CMS S&C: FY 2015 MDS Focused Survey Summary

The Centers for Medicare and Medicaid Services issued a new S&C letter on November 4, 2016 providing an overview of the results of the FY 2015 MDS Focused Survey pilot. In late 2012, the Office of the Inspector General issued a couple of reports reviewing nursing homes that reflected the need for increased scrutiny on MDS resident assessments and claims. That led to 2014’s MDS focused survey pilot to assess MDS 3.0 coding practices and how coding was related to resident care in nursing homes.

The pilot survey was rolled out nationally in 2015. The results from the FY 2015 MDS focused surveys were:

  • Most deficiencies, like most standard surveys, were cited at a S/S of D (56%) or E (25%). No IJs were identified, and only 1% of the deficiencies were cited at an Actual Harm level (G).
  • The most frequently identified F-tags were:
    • F-278 MDS Accuracy – Areas with the most common errors include:
      • Antipsychotics
      • Restraints
      • Falls
      • UTIs
      • Continence/Catheters
      • Pressure Ulcers
      • Scheduled Assessments – Quarterly, Annual, Significant Change
    • F-356 Posted Nursing Staffing Information
      • Staffing posting were often not up to date
      • Records were not retained for a minimum of 18 months as per regulation
    • F-279 Develop Comprehensive Care Plans
    • F-329 Free from Unnecessary Drugs
    • F-314 Treatment/Services to Prevent/Heal Pressure Ulcers
    • F-315 No Catheter/Prevent UTI/Restore Bladder
    • F-274 Comprehensive Assessment after Significant Change

Read CMS S&C letter “Fiscal Year (FY) 2015 Minimum Data Set (MDS) Focused Survey Summary” (Ref: S&C 17-06-NH) on the CMS website.

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