Updated Information on MDS 3.0 Staffing-Focused Survey
THCA received the following information from AHCA on the MDS 3.0 Staffing – Focused Survey.
- CMS is now referring to these surveys as “MDS 3.0 Staffing Focused survey” or “MDS 3.0 Focus Staffing survey”
- A major focus of the survey is compliance with F356 – §483.30(e) – Nurse staffing information
- Noncompliance results in automatic CMPs and if CMP meets the threshold, loss of Nurse Aide Training Program
- CMS is identifying the centers to receive this survey
- CMS is adamant that no information about training, surveyor focus, etc., may be shared with either individual centers or with associations
- Some state affiliates have heard that CMS has indicated the SSA will receive no additional funds for completing these focused surveys
Information from another state from a MDS 3.0 Staffing-Focused Survey
- Facility was presented with Entrance Letter that this is a survey for MDS accuracy and staffing
- Requested roster be completed within one hour; if not, would be cited (Worksheet #1)
- Needed to complete form 671 within 24 hours
- Requested list of all residents on anti-psychotics, admit, discharges and re-admits in the last 90 days
- Asked who the wound care RN was but did not interview her
- Requested all policies related to MDS, staffing and scheduling, infection control, restraints, falls, and psychotropic medications
- Requested daily staffing sheets for previous 18 months
- Did not interview staff or residents
Chart Review
- Surveyors reviewed 10 records
- Sample included residents with each QM – falls, wounds, catheters, and anti-psychotic medications
- Included two residents with reportable incidents but had not had a complaint investigation (falls with injury)
- Reviewed resident that had been previously cited at a “G” for wound care – only resident that was reviewed from their annual survey.
Potential Citations Anticipated:
Inaccurate records*
- I resident did not have a Significant Change MDS completed in December (resident with “G” for wound care”)
- Two residents had no diagnosis for anti-psychotic medications
- Five residents did not have a care plan for anti-psychotic medications but did have behavior care plans
- One resident did not have a care plan for pain or falls
*All were corrected prior to survey completion
Staff posting
- Did not have 18 months of staffing posting
We understand that DADS has begun the MDS 3.0 Staffing-Focused Surveys in Texas. THCA will keep you informed as we learn how the Texas Focused Surveys are going. |
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Commitment to Care
For questions or comments on any of the above Commitment to Care information please don’t hesitate to contact:
Gloria Bean-Williams, RN
Director of Clinical and Quality Services
Ph: 512-458-1257 or gbwilliams@txhca.org
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- Updated Information on MDS 3.0 Staffing-Focused Survey
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