These consequences underscore not only the urgency in addressing staffing challenges within inspection agencies, but also the compelling need for comprehensive reform within Centers for Medicare & Medicaid Services programs reliant on survey data. This reform is imperative to ensure fair, accurate and timely assessments that prioritize the safety and care standards crucial for nursing home residents and providers.

The consequences stemming from delayed surveys impact the financial landscape as well. For many nursing homes, surveys represent an avenue for impartial third-party feedback, which they integrate into their Quality Assurance and Performance Improvement (QAPI) processes. However, the flip side reveals a concerning reality: Past poor survey results, which never expire, exert lasting repercussions. These repercussions include less ability to refinance, loan defaults, exclusion from preferred networks, and diminished Five-Star ratings — which subsequently result in decreased occupancy rates.

Taking a bird’s-eye view, significant variations exist in the intervals between annual surveys and certifications across states. In New Hampshire, the average stands at a low of 321 days, while Hawaii reports the highest at a staggering 1,507 days. The national average falls at 530 days, with a few alarming outliers (Idaho, Kentucky, Maryland) in the 1,000-plus day range.

However, another concern lies in the incomplete narrative presented by these averages. State-based survey teams cover specific geographic areas, and survey timelines are often inconsistent across those areas, which is reflected within states. As an example, Massachusetts has a statewide average of 501 days between surveys. Yet examination at county levels reveals substantial discrepancies: Plymouth County records an average of 768 days between surveys, while Suffolk County experiences significantly shorter intervals at 357 days.

As highlighted in my previous report in McKnight’s Long-Term Care News, the occupancy rates in nursing homes exhibit a direct correlation with Five-Star ratings, and the Health Inspection component plays a pivotal role, essentially “wagging the dog” within the Five-Star system. A negative survey doesn’t just result in immediate repercussions; it has a prolonged impact due to the extended lag time between surveys.

Consider this: Distressed nursing homes often undergo acquisition and implementation of a “turnaround” team striving to enhance staffing, clinical outcomes and compliance. Despite measurable improvements in these areas, often reflected quarterly on Medicare.gov, their efforts encounter a roadblock. They face an agonizing wait for a new survey to uplift their Health Inspection rating. However, the waiting period for a new survey paints a starkly different picture across states: Virginia at 600 days, California at 680 days, and Maryland at an alarming 1,205 days.

One might reasonably assume that nursing homes on the Special Focus Facility (SFF) candidate list would undergo more frequent surveys. However, reality paints a different picture. Despite being on the proverbial “watch list” as SFF candidates, facilities in 37 states face, on average, an additional 90 days of waiting compared to non-candidate facilities. Shockingly, in 10 states, SFF candidates endure survey intervals over 200 days longer than their non-SFF candidate counterparts.

This discrepancy in survey frequency feels like not only an added punitive measure, but also a discouragement against prioritizing and enhancing quality improvement initiatives. The extended waiting period for surveys in SFF candidate facilities seems contradictory to the intended purpose of the designation.

I am urging CMS to critically assess the impact of staffing shortages on the nursing home industry, both in terms of quality of care and financial viability. I strongly advocate for a reconsideration of the Health Inspection domain calculation when survey intervals exceed 365 days. One potential solution is to reassess the inclusion of the oldest survey cycle and either replace it with the state average or utilize data from cycle one and cycle two exclusively.

Another consideration could involve reevaluating the entire Five-Star rating system, perhaps by temporarily suppressing the Health Inspection rating to avoid consumers misattributing a poor showing to the nursing home provider rather than the state agency. It’s imperative to ensure that any adjustments maintain clarity and accurately reflect performance without making unsubstantiated suggestions of subpar nursing home quality.

The fundamental question that demands attention is the correlation between survey results and the actual quality of care provided in nursing homes. While the Five-Star Health Inspection and Quality Measure domains exhibit little or no correlation, it’s crucial to explore other metrics that may more accurately depict quality.

The pressing inquiry revolves around determining the optimal survey interval. Are annual surveys sufficient to drive improved outcomes? Government agencies often assert that extended survey intervals lead to compromised care, yet we seem to lack empirical evidence to substantiate this claim. The absence of analytical insights in this realm is striking, given the wealth of available data that could guide our understanding.

We face a gap in analysis that could serve as a beacon to navigate these critical questions. There’s a substantial need for comprehensive research to decipher the true relationship between survey results and the quality of care provided in nursing homes.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

This strategic move positions the facility to excel in representing itself to external stakeholders and, crucially, defending against potential reputational challenges. 

Since that writing, my conviction in the concept of appointing a data czar has only grown stronger. Several recent experiences have concretely shown how a dedicated individual in this role can make a substantial difference. These experiences allowed me a more comprehensive understanding of a data czar’s role in ensuring data integrity and contextualizing the data to uphold the reputation of their nursing home. I’ll talk about one of them here.

A recent courtroom case I took part in involved a frail elder admitted to a nursing home with several pressure ulcers, post-CVA. One of the ulcers became unstageable, and shortly after admission the resident was transferred back to the hospital, where he died. Although he resided in the nursing home for less than a month, the nursing home was being held accountable for the pressure ulcers. Low staffing was part of the complaint.

Plaintiffs commonly include low staffing in their complaints, and this case was no different. Here, the plaintiff relied upon staffing sheets, various depositions from staff and family, and their interpretation of the state’s staffing requirements. 

The defense cited PBJ data and presented a more precise analysis of the staffing requirements in the facility’s state. Both of these sources supported the idea that the nursing home met the federal and state staffing requirements. 

Related to the pressure ulcers, while I wasn’t providing expert testimony on them, I did point out that the plaintiff’s expert was using a contemporary MDS 3.0 definition of ulcer coding that didn’t align with the MDS coding conventions that were in place when the nursing home assessed the resident. Thus, the plaintiff’s conclusion of “MDS manipulation” wasn’t valid. 

All that said, as I stood in the courtroom, it became clear that while accurate and contextualized data is undeniably crucial, it has its limits. The jury’s preconceptions of nursing homes, their comfort level discussing sensitive subjects like death, and the emotional state of the plaintiff’s family all played pivotal roles in the proceedings. 

