Staffing Verification Added for 2014
In mid-2014, CMS piloted a short-term focused survey to assess MDS 3.0 coding practices and its relationship to resident care in nursing homes in 5 states. Surveyors (who received specialized training for these surveys) reviewed the nursing home resident assessment processes in more depth than annual surveys. The pilot was completed in 8/14. Findings from the surveys include inaccurate staging and documentation of pressure ulcers, lack of knowledge regarding the classification of antipsychotic drugs, and poor coding regarding the use of restraints. Deficiencies were identified and cited on all but one survey (i.e., 24 of 25 surveys).
CMS will expand these surveys in 2015 to be conducted nationwide. The scope of some or all of the focused surveys will also be expanded to include an assessment of staffing levels. “…This assessment will aim to verify the data self-reported by the nursing home, and identify changes in staffing levels throughout the year.” Surveyors collect the CMS-671 [staffing] form in conjunction with Task 2 of the standard/annual survey process (SOM Appendix P). However, as this is the only “snapshot” currently collected, CMS is seeking more information on how staffing levels may fluctuate throughout the year.MDS/Staffing Focused Surveys will be conducted by State Agencies (SAs) nationwide and the number of surveys conducted will vary from state to state.
Similar to the 2014 pilot, States will be expected to allocate 2 surveyors for each survey, requiring an estimated 2 days on average. The expanded Focused Surveys are expected to begin in early FY2015.
“CMS will work with States to determine how many surveys should be conducted, and when they should take place throughout the year.”
CMS will also collaborate with States to identify the specific facilities to be surveyed, and is developing both the survey protocol and tool for the States’ to use.
“Record review, augmented by resident observations and staff and/or resident interviews, will be used by surveyors to validate MDS 3.0 coding and staffing levels. Additionally, while on-site, surveyors will ask a series of questions regarding staffing and MDS-related practices of the facility staff, leadership, and others as appropriate.”
In addition to phone and email support while SAs are conducting the reviews, CMS will provide a mandatory half day web-based training for the SA staff conducting reviews as well as one manager or trainer within the SA, prior to initiating the surveys.
These focused surveys will be surveys of record.
o“…MDS 3.0 inaccuracies and/or insufficient staffing noted during the survey will result in relevant citations, including those related to quality of care and/or life, or nursing services. If patterns of inaccuracies are noted, the case will be referred to the CMS RO and CO for follow-up. In the event that care concerns are identified during on-site reviews, the concerns may be cited or referred to the SA as a complaint for further review.
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