What is the Minimum Data Set Final Rule?

The Minimum Data Set (MDS) as a part of the Resident Assessment Instrument (RAI) was developed by the Health Care Financing Administration to assist Medicare/Medicaid certified nursing homes in developing a comprehensive care plan for each resident. The Institute of Medicine (IOM) report in 1986 identified uniform resident assessment as essential to improvement in the quality of care delivered to residents and reform of the survey process. When the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) became law in 1987, HCFA began a process of public comment leading to a final rule implementing the law. The process was completed on December 22, 1997. The Final Rule on the MDS includes the requirement to electronically encode and transmit all MDSs to the State in which each facility is licensed.

How does the MDS Final Rule affect Nursing?

The Final Rule specifies the responsibilities of facilities and nurses to complete the Resident Assessment Instrument (RAI), to encode the MDS in electronic format, and to transmit all MDSs to their State. The Final Rule is primarily concerned with the clinical and quality aspects of the Resident Assessment Instrument (RAI) and resident care. It complements the PPS rule, but applies to all residents of nursing facilities, while the PPS rule only affects residents in Medicare Part A stays.

What is the Minimum Data Set?

The Minimum Data Set is a standardized assessment instrument specified by HCFA and optionally supplemented by States (with approval from HCFA) which collects administrative and clinical information about residents. The MDS is a very complete and well-designed assessment which, when used with the Resident Assessment Protocols and professional judgment, is a comprehensive assessment and care planning tool. The use of the MDS is specified in the Long Term Care Resident Assessment Instrument User's Manual, Version 2.0 (MDS Manual). This manual is an essential reference for all nurses in nursing facilities.

The MDS collects assessment information on each resident's characteristics, activities of daily living (ADLs), medical needs, mental status, therapy use, and other things involved in comprehensive planning for resident care.

How is the Minimum Data Set used within Skilled Nursing Facilities?

The MDS is used to assess every resident in Medicare or Medicaid licensed facilities on admission, with a quarterly review and annual re-assessment. Significant change in a resident's condition causes a new comprehensive MDS (including review of the care plan) to be completed to insure the resident receives appropriate care.

For residents in Medicare Part A stays, the MDS is also used to determine payment. It is completed on the 5^th, 14^th, 30^th, 60^th and 90^th days following admission to the Medicare stay (or re-admission). The most relevant date for Medicare PPS purposes is the Assessment Reference Date (item A3a on the MDS form) with the other completion dates following as specified in the Final Rule and HCFA's Questions and Answer documents on the HCFA website.

The MDS can serve as the primary clinical assessment tool for all residents within nursing facilities. Using the concept of triggers and RAPS makes the MDS a comprehensive assessment. The MDS (with additional triggered assessments) is sufficient for most care setting. Other assessment forms in use in facilities should be examined for overlap with the MDS and duplicative forms eliminated.

What are the penalties for intentionally falsifying the MDS?

The Final Rule for MDS provides sanctions for intentionally falsifying MDSs: fines of up to $1,000 for each MDS a nurse falsifies, and a fine of up to $5,000 for each MDS that someone causes to be falsified. (Clinical disagreement does not constitute fraud or falsifying - if it is a legitimate clinical issue.) Accurately portraying the resident is the goal. If reviews by other clinicians identify inaccuracies in an MDS, changing the MDS to reflect the resident accurately is expected. Changes made to secure a higher payment, which are not supported by the registered nurse's assessment, may lead to sanctions.

What are Resource Utilization Groups?

Resource Utilization Groups (RUG-III) is a case mix system which sets payment based of the resources expected to be used to care for a resident based on the functional support requirement and medical needs of each resident. There are 44 groups used in the Medicare PPS program. (There are several alternative RUG-III groupings used in State Medicaid programs and for research purposes. Skilled Nursing Facilities must use the current Medicare RUG-III index.)

Resources are what the system pays for. Resources paid for include:

Time

Nursing (RN, LPN, aide)

Rehab (OT, PT, SLP, assistant, aide)

Non-rehab ancillaries

Medical supplies

Medications

Lab

Respiratory therapy

Radiology

General Services

Building and grounds maintenance

Dietary

Laundry

Activities

Capital

Buildings

Equipment

Utilization is how much resource is used to care for residents.