Throughout this legal battle, it became evident that my empathy to the resident’s family and to the nursing home, coupled with my steadfast focus on the nursing home’s data story, was the key to achieving a favorable outcome.

I’d like to acknowledge that finding a jury with a neutral opinion about nursing homes, and about aging in general, may be near impossible. The societal stigma attached to aging and death, and to the institutions associated with those realities, remains deeply ingrained no matter how we try to change it. 

In moments like these, I’m reminded of my favorite W. Edwards Deming quote: “Every system is perfectly designed to get the results it gets.” However, I’d like to take that concept a step further and add a twist. Despite systemic challenges, regulatory constraints, and reimbursement designs, the nursing home industry consistently exceeds what it’s expected to achieve. I fervently believe that this is due to the mission-driven individuals who work with the elderly. But perhaps that’s a topic for another blog!

As the “proxy” data czar during this courtroom case, my experience as a nurse working in nursing homes proved to be irreplaceable. In this role, I wasn’t just capable of telling the quantitative data story; I could also provide the vital qualitative perspective. It was the synergy between my data expertise and my deep understanding of the nursing home’s daily operations, as well as the human side of healthcare, that ultimately contributed to a positive outcome for the defense.

Data without subject matter expertise can be a double-edged sword, capable of being weaponized against you. However, the key to mounting a strong defense lies in knowing your data intimately and having the ability to tell your story in a way that only you can.

Furthermore, the empathy derived from working in a nursing home, where one understands the inherent joy and sadness of aging and the inevitable reality of death, is an invaluable asset. Compassion for residents and their families should be an essential part of the data czar’s job description.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Countless MDS training sessions, manuals, tip cards and software updates have filled our inboxes and daily industry news. However, if the arbiter of success isn’t making it past the Oct. 1 start date, then what is?

With this in mind, I turned to some of the best and brightest at Zimmet Healthcare: Alicia Cantinieri, Melanie Tribe-Scott and Amy Greer. In total, the three of them have completed dozens of public and private training sessions on the new MDS. But what I wanted to learn from them were any early warning signs that the transition wasn’t going well. Their response made me sound the alarm: “Fasten your seatbelts: It MIGHT be a bumpy ride.” However, they also offered several sage tips that should help you avoid unnecessary potholes.

Bumps related to Medicaid reimbursement 

States that are already using or converting to a Patient Driven Payment (PDPM) methodology for CMI are primarily using the Nursing component. Accurate documentation and coding of the resident’s “usual performance” in MDS Section GG is crucial, as well as the capture of diagnoses and other higher-acuity items. 

In states that are continuing to use the Optional State Assessment (OSA) or have rates frozen while the state adopts a PDPM system, MDS coding on OBRA assessment is also important as the OBRA assessments after Oct. 1 may be used in rate development or rate setting. 

As always, it’s crucial for the MDS and supporting documentation to be accurate. 

Therefore, three months out, do the following:

1. Self-audit or have a third party audit a random sample of OBRA assessments; the size of the sample depends on the number of assessments completed. Does the MDS coding have support in the medical record? Would another MDS assessor code the items the same way from the available documentation?

2. Review your facility’s process for collecting Section GG data. Is data gathered from all shifts? Is there evidence of multidisciplinary collaboration?

3. Review diagnoses coded on the MDS. Does the documentation support for diagnoses follow the RAI Manual guidelines? 

Bumps related to Medicare reimbursement

Double down on triple-check for Med A residents coding in Section K and Section O. Both of these sections added a new column that is required for PPS assessments at the start of the Medicare stay. The PDPM group will still pull from the “while a resident” column, as always. However, the extra column may cause some confusion. If the dietitian or MDS coordinator doesn’t fully understand the coding instructions, then reimbursement may be missed. For example, oxygen during the first three days of the Med A stay needs to be coded at both O0110C1a on admission and O0110C1b while a resident.

The same situation may occur in Section K. If the resident received tube feeding during the first three days of the Medicare stay, this must be coded at both K05201a and K05201b.

Regarding the PHQ-2 to 9, the facility should expect to see a decline in residents with a depression end-split, but not necessarily on the quality measure (QM). However, that decline in the end-split should not be extreme. A facility that was reporting a PDPM depression rate of 30% should not drop to 0%. If there IS an extreme decline, additional training may be required to ensure social services, or whoever is completing the assessment, understands the interview process for the PHQ-2 to 9. 

Therefore, three months out, do the following:

1. Monitor your PHQ-2 to 9 scores by pulling a report from your software.

2. Pay close attention to PDPM Section GG function scores.

3. Pay close attention to SLP and Nursing component scores dependent on Section K.

Bumps related to quality reporting

Although the Discharge Function Measure has a complicated formula and risk adjustment, if status on discharge indicates no improvement or minimal improvement from admission to discharge for many residents receiving rehab, it’s likely to be a red flag. This could indicate a lack of carryover from the rehab gym to performance back on the floor. With a focus on successful discharge to the community and rehospitalizations, ensuring the resident can translate performance in the gym to the unit and ultimately to their home as appropriate is key. 

Also remember that the data reporting threshold for QRP items will increase from 80% of the assessments to 90% for FY 2026. This affects MDS assessments beginning with CY 2024. A low data reporting percentage is related to “dashing” (—) the required data elements. Education or system changes may be needed to ensure the data reporting is at 90% or higher. With the additional assessment items on the new MDS, hitting 90% may be more of a challenge. Not only are there new QRP items, such as B1300 Health Literacy and transfer of health information, but we are also not well practiced in capturing these items. How have you operationalized their data capture?

Therefore, four months out, do the following:

1. Review the QRP Threshold Report in CASPER. If the facility is significantly below 90% after one complete quarter of data, it is critical to determine the reason why and make corrections if possible. 

2. Review the process for the UR meetings and discharge planning. Are the functional gains made by the resident in rehab translating to the rest of the day on the unit prior to discharge? 

3. Again, self-audit or have a third-party audit MDS assessments for accuracy. 

Bumps related to Five-Star 

The new MDS will affect Five-Star ratings, especially the QMs domain. With the elimination of Section G, four of the QMs will be affected (Increased ADLs, Pressure Ulcers, Improvement in Function, and Move Independently Worsened). These measures historically were calculated using data from Section G, but they will now use data from Section GG. In April 2024, these four measures will be “frozen” on Nursing Home Compare for three months to allow CMS to “catch up.” 

