Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Nursing Home Resident Assessment 
Quality of Care 
JUNE GIBBS BROWN 
Inspector General 
JANUARY 2001 
OEI-02-99-00040  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of

Inspector General.  It conducts short-term management and program evaluations (called

inspections) that focus on issues of concern to the Department, the Congress, and the public.  The

inspection reports provide findings and recommendations on the efficiency, vulnerability, and

effectiveness of departmental programs. 

OEI's New York regional office prepared this report under the direction of John I. Molnar,

Regional Inspector General, and Renee C. Dunn, Deputy Regional Inspector General.  Principal

OEI staff included:

REGION  HEADQUARTERS

Danielle Fletcher, Lead Analyst  Susan Burbach, Program Specialist

Lucille Cop  Barbara Tedesco, Mathematical Statistician

Vince Greiber  Linda Moscoe

Steve Shaw  Brian Ritchie

* All staff in the New York Regional Office participated in this inspection. 
To obtain copies of this report, please call the New York Regional Office at 212 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.hhs.gov/oig/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To assess the current state of practice of implementing nursing home resident assessments. 
BACKGROUND 
The Office of Inspector General undertook a series of nursing home inspections examining 
the quality of care in nursing homes. This report is a part of that series. A companion 
report  Nursing Home Resident Assessment: Resource Utilization Groups reviews the 
integration of the skilled nursing facility prospective payment system with the resident 
assessment. 
The Nursing Home Reform Act mandates that nursing homes use a clinical assessment 
tool known as the Resident Assessment Instrument to identify residents strengths, 
weaknesses, preferences, and needs in key areas of functioning.  This assessment is an 
integral part of the residents medical record.  It is designed to help nursing homes 
thoroughly evaluate residents and provides each resident with a standardized, 
comprehensive, and reproducible assessment.  Upon completion of the assessment, the 
information guides the team to prepare individualized care plans for each resident.  The 
minimum data set (MDS) is a component of the resident assessment which contains a 
standardized set of essential clinical and functional status measures. Triggers from the 
minimum data set identify conditions for additional assessment and review, and cause the 
nursing home to further evaluate a resident using Resident Assessment Protocols (RAPs) 
which lead to the care plan. 
This inspection is based on information gathered from three different sources: a medical 
review of nursing home medical records for a sample of 640 nursing home residents, a 
self-administered survey of 64 nursing home MDS coordinators, and a telephone survey of 
64 nursing home administrators. 
FINDINGS 
Generally, nursing homes follow a systematic process when implementing 
Resident Assessments 
All MDS coordinators report that an interdisciplinary team evaluates each resident and 
participates in the completion of the MDS form.  Almost all facilities, 81 percent, have a 
full time registered nurse in the MDS coordinator position.  Almost all nursing homes have 
i 
Nursing Home Resident Assessment  OEI-02-99-00040  some kind of ongoing training for staff that participate in the MDS.  A review of signed 
MDSs indicates that 85 percent of nursing homes had at least four professionals assess 
each resident. 
However, we found differences between the MDS and the rest of the medical 
record, some of which may affect care planning 
Differences 
A medical record review of the MDS shows an average of 17 percent of the 406 fields for 
each resident are different from the medical record.  We determined a difference to exist 
when our reviewers assessment did not match that of the nursing home. An explanation 
of possible reasons for this are discussed in the body of the report. 
One of the highest rates of difference is 31 percent in section G, Physical Functioning and 
Structural Problems.  The goal of this section is to assess the resident and develop a plan 
of care that maintains or improves the residents level of involvement in their activities of 
daily living.  This is to assure the resident is functioning at his or her highest potential. 
Many MDS coordinators (40 percent) report section G is the most difficult to complete, 
and 20 percent of the MDS coordinators report that they would make changes to section 
G.  This is one of the most subjective sections of the MDS. 
Resident Assessment Protocols 
Resident Assessment Protocols, or RAPs, flow from the MDS and guide the residents 
plans of care.  In practice, there are key elements or questions in the MDS that when 
answered in a specific way trigger one of 18 RAPs.  Seventy-six percent of the RAP 
decisions were the same for both our reviewers and the nursing home.  However, in 14 
percent of the records, the RAP was not triggered by the nursing home when our 
reviewers indicated one was triggered, and subsequently no care plan was developed for 
the resident.  In 11 percent of the records, the nursing home triggered RAPs when our 
reviewer did not.  Again, possible reasons are discussed in the body of the report. 
Care planning 
When reviewing whether there were care plans generated from the RAPs for our sample 
residents, we found that 26 percent of triggered RAPs do not have care plans.  One 
possible explanation for lack of care planning is that the medical issue may have been 
addressed, resolved, or included in another RAP. 
ii 
Nursing Home Resident Assessment  OEI-02-99-00040  Plans of care are generally being followed 
We also reviewed the progress notes for 30 days after the care planning date to determine 
whether the care plan was implemented.  Thirty-day progress notes from the medical 
record indicate follow up by the staff on almost all care plans.  Almost all MDS 
coordinators agree that care plans evolve from the MDS evaluations and their direct care 
staff use the care plans to provide treatment to the residents.  The director of nursing, 
MDS coordinator, or the direct care nurse is usually responsible for assuring that the care 
plan is implemented.  All MDS coordinators report reviewing the plan of care on some 
schedule.  Almost three-quarters of the coordinators report that the care plan is reviewed 
quarterly; more than 80 percent say it is reviewed as needed. 
RECOMMENDATIONS 
Clearly, nursing homes are attempting to systematically complete the MDS and implement 
the plans of care.  However, they are having difficulty administering an inherently complex 
process.  There are apparently differences in nursing home staffs understanding of the 
MDS and the resident assessment process. 
Based on our findings and the concerns of the nursing home MDS coordinators and 
administrators, we recommend that HCFA: 
<  more clearly define MDS elements, especially section G, and 
<	 work with the nursing home industry to provide enhanced and coordinated training 
to nursing homes to be sure that similar and accurate information about the MDS 
is being disseminated. 
AGENCY COMMENTS 
We received comments from the Health Care Financing Administration.  They concur with 
both of our recommendations and describe a number of important steps they are taking to 
improve understanding and implementation of the resident assessment, particularly the 
MDS.  We appreciate HCFAs thoughtful consideration of our report. 
The HCFA also provided technical comments which we have incorporated in the report. 
The full text of the comments is provided in Appendix C.  This also contains HCFAs 
comments on our companion report about the relationship between the resident 
assessment and the reimbursement system.  We discuss these comments in the other 
report. 
iii 
Nursing Home Resident Assessment  OEI-02-99-00040  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i

