Vital Compliance Insights
Healthcare regulatory compliance resource
Vital Compliance Insights
Navigating MDS Accuracy in Long-Term Care
Accurate MDS completion has become a regulatory lightning rod as the OIG and CMS intensify their scrutiny of long-term care documentation. This shift isn't merely procedural—it signals a comprehensive effort to identify potential fraud and ensure residents receive appropriate care based on accurate assessments.
The recent OIG work plan specifically targets resident falls resulting in major injuries, with investigators cross-referencing hospital claims against facility MDS documentation. When surveyors identify three or more examples of inaccurate MDS completion—now defined as a "pattern"—these findings may trigger referrals to OIG regional offices for fraud investigations. Beyond falls, diagnoses like schizophrenia are receiving particular attention, as inaccurate coding can significantly impact care approaches and medication regimens.
For facility leaders, this heightened scrutiny demands a systematic response. Start by ensuring your MDS coordinators have proper certification and education, then verify that all staff contributing documentation understand what they're recording. Implement regular audits to catch discrepancies before they become patterns, and foster interdisciplinary communication so different departments use consistent language and observations. Your compliance committee should conduct risk assessments, particularly for resident populations with high fall risks or complex diagnoses, and report findings transparently during QAPI meetings.
The stakes couldn't be higher—inaccurate MDS completion affects not just regulatory compliance but also reimbursement rates, Five-Star ratings, and most importantly, resident care quality. By strengthening your documentation systems now, you'll protect both your residents and your organization from the consequences of this unprecedented regulatory focus. Need guidance navigating these changes? Reach out to Verity Consulting for specialized assistance with your healthcare compliance challenges.
Hello, I will be your host. My name is Deanna Fye. I am a registered nurse and healthcare analyst. Let's get started.
Speaker 2:The views or opinions expressed in this podcast are for informational purposes only, not intended as legal or professional advice, and may not represent those of Verity Consulting. Although we make strong efforts to make sure our information is current at the time the podcast episode was recorded, verity Consulting cannot guarantee that all information in this podcast is always complete. All information in this podcast is subject to change without further notice.
Speaker 1:Welcome to Vital Compliance Insights In this episode. Today I'll talk about MDS accuracy, the minimum data set tool used to assess residents living in long-term care facilities. In prior episodes I did talk about the OIG Office of Inspector General and CMS Center for Medicare and Medicaid Services interest in really focusing a lot more on MDS accuracy and the implications related to that. So I'll go over some of that today in this episode. First of all, let me just go over the background. Well, the OIG has spoken to this matter, this issue, in prior years. They've made some modifications. Last March 2024, there was a work plan put out that really spoke to OIG's interest in looking at resident falls in facilities. That resulted issues, but certainly related to all of that is the correct resident assessment. Accurate resident assessment, accurate completion of the minimum data set tool. That then leads us downstream, as you know, to a plan of care that will meet the residents' needs. Also in this background review CMS. They have also been looking at MDS accuracy since, well, forever, since when I was a surveyor many years ago as a federal monitor. This is not new years ago as a federal monitor. This is not new. In 2025, there is a big push by CMS to look at F-641. F-641 is the regulatory requirement looking at the completion of the MDS in an accurate manner. So the surveyors have been really given some clear marching tools, marching orders, rather to look at accurate MDS assessments. So they've been sent out there. They're looking for patterns. They, being the surveyors, are looking for patterns and a pattern, just to be clear, is more than three examples of an inaccurate MDS completion. The surveyors are going to use the resident assessment critical element pathway. I've mentioned that in some prior episodes too, so just to kind of refresh you there a little bit, just to give you a little bit of background.
Speaker 1:The other Part of this episode I'll talk about will be cause and effect. What does it mean when we have inaccurate MDS coding? Okay, I'll talk about the poor care that could result increased scrutiny in inaccuracies, certainly fraud in incorrect coding of the MDS and how this all goes to five-star rating reviews as well. Now I'll just make a note really quick here the CMS has engaged with service recovery auditors to conduct audits to look for evidence of incorrect billing coding and billing for evidence of incorrect billing coding and billing. It related to overpayments and claims that have been made for resident care and throughout the different regions of the country. These companies are out at work looking and conducting different levels of MDS accuracy reviews and certainly the reimbursement. So that's ongoing and what I'll do is I'll upload on the Verity team website an article from Skilled Nursing newsletter and in that I'm sorry, skilled Nursing News, I'll upload the article that talks about the survey changes related to coding mistakes. So I'll add that. So look for that on the Verity team website.
Speaker 1:All right, so I'll cover some of the background. I'll go over the cause and effect of what does it matter if MDS coding occurs, and then, finally, I'll kind of wrap it up just by emphasizing what is a facility and organization going to do, what are the approaches we can take to try to mitigate, to deal with this greater scrutiny, to make sure things are in place, working correctly? So just to give you kind of an overview, I'll touch on, hopefully, those three main features of today's episode. Okay, well, let's start digging in a little bit Now. This is where I want to just emphasize that OIG has put a great deal of focus on falls, resident falls resulting in major injury, resident falls resulting in major injury and those residents that then would be sent to the hospital for care of some form or another. They're looking at the frequency, the occurrences. They're going to be really looking at this and doing some further inquiry and perhaps directing the CMS to also look at some of those. What's happening at this facility? Why are so many residents falling? Now, we do know residents fall, we understand this, but what's going on with major injuries? So it's going to ask a host of questions as to what's going on. Oig is also looking at diagnoses, particularly schizophrenia, and I've talked about that in some prior episodes as well Schizophrenia as a diagnosis. So when a resident is coded as schizophrenic, is that accurate? Is that correct? So that would be another example of what the OIG has been very interested in looking at and consequently, there will be some review there.
Speaker 1:I just wanted to go back to something I mentioned. The March 2024 work plan for the OIG talks about nursing facility-focused areas related to falls and they did publish assessing the accuracy of nursing home falls reporting in the MDS assessments. So it hasn't come out yet in 2025, but they will be providing nursing facility level data that will report the falls with major injury. So that information will come out. But I just did another check today and I have not seen that come out yet. So a report will come out talking about the characteristics of those nursing homes that did not report the falls and, again, did not accurately complete the MDS. Again, it hasn't come out yet. So OIG will be looking at Medicare claims data for hospitalizations related to major injury, falls with major injury, and you know they're going to want to look at the MDS data to find out if the assessments are accurately completed. And then, if there was a fall, a major injury fall, was it reported and if it wasn't reported, why?
Speaker 1:So there's going to be a lot of focus here for the OIG. I think you're getting the picture pretty clearly here, all right, and we're going to get to the part of this episode that will talk about what can we do. Okay, if you're not already doing it, things that we'll want to do. Always looked at the accuracy of an MDS completion, okay, and that will be. It's going to be really important to make sure the timing of the assessment is correct. The documentation to support it must be there, in place, retrievable, verified and like.
Speaker 1:I want to circle back to that recovery audit contractor activity. They're going to look to say well, you know there's different levels of noncompliance here. There's no documentation or the documentation is confusing, it's unclear. So it's going to be really, really important and I'll talk about what can a facility organization do? And I'll just reiterate again if a surveyor identifies three or more of the same inaccurate assessment pattern, that will be can be rather reported to the Office of Inspector General regional office for further review to determine if there's a pattern going on leading to fraud. So that's very different now, very different focus really has made it very clear that their surveyors are going to be out well trained, well you know, prepared to conduct these reviews where they're looking at MDS accuracy.
Speaker 1:It's not just the MDS itself is it filled out accurately but is the resident assessment accurate? Has it been completed, based on the data that was provided in that look back period of whatever it is to say. This is accurate information based on what we know and what we have, and I can find the documentation to support that. The documentation doesn't always have to be by the nurse, by the CNA, but it has to be by the nurse, the CNA and interdisciplinary team members. So we need to see the documentation in place. So when the surveyors are coming in, they're going to be looking for that.
Speaker 1:Okay, I've talked about in prior episodes about the importance of the interdisciplinary team coming together, talking with one another to make sure we're all on the same page, and there's so many different ways that that can occur, and I'll talk a little bit about that too. So we know that the CMS is asking us, asking surveyors, to be very prepared and focused. The CMS is still going to ask that F-642 be looked at to make sure there's compliance with the MDS certification, that it's completed by a registered nurse. And as a registered nurse myself, it's incumbent upon me and I'm required by license to conduct a comprehensive assessment and I'm going to sign that this assessment is correct, assuming that I know everyone has provided and given me the most accurate information. I've verified that it's accurate and then I can therefore certify that. So in the SOM, f642 is certainly going to come into play as well, not just F641, but certainly that'll be something that CMS surveyors will be looking at and the critical element pathway will be a tool to help guide them. So definitely, facilities are going to want to get familiar with looking at the critical element pathway under resident assessment.
Speaker 1:Okay, all right. So let's switch some gears here. What is a facility going to do now that we know all of this, or it's refreshed us to know all of this. Well, first of all, my background is in compliance and, as a former external monitor conducting corporate integrity agreements on behalf of the Office of Inspector General, I can tell you I look for systems.
Speaker 1:Is there evidence of a system? Whatever the issue is, in this case we're going to talk about the minimum data set Accuracy. Is there a system in place to make sure that the right people are completing it? And when I say the right people, registered nurse is the registered nurse educated, certified, to complete it accurately, to certify its accuracy? Do we have some of those really basic things in place? Do we have a backup plan? What if our resident assessment coordinator is not available for some reason or another? Do we have a system in place? So I always look for systems. What is the system? Who does what? When? Is it something that's reproducible, that functions? Has systems in place for when failures may occur, because failures do occur?
Speaker 1:Okay, are the persons responsible for providing the and recording the documentation that the MDS Resident Assessment Coordinator nurse will retrieve? Is that accurate? Have they been educated to report information accurately? Okay, have they been educated? All right. Have we done any kinds of audits to make sure? So if I have a new nursing assistant, I'm training this individual to fill out ADL activities of daily living data. Do they understand what it is there to record? Do they have an understanding? I'm going to do an audit. Yes, this new CNA that I just oriented and trained does know and does understand what I'm asking for when we're talking about, let's say, section GG, residence, functional status, any kind of documentation related to transfers, mobilities.
Speaker 1:Okay, so I'll get into a couple of examples in a minute on that. So again, what does a facility do Well? Do we have a good system in place? Have staff been educated? Have we done some audits just to make sure our systems are in place? Interdisciplinary team are we all engaged? Are we talking to one another? Do we have systems in place to make sure we are checking one another? Therapy says I see this, nursing says I see this. Are we seeing the same thing? Are we using the same language? Are we communicating clearly? So we're going to do some audits just to find out.
Speaker 1:In a facility, if we're all on the same page, why are there differences? Is it lack of knowledge? Is it maybe some system things, some maybe software issues, all right. And if we find and identify those things where there's some non-compliance or potential non-compliance, we need to conduct some re-education, fix the systems and put a plan in place going forward. So this is where I want to tie in the compliance officer and the compliance committee. They are critical in this whole process to make sure they have an understanding of who's doing what. Why do they have the tools, education to do those things? Are we validating it? If we identify some concerns, are we providing some education, clarification, some revisions? Are our policies and procedures in place? If not, or if they're unclear, let's fix those now.
Speaker 1:So all of this then gets translated, hopefully, by the compliance committee to say, hey, we're having a quality performance meeting coming up. Let's report on some things we identified and this is what we're doing about it. Okay, report on some things we identified and this is what we're doing about it, okay. So the QAPI meetings need to be fully informed of any concerns we may have. Or just that, hey, we've done some routine audits. Or we've done some random audits on, let's say, falls. We've done some section GG audits just to see if we're all on the same page and have a good understanding and that hopefully, then, will lead to a facility having transparency to say we have a potential weakness here and we need to come together as a team to put our heads together to fix something before it gets out of control. And I'll always talk about the compliance committee role and the corporate, the compliance chief's role to conduct those risk assessments to look for where are we at potential risk?
Speaker 1:If we have a population of residents that have a high likelihood of falling, then we need to make sure we're really looking at our systems that are in place. Okay, and I want to add this now while it's fresh in my mind it's not just like Section GG, looking at functional abilities of a resident. Oh, this resident's at risk for maybe balance issues that could lead to. Section J falls. Okay, I'm talking about those other MDS sections, like Section E, you know, anything related to behavior, for an example. There are other areas that could put a resident at risk for falls, for example. So just really looking at how things connect with one another is a really good practice. I mean it goes without saying. Section I any active diagnoses, like Parkinsonism, for example, is going to potentially put a resident at risk for falling. Section O. When we're looking at that, we're looking at special treatments, particularly those medications that can increase the likelihood of a resident falling.
Speaker 1:So, if I just stay, remain in the vein of just falls, looking at the big picture and putting it all together to make sure we are conducting audits that make sense. Are we doing things? Are we completing the MDS correctly, yes or no? But are we looking at all the other connecting pieces? And I think I would just really want to kind of start to summarize and say this is a great time for the interdisciplinary team to come together to ask each other the question do we have the tools we need? Do we have the education that we need, the support to do what we need to do? And people need to be honest and speak up and say we need more help, we need to change a few things. So this is a time when people need to come together to informed and even if you're not a nurse, you could be, let's say, a background could be social work, but engaging and asking questions to say I'm a representative of the compliance committee and I want to learn and understand.
Speaker 1:How do you get this coding on the MDS? How did you get that? Where did it come from? Show me, explain it to me so I can see it. In my past life as a surveyor I could see where there were gaps in documentation, and if the documentation's not there, it's really difficult for the resident assessment coordinator to complete an accurate and clear picture. And so that leads me to are the systems and when I say systems, the software, the tools that are used? Are they easy to use? Do they make sense? I have seen some evidence of some ADL tools where, for example, it'll prompt the CNA who's documenting was a bath given, yes or no? Well, was the resident out of bed, yes or no? Well, we need to take it a little step further to ask was the resident transferred out of bed with an assistance of one or two? We need good quality data, so make sure that our systems are able to provide those features so we can capture the data accurately and not get buried into multiple systems of trying to, as the resident assessment coordinator, go hunting for things and, having done the MDS role in my past life, it can be quite tiring trying to find things to find. You know how to validate different things. It shouldn't be that difficult.
Speaker 1:So I imagine many facilities and organizations throughout the country are nervous about the OIG stance. Cms marching orders go. Look for inaccurate MDSs that result in inaccurate assessment, resident assessments, plans of care and incorrect reimbursement that could be considered fraud. Patterns of inaccurate MDS assessments that could certainly be considered fraud and also criminal criminal and could be also considered a great concern for star ratings, of course, but just overall reimbursement and continued oversight by the CMS and OIG.
Speaker 1:This is a time when facilities need to say wait a minute, we do have things in place, but let's just make sure we take some time to do some audits, collect some data, verify that we are doing things correctly. And if things aren't correct, now's the time to come together and say okay, wait, we got to fix this. And this is a really important time for all of us to be transparent with one another, to say you know, we really do have a weakness here. Nothing's gone wrong yet, but it could. And I think that's just really a sign of a healthy organization when you can do that. And it's an even healthier sign when you can say we need help. We need to come together as a team, because I really do believe most facilities and organizations they want to do the right thing and sometimes it's just things kind of fall oops, fall apart and kind of go sideways. But things can get corrected and can get a facility back on track or just stay on track and avoid the OIG and CMS you know review in MDS accuracy. So if you feel that your facility or organization could use some help or assistance, some guidance in this topic, please reach out to verityteamcom for further assistance and consultation.
Speaker 1:Thank you for listening to this episode. Thank you for listening. Your time is appreciated. We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. Please feel free to reach out to Verity Consulting at verityteamcom if you'd like further assistance with your health care compliance needs. Stay tuned for the next episode, thank you.