CMS Releases Memos and Findings Report About MDS-Focus Survey

in Clinical & Quality

AHCA sent out the following important S&C memorandums on Friday, February 13, 2015 that CMS issued:

1)    MDS /Staffing Focused Surveys Update (with an attachment: MDS 3.0 Focused Survey Pilot Results)

2)    Nursing Home Compare “3.0” – Five Star Quality Rating System – Expanded and Strengthened

MDS/Staffing Focused Surveys Update – S&C 15-25

This memo provides additional information regarding the nationwide expansion of the MDS-focus survey and expansion to review nursing home staffing. Key points:

  • Training for surveyors will begin in early April 2015.
  • Training and surveys will be rolled out in two phases with Regions and States assigned to one of two groups.
  • Deficiencies identified during the surveys will result in relevant citations and enforcement actions.
  • Surveys will include a review of nursing home staffing to help CMS assess how staffing levels may fluctuate throughout the year.
  • Based on what was learned during the pilot, CMS revised the survey structure and processes (e.g., worksheets) to improve the usability, scalability, and effectiveness of the surveys.
  • No additional training or materials will be available to providers.  CMS advises providers to (a) review the information in the MDS RAI manual related to accurate completion of MDS assessments, and (b) review the guidance in Appendix PP relative to how to comply with requirements associated with the Resident Assessment.

MDS 3.0 Focused Survey Pilot Results

Abt Associates prepared the MDS 3.0 Focused Survey Pilot Results, which is attached to the S&C related to expansion of the MDS-focused survey.  The pilot surveys were conducted in 5 nursing centers in 5 states (Minnesota, Maryland, Virginia, Pennsylvania, and Illinois): that is a total of 25 nursing centers.  The primary purpose of these surveys, according to the report, was to “…evaluate adherence to MDS 3.0 reporting requirements, including the requirement to have an RN conduct or coordinate the assessments, and adherence to the required timelines for assessments.”  Additionally, the report states “A second goal was to evaluate the agreement between the MDS 3.0 assessments and the resident’s medical record.”

Key findings:

  • It is important to note the report states several times the findings cannot be generalized to all nursing centers because the sample is quite small and not representative of the total number of nursing centers in the country.  The report cautions how the findings from the pilot are interpreted.
  • 25% of MDS 3.0 assessments reviewed for falls showed disagreement between the MDS 3.0 and the medical record.
  • 18% of MDS 3.0 assessments reviewed for pressure ulcers showed disagreement between the MDS 3.0 and the medical record.
  • 17% of MDS 3.0 assessments reviewed for restraints other than side rails shoed disagreement between the MDS 3.0 and the medical record.
  • 15% of MDS 3.0 assessments reviewed for late loss ADLS (including bed mobility, toileting, transfer, and eating) showed disagreement between the MDS 3.0 and the medical record.

Nursing Home Compare “3.0” – Five Star Quality Rating system – Expanded and Strengthened –S&C 15-26

This memo summarizes the changes to the Five Star Rating System.  The information in the memo is very similar to the material shared by Thomas Hamilton on the SNF Open Door Forum held on Feb. 12, 2015.  According to the summary in the memo:

 February 20, 2015 Improvements to Nursing Home Compare include:

  • Including Quality Measures (QMs) for nursing homes’ use of antipsychotic medication in residents without diagnoses of schizophrenia, Huntington’s disease, or Tourette syndrome in the Five Star calculations.  One measure is for the new use of these medications in short-stay residents.  A second measure reflects continued use of such medications in long-stay nursing home residents.
  • Raising the threshold for nursing homes to achieve a high rating on all measures publicly reported in the QM dimension on the website.
  • Updating expectations for State Survey Agencies to conduct specialized, onsite surveys of a sample of nursing homes across the U.S. that assess adequacy of resident assessments and the accuracy of information reported to CMS that is used in calculating quality measures used in the rating system.

NOTE:  these materials have not yet been posted to the CMS website.  They have been submitted for posting and CMS is not certain when the will be available on their site.  This material has been sent to the State Survey Agencies and Regional Offices.  This is not confidential material and I encourage you to share it as necessary.

Lyn Bentley, MSW
Sr. Director of Regulatory Services
1201 L St., NW
Washington, DC 20005
Office:   202-898-6304
Mobile:  301-356-1766


Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20

Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15