How will the 10/1/23 changes to the MDS impact the 5-Star Quality Measure rating for nursing facilities?




On 9/20/23, CMS issued QSO-23-21-NH, which announced that CMS will replace some of the Quality Measures (QMs) used on Nursing Home Care Compare, in order to accommodate the elimination of Section G in the Minimum Data Set (MDS). The MDS changes have implications for 4 of 15 QMs used in the Nursing Home Five Star Rating System. QMs impacted by the MDS G-GG transition:

      • Percentage of Residents Who Made Improvements in Function (short stay)
      • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (long-stay)
      • Percent of Residents Whose Ability to Move Independently Worsened (long stay)
      • Percent of High-Risk Residents with Pressure Ulcers (long stay)

Starting in April 2024, CMS will freeze (hold constant) these four measures on Nursing Home Care Compare. In October 2024, CMS will replace the short-stay functionality QM with the new cross-setting functionality QM, which is used in the SNF Quality Reporting Program (QRP). The remaining three measures will continue to be frozen until January 2025 while the data for the equivalent measures are collected.


Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC
Director of Regulatory Services

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