Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

N F P
URSING  ACILITY  ERFORMANCE 
A R T
IN  SSESSING  ESIDENTS  IMELY 
S R
AND  UBMITTING  EQUIRED 
M D S R
INIMUM  ATA  ET  ECORDS 
Inspector General 
April 2005 
OEI-06-02-00730  Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs. This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs/its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 
and program evaluations (called inspections) that focus on issues of concern to the 
department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs. The OEI also 
oversees State Medicaid fraud control units, which investigate and prosecute fraud and 
patient abuse in the Medicaid program. 
Office of Investigations
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations. The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department. The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidances, renders advisory opinions on OIG sanctions to 
the health care community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y   
OBJECTIVE 
To determine the extent to which Medicare/Medicaid-certified nursing 
facilities meet Federal requirements to (1) assess residents according to 
the required time schedule; (2) submit records to the Minimum Data Set 
(MDS) Repository within the prescribed timeframe; and (3) submit 
records for all residents in Medicare/Medicaid-certified beds, as 
required. 
BACKGROUND 
Medicare/Medicaid-certified nursing facilities are required to assess the 
clinical and functional status of residents and submit assessment 
records to States for inclusion in the national MDS Repository 
maintained by the Centers for Medicare & Medicaid Services (CMS).  
MDS data are used by nursing facilities for resident care planning and 
by Federal and State governments for nursing facility payment 
determinations and long term care quality assurance purposes. 
Because of the importance of these uses, it is vital that facilities meet 
Federal MDS requirements and that the MDS database contains 
current information about its intended resident population. 
Federal law requires facilities to assess residents according to a set 
periodic schedule and submit MDS records within 1 month of 
completion.  Facilities must submit records of all residents in certified 
beds for inclusion in the national MDS Repository.  However, facilities 
must properly code records of residents in beds that are not certified by 
the Medicare/Medicaid programs to ensure that these records are not 
included in the national MDS Repository. 
To determine the extent to which facilities assess residents on time and 
submit resulting MDS records within the prescribed timeframe, we 
examined data from the national MDS Repository for a representative 
sample of 250 certified nursing facilities.  Our study covered the period 
of April 2002 to June 2003.  To determine the extent to which facilities 
correctly submit resident records, we compared MDS data to a list of 
residents present at the time of each sample facilitys latest standard 
survey performed during our study period. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  i  E X E C U T I V E   S U M M A R Y

FINDINGS 
Facilities performed 95 percent of resident assessments on time.  
Among the various types of required assessments, facilities performed 
both admission and quarterly assessments according to the schedule  
95 percent of the time and annual assessments 91 percent of the time. 
Among the 5 percent of the required admission and quarterly 
assessments that were late, half were dated within 7 days after the 
scheduled completion date. 
Facilities submitted 94 percent of resident records to their State 
MDS databases within the prescribed 31-day timeframe.  In fact, 
facilities submitted 70 percent of MDS records within 14 days2 weeks 
earlier than the 31-day required timeframe for submitting records. 
Among the 6 percent of records submitted late, half were submitted 
within 18 days after the required submission date. 
Facilities submitted records for 99.9 percent of residents in 
Medicare/Medicaid-certified beds, as required.  This high level of 
performance demonstrates that facilities have virtually no problems in 
meeting requirements for submitting MDS records of required residents 
to State databases for inclusion in the national MDS Repository. 
However, coding errors by facilities resulted in records for an 
estimated 1,812 residents in noncertified beds being 
inappropriately included in the national MDS Repository.  Facilities 
in certain States (about 9 percent of facilities overall) operate with some 
beds that are not Medicare/Medicaid-certified.  Records of residents in 
these beds should not be included in the national MDS Repository. 
However, we found records for an estimated 1,812 residents in such 
beds in the Repository.  Staff from these facilities in our sample 
reported some confusion over requirements for identifying and coding 
records for these residents.   
RECOMMENDATION 
Overall, our analysis verifies a high degree of facility performance 
resulting in a national MDS Repository that is current and 
representative of its intended resident population.  However, we 
recommend that CMS take additional action to ensure that facilities 
correctly code records of residents in noncertified beds so that no such 
records are included in the national MDS Repository. 
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Agency Comments 
In response to our recommendation, CMS indicated specific actions it 
plans to take to ensure that records for residents in noncertified units 
are not transmitted and stored in the MDS Repository. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  iii    T A  B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY ......................................... i

