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SMQT-LTCSP

study for CMS surveyor test- Nursing Home Survey Procedure

QuestionAnswer
OFF site prep in ACO by Team Lead (coordinator) basically includes 1. create survey shell 2. add team members 3. assign self as team lead 4. link any complaints and FRIs
When should Team Lead export survey shell from ACO? As close to survey start date as possible but NO MORE than FIVE business days so MDS data is up-to-date
What affect will there be on the survey shell if a facility has not submitted MDS assessment data? No MDS information will flow over and residents will not show in the shell. This can result in no offsite-selected residents.
What should be done if a team member was not added in ACO but attends all or portion of a survey? Update the team roster in ASE-Q under the facility name and correct Event ID. Do NOT remove a team member to prevent data loss
What might happen if a team member's name is removed from a survey team in ASE-Q? Data loss may occur. Leave team members on the list even if they leave a survey
How many complaints or FRIs should Team Lead (coordinator) include when completing the "offsite prep screen"? Include up to five in the initial pool and the sample.
The Team Lead (coordinator) should print what documents in preparation for facility entrance? 1.Facility Matrix with instructions 2. Entrance Conference worksheet 3. Beneficiary Notices worksheet.
How many copies of the Facility Matrix with instructions should be printed before facility entrance? one copy of the instructions and multiple blank matrix copies
How many Entrance Conference worksheets should be printed before facility entrance one copy
How many Beneficiary Notices worksheet copies should be printed before facility entrance three copies (Beneficiary Notification Review)
When sharing data with a "stick" (jump drive, thumb drive, flash drive) what must be done with any wi-fi connection Data transfer will be stopped if connected to Wi-fi. Team members need to disconnect from Wi-fi to make data transfer more secure.
True or False: the team is required to have an offsite prep team meeting False: team members should review the offsite prep information independently after receiving the shell from the team lead
True or False: Upon entrance the entire team will be present for an Entrance Conference. False: only the team lead (coordinator) will attend the entrance conference
True or False: The surveyor assigned to the Facility Task- kitchen, should immediately go to that area for a brief visit upon entrance to the facility True: All other surveyors (except the team lead) will go to their areas but the person assigned to "kitchen" will do this first and then go to assigned area.
True or False: Surveyors do not need a roster because all persons will be listed in the LTCSP Resident Manager False: residents may have been admitted, discharged or moved so the surveyor should ask for a roster for his/her assigned area upon entrance
After entrance, how many residents should each surveyor screen in his/her assigned area? ALL residents in the assigned area must be screened.
What is involved in the "initial pool process" (basics)? A brief screening of ALL residents in your assigned area and narrowing down residents to a pool of about eight (8) per surveyor.
Who should be "screened" during the initial pool process? ALL residents should be screened EXCEPT offsite selected and complaint/FRI residents who are already included and do not require screening
What does "screening" consist of (basic)? 1. quick review of the MDS indicators (and Matrix information if available) 2quick head-to-toe observation 3. a few high level questions & anything to clarify noted concerns
Initial pool subgroups include: offsite selected, complaint/FRI, new admission and________________ Vulnerable, as well as "identified concern" if person does not fit these other categories
During screening you do not need to take notes, but if you need some documentation to help organize your thoughts during screening where should you put those notes? Notes should be written on "Surveyor Notes" but at this step should not be included on the RI, RO or RR screens
If there are too many residents in your area who qualify for the initial pool (greater than eight) what should you do? Discuss this with the team. Work loads can be adjusted or time for the pool process may need to be increased.
True or False: a surveyor is allowed to do interview and observations during the screening phase of the initial pool process True: the surveyor may choose to interview and observe offsite selected and/or complaint/FRI residents during the screening phase.
Why should you review resident names and room numbers at the beginning of the screening process? The resident manager in LTCSP may not match the roster and may need correcting
After screening a resident, how do you assign him or her to your initial pool? Change the small initial pool indicator (icon) from "unknown"(U) to "yes" (Y)--make sure to select the appropriate subgroups"
How long should it take the facility to complete the facility matrix? The matrix should be completed within four hours.
How many residents of the following categories should be included in the total initial survey pool: smokes, dialysis, hospice, ventilator, transmission-based precautions? One resident for each of the listed categories should be included IF the facility has a person in such a category.
True or False: If you accidentally enter information under the wrong pool resident you will have to cut and paste to the correct person for each care area. False: there is the ability to "transfer Interview Answers to Other Resident" using the button found under the "Add/Update Resident" icon
What action must you take first before you can enter any documentation on any of the RI, RO or RR screens during the initial pool process? You must assess and mark the "interview status" of each person in your pool
True or False: Not all persons in your initial pool have to be interviewed True: those marked as non-interview-able will not require this, nor will the person who refuses or if they are out of the facility for the duration of the initial pool process.
