MDS Alert

Published on Wed Nov 30, 2016 PDF

Need help? Check out this new Section M surveyor training video.

The MDS Focused Surveys are continuing and the deficiency citations are flowing freely. You may be wondering what kinds of citations surveyors are handing out, and you might be surprised to learn that the most common ones are for MDS accuracy and failure to post nursing staffing information.

So says a Survey and Certification Group (S&C) memo detailing the Fiscal Year (FY) 2015 MDS Focused Survey results, which the Centers for Medicare & Medicaid services (CMS) released on Nov. 4. The memo (S&C: 17-06-NH) provides a summary of the survey results, as well as a review of facility compliance with the requirements for nurse staffing posting.

Hunt for These Types of Deficiencies at Your Facility

The vast majority of the deficiencies that surveyors cited had a scope and severity (S/S) level of either “D” (56 percent) or “E” (25 percent). According to CMS, “this translates to a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of isolated and pattern,  respectively.”

Of the 56 different types of deficiencies that surveyors cited, the most frequently cited F-tags were:

• F-278 — MDS Accuracy
• F-356 — Posted Nursing Staffing Information
• F-279 — Develop Comprehensive Care Plans
• F-329 — Free from Unnecessary Drugs
• F-314 — Treatment/Services to Prevent Pressure Ulcers
• F-315 — No Catheter/Prevent UTI/Restore Bladder
• F-274 — Comprehensive Assessment after Significant Change

The FY 2015 MDS Focused Surveys included on-site visits, during which approximately 45 percent of citations were related to MDS or staffing posting inaccuracy, and 55 percent were care-related citations, according to CMS. And very few of the surveyed facilities survived unscathed — 80 percent of facilities had at least one deficiency, with an overall average of 2.6 deficiencies per survey.

Clean Up Your Coding in 7 Key Areas

Beware: For the F-356 deficiencies, surveyors found that the most common reasons for noncompliance were that the posted staffing wasn’t up-to-date and facilities were not retaining staffing records for 18 months as required.

The F-278 deficiencies concerning MDS accuracy showed clear trends in the types of coding errors that surveyors discovered. During the investigations, surveyors found the following most common coding errors that led to the F-278 deficiency citations:

1. Antipsychotics — Coding was inconsistent for residents with and without antipsychotics. Also, coding reflected incorrect number of days antipsychotics were administered.
2. Restraints — Residents with restraints weren’t coded as having a restraint.
3. Falls — Residents not coded to reflect a fall when a fall had occurred.
4. Urinary tract infections (Utis) — Incorrect coding based on the UTI criteria in the RAI Manual.
5. Continence/Catheters — Coding was inconsistent for residents with and without a catheter, and coding was inconsistent with residents’ actual state of continence. Also, residents were coded as having a catheter with no diagnosis.
6. Pressure Ulcers — Coding was inconsistent for residents with and without pressure ulcers. Pressure ulcers weren’t coded at the correct stages, pressure ulcers were coded as healed when they were not healed, and the incorrect number of pressure ulcers were coded.
7. Assessments — The MDS Quarterly Assessment, Comprehensive (annual) Assessment, and Significant Change in Status Assessment (SCSA) were not completed in a timely manner or not completed at all.

CMS will continue to conduct the MDS Focused Surveysthrough FY 2016 and FY 2017. Based on the MDS Focused Survey results, CMS was so concerned about the miscoding of Section M — Skin Conditions that it posted a new surveyor training video on pressure ulcers. You can access the video at http://surveyortraining.cms.hhs.gov/Courses/126/SectionMVideo/SectionMVideo.html.

Link: To read the memo, go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-06.pdf.