, and the changes were considered “enormous” by long-term care professionals.  The most significant change was the replacement of MDS Section G: Functional Status with MDS Section GG: Functional Abilities and Goals.  This section has an impact on the Nursing Home Five Star Rating system as published on Care Compare.  The four quality measures (QM) impacted on Care Compare are:

  • Percent of Residents Who Made Improvements in Function (short stay) [reporting on Care Compare starting October 2024].
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (long stay) [reporting on Care Compare starting January 2025].
  • Percent of Residents Whose Ability to Move Independently Worsened (long stay) [reporting on Care Compare starting January 2025].
  • Percent of High-Risk Residents with Pressure Ulcers (long stay) [reporting on Care Compare starting January 2025].

Industry experts note that in addition to the quality reporting, the changes from G to GG will also have a huge impact on reimbursement, care planning, and staffing metrics.  The removal of Section G changes the staffing calculations for reporting on Care Compare.  The Staffing Rating will now be calculated using the SNF payment Patient-Driven Payment Model (PDPM).  Staffing rating reporting will begin in July 2024.  CMS is also instituting a penalty for providers that fail to submit or submit erroneous staffing data so that they will receive the lowest score possible for corresponding staffing turnover measures.

Other sections which changed to require more detail and additional data elements include:

  • Collection of data on Social Determinants of Health (SDOH) which includes race, ethnicity, transportation barriers, and health literacy (Section A)
  • Resident mood assessments, including social isolation (Section D)
  • Pain assessments (Section J)
  • Time frame of interventions related to nutrition and hydration (Section K)
  • High-risk drug classes use and indication significantly expanded to include antipsychotic use and drug regimen review. The evaluation must include if the resident received the medication as well as documentation by a physician for the clinical reason for a specific medication (Section N)
  • Time frame and intervention details of special treatments, procedures, and programs (Section O)

Excelas Compliance Regulatory Services

Find out more information on how we can help with Internal Audits:

Training and Documentation

Section GG requires involvement of the interdisciplinary team (IDT) to appropriately document a resident’s “usual performance” on self-care and mobility items.  Further, a qualified clinician is required to complete the assessment.  The RAI Manual states that the assessment of “the resident’s self-care performance is based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the assessment period.  CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the assessment period.”  Facilities must develop their own systems to complete this requirement as CMS does not mandate specific processes.

Providers must ensure that all staff involved in the assessment are trained to document in much more detail in the resident’s medical record to comply with these requirements.  This may be a change in process for many facilities.  In addition, it is recommended that providers maintain a record of internal changes regarding training and documentation practices.  This record will be useful in the survey process as well as for internal training evaluations.

Action steps

Training:  Long-term care providers must develop programs for continual interdisciplinary staff training on MDS and quality measures and maintain documentation of all staff training conducted in accordance with CMS communications.  CMS has published training videos to support providers in training programs.

Documentation:  Administrators must ensure documentation processes are consistent throughout the organization.  It is recommended that internal audits are conducted in areas including, but not limited to:

  • Admission criteria and admission primary diagnosis
  • Certification documents completed.
  • Treatment records, orders, and interventions for resident specific plans

It is critical that all data is documented in the resident’s medical record, including resident specific discussions held in meetings or family conferences.

Communication:  Providers must be transparent with all stakeholders, including residents, families, referral partners, payers, and staff, concerning the potential for changes in a facility’s Five Star Ratings due to new reporting requirements.  It is important to be proactive in these communications so there are no surprises when the ratings are published under the new system.

CMS has already issued notification of changes which will go into effect on October 1, 2024.  While these updates are not as sweeping as those effective October of 2023, it underscores the need for providers to be proactive in training, documentation, and coding practices.  Coupled with the current environment of high employee turnover, these areas become even more challenging as all levels of staff must be aware of the importance of recording all interventions with residents to comply with the MDS changes.  Excelas’ medical analysts have extensive experience in reviewing medical records unique to long-term care settings.  Our medical record audits can assist administrators in developing documentation procedures, preparing for surveys, and assessing staff training needs.  Contact us today to discuss your medical information management requirements.

Post Tags: