MDS Focused Survey Results in CT

We had our first MDS Focused Survey in a CT facility on Mon and Tues 7/27 and 7/28/15.

Here is a synopsis:

When the surveyors entered the facility, they first checked the posted staffing/census and the most recent survey posting.

The two surveyors handed us a copy of the Focused Survey Worksheet.

The surveyors did ask that we identify the private pay residents on the worksheet with a “P”.

The surveyors also requested from the facility:

1)      A list of all admissions and readmissions in the last 90 days of their entrance into the facility. Include name, room number, date of admission and/or readmission, where they came from, date of discharge, and where they were discharged to. From this data, the surveyors wanted to know who was a current resident in the facility.

2)      A copy off the floor plan

3)      18 months of staffing/census. Make sure your staffing sheets are updated daily!

4)      Location and extensions of key personnel

5)      Within 24 hours, a completed 671 form

6)      Policies and procedures:

a)      RAI/MDS Policy 

b)      Staffing and Scheduling

7)      Lap tops/computers for both surveyors.

There were no MDS findings.

We had a problem with staffing not being updated from the weekend.

Unfortunately, everything was fair game and they did find some issues: missing weekly weight; incomplete I/O; no AIMS.

MY opinion: very poor knowledge of RAI directives and the MDS.