INTRODUCTION ................................................ 1

FINDINGS ....................................................... 5

Facilities assess residents on time........................... 5 

Facilities submit records within the prescribed timeframe  ...... 5 

Facilities submit records of required residents ................. 6 

Facilities miscode some resident records...................... 6 

RECOMMENDATION ............................................ 7

ENDNOTES ...................................................... 9

APPENDIXES .................................................. 11

A:	  Detailed Methodology ................................. 11 

B: 	Descriptive Statistics, Estimates, Projections, 

   and Confidence Intervals .............................. 15 

C: 	Agency Comments .................................... 18 

ACKNOWLEDGMENTS ......................................... 20
   I N T R O D U C  T  I O N  
OBJECTIVE 
To determine the extent to which Medicare/Medicaid-certified nursing 
facilities meet Federal requirements to (1) assess residents according to 
the required time schedule; (2) submit records to the Minimum Data Set 
(MDS) Repository within the prescribed timeframe; and (3) submit 
records for all residents in Medicare/Medicaid-certified beds, as required. 
BACKGROUND 
The Medicare and Medicaid programs certify nursing facilities to provide 
skilled nursing and long term care for program beneficiaries.  Federal law 
requires Medicare/Medicaid-certified nursing facilities (hereafter referred 
to as facilities) to conduct comprehensive assessments of each residents 
functional capacity using a prescribed Resident Assessment 
Instrument.1,2  A subset of this Resident Assessment Instrument, the 
MDS is a core set of screening, clinical, and functional status elements 
 . . . that forms the foundation of the comprehensive assessment.3 Upon 
completion of each assessment, facilities are required to enter the results 
into a computer program and electronically submit records to the 
appropriate State MDS database.  In turn, the Centers for Medicare & 
Medicaid Services (CMS) routinely retrieve MDS records from each State 
database to compile a large computerized database, known as the national 
MDS Repository. 
The MDS data are used by facilities for resident care planning and by 
State and Federal programs for facility payment calculations and long 
term care oversight.  Facilities use data from the assessments to develop 
individualized resident care plans to meet the residents . . .  needs that 
are identified in the comprehensive assessment4 and to track a 
residents status between comprehensive assessments.5  The Medicare 
Part A prospective payment system uses MDS assessment data to 
determine an appropriate payment for skilled nursing facilities.6 Many 
State Medicaid programs also use MDS data in setting nursing facility 
payment rates.  CMS uses MDS data to calculate a series of quality 
measures, including the 10 Quality Indicator (QI) scores reported on the 
Nursing Home Compare Web site.7 
This inspection is part of our ongoing study of programs and systems 
affecting Medicare and Medicaid beneficiaries in certified nursing 
facilities. Because of the importance of the various uses of MDS data, it is 
imperative that the MDS database contains current information about its 
intended resident population.  To that end, facilities must comply with 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  1  I N T R O D
 U C T I O N  
requirements to assess residents on time, submit records timely, and 

submit records for required residents.

