There are FOUR REASONS that Mood scores are under-reported on CMI…

  1. It is the least concrete of the sections – things like rehab services, medications, specific medical conditions or services, are easy to keep track of for CMI based on the chart and the resident’s functioning. Does the resident get physical therapy, Yes/No? This is concrete and there is only one possible right answer. Mood though is HIGHLY subjective. Does the resident have trouble concentrating? Have less interest in participating in activities? Feelings of self-directed negativity? These are opinion questions, and are subject to the mood of the interviewer and the resident.


  1. It’s easier to say “no”. Ask a person a question, if they’re not in the right mood, the answers are all going to be “no.” Are you having trouble sleeping? No. Are you having trouble concentrating? No! no no no. It’s just easier, and is very often a reflexive answer. So when a staff member asks the resident the mood questions, even if there actually are deficits in these areas, they can easily be missed and scored as zeros because of this negative response bias.


  1. Shame – while mental health issues and treatments no longer carry the level of stigma they once did, there still can be embarrassment. Particularly with older residents, who come from a time when acknowledging psychological problems was extremely shameful, there can be a very strong resistance to acknowledging anything that can be seen as weak, mentally ill, or “needing help.” So when the questions are asked, particularly ones with direct depression-related content, there can be a resistance to admitting that these in fact may be the case.


  1. Staff time/focus – very often the person asking the resident the mood questions is pressed for time and does not have the time or patience to really talk to the resident in depth. Working in a skilled nursing setting is challenging and the focus can be on getting as much work done as quickly as possible. This leaves little room for exploration or discussion. So often there is no additional detail-oriented follow-up or assessment of the accuracy of the mood scores, even when the resident’s clinical record clearly indicates depressive behaviors.

How can these problems be addressed?


Integrated Therapeutic Services ( has a proprietary CMI Planning Protocol© that addresses these issues in FIVE ways:

  1. Early identification and planning – at ITS we take a proactive approach to treatment and to gathering CMI mood data. We work closely with the MDS department of the facility to identify residents who will be assessed over the next quarter, and begin the observation/data collection process as early as possible so there is consistent clinical documentation to support the appropriate scores when they are due.
  1. Independent mood assessment and reporting – Part of the ITS treatment planning process includes quarterly assessment of mood with the data points required by CMI included; we provide a written report to the facility with our psychologist’s clinical impressions and data supporting the scoring process. We have several customizable reports for this, which we tailor to the specific needs of each facility.
  1. Staff training – ITS provides training to facility staff who are responsible for capturing mood data to better identify depression symptoms when these occur and document them appropriately. Additionally ITS offers in-services geared towards all facility staff members about a variety of mental health topics to increase awareness and provide early detection of depression before it worsens to a crisis.
  1. Documentation – Our clinical documentation is specifically designed to be supportive of CMI/MDS data. What this means is that when the facility documents depression scores, these are supported in detail by the psychotherapy notes and clinical materials we provide, so there is consistency throughout the process.
  1. A facility-wide culture of positive mental health – ITS (INTEGRATED Therapeutic Services) was founded based on the principle that the psychologist is an integrated part of the resident’s care team. In this role we seek to make mental health an integral part of a facility’s mindset. Everything we do is designed to increase quality of life, improve compliance with care and active participation in therapeutic activities, and avoid deterioration of morale or hospitalization. When the staff’s focus is on maintaining good mental health, they are more likely to notice and record depressive behaviors accurately for CMI.


ITS provides comprehensive psychological services to SNFs. Our entire program is based around accurately and consistently capturing relevant data points for CMI/MDS. All of our services are provided at no cost to our client facilities, or on a consultation basis to non-client facilities. Please contact our office for a customized quote based on your specific needs or to set up a complimentary in-person assessment of your facility’s needs.

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Please contact our Director with any questions or to chat informally about any of the services we offer.

Dr. Alan Winder  Office: (516) 345-0456 | Cell: (917) 751-7254 | E-mail: