CMS to Expand MDS 3.0 Focused Surveys for Nursing Homes Pilot

Members | February 19, 2015

The Centers for Medicare and Medicaid Services (CMS) plans to expand the MDS 3.0 Focus Survey Pilot that was conducted in 5 states in June-July 2014.

The Centers for Medicare and Medicaid Services (CMS) announced its plan to expand its MDS 3.0 Focus Survey Pilot that was conducted in 5 states in June-July 2014. 

The expanded focused surveys will include a sample of nursing homes from all 50 states, and will continue to assess compliance with 42 CFR 483.20-Resident Assessment.

The surveys will also include a review of staffing to gauge fluctuation over the year.  

Implementing the Surveys in New States

The surveys will be implemented in 2 phases with CMS Regional Offices and states assigned to 1 of 2 groups, and will involve a sample of nursing homes to be surveyed in each state.

CMS will work with states to identify the facilities to be surveyed. A contractor may also supplement states’ efforts.

Surveyor training -- a 4-hour course to be conducted via webinar -- will begin in April of 2015. States will need to allocate 3 surveyors, at least 1 of which must be an RN, and 1 of which should be a supervisor. 

Regional Offices must allocate 1 surveyor.

Report on MDS 3.0 Focus Survey Pilot

Attached to the CMS announcement was the Abt Associates/CMS report on the focused survey pilot.

The pilot results included "relatively high levels of compliance" regarding RN coordination and assessment timing requirements.

"Room for improvement" was found in MDS 3.0/medical record agreement in 4 of the 7 clinical conditions reviewed:

  • Severity of injury associated with falls.
  • Pressure ulcer status.
  • Restraint use.
  • Late loss activities of daily living (ADL) status.

Levels of disagreement between the resident’s medical record and their MDS 3.0 assessment for these 4 conditions ranged from 15% to 25%. The disagreement found was concentrated in a small number of pilot facilities and states.

Both CMS and Abt Associates emphasize that the findings from the focused survey pilot should be interpreted with caution because, among other factors, the sample was not fully representative of the nation’s nursing homes.

The participating states volunteered and the State Survey Agency (SA) directors had discretion in the choosing facilities.

The surveyors for these surveys were specifically selected for the pilot, and were accompanied by the state RAI coordinator, “adding a level of MDS competency that [will not] be available” in the expanded process.

Each survey team was accompanied on their 1st survey by CMS staff, and a CMS consultant who provided technical assistance and ensured the protocol was implemented as intended and the survey worksheets correctly completed.