Audits, Surveys, and Scrutiny Oh My! :: Reliant Rehab

Audits, Surveys, and Scrutiny Oh My!

HIPPA compliance audits to resume for a second round very soon but no exact date known. Health & Human Services’ Office for Civil Rights (OCR) expects to single out only around 110 providers. Kelly McLendon, managing director of CompliancePro Solutions urges LTC providers to prepare sooner rather than later. Providers are encouraged to “performing security and risk analyses, updating privacy and security incident response plans and automating privacy and security investigation, tracking and management protocols.”


CMS launches focused surveys with increased scrutiny of Dementia and MDS/Staffing.

For Focused Dementia Care Surveys it is anticipated that starting this month surveyors will be in facilities small samplings of volunteer states, with histories of high use of antipsychotic medication and residents with diagnosis of Dementia, to look at a broad range of Dementia related care factors.  Some of the homes that participated in the Pilot from (California, Minnesota, New York, Illinois, and Louisiana), reported that the survey was intense and was based on residents with a diagnosis of dementia. The following are lessons learned from some facilities that were in the Pilot.

Focus During the Pilot

Facility Assessments – of those with dementia and their needs and working with families to learn specifics regarding the residents background, habits, preferences and needs

Involvement – of families, staff, and physicians

Care planning – are their medications (gradual dose reductions/plan) and needs/uncharacteristic responses (behaviors) care planned

Interactions – staff responses to resident behaviors

Monitoring/Documentation – medications particularly antipsychotics and their side effects

Revisions/Adjustments – to the overall plan based on the findings from the facility’s monitoring

Antipsychotic off label use – including physician ordering practices and documentation

Policies and Procedures – in line with F 309 and F 329 regarding caring for people with dementia and the reduction of antipsychotic off label use

Things to be aware of:

Facility staff from all disciplines including CNA’s, physicians and nurse practitioners were interviewed by surveyors during some of the Pilot surveys, so they need to be able to articulate why a resident is taking an antipsychotic medication and the dementia care provided for the resident and/or the plans for antipsychotic reduction. 

Staff should also be able to explain to surveyors what they do for difficult behaviors, such as (sun- downing, hording, rummaging, repeating things over and over, wandering, anxiety, aggression and agitation).

In summary, survey findings from the Pilot facilities resulted in 16 of the 20 surveys (80%) cited either F 309(Care of a Resident with Dementia) or F 329 (Unnecessary Use of Medications), and 11 out of 20 surveys (55%) cited both tags.  Other commonly cited tags included F520 (Quality Assessment and Assurance) and F 279 (Develop Comprehensive Care Plans).  There were 68 total deficiency citations out of the 25 nursing facilities surveyed, and four were cited at harm level. CMS has developed some online training on these areas that can be found here:

For focused MDS/Staffing Surveys the amount of facilities to be surveyed or which facilities will be targeted is unknown.  The Pilot states were (Minnesota, Maryland, Virginia, Pennsylvania, and Illinois).  Information below may help your facility prepare for the possibility of one of these surveys.

Focus During the Pilot

In depth review of the facilities MDS assessment process

Staging and documentation of pressure ulcers 

Knowledge regarding classification of antipsychotic drugs

Accuracy of coding for falls and restraints

Assessment of the staffing levels of the facility in order to verify the data self-reported by the nursing home on documents like the CMS-671 completed during annual surveys.

Based on feedback from nursing facilities that experienced one of the MDS Pilot surveys also indicates that the surveys are very intensive and require clinical nursing leadership to work with the surveyors answering questions and explaining details, the following are some guiding principles and useful information:

  • All direct care staff need to know their residents, including their needs, abilities, deficits and general demeanor. Facilities that had a good MDS Pilot Survey knew their residents inside and out.
  • Make sure your MDS and medical records are in agreement. Many of the deficiencies from the MDS Pilot Surveys were a result of the MDS and medical records not lining up or not being in agreement.  Print out an 802 and 672 to ensure accuracy.
  • An RN must conduct/coordinate the MDS assessment.
  • Be aware of and in compliance with the time frames for assessments and updates.

In general, most of the deficiencies focused/centered on the failure of the facility to accurately reflect the status of the resident. 

Things to be aware of:

In summary, citations from MDS/Staffing focused surveys shall include deficiencies related to quality of care and/or life, or nursing services.  These surveys can result in citations and affect the facilities’ 5 STAR rating.  Other training available on the CMS Surveyor Training site online can be located here:

These MDS Focused Surveys are separate from your annual survey and deficiencies and enforcement action can result directly from them. If a nursing facility receives one or more citation the final survey report (2567) is independent from any other survey.  If a concern is noted during one of the focused surveys, outside of the focus area, then it would be treated as a stand-alone concern and generate a separate survey which would result in an additional 2567. 

Info above is courtesy of Texas Health Care Association.


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