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

FINDINGS 
Nursing homes follow a systematic process  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Differences may affect care planning  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Plans of care are being followed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  15

APPENDICES 
A: Confidence Intervals  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

B: Minimum Data Set  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

C: Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

iv 
Nursing Home Resident Assessment  OEI-02-99-00040  I N T R O D U C T I O N  
PURPOSE 
To assess the current state of practice of implementing nursing home resident assessments. 
BACKGROUND 
The Senate Special Committee on Aging held hearings in the summer of 1998 following 
reports by the Health Care Financing Administration (HCFA) and the General Accounting 
Office (GAO) of serious concerns about nursing home residents' care and well-being. 
Subsequently, the Office of Inspector General (OIG) undertook a series of nursing home 
inspections examining the quality of care in nursing homes.  They include trends in 
reported abuse among residents, the role of the ombudsman in protecting residents, the 
capacity of the State survey and certification program, the trends in the Online Survey 
Certification and Reporting System (OSCAR) data, the access of nursing home survey 
results and access to nursing homes.  This report is a part of that series.  A companion 
report  Nursing Home Resident Assessment: Resource Utilization Groups, reviews the 
integration of the skilled nursing facility prospective payment system with the resident 
assessment. 
Generally a nursing home is a residential facility which offers daily living assistance to 
people who are either physically or mentally unable to live independently.  Residents are 
provided rooms, meals, assistance with daily living, and, in most cases, some medical 
treatment for those residents who require it. 
Medicare Part A can help pay for skilled nursing facility (SNF) care for up to 100 days in 
a benefit period when a beneficiary meets certain conditions.  These conditions include a 
requirement of daily skilled nursing or rehabilitation services, a prior three consecutive day 
stay in a hospital, admission to the SNF within a short period of time after leaving the 
hospital, treatment for the same condition that was treated in the hospital, and a medical 
professional certifying the need for daily skilled nursing or rehabilitation care.  In 1990 
Medicare paid $1.7 billion to nursing homes. In 1998 this amount had increased to $10.4 
billion1.  Medicare pays only a small portion of the nations nursing home bills.  Most bills 
are paid by personal funds, purchased long-term care insurance, and Medicaid. 
1
U.S. Department of Health and Human Services, Health Financing Administration, Office of the Actuary, National 
Health Statistics Group: http://www.hcfa.gov/stats/nhe-oact/tables. 
1 
Nursing Home Resident Assessment  OEI-02-99-00040  Medicaid coverage varies among States.  Medicaid eligible beneficiaries who require 
custodial care such as help with eating, bathing, taking medicine and toileting, as well as 
those who require skilled care may have a nursing home stay paid by Medicaid.  Medicaid 
payments to nursing homes in 1996 totaled $40.6 billion.  Despite the increase in Medicare 
and Medicaid payments, concern remains about the quality of care in nursing homes. 
In 1986 the Institute of Medicine conducted a study on nursing home regulation and 
reported prevalent problems regarding the quality of care for nursing home residents and 
the need for stronger Federal regulations.  In 1987 the GAO reported that over one third 
of nursing homes were operating under the Federal minimum standards. This report, along 
with widespread concern regarding nursing home conditions, led Congress to pass the 
Omnibus Budget Reconciliation Act (OBRA 1987).  As a part of OBRA 1987, Congress 
passed the comprehensive Nursing Home Reform Act (P.L. 100-203), expanding 
requirements that nursing homes have to comply with prior to Medicare or Medicaid 
certification. 
The Resident Assessment 
The Nursing Home Reform Act mandates that nursing homes use a clinical assessment 
tool known as the Resident Assessment Instrument (RAI) to identify residents strengths, 
weaknesses, preferences, and needs in key areas of functioning.  The RAI is designed to 
help nursing homes thoroughly evaluate residents and provides each resident with a 
standardized, comprehensive, and reproducible assessment. With consistent application 
of item definitions, the RAI ensures standardized communication both within the facility 
and between facilities.  Basically, when everyone is speaking the same language, the 
opportunity for misunderstanding or error is diminished considerably.2 
The RAI was developed by a research consortium under contract with the the health Care 
Financing Administration (HCFA) and consists of three key components: the Minimum 
Data Set (MDS), Triggers and Resident Assessment Protocols (RAPs), and Utilization 
Guidelines.  Most States required nursing homes to begin implementing the RAI in 1991. 
It was intended that the RAI be a dynamic tool, and HCFA began developing version 2.0 
