INDUSTRY UPDATE: MDS Focused Surveys
According to the Survey & Certification Memorandum (S&C:15-25-NH) dated February 13, 2015, based on the pilot experiences CMS revised the survey structure and processes to improve the usability, scalability, and effectiveness of the survey. The surveys will continue to assess compliance with the federal resident assessment regulation and other applicable regulations that are identified during the investigatory process. The surveys will also include a review of nursing center staffing in order to assess how staffing levels fluctuate throughout the year.
CMS has announced that deficiencies identified during the surveys will result in relevant citations and enforcement actions in accordance with normal and existing CMS policy and regulations. If care concerns beyond the MDS and staffing focus of this survey are identified, those concerns will be investigated during the survey or, if immediate investigation is not possible, registered with the state agency as a complaint for further review.
Prepare Your Team
Your team’s response to changes in post-acute care will impact quality outcomes, facility systems, compliance and, ultimately, reimbursement. It is important for staff at all levels to receive updated training, tools and resources.
Regulatory Preparedness Services
Pre-Survey Preparation
– Standard/traditional and QIS preparation
– Quality improvement
– Onsite assistance during survey
– Mock survey (full or focused) – traditional and QIS
– Immediate Jeopardy assistance
– Focused clinical system reviews
– Key Performance Metric assessment
Quality Improvement Assistance
– Root Cause Analysis process review
– Quality Assessment and Performance Improvement (QAPI) services
– Quality measures and five-star analysis and improvement
– Corporate compliance program review and validation
– Clinical and quality assistance with acquisition management
Regulatory Response Services
Post-Survey Response
– Plan of Correction assistance
– Plan of Correction templates, audit tools and more
– Directed Plan of Correction assistance
– Special Focus Facility assistance
– Litigation review and testimony
– Monitor and receivership assistance
– ZPIC/RAC response
– OIG response
Quality Turn Around Response
– Statement of Deficiency assistance
-Root Cause Analysis of repeat clinical quality concerns
– Action Plan creation
– Policy and procedure review, edit, replace
– Clinical system implementation
– Staff training
– Leadership mentoring
– Enforcement remedy mediation and assistance
– Monitoring after system implementation
– Assistance with state or federal Directed Plans of Correction, System Improvement Agreements (SIA) and Special Focus Facility designation.