MDS Focused Surveys to be rolled out in May

As CMS announced in a 2014 S&C letter, MDS-focused surveys are set to be rolled out nationwide in 2015. New York DOH, Texas DADs and the Maryland DHMH have announced that they will begin conducting these surveys starting in the next fiscal year. The surveys are expected to take approximately 2 days. Other information provided about the surveys includes:

  • Surveyors will need access to resident medical records, including MDS 3.0 assessments and other information that supports coding (DADs notice)
  • Surveyors will need access to facility staffing and other requested documentation (DADs notice)
  • Surveys will focus on compliance with the MDS, but also nurse staffing requirements, so it will address compliance with all tags under Resident Assessment 483.20 and Nursing Services 483.30 (DHMH notice)
  • An MDS Focused Survey Worksheet will be distributed that must be completed as soon as the survey is initiated, and will require information on both SNF and LTC residents with any of these conditions noted in the past 90 days:
    • Restraints
    • Falls with major injury
    • Pressure Ulcers
    • Urinary Catheters
    • UTI
    • Antipsychotic Medications
    • Ext. Assist of 2 or more
    • These surveys will not impact the standard survey cycle, as they are not part of the annual survey or part of a complaint investigation
    • If deficient practices are noted during the survey, a Statement of Deficiencies will be issued and a Plan of Correction will be required
    • Surveyors will hold an exit conference at the end of the survey to discuss findings, but scope/severity will not be provided until the SOD is provided


Need help with survey preparation? Contact CMS Compliance Group today for this and other compliance assistance.

Reach out today and let's get started!

Urgent Compliance Concern? Call CMSCG

(631) 692-4422
cmscg podcast. five-star quality

Contact CMS Compliance Group

© 2011-2024 CMS Compliance Group, Inc. All Rights Reserved. Privacy Policy