Accurate documentation is crucial for nursing home operators aiming to maintain strong nursing home star ratings under the Five-Star Quality Rating System. The accuracy and completeness of the Minimum Data Set (MDS) are vital, as mistakes can impact a facility's rating for a year or more.
Industry experts emphasize the need to follow state-specific MDS coding guidelines and stay updated on changes to the Quality Reporting Program (QRP) thresholds. The Centers for Medicare & Medicaid Services (CMS) continuously tracks new quality measures, making it essential for facilities to keep up with these changes.
While there are fewer MDS updates this year, operators should be aware of new diagnosis codes. Amy Greer, director of quality initiatives at Zimmet Healthcare Services Group, advises that running weekly and six-month assessment reports can help monitor quality measures and data used by CMS for star ratings. Failing to submit Payroll-Based Journal (PBJ) data accurately and on time can lead to significant penalties, including an 18-month star reduction.
MDS Documentation and Quality Measures
Alicia Cantinieri, Managing Director of clinical reimbursement and regulatory compliance for Zimmet, highlighted the importance of supporting MDS Section GG coding with appropriate documentation. The data must align with clinical assessments in the resident's medical record, as auditors and surveyors closely examine this information.
Facilities should regularly audit their MDS assessments to maintain a high-quality measure score. Ensuring the accuracy of these assessments can avoid unexpected changes in star ratings. CMS has expanded the factors influencing overall quality scores, so operators must prepare for the potential impacts of new items and communicate these with stakeholders, including residents, families, hospitals, and third-party lenders.
Activities of daily living (ADLs) are critical to a facility's star rating. Facilities must monitor ADLs closely, compare them with previous assessments, and ensure accurate documentation. If a decline in ADLs is noted, it should be documented along with any additional therapies provided, encouragement for ADL independence, and referrals to necessary therapies.
Facilities should also identify and document the root causes of ADL decline, such as pain, depression, or refusal of treatment. This comprehensive approach helps ensure that nursing home star ratings reflect the quality of care provided.
Addressing Pressure Ulcers and Other Concerns
For residents at risk of pressure ulcers, it's essential to identify vulnerable individuals and review policies and procedures. Monitoring staff communication about new wounds or skin issues is crucial. Greer emphasizes the importance of evaluating whether policies are effective: "If the policy isn't followed, [know] what in the policy isn't working? Why do residents keep getting pressure ulcers? How does the staff know to alert someone else? These are all things you should think of because this ultimately impacts your quality measures."
Preventative measures like toileting schedules, regular check-ins, and root cause analysis are essential for maintaining high star ratings. Facilities should also document any interventions and adjustments made to care plans.
Proposed Changes in the SNF Payment Rule
In the 2025 Skilled Nursing Facility (SNF) Proposed Payment Rule, CMS has changed the MDS, including removing specific primary diagnoses from the Patient-Driven Payment Model (PDPM) ICD-10 list. Cantinieri notes that these changes are less extensive than last year's but still require attention. Conditions like asthma, COPD, and chronic lung disease, which account for many Part A stays, are among the updated non-therapy ancillary (NTA) comorbidities.
Starting in fiscal year 2027, Standardized Patient Assessment Data Elements (SPADE) will include questions related to social determinants of health and discharge planning. These elements will ask about a resident's living situation, food security, and utility access. Additional questions will cover vaccination status, pain management, and depression.
CMS will require facilities to provide MDS data on selected quality measures three years before implementation. This process is similar to an audit, with facilities given 45 days to submit the required documentation. Failure to comply may result in a 2% reduction in the facility's Medicare market basket percentage.
Overall, nursing homes must stay vigilant and proactive in maintaining accurate MDS documentation and understanding the evolving landscape of quality measures to preserve their nursing home star ratings.
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