Providers focused on Five Star improvement often look to the MDS department as a driver of Five Star performance. Let’s examine the potential impact of the MDS on facility star ratings and consider key focus areas for coding accuracy…

Before jumping to the conclusion that MDS is the root cause of five star trouble, first consider the makeup of the Five Star Program and the significance of program timelines on impacting future star ratings.

The Five Star ratings are made up of:

  • Health Inspections based on a three-cycle history
  • A four-quarter average of quality measures
  • PBJ reporting for staffing for the last full quarter

The MDS department has a small impact on survey outcomes, a moderate impact on the MDS based quality measures, and affects staffing as it relates to MDS census and acuity reported on the MDS.

  • Survey – The MDS directly impacts survey outcomes based on the potential for MDS and Care Planning related citations. It is important to consider if the MDS is coded correctly by the resident assessment coordinator, and if the documentation in the chart is sufficient to support the MDS coding. There could be an educational need for the MDS nurse(s) or it may be necessary to look at the documentation schedules/requirement for the facility and shore up that program or policy. For care plan citations, assess the risk for deficiencies for an incomplete plan of care, or not following through with the plan of care. Based on the root cause, an education plan and revision of policy may need to be developed.
  • Staffing – The MDS impact on staffing is based on the MDS census reported in the iQIES systems and the MDS acuity from Case Mix Scores of the census for the time frame being reported. Providers should use the 1704D Daily MDS Census Detail and 1704S Daily MDS Census Summary reports in the Payroll-Based Journal (PBJ) report category along with the MDS roster and Missing assessment reports to ensure census reporting is correct. Periodic accuracy reviews should be completed to ensure acuity is reflected accurately per the RAI coding rules to impact the Case Mix appropriately.
  • Quality Measures – The most significant impact from MDS is on the quality measure component of the Five Star rating. There are 9 MDS based quality measures included for Five Sar reporting, and 3 claims based quality measures. Processes for systematic review of coding accuracy for the 9 MDS based quality measures should be in place, as well as accurate coding of covariates and exclusions when applicable.
    • Long Stay Quality Measures included in the Five Star Reporting
      • Percentage of residents experiencing one or more falls with major injury
      • Percentage of high-risk residents with pressure sores
      • Percentage of residents with a urinary tract infection
      • Percentage of residents with a catheter inserted and left in their bladder
      • Percentage of residents whose need for help with daily activities has increased
      • Percentage of residents who received an antipsychotic medication
      • Percentage of residents whose ability to move independently worsened
    • Short Stay Quality Measures included in the Five Star Reporting
      • Percentage of residents who made improvements in function
      • Percentage of residents who newly received an antipsychotic medication

If these areas of coding are correct, the MDS is accurate, and triggers indicate a need for clinical systems review.

The MDS has a ripple effect on facility reimbursement, quality measures and care quality. Join us for our upcoming series The Impact of the MDS beginning February 7, 2024 , where we will target what facility leaders need to know about the MDS to oversee and drive reimbursement, quality measures/QRP, Five Star success and care quality. Proactive’s MDS experts will provide clarity on crucial performance areas impacted by the RAI process, avoiding common errors and driving outcomes through MDS accuracy in your facility.




Rosanna Benbow, RN, CCM, ICC, IP, DNS-CT, QCP, RAC-CTA
Regional Director

Was this article helpful? Access weekly insights when you sign up for our weekly newsletter!