True or False: only interview in the Care Areas that match a resident's MDS indicators during the initial pool False: interview in each care area except for those areas that may not be applicable to all residents (such as catheter)
True or False: the interview questions provided by CMS are required and the surveyor must ask each one during the initial pool interview False: the questions listed are meant as a guide and can be asked as each surveyor would like as long as the intent of the care area is maintained.
Does a surveyor have to answer every care area for persons in the initial pool? yes, each area should either indicate "Further investigation" is needed OR there is "No Issue/NA"
How do you know if your RI (resident interview) RO (resident observation) and RR (record review) are complete in the initial pool? When every item has been marked on each screen a green check mark will show on the icon to indicate completeness
What should be done if an initial pool resident stops an interview partway? Try again later, but if unable, leave the rest of the interview blank. If you completed the RO and RR areas place a check mark next to "COMPLETE" on the resident's interview screen OR move the resident to the "Complete" folder (you will get a warning)
How many resident representative /family interviews should be done on the first day of survey? The team should try to complete three interviews to be better informed for sampling decisions
True or False: it is ideal to stay on the unit while doing record review instead of working in the conference room True: this allows the surveyor the ability to continue with observations
True or False: all persons in the initial pool will have the same questions listed under RR (record review) False: the record review areas will be based on interview status, certain MDS indicators and whether or not the person is a new admission
If immediate jeopardy is a concern what should the team do immediately? Confer, go to Appendix Q and use the immediate jeopardy decision making tool; contact supervisor
When team and supervisor agree about the presence of an IJ who should inform the facility? The team lead (coordinator)with the person who discovered the IJ must meet with facility administrator and other appropriate staff. ALWAYS have two surveyors!
How soon should the facility take action related to the removal of immediate jeopardy? The facility administrator or designee should begin immediately
What information should the facility be given when IJ has been determined in order for them to take corrective action Resident identifiers; the tag number; enough information to determine the cause and format a corrective action to remove the immediate risk.
What should be done immediately before starting the end of day one team meeting? All team members need to share their data with the team lead (coordinator)
During the end of the day team meeting, what should the rest of the surveyors consult? The surveyors should follow along in the procedure guide.
When does the survey team need to expand the sample during the day one team meeting? If substandard quality of care is suspected and the scope needs to be determined or to see if their is sufficient evidence to rule it out
Is expanding the sample the same as extending the survey? No, expanding the sample determines whether substandard quality of care (SQC) did or did not exist. IF it is determined that SQC exists, this only occurs with a pattern or widespread problem and this is when the extended survey is initiated
What does an "extended survey" look for? The purpose of the extended survey is to look for structure and process factors, systemic issues, that have resulted in substandard quality of care issues within the facility.
How long should the team expect to meet to choose the final sample for investigation? Anticipate at least an hour
During the final sample selection the team should sample how many residents per complaint care area, if able. Three should be chosen if there are enough marked under that care area as "further investigation"
If the sample size is not met, what should the team consider to increase the sample number 1. Add those persons marked for "unnecessary medication review" 2. Look at persons with quality of life concerns and/or resident rights 3. Look at prior surveys and complaints 4. Consider adding someone from an unrepresented area of the building
What must the team lead (coordinator) do to assure the workload is distributed evenly before finalizing the sample? Assign surveyors to all residents on the list and click on "view current workload" at the top right corner of the screen
What type of records are needed for the "closed record review"? Three records including a death, a hospitalization and discharge.
What should be done if the team is unable to find a resident that fits the categories for closed record review? Simply do not complete the closed record review for that area/category
What should a surveyor do if there is no available pathway for an investigative area? Utilize Appendix PP to guide the investigation. The regulation and interpretive guidance are also available within the software by clicking on the tag#
There are three major methods of investigating, observation, interview and record review. In what order should these occur? Observations are critical and should occur on-going throughout the investigation. Record review, such as looking at resident charts, may be done along with observations. Surveyors will likely want to wait to do interviews until later.
When doing interviews, is there a "correct" order in which to do them? An investigation may be more accurate if interviews start at the front line staff level (as applicable). Starting an interview at the top may result in coaching from supervisors to front line staff effecting the accuracy of responses received.
Where should documentation take place during the investigation phase? There are two areas: "investigation notes" which should be used to document information that is specific to a care area OR "resident notes" where you can document general information that may apply to all care areas.
During the investigation phase of the survey, can a surveyor investigate a resident not listed in the final sample? Yes, however, the team should be consulted regarding additions. The surveyor can click on "add new investigation" icon to add them to their work load.
When can a surveyor remove a care area rather than following through with an investigation? If there is a reason that an investigation cannot be completed such as discharge, or it was added in error, the surveyor can click on the "X" in the remove column and provide the rationale for removal.