of the RAI in early 1993 which is now in use.  The HCFA is committed to continuous 
reviews and updates. 
The RAI is intended to be completed by an interdisciplinary team of nursing home staff 
who gather facts about the residents strengths and needs. The interdisciplinary team 
should ideally include dieticians, speech, physical and occupational therapists, social 
workers, pharmacists, and nurses. The attending physician is also an important participant 
2
U.S. Department of Health and Human Services, Health Care Financing Administration, Long Term Care Resident 
Assessment Instrument Users Manual Version 2.0 October, 1995. 
2 
Nursing Home Resident Assessment  OEI-02-99-00040  in the RAI process providing valuable input on sections of the MDS and RAPs.  Federal 
regulations require each individual who completes a portion of the RAI to sign, date, and 
certify its accuracy.  Regulations also require a registered nurse sign and certify that the 
assessment is complete.  Upon completion of the assessment, the information guides the 
team to prepare individualized care plans for each resident. 
The Minimum Data Set 
The MDS 2.0, a component of the RAI, contains a standardized set of essential clinical 
and functional status measures.  It must be collected on every resident in the nursing home 
at regular intervals during their nursing home stay regardless of the method of payment. 
Nursing homes are required to conduct initially and periodically a comprehensive, 
accurate, standardized, reproducible assessment of each residents functional capacity. 3 
All residents must be completely assessed in the first 14 days after admission, promptly 
after a significant change in their physical or mental condition, and at least once every 12 
months.  Additionally, all MDS assessments must be reviewed at least every 3 months to 
assure continued accuracy.  The prospective payment system was phased into nursing 
homes in July of 1998, and all nursing homes were expected to comply with the new 
system in January of 1999.  Skilled nursing facilities are required to classify residents into 
one of 44 Resource Utilization Groups (RUGs-III) based on assessment data from the 
MDS for reimbursement.  Since the implementation of the prospective payment system 
there is a more frequent MDS schedule for those residents reimbursed by Medicare Part 
A. 
Triggers and Resident Assessment Protocols 
Specific responses to MDS items alert the nursing home to potential problems for the 
resident.  These triggers are associated with specific questions on the MDS.  If one or a 
combination of MDS elements are triggered, the resident is identified as someone who has 
or may develop specific functional or clinical problems.  Triggers identify conditions for 
additional assessment and review, and cause the nursing home to further evaluate a 
resident using Resident Assessment Protocols (RAPs).  Triggers indicate that specific 
clinical factors are present that may or may not represent a condition that should be 
addressed in the plan of care.  The MDS responses that define triggers are specified in 
each RAP. 
The Nursing Home Reform Act requires RAPs at the 14 day comprehensive assessment, 
significant changes, and annually.  The RAPs assist in the development of plans of care. 
There are 18 RAPs in Version 2.0 of the Resident Assessment Instrument.  They include 
items such as cognitive loss/dementia, ADL function/rehabilitation, psychosocial well-
3
U.S. Department of Health and Human Services, Health Care Financing Administration, Long Term Care Resident 
Assessment Instrument Users Manual Version 2.0 October, 1995 
3 
Nursing Home Resident Assessment  OEI-02-99-00040  being, nutritional status, dehydration/fluid maintenance, and pressure ulcers. 
Plans of Care 
The theory behind the RAI is that a strong link between MDS, RAPs and care planning is 
essential to provide each resident with a solid approach to prevent avoidable decline and 
build upon current strengths.  Meaningful care planning takes into account the unique 
traits of each resident which translates into providing good quality of care and quality of 
life.  The OBRA 87 requires that each nursing home resident have a comprehensive plan 
of care.  This plan is based on information gathered by the MDS and any further review 
and assessment.  The plans of care must include measurable objectives and timetables to 
meet the resident's medical, nursing, and mental needs identified in the comprehensive 
assessment.  The services provided under the plan of care are to attain or maintain the 
residents highest practicable physical, mental, and psychosocial well-being.  The plans of 
care are to be periodically reviewed and revised when necessary after each assessment. 
MDS Coordination 
When Medicare reimbursement became linked to resident assessments, MDS coordinator 
roles became more vital to nursing homes.  MDS coordinators are generally registered 
nurses who oversee the assessments and paperwork in order to guarantee proper 
completion.  The MDS coordinators work with an interdisciplinary staff to produce the 
written and electronic documents necessary for Medicare reimbursement.  The MDS 
coordinator also assures that each residents MDS is coded accurately so that the nursing 
home is financially able to provide all necessary services. 