Once the QMs are unfrozen, they will be based upon MDS data from Q3 2023. You don’t want this to be the point where you realize your facility has been missing documentation opportunities from Oct. 1 and onward. After Oct. 1, carefully review all MDS assessments on a weekly basis for coding accuracy. Don’t do this review monthly; accumulated errors will be time-consuming to correct, and possibly lower QM scores can impact your QMs star rating and possibly even your overall star rating. 

Therefore, one month out, do the following:

1. Go “old school.” Frozen QM CASPER reports will not suffice your QAPI or auditing needs. “Back of the envelope” is often as good as a dense analytical report. Manually track, audit and analyze those negative outcomes 

2. Ensure your clinical staff are educated on the changes. Are your CNAs coding accurately? Is your MDS coordinator updated and supported? 

3. Begin a QAPI for any issues that might arise during the transition (e.g., complete, accurate CNA coding; nursing documentation in ADL decline).

Bumps related to care planning

We’ve discussed how a facility might see a decline in residents triggering depression. It’s essential to ensure you’re properly identifying residents with depression, regardless of payer type or QM definition. Once you’ve done so, creating an appropriate care plan and evaluating its effectiveness is key to success. 

An exact cross-over between Section G and Section GG cannot be made. However, the facility should not see a significant difference in coding. For example, a resident typically coded extensive to total for ADLs in Section G should not be coded as independent to set up functional abilities in Section GG. Review and monitor for such differences prior to submission, as they may impact the care plan and Medicaid reimbursement in some states. Significant differences may indicate a need for additional CNA training or an update to the documentation system.

The facility should update verbiage in care plan templates to reflect the functional abilities in Section GG as opposed to Section G. Be sure to include new items in care plans such as social isolation, health literacy and indications for medications.

Therefore, immediately do the following if you haven’t already:

1. Provide follow-up education to CNAs on GG coding now and then two to three weeks after implementation of the new coding.

2. Supply additional education on interview techniques for the BIMS and PHQ-2 to 9.

3. Review GG coding prior to MDS submission for the first three or four weeks on all payer sources to ensure accuracy. 

Bumps related to survey

Surveyors will likely focus on Section GG and the newer items. If your facility lacks supporting documentation or has no process to gather the data to make a functional assessment, there will be a problem. Facilities that choose not to have CNAs document Section GG items still need a system for daily documentation to indicate the resident’s status and care provided, provide support for rehab referrals due to a change in function, and track significant changes. Lacking these items can be detrimental to the accuracy of assessment and care planning. 

Regarding missing indications in Section N, if the assessors are checking off “no” to indications for high-risk meds, that might signal an issue with documentation. Clinical support is required from the prescriber and not simply a diagnosis with no further support or rationale in the clinical record. The SOM requires physician’s visits to include an evaluation of the resident’s condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident’s current medical regimen, which is in line with the indication for high-risk medications in MDS Section N. 

Therefore, three months out, do the following:

1. Self-audit or have a third-party audit documentation to support change in function in ADLs and rehab referrals. 

2. Conduct a monthly review of CNA ADL documentation and ensure their involvement in the care plan meetings. 

3. Self-audit or have a third-party audit high-risk medications and clinical rationale. Pharmacy partners would be great for this. 

One final potential bump 

Have you updated your facility assessment, policy and procedures to reflect the new MDS changes? Is your interdisciplinary team comfortable with these changes? Specifically, are your nurses educated on medication reconciliation at discharge? Do they understand indication vs. diagnosis? Who will be responsible for ensuring that this requirement is completed, accurate and documented? 

Therefore, one month out, do the following:

1. Have conversations with members of your clinical team to gauge their adjustment to the changes. Do they have any ideas that may help improve your documentation?

2. Review all policies, procedures, facility assessments and census and condition reports to ensure that they are updated and that they accurately and compliantly reflect changes to the MDS. Incorrect or outdated data can also have repercussions for your health inspection survey. 

3. Audit your medication reconciliation and discharge documentation monthly.

This “new MDS” doesn’t carry the title MDS 4.0 but maybe it should. The amount of change is significant. Do fasten your seatbelts because we will experience bumps. However, a seatbelt constructed of audits, education and QAPI will keep you safe. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

I know you’ve thought that while reading a memo from the Centers for Medicare & Medicaid Services or your state agency, taking in a newspaper or TV report, listening to a politician speak, or even looking through your own policy and procedure manual. 

And I know you’ve thought that more than once. I certainly have during my career. Sadly, the person “laying down the truth,” the person who makes your eyes roll or blood boil, is often the one coming from a position of power.

Over the last few decades, I’ve tried to improve the quality of the nursing home industry, but it feels like I’ve spent just as much time giving explanations to external stakeholders who seem to hold dominion over the industry yet know so little about it. How could that be? They are confident, often armed with data. And since their self-determined insights are “data-driven,” doesn’t that mean they are true? 

Thanks to The New York Times and many other news outlets, plaintiff attorneys, insurers, government bureaucrats, and external stakeholders, I’ve realized that data without subject matter expertise is more harmful than the absence of data. Why? Because data without subject matter expertise can be weaponized against you.

It is essential, therefore, to not allow your data story to be told absent of you, the subject matter expert. I liken it to an opinion piece written by ChatGPT. (Incidentally, I tried writing this blog using ChatGPT. It was fascinating, frightening and laughable.) Without true subject matter expertise, something written by ChatGPT cannot account for context, delve for insights, or express any actual knowledge. 

Instead, all the AI tool can currently produce is a collection of generally accepted concepts that skim the surface of the topic. People who have data but don’t truly understand it can do little better.

To better illustrate my point, I recall the last couple of cases in which I provided expert witness support to the defense team. In each case, the nursing home was being sued and accused of inadequate staffing, among other things. What happened at the bedside could not be determined from PBJ data and cost reports, but regardless, the plaintiff’s attorneys were using this data to present conclusions about care to the jury. Elements of Five-Star, the STRIVE study and staffing sheets were selectively used to present “their” data-driven narrative. What was absent from these cases was deep subject matter expertise — but that was my job.

