MDS and Focused Staffing Surveys Starting in 2015

In a recent S&C letter, “Nationwide Expansion of Minimum Data Set (MDS) Focused Survey,” CMS provided the results of its pilots on focused surveys for MDS coding practices. The 2014 pilot program consisted of testing the MDS-focused survey in 5 states, and provided a wealth of insights to the surveyors. The new survey type provided the surveyors with more time to review MDS data than they have on annual surveys, and deficiencies were cited in 24 of the 25 pilot surveys that were conducted. With strong results in the pilot that included findings around pressure ulcers, antipsychotic drug classifications and use of restraints in the pilot, CMS has decided to roll this survey type out nationwide in 2015.

What is the MDS 3.0 Focused Survey All About?

Starting in FY 2015, these MDS-focused surveys will start, but the number that will be conducted by state will vary, and CMS will work with the states to determine the number that should be conducted and when they will occur. The states will also be providing information to CMS on which facilities should be surveyed. The format of these surveys will include record review, resident observations, and staff and/or resident interviews that will validate MDS 3.0 coding and staffing levels.

Reported Staffing Reviews

Since staffing levels are provided only on the annual survey, CMS is looking for information on “fluctuations” in staffing levels throughout the year, as these will impact the quality of care being provided to residents. The staffing levels assessment will be conducted as part of the MDS-focused surveys.


If inaccuracies to the MDS 3.0 coding are found during survey, citations will be issued, including quality of care deficiencies, quality of life deficiencies and nursing services deficiencies. If pattern deficiencies are found, follow up by a CMS RO and CO will be recommended. If there are care concerns found during these on-site reviews, they may be cited or the SA will be given them to review as a complaint.

Read the October 31, 2014 S&C Letter (Ref: S*C 15-06-NH) on the CMS website.

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