MDS Alert

How your Five-Star Quality Rating will change drastically next year.

The Centers for Medicare & Medicaid Services (CMS) has big plans for seriously cracking down on nursing home quality-of-care issues in 2015 — and you can expect unprecedented scrutiny of your MDS 3.0 coding practices. Here’s what next year has in store.

Get Ready for 5 Big Changes

On Oct. 6, CMS announced that it will expand the Nursing Home Five-Star Quality Rating System next year. Beginning in 2015, CMS will implement the following changes to the system:

1. Focused Survey Inspections — CMS and states will implement nationwide focused survey inspections for a sample of nursing homes. These inspections will expand upon the piloted special surveys of MDS coding that CMS conducted in fiscal year (FY) 2014. Beginning in January 2015, the inspections will aim to improve verification of staffing and quality measure information in the Five-Star Quality Rating System.

2. Payroll-Based Staffing Reporting — CMS will implement a new quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. The new system will allow CMS to calculate staff turnover, retention, types of staffing, and levels of different types of staffing.

3. New Quality Measures — CMS will increase the number and type of quality measures it uses in the Five-Star Quality Rating System. Beginning in January 2015, the first new measure will rate the extent to which nursing homes are using antipsychotic medications. Later on, CMS will also institute measures like claims-based data on re-hospitalization and community discharge rates. 

4. Inspection Data — CMS will strengthen requirements for timely and complete inspection data among states, ensuring that states maintain a user-friendly website and complete inspections of nursing homes to include in the rating system.

5. Improved Scoring Methodology — CMS will revise the scoring methodology to calculate each nursing facility’s quality measure rating. CMS will still weight nursing homes’ self-reported components of the scoring methodology lower than other sources.

These changes may impact not-for-profit nursing homes differently than for-profit facilities. This is particularly true regarding staffing data, as CMS plans to gather more information in the surveys of how staffing levels may fluctuate throughout the year, noted Evvie Munley, senior health policy analyst for Washington, D.C.-based Leading Age, in a Nov. 4 analysis.

“Independent research already shows that not-for-profits tend to staff higher than for-profits,” Munley said. “The issue now is the determination of what staffing data should be counted and reported.”

Double-Check Your Pressure Ulcer and Restraints Coding

In an Oct. 31 Survey & Certification (S&C) memo, CMS announced the 2015 nationwide expansion of the MDS-focused surveys. CMS also reviewed the findings of the 2014 pilot surveys.

In the 2014 pilot focused on MDS coding practices, surveyors with specialized training for these surveys reviewed nursing home resident assessment processes more in-depth than annual surveys, CMS explained. Nursing homes in five states underwent the pilot MDS-focused surveys.

Watch out: According to CMS, the 2014 pilot surveys found that nursing homes had:

• Inaccurate staging and documentation of pressure ulcers;
• Lack of knowledge regarding the classification of antipsychotic drugs; 
• Poor coding regarding the use of restraints; and
• Deficiencies on 24 out of the 25 surveys.

Bolstered by these findings in the pilot surveys, CMS will launch a greatly expanded version of the survey program beginning early next year. And keep in mind that these top findings from the 2014 pilot surveys will be prime target areas for surveyors in the second round of surveys (see articles on pages 125 and 126).

What to Expect for the 2015 Surveys

Although the 2015 surveys will be nationwide, the number of surveys conducted will vary from state to state, according to CMS. States will allocate two surveyors for each survey and will work with CMS to identify which specific facilities to survey.

If CMS selects your facility for a focused survey, expect the surveyors to review records, gather resident observations, and interview staff and/or residents to validate your MDS coding and staffing levels. While on-site, the surveyors will also ask a series of questions regarding staffing and MDS-related practices of the staff, leadership and others. 

Beware: These focused surveys will have real consequences if surveyors find MDS coding inaccuracies or insufficient staffing. You could face citations and referral of care concerns to your state agency as a complaint for further review. And if the surveyors discover patterns of MDS inaccuracies, the surveyors will refer to your case to the CMS Regional Office and Central Office for follow-up.

Link: To read the Oct. 31 S&C memo, “Nationwide Expansion of Minimum Data Set (MDS) Focused Survey” (S&C: 15-06-NH), go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-06.pdf.