Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

JANUARY 2001 

OEI-02-99-00040 

Nursing Home Resident Assessment 

Quality of Care 
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 
EXECUTIVE SUMMARY 

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 

Nursing Home Resident Assessment i 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 resident’s 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. 

Nursing Home Resident Assessment ii 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 HCFA’s 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 HCFA’s 

comments on our companion report about the relationship between the resident 

assessment and the reimbursement system. We discuss these comments in the other 

report. 

Nursing Home Resident Assessment iii OEI-02-99-00040 
TABLE OF CONTENTS 

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

Nursing Home Resident Assessment iv OEI-02-99-00040 
INTRODUCTION 

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 nation’s 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. 

Nursing Home Resident Assessment 1 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 User’s Manual Version 2.0 October, 1995. 

Nursing Home Resident Assessment 2 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 resident’s 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 well3

U.S. Department of Health and Human Services, Health Care Financing Administration, Long Term Care Resident 

Assessment Instrument User’s Manual Version 2.0 October, 1995 

Nursing Home Resident Assessment 3 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 

resident’s 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 resident’s 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. 

Nursing Home Resident Assessment 4 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 threestage 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. 

Nursing Home Resident Assessment 5 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 resident’s 

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.

Nursing Home Resident Assessment 6 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 President’s Council on Integrity and Efficiency. 

Nursing Home Resident Assessment 7 OEI-02-99-00040 
FINDINGS 

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 patient’s 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. 

Nursing Home Resident Assessment 8 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 

Nursing Home Resident Assessment 9 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 

Nursing Home Resident Assessment 10 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 resident’s level of involvement in their 

activities of daily living (ADLs). The ADLs assure the resident is functioning at his or her 

highest potential. A resident’s 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 Selfperformance 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 resident’s 

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 resident’s 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 

Nursing Home Resident Assessment 11 OEI-02-99-00040 
Nursing Home Resident Assessment 12

if that was the case, we looked at the RAPs. 

RAP decisions are the same for both our reviewers and the nursing home. 

percent of the records, the RAP was not triggered by the nursing home, and subsequently

no care plan was developed for the resident. 

planning is that the medical issue may have been addressed, resolved, or included in

another RAP. 

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. 

if information regarding a resident’s 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. 

“Psychosocial Well-Being” (38 percent ), “Activities” (37 percent), and “Mood State” (37

percent). 

Functional Rehabilitation Potential” (10 percent). 

and we found no clear evidence that payment source makes a difference.

OEI-02-99-00040

As can be seen in Chart 1, 76 percent of the

However, in 14

One possible explanation for the lack of care

However, our analysis did not include whether or not this actually

In addition,

The RAPs with the greatest differences are

The RAPs with the least differences are “Feeding Tubes” (2 percent) and “ADL

We tested the RAPs by payor source,
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 

Protocol (RAP) 

Total 

Difference 

(%) 

Reviewer 

Trigger Only 

(%) 

NH 

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 

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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. 

Nursing Home Resident Assessment 14 OEI-02-99-00040 
RECOMMENDATIONS 

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 HCFA’s 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 HCFA’s 

comments on our companion report about the relationship between the resident 

assessment and the reimbursement system. We discuss these comments in the other 

report. 

Nursing Home Resident Assessment 15 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 

ESTIMATE 

CONFIDENCE 

INTERVAL 

Percent of nursing homes had 4 or more 

professions assess each resident 

85% +/- 7% 

Percent of MDS coordinators who are 

registered nurses 

81% +/- 9% 

Percent of nursing home administrators 

who find the MDS manuals clear and 

easily understandable 

42% +/- 19% 

Percent of MDS coordinators who find 

the MDS manuals clear and easily 

understandable 

80% +/- 9% 

Percent of MDS coordinators who find 

Section G difficult 

39% +/- 25% 

Percent of MDS coordinators who would 

change Section G 

20% +/-16% 

Percent of MDS fields with differences 17% +/- 2% 

Percent of RAPs that match 76% +/- 2% 

Percent of RAPs triggered by our 

reviewers but not the nursing homes 

14% +/- 6% 

Percent of RAPs triggered by nursing 

homes but not our reviewers 

11% +/- 5% 

Percent of triggered RAPs without care 

plans 

26% +/- 6% 

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APPENDIX B 

Minimum Data Set 

In this appendix we have included a complete copy of the Minimum Data Set. 

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APPENDIX C 

Agency Comments 

In this appendix, we present in full the comments from the Health Care Financing 

Administration. 

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