Requirements for MDS. 
Schedule for assessing residents Section 1819 of the Social Security Act, 
added by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), 
specifies a schedule for assessing residents and provides a specific time by 
which a nurse must sign the record indicating that the assessment has 
been completed.8  The schedule begins with a comprehensive assessment 
of each newly admitted resident by day 14 of his or her stay (see Table 1). 
Table 1 
OBRA 1987 Schedule for Assessing Residents 
Assessment Type  Deadline 
Admission  By day 14 after admission to facility 
Quarterly  Within 92 days of the previous assessment 
Annual  Within 365 days of the previous comprehensive assessment 
Significant Change  Within 14 days of the date of a significant change in clinical condition 
Source:  42 CFR  483.20(b-c), CMS Resident Assessment Instrument Version 2.0 Manual. 
As a residents stay progresses, a facility must conduct quarterly and 
annual assessments. Facilities must also conduct a comprehensive 
assessment whenever residents experience a significant change in their 
clinical condition.  Residents whose facility stay is covered under 
Medicare Part A must be assessed more frequently and CMS uses 
assessment data to calculate facility payments under Medicares 
prospective payment system.9 
Timeframe for submitting records Facilities must electronically submit  
records to their State MDS database within 31 days after a particular 
event, such as the completion date of a resident assessment or date of 
discharge from, or reentry to, a facility.10,11 
Submitting records of residents Facilities must submit records to State MDS 
databases for all residents who are in certified beds.  As mentioned above, 
these data are compiled by CMS in the national MDS Repository. 
Because most facilities are exclusively composed of certified beds, MDS 
records for all their residents should be included in the national MDS 
Repository. However, a relatively small number of certified facilities in 
certain States also include beds that are not certified by the 
Medicare/Medicaid programs (referred to as noncertified beds).  To meet 
MDS requirements, facilities must properly code records of residents in 
these noncertified beds so that no such records are included in the 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  2  II NN TT RR OO DD
 UU CC TT II OO NN
national MDS Repository. In practice, CMS requires facilities to indicate, 
in a specific database field, the authority (Federal, State, or neither) 
under which the record is submitted.12 CMS only retrieves those records 
with Federal authority for inclusion in the national MDS Repository. 
CMS Oversight of MDS Data. 
As part of its oversight of long term care, CMS has a number of 
management controls to facilitate proper and prompt submission of 
resident assessment data. The electronic MDS system used by facilities 
to enter assessment data uses automated warning messages to alert 
facility staff to questionable or inconsistent data as they submit records to 
State MDS databases. Further, facility and Federal and State program 
managers can generate reports that list or summarize these messages to 
identify problems or target training needs. Additionally, State survey 
agencies have authority to issue deficiency citations for noncompliance if 
surveyors find evidence of problems with late, incomplete, or inaccurate 
assessments during a facility inspection.13 Finally, in September 2001, 
CMS awarded a contract for the Data Assessment and Verification project 
to assess the accuracy and completeness of MDS data. 
METHODOLOGY 
To meet the objectives of this inspection, we examined MDS records for a 
randomly selected sample of 250 Medicare/Medicaid-certified nursing 
facilities that had a standard survey conducted between April 1, 2002, 
and June 30, 2003. (See Appendix A for a detailed description of the 
inspection methodology.) 
To determine the extent to which facilities assess residents on time, we 
examined sample facility MDS records for three types of assessments 
(admission, quarterly, and annual) to determine whether each resident 
was assessed according to the OBRA 1987 schedule. To determine the 
extent to which facilities submit MDS records within the prescribed 
timeframe, we determined whether each record was submitted within 31 
days, as required. We also identified whether sample facilities had been 
cited for a deficiency related to these timeliness requirements by State 
survey agencies during the study period. To determine the extent to 
which facilities submitted records for all residents in Medicare/Medicaid-
certified beds, we compared MDS records to lists of these residents 
present in the facility at the time of the last standard survey during the 
study period. This comparison also allowed us to determine whether 
facilities had incorrectly coded records of residents in beds not 
OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  3  I N T R O D U C T I O N  
Medicare/Medicaid certified, thereby resulting in their inclusion in the 
national MDS Repository. 
Standards 
We conducted this inspection in accordance with the Quality Standards 
for Inspections issued by the Presidents Council on Integrity and 
Efficiency. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  4  
 F I N D I N G S
Facilities performed 95 percent of  Among the various types of 
resident assessments on time    required assessments,
facilities performed both 
admission and quarterly 
Table 2  assessments according to the 
required schedule 95 percent 
Proportion of Resident Assessments 
of the time and 91 percent of 
Performed on Time  
the time for annual 
Assessments  Percent  n  assessments. (See Table 2.)  
Among the 5 percent of the 
All  95  122,559 
required admission and 
Admission  95  33,872 
quarterly assessments that 
    Quarterly  95  72,542  were late, half were dated 
within 7 days after the 
Annual  91  16,145 
scheduled completion date. 
Source:  OIG analysis of MDS assessment records. 
At the facility level, 7 percent 
of facilities (19) performed more than 20 percent of their assessments late 
and accounted for 29 percent of all late assessments.  Among these 19 
facilities in our sample, only 3 were cited by State surveyors for 
deficiencies related to the timeliness of resident assessments during the 
study period. 
Facilities submitted 94 percent of resident  In fact, facilities submitted 70 
records to their State MDS databases within  percent of MDS records within 
14 days2 weeks earlier than 
the prescribed 31-day timeframe   
the 31-day required timeframe 
for submitting records. Among 
the 6 percent of records submitted late, half were submitted within 18 
days after the required submission date. 
At the facility level, 10 percent of facilities (22) submitted more than 20 
percent of their MDS records late and accounted for 52 percent of all late 
submissions. Among these 22 facilities, only 1 had received a deficiency 
related to timely submission of resident records during the study period.  
Further, 3 of these 22 facilities were also among the 19 sample facilities 
that performed more than 20 percent of their assessments late.  None of 
these three sample facilities were cited by State surveyors for deficiencies 
related to meeting MDS timeliness requirements during the study period. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  5  F I N D I N G S  

