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n the world of the Minimum Data Set (MDS), almost nothing is as nerve-wracking as an annual survey. Whether it is with 3 surveyors for 3 days or 4 surveyors for 7 days, the facility must be on its best behavior and put its best foot forward. Although the facility should always be ready for any survey, in my experience most facilities scramble at the last minute to spruce up and clean up anything and everything necessary. I have participated in many audits in the months leading up to a survey only to end up waiting idly for weeks. One often hears, “We’re waiting for the surveyors!” Depending on the surveyors’ schedules, however, it may take weeks or months for them to make that fateful visit.
       Prior to a survey, the state or federal team coordinator obtains the same Quality Indicators (QI) reports you and I download every month. He or she also obtains a statement of deficiencies from the Centers for Medicare & Medicaid Services (CMS) form 2567, as well the history of deficiencies from the Online Survey, Certification, and Reporting System (OSCAR) report, which shows patterns of repeat deficiencies in particular federal tags (F-Tags). This report also lists the dates of any complaint investigations and federal monitoring surveys conducted over the last 4 years.
       The Quality Measure/Indicator Monthly Trend Report shows a facility’s monthly scores on any single Quality Indicators/Quality Measures (QI/QM) category. The data, displayed in a graph, allow the user to determine whether the facility’s scores are increasing or decreasing over time and evaluate how those scores compare with state and national averages.
       According to the American Health Care Association (AHCA), a standard survey assesses these topics:
• Compliance with resident rights and quality of life requirements
• The accuracy of the residents’ comprehensive assessments and the adequacy of care plans based on these assessments
• The quality of care and services furnished, as measured by indicators of medical, nursing, rehabilitative care and drug therapy, dietary, and nutrition services; activities and social participation; sanitation and infection control
• The effectiveness of the physical environment to empower residents, accommodate resident needs, and maintain resident safety, including whether requested room variances meet the health, safety, and quality of life needs of affected residents.
       The goal is to have a deficiency-free survey. When it comes to the MDS, here is what I have found. Although accuracy of a section is not the responsibility of the MDS coordinator, it does help to catch certain items before printing or transmitting the MDS. Also, by reviewing the QIs, one can double check selected items that would be targeted by the surveyors to investigate. Every month, I review the results. Other team members, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), should also review the QI report. This review process makes correcting any inaccuracies easy.
       Be sure to review the revised CMS guidelines for pressure ulcers (Federal Tag 314) and urinary incontinence (Federal Tag 315). Ensure that your comprehensive assessments, Resident Assessment Protocols (RAPs), and care plans address each individual’s particular situation regarding these topics. This will take a team approach of assessing, planning, implementing, and evaluating.
       All areas of caring for the resident are important. All departments are involved, in one way or another, with direct resident care or support. However, we all know about accountability and who is ultimately responsible. The administrator and DON do their best to guide and direct care, but they cannot do it all. The facilities that succeed are those that work well together.
       How does staffing affect the MDS coordinator? Is the MDS your only job responsibility? How do you relate to the other disciplines? Make sure you are clear regarding other nursing responsibilities. Any problems you have should be brought to the quality committee, supervisor, and administrator to be worked out. May all of your surveys be a success!

Questions and Answers

       Question: “What happens when an MDS is late?” (licensed practical nurse, California)
       Answer: Relax. It is not the end of the world. We all make mistakes. Complete the MDS as soon as you discover that it is late. Examine your system so that you can prevent it from happening again.
       Question: “When will CMS correct the problem of restaging a pressure ulcer as it heals?” (registered nurse, New York)
       Answer: Discussion is ongoing now with CMS, the National Pressure Ulcer Advisory Panel (NPUAP), and the Wound, Ostomy, and Continence Nurses (WOCN) Society on how to code pressure ulcers. Remember, currently the rule of thumb is to “downstage” a pressure ulcer—although we know that, “once a stage 4, always a stage 4.”

MDS News

       The CMS will continue to reimburse those nursing facilities with Medicare residents affected by Hurricane Katrina, even though information may have been lost. A CMS press release states, “Because of hurricane damage to local healthcare facilities, many beneficiaries have been evacuated to neighboring states where receiving hospitals and nursing homes have no healthcare records, information on current health status, or even verification of the person’s status as a Medicare or Medicaid beneficiary. [The agency] is assuring those facilities that in this circumstance the normal burden of documentation will be waived and that the presumption of eligibility should be made.”
       To view the entire press release, visit http://www.cms.hhs.gov/media/press/release.asp?Counter=1546.