In addition MDS coordinators affect the quality of care of the residents.  Completing a 
thorough and accurate comprehensive assessment enables the nursing home to provide 
appropriate plans of care for each resident.  The MDS coordinators can provide a global 
picture of each resident and can spot weaknesses in their plans of care. 
Prior Studies 
The Research Triangle Institute completed a study in 1995 entitled Evaluation of the 
Nursing Home Resident Assessment Instrument that examined the effect of the resident 
assessment instrument on quality of care in nursing homes.  One finding suggested that 
administrators and directors of nursing positively accepted the RAI and believed it helped 
individualize the plans of care.  Another key finding suggested the overall quality of care 
and care planning improved in nursing homes when the RAI was implemented.  In 
addition, the study indicated that the RAI significantly reduced hospitalization rates and 
improved resident outcomes in certain areas. 
4 
Nursing Home Resident Assessment  OEI-02-99-00040  However, recent reports by the Office of Inspector General4 and another researcher5 found 
that the failure to provide comprehensive assessments was among the 10 most frequently 
cited deficiencies in nursing homes.  A 1996 study for HCFA reported that between 25 
and 30 percent of nursing homes were deficient in their development of comprehensive 
assessments and/or comprehensive care plans. 
METHODOLOGY 
This inspection is based on information gathered from three different sources: a medical 
review of nursing home medical records for a sample of 640 nursing home residents, a 
self-administered survey of 64 nursing home MDS coordinators, and a telephone survey of 
64 nursing home administrators.  We conducted our field work between June and August 
1999. 
Sample Selection 
We selected Medicare, Medicaid, and private pay nursing home residents using a three-
stage stratified, cluster sample.  First, we selected a stratified sample of eight States to 
include the four States with the most certified nursing home beds (California, New York, 
Texas, and Illinois), two States randomly selected from the four currently using a 
prospective payment system for Medicaid reimbursement in a HCFA demonstration 
project (Mississippi and Maine),  and two States randomly selected from the remaining 40 
States (Connecticut and Virginia). 
Skilled nursing facilities refers to nursing homes that participate in Medicare.  Nursing 
facilities refers to nursing homes certified to participate in Medicaid.  For the purposes of 
this study, we will refer to Medicare, Medicaid, and private pay facilities as nursing homes 
because we included all payor types for the sample selection. 
Next, we randomly chose eight nursing homes in each of the eight sample States, 
excluding nursing homes with a bed count of less than 60 to ensure a sufficient number of 
residents who fit the selection criteria.  Finally, we randomly selected 10 residents in each 
nursing home for a total of 640 residents.  This selection was made from all nursing home 
residents who were in the 64 sample nursing homes in December 1998, regardless of 
payment source.  These residents were admitted to the nursing home between July 1998 
and December 1998.  We selected the 14 day admission assessment completed for the 
resident from July to December 1998 and reviewed all the medical records prior to this 
4 
Department of Health and Human Services, Office of Inspector General, Office of Evaluations and Inspections, 
Nursing Home Survey and Certification: Deficiency Trends OEI-02-98-00330, March 1999. 
5 
Charlene Harrington, Ph.D. The Regulation and Enforcement of Federal Nursing Home Standards, 1991-1996 University of
California, Department of Social and Behavioral Sciences, March 1998. 
5 
Nursing Home Resident Assessment  OEI-02-99-00040  assessment.  Data for all samples were weighted and projected to the universe. 
Medical Review and Analysis 
Comparison with the medical record.  We obtained the services of a medical review 
contractor who employed nurses with experience in completing the MDS in nursing homes 
and in consulting and training on the MDS process to conduct the review.  These nurses 
visited each nursing home and completed a 14 day assessment based on the residents 
medical record for the same 14 day time period.  In doing so, our reviewers did not refer 
to the original MDS during their review nor did they contact the residents or the staff to 
complete their assessments.  They were instructed to complete each field of the 
assessment only if there was sufficient and reliable information in the medical record to 
warrant a determination.  Subsequently, we made a comparison of the results for each 
field.  In this way, we were able to determine if the nursing homes resident assessment 
was consistent with the rest of the medical record. 
Nine residents did not fit our selection criteria, thus leaving a sample of 631 residents.  All 
but three completed copies of the MDS were forwarded to us by the nursing home.  The 
nurses were unable to complete some fields in the MDS due to lack of information in the 
medical record6.  Most of these fields required information that was inappropriate for a 14 
day assessment.  All other fields had sufficient information for our reviewers to complete 
