How the Removal of MDS Section G Is Affecting Quality Measures, Staffing Calculations, and Five-Star Ratings

Implementing changes to the Minimum Data Sets (MDS) will have large implications for operators beyond quality assessments, and with a possible direct impact on Five Star Ratings in the coming months.

The removal of Section G and replacement with section GG is of particular concern to experts on the matter, who called upon nursing homes to adjust their process for recording the more intense details in documentation now required in MDS.

And, in order to prevent slippage in rating, it is of paramount importance that operators keep track of changes internally, especially during the period of frozen quality measures. This information along with common sense practices such as training staff for the changes and keeping referral partners in the loop should minimize any negative impact.


“The changes from removing Section G and replacing it with Section GG are really huge,” Jennifer Gross, Post-Acute Informatics Specialist at Net Health, said during a presentation on operational strategies for operators. Net Health creates specialized technology solutions for providers in areas related to wound care, rehab therapy, post-acute, and occupational health.

Gross underscored the substantial influence MDS changes will exert on reporting and operations within skilled nursing facilities. The updates have been referred to by some as “MDS 4.0,” reflecting their magnitude in affecting reimbursement, quality reporting, and the overarching care planning process, she said.

“The changes from removing Section G and replacing it with Section GG are really huge,” she said.


Gross said while section G traditionally concentrated on specific Activities of Daily Living (ADLs) over a seven-day period, in contrast, Section GG introduces a more detailed approach, incorporating both late loss and earlier loss in ADL indicators, such as walking mobility.

For example, Section G primarily looked at whether an activity was weight-bearing or not, without delving into the specific effort exerted by staff members. Section GG, on the other hand, introduces the concept of determining whether a helper, be it a CNA, nurse, or therapist, is doing more or less than half of the effort for a particular ADL activity. This shift in perspective requires a change in mindset, as a higher score in Section GG now signifies greater independence, unlike within Section G where a higher score indicated higher dependence.

The removal of Section G has an impact on various quality measures, Gross said, including new or worsening pressure ulcers for short stay, short-stay improvement in function, long-stay ADL measure, long-stay worsening mobility and incontinence measures for residents in the low-risk population.

“Now, a really significant change you might not be thinking of right now is the incontinence measure because the low risk incontinence measure which was the prevalence measure and everybody’s rate was around 40% or so, is being replaced by the percent of residents with new or worsened bowel or bladder incontinence,” she said. “So, you’re going to see a big change in your rates most likely when this change comes through.”

This alteration necessitates that Section GG be included in all assessments, which require initial or periodic assessments of all residents in a facility, impacting long-term residents and compelling facilities to adjust their assessment processes, she said.

Another notable change involves the addition of items to collect data on Social Determinants of Health (SDOH), encompassing race, ethnicity, transportation barriers, and health literacy.

“That section of the MDS has greatly expanded potential transportation barriers that the resident experiences in community health literacy,” Gross said.

Impact on Five-Star Ratings

The ripple effect extends beyond quality measures, with a direct impact on Five-Star Ratings, Gross said.

Gross highlighted that the removal of Section G not only affects the quality measure domain, but also influences the staffing domain, particularly the acuity adjustment based on RUG-IV – the latter groups nursing home residents according to their clinical and functional status.

This shift necessitates a reassessment of performance metrics and an understanding that ADL performance in Section GG does not equate to Section G, Gross said.

Specifically, the acuity adjustment in staffing, based on RUG-IV, becomes problematic without Section G. This has implications for both quality measures and staffing calculations in the Five-Star rating system.

“Without Section G you can’t calculate RUGS anymore,” she said. “It just does not work. So keep in mind that you shouldn’t make the mistake of assuming that a facility’s ADL performance in Section G will be the same in Section GG.”

Preparing for changes

Gross said that ss skilled nursing operators grapple with these profound changes, it is necessary to assess the impact on quality measures, making necessary adjustments to internal processes.

Additionally, considering the direct impact on staffing acuity adjustments for Five-Star ratings is paramount for facilities striving to maintain quality care standards.

She also recommended adapting processes related to capturing ADLs to align with Section GG requirements, keeping track of changes internally, especially during the period of frozen quality measures.

“Just to keep track internally, maybe maintain a listing on a spreadsheet of residents who have had changes in their key quality measure areas before from pre-October to post-October so that you have at least a little bit of an idea of what to expect when the QM has come back online and 2024.” she said.

She recommended providing high-level conceptual training on the impact of MDS changes on quality measures to ensure that interdisciplinary teams are well-versed in the MDS changes.

Lastly, she recommended communicating proactively with referral partners, payers, residents, and families about potential shifts in reporting and quality measures.

“External stakeholders that are not within the walls of your skilled nursing facility or within your organization, need to be kept up to speed so communication is always really important,” she said. “So firstly, [communicate with] your referral partners, the hospitals, that you’re working with your payers. Make sure that you have some talking points if you are anticipating changes in your public reporting.”