MDS Alert

Get a handle on the new initial pool process, and exactly how surveyors may choose residents.

The initial pool process technically begins before surveyors set foot in your facility. Surveyors come to your facility with 70 percent of residents already chosen, with the selections generated via the MDS.

Once surveyors are in the building, the rest of the initial pool process begins once surveyors are in their assigned areas, says Maureen Kelly, senior consultant at LW Consulting Inc.,  in Harrisburg, Pennsylvania, during a webinar. The initial pool process will take about 8-10 hours, she says, and will begin hopefully be the end of the first day or the beginning of the second day.

Surveyors choose the final 30 percent of the pool as they begin their survey, going room to room without staff. "Initial pool selection is based exclusively on surveyor-identified information and is not reliant on staff input at this point," says the Centers for Medicare and Medicaid Services (CMS).

Basically, the door-to-door must be without staff from the facility, says Marilyn Mines, Rn, BC, RaC-Ct, senior manager at Marcum LLP, in Deerfield, Illinois. "The order in which the survey team conducts the door to door: door to door, then screen; interview and observe first, then to door to door; door to door, screen, then observe," she says.

Surveyors will be paying special attention to residents who are dependent on staff, and therefore at high risk for care concerns, Kelly says. They'll also be focused onresidents who have been admitted to the facility within the past 30 days (as you will identify on your matrix), as well as residents who are vulnerable due to their condition, possess an identifiable concern, or have filed a complaint or been the subject of a facility-reported incident.

Note: "If a team has more than five residents with complaints or facility-reported incidents to be included with the Standard survey, those residents would be in addition to the initial pool and sample size. In these cases, we expect either the size of the survey team to be increased, or the duration of the survey to be lengthened," CMS says in the Long Term Care Survey Process Procedure Guide.

However, there are two exceptions, CMS notes:

1) If the survey software chooses more than five residents in the off-site selection who also have a complaint or facility-reported incident, the surveyor will just include them in the initial pool, or

2) "If there is a general care concern that is not tied to a specific resident and would be addressed during the standard survey (e.g., the complaint is tied to a facility task or a care concern such as there is not enough water available for residents)."

Each surveyor will select around eight residents but can include more or fewer, Kelly says. The number may depend on the type of unit to which the surveyor has been assigned. For example, if the surveyor is on a rehab unit with an especially high number of new admissions, he may include more than eight residents, Kelly says. If the surveyor is assigned to a locked dementia unit, he may prioritize residents based on a brief screening, she adds.

Remember: The new survey process is laser-focused on surveyors' observations and interviews directly with residents or their representatives - they'll rely on staff interviews only if they have to, Kelly says.

After surveyors complete their interviews and observations, they'll conduct a limited record review. The Long-Term Care Survey Process Procedure Guide specifically instructs surveyors to conduct these record reviews while still on the floor - not in a conference room - to maximize their observations of residents. They'll be looking for documentation of advanced directives, confirming specific information they gleaned from interviews and observations, and looking to identify any further concerns.

If a resident cannot be interviewed, refuses, or is unavailable, expect surveyors to take deeper dive into her records. In this situation, CMS instructs surveyors to keep an eye out for:

• pressure ulcers,
• dialysis,
• infections,
• nutrition (or lack thereof, as evidenced by weight loss),
• falls in the past 120 days,
• ADL decline in the past 120 days,
• low-risk bladder and bowel,
• unplanned hospitalizations,
• elopement,
• and change of condition in the past 120 days.

Therefore, you have even more incentive to make sure residents with these conditions have the proper documentation in their clinical records, as well as the MDS.

Surveyors will be looking out for high-risk medications and hospice for newly admitted residents who do not have an MDS, CMS notes.