Dementia Focus Surveys

Karen Morris in Clinical & Quality

CMS has posted the attached S&C letter #15-31 related to the results of the Dementia Focus Survey Pilot that was completed last year. The final report, which is attached to the S&C memo, describes in more detail the results of the pilot. CMS is expanding its work based on the pilot and has invited the states to conduct the dementia focus surveys in FY 2015 on a voluntary basis. We have not heard officially that NYS has volunteered at this point, however, we anticipate that may occur at some time in the future based on New York’s participation in the pilot. We have requested DOH share with us any training and/or survey tools they receive from CMS.  Below are notes we received from AHCA’s review of the S&C and the pilot.

Key Points from Report

  1. The states where the pilot surveys were conducted: Illinois, Minnesota, New York, California, and Louisiana.

  2. There were five nursing centers in five states that were surveyed for this pilot: one that was considered by the state a “best-practice” center and four others.  The “best practice” centers received no deficiency citations, even if surveyors identified potential deficiencies. 

  3. Of the 20 centers that were surveyed, 16 were cited at either F309 (Care of a Resident with Dementia) or F329 (Unnecessary Use of Medications).

  4. 11 of the 20 centers were cited at both tags (F309 and F329).

  5. Of the 68 total deficiency citations, 4 were at a G or harm level (three in CA and one in IL).

  6. Next Steps:

a. The dementia care focused survey process will be revised and this streamlined version will be used in both traditional and QIS States.

b. The streamlined version will also be used during complaint surveys

CMS Expansion Project

  1. States have been invited to conduct dementia focused surveys in FY 2015 on a voluntary basis using the revised survey tools.

  2. The expansion project will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications

  3. CMS will provide criteria for determining specific facilities to be surveyed in those volunteer states.

  4. CMS has initiated a comprehensive survey effort in TX.  A CMS subject matter expert will accompany each survey team on its initial survey.

  5. All deficient practices noted during the surveys will result in relevant citations.

AHCA has requested the surveyor worksheets from CMS in order to develop helpful training tools/tip sheets to share with states to prepare members who may receive these focused surveys.

Karen Morris

Director, Clinical & Quality Services
518-462-4800, ext. 15