MSD Focused Surveys

CMS issued Survey & Certification Memo 15-06-NH (click here for the memo) on October 31st that announces an expansion of the 5-state pilot program that was focused on MDS coding practices.  The pilot program found deficiencies in 24 of 25 facilities’ MDS coding practices that had a negative impact on the ability of surveyors to identify deficiencies in patient care.  Findings included inaccurate staging and documentation of pressure ulcers, problems with classification of antipsychotic drugs, and poor coding concerning use of restraints.  This pilot project followed a 2013 report from the OIG that indicated found issued with MDS information as the OIG reported on issues concerning NF care planning and discharge planning.

To be coupled with the MDS surveys will be a staffing surveys in order for CMS to validate what is now reported during the annual survey on the CMS-671.  Staffing levels will be assessed during the expanded MDF “Focused Surveys”.

The Focused Surveys will begin in early FY2015, which is any time now.  CMS will work with States to determine how many surveys will be conducted, and when, as well as whether specific facilities should be surveyed.  IHCA understands that Indiana will have 12 facilities as part of this expanded program.  A survey protocol and tool is also being developed.  Record review and interviews will be utilized in the surveys.