the MDS. 
The methodology is useful to identify differences between what our reviewers would have 
entered in the MDS based on a review of the other medical records, versus what the 
facility nurses observed in the actual physical assessment of the patient.  Our method does 
not permit a specific determination of why the differences occurred -- e.g., an error in the 
MDS review by the observing nurse, an error or omission in the medical record, or simply 
an honest difference of opinion given a similar set of facts.  However, overall such 
differences might highlight the need to take steps to ensure greater consistency. 
Triggering of RAPS.  Additionally, the reviewers generated appropriate RAPs based on 
the MDS that they prepared.  Resident Assessment Protocols generated by the nursing 
home were not available for 75 of our sample residents leaving 556 of 631 residents.  We 
compared the RAPs generated by our reviewers to those of the nursing home. 
Plans of care.  Finally, our reviewers evaluated the medical records for the 30 day period 
after the MDS was completed to determine if plans of care were appropriately developed, 
and if the 30 day progress notes reflected implementation of the plans of care.  They 
reviewed all records where a RAP was generated and there was a plan of care to 
determine if the care plan was implemented. 
6
These fields include B6, C7, E3, E5, G3a, G9, H4, I3, K3, N5a, R1a, R1b, and R1c.
6 
Nursing Home Resident Assessment  OEI-02-99-00040 Surveys 
We sent a self-administered questionnaire to each MDS coordinator in the 64 nursing 
homes in our sample and asked questions regarding the implementation of the resident 
assessment and plans of care.  We had a 100 percent response rate from the MDS 
coordinators.  We obtained information regarding the characteristics, training, and 
coordination of the staff who complete the assessments and plans of care.  In addition, we 
looked at the structures and processes the staff use to perform the resident assessment and 
their satisfaction with the process. 
Interviews 
We conducted structured telephone interviews in July 1999 with nursing home 
administrators in each of the 64 sample nursing homes.  We had a 100 percent response 
rate from the nursing home administrators.  We asked them questions regarding the 
implementation of the resident assessment and plans of care.  During these interviews, we 
also obtained information from them regarding the characteristics, training, and 
coordination of the staff who complete the assessments and plans of care. We also looked 
at the structures and processes the staff used to fulfill the resident assessment instrument 
requirements and their satisfaction with the process. 
Limitations 
The results of this analysis are limited by the information available in the medical record. 
In some cases, the nursing home completes the MDS based on observation of or 
discussion with the resident about which there may not be any other information in the 
medical record. 
For Section P: Special Treatment and Procedures, which includes minutes of occupational 
and physical therapy given in the last 7 days, the reviewer compared the therapy logs to 
the MDS.  In some cases, the logs were kept in units of 15 minutes.  The reviewers 
converted the units to minutes. 
This inspection was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
7 
Nursing Home Resident Assessment  OEI-02-99-00040  F I N D I N G S  
Generally, nursing homes follow a systematic process when 
implementing Resident Assessments 
Interdisciplinary team 
All MDS coordinators report that an interdisciplinary team evaluates each resident and 
participates in the completion of the MDS form.  About 75 percent of  MDS coordinators 
indicate that the interdisciplinary team is composed primarily of physical therapists, speech 
therapists, occupational therapists, activity directors, dietitians, social workers and floor 
nurses for all 5, 14, 30, 60 and 90-day assessments.  All MDS coordinators say that the 
interdisciplinary team gets together to discuss the patients current condition as well as to 
discuss and monitor the plans of care.  Ninety-three percent of MDS coordinators report 
that the same staff are also responsible for completing the patients plan of care. 
A review of signed MDSs indicates that 85 percent of nursing homes had at least four 
professionals assess each resident.  Less than 3 percent of MDSs are completed only by a 
registered nurse.  Physicians rarely sign the MDS; there is no requirement that they do so. 
MDS coordinator 
Almost all facilities have a person in the position of MDS coordinator.  Eighty-one percent 
of MDS coordinators are registered nurses, and the remainder are either LPNs or  LVNs 
(15 percent) or social workers (4 percent).  Although a MDS coordinator is not required 
to be a registered nurse, a registered nurse is required to sign and verify all sections of the 
MDS.  About 20 percent of administrators also state the MDS coordinator does not sign 
the completed MDS in his or her nursing home. 
Almost all MDS coordinators have at least 2 years experience in a geriatric setting, and 
over 50 percent have more than 10 years experience.  The role of the MDS coordinator in 
nursing homes is a fairly new position.  About 60 percent of MDS coordinators have 
