Harmony Healthcare Blog

2015 MDS Focused Survey Results

Posted by The Harmony Team on Tue, Nov 15, 2016

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

survey_redCheck.jpgA recent CMS Survey and Certification Letter depicts the 2015 MDS Focused Survey results in terms of the Scope and Severity of deficiencies, the most frequently Cited Deficiencies and Common Errors. Here is a summary:

  1. Scope and Severity Level Percentage of Deficiencies

    Scope and Severity

    Percentages of Deficiencies 













  1. The highest cited deficiencies across scope and severity levels:
    On-site MDS Focused Survey visits showed that approximately “45% of citations were related to MDS or staffing posting inaccuracy” and that the remaining 55% were care related.
    • F278 – MDS Accuracy (The most shared coding errors antipsychotics and pressure ulcers)
    • F356 – Posted Nursing Staffing Information
    • F279 – Develop Comprehensive Care Plans
    • F329 – Free from Unnecessary Drugs
    • F314 – Treatment/Services to Prevent/Heal PUs
    • F315 – No Catheter/Prevent UTI/Restore Bladder
    • F274 – Comprehensive Assessment after Significant Change
Fiscal Year 2015 MDS Focused Survey Summary
  1. Common Errors
    For deficiencies cited for MDS Accuracy (F-278), surveyors found trends in the types of coding errors that occurred.  Below is a list (not all inclusive) of the most common errors found during the investigations.
    • Antipsychotics
      1. Coding inconsistent for residents with and w/o antipsychotics.  
      2. Incorrect number of days administered
    • Restraints
      1. Residents with restraints not coded as having a restraint.
    • Falls
      1. Residents not coded to reflect a fall when a fall had occurred.
    • Urinary Tract Infections (UTI)
      1. Incorrect coding based on UTI criteria in RAI Manual.
    • Continence/Catheters
      1. Coding inconsistent with residents with and without a catheter.  
      2. Residents coded as having a catheter with no diagnosis.
      3. Coding inconsistent with residents’ actual state of continence.
    • Pressure Ulcers
      1. Coding inconsistent with residents with and without pressure ulcers.  
      2. Pressure Ulcers not coded at the correct stages.
      3. Coded as healed when not healed. Incorrect number of pressure ulcers coded.
    • MDS Quarterly, Comprehensive (annual), and Significant Change in Status Assessment (SCSA)
      1. Not completed timely or not completed at all.
Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your MDS Accuracy.  Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 
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Tags: MDS Focused Survey

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