Jennifer LaBay​The nurse assessment coordinator (NAC) has a unique, highly specialized role in the skilled nursing facility (SNF) post-acute care setting. The NAC must possess knowledge that combines clinical, financial, and regulatory compliance information. From the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual to the Nursing Home Five-Star Quality Rating System: Technical Specifications and all the related regulations in between, there are thousands of pages of federal regulation and guidance that the NAC must understand to succeed in the role—not to mention any state-specific requirements for minimum data set (MDS) coding and Medicaid payment. Because the position is so specialized, clinical leadership must weigh the risks of utilizing the NAC to cover open nursing positions against the benefits. While temporarily shifting the NAC to an open spot may solve an immediate problem, it could also negatively affect reimbursement, quality outcomes, and the facility’s Five-Star rating.

Medicare and/or Medicaid Revenue

The MDS drives payment for Original Medicare using the Patient-Driven Payment Model. This system consists of six components: five case-mix adjusted and one non-case-mix. The five case-mix-adjusted components derive almost exclusively from MDS coding. The NAC must be not only well-versed in the MDS coding instructions but also aware of the case management intricacies involved in assessment reference date (ARD) selection and Interim Payment Assessment determinations. Both of these factors can have a significant impact on a facility’s bottom line.

In case-mix states utilizing the legacy payment systems, the MDS drives Medicaid payment as well. A NAC working the floor is not managing the Medicare or Medicaid caseloads. When finally able to complete the MDS, he or she may not have adequate time for a comprehensive review of supporting documentation. This can lead to overlooking details, such as missing documentation to support intravenous fluids, selecting the wrong ICD-10-CM codes as the primary diagnosis, or not timely setting the ARD. All of these mishaps can lead to loss of revenue or provider liability. Who manages MDS responsibilities when the NAC is working the floor? If the facility is lucky enough to have someone covering the NAC’s duties, does that person have the knowledge to do it correctly? Does the substitute know the MDS coding instructions? Is he or she aware of the timeliness requirements for setting ARDs appropriately? Is the facility following ICD-10-CM coding guidelines? These are important questions to consider when attempting to manage the staffing crisis by utilizing the NAC in other roles.

Quality Measures

Quality measures (QMs) affect many aspects of the SNF world; they drive the facility’s quality improvement efforts, influence the survey process and the Five-Star rating, and are publicly reported for consumers. There are some claims-based QMs, but most of the measures are directly based on what is coded on the MDS. If there is a delay in completing assessments due to a staffing issue, rushing to complete assessments may cause inaccuracies when insufficient time is invested in researching records. Or inadequate training of the person completing assessments can lead to inaccurate coding, as well. It is important to monitor the QMs closely when backup NACs complete assessments to identify any errors and make modifications timely.


QM reports found on the CASPER and Care Compare websites contain historical data, so facility leadership may not immediately see the effects of their staffing decisions. Publicly reported and Five-Star QMs present four quarters of data, but because there is a full quarter of lag time in reporting, the data on these reports are 6 to 18 months old. Once the QMs are calculated for public reporting, facility staff cannot make any corrections to change the data. So the only things that can shift QM numbers are the passing of time, accurate assessments moving forward, and quality improvement efforts.

Additionally, the staffing star rating uses MDS data to determine the census for hours per resident day calculations. If discharge assessments are not completed in a timely manner, the facility census will appear larger in the Five-Star census than it actually is at the facility. This can result in the publicly reported staffing calculation showing that the facility is not staffing adequately for the census, when in reality, the MDS census was incorrect due to missing discharge assessments.

The QM and staffing ratings also affect the overall Five-Star rating. If a facility is rated at five stars for staffing, a star would be added to the overall star rating. If the facility has a one star in staffing, even if due to incomplete discharge assessments, this would subtract one star from the total. If a facility is at five stars for QMs, it adds a star to the overall star rating. Dropping to four QM stars or less due to a lack of oversight and management of the MDS process harms the overall star rating. Moreover, if a facility already not performing well with QMs drops from a two-star rating to a one-star in QMs, the facility will lose a star in the overall star rating.

Managing MDS and Medicare Compliance

Therefore, before turning to the NAC to cover an open shift, nursing home leadership must consider how that vacant or inadequately filled position will affect the facility in the long run.

However, when there is no alternative and the NAC must be used to provide resident care, there are some steps leadership can take to reduce declines in quality and revenue. Ample cross-training of duties by incorporating Resident Assessment Instrument (RAI) requirements and definitions into interdisciplinary team assessments positions more staff members to contribute to the MDS process. Leadership can also optimize facility software, when possible, to prompt nursing staff for documentation based on the ARD and assessment type. If the clinical team provides documentation with knowledge of how it is used in the RAI process, it is less likely information will be missed. Also, to decrease the risk of provider liability due to missed assessments, leadership can include ARD selection in the admitting nurse’s duties. Finally, they can ensure there is a backup NAC who periodically completes assessments to keep skills up, so that if assistance is needed with MDS completion, a trained person is available to assist. Many organizations utilize floating NACs or temporary NAC agencies to assist with MDS completion. While these steps require advance preparation, they can mitigate the unintended consequences of diverting resources from the NAC role. By recognizing the vital nature of the role and enhancing the facility’s ability to fulfill NAC responsibilities, leaders can prevent something they intend as a solution from causing additional problems.

Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, is curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).