SLIDE 1 ARE YOU READY FOR THE
CMS MDS & STAFFING SURVEY PROCESS
BY: KIMBERLY SMOAK, MSH, QIDP CHIEF OF FIELD OPERATIONS AGENCY FOR HEALTH CARE ADMINISTRATION ROBIN A. BLEIER, RN, LHRM, CLC
PRESIDENT RB HEALTH PARTNERS, INC.
Coming to you or your colleague soon!
SLIDE 2
Todays Program Objectives
SLIDE 3 Today’s Program Objectives
- 1. Explain what the CMS MDS Survey
Process is?
- 2. Discuss the Pilot Project, and Florida
surveys and results.
- 3. Affirm the Entrance Conference
process.
SLIDE 4 Objectives (continued)
- 4. List the Data and the Four Time Frames for
submission you would be expected to follow.
- 5. Discuss Staffing aspects for Compliance.
- 6. List Steps for YOUR success.
SLIDE 5
Let’s Get Started!
SLIDE 6 CMS MDS Survey Process
Dear Administrator This letter is to inform the facility that they will be included in a MDS focused survey which per the Survey & Certification Memo 15-06 NH October 2015 is a nationwide initiative. The letter references that two to four surveyors will plan to be on site for two days (not in advance). It is not with advance notice.
SLIDE 7
Entrance Conference
Using the Facility Copy of the Entrance Conference, providers will note that there are four categories each with associated time frames to provide specified data to the surveyors completing your compliance review.
SLIDE 8 Entrance Conference
The Time Frames are:
Immediately Upon Entrance Within One Hour of Entrance Within 24 Hours of Entrance Upon Request or as needed
SLIDE 9 Immediately Upon Entrance
There are six pieces for this section:
- 1. Worksheet # 1 Resident Census Sheet
(alphabetical with room numbers)
- 2. Computer access
- 3. Facility Floor Plans
SLIDE 10 Immediately Upon Entrance
- 4. Transfer Records for the last 90 days
- 5. Identification of Wound Care Nurse (or
nurse who coordinates wound care)
- 6. Identification for who is responsible for
staffing
SLIDE 11 Within One Hour of Entrance
There are four pieces for this section:
- 7. Key personnel list with location and ext.
- 8. Computer access
- 9. All facility policies and procedures related
to resident assessment instrument (RAI), including the minimum data set (MDS)
- 10. All facility policies and procedures related
to staffing and scheduling
SLIDE 12 Within 24 Hours of Entrance
There is one piece for this section:
- 11. Completed CMS form 671 (Medicare
Medicaid application)
SLIDE 13
Pilot Test
In the initial pilot testing, there were five states that participated. The testing ended August 2014 and included a total of 25 SNFs.
SLIDE 14 Pilot Test Activities
These facilities were surveyed for:
- MDS coding accuracy,
- accurate MDS-based reimbursement
levels, and
- RAI focused care planning that
matches resident needs and promotes person-centered care.
SLIDE 15
Pilot Test Results
The results were not complimentary, of the 25 facilities surveyed, 24 received deficiencies for errors related to MDS coding. CMS cited several prominent areas.
SLIDE 16 Pilot Test Results
CMS Cited Areas:
- Errors in MDS coding (esp. in certain
sections)
- Inaccurate staging and documentation
- f pressure ulcers
- Lack of knowledge regarding
classification of antipsychotic medication
- Poor coding regarding the use of
restraints
SLIDE 17 To Have Upon Request
- 12. Make staff members and other policies
and procedures available to surveyors upon request.
SLIDE 18 Avoid Possibly Citations
P R E P A R E
Did YOU P.R.E.P.A.R.E.? P-prepare in advance R-review the findings of others E-encourage daily compliance P-plan to audit routinely A-assure your plan is in place R-read the public findings E-enjoy the fruits of your labor
SLIDE 19
History Helps Us Prepare
Reviewing the results of others helps us to prepare for the future. Results from the states that were included in the initial survey findings support our learning and guide additional review; however, the real key is to use and embrace the directions in the MDS manual especially the item-by-item section.
SLIDE 20 Citations
If non-compliance is identified during this process, based on the experiences of the 25 facilities already surveyed, your facility may expect citation in one or more of the following (but not limited to):
F 157 Notification of Change F 272 Not Assessing Timely F 273 Not Assessing Timely
SLIDE 21 Citations
F 274 Significant Change in Condition
F 275 Not conducting annual
assessment timely
F 276 Not conducting quarterly
assessment timely
SLIDE 22 Citations
F 278 Inaccurate coding (skin, antipsychotic
medications, accurately reflect status)
F 280 Failure to include resident in care plan F 281 Scope/practice LPN (prof. standards)
SLIDE 23 Citations
F 282 Qualified individuals F 287 Encoding/Transmitting data
timely
F 323 Failure to provide equipment to
assist with fall prevention
SLIDE 24 Citations
F 315 Timely evaluation for catheter removal F 329 Failure to monitor for psychotropic
medication effectiveness
F 520 Failure to monitor MDS assessment
accuracy and failure to develop action plan to correct identified non- compliance
SLIDE 25
Staffing Compliance
SLIDE 26 Nursing Staffing Information
Federal nurse daily staffing information posting requirement includes:
Facility Name Current Date Total number and actual hours worked by
the following categories:
- registered nurses
- licensed practical nurses
- certified nurse aides
and
SLIDE 27 Nursing Staffing Information
Federal requirements continued:
Resident census Post at the beginning of each shift Post must be:
- clear and readable format
- in a prominent location easily accessible
to residents and visitors
and
SLIDE 28 Nursing Staffing Information
Federal requirements continued:
Provide public access, (upon oral or
written request), make nursing staffing data available to the public for review at a cost not to exceed the community standard.
Facility data retention requirements,
maintain posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
SLIDE 29
It is not to late to prepare for success! While the first 11 Florida surveys were completed by September 30th (FYE), CMS requires that they be continued.
Preparation is Key!
SLIDE 30
Successful facilities embrace the RAI manual and the MDS coding directions in the manual Chapter 3.
Key to Preparation…
SLIDE 31 Ready or Not Here CMS Comes!
YOUR STEPS FOR SUCCESS!
A few questions to consider:
- 1. Evaluate your facility risk.
- 2. Affirm you have the listed
policies and procedures?
SLIDE 32 Ready or Not Here CMS Comes!
- 3. Audit to affirm to assure that your
MDSs are coded to match your residents during the assessment reference date (ARD)?
- 4. Audit to affirm if your assessments
(CAAs) & Care Plans reflect resident centered & directed care?
SLIDE 33 In Conclusion
The CMS MDS & Staffing Survey is here to
- stay. A few questions:
- How are YOU the licensed Nursing Home
Administrator inspecting what you expect?
- Do you have the Policies and Procedures
required?
- What is your system to assure:
- Care plan compliance
- Posting Compliance
SLIDE 34
Finally…
At the end of the Day…F 490 is about how the licensed nursing home administrator manages to ensure compliance of these and all requirements regardless if you personally know how to or have time to complete the designated tasks or not.
SLIDE 35
We Thank You!
Thank you for attending our session. To reach Kimberly Smoak please: Email: Kimberly.Smoak@ahca.myflorida.com Call: 850.412-4516 or 850.559.8273 To reach Robin please: Email: robin@rbhealthpartners.com Call: 727.786.3032
