Q: Why is the OIG auditing the accuracy of falls data from MDS assessments submitted by nursing homes? 

A: In April, the Office of Inspector General added the MDS falls audit to its 2024 Work Plan. Nursing homes are federally required to report resident falls in patient assessments. 

For each certified nursing home, CMS uses the MDS fall data to determine the percentage of resident falls that result in major injury. CMS posts the percentages on its Care Compare website to provide consumers with helpful information about the relative performance of each nursing home in this critical area. 

The new OIG study, which is expected to be completed in 2025, will use claims data to identify hospitalizations due to falls with major injury among nursing home residents that are Medicare enrollees. The study also will include residents who are dually enrolled in Medicaid. Next, auditors will use MDS assessments to determine the extent to which nursing homes reported those falls which were identified via the claims data. 

The work plan announcement makes clear auditors will examine characteristics of the residents whose falls were not reported, while also examining the characteristics of nursing homes that did not report falls via the MDS even though claims data showed hospitalizations due to falls.

There have been prior studies that found a discrepancy between falls data reported in MDS assessments and Medicare claims for hospitalizations related to falls. As reported in 2019, a University of Chicago study found that only 57.5% of such hospitalizations were also reported in the corresponding MDS. It is unclear whether the OIG audit will find similar evidence of underreporting falls. 

SNF operators and facility leadership should expect that such scrutiny from auditors will cause increased focus on fall issues by regulators.