The data story that I was able to tell was far more compelling. The nursing home wasn’t perfect, but with additional data and deeper insight into how it could and could not be aligned, I was able to authentically represent the home in a far more balanced manner. 

The nursing home was caring for a unique population (people with mental illness) that necessitated the creation of customized benchmarks. These benchmarks included nursing homes caring for similar types of residents in similar markets. With this insight, I was able to supply meaningful context on the nursing home’s staffing patterns, clinical outcomes and regulatory compliance. Healthcare is not a national industry, nor do all nursing homes care for the same residents, so a completely different perspective emerged once appropriate benchmarks were considered. 

To be clear, the need to be your own “data defender” isn’t limited to the courtroom. In our Advisory Services at Zimmet Healthcare Group, we often work with lenders. In a recent project, we were evaluating an operator who was seeking refinancing for a recently acquired portfolio. The Five-Star system and PBJ metrics told a not-so-favorable story. Add to that mix a very concerning regulatory history including SFF candidacy, and on the first pass, the lender didn’t feel positive toward this operator. 

However, a deeper, more thoughtful understanding of these nursing homes’ data, in relation to when this operator took over the facilities and in the context of the operator’s regional peer group, revealed a different story. 

The nursing homes with the most troubled regulatory history as reported through Five-Star and SFF had performance being principally driven by Cycle 2 and Cycle 3 survey periods. In most markets, that could mean anywhere from a year and a half ago to three-and-a-half years ago. However, for these particularly troubled nursing homes, the average interval between annual surveys was more than 700 days! In other words, the new operator was carrying the negative results of the prior owner and would be doing so for several more years. Putting this and other findings into context significantly changed the perception of the operator’s portfolio, and we were able to establish appropriate and more stable short-term success metrics. 

So, how can you be your own data defender? 

First, someone in your organization must be anointed the “data czar.” It’s a big responsibility, and it should come with a corner office with views of the mountains — but in reality, a cup of coffee and a sincere thank you might do just fine. If you don’t have the time or talent to fill this role in-house, it can be outsourced. Either way, it is essential. 

Secondly, the data czar must ensure the accuracy and integrity of all the data that you produce. Likely you have these processes in place already, but having a centralized view of all your data is an additional layer of protection.

Thirdly, the data czar should periodically examine your complete data profile. What story does the data tell? Does the story have inconsistencies or gaps? Is the story consistent with your marketing messages, accurately describing the care that is being rendered? Do you need additional data sets to tell the story better or more credibly?  

Data without subject matter expertise can be weaponized against you, but you can mount a defense by knowing your own data and telling your own story as only you can. If you do, you’ll find that data can guide and protect you while illuminating the path of quality improvement. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Close to the end of his beautiful life, it became clear that we needed more support to manage the pain and other symptoms associated with this horrible cancer. Despite my sister and I both being nurses, my Dad concluded that his needs exceeded our desire to care for him at home, and he was right. He chose hospice care in an inpatient setting; it was a difficult decision, but the best one.

Caring for Dad meant getting up close and personal with the U.S. healthcare system. While the journey was peppered with moments of inelegant bureaucracy, there were moments of grace as well. And overall, Dad’s care at the end of his life was dignified, skillful and merciful. Hospice allowed me to be a son and not a nurse. The family was able to tell stories, share music and memories, and ultimately say goodbye. No regrets.

In 2020 1.72 million Medicare beneficiaries were enrolled in hospice care, which represents a 6.8% increase from the prior year. Yet the hospice benefit is seldom elected in the nursing home. An earlier publication on hospice utilization in nursing homes identified that only a small fraction of those who qualified for the hospice benefit accessed it. 

That said, hospice utilization has increased since the initial introduction of the benefit, likely due to societal acceptance and broadening of what is considered a terminal diagnosis, such as Alzheimer’s disease. Research has repeatedly supported the management of a nursing home resident’s pain and other common symptoms significantly improves when receiving hospice services, as does family satisfaction. The evidence is clear: Hospice is most often the right choice.

Providing less than excellent care at end of life isn’t the intention of caregivers in nursing homes — in fact, many facilities have extraordinary palliative care programs in place. However, how effective can these programs be when so many facilities are treading water just to get through the day? Can we truly believe that we are doing the best job for our dying residents while we are challenged with filling shifts and addressing high turnover rates? Wouldn’t some extra sets of hands benefit not only residents and families, but also staff? 

I’d like to make another point, though. A person who has hospice indicated on their Minimum Data Set (MDS O0100K2) will be excluded from multiple CMS Quality Measures (QMs). For example, if hospice is coded on the MDS, the resident’s decline in ADLs or lack of improvement in function will not be counted against the facility — as, of course, they shouldn’t be. That is because the indication of hospice on the MDS is one of the exclusions for these measures. Look at the list of measures below. All will exclude hospice residents from their calculations. Some of these measures are part of CMS’s SNF and some states’ VBP program, the QRP program, Five-Star, and the survey process measures. 

Residents actively dying and not on hospice will still be counted in these measures, negatively impacting your quality metrics.

Hospice (O0100K2), as indicated on the MDS, will exclude you from the following CMS quality measures:

1. ADL Decline Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (LS)
2. Percent Of Residents Who Used Antianxiety or Hypnotic Medication (LS)
3. Worsening In Independent Movement Percent of Residents Whose Ability to Move Independently Worsened (LS)
4. Improvement In Function Percent of Residents Who Made Improvements in Function (SS)
5. Number Of Hospitalizations Per 1,000 Long-Stay Resident Days
6. Percentage Of Short-Stay Residents Who Were Re-Hospitalized After a Nursing Home Admission 
7. Rate of Successful Return to Home and Community From a SNF
8. Percentage Of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
9. Number Of Outpatient Emergency Department Visits Per 1,000 Long-Stay Resident Days
10. Percent Of Residents Who Lose Too Much Weight (LS)
11. SNF Functional Outcome Measure: Discharge Self-Care Score for Skilled Nursing Facility Residents 
12. SNF Functional Outcome Measure: Discharge Mobility Score for Skilled Nursing Facility Residents 
13. SNF Functional Outcome Measure: Change in Self-Care Score for Skilled Nursing Facility Residents
14. SNF Functional Outcome Measure: Change in Mobility Score for Skilled Nursing Facility Residents

Hospice for my Dad was the right thing. It wasn’t perfect, nor were prior hospice experiences with other family members. But it was as close to perfect as death can be. His care was imbued with competent and compassionate symptom management — and, most importantly, with dignity and respect. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Today, when I read the most current proposed SNF rule for fiscal year 2024, with program initiatives starting as far out as FY 2027, I think, “Surely I’ll be retired by then, or even worse!” But long periods of time pass as quickly as the setting sun, and even initiatives scheduled to begin years away require our attention now. Such is the case with the proposed new measures in the SNF Value-Based Purchasing program.

