Early Results of CMS MDS Focused Survey Initiative

Following completion of a pilot study, the Centers for Medicare and Medicaid Services (CMS) announced in February the nationawide expansion of an MDS/Staffing Focused Survey. The intent of the focused survey is to assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and its relationship to resident care in nursing homes.

In the earlier pilot study the following was found:

• 25% of MDS 3.0 assessments reviewed for falls showed disagreement between the MDS 3.0 and the medical record;
• 18% of MDS 3.0 assessments reviewed for pressure ulcers showed disagreement between the MDS 3.0 and the medical record;
• 17% of MDS 3.0 assessments reviewed for restraints other than side rails showed disagreement between the MDS 3.0 and the medical record;
• 15% of MDS 3.0 assessments reviewed for late loss ADLs (including bed mobility, toileting, transfer, and eating) showed disagreement between the MDS 3.0 and the medical record.

So far, the findings from the focused surveys conducted nationwide demonstrate incidents of inaccurate coding of falls with major injuries on discharge assessments. In at least 2 states, providers have received MDS accuracy citations because discharge assessments were not modified to reflect a fall with major injury after the resident was treated at the hospital and returned to the facility. LeadingAge provides some guidance on how to code falls on the MDS.

LeadingAge New York is looking to hear from members who have had an MDS focused survey and what their experience has been.

Contact:  Elliott Frost, efrost@leadingageny.org, 518-867-8832