worked 1 year or less in a MDS coordinator role at their current nursing home.  Over 65 
percent have no prior experience as a MDS coordinator in another nursing home. 
Almost all MDS coordinators are full time employees and only work in one nursing 
home, although MDS coordinators fill multiple roles in that nursing home.  Over half 
indicate that they have responsibilities other than that of MDS coordinator.  About 20 
percent of those who have other responsibilities serve as the director or assistant director 
of nursing while about 70 percent serve in other RN managerial roles. 
8 
Nursing Home Resident Assessment  OEI-02-99-00040  Regarding the MDS process, 73 percent of MDS coordinators say they sometimes have 
difficulty adhering to the MDS time schedules.  More than half of these say it is due to the 
rapid admission and discharge rates of residents.  One-quarter say this is due to insufficient 
staff. 
Training 
Both MDS coordinators and nursing home administrators report ongoing training for all 
staff that participate in the MDS.  About 70 percent of nursing home administrators state 
that the ongoing training is required by the nursing home.  Nursing home administrators 
say that their staff is trained by private consultants, corporations, fiscal intermediaries, 
State associations, and the Health Care Financing Administration. 
MDS Coordinators say that ongoing training is most commonly a combination of formal 
workshops outside the nursing home, formal training within the nursing home, informal 
on-the-job training, or referencing the MDS manual.  Seventy-three percent say that their 
on-going MDS training includes formal workshops, either at the facility or another 
location. 
About 80 percent of MDS coordinators find the MDS manual to be clear and easily 
understandable, however, only 42 percent of nursing home administrators believe their 
staff feel the same way.  Some administrators report that their staff find the manuals to be 
vague and confusing and open to interpretation.  MDS coordinators who do not find the 
manuals clear and easily understandable suggest that the MDS manual could be clearer, 
more specific, more descriptive, and with more examples and situations. Specifically, the 
activities of daily living (ADL) in section G are reportedly most difficult. 
According to both administrators and MDS coordinators, updates that affect the MDS 
come from several sources, primarily HCFA memos and bulletins and State memos and 
bulletins.  About half (56 percent) of nursing home administrators and 40 percent of MDS 
coordinators mention other professional organizations as a source for updates, and 
approximately 40 percent of both groups mention the Internet as the source for updates; 
particularly the HCFA and the American Health Care Association site. 
However, we found differences between the MDS and the rest of the 
medical record, some of which may affect care planning 
Differences 
An average of 17 percent of the 406 fields for each resident are different from the medical 
record.  We determined a difference to exist when our reviewers assessment did not 
match that of the nursing home.  See Table 1 on the following page for a complete listing 
9 
Nursing Home Resident Assessment  OEI-02-99-00040  of difference rates for all MDS sections.  At least 3 percent of the fields for all residents 
have differences.  Difference rates for residents range from 3 percent to 30 percent.  Only 
1 percent of residents have MDS difference rates of  5 percent or less, and 11 percent of 
residents have difference rates of 10 percent or less. 
Table 1 
Rates of Differences for All Sections of the MDS 
Section  Rates  # of Fields 
B. Cognitive Patterns  20%  15 
C. Communication/Hearing Patterns  10%  15 
D. Visual Patterns  24%  5 
E. Mood and Behavior Problems  12%  27 
F. Psychosocial Well-Being  22%  19 
G. Physical Functioning & Structural Problems  31%  52 
H. Continence in Last 14 Days  15%  17 
I. Disease Diagnosis  5%  57 
J. Health Conditions  16%  37 
K. Oral/Nutritional Status  10%  21 
L. Oral/Dental Status  22%  7 
M. Skin Condition  15%  32 
N. Activity Pursuit Patterns  26%  24 
O. Medications  24%  8 
P. Special Treatments & Procedures  15%  56 
Q. Discharge Potential & Overall Status  37%  4 
T. Therapy Supplement for Medicare PPS  29%  10 
TOTAL  17%  406 
Source: OIG medical review 
As noted in the background section, the methodology used in this report is useful to 
identify differences between what our reviewers would have entered in the MDS based on 
a review of the other medical records, versus what the facility nurses observed in the 
actual physical assessment of the patient.  Our method does not permit a specific 
10 
Nursing Home Resident Assessment  OEI-02-99-00040  determination of why the differences occurred -- e.g., an error in the MDS review by the 
observing nurse, an error or omission in the medical record, or simply an honest difference 
of opinion given a similar set of facts.  However, overall the differences revealed in our 
review highlight the need to take steps to ensure greater consistency. 
One of the consequences of our analysis is the fact that some categories are affected more 
than others.  Among sections with the highest difference rate are Section G: Physical 
Functioning and Structural Problems (31 percent) and Section Q: Discharge Potential and 
