Three Consultants Reviewing Notes in Lobby

The survey can impact an organization’s quality rating, and focuses on compliance with long-standing regulations and how self-reported data matches those regulations.

Navigating health reform

Long-Term Care Providers Can Prepare for the MDS and Staffing Survey

  • 1/28/2016

The Minimum Data Set (MDS) and Staffing survey is continuing to be rolled out to more states in 2016. Organizations should understand the focus of the survey and prepare for it, because the results can impact its Nursing Home Compare five-star quality rating

In 2014, the Centers for Medicaid and Medicare Services (CMS) launched a voluntary pilot study in nursing homes with a special focus on the MDS and self-reported staffing data, as reported on CMS 671 and 672. The pilot survey was launched in five states and included 25 facilities. The survey can occur at any time and is above and beyond the annual regulatory survey that skilled nursing facilities and nursing facilities are required to do. No new regulations are involved in this survey, but the focus is on compliance with long-standing regulations and how the self-reported data matches those regulations. 

This new survey has two main components: 

  • Self-reported staffing data (CMS form 671 and 672), which is gathered during the annual regulatory survey, and 
  • Accuracy of MDS coding and how that relates to patient care, the five-star quality rating, and quality measures. 

The purpose of this new survey is to verify the accuracy of data that does not have a built in system of checks and balances. 

In the pilot study, 24 out of the 25 facilities were cited for incorrect staffing data and/or MDS coding errors. 

Why is this self-reported data important? 

CMS uses the MDS data in a variety of ways:

  • To drive the care planning process as mandated by the Omnibus Budget Reconciliation Act of 1987 
  • To drive payment for Medicare, and in some states, Medicaid 
  •  To compile quality measure data 
  • To generate the organization’s five-star quality rating 

CMS is aware that organizations may increase staffing when the survey window opens, so it wanted a wider view of facilities’ actual staffing patterns. Staffing information, in addition to MDS data, are used to generate the five-star quality rating as seen on Nursing Home Compare


In 2015, this survey was launched in all remaining states not included in the original pilot program. CMS will be working with each state to determine which facilities will be looked at as the survey continues roll out in 2016. 

CMS has indicated that two surveyors (with web-based training provided by CMS) will conduct each survey over a two-day period. 

Survey process 

Upon arrival at each facility, the surveyors will provide an “entrance conference” worksheet with 12 listed items. The facility must prepare these items for the surveyors, within a designated time frame. 

The survey will include a review of 10 resident records, staff and resident interviews, and resident observation. This information will be used to substantiate or refute the MDS coding data. Surveyors will also observe the MDS department to examine the following issues: 

  • Staffing ratio to workload 
  • Completion of the MDS (done by a registered nurse) 
  • MDS policy and procedures that specify who is responsible for each section of the MDS, and how and when sections are to be completed 

Surveyors will also be looking at the number of residents per facility, how many MDS surveys are being completed and submitted, and how many staff members are participating in the resident assessment instrument (RAI) process. 

Though they will initially look at specific areas of the MDS, surveyors may expand the survey process at any point based on their observations. The pilot study focused on seven main MDS areas, four of which had the most citations or incorrect coding associated with them. 

  • Restraints (errors) 
  • Falls with major injury (errors)  
  • Pressure ulcers (errors)  
  • Late loss activities of daily living (errors) 
  • Urinary tract infections  
  • Urinary catheters  
  • Use of antipsychotic medication 

Coding of these sections can have a significant impact on quality measures and the facility’s five-star quality rating, which is why these sections are examined. In addition to accuracy, surveyors will also look for timely completion and submission of the MDS data and timely completion of the planning process. 

Possible outcomes 

The facility will receive a traditional CMS 2567 Statement of Deficiencies and Plan of Correction form after completing the survey and the survey team will use F Tags, which provide associated descriptions of a facility’s deficiency, for citations. The F tags most likely to be used will be F272-287, which relate to the RAI and assessment process. (F tags descriptions can be found in the State Operations Manual SOM appendix PP.) 

As the survey team looks at staffing ratios, it will determine if a facility is at an acceptable level based on whether it is providing the required needs for patient safety and care—meeting the state mandated minimum ratio will not be enough to ensure the facility meets the acceptable level that CMS desires. With the 2567 report, the staffing and quality measure domains of the five-star quality rating will be affected if the facility has received citations. It is unclear if they will be adjusting the health inspection domain. 

How to prepare

In advance of the MDS survey, consider the suggestions below to help improve your processes.  

  • Use the “entrance conference” sheet as a guideline and tool to prepare your staff for this unique survey. 
  • Develop policies and procedures as they relate to the RAI process. 
  • Target your own high-risk areas. CMS has determined high-risk areas, but you should look beyond these.  
  • Do mock surveys and random chart audits to determine documentation accuracy. 
  • Team involvement is important and the organizational administration should lead the way. Set up an internal system of accountability and demand a commitment to better documentation. 
  • MDS accuracy is of upmost importance. 

How we can help 

As your facility prepares for the MDS survey, CLA can help you use your MDS software to point you in the direction of potential inconsistencies and errors. We can also help you develop policies and procedures that will meet the survey requirement of the RAI process. In addition, we can provide documentation audits to determine if your data is correct, if the RAI manual is being followed correctly, and if you have high-risk conditions that are not being monitored or followed up on. Our mock survey can help you determine if your organization is ready for the survey team and help develop risk meetings to make sure you are addressing both the MDS target areas as well as the annual regulatory survey. 

CLA can guide individual facilities and organizations during the actual survey process to help work through the requests from the survey team using our benchmarking and analytic data tools.