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!
Todays Program Objectives
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.
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.
Let’s Get Started!
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.
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.
Entrance Conference The Time Frames are: Immediately Upon Entrance Within One Hour of Entrance Within 24 Hours of Entrance Upon Request or as needed
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
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
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
Within 24 Hours of Entrance There is one piece for this section: 11. Completed CMS form 671 (Medicare Medicaid application)
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.
Pilot Test Activities These facilities were surveyed for: o MDS coding accuracy, o accurate MDS-based reimbursement levels, and o RAI focused care planning that matches resident needs and promotes person-centered care.
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.
Pilot Test Results CMS Cited Areas: o Errors in MDS coding (esp. in certain sections) o Inaccurate staging and documentation of pressure ulcers o Lack of knowledge regarding classification of antipsychotic medication o Poor coding regarding the use of restraints
To Have Upon Request 12. Make staff members and other policies and procedures available to surveyors upon request.
Avoid Possibly Citations Did YOU P.R.E.P.A.R.E.? P P -prepare in advance R R -review the findings of others E E -encourage daily compliance P P -plan to audit routinely A A -assure your plan is in place R R -read the public findings E E -enjoy the fruits of your labor
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.
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
Citations F 274 Significant Change in Condition F 275 Not conducting annual assessment timely F 276 Not conducting quarterly assessment timely
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)
Citations F 282 Qualified individuals F 287 Encoding/Transmitting data timely F 323 Failure to provide equipment to assist with fall prevention
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
Staffing Compliance
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
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
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.
Preparation is Key! It is not to late to prepare for success! While the first 11 Florida surveys were completed by September 30 th (FYE), CMS requires that they be continued.
Key to Preparation… Successful facilities embrace the RAI manual and the MDS coding directions in the manual Chapter 3.
Ready or Not Here CMS Comes! A few questions to consider: YOUR STEPS 1. Evaluate your facility risk. FOR 2. Affirm you have the listed SUCCESS ! policies and procedures?
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?
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
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.
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
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