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How Can Deficiency Data Be Used to Get Ahead of Surveyors?

By Jane Belt, MS, RN, RAC-MT, RAC-MTA, QCP - April 24, 2019

Meeting and discussing with hundreds of nurse assessment coordinators (NACs) and fielding a wide array of questions about the Resident Assessment Instrument (RAI) process, the Minimum Data Set (MDS), Care Area Assessments (CAAs), and person-centered care plans over the years, it seemed a relatively easy assignment to discuss using deficiency data to provide useful information for the NAC. Survey data also abounds with the full text of statement of deficiencies posted monthly on the Centers for Medicare & Medicaid Services’ (CMS’s) Five-Star Quality Rating System website. With the help of a data analyst, we sifted through over 3,000 records. We looked at the numbers, determined the types of citations most often encountered by the NACs, and identified key issues and trends. To say the least, the data forced this writer to take a new approach and figure out a new angle to tackle the task, , as the cited deficiencies seemed to be much of the information that we have read before when looking at the most frequently cited F-tags. So what does the NAC need to consider in order to avoid the common pitfalls that we often see when the surveyors comb through the records?


We found the most frequently cited deficiencies that had a relationship to the RAI, MDS, and care planning. The following table and numbers are based on recently reported CMS data which began July 1, 2018, and details cited deficiencies at a B or higher level of scope and severity.



Total Cites

Number of Cites at D or Above

Highest Level of Severity


Comprehensive Care Plans



27 - J; 3 - K


Care Plan Timing and Revision



7 - J; 3 - K


Accuracy of Assessments



2 - G


Baseline Care Plans



2 - J


Comprehensive Assessments



1 - H


Comprehensive Assessment after a Significant Change



4 - F


As stated above, the details actually did not reveal any huge surprises – they all seemed to be things the NAC should know already. Here are a few examples from the Comprehensive Care Plans deficiencies:

F656 – Comprehensive Care Plans

  • A resident was ordered an anticoagulant and the MDS was coded that the medication was received for seven days. However, the care plan for the matching time frame did not contain evidence that the resident received an anticoagulant and there were no approaches or interventions listed.

  • An alert and oriented resident remarked to surveyors that he did not want to be there, did not like his roommate, and did not understand why he had to have a feeding tube. The social worker was interviewed by the surveyor and stated knowledge of attempts to provide explanations to the resident and of offers to change his room. The nursing notes addressed on specified dates over the two months prior to the survey that the resident had an altercation with his roommate about the loud TV, an episode of leaving the facility and walking down the road, and an episode of the resident pulling out the feeding tube. There were no revisions or updates to the resident’s care plan after these exhibited behaviors. The resident’s behaviors were not addressed anywhere in the care plan.   

  • A resident’s medical record contained no comprehensive care plan for a resident that had been in the facility for over six weeks.

  • Another resident did not have a person-centered comprehensive care plan until the omission was identified by the surveyor. The care plan was 30 days overdue.


Let’s stop right here and take a look at these issues. How could medications be omitted on the care plan? In the next example, the survey information showed how often the documentation appeared in the medical record to spell out that the behaviors were exhibited, and they were still missed when completing the MDS and developing the care plan? Next, we know that most MDS software programs generally create easy-to-access reports about data submission deadlines. Finally, we learn early on in our first trainings about the MDS to sign the MDS in item Z0500B when the MDS is completed, and for comprehensive assessments, to sign and date item V0200C2 when the care plan is completed.  


So what can be done to avoid the citations from ever occurring?

  1. When you believe the care plan is “finished” – do you review the most recent physician orders to make certain the medications have been addressed on the care plan? Does the nurse need to alert the nursing staff of any specific side effects, including the nurse aides to be mindful when working or interacting with the resident? Are all the treatments addressed? Have any medications or treatments been discontinued that should be removed from the care plan?

  2. Before entering the last period on that care plan – have you read the nursing progress notes to make certain events were picked up not only on the MDS, but on the care plan? Could shift supervisors or night shift staff complete a copy of AANAC’s MDS Data Collection for the NAC. The MDS nurse could enter the desired assessment reference date (ARD) on the tool to automatically set the look back period and get some help scouring the medical records. Yes, the life of the NAC is very busy and often it seems there is not enough time to do the job. Be creative and utilize others that may have some slower pace things going on during their shift.

  3. How could a comprehensive care plan not be completed when we think about the accuracy of the assessment? In section V, item V0200C2 the instruction read, “The date on which a staff member completes the Care Planning Decision column (V0200, Column B), which is done after the care plan is completed.” Does this person realize that their signature and date are attesting to the accuracy of the statement that the care plan is completed? The signatures and dates are so important in the world of medical records – the task cannot be taken lightly.

  4. Does the facility’s MDS software have reports that can be requested at least weekly to determine if any RAI process components have not been completed? When warnings come up on the software, the NAC must take the time – without fail – to read them and address any alerts. 


As noted earlier – there was no huge surprise or mystery attached to these deficiencies. The experienced NAC knows the regulations, timing requirements, the importance of gathering timely and accurate information before even starting the MDS or revising a care plan. Yes, like many things, it is important to remember the basics and take time to do the job correctly. Checks and balances require looking for the problem BEFORE the surveyors find it.


