Nursing home quality measures historically relied on information submitted through the MDS or the claims. Facilities focused heavily on assessment accuracy because MDS coding largely determined publicly reported quality outcomes for MDS-based measures. In 2026, that paradigm changed.

In June 2025, CMS announced its intent to reclassify the Long-Stay Antipsychotic Measure, effective Jan. 1, 2026, as a hybrid measure and has also announced its plan to reclassify the Long-Stay Falls with Major Injury as a hybrid measure. Hybrid measures combine MDS assessment data with Medicare claims, Medicaid claims, Part D prescription drug data, and Medicare Advantage encounter information. While this approach is intended to improve accuracy and reduce underreporting, it also creates new challenges for providers who do not have control over the claim and encounter information. 

What Was the Catalyst for the Hybrid Quality Measures?

The Dept. of Health and Human Services (HHS) Office of the Inspector General (OIG) published a report in May 2021 in which they found that MDS-based reporting understated the use of antipsychotics in nursing homes and identified discrepancies between the MDS and Medicare Part D claims, including residents receiving antipsychotics not coded on the MDS assessments. Following the timeline, in January of 2023, CMS began the MDS Schizophrenia audits and announced Quality Measures adjustments for erroneous schizophrenia coding. In November 2024, CMS made significant updates to Appendix PP, including guidance on unnecessary psychotropic medications, documentation of schizophrenia, resident rights, medical director responsibilities, informed consent, and surveyor expectations. Then, in June 2025, CMS announced a new Hybrid Long-Stay Antipsychotic Measure that uses not only MDS data but also Medicare Part D and Medicaid claims, as well as Medicare Advantage encounters. 

More recently, in September 2025, OIG released another report, this time regarding falls with major injury, noting that nursing homes failed to report 43 percent of those falls on MDS assessments. They concluded that MDS data alone understates the true incidence of serious falls. As a result, CMS developed another hybrid measure, this one as the Hybrid Falls with Major Injury. This respecified measure will first identify falls reported on the OBRA Discharge Assessment (or on the End of PPS combined with the OBRA Discharge). CMS will then review Medicare Fee-for-Service claims for inpatient hospitalizations, emergency department visits, and observation stays with a primary diagnosis that indicates a fall with a qualifying major injury. If a qualifying fall is identified on the MDS or the claim, the resident will trigger the measure.

Practical Implications for Hybrid Measures

Hybrid methodologies can affect quality measures even if the antipsychotic medication was not received or coded during the 7-day MDS look-back period, or if the fall with major injury was omitted from the MDS. Documentation, diagnosis support, incident reporting, MDS coding, and hospital communication will all need to align because CMS will be validating one data source against the other.

The Quality Measure Report now indicates why the LS Antipsychotic Measure was triggered, which will assist facilities in their Quality Assurance Performance Improvement plans.

As of now, we know that CMS has been gathering data since 2025; however, they have not yet announced when the data for the respecified measure will be publicly reported. It is not an "if," it is a "when." Training regarding the Hybrid Falls with Major Injury is available on the CMS website and includes a detailed explanation for how the measure will be calculated. 

What is Coming?

The OIG announced on June 29 that they have initiated a new work plan, this one again regarding antipsychotic use in nursing homes. The new work plan appears to be a continuation of their review of antipsychotic use in nursing homes, released in March 2026, in which, instead of 40 surveys, they will now conduct a nationwide analysis of antipsychotic use among Medicare beneficiaries residing in nursing homes, including those with a diagnosis of dementia. As of today, the HHS OIG website timeline doesn't include anticipated start or completion dates; more information will be released as the OIG progresses through the Work Plan.

As we have seen here, historically, major changes from CMS have resulted from OIG Work Plan Projects that identify potential gaps in oversight, compliance, or quality of care, leading to updated regulations, audits, and revisions to quality measures. 

Alicia Cantinieri, MBA, BSN, RN, CHC, RAC-MT, RAC-CTA, DNS-CT, QCP, is the managing director, clinical reimbursement and regulatory compliance, Zimmet Healthcare Services Group.

Questions or comments on the article? Contact Patrick Connole at pconnole@parkplacelive.com.