For 89 percent of facilities, we 
Facilities submitted records for 99.9 percent 
found records in the national 
of residents in Medicare/Medicaid-certified 
MDS Repository for every 
beds, as required 
resident occupying a certified 
bed at the time of the last 
standard survey during the study period.  While the other 11 percent of 
facilities omitted records for at least 1 resident occupying a certified bed, 
only 1 facility out of 244 sample facilities omitted records for 3 or more 
required residents.14  Projecting the small error rate to the population of 
residents in certified beds, records for an estimated 2,195 residents were 
erroneously omitted from the national MDS Repository, which contains 
records for about 1.5 million residents.  This high level of performance 
demonstrates that facilities have virtually no problems meeting 
requirements for submitting MDS records of required residents.   
Only an estimated 9 percent of 
Coding errors by facilities resulted in 
Medicare/Medicaid-certified 
records for an estimated 1,812 residents in 
nursing facilities nationwide 
noncertified beds being inappropriately 
were operating any noncertified 
included in the national MDS Repository 
beds during the study period.15 
However, 40 percent of these 
facilities miscoded the submission authority for records of at least one 
resident in a noncertified bed, thereby causing those records to be 
included in the national database.   
The primary cause of such records being included in the national MDS 
Repository was facility confusion over requirements regarding records of 
residents in noncertified beds.  Representatives of these facilities reported 
an incorrect belief that their facility should submit records for all 
residents under Federal authority regardless of bed classification or 
reported that staff were unaware of the certification status of a residents 
bed.16 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  6  
 R E C O M M E N  D A T  I O N  
Overall, our analysis verifies a high degree of facility performance 
resulting in a national MDS Repository that is current and representative 
of its intended resident population, with few exceptions. Nearly all 
facilities performed well in assessing residents on time, submitting 
records timely, and submitting records of residents in certified beds.  
However, confusion over requirements for identifying and coding records 
of residents in noncertified beds resulted in the inclusion of such records 
in the national MDS Repository. 
We recommend that CMS ensure that nursing facilities correctly 
code records of residents in noncertified beds so that no such 
records are included in the national MDS Repository. 
CMS could target education to facilities that include noncertified beds.  
We recognize that CMS has previously taken steps to instruct facilities 
regarding designation of the authority (Federal, State, or neither) under 
which a facility is submitting an MDS record.  However, interviews with 
facility staff suggest that some confusion remains.   
CMS could also enhance the MDS software it makes available to facilities 
to simplify the coding of record submission authority.  CMS previously 
suggested such an enhancement to MDS third-party software vendors. In 
its 2001 Draft Provider Instructions Regarding Authority to Submit MDS 
Records and Use of the Sub_Req Field,17 CMS suggested that vendors 
include a room and bed registry feature which would identify the 
certification status of resident locations and automatically code their MDS 
records with the appropriate submission authority.  CMS should consider 
whether it would be practical and beneficial to include this enhancement 
in its MDS software. 
___________ 
OIG will separately furnish CMS with information regarding our sample 
records of residents whose assessment information was miscoded, so that 
CMS may remove these data from the national MDS Repository.  For 
possible followup, we will also identify and provide CMS with a list of 
sample facilities that performed poorly in assessing residents on time and 
submitting records timely, yet had not been cited with deficiencies by 
State survey agencies. 
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Agency Comments 
In response to our recommendation, CMS indicated specific actions it 
plans to take to ensure that records for residents in noncertified units are 
not transmitted and stored in the MDS Repository.  These actions include 
informing State survey agencies and MDS coordinators of the need for 
providers to properly code MDS records to accurately reflect resident 
categories and conducting analysis to explore improving the next version 
of its MDS freeware to assist providers in making these determinations. 
The full text of CMSs comments is presented in Appendix C. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  8    E N D N O T E S   
1 Social Security Act, Sections 1819(b)(3) and 1919(b)(3).  
2 42 CFR  483.20. 
3 The Centers for Medicare & Medicaid Services, Resident Assessment 
Instrument Version 2.0 Manual, pp. 1-1, 1-4. 
4 42 CFR  483.20(k)(1). 
5 The Centers for Medicare & Medicaid Services, Resident Assessment 
Instrument Version 2.0 Manual, p. 2-15. 
