I keep hearing about MDS-focused surveys. What are they?
The Centers for Medicare & Medicaid Services has instituted a survey process to assess the accuracy and the compliance with the MDS scheduling process.
CMS has already conducted pilot surveys in five states. The good news is that those pilot surveys showed good compliance with the MDS schedule and coordination. Improvement needed was reflected in four key areas including severity of injury with falls, pressure ulcer status, restraint use and late loss ADL coding.
We are now facing a nationwide rollout of this process. Another component of this MDS focused survey is review of staffing in the facility to meet care needs. According to CMS Survey & Certification Letter 15-25-NH (sent on February 13, 2015), training for surveyors began in early April 2015 and states assigned a minimum of three surveyors to be trained. Deficiencies identified during these focused surveys will result in citations and enforcement actions.
What can you do to prepare for these MDS-focused surveys? First, audit your MDSs to ensure the care process, which includes the completion of the MDS and functional risk assessments, continues with the completion of the CAAs (Care Area Assessments); includes the development of an individualized care plan; is implemented at the bedside; and finally, is periodically reviewed and revised as needed.
Second, make sure the assessment process is being completed on a timely basis. That includes completing the MDS and CAAs within 14 days of admission; and completing an MDS when there is a Change of Therapy (COT) or an End of Therapy (EOT), with a Significant Change in Status (SCSA).
It is also essential that Entry and Discharge Assessments are completed timely and accurately.