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 MDS Focused Surveys Show That Centers Need To Be More Accurate

In 2014, the Centers for Medicare & Medicaid Services (CMS) and five volunteer states piloted a new type of survey focused specifically on assessing Minimum Data Set (MDS) coding practices and their relationship to resident care in skilled nursing care centers. CMS subsequently expanded the MDS-focused surveys to all states and added a review of nursing center staffing.
The surveys consist of a review of MDS 3.0 assessments and medical records, interviews with staff and residents, and resident observations conducted by specially trained surveyors. This enables surveyors to review the nursing center resident assessment processes in-depth—more so than during an annual survey.
CMS has released a summary of the results of MDS 3.0 Focused Surveys conducted during fiscal year 2015 (October 2014 to September 2015), highlighting the types of deficiencies and errors identified on the surveys.
CMS notes that the majority of deficiencies were cited at a scope and severity level of “D.” The most frequently cited deficiencies include:
·         MDS Accuracy
·         Posted Nursing Staffing Information
·         Develop Comprehensive Care Plans
·         Free from Unnecessary Drugs
·         Treatment/Services to Prevent/Heal PUs
·         No catheter/Prevent UTI/Restore Bladder
·         Comprehensive Assessment after Significant Change
Common coding errors affecting MDS accuracy most often were related to antipsychotics, pressure ulcers, falls, and use of restraints.
For deficiencies related to posted staffing, surveyors found that the most common reasons for noncompliance were that the staffing posted were not up to date, and staffing records were not retained for 18 months as required.
CMS offers several resources to assist nursing centers in achieving and improving compliance, including a review of Chapter 3 of the Resident Assessment Instrument (RAI) Manual, training modules for completing the MDS assessment, and contact information for state RAI coordinators.
CMS says it will continue to conduct the MDS 3.0 Focused Surveys through FY 2017.
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