MDS Alert

Published on Mon May 30, 2016 PDF

Make sure you have these crucial documents on-hand for surveyors.

If you’re wondering which key action points and preparation tasks you need to do right now to prepare for an annual survey, you can rest easy. Utilize this to-the-point checklist to ensure that you’re on the right track when it comes to getting ready for a visit from surveyors, courtesy of Kris Mastrangelo, President and CEO of Harmony Healthcare International:

• Have Forms 672 and 802 at the ready. The Department of Public Health/Department of Health wants these forms as soon as possible. See instructions in the State Operations Manual (SOM).
• Keep other documents on-hand. These include staffing for each day of the survey, your activities calendar, menus, medication pass times, the last four months of new hires, your current census list, and the past four months of discharges. All documentation that surveyors need, as well as the time frames to give them, are in the SOM.
• Review your Casper Report and Quality Measure (QM) triggers. Ensure that the Quality Assurance (QA) Committee has addressed triggers greater than 75 percent, as well as individually on each care plan and facility-wide.
• Review your policies for accident/incident reporting and investigations.
• Review your policies for abuse and neglect. Ensure all your staff know your policies.
• Ensure staff know your medication pass policy. Make sure your nursing staff know the policy for feeding tubes, residual checks, flushes between medications, etc.
• Ensure CNA staff follow the Plan of Care (POC).
• Confirm your fall prevention program and ensure that all staff know your program.
• Always be in “survey mode.” Coach your team on: 

        o How to answer surveyors’ questions.
        o Proactive management — on a routine basis:
               Check for expired meds,   
               Check medication and treatment carts, and
               Observe all aspects of care routinely.

• Keep a preventive skin care and pressure ulcer protocol. Ensure that all care staff know and follow the protocol.
• Conduct bladder assessments.