MDS Alert

Published on Mon Jan 08, 2018 PDF

Practice filling out the matrix now as part of your survey readiness preparations.

The many changes in the new long-term care survey process may be overwhelming, but focus on learning exactly what you can do to be prepared.

"The information required on the provider matrix is extensive with tight timelines for producing the information for the survey team," says Linda elizaitis, Rn, Bs, RAC-CT, president of CMS Compliance Group Inc. in Melville, New York. "The completed matrix for new admissions within the last 30 days, who still reside in the facility, is required immediately upon entrance, per the Entrance Conference Form."

The matrix for new admissions is required because any resident admitted within the last 30 days may not have their MDS assessments in the QIES ASAP repository for the surveyors to access, says Marilyn Mines, Rn, BC, RaC-Ct, senior manager at Marcum LLP, in Deerfield, Illinois. "This matrix will tell the team members what the issues with the new residents are," she adds.

Remember, the completed matrix for all other residents is due to the surveyors within four hours of the surveyor's entrance to your facility. "Providers will fall flat if they don't have any of this information pulled together in advance," Elizaitis says.

Surveyors will be looking for accuracy across all aspects of care provision and documentation, and filling out the survey-specific documents is no exception.

"Part of being able to prepare this data accurately will require education of the staff who are responsible for completing the matrix accurately; these staff members need the directions for how to complete this document," Elizaitis says.

Education is key, but practice makes perfect.

If your annual recertification date is approaching, you have no time to waste in preparing for the surveyors' appearance and 2018-specific demands. "I recommend that facilities that are very close to their annual recertification date run two separate matrices that are updated frequently, so the staff are used to pulling the required information together and keeping it relatively up to date," Elizaitis says. "That will make it less stressful when the survey team enters the facility."

The new matrix requirements are available now (see link at end of story), so you can prepare accordingly. Basically, the content surveyors will need in the matrix sheet are linked to Critical Element pathways, as well as previously submitted MDS information. They'll use the information you provide on the matrix to help them conduct investigations during the survey process, Elizaitis says.

Beware: "This matrix is different from the previous one, and the directions are more specific and defined. Whoever is going to fill this out must know the current definitions and directions," Mines says.

Accuracy always matters, and you should incorporate protocols to ensure that the matrix is accurate during your practice runs, as well as during the actual survey. "It is important to keep documentation related to the plan of care for each resident accurate and consistent across all areas of the medical record, including the MDS," Elizaitis notes.

"Remember, 70 percent of the survey sample is predetermined by the survey software that uses MDS data to determine that part of the sample. Coupling this with the 30 percent sample chosen by the surveyors provides multiple opportunities for potential survey issues to be identified when the surveyors start to review the content of the facility's matrix against medical record content," she says. You can't go wrong in taking any and all steps to ensure that the information you provide on the matrix is mistake-free.

What can go wrong?

Surveyors can punish inaccuracies with Ftags, and will have their own observations to rely upon when checking the truthfulness and accuracy of the matrix content. "We recently heard about a facility receiving multiple MDS-related citations under the Long Term Care Survey Process (LTCSP), so MDS data needs to be accurate and match what is being entered on to the matrix," Elizaitis says. "Also, don't forget that surveyors are expected to be out on the units doing their records review, so there is a lot of time for observation."

Plus, inaccuracies on the matrix could trigger further investigations during the survey. "If what surveyors observe or read in a medical record, including MDSs, does not match what is on the matrix due to inaccuracies and inconsistencies, there are a host of issues that could arise for a facility, including concerns with quality of care, infection control, and comprehensive resident-centered care plans," Elizaitis says.

Don't get snagged with last-minute stress; make sure whichever staff member may be responsible for filling out the matrix during a survey practices now. Keep all of the documentation you'll need updated and on hand, so you can provide surveyors with the information you need without seemingly minor - but potentially costly - mistakes.

Resource: You can access the new matrix and instructions through this link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Matrix-with-Instructions-Content-Unchanged.pdf.