To cut to the chase, the money in the VBP program isn’t changing. We are still talking about 2% of your Medicare FFS Part A payments. And although this program is positioned as a carrot, it’s hard to see it as anything other than a stick. 

The money (2%) is taken from you (called the “withhold”), and the Centers for Medicare & Medicaid Services skims some off the top for the Medicare Trust Fund. Currently, 60% of the total withhold is returned to the best-performing SNFs. Though the proposed rule discusses increasing the percentage returned to 66% in FY 2027. Again the carrot seems more like a stick.

The fundamentals are not new. However, change is happening. In the FY 2024 proposed rule, CMS references four measures that may be added to the program, and one measure to be replaced. While the total financial pot is not set to change, the proposed rule lays out a much broader set of measures to identify the best-performing facilities. And unlike my younger self, it is prudent to act now to ensure that you are classified among the best-performing SNFs and to secure future incentive payments.

The good news is that these measures are mostly known to you — they have been used in other programs such as Five-Star and QRP. Some of these measures are MDS based, while others are claims based. This table summarizes all the existing, approved, and to-be-approved measures that likely will comprise the SNF VBP program.

The proposed rule also addresses health equity and the reduction of health outcome disparities in SNFs. Kiran Sreenivas, vice president of research at the American Health Care Association/National Center for Assisted Living, sums up this new addition nicely: “The proposed addition of the Health Equity Adjustment to the SNF VBP Program starts in FY ’27. This is an encouraging step to address disparities. It rewards facilities that admit at least 20% complex residents, which is defined as dually eligible for Medicare and Medicaid.” These SNFs must also provide high-quality care. Sreenivas notes that this “doesn’t reduce resources to SNFs since CMS will be increasing the payback percentage to 66% from the current 60%. That increase translates to approximately $27 million more available to providers to invest in quality improvement.”

If I were to advise my past self, I would tell him that the FY 2027 payout actually began last year. The data that will drive your future success with VBP is in the past and present. (Look at the baseline periods in the table above.) I would also tell him:

• Ensure the data integrity of your MDS measures. CMS promises additional scrutiny of these specific measures.
• Claims-based measures are nearly impossible to manage. Use a proxy measure. For example, the hospital utilization measures can be simply tracked with MDS, or your EHR, or even the back of an envelope! 
• QRP, VBP, and the other dozens of quality measures are your tools as much as they are for CMS and consumers. Make them real. Build them into your QAPI and operations.
• Don’t believe them when they say peroxide will turn your hair blond. It won’t. It will be awful. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

More recently, the agency began conducting off-site audits to assess the accuracy of Minimum Data Set (MDS) data. They are currently examining nursing homes’ evidence for appropriate documentation, assessment, and coding of residents’ schizophrenia diagnoses.

If CMS identifies inaccuracies in a nursing home’s MDS coding, the facility’s Five-Star rating will be downgraded by one star for six months, which can negatively impact admissions, jeopardize community partnerships, and draw attention from other external stakeholders. However, even more concerning is how these coding problems affect residents.

Inaccurate coding of schizophrenia will result in an improper care plan. Clinicians may improperly ascribe a resident’s acute signs and symptoms to the wrong diagnosis. Future discharges to the community or other care settings will become more difficult for a resident who has been improperly diagnosed.

This has become a top-of-mind issue for providers, or at least should be.

I am presenting a free webinar Tuesday on this very topic together with my mighty colleagues at Zimmet Healthcare Services Group: Alicia Cantinieri, vice president of MDS policy and education, and Melanie Tribe-Scott, director of quality innovations. We will explain the CMS audit plan, review its consequences, and assist facilities in evaluating and mitigating their risk. 

In advance of this webinar, I’d like to share with you this flow diagram that details the new schizophrenia MDS audits (click to enlarge). The diagram was created by reviewing various CMS documents.

It’s difficult to know in advance whether your nursing home will receive the “Dear Administrator” certified letter indicating that you will be audited. However, if you do, that letter will include a detailed checklist outlining what is expected of the facility within two business days. It is essential to have a clear, failure-free process in place to receive and immediately respond to the letter, even during vacations and holidays.

You will be required to immediately set up access to a web portal; the process for doing so is detailed in the letter. Step 9 is key. Here you have to make a decision: 1. schedule the CMS audit, which translates into an attestation statement (attachment C of the letter) that states that you believe your facility’s documentation is appropriate and accurate, or 2. self-report that the documentation is not accurate and submit a corrective action plan. Ultimately, even if you choose the second option, CMS may reject your plan and require the formal audit anyway. To be clear, there is no option to state that your documentation and care is accurate and therefore “don’t audit me.” 

“It is possible that a nursing home isn’t aware that they have a problem. So how could you possibly choose to self-report or schedule the CMS audit within two business days?” states Cantinieri. “To be successful, do not wait for a letter. You must immediately conduct an independent audit of those identified on the MDS as having schizophrenia.” 

This is not a 10-minute process, Tribe-Scott reminds me. When a resident has I6000 (schizophrenia) indicated on the MDS, we would expect to see a clear indication of that diagnosis in the resident’s medical history, documentation of behaviors, indications of symptoms such as hallucinations or delusions, and documentation of pharmacological and nonpharmacological interventions. Cantinieri adds: “It is the exception, not the norm, to have a ‘new diagnosis’ of schizophrenia in later life. Review your documentation for the diagnosis as per the RAI Manual instructions under Section I and State Operations Manual guidance.”   

