MDS accuracy, staffing data among most cited deficiencies, CMS reveals

Deficiencies in Minimum Data Set accuracy and posted nurse staffing information were the most commonly cited among MDS 3.0 Focused Surveys conducted in fiscal year 2015, according to a new report.

The FY 2015 MDS Focused Survey Summary, released on Friday by the Centers for Medicare & Medicaid Services, includes the scope and severity of deficiencies cited in the survey, as well as the top cited deficiencies.

“We are providing information on the results of the surveys conducted in FY 2015 and technical advice so that facilities can learn from the findings and improve the accuracy of the MDS 3.0 assessments they conduct,” CMS said in the summary.

The three most common deficiencies among the 56 cited were: MDS accuracy (F-278), posted nursing staffing information (F-356) and develop comprehensive care plans (F-279).

The list also includes:

  • Free from unnecessary drugs (F-329)

  • Treatment/services to prevent/heal PUs (F-314)

  • No catheter/prevent urinary tract infections/restore bladder (F-315)

  • Comprehensive assessment after significant change (F-274)

The surveyors also noted trends among the types of coding errors that caused providers to receive an MDS accuracy citation, including coding inconsistencies for residents receiving antipsychotics or having a restraint, failing to code for UTIs in accordance to the RAI Manual, and not coding pressure ulcers at the correct stages.

For posted staffing-related deficiencies the most common culprit was having posted staffing information that was not up-to-date, and not retaining staffing records for 18 months.

Fifty-six percent of the deficiencies were cited at scope and severity level D, or no actual harm with potential for more than minimal harm that is not immediate jeopardy. An additional 25% of citations were level E.

To read the full summary report, and see the resources CMS suggests for improving MDS accuracy and compliance, click here.