Overall Status (37 percent).  The goal of Section G is to assess the resident and develop a 
plan of care that maintains or improves the residents level of involvement in their 
activities of daily living (ADLs).  The ADLs assure the resident is functioning at his or her 
highest potential.  A residents ADL performance may vary from day to day or shift to 
shift; therefore, a proper assessment takes into account multiple perspectives over the 
course of 7 days.  Fields within Section G with the highest difference rate are Self-
performance Assessment of Locomotion off Unit (47 percent) and Self-performance 
Assessment of Locomotion on Unit (47 percent).  Section Q, Discharge Potential and 
Overall Status, which also has a high difference rate, includes questions that are answered 
with information gathered from the caregivers, the resident and his family.  The 
information is quite subjective and may change due to a number of factors such as whether 
the resident likes the nursing home. 
Thirty-nine percent of nursing home MDS coordinators report Section G the most difficult 
to complete. When asked which section they would change, 20 percent report they would 
change Section G.  Some explained that the staff views capabilities differently [and the 
capabilities] remain subjective and they would like more well-defined levels. Some 
MDS coordinators also note that some sections on the MDS are repetitive and that the 
assessment needs to be condensed. 
Three sections have low difference rates of 10 percent or less.  They include Section I: 
Disease Diagnosis (5 percent), Section C: Communication/Hearing Patterns (10 percent), 
and Section K: Oral/Nutritional Status (10 percent).  The criteria for evaluating a disease 
or infection in Section I is much less subjective than other fields. 
Resident Assessment Protocols 
Resident Assessment Protocols, or RAPs, flow from the MDS and guide the residents 
plan of care.  In practice, there are key elements or questions in the MDS that when 
answered in a specific way trigger one of the 18 RAPs.  For example, if in the cognitive 
pattern section of the MDS a residents decision making ability was coded as moderately 
or severely impaired that would trigger the cognitive loss RAP and that weakness would 
have to be addressed in the residents plan of care. 
Another consequence of our analysis is a concern that the differences that we found 
appear to be significant enough to affect the care planning process.  In order to determine 
11 
Nursing Home Resident Assessment  OEI-02-99-00040  if that was the case, we looked at the RAPs.  As can be seen in Chart 1, 76 percent of the
RAP decisions are the same for both our reviewers and the nursing home.  However, in 14
percent of the records, the RAP was not triggered by the nursing home, and subsequently
no care plan was developed for the resident.  One possible explanation for the lack of care
planning is that the medical issue may have been addressed, resolved, or included in
another RAP.  However, our analysis did not include whether or not this actually
occurred.
In 11 percent of the records, the nursing home triggered RAPs when our reviewer did not. 
Differences on the MDS may have resulted in different RAPs being triggered.  In addition,
if information regarding a residents condition is absent from the medical record, our
reviewer would not have noted the condition on the MDS which could have resulted in a
missed RAP trigger.
Chart 1
Source: OIG medical review
Table 2 on the following page lists the 18 RAPs and the decisions of both the medical
record reviewer and the nursing home.  The RAPs with the greatest differences are
Psychosocial Well-Being (38 percent ), Activities (37 percent), and Mood State (37
percent).  The RAPs with the least differences are Feeding Tubes (2 percent) and ADL
Functional Rehabilitation Potential (10 percent).  We tested the RAPs by payor source,
and we found no clear evidence that payment source makes a difference.
12
Nursing Home Resident Assessment                                                                                                                                          OEI-02-99-00040 Almost all MDS coordinators (86 percent) report that the RAPs are helpful when 
developing the plan of care.  Additionally, some coordinators would like to see additional 
RAPs generated about pain management, the management of infections, and respiratory 
conditions. 
Table 2 
Nurse Reviewer and Nursing Home Responses to RAPs 
Resident Assessment  Total  Reviewer  NH 
Protocol (RAP)  Difference  Trigger Only  Trigger Only 
(%)  (%)  (%) 
Psychosocial Well-Being  38  17  21 
Activities  37  14  24 
Mood State  37  18  18 
Visual Function  36  22  14 
Dehydration  34  18  16 
Dental Care  33  19  14 
Psychotropic Drug Use  30  25  5 
Nutritional Status  29  11  18 
Falls  27  15  12 
Communication  21  11  10 
Behavioral Symptoms  19  15  5 
Pressure Ulcers  19  12  8 
Physical Restraints  18  16  1 
Urinary Incontinence  18  11  7 
Cognitive Loss  18  7  11 
Delirium  16  7  9 
ADL  Rehab Potential  10  7  3 
Feeding Tubes  2  2  0 
* Percentages do not add to 100 percent due to rounding.  Source: OIG medical review 
13 
Nursing Home Resident Assessment  OEI-02-99-00040  Care planning 
When reviewing whether appropriate care plans were generated from the RAPs for our 
