CMS to Expand MDS and Staffing Survey Nationwide

Following the recent evaluation of a pilot study, the Centers for Medicare and Medicaid Service (CMS) announced plans to rollout nationwide, a new survey process that focuses on the MDS, and in addition, will review nursing home staffing to help CMS assess how staffing levels may fluctuate throughout the year.

The pilot study that took place in five states (MD, PA, VA, IL,MN) in June and July 2014, found the following:

While the Pilot results indicate relatively high levels of compliance related to Registered Nurse (RN) coordination and assessment timing requirements, there is room for improvement in MDS 3.0/medical record agreement in four of seven clinical conditions reviewed, including: 1) the severity of injury associated with falls; 2) pressure ulcer status; 3) restraint use; and 4) late loss activities of daily living (ADL) status. Review of these four clinical conditions showed levels of disagreement between the resident’s medical record and their MDS 3.0 assessment of 15 to 25 percent.

The Centers for Medicare and Medicaid Services

The surveys will be rolled out in two phases with regions and states assigned to one of two groups. In February, CMS will inform regional offices and states regarding the group to which they are assigned. Each phase will begin with training. Regions and states will also need to identify a Point of Contact (POC) to be the primary recipient of information pertaining to these surveys. A sample of nursing homes will be surveyed in each state. CMS will work with states to identify the specific facilities to be surveyed. In addition, CMS may work with a contractor to supplement states’ efforts to conduct surveys.

LeadingAge NY will attempt to get additional information regarding implementation in NYS at its regularly scheduled provider association/Department of Health meeting in March. In the meantime, CMS has advised nursing homes to review AppendixPP of the SOM and the MDS RAI Manual for information on completion of the MDS and the relevant regulations.

Contact: Elliott Frost, efrost@leadingageny.org, 518-867-8832