MDS 3.0 Items

CMS releases a memo announcing expansion of MDS and surveys

On October 31st, 2014 CMS released Survey and Certification Memo 15-06-NH announcing the expansion of the MDS and Staffing Focused Surveys to begin in FY 2015.

MDS/Staffing Focused Surveys will be conducted nationwide and the number of surveys conducted will vary from state to state.

Summary of CMS Memo

  • CMS will collaborate with States to identify the specific facilities to be surveyed.
  • CMS is developing both the survey protocol and tool for the States’ to use.
  • The surveyors will ask a series of questions regarding staffing and MDS related practices of the facility staff, leadership, and others as appropriate.
  • MDS 3.0 inaccuracies and insufficient staffing noted during the survey will result in relevant citations, including those related to quality of care and/or life.
  • If care concerns are identified during on-site reviews, the concerns may be cited or referred to the State Agency as a complaint for further review.

Results from 2014 Pilot Program

In mid-2014, CMS piloted a short-term focused survey to assess MDS coding practices and its relationship to resident care in nursing homes in five states.   CMS provided the following findings from those surveys:

  • 24 out of 25 facilities received citations resulting from these surveys.
  • Identified inaccuracies in staging and documentation of pressure ulcers.
  • Identified lack of knowledge regarding the classification of antipsychotic drugs.
  • Identified coding issues related to the use of restraints.