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.

Connecticut MDS Focused Survey Information from Murtha Cullina, LLP

From DPH quarterly meeting, as reported by Murtha Cullina, LLP to their clients in a memo dated July 1, 2015:

Barbara Cass disclosed there would be approximately 6 MDS Focused Surveys for 2% to 2 1/2% per year.in a quarterly  meeting at DPH.

Barbara Cass, Lori Griffin, Karen Gworek and Connie Green have been trained to perform the MDS focused surveys.  They must be completed by Sep 30, 2015.

The national association shared the following additional information: (1) a major focus of the survey is compliance with F356 - §483.30(e) - Nurse staffing information; (2) noncompliance results in automatic CMPs and if CMP meets the threshold, loss of Nurse Aide Training Program; (3) CMS is identifying the centers to receive this survey; (4) CMS is adamant that no information about training, surveyor focus, etc., may be shared with either individual centers or with associations; and (5) some state affiliates have heard that CMS has indicated the state agencies will receive no additional funds for completing these focused surveys.

Last week, a facility underwent the first MDS focus survey in Connecticut. That provider shared the following details about the survey. The surveyors requested the following:
1. a tour of the building and a floor plan;
2. MDS policies and procedures as well as the staffing policy;
3. admission/discharges for the last 90 days (with admissions broken down
by long-term and short-term);
4. A&Is for all falls with injuries;
5. the facility worksheet form that was sent via blast fax within 1 hour;
6. interviews with staff focusing on the number of staff on the floor and
resident to staff ratio.
The provider reported that the survey team focused on skin issues. They reviewed 10
records and were in the building for two days. The facility expects one MDS related tag

and two non-MDS tags.

Important Payroll Based Journal Action Items

Important PBJ Action Items (posted 07/24/2015)

- View PBJ Training Modules for an introduction to the PBJ system and step by step registration instructions. Four training sessions will be available beginning July 27th on QTSO e-University, select the PBJ option. (https://www.qtso.com/webex/qiesclasses.php)

- Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users, if you don't already have one for other QIES applications. (https://www.qtso.com/cmsnet.html)

- Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access. Registration will be available beginning Aug. 4th. (CMS QIES Systems for Providers page)

- PBJ Corporate and Third-Parties must use the current form based process to register for a QIES ID. The MDS forms will be updated to include PBJ and will be available Aug. 4th. The forms are available under the Access Request Information / Forms section on the right side of the page. (https://www.qtso.com/)

- Review the PBJ Data Specifications and Errata for the October 1, 2015 release appearing in the Downloads section at the bottom of the page. (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html)

- In an effort to serve you better, we are offering a vendor ListServe. This information will be used to contact you with important news, updates, and conference call information. (https://www.qtso.com/vendor/post.php)

- The CASPER Reporting and PBJ systems will be available on October 1, 2015. A user will be able to submit XML files or manually enter staffing and census data for work performed on or after October 1, 2015. (CMS QIES Systems for Providers page)

From https://www.qtso.com/vendorpbj.html

MDS Focused Survey results NC

No deficiencies

MDS/Staffing Focused Survey Results: North Carolina

Three citations:  D,E,B
Missed Sig Change after LTC resident hospitalized and returned for skilled care with new catheter and two new pressure ulcers.
MDS inaccurate for 6 of 8 residents (primary issue:  Pre-populating from previous MDS)
Did not have 18 months of the staffing sheets required by F356.  Facility kept 12 months at a time.

MDS/Staffing Focused Survey Results: MA

Done in MA in June by regular surveyors, not from the complaint unit:  Three citations.  MDS coding error, missed fall.  Staffing posted did not include facility name,  resident who went to hospital had discrepancy in MOLST form at hospital and wishes for end of life when readmitted.  Their MDS Worksheet #1 did not contain a line for antipsychotics.  *update:  provider called back and form did have line for antipsychotics. It was the same form.

MDS Focused Survey Results Virginia

 Resident Assessment- facility failed to ensure accurate MDS Assessments for 4 of 10 residents

                   2 was for a foley, 1 re-entry assessment was not done,  fracture was not coded on 2 

                           assessments on 1 resident

       

 Quality of Care- facility failed 2 anchor catheter tubing for 2 residents and 1 resident did not have

                   a medical diagnosis for a foley

Quality of Care- facility failed to ensure an atmosphere free from hazards because 1 resident

                           had his catheter tubing wrapped around his ankle 

Staffing- the facility failed to post the daily staffing sheet on Day 1 of the survey