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Series: MDS Mastermind | Session 7: Expert Quality Measure Management
Wednesday, June 15, 2022, 12:30 PM - 1:30 PM EDT
Category: Education Events

— MDS Mastermind Series Session 7 —

MDS Mastermind: Expert Quality Measure Management 

Wednesday,  June 15, 2022 • 12:30 pm - 1:30 pm EST • Webinar

Click here to view the brochure

Click here to Register

Session 7: Expert Quality Measure Management 

Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and systems that are associated with the ability to provide high-quality health care. This session will review Quality Measures, applicable definitions, and how each Five-Star MDS-based measure is calculated with a focus on ways in which facilities can monitor and improve their Five-Star rating through the Quality Measure domain.

Presented by: Eleisha Wilkes, RN, GERO-BC, RAC-CT, DNS-CT, Clinical Consultant, Proactive Medical Review

Projected Learning Outcomes/Course ObjectivesAt the conclusion of each session, the learner will:

  • Understand the relationship between the MDS 3.0, Quality Measures, and the 5-Star Rating System
  • Review applicable CASPER reports for QM monitoring
  • Interpret data and establish benchmarks for QA and performance improvement activities

Course Content

  • 30 minReview of Five-Star MDS 3.0 based Quality Measures
  • 15 minReview of CASPER QM reports used for QM monitoring
  • 10 minInterpreting data and performance improvement considerations
  • 5 minClosing comments and Q&A

Target Audience: MDS/RAI staff, Nurse Leaders, Administrators, PT, OT, ST, QA/QAPI team members

Instructional LevelIntermediate


This 8-week series running May-June 2022 emphasizes skill building for serving effectively as the MDS/RAI Coordinator. New or seasoned MDS staff will improve mastery of the MDS and detailed coding implications for ensuring proper reimbursement, accurate Quality Measures, and survey preparedness.

Sessions will offer a refresher of critical MDS 3.0 concepts for those new to MDS, as well as expanded content targeting:

  • Overcoming common coding and documentation errors
  • Avoiding the most prevalent PDPM and Case Mix Index (CMI) missed opportunities
  • Preventing MDS related survey deficiencies and current medical review risks
  • Effective Person-Centered Care Planning
  • QM & SNF QRP Accuracy


Gain insights that will drive reimbursement and QM improvement.


  • MDS/RAI staff
  • Nurse Leaders
  • Administrators
  • PT, OT, ST, QA/QAPI team members


 SCHEDULE [weekly; Wednesday's at 12:30 pm EST; May 4 - June 22]

  • MAY 4: Ruling MDS 3.0 Assessment and Completion
    As step one of ensuring MDS 3.0 accuracy, differentiating between assessment types and completion requirements is key. As the introductory session, this webinar will provide an overview of MDS 3.0 Assessment types and scheduling requirements with special focus on the Significant Change in Status Assessment, Interim Payment Assessment and Interrupted Stay policy.
  • MAY 11: Becoming an MDS Genius: Rooting out Common Coding Errors
    Attendees will gain insight into common MDS 3.0 coding errors and areas of opportunity for increasing assessment accuracy for care planning and reimbursement. Best practices to enhance supportive documentation to reflect resident conditions and services will be emphasized. Auditing and monitoring activities will be reviewed with specific strategies for providers to drive program improvement.

  • MAY 18: Masterly Assessment and Reporting of Self-Care and Mobility 
    This session will review MDS items in sections G and GG used to report functional, self-care, and mobility status and goals. The intent of and differences between these sections will be reviewed with emphasis on assessment processes and supporting documentation for Admission and Interim GG performance items which are used to determine the PT, OT, and Nursing Function Scores under PDPM.
  • MAY 25: Becoming a CAA and Care Planning Maestro 
    Are your care plans comprehensive, timely, and person-centered? Who is involved in the care planning process? In this session, we’ll review how to achieve effective care planning through an Interdisciplinary Team approach by bridging the gap between MDS Care Area Assessments and planning care around the resident’s goals and preferences.
  • JUNE 1: Achieving PDPM Success (Part 1)
    This session will provide part 1 of the Patient Driven Payment Model (PDPM) review. Attendees will be refreshed on the logistics of the PT, OT, and SLP components of the model as well as become better prepared to promote and ensure MDS and ICD.10 coding efficiency. Emphasis of this session will be understanding the payment model and the impact on interdisciplinary team operations with strategies to succeed.

