What Healthcare Teams Need to Know About MDS Assessments and OIG Audits

During our webinars on the OIG’s ICPG for Nursing Facilities (watch Part 1 and Part 2) questions arose about the Minimum Data Set (MDS).  

The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment.  

CMS publishes a manual that provides more insight into assessments for long-term care facility residents. It can be found here: https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf 

Some key areas of the MDS include: 

• Identification Information 
• Hearing, Speech, and Vision  
• Cognitive Patterns  
• Mood  
• Behavior  
• Preferences for Customary Routine and Activities  
• Functional Abilities 
• Bladder and Bowel  
• Active Diagnoses 
• Health Conditions  
• Swallowing/Nutritional Status 
• Oral/Dental Status  
• Skin Conditions 
• Medications  
• Special Treatments, Procedures, and Programs 
• Restraints and Alarms  
• Participation in Assessment and Goal Setting  
• Care Area Assessment (CAA) Summary  
• Correction Request 
• Assessment Administration 

The manual also includes information about assessments for the Resident Assessment Instrument (RAI) which was also mentioned during the webinars. Information related to the RAI in the manual includes: 

• Introduction to the Requirements for the RAI  
• CMS Designation of the RAI for Nursing Homes 
• Responsibilities of Nursing Homes for Completing Assessments 
• Responsibilities of Nursing Homes for Reproducing and Maintaining

Assessments  

• Assessment Types and Definitions  
• Required OBRA Assessments for the MDS 
• The Care Area Assessment (CAA) Process and Care Plan Completion  
• Skilled Nursing Facility Prospective Payment System Assessment Schedule 
• MDS PPS Assessments for SNFs  
• Combining PPS Assessments and OBRA Assessments 
• PPS and OBRA Assessment Combinations 
• Factors Impacting SNF PPS Assessment Scheduling  
• Expected Order of MDS Records 
• Determining the Item Set for an MDS Record 

The HHS OIG will periodically audit some of the elements associated with the RAI and/or MDS. 

For example, in March of 2024, OIG announced a Work Plan item that will assess the accuracy of nursing home falls reporting in MDS assessments. OIG plans to:   

• Assess the accuracy of the patient assessment data used to calculate nursing home falls rates 
• Identify hospitalizations due to falls with major injury among Medicare enrollees receiving nursing home care using Medicare claims 
• Assess the extent to which those falls were reported by nursing homes in patient assessments 
• Examine the characteristics of the people who did not have their falls reported 
• Examine the characteristics of nursing homes that did not report falls among their residents  

This report is expected to be completed and shared publicly sometime in 2025. (See the work plan item here: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000840.asp).  

The OIG performs other evaluations and audits related to nursing facilities.  

Examples of some of these reports include: 

• “Concerns Remain About Safeguards To Protect Residents During Facility-Initiated Discharges From Nursing Homes” https://oig.hhs.gov/reports/all/2024/concerns-remain-about-safeguards-to-protect-residents-during-facility-initiated-discharges-from-nursing-homes/  
• “Nursing Home Residents With Endangering Behaviors and Mental Health Disorders May Be Vulnerable to Facility-Initiated Discharges” https://oig.hhs.gov/reports/all/2024/nursing-home-residents-with-endangering-behaviors-and-mental-health-disorders-may-be-vulnerable-to-facility-initiated-discharges/ 
• “Long-Term Trends of Psychotropic Drug Use in Nursing Homes” https://oig.hhs.gov/reports/all/2022/long-term-trends-of-psychotropic-drug-use-in-nursing-homes/  
• “Massachusetts Could Better Ensure That Nursing Homes Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control” https://oig.hhs.gov/reports/all/2024/massachusetts-could-better-ensure-that-nursing-homes-comply-with-federal-requirements-for-life-safety-emergency-preparedness-and-infection-control/  
• “Certain For-Profit Nursing Homes May Not Have Complied With Federal Requirements Regarding the Infection Preventionist Position” https://oig.hhs.gov/reports/all/2024/certain-for-profit-nursing-homes-may-not-have-complied-with-federal-requirements-regarding-the-infection-preventionist-position/  

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