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LTC General

LTCSP-1

TermDefinition
What is a partial extended survey? A survey that is conducted after a substandard quality of care is found during an abbreviated standard survey or during a revisit, when substandard quality of care was not previously identified.
What does a partial extended survey evaluate? The participation requirements subsequent to a finding of substandard quality of care during an abbreviated standard survey.
What does a facility lose the ability to do when a partial extended survey is conducted? The ability to train nurse aides.
What is an Extended Survey? A Survey is conducted when there is a finding of substandard quality of care during a standard survey.
What is included in an Extended Survey review? 1. A larger sample of residents 2. In-service training 3. Examination of consultant contracts- if appropriate 4. Policies & procedures related to noncompliance 5. Nursing & physician services, administration & other requirements.
When should an Extended Survey be conducted? 1. Prior to exit conference of the standard survey OR 2. No later than 14 days after the completion of a standard survey .
What is the definition of Past Noncompliance? Facilities being out of compliance before a standard survey, but regained substantial compliance before the standard survey began.
What three requirements must be met in order to cite non compliance with a specific F or K tag? 1. Facility wasn't in compliance; AND 2. Noncompliance occurred after exit date of the last standard survey & before current one; AND 3. There is sufficient evidence that facility corrected the noncompliance & is in substantial compliance now.
Where would you find the criteria for Determining Citations of Past Noncompliance at time of current survey? SOM 7501.1
What is considered severe weight loss? Weight loss greater than 7.5% in 3 months.
True or False: Functional status and medical/clinical statuses are considered the same things. False: Functional status differs as it considers the whole of a person's life with the intent of assisting that person to function at the highest practicable level of well-being.
What are the three parts of the RAI assessment process? 1. Completing of the MDS 2. Care Area Assessment (CAA) 3. Development of a comprehensive care plan.
What are the three basic components of Resident Assessment Instrument (RAI)? 1. MDS 2. CAA 3. RAI utilization guidelines
What important resident information does the three components of the RAI give? Information about a resident's functional status, strengths, weaknesses & preferences as well as offering guidance on further assessment once care area issues/concerns have been identified.
True of False: The Care Area Assessment (CAA) is a requirement for a Medicare assessment. False: A CAA is only required for comprehensive clinical assessments (Admission, Annual, Significant Change in Status {SCSAs} or Significant Correction of a Prior Full Assessment {SCPA}).
What is the Function of a Care Area Assessment? It is a decision facilitator, meaning it should lead to a more thorough understanding of an area of concern that was triggered for further review.
What role do the Care Area Triggers play in care planning? Along with the CAA it forms a critical link between the MDS and care planning.
What are the Care Area Triggers? They are the specific response options from the MDS that are indicators of 20 particular care areas that affect nursing home residents.
What are MDS triggers? They are specific resident responses for one or a combination of MDS elements. They identify those who have or are at risk for developing specific functional problems & require further evaluation.
What does CASPER stand for? Certification & Survey Provider Enhanced Reporting System
How many reports are included under CASPER? There are four reports: 1. Characteristics Report 2. Facility QM Report 3. Resident Level QM Report 4. Submission Statistics. They are all generated from the MDS.
Where are the CASPER reports generated from? MDS
What determines the Severity of Deficiency Level? The degree of harm that resident(s) either suffered or could have suffered.
What are the four Severity Levels? Level 1: No actual harm w/ potential for minimal harm Level 2: No actual harm w/ potential for more than minimal harm Level 3: Actual harm that is not IJ Level 4: IJ to resident health & safety
What determines the Scope Level? The number of residents who were or could have been affected.
What are the three Scope Levels? 1. Isolated; one or limited number of residents involved. 2. Pattern; more than a minimal number affected, situation has occurred in several locations, or same residents repeatedly affected. 3. Widespread; throughout facility or systemic failure
When would Category 1 Remedies be imposed? When a facility has isolated deficiencies that constitute potential for no more than minimal harm, or in cases of past noncompliance.
What are Category 1 Remedies? DPoC State Monitoring Directed in-service training
What are Category 2 Remedies? DPNA Denial of payment for all individuals (only imposed by CMS) CMP of $50 - $3,000 per day CMP of $1,000 - $10,000 per instance
What are Category 3 Remedies? Temporary management Immediate termination CMP of $3,050 - $10,000 per day CMP of $1,000 - $10,000 per instance
What are some factors that may be considered when determining Enforcement Remedies? S/S value Facility history Repeat deficiencies Culpability
What are the five criteria needed for an acceptable PoC? 1. How corrective action will be accomplished. 2. How facility will identify other potential affected residents. 3. What measures will be put in place or changes to be made. 4. How facility will monitor. 5. Dates corrective actions will be completed.
What is a DPoC? Directed Plan of Correction: A plan that the SA, RO or temporary manager develops to require a facility to take action within a specified time frame. A PoC is developed by the facility.
What is a Catastrophic Reaction? An extraordinary reaction of a resident to ordinary stimuli.
Created by: Debra Bernier 1
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