  • JUNE 8: Achieving PDPM Success (Part 2)
    This session will provide part 2 of the Patient Driven Payment Model (PDPM) review. Attendees will be refreshed on the logistics of the Nursing and NTA components of the model as well as become better prepared to promote and ensure MDS and ICD.10 coding efficiency. Emphasis of this session will be understanding the payment model and the impact on interdisciplinary team operations with strategies to succeed.

  • JUNE 15: Mastering Quality Measure Management
    This session focuses on implementing effective fall prevention staff training programs and best practices for engaging staff in the fall prevention program.  
    • Identify key components of successful LTC falls training programs. 
    • Understand and apply strategies to engage and empower staff in the fall prevention program.
    • Describe best practices for promoting a fall prevention culture.
  • June 22: Surmounting Survey and Audit Preparedness
    From accuracy of the assessment to effective care planning, RAI/MDS processes are guaranteed to be a focus of survey and auditing activities. This session will provide tips and strategies for successfully managing the survey process from the MDS perspective and suggestions for staying “audit ready” throughout the year.


Proactive will record webinar sessions and maintain recordings of each session in the series on the GoToTM  Webinar site. These recordings will be made available to paid registrants at no additional charge. Recordings are typically available within one week of the live webinar session. Webinar Recording Procedure:

  • Webinar recordings are hosted on GoToTM Webinar and are accessible via a link made available by Proactive. Complimentary access to the recording of each webinar session will be provided to registrants.
  • No CE is granted for viewing recorded webinars.


  • KBN: 5-0014-12-23-1020 - This seminar has been approved for 1.2 contact hours for nursing facility administrators by the Kentucky Board of Licensure for Nursing Home Administrators and Kentucky Board of Nursing for RN/LPNs. *Must attend entire program and complete a speaker/seminar evaluation form to receive 1.2 contact hours certificate. 
  • *Must attend entire program and complete a speaker/seminar evaluation form to receive 1.2 contact hours certificate.
  • Kentucky Board of Nursing approval of an individual nursing continuing education provider does not constitute endorsement of offering content.
  • Administrators (NAB/NCERS): Each live session within this series has been applied for and/or approved for 1 participant hour of continuing education for Administrators
  • NOTES:
    • Proactive Medical Review is an approved provider of both NAB/NCERS and KBN.
    • No CE is granted to participants who fail to attend the entire session.
    • CE is only granted for attendance of live webinars; no CE is granted for viewing recorded webinars.


Participants may register for each session individually or register for the full series at a discounted rate. Registration for the live webinars includes access to the webinar recording (note: no CE is granted for viewing recorded webinars).


  • LeadingAge Kentucky Members: $400
  • Non-Members: $640


  • LeadingAge Kentucky Members: $55
  • Non-Members: $85
Click here to Register

Additional Attendees:

  • An additional $10 per person will be billed post-webinar for additional attendees seeking credit.
  • You may view these webinars with your team, without sharing the webinar link, on one device.
  • Paid registrations are limited to one connection per webinar link. Links to join the webinar are unique and tied to the registrant name. While others can view the webinar on the same devise with you, the link should not be forwarded.
  • Please note the webinar link cannot be shared with others.
  • Multiple connections will either be billed or removed from the webinar.

Transfers, Cancellations, & No-shows:

  • Registrations are fully transferable. Transfers must be submitted via email to Rhonda Hoyer no later than 48 hours prior to the webinar.
  • A full refund will be given to all cancellations received 10 or more business days prior to the program.
  • A $50 administrative fee will be charged to all cancellations received ten (10) to eight (8) business days prior to the program.
  • No refunds will be given to cancellations received seven (7) or fewer business days prior to the program.
  • LeadingAge Kentucky reserves the right to cancel the program due to insufficient enrollment in which case pre-registered participants will be notified and full refunds provided.
  • No-shows will be billed. No refunds for failure to log-in at the time of the event.

Contact: Rhonda Hoyer