‘The Audits Are Here’: Ways Nursing Homes Can Ease Regulatory Pressures After MDS Changes

As nursing homes are still in the process of updating their procedures to align with October 2023’s MDS requirements, avoiding compliance and payment problems involves having accurate data, and it all begins with its collection.

Data collection has become a tough exercise in the midst of staffing challenges, and many facilities have yet to update their Clinical dashboards, according to Leah Klusch, Executive Director of The Alliance Training Center. Aside from training, some common sense ways beyond having good policies and practices in place, especially at the admissions stage, include having the right personnel to address the audits and sign off on the assessments.

Moreover, communication between clinical teams through regular meetings and provision of quick guides of key sections of the RAI manual will help staff stay up to date, she said. 


Facilities will benefit from ensuring team members have access to updated Minimum Data Sets (MDS) manuals with quick copies of key sections. Moreover, updated discharge practices are also needed, said Klusch.

“The audits are very much here. The first thing you have to be aware of is that a lot of audit requests are coming in the mail and you got to look at how quickly you can identify the actual audit activity,” said Klusch during a webinar hosted by the American College of Health Care Administrators (ACHCA).

And, it’s important to assign the task of opening the audit paperwork to staff dedicated to this purpose, she said.


Facilities are having to deal with a new set of functional performance documentation on all admissions as well as assessments due to the change over to Section GG. And along with that, all nursing homes have to contend with the 5-claims audits, a form of external audit on claims related to PDPM, the patient driven payment model.

“There are things that you need to look at on an ongoing basis that may not be included in some of your dashboards yet,” said Klusch. “I suggest you should have a paper manual in each building. It’s extremely important to get easy, efficient copies of parts of the manual for members of the team that you want to discuss specifics with or for orientation programs,” she said.

The new MDS requires numerous core process and management changes relating to the facility’s database, said Klusch. “If you have not changed things, if you don’t have new processes. if your team has not, not only updated some of their data collection process but some of your documentation tools, you’re not updated. You’re going to have a lot of difficulty with accuracy on your data,” she said. “Clinical and operational leadership need to have a set of policies and responsibilities so that you can document your review process and transmit the right records.”

The MDS changes have been sizable and overwhelming for facilities to implement, but the right steps can go a long way in ensuring success in data collection and succeeding at audits.

“I just totally understand and respect the size of the operational and clinical changes that we had to make to be compliant on the first of October. So first of all, [ask yourself] does your facility or your company for corporate groups have a written policy and procedure document for admissions?” she said.

Staying on top of data collection

The staffing shortages have delayed putting in place some of these common sense practices, but Klusch stressed the importance of understanding the ramifications behind inadequate data collection.

“I know we have staffing issues, but we have to understand that we are precipitating payment and regulatory oversight with our data. And so when that changes, we have to make sure that our department heads and that our teams have the information in hand that they can reference. That’s why these quick copies of parts of the RAI manual are a good idea,” she said.

Also a good idea is regular monitoring of CASPER reports. Klusch recommended delving into these reports as another easy way to access information because CASPER reports are designed to provide public health leaders and emergency managers with quick, relatively inexpensive, flexible, simply formatted information. Administrators and clinical leadership should all be monitoring these, she said.

Dedicated roles

Facilities will also benefit from adding MDS coding responsibilities and data formulation competencies to relevant job descriptions, she said, making sure the right staff is assigned certain responsibilities.

“[Be clear about] who’s responsible for documenting the essential information at the time of admission,” Klusch said.

In documentation, she also suggests reviewing the electronic management records (EMR) and making sure it captures all required MDS data.

And last but not least, staff should be provided with MDS coding manuals, including Appendix D, and other resources, to staff conducting resident interviews.

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