Time was collected using Staff Time Measurement studies to actually associate the direct time staff spent with residents, time spent on behalf of residents, and other time associated with the operation of the nursing facility. Time was collected from good facilities in 12 states. ("Good" facilities had no deficiencies on their last survey, and were acceptable to their Fiscal Intermediary and the State licensing office.

Cost reports provided costs of labor and services.

Claims provided non-rehab ancillary costs,

Groups are the grouping determined through analysis to identify residents with similar characteristics using similar resources

An MDS 2.0 was completed on each resident during the study period.

Sophisticated grouping analysis and a final review by an external panel of experts determined the final groups.

What is the relationship between MDS and RUG-III?

The MDS collected during the Staff Time Studies was the basis of the groups, the independent variable in the analysis. The MDS on a resident is analyzed using grouper software to determine the RUG-III group to which the resident belongs. The RUG-III directly determines the payment for each day of the resident's stay.

The RUG-III grouper uses 108 MDS 2.0 items to calculate the RUG-III score.

Thus, the MDS is used to calculate the RUG-III group, but the MDS is a separate process from the RUG-III system.

How is RUG-III calculated?

Using the MDS, the grouper program first calculates an ADL score, a depression index, and a cognitive performance score. It then identifies each of the major groupings for which the resident is qualified. It then compares the payment level of each group, and reports the highest paying group.

While it is technically possible to calculate a RUG-III by hand, it is very time consuming, and very difficult to do accurately. Use a grouper!

The ADL index, depression index and cognitive performance scales are also very useful clinically! They can help identify residents with depression and help guide the care planning to help the resident cope or resolve the depression. The cognitive performance scale can assist during care planning to set realistic goals for residents, as well as to identify changes in cognition that could be reversed or treated.

What is the relationship between RUG-III and payment?

Each of the 44 RUG-III groups has a specific daily payment associated with it. The federal payment for each RUG-III group is the same for all facilities in a geographic area. The payment level will vary by geographic area.

What is the schedule of MDS for PPS?

The RUG-III level set by the MDS determines the payment for specific days of the resident's stay. The day of admission counts as day one for all MDS calculations. For Medicare Part A purposes, the assessment reference date (ARD, item A3a on the MDS form) is the key date used to identify assessments. The ARD is the date at which the assessment represents the resident's condition, including a common point to count back for items which refer to a number of days. The assessment reference date determines the coverage period of each assessment.

MDS	Stay Days Covered	Assessment Reference Date	Grace Days
5 day	1-14 day	1-5	3
14 day	15-30	11-14	5* (if not OBRA)
30 day	31-60	21-29	5
60 Day	61-90	50-59	5
* If the 5 day assessment is completed as a comprehensive assessment with RAP and care plan, then the 14 day assessment can utilize the 5 grace days. OBRA requires a comprehensive assessment be complete by day 14.

If the resident leaves the facility and is admitted to another facility, and returns, the schedule of assessments starts over. If the resident experiences a significant change in condition, a new comprehensive assessment is required, and will set a new payment level until the next scheduled assessment. Note that all scheduled assessments are scheduled from the admission date (or re-admission.) A special case is when all therapies are discontinued on a resident in a Rehab RUG-III group: a full assessment (or comprehensive if also a significant change in the resident's condition) is required with an assessment reference date from 8 to 10 days after the last day of any therapy.

What processes, policies and procedures should nurses put in place to support PPS?

Nurses should evaluate all resident assessment and care planning policies and procedures, and update them to prevent duplication of effort and to conform to the new requirements of PPS and the MDS final rule. Include other disciplines and staff groups to insure good communication to improve care and resident outcomes. Pre-admission screening needs to be reviewed, and the utilization review process of determining resident skill needs should be re-evaluated. The nurse, pharmacist, and medical director should coordinate a review of medical orders for new admissions to insure appropriateness of medications and treatment. Where other disciplines or staff groups are involved, including those groups in the planning will help insure good communication. Special attention should be paid to assessment procedures to insure timely and accurate assessments.