If you are audited, CMS will request:

a. MDS assessments at time of admission, the first assessment that was completed with the resident being coded for a schizophrenia diagnosis, and the most recently completed MDS assessment

b. Behavioral health records, including practitioner assessment(s) pertaining to the diagnosis of schizophrenia

c. Medication administration records, progress notes (i.e., gradual dose reduction attempts, etc.), and medication orders pertaining to antipsychotic medication use, if prescribed

d. Other information related to the resident’s schizophrenia diagnosis and antipsychotic medication use, if prescribed

We’ve closely observed the process since the audits have begun. Some providers have had official audits, while others have self-disclosed inaccuracies and submitted plans of correction. Most outcomes from CMS have been the same: Nursing homes with coding inaccuracies had their overall and long-stay quality measure ratings downgraded to one star, thereby lowering the facility’s overall rating by one star. As a result, some facilities dropped out of preferred networks; others received additional scrutiny from external stakeholders.

These consequences, however, are really not the point. Rather, we should be asking ourselves some hard questions: How did we get here? How could any of our facilities manufacture fictitious diagnoses in order to avoid triggering a quality measure? How could we possibly put our residents in potential harm’s way to protect our ratings or continue the use of an unnecessary chemical restraint? It is impossible for me to get my head around this. 

Do regulatory sticks and carrots play a role in this behavior? In some states, nursing homes are financially rewarded for low rates of the antipsychotics and antianxiety quality measures, and all facilities are penalized for high rates. The intentions are noble: lower rates of psychotropics. But do these sticks and carrots motivate the wrong behavior? 

If you are reading this blog, you are almost certainly doing the right thing. I’m delighted that the majority of the industry is also acting as it should. Yet as the saying goes, a few bad apples do spoil it for the rest of us. 

My best advice is to take stock in your own practice. Look inward. If you find problems, do a root cause analysis to ferret out their origins. See you at the webinar, if you can make it.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Poor support of staff contributes to a negative reputation in the community, complaints to an ombudsman or the local department of health, or even whistleblower complaints, among others. As a result, your facility might experience undesired resident outcomes, a lawsuit, an allegation of criminal actions, or investigations by external oversight agencies. 

The 10 strategies that I presented last month can be applied to support your employees and lessen the likelihood you’ll experience these negative consequences. Here they are:

1. Expect things to happen, and get ahead of them.

Providing a safe environment for your residents, visitors and staff is obvious and non-negotiable. In general, nursing homes do a fine job with this, but the potential for mishaps is always there. Schedule periodic environmental walkthroughs on all shifts, every day of the week. Ask other staff members to conduct these safety checks. Their fresh eyes will always identify something that you might have missed. A nurse assistant, therapist and social worker will each spot different environmental hazards.

But in addition to the environment, life happens. And we all find ourselves in the circumstances of being an unexpected caregiver to elderly parents, sick children or other family members and friends. Does your organization support your team members in times of personal crisis, or does it discipline them for being late or calling out? A while back I wrote about Archangels. Archangels is an organization that provides support to unpaid caregivers. Check them out! They’re doing wonderful things to support our nursing home industry and can help you to support your staff. 

Your staff has feedback to share. If they don’t have a place to do so with you, they will share with others. Residents, families, employee unions, departments of health, surveyors and other people will hear the concerns that you are not. Acknowledging staff and creating a safe place for them to voice their concerns is necessary. The distance between the breakroom and the boardroom is vast. Dispelling the “us versus them” mentality is essential and benefits everyone.

2. Sail into problems. 

Celebrate the opportunities to do better. Your skills at root cause analysis come into play here! We all understand the concept of a resident council, but have you considered an employee council? Every complaint is a gift, and often a second chance.

Some of the greatest challenges I experienced as a charge nurse in a nursing home involved helping nurse assistants to cope with abusive residents and families. The physical abuse that they received from residents was nothing compared to the hurtful verbal abuse that they endured. Though it mostly stemmed from residents’ cognitive impairment, sometimes it did not, and that was especially hard. Though “the customer is always right,” remember that our coveted staff are our customers as well. Confronting these challenges is essential, even if there is no obvious solution.

In the city nursing home where I worked for 10 years, I encountered a unique set of challenges. Its staff represented tremendously diverse cultural backgrounds, and so did its residents. Sometimes these differences resulted in conflict, but turning the conflict into opportunity had a tremendous benefit. I distinctly remember facilitating conversations around end-of-life care and pain management by asking staff to share their cultural beliefs on these sensitive topics. Through open dialogue we learned about each other. We contrasted our beliefs with those of the residents, and suddenly differences became opportunities and not barriers. It was magical. 

3. Call with good news.  

Staff don’t want to only hear from their supervisors in the context of a performance review, or when they’re being “written up” and given “tough love.” Instead, how about “catching them” doing something good? Celebrating birthdays is great, but do people really need to wait a year to know they’re valued? Role-modeling appreciative behavior is key. Remember, it doesn’t need to always fall on you, but creating an environment or a culture where positive feedback is common — “You are so kind to Mr. Yanny.” “I love how much you helped Sheila during orientation.” — helps cultivate a wonderful place to work. Create a vehicle for peers to nominate a coworker for an award or some type of acknowledgment. 

4. Make data your superpower. 

You are sitting on a treasure trove of staffing data. For example, what happens to the data you accumulate through your employee hotline? Check out CMS’ Care Compare and examine your overall and RN turnover rates. How do your turnover rates compare to your closest peer group nursing homes and the state average? 

What about employee satisfaction surveys? Many of you conduct them, but what happens to the results? Are they driving change? Supporting existing practices? Shared with staff? Or tucked away without review?

5. Read charts. 

Here I’m not referring to resident charts, but rather accumulated staff information. For instance, I often wonder about exit interviews. Do you do them? Are you doing them “for real” or just as a formality? What about call-outs? Does a pattern emerge when you pull back and look at the data? These are opportunities to learn about your staff and prevent future attrition. For many reasons, it’s easier said than done. Do your best, which I suspect is pretty darn good. 

Now consider your PBJ data. With some digging, you can examine your contract staff utilization compared to others in your market. Are there days of the week you tend to run significantly low? Expect your next survey to occur then. From reviewing employee incident reports, do incidents tend to happen on a particular shift, weekend or day? What makes these time periods more problematic than others? 

