Industry Insights

CMS to Expand Focused Surveys

November 2014
Author:  Bob Lane

Bob Lane



Health Care

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Oklahoma City, OK 73102-9421

Oklahoma City

The Centers for Medicare & Medicaid Services (CMS) undertook a short-term focused survey pilot in mid-2014 to assess Minimum Data Set (MDS) Version 3.0 coding practices and the relationship to resident care in nursing homes. The pilot was implemented in five states and concluded in August 2014; it offered a more in-depth review of nursing home resident assessment processes than in normal annual surveys. There were 25 surveys completed during this pilot, and deficiencies were identified and cited on 24 of them. Due to these results and the survey’s ability to help surveyors identify errors and deficiencies related to MDS coding and resident care, the surveys will be expanded nationwide in 2015.

In addition, the need to verify the accuracy of information pertaining to nursing home staffing also has been identified as a priority, given that staffing information typically is collected only at the time of the annual survey—through the CMS 671 form—and does not provide information on staffing fluctuations throughout the year. This information now will be collected through the expanded MDS survey process.

CMS intends to conduct these expanded focused surveys nationwide beginning early in federal fiscal year 2015, which began October 1, 2014. CMS will work with states to determine how many surveys should be conducted and when they should take place throughout the year; the agency and states will identify which providers will be surveyed. The survey protocol and tool states will use for this survey are being developed, but the process will include record review, resident observations and staff and/or resident interviews.

Noncompliant providers will be subject to relevant citations, including those related to quality of life and/or care or nursing services. In addition, any other observed care concerns also are subject to referral to the state survey agency for follow up as a complaint.

For assistance with these issues, or for more information on this expanded survey process, contact your BKD advisor.

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