Volume XXX, Number 7
 July 2015

Updated Information on MDS 3.0 Staffing-Focused Survey

THCA received the following information from AHCA on the MDS 3.0 Staffing – Focused Survey.

  • CMS is now referring to these surveys as “MDS 3.0 Staffing Focused survey” or “MDS 3.0 Focus Staffing survey”
  • A major focus of the survey is compliance with F356 – §483.30(e) – Nurse staffing information
  • Noncompliance results in automatic CMPs and if CMP meets the threshold, loss of Nurse Aide Training Program
  • CMS is identifying the centers to receive this survey
  • CMS is adamant that no information about training, surveyor focus, etc., may be shared with either individual centers or with associations
  • Some state affiliates have heard that CMS has indicated the SSA will receive no additional funds for completing these focused surveys

Information from another state from a MDS 3.0 Staffing-Focused Survey

  • It is a 2-3 day survey
  • Facility was presented with Entrance Letter that this is a survey for MDS accuracy and staffing
  • Requested roster be completed within one hour; if not, would be cited (Worksheet #1)
  • Needed to complete form 671 within 24 hours
  • Requested list of all residents on anti-psychotics, admit, discharges and re-admits in the last 90 days
  • Asked who the wound care RN was but did not interview her
  • Requested all policies related to MDS, staffing and scheduling, infection control, restraints, falls, and psychotropic medications
  • Requested daily staffing sheets for previous 18 months
  • Did not interview staff or residents

Chart Review

  • Surveyors reviewed 10 records
  • Sample included residents with each QM – falls, wounds, catheters, and anti-psychotic medications
  • Included two residents with reportable incidents but had not had a complaint investigation (falls with injury)
  • Reviewed resident that had been previously cited at a “G” for wound care – only resident that was reviewed from their annual survey.

Potential Citations Anticipated:
Inaccurate records*

  • I resident did not have a Significant Change MDS completed in December (resident with “G” for wound care”)
  • Two residents had no diagnosis for anti-psychotic medications
  • Five residents did not have a care plan for anti-psychotic medications but did have behavior care plans
  • One resident did not have a care plan for pain or falls

*All were corrected prior to survey completion

Staff posting

  • Did not have 18 months of staffing posting

We understand that DADS has begun the MDS 3.0 Staffing-Focused Surveys in Texas. THCA will keep you informed as we learn how the Texas Focused Surveys are going.

President’s Report


 Legislative Update


 Commitment to Care

For questions or comments on any of the above Commitment to Care information please don’t hesitate to contact:
Gloria Bean-Williams, RN
Director of Clinical and Quality Services
Ph: 512-458-1257 or gbwilliams@txhca.org


State News


National News

  • Updated Information on MDS 3.0 Staffing-Focused Survey


Announcements & Recognitions


THCA’s 65th Annual
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Download a printable copy of the July 2015 edition of THCA Notes