6. Put your money where their mouths are. 

Many nursing homes provide free meals to their staff. Sometimes this is only for hard-to-staff shifts like weekends, but I’ve also heard of nursing home kitchens providing to-go meals at cost or even free to their staff. 

Nursing homes excel at hosting holiday events for residents and families. Potluck and other food activities seem to induce hugs and smiles. Feed your residents warm soup at night when they have trouble sleeping, and encourage staff to take a moment and enjoy some soup with the residents as well. 

Your mind is probably racing through the regulatory obstacles inherent in some of these suggestions. But take a step back and consider: At what point can you watch your staff’s backs instead of your own backside? Legal offices, don’t forget what business you’re in. 

7. Don’t rotate staff.  

Ten years ago, I wrote about the merits of not rotating nurse assistants and engaging them in the creation of assignments. It’s been a while, but the tangible benefits of this approach remain. Treat floating and agency staff as guests. Assign them a staff buddy to help them during their shift. Bottom line, you are grooming your next hire. This is a relationship business; we understand that concept in terms of our residents and families, but it should extend to our valued team members. 

8. Put yourself on hold.  

Call your facility and listen to the outgoing message when you are placed on hold. Sure, you talk about the outstanding care that residents receive, but is there any messaging about the staff that cares for them or the benefits of joining your team? 

Go to your nursing home’s website and submit an employee inquiry online. I did several. Often, I didn’t get a response to a general employment inquiry. This happens when servers go down or emails get jammed. Read the mission statement posted on your nursing home’s website. Does your awesome mission also embrace your staff? 

There are plenty of places online where you can read what staff are saying about your nursing home. Indeed, Yelp, Google and Glassdoor are a few examples. Remember, these aren’t just forums for staff to post their gripes; there always is an opportunity to learn. 

9. Stop admissions.  

You send a powerful message to staff when you put a temporary freeze on admissions. Now, this doesn’t need to be all admissions, but if your staff are telling you that they are overwhelmed or unable to care for a specific resident cohort, stop and take a pause. These actions speak volumes, and your staff will become your greatest champion. Since most nursing homes are part of a larger corporation, this ideology must be supported throughout the organization. Delegation of decision rights therefore must be part of this process. 

10. Learn how to apologize. 

We all make mistakes. If you blow it, own it and apologize. Foster a culture of forgiveness and humility. When you miss the mark and are not the role model that you strive to be, say you are sorry and mean it. Be specific and ask for forgiveness, then forgive yourself. Identify how you would have wanted to act in the given situation. Learn and grow. 

You can mitigate employee risk and put a stop to the negative consequences and future losses. But ultimately, nursing home operations will never be free from risk. Hopefully these 10 actions will result in more empowered and committed staff — a winning combination for you and your residents!

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

What operators and providers may not realize is how many sources of risk they grapple with on a daily basis.

Risk in a nursing home comes from almost too many sources to name: residents and families, federal and state regulators, vendors, payers, insurance companies, referral sources, partner relationships, plaintiff attorneys, the media. And, though an operator may not like to admit it, some of the risk comes from their staff.

Whatever the source of risk, a poor resident outcome may result in a lawsuit, an allegation of criminal actions, or investigations by any number of higher-ups: state attorneys general, Medicaid fraud control, the Department of Justice, or the Office of Inspector General. 

There are 10 things that you can do tomorrow to mitigate risk, beyond the fatherly advice of “be careful.” Let’s review them together.

1. Expect things to happen, and get ahead of them. Aristotle said that quality is not an act, but a habit. Providing a safe environment and safe care is non-negotiable. Start by thinking about your nursing home in terms of its true overall safety. Notice that I didn’t include the phrase “in your survey window.” I didn’t focus on Monday through Friday. I didn’t mention the day shift. Most bad things don’t happen when the lights are shining bright, and staff are striding through the hallways. Over 24 hours a day, 365 days a year, though, there will be times that are riskier than others. So constantly ask yourself: How safe is your facility at its least safe point? Better yet, look at past incidents to determine the riskiest times to be a resident in your building. By expecting things to happen, you will gain insight into how to mitigate them.

2. Sail into problems. Every complaint is a gift, and often a second chance. Be curious when something occurs; don’t neglect the details. Many of us are very skilled at doing root cause analysis — here’s where those skills pay off! Solve the problem at the lowest possible level, meaning at its very core. When a staff member, family member, or resident reports a problem, it should be celebrated.

3. Call with good news. Often, family members only hear from us when we have bad news. That’s unfortunate, because we do many great things with our residents that families are not aware of. Reaching out to share a resident’s accomplishments, even if they seem small, creates a positive record with the family. They’ll trust you more, and when a problem arises, they’ll be more likely to turn to you to solve it versus someone else.

4. Make data your superpower. Start by looking at your facility assessment. How does it inform your budget, staffing and training? What do your Five-Star rating and social media presence tell the community (and potential staff) about your facility and its care? Your public data is manipulated to serve various agendas, but we never talk about how this data can be your superpower and help you tell the best possible story.

5. Read charts. I can feel your grimace, but bear with me! Does the medical record tell a consistent and coherent story about the resident? Do a gap analysis. Are the strengths and weaknesses that were identified on the MDS reflected in the resident’s care plan? Is there documentation to support that the care plan was implemented? Is there documentation about the results of that care? If you are missing documentation, your system is likely asking too much of its caregivers. Honestly, I have never seen a record without missing documentation. But I have seen countless examples of duplicated documentation, and of policies and procedures that exceed state and federal requirements. 

6. Put your money where their mouths are. Families (and residents) have always been concerned about food and nutrition over everything else. Therefore, properly investing in food and mealtimes, and in the staff required to support residents’ nutrition, is essential. Easier said than done — but think of the problems you avoid by doing so. Pay careful attention during end of life. We know that forced hydration and nutrition are not only undignified, but cause pain for the dying resident. Family may mistakenly feel that you are “starving” a loved one by not giving them food and water at the end of life. Bring them along on this process and share the evidence that supports this care. 

7. Don’t rotate staff. We are in a relationship business. Rotating staff compromises our efforts to build trust, safety, and efficiency. Think about primary care nurse assistant teams. Even with our staffing shortage, maintaining staff should be the goal. It’s the right thing for the residents, it’s the right thing for staff, and it increases safety and efficiency. Even with contract staff, work diligently to ensure the same staff are being sent from the agency. Insist upon it.

