Wednesday, November 9, 2016

CMS Issues MDS Focused Survey Summary

In memorandum S&C: 17-06-NH, dated November 4, 2016, CMS provides an overview of the results of the FY 2015 MDS Focused Surveys, outlining the background on MDS Focused Surveys and the types of deficiencies and errors identified in the surveys. CMS also provides technical resources for providers to help improve accuracy and help providers maintain compliance. CMS implemented MDS Focused Surveys nationwide for a sample of nursing centers in 2015 after piloting the survey in 2014, and will continue to conduct the MDS 3.0 Focused Surveys through FY 2016 and FY 2017. The surveys are used to audit the accuracy and reliability of data reported by nursing centers.

The memorandum summarizes FY 2015 results in terms of the scope and severity of deficiencies, noting that the majority of deficiencies were cited at a scope and severity level of “D”; top cited deficiencies across scope and severity levels, such as MDS Accuracy and Posted Nurse Staffing Information; and common coding errors affecting MDS accuracy, such as those related to antipsychotics and pressure ulcers.

During on-site MDS Focused Survey visits, CMS found that approximately 45% of citations were related to MDS or staffing posting inaccuracy and that 55% were care related. Eighty percent of facilities surveyed had at least 1 deficiency with an overall average of 2.6 deficiencies per survey.

CMS recommends several resources to assist nursing centers in achieving and improving compliance, including a review of Chapter 3 of the RAI Manual; training modules for completing the MDS assessment; and contact information for State RAI Coordinators.

For questions or comments on the memorandum, contact

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