Good Afternoon all,
I wanted to share with you that we have started the MDS surveys. I have asked Becca Cheek to put together a short synopsis of the MDS survey process so that I could send out to NH’s so you would have some idea of what to expect if you are selected. We are required by CMS to complete 9 surveys.
If you have any questions about the below please contact Bekka Cheek as she is the coordinator for this project.
Cindy
From: Cheek, Rebekka P
Sent: Thursday, May 07, 2015 11:14 AM
To: Deporter, Cindy
Subject: MDS 3.0 Staffing/Focused Survey
So this is the process we are following
Should be a 2 day Survey
This is the process summarized:
1st thing:
We give the facility Worksheet #1 (which is a facility census with columns for specific areas that we focus on). We need this form within 1 hour
The facility is to complete Worksheet #1 based on the resident census on the day of on-site, the facility is to identify each resident and any of the areas on worksheet #1 that apply to the resident in the last 90 days. The areas are: Restraints, Falls with Major Injuries, Pressure Ulcers, UTI’s, Urinary Catheters, Antipsychotic Medications, Ext assist of 2, Skilled, LTC. There should be at least one entry for each resident because at the bare minimum each resident is either Skilled (receiving therapy services) or LTC.
We also request Admission/Readmissions within the last 90 days from an Acute Care or Psych Hospital and are currently residents in the facility. We need this piece of information to include. resident name, room number, date of discharge (if discharged), date of admission to facility or readmission to facility, disposition, where resident was admitted from, if resident is skilled or LTC, We also need this within 1 hour
From the 2 above pieces of information, we then pull a sample of 10 resident to review.
We also immediately do staffing to verify required staffing is posted and that they have staff as scheduled and as required.
We also request 18 months of staffing – they do not need to copy – we just need to review it.
We request a copy of the floor plan
We verify if there is a wound nurse and who is responsible for staffing
We request of list of key personnel
We request Policy and Procedure for:
Staffing/Scheduling
Resident Assessment Instrument
And others as applicable and needed
We also have the facility complete a 671.
We should be able to complete surveys within 2 days. We are focusing on Assessment/Staffing, but may need to expand to look at other areas if need be.
T Rebekka Parker Cheek
North Carolina Department of Health and Human Services
Facility Survey Consultant II / QIS Trainer
Division of Health Service Regulation
Nursing Home Licensure and Certification
1205 Umstead Drive
Raleigh, NC 27603
Phone 919-909-0379
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