Impact of Revised Guidance on MDS Coding:

Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
Ref: QSO-25-07-NH
Date: November 18, 2024
To: State Survey Agency Directors
From: Director, Quality, Safety & Oversight Group (QSOG)
Subject: Revised Long-Term Care (LTC) Surveyor Guidance

Significant Revisions to Enhance Quality and Oversight of the LTC Survey Process

Background:

The Centers for Medicare & Medicaid Services (CMS) is dedicated to enhancing the efficacy and efficiency of oversight and compliance programs in nursing homes. This initiative ensures our key responsibility—protecting residents’ health and safety—remains a priority. By employing a data-driven approach, CMS continually identifies improvement areas, implementing solutions that bolster care quality.

Our updates in health and safety address emerging trends in nationwide deficiency citations, ensuring our guidance aligns with current best practices.

Memorandum Summary:

Revised Surveyor Guidance:
CMS has released new guidance for nursing home surveyors on various topics, including:

• Admission, Transfer & Discharge
• Chemical Restraints/Unnecessary Psychotropic Medication
• Resident Assessment
• Quality of Life and Quality of Care
• Administration
• Quality Assurance Performance Improvement (QAPI)
• Infection Prevention and Control

Additionally, clarifications and technical corrections have been made throughout Appendix PP.

Associated Training and Resources:

• Training will be available upon release of this memorandum for both surveyors and providers.
• Advance copies of Critical Element Pathways and Appendix PP are attached.
• Revised Survey Resources will be posted on February 24, 2025.

Effective Date:
Surveyors will begin using this guidance on February 24, 2025. This timeframe allows ample preparation for both surveyors and nursing home providers.

Impact on MDS Coding:

Interdisciplinary Team (IDT) members responsible for MDS coding should note the direct impact of proper coding on survey deficiencies. Each Pathway identifies specific MDS sections, emphasizing the importance of timely assessments, particularly for Section GG, which is vital across all pathways. Other frequently referenced sections include: B, C, E, GG, H, I, J, K, L, N, O, P, Q.

Critical Element Pathways:

1. Pain Recognition and Management:
   • Review comprehensive and quarterly MDS sections: C, GG, J, K, L, N, O, P.
   • Assess care plans for goals, interventions, and effectiveness in pain management.
2. Respiratory Care:
   • Focus on comprehensive and quarterly MDS sections: C, GG, J, O.
   • Review care plans for treatment, care protocols, and emergency procedures.
3. Unnecessary Medications and Chemical Restraints:
   • Evaluate comprehensive and quarterly MDS sections for medication concerns.
   • Review medication regimens and care plans for high-risk individuals.
4. Hospitalization:
   • Examine MDS sections: B, C, E, GG, I, J, N, O.
   • Ensure care plans address symptom management and re-hospitalization prevention.
5. Accidents:
   • Focus on MDS sections: C, E, GG, H, J, N, O, P.
   • Observe and interview based on reviews to guide assessments.
6. Discharge:
   • Analyze MDS sections: A, C, GG, Q.
   • Consider care plans addressing diagnosis, rehabilitation, and discharge planning.

These revisions are designed to streamline care and improve precision in resident assessments, ultimately enhancing resident safety and care quality.

 

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The Following Pathway is especially important for MDS Coordinators to  Review:

CENTERS FOR MEDICARE & MEDICAID SERVICES

Resident Assessment Critical Element Pathway

Form CMS 20131 ( 02/2025 ) Page 1

Use this pathway for the following: a) when MDS concerns are noted but you are not using a care area pathway (i.e., the care area did not require

further investigation), or b) for concerns about the facility’s MDS data completion or submission activities.

Record Review:

MDS Accuracy Concerns:

o Does information in the MDS correspond with information

obtained during observations and interviews with the resident,

facility staff, and resident’s family or representative;

o Have appropriate health professionals assessed the resident? For

example, has the resident’s nutritional status been assessed by

someone who is knowledgeable in nutrition and capable of

assessing the resident;

o Based on your total review of the resident, is each portion of the

assessment accurate;

o Is there any evidence that an individual willfully and knowingly

coded MDS assessment information inaccurately or falsely;

o Is the quarterly review of the resident’s condition consistent with

information in the progress notes, plan of care, and your resident

observations and interviews; and

o Based on the facility documentation, did the facility adhere to the

guidelines for conducting a Resident Assessment (e.g.,

Significant Change in Status Assessment)?

(Note: Facility documentation is defined as information obtained

from the facility that includes resident care and issues that are

tracked such as an incident/accident report, clinical record,

wound log, transfer log, and ANY other type of documentation

that contains evidence of resident issues.)

Completion and Submission Concerns:

o Compare the alphabetical list of residents provided by the

facility against the resident listing in the software. Residents on

the alpha list and not in the software should be new admissions

(admitted in the last 30 days). If they are not new admissions,

there may be MDS submission issues (and that’s why they are

not in the software listing);

o Are the appropriate certifications in place, including the RN

Coordinator’s certification/signature of completion of an

assessment or Correction Request and the certification of

individual assessors of the accuracy and completion of

portion(s) of the assessment or tracking record completed or

corrected;

o Was the assessment completed and submitted timely? If not,

why not; and

o What is the assessment type that wasn’t completed or submitted

timely?

skillednursingsupport/maria.messina@skillednursingsupport.com/NOV 2024