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.