The rumbling in the background is getting louder – I HAVE NO TIME!


What is the NAC to do?

Not to worry, we are not going to get into a dissertation on time management, but we want you to consider some ideas that if you are willing to try you just might see a more productive day in your future.

  • Create a To Do Today list – The NAC has a schedule for MDSs. Does every member of the IDT have a copy of that schedule? If not, why not?

  • Put your tasks to do in order of priority – Use numbers and letters of the alphabet. Least important tasks go to the bottom and yes, might even get carried over to the next day’s To Do list.

  • Block time off for task completion – Don’t allow interruptions unless there is a full-scale emergency. Close down any computer tabs not necessary for the task at hand; turn off social media; create a signal of some sort for family members or babysitters to be able to reach you, but no one else! 

  • Break time and lunch time are important – Use these times AND take them to recharge your batteries.

  • Use the resources that are available to you:

  • Avoid long discussions with an office mate on how to code the MDS. Use the RAI manual every day, every time you have a question. Still concerned? Yes, discuss with the knowledgeable expert you know. If all else fails, use your clinical judgement - review the resources available, review the objective facts that are evident, and make a clinical decision. If concern remains, use the AANAConnect community, keep track of the issue, and determine if more information makes the answer more clear. Going over and over the same points is not a good use of time.

  • The interactive AANAC tool – Regs for NACs – this tool provides quick access to a snapshot of the key regulations impacting the NAC – click on the desired regulation and instantly go to that portion of the document and read the regulations and key guidelines. Have a shortcut on your desktop to access Appendix PP (the regulations) and any other frequently used resources to save time.

  • The CASPER manual and the posted resources are invaluable to the NAC, but the NAC must use them. What’s so great?

Provider Reports

  • Survey History Profile Report – remind yourself of previously noted weak areas and are you considering those in developing care plans?

  • MDS Activity Report – details assessment reasons, ARDs, and submission dates; scan briefly to make certain there are not dates that seem odd. And yes, sometimes assessments are not submitted timely, but then you must report this to the QAA committee so that the issue can be addressed and resolved

  • MDS 3.0 Assessments with Error Number – select a time frame and an error number. For example, -3810a is a WARNING that identifies residents with a late submission date (more than 14 days after the entry tracking date)

  • Admission/Reentry or Discharge Records – ask the night shift if they would have time to match this up with a census report

  • MDS 3.0 Error Detail Report - if you are managing the MDS department, take a look to see if there are any trends in errors and same thing with the MDS 3.0 Missing OBRA Assessment Report  

MDS 3.0 Quality Measure (QM) Reports

  • MDS 3.0 Facility-Level Quality Measure Report – calculated weekly for the assessments submitted since the previous week’s data calculation. It tells you how your facility compares to the state and national rates. If the facility’s group national percentage is at 75 or greater, that’s a guarantee that some or all of those residents will be reviewed in an annual or complaint survey.

  • MDS 3.0 Resident-Level Report – identifies the residents (active and discharged) that are included in the calculations for the Facility-Level Report and denotes with an “X” which individual residents triggered the specific Quality Measure. You have a ready-made guide to assess the care plan – for that specific resident, make sure you can locate the information needed on the plan of care. These reports are available to the surveyors, too, so no surprise when certain residents appear in their sample for review. The beauty is that you have looked and reviewed that care plan and it is ready. The surveyors have access to this information – why not use it on a consistent basis to get ahead? Take the resident-level report everywhere you go – morning meeting, care plan meeting, developing care plans, and validating MDS and care plan accuracy. Take notes and write down tidbits that you hear or see.

If you are not sure you understand all the CASPER reports and/or where to find and use them, here is the link to this gold mine of information.

  • Next, remember the link between the MDS and the care plan are the Care Area Assessments (CAA)

  • A sure-fire way to double-check the completeness of the care plan is to read those CAA summaries. The interdisciplinary team (IDT) members have completed to the best of their abilities and certified this accuracy with their signatures. This accurate information then triggers specific care areas leading to additional assessment and analysis of causes, risk factors, and complications for the individual resident. Do all IDT members use the evidence-based tools identified by the facility and use that CAA information to make decisions as to why their findings require (or not) interventions? Is each member of the IDT reviewing their portion of the care plan and considering whether the information from the CAA analysis has been used in developing resident-centered interventions on the care plan?

  • If some condition, impairment, disease, problem, need or strength of the resident is coded on the MDS and a CAA is triggered, the care plan in all likelihood should address those findings.

  • Finally – do remember – the care plan belongs to the resident. The resident is the center of everything we do. If a surveyor asks the resident a question about participating in goal setting and interventions, what will the resident or representative say? Does the care plan address the goals of the resident?


Don’t get caught up on interventions that sound great, but are not reasonable. One other observation in looking at survey citations, the facility was cited for placing this intervention in place for a resident who had multiple falls: “Do not stand up!” The resident had a BIMS score of 3 and was unable to read the sign. Interventions must match the resident’s abilities and functional status. 



Maybe the reader wanted more survey deficiency details – we must admit they are interesting to read. But for the moment we want to focus on the future and what can we do to be ready for the surveyor. With the resources we have (and many the same as the surveyors) we need to focus on being ahead of the surveyors.


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