When major changes to the minimum data set (MDS) take effect October 1, 2023, they will affect many roles in addition to nurse assessment coordinators (NACs). The expected changes will require clinical leadership to update policies and review clinical and documentation practices to ensure the MDS accurately reflects the services provided. Also, the interdisciplinary team (IDT) must consider these changes when developing care plans and providing patient care. Clinical leadership, the NAC, and IDT members should apply the following tips to start preparing for coming MDS changes. ​

1. Provide tr​​aining on ethnicity, race, and culturally competent care planning.

Several data elements that focus on social determinants of health are now in the MDS, including expanded options for ethnicity and race on the upcoming MDS 3.0 Nursing Home Comprehensive Item Set, version 1.18.11. While this may initially seem like a minor change to the MDS, the IDT must consider how these items affect health, functioning, quality of life, and risks and consider these factors when developing the care plan. Appendix PP in the State Operations Manual provides the following guidance with F-tag 656: “The services provided or arranged by the facility, as outlined by the comprehensive care plan, must be culturally competent and trauma-informed.” 

Race and ethnicity will also become Standardized Patient Assessment Data Elements (SPADEs) for the Skilled Nursing Facility Quality Reporting Program (SNF QRP) starting October 1, 2023. The SNF QRP requires SNFs to report all MDS items used to calculate the SNF QRP measures and SPADEs. Required MDS items that are coded with a dash, indicating the item was not assessed, count against compliance with the SNF QRP annual payment update (APU) threshold, which mandates that at least 80 percent of MDS assessments report 100 percent of the required data elements. Noncompliance results in a 2 percent reduction to the Medicare APU for the facility for that program year.

2. Deve​​lop the process for documenting the communication of the reconciled medication list. 

Two SNF QRP process measures will also begin collecting data on discharge assessments starting October 1, 2023—the Transfer of Health (TOH) Information to the Provider and the TOH Information to the Patient. These measures rely on documentation from the discharging nurse to support that a current reconciled medication list has been provided to either the patient or caregiver or the subsequent provider as appropriate. Additionally, the documentation must demonstrate how this information was provided, whether verbally, on paper, through an electronic health record or health information exchange, or by other methods. If this process lacks supporting documentation in the medical record, the MDS will be dashed, showing there is no information or the item was not assessed. Coding these items with a dash will also count against compliance with the SNF QRP APU threshold. 

3. Provide training to the ID​T to identify and address social isolation.

A new MDS item asks the resident, “How often do you feel lonely or isolated from those around you?” It is coded with a frequency from never to always and includes options to code if the resident declines to respond or is unable to respond. However, when the IDT identifies symptoms of social isolation, it is responsible for identifying the root cause and potential risks, as well as implementing interventions to mitigate these risks. This MDS item is included in the SPADEs, but a dash is not an allowable response option for this item.

Appendix PP emphasizes the significant impact that social isolation may have and addresses it in several sections of guidance. F604, Respect and Dignity, instructs surveyors to observe for social isolation, withdrawal, and loss of self-esteem, among other indicators. Appendix PP also addresses social isolation as a potential consequence of a fall, a complication related to fecal incontinence or having a feeding tube, an adverse effect of medications, and as a manifestation related to trauma or post-traumatic stress disorder. 

4. Train n​​urses to query physicians for appropriate indication for medications. 

Several changes will likely affect Section N, Medications, with the MDS v1.18.11 this fall. Among them is the addition of anti-platelet and hypoglycemic medications to the list of high-risk drug classes coded on the MDS when received in the seven-day look-back period. However, starting October 2023, the MDS will also identify whether there is an indication of use for all medications the resident received within that drug class. All the high-risk drug classes and indication-of-use items are also considered SPADEs and, if dashed, would count against compliance with the SNF QRP APU threshold. Additionally, if the MDS indicates a medication does not have an indication for use, surveyors may use this information to identify unnecessary drugs. Appendix PP provides guidance with F-tag 757 that defines unnecessary drugs and includes “medications without adequate indication for use” as part of this definition under §483.45(d). 

Even before implementation of the new requirements, clinical leadership can strengthen processes around medications and train nurses to query physicians for an appropriate indication of use when one is not provided for a medication. However, it is important for nurses to recognize that it is outside their scope of practice to assign a diagnosis. For example, the physician orders an antibiotic after receiving the results of the a urine analysis. The nurse cannot create a new diagnosis of a urinary tract infection without having physician documentation that supports this new diagnosis. Nurses must be trained on how to follow up with the physician to gather the appropriate documentation to support the indication of use of this new medication.​

5. Review all MDS changes and develop a plan.

Clinical leadership, the NAC, and the IDT must begin preparing for 59.5 new items being added to the MDS 3.0 Item Sets, v1.18.11. However, the updated Resident Assessment Instrument User’s Manual, which will provide coding instructions for these new items, has not yet been released. Until then, facility staff will need to use the draft MDS item set to identify changes, recognize facility policies they may impact, and review procedures that may not fulfill the documentation requirements necessary to support MDS coding. 

Jessie McGill, RN

With this information, develop a plan for training staff and updating policies and procedures. Facility staff can use the Centers for Medicare & Medicaid Services’ document Overview of Data Elements Used for Reporting Assessment-Based Quality Measures and Standardized Patient Assessment Data Elements Affecting FY 2025 Annual Payment Update (APU) Determination to identify the specific MDS items. The document can be found at https://www.cms.gov/files/document/fy-2025-snf-qrp-apu-table-reporting-assessment-based-measures-and-standardized-patient-assessment.pdf. The FY 2025 program year uses calendar year 2023 data and will start including the new SPADEs and measure data starting October 1, 2023.

Jessie McGill, RN, RAC-MT, RAC-MTA, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).