6 The Centers for Medicare & Medicaid Services, Resident Assessment 
Instrument Version 2.0 Manual, p. 2-40.  The MDS system assigns a 
Resource Utilization Group (RUG-III) code to each resident.  That code 
determines the reimbursement rate when included on a Medicare bill. 
Bills submitted without a RUG-III code may only be eligible for a reduced 
default rate. 
7 Additionally, State survey agencies use MDS-based Quality Indicator (QI) 
reports to prepare for inspections of facilities.  MDS data provide facility 
administrators and government program managers with a valuable 
source of information about residents and their care needs. 
8 42 USC  1395i-3(b)(3)(c).  Parallel authority for the Medicaid Program 
may be found at Section 1919(b)(3) of the Social Security Act 
(42 USC  1396r(b)(3)). 
9 Medicare PPS requires assessments at days 5, 14, 30, 60, and 90, and 
after any significant change in clinical condition.  OBRA 1987 
assessments may be used to meet Medicare PPS assessment 
requirements whenever timeframes coincide.  For example, an admission 
assessment could be used as the 14-day Medicare PPS assessment for 
billing purposes.    
10  42 CFR  483.20(b)(3). 
11  The Centers for Medicare & Medicaid Services, Resident Assessment 
Instrument Version 2.0 Manual, p. 5-3.   
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  9  12 To make this designation, facilities must indicate one of three options in 
a field called SUB_REQ for each resident record.  Federal authority 
(value=3) indicates an MDS record for a resident in a 
Medicare/Medicaid-certified unit.  CMS is authorized to collect MDS 
information for these residents.  State authority (value=2) indicates an 
MDS record for a resident in a unit that is neither Medicare nor 
Medicaid certified, but from a State that requires record submission 
nevertheless.  No authority (value=1) indicates an MDS record for a 
resident in a unit that is neither Medicare nor Medicaid certified, and 
neither the State nor Federal governments have authority to collect 
MDS information for residents in this unit.   
13 The specific deficiencies include F-272, performing assessments; F-273, 
timely admission assessments; F-274, timely assessments for significant 
change in status; F-275, timely annual assessments; F-276, timely 
quarterly assessments; and F-287, timely submissions.  
14 We were unable to contact representatives of this facility due to an 
ownership change and pending legal issues. 
15  This estimate results from a projection that 1,410 of the 16,236 facilities 
were operating noncertified beds during the study period, based upon 
our sample, as verified by documentation obtained during data 
collection. 
16  We attempted to contact representatives for the nine sample facilities 
identified as having incorrectly coded records for three or more residents 
in noncertified beds and spoke to six of them.  After multiple attempts, 
we were unable to speak with the appropriate individuals from the 
remaining three facilities.  
17 The Centers for Medicare & Medicaid Services, Long-Term Care 
Resident Assessment Instrument Version 2.0, Draft Provider 
Instructions Regarding Authority to Submit MDS Records and Use of 
the Sub_Req Field, Revised October 2001. 
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Detailed Methodology 
The population for this inspection is the 16,236 certified nursing 
facilities that had a standard survey conducted between April 1, 2002, 
and June 30, 2003, as identified in the Online Survey and Certification 
and Reporting (OSCAR) database. Because State survey agencies are 
required to conduct standard survey inspections every 15 months, this 
population includes all certified nursing facilities operating during the 
study period, with the exception of any facilities that were not inspected 
as required. The report findings are projectable to this population of 
facilities and, within this population and study period, to their 
assessments performed under the OBRA 1987 schedule, records 
submitted to the national MDS database, and residents in certified or 
noncertified beds.  Report findings do not address the extent to which 
facilities assessed residents according to the schedule for assessments 
associated with the Medicare Part A prospective payment system, 
because over half of these records in the MDS database had neither an 
admission date nor a reentry datedates required for analysis.  
Sample 
We used a stratified sample design to randomly select facilities for 
review.  Using information in OSCAR, we determined whether each 
facility had any noncertified beds.  As mentioned, facilities must code 
records of residents in noncertified beds differently than those of 
residents in certified beds.  We grouped facilities into two strata:  
those with only certified beds and those with both certified and 
noncertified beds.  Facilities were identified as including both 
certified and noncertified beds when OSCAR data indicated that the 
total facility bed count was greater than the total number of certified 
beds in the OSCAR database.  We randomly selected 150 facilities 
from the stratum of facilities with only certified beds and 100 
facilities from the stratum of facilities with certified and noncertified 
beds. (See Table 3.) 
