MDS Alert

Published on Mon Feb 26, 2007 PDF

Follow these steps to get your survey off on the right foot.

You might think of the CMS-802  roster/sample matrix as homework that can either score points with surveyors -- or earn the facility an F tag right off the bat. You have about an hour or until the end of the initial tour to give surveyors the form, which means you need a systematic plan to have the information accurate and at hand.

The survey reality: The CMS- 802 form lists every resident in the facility and information about their conditions, including pressure ulcers, restraints, etc. By looking at the form, the surveyor knows you have 12 residents in restraints and the form identifies those residents, says Nathan Lake, RN, an MDS expert in Seattle.

Being able to hand over the form timely "creates a more positive initial impression with surveyors than staff scrambling or taking too long" to produce it, says Janet Dykstra, MS, RN, CDONA/LTC, with LW Consulting in Jenkintown, PA. Surveyors may grant an exception to the deadline if they arrive on the weekend or after hours, adds Lake.

The problem: "Facilities sometimes have trouble keeping the CMS-802 up to date," says Karen Merk, RN, a senior care consultant with Briggs Corporation in Des Moines, IA. The reason can "be a management issue where the person responsible ends up being pulled in too many directions," she says. But keeping the information up to date is also time-consuming, she adds. "There's a lot of information on the form that needs to be addressed on a daily basis: falls, a new pressure ulcer, a newly diagnosed infection or order for an antibiotic, etc."

Solution: "The facility needs a system to update the [CMS-802] information -- not just for the survey, but so the interdisciplinary team knows what's going on in the building," says Joan McCarthy, NHA, manager, healthcare, RSM McGladrey Inc. in Chicago. 

Don't Overrely on the MDS

Most MDS software allows you to pull information from residents' MDS assessments to complete the forms. Yet the information should be "current ... and present a snapshot of the facility when surveyors walk in the door," says Lake.

One way to do it: You can keep a "running roster" of residents' names with updated information during the "open survey window," suggests Marilyn Mines, RN, RAC-C, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. Start "with an up-to-date computer printout." Then, as the census/resident population changes, cross off and add residents' names and their "pertinent information" for the CMS-802, she advises.

For example, if a resident is no longer using a restraint or the pressure ulcer has healed, you'd update that, adds Mines.

To update the information, some MDS teams have a weekly meeting to print out what's in the system and manually update the forms, says Lake. The software "will tell them the facility has 10 people with pressure ulcers, and the team will ask: Do we have more or less than that? What do we need to update?"

Since the MDS "gives a picture of the resident at a point in time, which can change, staff should update the forms by making rounds and actually looking at the resident," says Sheryl Rosenfield, RN, RAC-C, BC, director of clinical services for Zimmet Healthcare Services Group in Morganville, NJ.

Also keep in mind that some of the definitions on the CMS-802 don't  match the MDS ones exactly, even though the software pulls the information off the MDS to complete the form, cautions Rosenfield.

Editor's note: Read "Meet The Short-Stay Challenge To Complete The CMS-802" in this issue.