MDS 3.0 – Changes in the Survey Process. By Haideh Najafi, RN, BSN, MSED, EDS And Tedi Beckett, RN, MSN September 15, 2010. Objectives. Describe the difference between MDS 2.0 and MDS 3.0. Describe the effect of MDS 3.0 on the survey process.
MDS 3.0 – Changes in the Survey Process
Haideh Najafi, RN, BSN, MSED, EDS
And Tedi Beckett, RN, MSN
September 15, 2010
Section J – Health Conditions (Pain)
Section M – Skin Conditions
Section O – Special Treatments, Procedures, & Programs
Section P – Restraints
Section Q – Participation in Assessment & Goal-Setting
Pain assessment requires asking the resident detailed questions about:
Section J requires staff to answer questions about non-verbal indicators of pain and about the resident’s pain medication regimen.
Falls Prior to Admission and Falls Since Admission
standards do not
There will be changes in:
a) Sample selection.
b) Validating interviews.
c) Care Area Assessment (CAA) process.
d) The tasks & the SOM.
The survey process will go back to the 1995 survey procedures until QI/QM data become available.
Yes, CMS is changing some of the survey forms.
Are the survey
Teams will not be able to generate an off-site sample based on the QI’s during this interim period.
Issues & the off-site sample will be based on:
3) Areas of concern that relate to each
1) Physical dependency.
2) Functional dependency.
3) Cognitive functioning.
WHP sample selection:
Residents that are encouraged but not required to be placed on the sample:
Verify that information obtained and recorded during the structured interviews on the MDS 3.0 is accurate and correct.
Review Care Area Triggers (CAT’s). All CAT’s do not necessarily require care planning.
Review the documentation that is the basis for the facility’s decision to care plan a CAT or not.
Surveyors use the “Location and Date of CAA Documentation” column on the CAA summary (section V of the MDS 3.0) to find where the CAA documentation can be located in the resident’s record. Review this documentation.
The documentation of the CAA findings and decision–making process may appear anywhere in a resident’s records “e.g: flow sheets, progress notes, care plan summary, CAA narrative.”
Look for evidence that the information from the resident’s interviews has been incorporated into a care plan (especially from section Q).
F-168 - Right to receive information from agencies acting as client advocates and be offered the opportunity to contact these agencies.
Cite if the facility did not make a referral to the LCA within 10 business days of the resident answering “Yes” to Q0500A. The facility must follow-up with the LCA if there is no face-to-face visit to the resident within 10 business days of the referral date.
F-172 Access to residents by any entity or individuals who provide health, social, legal, or other services
F-204 Sufficient preparation and orientation for safe & orderly discharge from the facility
Cite if the discharge preparation did not include:
F-250Medically-related social services to attain or maintain highest practicable well-being
Cite if medically related social services for discharge planning did not include resident responses to Section Q or if plans to return to the community were not coordinated with the LCA by the social worker/designee.
F-272 through F-278 - Comprehensive, accurate, timely assessment of the resident’s functional capacity
F-279 Comprehensive plan of care
F-280 Right to participate in planning care and treatment
F-284 Discharge planning