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A Minimum Data Set (MDS) is a standardized screening and assessment tool to be used by an MDS nurse. It is stipulated by the CMS (Centers for Medicare and Medicaid Services) and designed to assess a senior’s functional, medical, psychosocial, and cognitive status. The tool’s primary purpose is to conduct clinical assessments on a resident’s health status during admission. The results determine whether a resident qualifies for Medicare or Medicaid.

In 2010, the CMS redesigned the minimum data set to improve its reliability, accuracy, and utility. The changes meant that residents were now included in the assessment process. Also, standardized protocols were developed for other settings, like non-critical access hospital swing beds (non-CAH SBS), which can qualify for SNF-level services, provided a beneficiary receives acute care as a hospital inpatient covered by Medicare Part A. These improvements have resulted in higher levels of accuracy for clinical assessments.  

Upon admission into a long term care facility, the MDS coordinator—usually a registered nurse—will conduct an MDS assessment. The coordinator measures several areas of functioning, including physical, psychological, and psychosocial. By measuring these specific areas, the facility will gain a comprehensive view of a resident’s functional capabilities, thus, allowing them to create a personalized care plan using the facility’s long term care software. 

Suppose facilities do not produce accurate MDS assessments. In that case, the facility’s quality of care will be jeopardized, and PDPM reimbursements can be negatively affected, ultimately affecting the facility’s financial standing. Therefore, it is of utmost importance that facilities understand MDS applicability and implement all that is required under PDPM. 

The Importance of MDS Documentation

Minimum Data Set assessment is a critical part of PDPM reimbursements for long term care facilities, meaning MDS documentation is crucial for facilities looking to maximize their reimbursements. While there is a wide range of MDS resources available online, facilities wishing to better understand MDS requirements and their relation to reimbursements should start by reading the Minimum Data Set 3.0 Frequency Report. This document is updated every quarter, giving summaries for active residents (those who have had transactions within 150 days) in a long term care facility. 

The MDS assessment information is then consolidated to create a resident’s profile with standard information on a resident’s nursing conditions (Activities of Daily Living, cognitive capabilities, behavioral issues, restorative needs, therapeutic requirements, and medical diagnosis).

Facilities also need to understand the Resident Assessment Instrument (RAI), a tool that nursing home staff can use to gather comprehensive information on a resident’s capabilities and needs, which must be addressed in an individualized care plan using their long term care software. This is highly beneficial, as it allows staff to evaluate a resident’s holistic needs and identify the conditions that are significant to improving their quality of life and care. 

The RAI manual was last updated in 2019. The RAI process has several federal requirements, such as:

A physician is looking through MDS documentation to ensure it is accurate.
MDS documentation is crucial for facilities looking to maximize their reimbursements.
  • Accurately assessing the resident’s status
  • Ensuring a registered nurse and other appropriate health professionals each conduct an assessment
  • Ensuring direct observation and open communication between the resident and the care staff on all shifts

A common phrase in healthcare is, “If it wasn’t documented, it wasn’t done.” And when it comes to MDS, this is especially true. Aside from understanding the formal requirements for the MDS assessments, facilities also need to ensure assessments are conducted and accurately recorded. Failure to do so will result in financial penalties by state and federal agencies. 

Furthermore, MDS errors can also impact a facility’s quality measures and five-star rating, ultimately negatively impacting the facility’s reputation in the community and resulting in financial difficulties and census problems. 

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The Role of an MDS Nurse  

As mentioned earlier, a Minimum Data Set assessment is usually conducted by an MDS nurse or resident assessment coordinator. The primary role of an MDS nurse is to assess and monitor the proper treatment of residents in a long term care facility. 

The typical duties of an MDS include:

An MSD nurse is determining a resident's health status.
Minimum Data Set assessment is usually conducted by an MDS nurse.
  • Determining whether the health status and resident care plans meet state and federal standards 
  • Performing initial Minimum Data Set assessments for new residents
  • Developing personalized care plans (including long and short-term goals) for each resident based on the Minimum Data Set form and results.
  • Conducting meetings with multidisciplinary teams, facility staff, residents, and their families.
  • Liaising with local therapists and specialists in the community to ensure that the care plan goals are met.

Regarding training and qualifications, MDS nurses must first obtain a nursing license from either a National League of Nursing (NLN), the American Association of Colleges of Nursing (AACN), or a bachelor’s degree in nursing from a credible medical institution. They must also have a minimum of one year of working experience as a licensed nurse, preferably in a long term care setting. This experience will allow them to comprehend the complexities of working with seniors and familiarize them with the intricacies of MDS documentation

A qualified MDS nurse can expect a high salary, something in the range of $14,526 to $389,089, with a median salary of $70,285. Of course, the salary benefits differ depending on whether they work part-time or full-time and how experienced and qualified they are. 

Furthermore, another important responsibility of an MDS nurse is to conduct MDS-focused surveys. Facilities are often visited by MDS surveyors, who request MDS forms, complete reports of the current nursing home residents on the survey day, and the available and occupied beds report. These reports allow surveyors to know a resident’s location, payor type, and what items are required for the entrance worksheet.

MDS nurses will often use MDS assessment tools to complete MDS surveys, as it easily allows them to import and export resident data from the facility’s care plan software. Also, the built-in MDS automation tools of nursing home software systems help to improve workflow efficiency, as nurses can update resident data at the click of a button instead of sifting through paperwork. 

Value Your MDS Nurses to Ensure Accurate Minimum Data Set Assessments

Prior to adopting long term care EHR systems, facilities used paper documentation. This was inefficient and inaccurate, and it led to incorrect Minimum Data Set assessments and inaccurate PDPM reimbursements. Paper records also increased the time needed for administrative duties and record maintenance for MDS nurses.  

A physician is discussing the minimum data set assessments with a resident to explain what payments needs to be made.
Incorrect Minimum Data Set assessments lead to inaccurate PDPM reimbursements.

If facilities want to maximize their PDPM reimbursements, they must ensure that MDS regulations are not only met but also properly documented. This means that the facility’s PDPM reimbursement experts, the MDS nurses, must be knowledgeable enough to train others on adequate documentation while ensuring all inputted data is thorough and accurate.

Facilities should never underestimate the importance of their MDS nurses, because they are directly responsible for PDPM reimbursements. From the moment a resident enters a facility to the day they are discharged, the MDS nurse will manage and interpret the varying forms of data needed to complete MDS surveys and assessments. 

Therefore, facilities should make their MDS nurses feel respected and valued by offering a competitive salary with sign-on bonuses, generating reasonable schedules, checking in on them regularly, and creating a fun and lively atmosphere where nurses want to work. 

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Cindy Wong
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