News, Skilled Nursing Facility

Common deficiencies found in MDS 3.0 assessments

In a memo published November 4, CMS highlights common deficiencies and errors found among MDS 3.0 assessments in long-term care facilities. These inaccuracies are reflected in the results of the organization’s FY2015 MDS Focused Surveys. In total, 56 deficiencies (F-tags) were cited. The most frequently cited deficiencies include:

  • F278 – MDS Accuracy
  • F356 – Posted Nursing Staff Information
  • F279 – Develop Comprehensive Care Plans
  • F329 – Free from Unnecessary Drugs
  • F314 – Treatment/Services to Prevent/Heal Pus
  • F315 – No Catheter/Prevent UTI/Restore Bladder
  • F274 – Comprehensive Assessment after Significant Change

Common errors found in deficiencies cited for MDS Accuracy (F-278) include:

  • Antipsychotics
    • Coding inconsistent for resident with and w/o antipsychotics
    • Incorrect number of days administered
  • Restraints
    • Residents w/restraints not coded as having a restraint
  • Falls
    • Residents not coded to reflect a fall when a fall had occurred
  • Urinary Tract Infections (UTI)
    • Incorrect coding based on UTI criteria in RAI Manual
  • Continence/Catheters:
    • Coding inconsistent with residents with and w/o a catheter
    • Residents coded as having a catheter with no diagnosis
    • Coding inconsistent with residents’ actual state of continence
  • Pressure Ulcers:
    • Coding inconsistent with residents with and w/o pressure ulcers
    • Pressure Ulcers not coded at the correct stages
    • Coded as healed when not healed
    • Incorrect number of pressure ulcers coded
  • MDS Quarterly, Comprehensive (annual), and Significant Change in Status Assessment (SCSA):
    • Not completed timely or not completed at all

Surveyors found the most common reasons for deficiencies relating to posted staffing (F-356) were staffing posts that were not up to date and staffing records that were not retained for 18 months, per regulation.

To help your facility be prepared and compliant on survey day, visit the HCPro marketplace for more information about Long-Term Care MDS Coordinator’s Field Guide, a newly published book focused on helping coordinators and other nursing home staff complete the MDS 3.0 accurately, interpret MDS sections, identify and resolve MDS discrepancies prior to submission, and guide facilities to positive survey outcomes and accurate reimbursement. Check out an excerpt here!