Harmony Healthcare International offers the following insight, which was shared by clients across the country:
- ADLs are a Top Focus: Surveyors aren't just checking the medical record for supportive documentation. They are also interviewing direct care staff to see if levels of assistance that are described verbally match the documentation in the medical record and on the MDS Assessment.
- Shorter, More Intense Visits: The survey is typically 2-3 days long. Surveyors come prepared with a list of assessments to review, but are also pulling additional assessments once those are completed. Surveyors are evaluating the assessments together, side-by-side, in some cases.
- Not Just a Paper Review: Surveyors spent time reviewing medical records, but also asked questions about potential quality of care issues they saw while walking around the facility. Surveyors were very visible on the units throughout the survey process.
- Expanded Focus, If Need is Noted: Surveyors are on the lookout for areas that are beyond the scope of the MDS Survey that may affect patient care. Deficiencies identified during the surveys will result in relevant citations and enforcement actions in accordance with normal and existing CMS policy and regulations. Particular areas that have caught the surveyors attention were devices that could be restraints, feeding patients in bed, and patient dignity issues.
- Questions Are Deferred: Surveyors have answered very few questions during the process, which has been frustrating for some clients who want to learn from potential mistakes and correct practices immediately. However, surveyors did provide a toll-free number that providers could use to ask their questions.
CMS has stated that areas that are found to be in non-compliance will be investigated at the time of the MDS Focused Survey, or will be referred to the State Agency as a concern. Deficiencies identified during the surveys will result in relevant citations and enforcement actions. Preparation for the MDS Focused Survey includes being familiar with RAI Scheduling and Coding guidelines, as well as Appendix PP of the SOM.
Harmony Healthcare International recommends that facilities ensure that ADL documentation in the medical record matches staff perception of Self-Performance and Support assistance that was provided. Great survey preparedness techniques, including QAPI on any area of concern, will help the facility have a successful MDS Survey.
For more information on the MDS Focused Survey and how you can better prepare your SNF's quality, documentation and compliance programs, please contact Harmony Healthcare by clicking here or calling our office at (800) 530-4413.