Here's the summary:
They entered Tuesday after lunch and exited Weds. On entry, they asked for the regular survey stuff: floor plan, key personnel, contacts, 672. They asked for list of Admissions/ Discharges for past 90 days including details of where admitted from/discharged to.
They asked for policies and procedures on Pressure Ulcers, Catheters, Restraints, UTIs, Falls, and Anti-psychotics. They did not immediately ask for P & P on Staffing/Scheduling or Resident Assessment Instrument but were given these later.
They gave us copy of Worksheet 1 (previously distributed). They did not appear to pay any attention to the column on Extensive Assist of 2. From this, they selected a sample of 10 residents for review.
Surveyors immediately verified that staffing was posted as required. Surveyors also requested 18 months of staffing sheets.
They looked at most recent MDS completed for the 10 residents in sample, regardless of whether it was OBRA or PPS assessment. They did not look at any MDSs in progress. In this facility, during MDSC vacancy, another IDT member was assigned to complete interviews. Not all interviews were completed during this time and we were cited for missed interviews on 3 of 10 residents reviewed. One pt reviewed had order for “Seroquel for anxiety.” In Section N, the MDSC coded this as Antianxiety med. This is incorrect per RAI Guidelines. Medications are to be coded on the MDS based on the drug classification, not its use. This was included in citation for inaccurate resident assessments.
Surveyors observed wound care on 2 patients but gave no citations for quality of care.
Note from Judy:
Never give a surveyor an MDS "in progress." If it's not attested to, it's not an MDS yet.
One more to go and Virginia will have it's five. They are supposed to be done by the end of September. If you are a Virginia provider and have had the 5th MDS focused survey, please let me know the results. Thanks!
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