Embrace the Operational Approach to MDS 3.0

Long-term care professionals are using a variety of approaches to streamline work within the MDS 3.0 assessment process implemented last October. Some of these approaches have indeed been positive as interdisciplinary teams adapt to such significant change. Through my consultative work I have assisted facilities in developing policies and processes to improve compliance and increase efficiency while working with this new payment system. Sharing the structure of these approaches will help others deal with the changes and demands of the updated process. In particular, this article will detail the operational approach to MDS 3.0. Before we examine it, however, heed this reminder: Changes to the MDS and the RUG payment process are significant for all levels of operational and clinical management. Greater staff involvement is necessary.


Providing specific operational training on the MDS 3.0 assessment to senior management teams has proven to be successful with many ownership groups. This approach allows senior management to understand the size and implication of the new data set and its impact on the regulatory and payment process. Many managers are used to sending their MDS nurses to training and then expect them to manage the process. That outdated method does not work with these changes because the new process impacts many departments and the potential for payment loss and/or regulatory risk is much higher.

MDS nurses and members of the interdisciplinary teams who code sections or items of the MDS must have proper resources and training on the 3.0 process. And it needs to be specific to the time.

It is also important that the person managing the MDS assessment process is allowed to communicate with facility administration so interdisciplinary participation and performance is defined and monitored. Teams that have instituted this change are finding it to be positive. Along with this protocol the actual assessment activity in facilities is now identified and reviewed weekly with operational teams. This includes the number of assessments by type and confirmation of validation. MDS managers should meet with administrators weekly to discuss assessment issues and activity. In facilities that have implemented this practice, process efficiency as well as team accountability has improved dramatically. Senior managers are free to track issues with software performance and increase communication to their vendors. Remember, all facilities have new software that requires training and adjustments in the MDS office. First, managers and MDS staffs need to have training on the process and then manage the assessment process operationally to ensure compliance and lower risk. The MDS 3.0 is not just a different assessment format; it is a refreshed process with many new definitions, timelines, and requirements that creates a very specific and detailed database of facilities’ services, demographics, and outcomes.


As a consultant I like to make a thorough assessment of the MDS office. This is the hub of data communication for interdisciplinary teams but also the location of data input into the systems that transmit assessment documents for validation. The office’s location must provide an efficient work environment, promote communication within the operational and clinical teams, and be conducive to data entry and record review. There must be adequate software and hardware to correlate and transmit resident data. MDS 3.0 has shortened the timelines for completion and transmission of the data sets as well as required additional lengthy assessments for discharge and reentry. This dramatically increases the number of assessments MDS nurses must do.

Assess the MDS office for efficiency and see that there is adequate work space and resources for nurses to complete these tasks. For instance, some high-acuity facilities have introduced double screens for MDS nurses working on high volumes of assessments. This allows two files to be open at once. Hardware capacity must also be evaluated to prevent downtime.


Another common issue is the challenge of getting accurate coding of ADL performance from caregiving staff during the assessment reference period. We all understand the importance of the ADL score, but the decline of ADL values from the MDS 2.0 to 3.0 systems has not been widely discussed.

Frontline ADL assistance for Bed Mobility, Transfer, Eating and Drinking, and Toilet Use must be coded from each shift during the assessment reference period. Most facilities have attempted this without success. Staff documentation habits can be improved by requiring that simple ADL trackers be completed during the assessment reference period during each shift. Scoring needs to be monitored by nursing or MDS staff with informal case-related training when needed to nurture this understanding. Large, formal in-service programs have not been as effective as one-on-one discussions, such as asking, “What did you do for Mr. Jones this shift?” and then translating the reply into correct coding.

Once paper compliance has been achieved, moving back to other systems improves the coding behavior. Obviously, ADL scores must be correct to produce accurate assessments and proper payment. It’s an old issue with a renewed focus because of the regulatory and payment risks involved. Discuss ADL scores at utilization meetings, during care planning, and in other communications related to resident functional performance as well as the relationship of ADL to rehab services. Regulators and payers will consider the ADL values as they relate to the services and outcomes of the stay. Monitor this carefully. Operations needs to pay attention to this and should have RUG distribution reports with ADL scores as part of routine review.


MDS nurses and members of the interdisciplinary teams who code sections or items of the MDS must have proper resources and training on the 3.0 process. Training needs to be specific to the time-remember there are many updates-and all new team members should receive specific guidance on their responsibilities in the process.

Live training is usually effective but not always available. Facilities are wise to seek quality, updated MDS training via subscription to reinforce the knowledge base of the current team members as well as educate those who are new. The risk associated with wrong coding because of a lack of knowledge of the process or the coding rules for their MDS sections or items is well known. The database will be used in many ways to identify facility services and outcomes for residents and coding the MDS wrong can increase regulatory and payment issues. Orientation programs must include definitions from MDS 3.0 and direct-care staff should be taught to code ADLs as part of their entry training. Web systems are much faster to update content as the definitions and assessment process are adapted by CMS. Again, Web-based MDS 3.0 training for new staff is practical, but make certain it has a competency component along with individual tracking so management can monitor completion.


At the time of this writing, all manuals need to be updated to September 2010. Check manuals in your facilities and make certain they are all updated. If you purchase updated manuals be sure to check that the updates actually arrive. Assign a team member to monitor Web sites and listservs for updates and to bring that information back to the team. Trainees should have the updated RAI User’s Manual; this is a simple issue to check and you may be surprised that MDS nurses or members of your interdisciplinary team can’t locate the latest manual or the manual they are using is not updated. Manuals are not expensive and they direct the coding of the database that will be paying your facility’s Medicare and in some states Medicaid payments. Manuals should be on the desk and open during working hours because of the volume of changes in the process and the number of new definitions. The MDS manual is part of the regulatory process and many regulators, reviewers, and auditors will be using its content as a resource. No MDS 2.0 manuals should be in use.

Operational teams must identify the knowledge base of the rehabilitation department related to the rules, timelines, and definitions in the MDS 3.0 manual. Even though some therapists have been trained, it would be helpful to determine that all rehab staff know the definitions in the 3.0 manual for Chapter 3, Section O400. This part of the manual contains all definitions and directions for coding minutes of therapy to be included on the MDS. The definitions for coding minutes of therapy are on pages Section O-13 to 24. There are many well-qualified rehab professionals who do not have these new definitions and policies as a reference. Staff will appreciate the support and if any of your claims are questioned, you will know that the minutes of therapy are correct and reflect program definitions.

Some therapists also need specific information about the ADL scores and their impact on payment levels as well as the outcome data reviewed by Medicare and its regulators. A good suggestion is to hold a meeting with operational and clinical leadership, the MDS nurse, and rehab staff. Have a current RUG report with payment levels and ADL scores ready for discussion. The administrator should also expect therapy staff to sign for the minutes of therapy in Section O400 on Section Z under the attestation. Most Medicare payment is based on rehab payment and so most post-payment audit activity will be focused on the documentation from therapy records, which makes attestation very important. Rehabilitation documentation must be resident-specific and progress to goals should be stated in terms of skilled service and the resident’s actual progress. Review the Medicare Benefit Policy Manual, Chapter 8, Section 30.4 for the criteria for skilled therapy that will be used for claims review. There must be open communication between clinical and rehab and the resident record must document the specific skilled services as well as the outcomes.

The MDS 3.0 process demands resident-specific plans, documentation, and summaries for rehab services. Record review is vital. Is the documentation specific to a resident’s diagnosis and situation? Rehab services are the responsibility of the facility whether they are practiced in-house or contracted and must meet Medicare program criteria.


Building an accurate, efficient, timely assessment process requires the focus and skills of the entire operational and interdisciplinary team. The simple steps mentioned here can solve many of the stresses and issues that could produce regulatory or payment risks. Operational professionals must be trained to understand the MDS 3.0 process, structure, and database issues. With this knowledge and with operational leadership, facilities can create compliant processes and avoid unnecessary issues. The MDS manager can’t implement this process without operational involvement and support. By evaluating current processes, being knowledgeable of the MDS 3.0, and providing leadership for the interdisciplinary teams, operational professionals can attain compliance and lower risk. LTL

The MDS 3.0 process demands resident-specific plans, documentation, and summaries for rehab services. Record review is vital.

Leah Klusch is Founder and Executive Director of The Alliance Training Center, Alliance, Ohio. As an educator and consultant, she has extensive experience in presenting motivating programs for a variety of healthcare professionals. Klusch can be reached at (330) 821-7616. Long-Term Living 2011 March;60(3):34-39

Topics: Articles , Facility management , MDS/RAI , Regulatory Compliance