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Table 3 
Sample Design of Certified Nursing Facilities With 
Standard SurveysApril 2002 Through June 2003 
Population of 
Stratum  Sample 
Facilities 
Facilities With Only Certified Beds 14,523  150 
Facilities With Certified and Noncertified Beds 1,713  100 
  Total  16,236  250 
 Source:  OIG analysis of OSCAR data. 
Note that this design resulted in a sample of 250 facilities with certified 
beds (all facilities in both strata) and includes 100 facilities with some 
noncertified beds in addition to their certified beds.  Facilities with 
certified and noncertified beds were oversampled to ensure adequate 
representation of these facilities for analysis purposes. 
Data 
MDS Records We extracted all MDS records for the 250 sample facilities 
from the national MDS Repository for the 15-month sample period.  
This process identified 272,549 resident records, which included all 
assessments along with discharge and reentry records.  Among these 
records, we identified 122,559 scheduled OBRA assessment records 
(admission, quarterly, and annual).  (See Appendix B.) 
Deficiency Data  We obtained information from the OSCAR database 
concerning any deficiencies cited by State survey agencies during the 
study period related to sample facility performance in assessing 
residents and submitting MDS records.   
Lists of Residents in Certified Beds From State survey agencies, we 
requested lists of residents in Medicare/Medicaid-certified beds at the 
time of the last standard survey.  State agencies provided complete 
listings of residents in certified beds for 244 of the 250 sample facilities, 
for a total of 21,349 residents in certified beds.  Most State survey 
agencies provided Form CMS-802, Sample/Roster Matrix, a standard 
form used during standard survey inspections.  In other cases, we 
obtained resident lists in other formats, such as surveyor tour notes and 
facility-produced census printouts or meal lists.   
Lists of Residents in Noncertified Beds We also requested from State 
survey agencies lists of residents in beds not Medicare/Medicaid 
certified at the time of the last standard survey.  Based on OSCAR data, 
we had originally selected 100 facilities identified as having some 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  12  A P P E N D I X ~ A  
noncertified beds in addition to certified beds.  However, State survey 
agency documentation revealed that only 73 sample facilities were 
actually operating noncertified beds at the time of the survey.  The 73 
facilities are composed of 71 facilities that were originally identified in 
OSCAR as having both certified and noncertified beds and 2 facilities 
that were originally identified in OSCAR as having only certified beds.  
This difference between OSCAR and State documentation appears to be 
primarily due to inaccurate/out-of-date facility bed count information in 
the OSCAR database.  State agencies provided complete listings of 
residents in noncertified beds for 65 of the 73 facilities, for a total of 
1,268 residents in noncertified beds. 
Because we did not receive lists of residents in noncertified beds for 
more than 10 percent of these facilities, we conducted an analysis to 
determine whether the nonresponse introduced bias into our statistical 
estimates. The nonresponse analysis compared the facility 
characteristics of the 65 facilities for which we did receive a list of 
residents in noncertified beds with the facility characteristics of the  
8 facilities for which we did not  receive a list of residents.  We found no 
statistical differences between the two groups based upon bed count, 
provider category, type of ownership, or profit status, suggesting that no 
bias was introduced. 
Analysis  
Assessing Residents  To determine the extent to which facilities assess 
residents according to the schedule set forth by OBRA 1987, we 
examined MDS records related to admission, quarterly, and annual 
assessments from each sample facility.  While we did not review 
assessments performed exclusively for Medicare Part A payment 
purposes, we did review those Medicare-related assessments that 
coincided with the OBRA 1987 schedule.  (See Appendix B.)  We checked 
each assessment record to determine whether the date a nurse indicated 
the assessment was completed met the schedule requirement. We 
calculated the proportion of assessments that met the schedule and the 
proportion of facilities accounting for any late assessments. We also 
identified facilities that performed a high proportion of resident 
assessments late and whether those facilities had been cited for any 
related deficiencies by a State survey agency during the study period.  
Submitting MDS Records  To determine the extent to which facilities 
submit MDS records within the prescribed timeframe, we examined all 
records submitted to the national MDS Repository by sample facilities 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  13  A P P E N D I X ~ A  
over the study period.  These records included all assessments, whether 
completed under the OBRA 1987 or Medicare Part A schedules, as well 
as resident discharge and reentry records.  We assessed each record to 
