| The Minimum Data Set (MDS) and Annual
Survey of Nursing Homes
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of BQA 00-080 (PDF, 10 KB)
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Date: December 29, 2000 DSL-BQA-00-080
To: Skilled Nursing Facility NH 48
From: Jan Eakins, Chief, Provider Regulation and Quality Improvement Section
via: Susan Schroeder, Director, Bureau of Quality Assurance
The federal requirement for certified nursing homes to electronically
encode and submit the Minimum Data Set (MDS) to the State MDS System was previously
implemented for all resident assessments completed on or after 6/22/1998. The State MDS
System now contains over two years’ worth of nursing home resident assessment data.
Notwithstanding the requirement to submit MDS data, nursing homes are also required to
complete the Annual Survey of Nursing Homes each year. This survey [not available on
the Internet] contains several sections that could be completed using data stored in
the State MDS System. Analysis of the MDS data submitted by nursing homes during the past
two years indicates that the quality of MDS data is generally good. However, our analyses
have also identified several problems, including missing or erroneous dates and missing
assessments, particularly discharge assessments. These problems are widespread enough that
it will not be possible to use 2000 MDS data in place of the corresponding questions in
the Annual Survey of Nursing Homes. Until these problems with the completeness and
accuracy of MDS data are eliminated, nursing facilities will have to continue to provide
the same information via the Annual Survey. Fortunately, nursing facilities have the tools
needed to monitor their MDS submissions and achieve the necessary level of data integrity.
Several actions were initiated in 2000 to improve the quality of MDS data stored in the
State MDS System. Warning messages were elevated to fatal record messages, which have
prevented records with obvious errors from being accepted by the State MDS System. Nursing
homes are now able to use an automated process to correct errors in MDS records that
previously were accepted by the State MDS System. In addition, many reports have been made
available to nursing homes to access online through the State MDS System. These reports
provide information on previously submitted MDS records and missing assessments and should
be used by nursing homes to ensure data integrity and the completeness of their MDS
submissions.
Listed below are activities that will assist nursing homes in identifying problems with
MDS completion, encoding, and submission:
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Conduct quality improvement reviews of completed assessments to ensure assessments are
coded accurately and RAI definitions are followed.
-
Transmit completed MDS assessments to the State MDS System routinely. Weekly submissions
are recommended. Review all errors reported on Initial and Final Validation Reports.
Correct fatal record errors and resubmit rejected MDS records. If necessary, correct
non-fatal record errors using the automated correction process.
-
Review the online Roster Report and verify that only current residents are listed.
-
Review the online Missing Assessment Report and follow-up on any resident identified as
having missing assessments.
-
Review the online Duplicate Resident Report. Review the accuracy of resident names,
social security numbers, birthdates, and gender. Residents should only be listed once.
Contact Chris Benesh at (608) 266-1718 or Cindy Symons at (608) 266-9675 if the same
resident appears more than once on this report.
-
Review the online Error Summary by Facility Report that contains information on
non-fatal MDS record errors. Take appropriate action to prevent identified errors from
reoccurring.
The Bureau of Quality Assurance and the Bureau of Health Information are hopeful that
in the future State MDS data can be utilized with confidence and a large number of
duplicative questions can be removed from the Annual Survey of Nursing Homes. This will
only occur if nursing homes improve the accuracy of MDS assessment data and take actions
to ensure that all required MDS records, particularly discharge assessments, are submitted
timely. If you have questions regarding the RAI/MDS process, contact Billie March, RAI
Education Coordinator, at (608) 266-7188. Questions related to MDS encoding or submission
should be directed to Chris Benesh, MDS Automation Coordinator, at (608) 266-1718.
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