8. Put yourself on hold. Look at what your facility’s marketing materials say. Are you overpromising and underdelivering? It is essential that you accurately represent your facility on your website, in social media, and in your marketing collaterals. Call your facility and listen to the outgoing hold message. What does it say, and is it accurate?

9. Stop admissions. If you cannot deliver appropriate care for the residents you currently have, you must stop admissions until you can. Individually, that might mean pausing admissions for certain types of residents where staff competencies don’t exist. Be brave. You may also need to conduct a facility-wide stop, where you carefully assess whether your staffing is adequate to address the acuities in your current resident population.

10. Learn how to apologize. Be impeccable with your word. If you say that you’re going to do something in response to a negative event, you must deliver. Try not to take things personally, but always do your best. Check back with residents and families to see if they are satisfied with how the negative event was handled. This will help you prevent further mistakes.

You can mitigate risk and future losses, but just like crossing the street, nursing home operations will never be free from risk. These 10 actions, however, will reduce a significant volume of risk coming from your nursing home and provide important benefits.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

The MDS changes that will be implemented come October 2023 are significant and should not be simply delegated to your amazing Resident Assessment Instrument (RAI) coordinator. Version 1.18.11 of the MDS will impact reimbursement systems, quality measurements, surveys and Five-Star, to name a few. As such, your policies, procedures, and mechanics around data capture also will need to be updated. This will be a major organizational shift in how you assess, document and report about care. It will impact your bottom line, your public data profile and — most importantly — the care you deliver to your residents.

The following timeline offers some guidance and practical suggestions to ensure a successful transition to the new MDS this year. A winning strategy begins now.

January – March

Now is the time to begin an interdisciplinary review of the updated MDS items. If you go to this page and scroll down to the “Downloads” section, then select the ZIP file labeled “MDS 3.0 Draft Item Sets v1.18.11”, you’ll find all you need to start this process. Within the ZIP file, you’ll find a PDF labeled “Item Set Change History” that summarizes all of the alterations to the MDS.

Identify what items were deleted, changed or added, and then circulate this information to the team to determine the following:

1. What policies and procedures will need to be created/updated or retired?
2. What documentation forms, either electronic or paper, will need to be created/adjusted or retired?
3. Who’s going to do 1 and 2, and when will they do it by?

For example, under the category of “new items,” we are now hearing in the resident’s voice how they define their ethnicity, race and preferred language. We are assessing the lack of access to transportation and how that impacts daily living. Who is doing this assessment and how? How will this information make it into daily care and discharge planning?

New items (think QRP measures) from the Standardized Patient Assessment Data Elements (SPADEs) are included. Specifically, the two new process measures in SNF QRP: Transfer of Health Information to the Provider Post-Acute Care and Transfer of Health Information to the Patient Post-Acute Care are added into the mix. Absence of this MDS assessment data will have direct financial consequences.

April – June 

Quarter two of 2023 will see the final version of the MDS 3.0 v1.18.11 item sets. Also, the RAI manual will be released. And as far as training, CMS hasn’t specified a time, but start looking for its announcements for MDS training. 

With the final item sets and the manual, you are ready to finalize all policies, procedures and documentation forms that you identified in quarter one. A thorough review of the RAI Manual will reveal the specific details you’ll need to ensure proper implementation. In addition to the MDS items that have changed, consider items that haven’t changed but have historically challenged your facility. Take the opportunity to “reboot” and address these thorny items. Assessment of Section GG is a perfect example.

Some nursing homes have only completed Section GG for PPS assessments; now it is required for all OBRA assessments as well.  As we’ve seen during MDS compliance audits, some facilities take information from their therapy notes to complete Section GG. This hasn’t been shown to be the best practice — plus, if the resident isn’t receiving therapy, there will be no therapy notes, so where will the data come from? 

CMS has been remarkably silent about the many other systems, beyond resident assessment and care planning, that are impacted by the MDS changes. For example, how will the transition from the PHQ-9© to the PHQ-2 to 9© impact the depression end split? Items in Section O, Special Treatments, Procedures, and Programs, will be much more specific in type and in time/location of service delivery. This has care planning implications, but the added specificity will also provide details that suggest the possibility of PDPM adjustments. 

Not just CMS, but many states also have not gone on record regarding Medicaid CMI reimbursement. How will they, and private insurers, respond to the elimination of required MDS items that generate a RUG? Might they require an Optional State Assessment? If so, how would that fit into your policies, procedures, and workflow?

Five-Star will be significantly impacted, and not only by the promised staffing study; the removal of Section G items means current staff acuity adjustments cannot be performed and several quality measures become incalculable. A Section G to GG would be reckless. CMS has yet to provide any guidance on this subject.

The proposed rule for FY 2024 hopefully will clarify many of these unanswered items, particularly the questions related to reimbursement.

July – September 

OK, we are in the home stretch! I hope you took a vacation and feel refreshed! Practice makes perfect, and that’s what needs to happen in quarter three. Follow your soon-to-be-finalized MDS policies and procedures. In-service your team on the new documentation forms. Listen to their feedback. Are the requirements reasonable? Are your new policies and procedures setting you up for successful data capture?

Consider your existing QAPI projects. Do they need to be revised because of a reliance upon MDS data? Give the same consideration to your internal compliance programs, as they will likely need to be modified to be effective with the new data sets. Expand your compliance concerns to address the HIPAA-compliant method for sharing Provision of Current Reconciled Medication List to the Subsequent Provider and to the Resident at Discharge.

In addition to the information provided by CMS, consider other MDS education. When sourcing third-party education, make sure you know the teacher’s credentials. The American Association of Post-Acute Care Nursing offers various certification programs that have a clear ROI and are led by highly qualified master teachers. 

You might make New Year’s resolutions or just be tenaciously goal-directed. You might also agree or disagree with the timeline I’ve put forth here. That’s fine. Whatever course you set, remember that success is the result of purposeful, focused activity. 

One of the many things that I love about the nursing home industry is that there is no challenge we haven’t mastered. We will succeed, and resident care will improve as a result. 

May 2023 take you from strength to strength, for you and our nation’s elders.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.