determine whether it was submitted within 31 days of the relevant 
event, such as assessment completion date or date of discharge, for the 
particular type of record.  We calculated the proportion of records that 
were submitted as prescribed and the proportion of facilities accounting 
for any late submissions.  We also identified facilities that had 
submitted a high proportion of records late and whether those facilities 
had been cited for any related deficiencies by a State survey agency 
during the study period. 
Submitting Records of Residents in Certified Beds To determine the extent 
to which records of residents in certified beds were reported to the 
national MDS Repository as required, we compared MDS records to lists 
of these residents identified during State surveys.  This analysis was 
conducted for 21,349 residents in certified beds of the 244 facilities for 
which we obtained lists from States.  Residents listed as being in 
certified beds at the time of the survey for whom MDS records were not 
found were considered missing in error, with the exception of residents 
with stays of fewer than 14 days.  We calculated the proportion of 
residents in certified beds whose records were included in the national 
MDS Repository as required, and projected this finding to the entire 
database. 
Submitting Records of Residents in Noncertified Beds To determine the 
extent to which records of residents in noncertified beds were included 
in the national MDS Repository, we compared MDS records to lists of 
these residents identified during State surveys.  This analysis was 
conducted for 1,268 residents in noncertified beds from the 65 facilities 
for which we obtained lists from States.  We initially considered as 
errors records found in the national MDS Repository of residents in 
noncertified beds at the time of the survey.  Following this initial 
identification of questionable resident records, we made a final 
determination after further examining MDS records and contacting 
representatives of facilities by telephone for clarification, as needed.  We 
calculated the proportion of residents in noncertified beds whose records 
were included in the national MDS Repository and projected this 
finding to the entire database. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  14  
 A P P E N D I X   ~   B
Descriptive Statistics, Estimates, Projections, 
and Confidence Intervals 
Sample and Analysis Descriptive Statistics:  
Assessments and Records 
Number 
Assessments 
Total OBRA Scheduled Assessments  122,559 
OBRA only  97,835 
  Medicare/OBRA combined  24,724 
    Admission Assessments  33,872 
OBRA only  11,550 
  Medicare/OBRA combined  22,322 
    Quarterly Assessments  72,542 
OBRA only  70,263 
  Medicare/OBRA combined  2,279 
    Annual Assessments  16,145 
OBRA only  16,022 
  Medicare/OBRA combined  123 
Submitted Recordsa 
All Submitted Records  272,549 
  Admission Assessment Records   33,009 
  Quarterly Assessment Records  71,692 
  Annual Assessment Records  15,958 
Medicare PPS-Only Assessment Records  55,786 
  Change in Status Assessment Records   12,509 
  Significant Correction Records  127 
  Discharge Records  65,333 
  Reentry Records  18,135 
Residents 
Total Residents on Rosters  22,617 
  Residents in Certified Beds  21,349 
  Residents in Noncertified Beds  1,268 
a Submitted records, for purposes of analysis, include only the original version of 
records, not corrections. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  15  A P P E N D I X ~ B  
Estimates and Confidence Intervalsb
Lower 95%  Upper 95% 
Confidence  Confidence 
  Estimate  Interval  Interval  n 
Assessments Performed on Time 
All Assessments   94.67%  93.40%  95.94%  122,559 
Admission Assessments  95.24%  9
 3.52%  96.96%  33,872 
Quarterly Assessments  95.28% 
 94.14%  96.42%  72,542 
Annual Assessments  90.86%  8
 8.49%  93.23%  16,145 
Median Days Late (among assessments 
performed late) = 7 
Facilities Performing More Than 
20% of Assessments Late  6.92%  3.29%  10.55%  250 
Proportion of All Late Assessments  
by Facilities Performing More Than  
20% of Assessments Late   28.49%  12.63%  44.35%  122,559 
Records Submitted Within 31-Day Timeframe 
All Records  94.07%  92.15%  95.99%  272,549 
Admission Assessment Records   94.41% 
 92.27%  96.55%  33,009 
Quarterly Assessment Records  94.33%  92.06%  
 96.60%  71,692 
Annual Assessment Records  93.03%  90.33%  
 95.73%  15,958 
Medicare PPS Assessment Recordsc
 96.37%  94.47%  98.27%  55,786 
Change in Status Assessment Records  
95.13%  92.93%  97.33%  12,509 
Discharge Records 
 92.21%  90.31%  94.11%  65,333 
Reentry Records 
 92.53%  90.18%  94.88%  18,135 
Records Submitted Within 14 Days  70.39%  64.96%  75.82%  272,549 
Median Days Late (Among 
Records Submitted Late) = 18 
Facilities Submitting More Than 
20% of Records Late  10.16%  5.71%  14.61%  250 
Proportion of All Late Records by 
Facilities Submitting More Than 
20% of Records Late  51.93%  34.45%  69.41%  272,549 
b Weighted estimates, standard errors, and projections were calculated using Sudaan statistical software. 
c Medicare assessments used for payment purposes and not combined with OBRA. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  16  A P P E N D I X ~ B  

