In a Survey and Certification memo (S&C: 15-06-NH) issued to state survey agency directors in late 2014, the Centers for Medicare & Medicaid Services (CMS) announced that in 2015 the Minimum Data Set (MDS) Focused Survey process will be expanding nationwide. The target number of surveys to be conducted will vary from state to state. CMS and the state survey agencies will work together to determine which facilities in each state will be selected for participation in the expanded pilot test.
The 2015 MDS Focused Survey pilot will be conducted in each state by at least two surveyors who have been specifically trained to assess the accuracy of the MDS assessment data.
The surveyors will spend approximately two days in the facility and will conduct an exit conference at the end of the survey to detail their findings with facility staff. This new survey process could result in survey deficiencies being issued to the facility for inaccurate MDS coding and negative resident outcomes.

Pilot Reveals Deficiencies

Highlights of the initial pilot test were released as part of the memo’s background information. A total of 25 facilities were surveyed for MDS coding accuracy, accurate MDS-based reimbursement levels, and Resident Assessment Instrument (RAI)-focused care planning that matches resident needs and promotes person-centered care.

Of the 25 facilities surveyed in the pilot, 24 received deficiencies for errors related to MDS coding, CMS cited inaccurate staging and documentation of pressure ulcers, lack of knowledge regarding the classification of antipsychotic drugs, and poor coding regarding the use of restraints (CMS, 2014).

While the survey process continues to be refined, field reports from facilities in the initial pilot test indicate that upon arrival at the facilities the survey teams issued an instructional letter to the nursing home administrator outlining the survey process. Facility staff were asked to immediately provide the current census, an alphabetical resident census with room numbers, and a copy of the floor plan.

Surveyor Requirements

Within one hour of the entrance, staff were asked to provide 1.) the 10 most recently completed MDS assessments—required by the Omnibus Budget Reconciliation Act of 1987 (OBRA)—that had been submitted for current residents, as well as 2.) any subsequent correction requests that had been submitted for those assessments, and 3.) medical records to support the MDS coding. OBRA assessments that included coding decisions based on the Prospective Payment System were part of the 10-assessment survey process. Facility staff were also asked to provide:
■ Copies of policies and procedures related to the RAI, the MDS, and the Quality Measures;
 ■ The staffing schedules for all staff involved in scheduling, coding, and transmitting MDS data, with their roles in the assessment process delineated;
 ■ The name and contact information for the quality assessment and assurance coordinator;
■ A list of all residents who had fallen in the past 12 months (date of the fall and any resulting injury); and
 ■ Focused Survey Facility Worksheet (form provided by the surveyor) to reflect a list of current residents (names and room numbers) with any of the following conditions and/or devices in use in the past 90 days (note that if a resident had more than one of the conditions listed below, he or she would be listed separately on the worksheet):
 — Pressure ulcers
 — Indwelling catheters (including urethral catheters, suprapubic catheters, and nephrostomy tubes)
 — Restraints other than side rails, including those used on an as-needed basis
 — Urinary tract infections
 — Antipsychotic medications.

What Providers Can Expect

CMS indicated that during the 2015 pilot testing, surveyors will conduct a record review, augmented by resident observations and staff and/or resident interviews, in order to validate MDS 3.0 coding and staffing levels.

If deficient practices are noted during the MDS Focused Survey, facilities might be cited under the RAI F-Tags F272 through F287. Information about these tags is located in the “State Operations Manual (SOM) Appendix PP.” These F-Tags outline the requirements for MDS assessment accuracy and the completion and timing of OBRA assessments. They also stipulate that individuals who complete a portion of the assessment must sign and certify the accuracy of that portion of the assessment and that a registered nurse must sign and certify that the assessment is completed (CMS, 2014).

Additionally, the Code of Federal Regulations (42 CFR 483.20[j]) indicates that civil monetary penalties could be issued for falsification of assessment data. Facilities could be cited if deficient practices are noted in survey tags related to quality of care, quality of life, or nursing services.

Accuracy of the MDS data is linked to Medicare and Medicaid payment, Quality Measures, Five-Star ratings, and optimal person-centered care planning, the memo said, referencing a 2013 Office of Inspector General report indicating that 37 percent of facilities did not develop a care plan that met federal requirements and did not provide services according to the care plan.

Self-Reported Staffing Scrutinized

The S&C-15-06-NH memorandum also announced that as part of the MDS Focused Survey process, surveyors will be conducting a review of the facility’s self-reported staffing levels. “This assessment will aim to verify the data self-reported by the nursing home and identify changes in staffing levels throughout the year,” the memo said. According to federal regulations (42 CFR 483.30[a]), sufficient staffing is critical to meeting resident care needs.

During each annual survey, facility staff are required to fill out the CMS-671 form (CMS, 2002). This form identifies staffing during the two weeks prior to the beginning of the survey. Since facility managers self-report their staffing levels, surveyors will conduct independent verification of form data during the MDS Focused Survey.
Nursing home managers often increase survey preparation when their annual survey window draws near. With the MDS Focused Survey pilot being conducted in each state, providers should let their staff know that the facility is always in its window. Surveyors could be knocking on the door this coming Monday.
Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.