This is a report of an MDS Focused Survey from the Aanac list serve. This is one person's experience. Her advice is just that, and not all of her advice is based in regulatory requirements. I am printing this for the walk through of her experience:
They walked into the facility and got right to it. One of them went out on the floor with the MDS Coordinator while the other spoke with the DON/Administrator. They handed out the letter to the administrator (found on AANAC, I believe).
-They didn't hand out any surprises. What is available on AANAC is what they handed to us. They did request that the MDS Worksheet be handwritten. They wanted a policy for each column on the worksheet (except Skilled, LTC, Extensive Asist of Two). We didn't have a policy for UTIs, but the Infection Control policy was given instead and they "were fine with it" per the DON.
- The "Extensive Assist of Two" column - the MDS Coordinator went by the resident's most recent MDS.
- They wanted to know why Sig Changes were done, so if you're not noting the reasons why in the nurse's notes, I'd suggest starting...
- Overall, they weren't *as* focused on the MDS as I'd thought they would be. They zeroed in on psychotropics and catheters, making sure each resident had documented justification for the catheter, making sure dose reductions and behaviors were documented for the psychotropics.
- They did ask specifically (per the MDS Coordinator) for "MD Documented Behaviors" for residents on psychotropics. In this case, the MDS Coordinator was able to find an MD progress note that did document on behaviors. But honestly, I've not heard of any requirement that the MD documents on behaviors....usually it is the nurse who documents on the behaviors, sends that fax to the MD, and s/he decides what to do. So, we'll have to start doing something different in all of our facilities. This was not an issue at all with the regular state survey we had at a different facility last week.
- Remember that per current best practices, foley caths should be changed PRN, not monthly. If the MD orders otherwise, we should educate the MD as to current best practices, and the MD can decide what to do.
- Make sure that if a resident has a catheter, any pertinent diagnosis are captured in Section I.
- They did watch some pressure ulcer dressing changes. They were very happy with weekly wound documentation, which clearly shows the wound progress.
- This may not even be worth mentioning, it was just a hunch the MDS Coordinator got. The surveyors seemed to want to know how well the MDS Coordinator knew the CNAs. They asked her to go out on the floor and introduce them to CNAs, and they'd ask her, "Now what's her last name...?" Maybe they were just honest questions. But the MDS Coordinator said her radar went up. It "felt" to her like they wanted to make sure the MDS Coordinator had a relationship with the CNAs.
- Staffing was a big part of the survey. Per the staff, it felt like two different surveys - one was the MDS Focused Survey, the other was the Staffing Survey. The staff kept on trying to figure out the relationship between the two. But, nobody knows what that relationship is. Just make sure your staffing sheets and staffing ratio sheets are updated...
- I heard that for some MDS Focused surveys, the surveyors had obviously just learned the MDS process themselves. That was definitely NOT the case here.
- The surveyors were extremely kind and understanding, and I'm not just saying that on the offchance they are reading this ha. Coffee and rolls were provided to them, and they were appreciative of that. I only mention it because it's such a small gesture - why not do it? We did *not* do that with the surveyors we had in our facility last week, and the atmosphere was 100% different. I'm not saying coffee and rolls make all the difference, but I think it may play a small role in making them feel appreciated and welcome, rather than unwanted and in a hostile environment.
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