CMS completed the FY 2015 MDS Focused Surveys and is providing an overview of the results. View the results.
In 2012, the Office of Inspector General (OIG) reviewed nursing facility records and found that 1/3 of those reviewed did not contain evidence of compliance with Federal requirements regarding resident assessments. The OIG reported that SNFs misreported information on the MDS for 47% of claims reviewed. In 2014, CMS, piloted a short-term focused survey with 5 volunteer states to assess MDS 3.0 coding practices and the relationship to resident care. CMS then announced expansion of these surveys to be conducted nationwide in 2015.
- In October 2015, the Government Accountability Office (GAO) reviewed QMs calculated using MDS 3.0 assessments, and recommended CMS establish and implement a clear plan for ongoing auditing to ensure reliability of data self-reported by nursing homes, including payroll based staffing data and data used to calculate MDS 3.0-based clinical quality measures. Based on the above, the MDS 3.0 Focused Surveys will continue through FY 2016 and FY 2017. View results summary from LeadingAge National below.
FY 2015 Results
- Scope and Severity:
- The majority (56%) of deficiencies were cites at scope and severity level “D”, followed by an S/S of “E” (25%). [no actual harm with potential for more than minimal harm that is not immediate jeopardy; and a scope of isolated and pattern, respectively].
- Scope and Severity Level Percentage of Deficiencies
B – 5%
C – 11%
D – 56%
E – 25%
F – 3%
G – 1%
Top Cited Deficiencies:
- F278 – MDS Accuracy
- F356 – Posted Nursing Staffing Information
- F279 – Develop Comprehensive Care Plans
- F329 – Free from Unnecessary Drugs
- F314 – Treatment/Services to Prevent/Heal PUs
- F315 – No catheter/Prevent UTI/Restore Bladder
- F274 – Comprehensive Assessment after Significant Change
Common Errors:
- Antipsychotics:
- Coding inconsistent for residents with and w/o antipsychotics
- Incorrect number of days administered
- Restraints: Residents w/restraints not coded as having a restraint
- Falls: Residents not coded to reflect a fall when a fall had occurred
- Urinary Tract Infections (UTI)
- Incorrect coding based on UTI criteria in RAI Manual
- Continence/Catheters:
- Coding inconsistent with residents with and w/o a catheter
- Residents coded as having a catheter with no diagnosis
- Coding inconsistent with residents’ actual state of continence
- Pressure Ulcers:
- Coding inconsistent with residents with and w/o pressure ulcers
- Pressure Ulcers not coded at the correct stages
- Coded as healed when not healed
- Incorrect number of pressure ulcers coded
- MDS Quarterly, Comprehensive (annual), and Significant Change in Status Assessment (SCSA):
- Not completed timely or not completed at all
- For deficiencies related to posted staffing (F-356), most common citations were for posted staffing not up to date; staffing records not retained for 18 months, per regulation (42 CFR 483.30(e)).
Resources for Improved MDS Accuracy and Compliance
- The CMS regulations for the RAI, including the MDS 3.0 and the Care Area Assessments (CAAs) are found at 42 CFR 483.20. Interpretive guidance for these regulations is found in Appendix PP of the SOM at F-tags 272 through F287.
- The RAI Manual provides instructions to accurately code the MDS assessment and provide appropriate care. This manual can be found through this link.
- Within the manual, CMS recommends facilities review Chapter 3 for specific instructions on how to code each section of the MDS assessment. Based on the survey findings, CMS has revised guidance for Falls, Pressure Ulcers, and classifying medications to clarify coding instructions. Chapter 2 describes the requirements for when assessments must be completed.
- Some specific areas in Chapter 3 of the RAI Manual that providers may want to review include:
Antipsychotic Medications (MDS Item N Page N4- N9)
Restraints (MDS Item P Page P1 – P8)
Falls (MDS Item J Page J26 – J34)
UTI (MDS Item I Page I1- I9)
Pressure Ulcers (MDS Item M Page M1 – M30)
Continence (MDS Item H Page H1 – H2)
Training modules for completing the MDS assessment are found through this link. - A new training module has been added to help providers address pressure ulcers.
- Contact information for State RAI Coordinators can be found in Appendix B RAI Manual and found through this link.