Estimates and Confidence Intervals (continued) 
Lower 95%  Upper 95% 
Confidence  Confidence 
  Estimate  Interval  Interval  n 
Residents in Certified Beds 
Residents with Records in MDS, as Required  99.85%  99.79%  99.91%  21,349 
Residents Records Omitted from MDS 
(Error rate)   0.15%  0.09%  0.21% 
Facility Performance  
  Did Not Omit Records of Residents  88.67%  84.04%  93.30%  244 
  Omitted Records of at Least One Resident  11.33%  6.70%  15.96% 
Projections 
  Residents in Population  1,421,160  1,291,389  1,550,930  21,349 
  Residents in Population With Records  
Omitted From MDS  2,195  2,194  2,195 
Residents in Noncertified Beds 
Records Not in MDS (Coded Correctly)  92.20%  79.50%  99.58%d 1,268 
Records Inappropriately in MDS (Error rate) 7.80%  0.42%d  20.50% 
Facility Performance 
Did Not Miscode Records of Residents  60.16%  42.46%  77.86%  65 
Miscoded Records of at Least One Resident  39.84%  22.14%  57.54% 
Projections 
Residents in Population  23,230  1,268d  58,123  1,268 
Residents in Population With Records 
Inappropriately in MDS  1,812  1,799  1,825 
d The actual lower confidence interval includes 0 and the actual upper confidence interval includes 100%.  
Thus, the lower and upper limits presented here are based on sample findings. 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  17    A P P E N D I X   ~   C
Agency Comments 
  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  18  A P P E N D I X ~ C  

  OEI-06-02-00730  FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS  19  This report was prepared under the direction of Judith V. Tyler
Regional Inspector General for Evaluation and Inspections in the Dallas
Regional Offce; and Kevin Golladay, Assistant Regional Inspector
General. Other principal Offce of Evaluation and Inspections staff who
contributed include:
Blaine Collins Team Leader
Scott Whitaker Project Leader
Deborah McGurk Program Analyst
Ruth Ann Dorril Program Analyst
Tricia Davis Director, Medicare and Medicaid Branch
Program Specialist
Sandy Khoury, 
Technical Assistance
Barbara Tedesco Mathematical Statistician
Scott Horning,  Program Analyst
Kevin Farber Mathematical Statistician
OEI.06.02-00730 FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS