Remember last year when CMS reported they would implement a new MDS-focused survey inspection nationwide? This type of survey was to be in addition to the “typical” annual state and/or federal inspection that those in long-term care simply call… “survey.”

Well, the results of the first batch are in! Results were released by CMS (Center for Medicare and Medicaid Services) in a recent Memo from the Center for Clinical Standards and Quality/Survey & Certification Group. Click here to view the Memo.

Why the New Survey Anyway? A Little Background

As you know, the primary purpose of the MDS 3.0 resident assessment is to serve as the clinical basis for individualized care planning and delivery of person-centered care. Federal regulations requiring the MDS 3.0 and the Care Area Assessments (CAAs) apply to all Long-Term Care (LTC) facilities participating in Medicare and Medicaid.

The MDS 3.0 has grown in scope and is intertwined in multiple areas of LTC. Now more than ever, assessment accuracy has a critical role in optimizing person-centered care planning and ensuring each resident is able to attain and “maintain the highest practicable physical, mental, and psychosocial well-being.” Here are a few areas that MDS data now drives:

  • Resource Utilization Group (RUG) score determination and associated Medicare payment rates (RUGS IV)
  • Medicaid [Case Mix] payment rates (RUGS III or RUGS IV – some states)
  • Quality monitoring such as the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
  • Quality Measures, including those used in the Five-Star Quality Rating System on the CMS Nursing Home Compare website

CMS and OIG (Office of Inspector General) uncovered several issues over the past few years relating to the accuracy of MDS 3.0 assessments which sparked the new MDS-Focused Survey. In 2012, OIG performed a review of nursing facility records and found that SNFs misreported information on the MDS for 47% of claims reviewed. In 2014, CMS, together with five volunteer States, piloted a short-term focused survey to assess MDS 3.0 coding practices and its relationship to resident care in nursing homes. In October 2015, the Government Accountability Office (GAO) reviewed QMs that are calculated using MDS 3.0 assessments, and recommended CMS establish and implement a clear plan for ongoing auditing to ensure reliability of data self-reported by nursing homes, including payroll based staffing data and data used to calculate clinical quality measures based on the MDS 3.0. These findings led to the conclusion that MDS 3.0 Focused Surveys would continue to be conducted through FY 2016 and FY 2017.

The Results?

Scope and Severity:

The majority (56%) of deficiencies were cites at a scope and severity level of “D”, followed by “E” (25%). This translates to a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of isolated and pattern, respectively. Below is the percentage of deficiencies found at each level:



Top Cited Deficiencies:

Across the scope and severity levels, there were 56 different deficiencies (F-tags) cited. The more frequently cited deficiencies are listed below:


Common Errors:

For deficiencies cited for MDS Accuracy (F-278), surveyors found trends in the types of coding errors that occurred. Below is a short summary of the most common errors found during the investigations:



For deficiencies related to posted staffing (F-356), surveyors found that the most common reasons for noncompliance were that the staffing posted was not up to date, and staffing records were not retained for 18 months, per regulation requirements.

Resources for the MDS Team

CMS aims to help providers maintain compliance to improve the safety and quality of care nursing home residents receive. Several resources are available for SNF’s to access to help improve compliance:

  1. The CMS regulations for the RAI, including the MDS 3.0 and the Care Area Assessments (CAAs) are found at 42 CFR 483.20. Interpretive guidance for these regulations is found in Appendix PP of the SOM at F-tags 272 through F287 at 
  2. The RAI Manual provides instructions to accurately code the MDS assessment and provide appropriate care.
  3. Within the manual, CMS recommends facilities review:
    • Chapter 3 for specific instructions on how to code each section of the MDS assessment. Based on the survey findings, the guidance for Falls, Pressure Ulcers, and classifying medications have been updated to clarify coding instructions for providers.
      • Antipsychotic Medications (MDS Item N Page N4- N9)
      • Restraints (MDS Item P Page P1 – P8)
      • Falls (MDS Item J Page J26 – J34)
      • UTI (MDS Item I Page I1- I9)
      • Pressure Ulcers (MDS Item M Page M1 – M30)
      • Continence (MDS Item H Page H1 – H2)
  4. • Training modules for completing the MDS assessment can be found at
  5. Based on the complexity of coding Pressure Ulcers and the errors identified on the surveys, there is a new training module to help providers address pressure ulcers.
  6. Providers and MDS Coordinators may also want to contact their State RAI Coordinators for questions. Contact information for State RAI Coordinators can be found in Appendix B RAI Manual and found at

In Summary

The MDS Focused Surveys were utilized to audit the accuracy and reliability of data self-reported by nursing homes. During on-site MDS Focused Survey visits the following was found:

  • 45% of citations were related to MDS or staffing posting inaccuracy
  • 55% were care related citations
  • 80% of the facilities surveyed had at least 1 deficiency
  • Average # of deficiencies per survey was 2.6

In an ongoing effort to monitor and audit this process, the MDS Focused Surveys will continue to be conducted throughout the country. It is the intention of CMS that SNF’s will use the reported findings above, as well as the resources identified, to ensure the MDS team is proficient in data collection, coding and the MDS process to improve accuracy and compliance with the goal of improving the safety and quality of care nursing home residents receive.

If you are in need of additional MDS guidance or training, use our “Just Ask Q&A” feature or contact us at

In Your Corner,


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