CMS Focused Surveys

Over the last several years, CMS has issued Survey and Certification letters regarding specialized surveys with a focus on these areas:

1) MDS and Staffing
2) Dementia
3) Medication Related Events
4) Infection Control (in pilot phase)

MDS and Staffing

In 2014, CMS piloted the MDS Focused Survey. Twenty-five facilities were involved in the pilot. The intent was to focus on MDS coding and accuracy and its impact on resident care in nursing homes.

The findings of these pilot surveys included discrepancies between documentation and coding on the MDS. Deficiencies were received in 24 of the 25 facilities to MDS coding (CMS, 2014) 

Additionally, the surveys will include a review of nursing home staffing to help CMS assess how staffing levels may fluctuate throughout the year. Currently, all facilities are required to complete the CMS-671 form during annual survey. Since this information is self reported, surveyors will review the form and confirm its accuracy.


In 2014, CMS initiated a pilot project in which it invited states to participate regarding a Focused Survey on residents with dementia. Five states participated, with each state completing four surveys and an observation visit.

Excluding the five observational surveys, 16 out of 20 surveys (80%) cited either F309 (Care of a Resident with Dementia) or F320 (Unnecessary use of Medications) and 11 out of 20 survey (55%) cited both tags. (CMS, March 2015)

CMS expanded on the pilot program and invited states to participate in 2015. Included in the expansion were updated survey tools that were revised from the pilot. This expansion project involved a more intensive targeted effort to improve surveyor effectiveness in citing poor dementia care and overutilization of antipsychotic medications than was previously done in 2014. Six states participated in the expansion.

Medication Related Events

In February 2014, the Office of the Inspector General (OIG) released its report, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.” The OIG found that one in three skilled nursing facility (SNF) residents were harmed by an adverse event or temporary harm event within the first 35 days of a SNF stay and 37 percent of the adverse events were related to medication.

The second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use causing harm ranging from hospitalization to death.

• Identify preventable adverse drug events that have occurred or may occur;
• Determine whether facilities identify residents’ risk factors for adverse drug events and implement individualized interventions to eliminate or mitigate those risk factors; and,
• Determine if the facility has implemented effective systems to prevent adverse drug events as well as recognize and respond to adverse drug events that do occur in order to minimize harm for the individual and prevent recurrence of the event.

Infection Control (currently in pilot phase)

The Centers for Medicare & Medicaid Services (CMS) has begun a three year pilot project to improve assessment of infection control and prevention regulations in nursing homes, hospitals, and during transitions of care.
All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor. New surveyor tools and processes will be developed and tested, focusing on existing regulations as well as recommended practices (such as those for antibiotic stewardship and transitions of care). Ten pilot surveys to be conducted in Fiscal Year (FY) 2016 will occur in nursing homes. Surveys in FY17 and FY18 will be conducted in nursing homes and hospitals.

Project Outcomes: New surveyor infection control tools and survey processes that can be used to optimize assessment of new infection control regulations.


CMS Survey and Certification Letter, S&C 15-25 NH
CMS Survey and Certification Letter, S&C 16-05-ALL
CMS Survey and Certification Letter, S&C Letter 15-06 NH
CMS Survey and Certification Letter, S&C: 15-47-NH
By Kindred Rehabilitation Services