Department of Health and Human Services 


OFFICE OF 

INSPECTOR GENERAL 

NURSING FACILITY PERFORMANCE 

IN ASSESSING RESIDENTS TIMELY 

AND SUBMITTING REQUIRED 

MINIMUM DATA SET RECORDS 

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 Investiga ions t

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 facility’s latest standard 

survey performed during our study period. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS i 
EXECUTIVE SUMMARY

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 days—2 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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS ii 
EXECUTIVE SUMMARY 

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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING 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 resident’s 

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 assessment”4 and to “track a 

resident’s 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 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 1 
INTROD UCTION 

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 resident’s 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 Medicare’s 

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 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 2 
INTROD UCTION

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/Medicaidcertified 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 

O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 3 
INTRODUCTION 

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 President’s Council on Integrity and 

Efficiency. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 4 
∆ FINDINGS 


Among the various types of 

required assessments,

Facilities performed 95 percent of 

resident assessments on time 

facilities performed both 

admission and quarterly 

assessments according to the 

required schedule 95 percent 

of the time and 91 percent of 

the time for annual 

assessments. (See Table 2.) 

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. 

Table 2 

Percent n 

All 95 122,559 

95 33,872 

95 72,542 

91 16,145 

Proportion of Resident Assessments 

Performed on Time 

Assessments 

Admission 

 Quarterly 

Annual 

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. 

In fact, facilities submitted 70 

percent of MDS records within 

Facilities submitted 94 percent of resident 

records to their State MDS databases within 

14 days—2 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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 5 
FINDINGS 

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. 

Coding errors by facilities resulted in 

records for an estimated 1,812 residents in 

noncertified beds being inappropriately 

included in the national MDS Repository 

Only an estimated 9 percent of 

Medicare/Medicaid-certified 

nursing facilities nationwide 

were operating any noncertified 

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 resident’s 

bed.16 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING 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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 7 
RECOMENDATION 

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 CMS’s comments is presented in Appendix C. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING 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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING 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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 10 
∆ APPENDIX ~ A 

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 date—dates 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.) 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 11 
APPENDIX~A 

Table 3 

Stratum Sample 

14,523 150 

1,713 100 

16,236 250 

Sample Design of Certified Nursing Facilities With 

Standard Surveys—April 2002 Through June 2003 

Population of 

Facilities 

Facilities With Only Certified Beds

Facilities With Certified and Noncertified Beds

 Total 

 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 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 12 
APPENDIX~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 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 13 
APPENDIX~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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 14 
∆ APPENDIX ~ 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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 15 
APPENDIX~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% 

Quarterly Assessments 95.28% 

Annual Assessments 90.86% 

93.52% 96.96% 33,872 

94.14% 96.42% 72,542 

88.49% 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% 

Quarterly Assessment Records 94.33% 

Annual Assessment Records 93.03% 

92.27% 96.55% 33,009 

92.06% 96.60% 71,692 

90.33% 95.73% 15,958 

Medicare PPS Assessment Recordsc

Change in Status Assessment Records 

Discharge Records 

Reentry Records 

96.37% 94.47% 98.27% 55,786 

95.13% 92.93% 97.33% 12,509 

92.21% 90.31% 94.11% 65,333 

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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 16 
APPENDIX~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) 

Records Inappropriately in MDS (Error rate)

92.20% 

7.80% 

79.50% 

0.42%d

99.58%d

 20.50% 

1,268 

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. 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 17 
∆ APPENDIX ~ C 

Agency Comments 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 18 
APPENDIX~C 

 O E I - 0 6 - 0 2 - 0 0 7 3 0 FACILITY P ERFORMANCE IN ASSESSING RESIDENTS AND S UBMITTING MDS RECORDS 19 
OEI. 06. 02- 00730

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

Sandy Khoury, Program Specialist

Technical Assistance

Barbara Tedesco Mathematical Statistician

Scott Horning, Program Analyst

Kevin Farber Mathematical Statistician

FACILITY PERFORMANCE IN ASSESSING RESIDENTS AND SUBMITTING MDS RECORDS