sample residents, we found that 26 percent of triggered RAPs do not have care plans. 
However, the medical issue may have been addressed, resolved, or included in another 
RAP.  Psychotropic Drug Use, Dental Care,  and Visual Function are the RAPs 
most commonly missing care plans.  Residents who require dentures or eye glasses will 
always trigger the Dental Care or Visual Function RAPs, however, care planning is 
usually unnecessary if the resident already has these devices.  Feeding Tubes is the RAP 
which most consistently results in care planning. 
It is noteworthy that nursing homes occasionally completed care plans for RAPs not 
triggered.  Falls is an example where 8 percent of the medical records indicated care 
plans when the RAP was not triggered. 
Plans of care are generally being followed 
We then reviewed the progress notes for 30 days after the care planning date to determine 
whether the care plan was implemented.  Thirty-day progress notes from the medical 
record indicate follow up by the staff on virtually all care plans. 
Almost all MDS coordinators agree that care plans evolve from the MDS evaluations and 
their direct care staff use the care plans to provide treatment to the residents.  The director 
of nursing, MDS coordinator, or the direct care nurse is usually responsible for assuring 
that the care plan is implemented.  All MDS coordinators report reviewing the plan of care 
on some schedule.  Almost three-quarters of the coordinators report that the care plan is 
reviewed quarterly; more than 80 percent say it is reviewed as needed. 
14 
Nursing Home Resident Assessment  OEI-02-99-00040  R E C O M M E N D A T I O N S  
Clearly, the nursing homes are attempting to systematically complete the MDS and 
implement the plans of care.  However, they are having difficulty administering an 
inherently complex process.  There are apparently differences in nursing home staffs 
understanding of the MDS and the resident assessment process. 
Based on our findings and the concerns of the nursing home MDS coordinators and 
administrators, we recommend that HCFA: 
<  more clearly define MDS elements, especially section G, and 
<	 work with the nursing home industry to provide enhanced and coordinated training 
to nursing homes to be sure that similar and accurate information about the MDS 
is being disseminated. 
AGENCY COMMENTS 
We received comments from the Health Care Financing Administration.  They concur with 
both of our recommendations and describe a number of important steps they are taking to 
improve understanding and implementation of the resident assessment, particularly the 
MDS.  We appreciate HCFAs thoughtful consideration of our report. 
The HCFA also provided technical comments which we have incorporated in the report. 
The full text of the comments is provided in Appendix C.  This also contains HCFAs 
comments on our companion report about the relationship between the resident 
assessment and the reimbursement system.  We discuss these comments in the other 
report. 
15 
Nursing Home Resident Assessment  OEI-02-99-00040  APPENDIX A 
Confidence Intervals for Key Findings 
We calculated confidence intervals for the key findings.  The point estimate and 95 percent 
confidence interval are given for each of the following findings.  The point estimates and 
confidence intervals for the findings vary based on the standard error for each individual 
finding. 
KEY FINDINGS  POINT  CONFIDENCE 
ESTIMATE  INTERVAL 
Percent of nursing homes had 4 or more  85%  +/- 7% 
professions assess each resident 
Percent of MDS coordinators who are  81%  +/- 9% 
registered nurses 
Percent of nursing home administrators  42%  +/- 19% 
who find the MDS manuals clear and 
easily understandable 
Percent of MDS coordinators who find  80%  +/- 9% 
the MDS manuals clear and easily 
understandable 
Percent of MDS coordinators who find  39%  +/- 25% 
Section G difficult 
Percent of MDS coordinators who would  20%  +/-16% 
change Section G 
Percent of MDS fields with differences  17%  +/- 2% 
Percent of RAPs that match  76%  +/- 2% 
Percent of RAPs triggered by our  14%  +/- 6% 
reviewers but not the nursing homes 
Percent of RAPs triggered by nursing  11%  +/- 5% 
homes but not our reviewers 
Percent of triggered RAPs without care  26%  +/- 6% 
plans 
16 
Nursing Home Resident Assessment  OEI-02-99-00040  APPENDIX B 
Minimum Data Set 
In this appendix we have included a complete copy of the Minimum Data Set. 
17 
Nursing Home Resident Assessment  OEI-02-99-00040  18 
Nursing Home Resident Assessment  OEI-02-99-00040  19 
Nursing Home Resident Assessment  OEI-02-99-00040  20 
Nursing Home Resident Assessment  OEI-02-99-00040  21 
Nursing Home Resident Assessment  OEI-02-99-00040  22 
Nursing Home Resident Assessment  OEI-02-99-00040  23 
Nursing Home Resident Assessment  OEI-02-99-00040  APPENDIX C 
Agency Comments 
In this appendix, we present in full the comments from the Health Care Financing 
Administration. 
24 
Nursing Home Resident Assessment  OEI-02-99-00040  25 
Nursing Home Resident Assessment  OEI-02-99-00040  26 
Nursing Home Resident Assessment  OEI-02-99-00040  27 
Nursing Home Resident Assessment  OEI-02-99-00040  28 
Nursing Home Resident Assessment  OEI-02-99-00040  29 
Nursing Home Resident Assessment  OEI-02-99-00040