MDS Alert

Learn how your staffing sheets could land you in hot water.

The MDS-Focused Surveys are in full swing, and skilled nursing facilities (SNFs) are beginning to report back on what’s happening — and what’s happening to many facilities is multiple citations.

Prepare Yourself for Meticulous Surveyors

As expected, SNFs are reporting that their first step in the MDS-focused surveys is to complete the MDS Worksheet #1, noted MDS expert Judy Wilhide-Brandt, RN, BA, RAC-MT, C-NE of Judy Wilhide Consulting Inc. in a recent blog posting. (See “Can You Fill Out This MDS-Focused Survey Worksheet In 1 Hour?” MDS Alert Vol. 13, No. 5, page 53.)

Surveyors are asking for the last 18 months of nursing staffing reports and most appear to be cracking down on missing staffing data, Wilhide-Brandt added. Surveyors are also requesting to see a variety of policies and procedures, including those addressing MDS completion, restraints, urinary tract infections (UTIs), antipsychotic medications, and staffing and scheduling.

The MDS-focused surveys are shorter than other surveys, typically only two or three days, according to an Aug. 3 blog posting by Beckie Dow of Harmony Healthcare International (HHI). SNFs have reported to HHI that surveyors are arriving at facilities with a prepared list of assessments to review, but they’re also pulling additional assessments. In some cases, surveyors are evaluating the assessments together, side-by-side.

In addition to reviewing MDS records, staffing sheets and facility policies, surveyors are asking for a tour of the facility and are asking questions about potential quality of care issues that they see while walking around the facility, Dow said. “Surveyors were very visible on the units throughout the survey process.”

Beware: Also, surveyors aren’t limiting their citations to the MDS survey’s scope — SNFs are reporting that surveyors are handing out citations for any and all deficiencies identified during the surveys, Dow noted. “Particular areas that have caught the surveyors’ attention were deficiencies that could be restraints, feeding patients in bed, and patient dignity issues.”

Don’t Make Costly Staffing-Report Mistakes

Many providers are getting slapped with citations and even Civil Money Penalties (CMPs) for not having their staffing sheet readily available and/or having incomplete staffing data.

Examples: A Florida SNF received a CMP for not having the staffing sheet in a readily accessible and viewable location for the surveyors, as well as not having the staffing sheet in the correct format, according to Wilhide-Brandt. A facility in New York and one in Maine also received citations for not posting staffing information. A North Carolina facility received a citation for not having 18 months of the staffing sheets available; the facility kept only 12 months at a time.

A facility in Massachusetts also received a citation for their staffing posting, specifically because it did not include the facility name, while another facility in that state received a citation for not posting the daily staffing data, Wilhide-Brandt reported on her blog. A Virginia SNF faces a citation for failing to post the daily staffing sheet on the first day of the MDS-focused survey.

Don’t fall victim to this citation — follow these rules for complying with Nurse Staffing Information (F356):

• The facility must post the following information on a daily basis:

o Facility name, current date, and census.

o Total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident careper shift:

§ Registered nurses,

§ LPN/LVN, and

§ Certified nurse aides.

• Data must be posted:

o In a clear and readable format.

o In a prominent place readily accessible to residents and visitors.

• Facilities must, upon request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

• Facilities must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Get Your ADL Documentation in Order

Activities of Daily Living (ADLs) are another top focus of the MDS-focused surveys, Dow reported. HHI clients have reported that surveyors are going beyond simply checking the medical record for supportive documentation — “they are also interviewing direct care staff to see if levels of assistance that are described verbally match the documentation in the medical record and on the MDS assessment.”

Look out: Beware that in some cases, ADL data may not match up, warns Marilyn Mines, RN, BC, RAC-CT, MDS Alert consulting editor and senior manager of clinical services for FROST Healthcare in Deerfield, Ill. “Staff must be aware of changes that might have occurred since the MDS was completed, possibly the result of therapy or restorative nursing, and maybe the significant change MDS is in the process of being completed or the resident has not yet met the criteria.”

Your daily documentation should match, “but what is observed today may not match what is on the MDS for this and other reasons (acute illness resulting in less independence),” Mines notes. “Often staff is overwhelmed by surveyors and lose their voices even when the latter may be wrong or uninformed.”

Best bet: “Ensure that ADL documentation in the medical record matches staff perception of self-performance and support assistance that was provided,” Dow recommended. “Great survey preparedness techniques, including QAPI [Quality Assurance & Performance Improvement] on any area of concern, will help the facility have a successful MDS survey.”

Double-Check Falls-Related Coding Accuracy on Discharge Assessments

Yet another issue that surveyors have cited numerous times so far involves coding falls with major injuries on the Discharge assessment, according to an Aug. 5 report by Washington, D.C.-based Leading Age. “In at least two states, providers have received an MDS accuracy citation because a Discharge assessment was not modified to reflect a fall with major injury after the resident was treated at the hospital and returned to the facility.”

Example: An Ohio SNF that recently underwent an MDS-focused survey reported to Wilhide-Brandt that they received a citation involving MDS accuracy for a discharge assessment. The case involved a resident who fell within the facility and hit his head, and then went to the emergency department for an evaluation. Although the discharge assessment was coded as a fall with injury, J1900B — Injury (except major), the resident was readmitted 10 days later with a discharge summary that stated he had a subdural hematoma.

The surveyors gave the facility a citation because the MDS coordinator should have modified the Discharge assessment upon readmission to reflect that the resident had a fall with major injury (J1900C — Major injury), which specifically includes subdural hematoma.

Important: Remember that the fall must occur in the look-back period, “but the extent of the injury may be determined after the ARD [Assessment Reference Date], and after a discharge to the hospital,” Leading Age stated. “If a fall that has been previously coded on an MDS has an injury that was determined after the MDS has been transmitted and accepted into the national repository, the MDS must be modified to reflect the correct code for the type of injury.”

Brace for Real Citations, But Not Immediate Answers

Clearly, surveyors conducting MDS-focused surveys aren’t shying away from handing out citations, both within and outside the scope of these surveys.

At the very first hint of the creation of the MDS-focused surveys, the Centers for Medicare & Medicaid Services (CMS) didn’t mince words about the very real consequences — making clear that if surveyors found areas of noncompliance, they would investigate them at the time of the MDS-focused survey or refer them to the State Agency as a concern, according to Dow. Deficiencies that surveyors identify in the surveys will result in relevant citations and enforcement actions.

What’s more: “Surveyors have answered very few questions during the process, which has been frustrating for some clients who want to learn from potential mistakes and correct practices immediately,” Dow lamented. Some surveyors are, however, giving facilities a toll-free number to call to get answers to theirquestions.