When should facility task assignments be completed? This will vary, depending on the task; however, is should not interfere with completing the initial pool activities.
When will a resident's name display in the "resident box" under a facility task? If the resident has an applicable MDS indicator that relates to that task, their name will show (such as weight loss under dining)/ surveyors can also add residents where applicable such as under infection control or beneficiary notices.
During the medication administration observation, how many medications should be observed? Twenty-five (25) opportunities of different routes, units and shifts should be observed.
Who can observe medication administration? Nurses or pharmacists are the best persons to be assigned to this task. Any other surveyor, such as a social worker, would require additional training
Who can complete the medication storage task? Any surveyor can perform this task; however, consider that nurses and pharmacists may have a higher comfort level and training for this task
Who can complete the kitchen task? Any surveyor can perform this task. If there is a dietitian on the team they may have a higher level of comfort with this task.
Who should do the dining task? Generally, the entire team takes part in dining observations. If any one surveyor has a concern they should mark the corresponding tag and document. One person should be assigned to complete the remainder.
Which team member should be assigned to do the beneficiary notification task? Any team member can complete this, but it may be easiest for the team lead (coordinator) as they can present the paperwork and explain the process during the facility entrance conference.
Before setting up the resident council meeting, what must be done? Talk to the resident council president (if there is one) about a time and to get permission to review the last three months of notes; notify the ombudsman of the meeting if this is okay with the resident council president.
Who can come to the resident council meeting during survey? Surveyors can invite any resident but should try to keep the number to 12 or less; the ombudsman may be invited if okay with the council president; staff should not attend
How many surveyors should work on the infection control task? All surveyors will observe throughout the survey for breaks in infection control; however, one main person should interview related to the facility plan for infection prevention & antibiotic stewardship
Why should the QAA/QAPI task be completed towards the end of the survey? This allows the team to discuss and investigate any potential systematic issues-- concerns about harm, IJ or patterns identified by two or more surveyors
If there are concerns with sampled residents related to having trouble accessing their funds in their facility account or not receiving a quarterly statement what should be done? The team should make sure to have someone complete the Personal Funds facility task
If anyone on the team has concerns related to the environment should the team complete the entire environmental review task? This is not necessary. Review the specific concerns that have been noted. Remember, Emergency Preparedness is not part of this task.
Should the resident assessment task be completed by all surveyors? No, this only needs to be done if there are MDS discrepancies for care areas not marked for further investigation or there have been delays in completion or submission of MDS assessments.
Who should respond the the sufficient and competent nurse staffing task? One person should be assigned, but all surveyors should watch for concerns where staffing may be related to resident complaints or quality of life or care concerns. These surveyors should answer any corresponding CE
How does a surveyor know if all investigation work has been completed? Review both the facility task screen and the investigation task screen. All areas must have a green check mark to be considered complete (remember, shared tasks are not completed by all surveyors)
When discussing potential citations, if the team makes a determination noncompliance. Then what? Non-compliance of a tag must be followed by an agreement on scope and severity. A single surveyor may have noted an isolated incident, but when the team is gathered a pattern may appear.
Where can the surveyor find guidance related to scope and severity? The severity and scope grid is located in the survey resources folder.
What is the lowest level of deficiency on the severity grid? No actual harm BUT there is the potential for "minimal harm"--this severity level "1"
What is the highest level of deficiency on the severity grid? This is severity level "4" that states there is "immediate jeopardy to resident health or safety"
What does severity level 2 on the severity grid stand for? "no actual harm with potential for MORE than minimal harm that is NOT immediate jeopardy"
On the severity grid, what would level 3 stand for? "ACTUAL harm" that is not immediate
What does "scope" mean when talking about deficiencies? The scope describes how widespread the noted deficient practice is.
What are the three scope levels on the severity and scope grid? 1. Isolated= 1 or very limit number of residents or staff involved 2. Pattern= more than a very limited number or repeated occurrences of the same deficient practice, but not pervasive. 3. Widespread= pervasive or represents systemic failure
Which level of severity should the team choose if several residents had a severity of 2 but 1 resident had a severity level of 3 for the same tag? The severity should always be documented at the highest level; the scope should match the scoring for the highest severity (if their was a pattern at 2, but only one at 3, then it is isolated)
What does the letter "K" stand for on the severity and scope grid? A pattern of immediate jeopardy to resident health or safety exists
What does the letter "I" stand for on the severity and scope grid? Actual harm that is not immediate but is widespread exists
Should the surveyor consider the facilities five star rating when doing a survey? No; however, the CMS five star rating will be impacted by survey outcomes. For instance any S/S of substandard quality of care will have an impact on their star rating
What is the "universe" in relation to citations? The universe is the number of residents investigated for each care area as noted on the Sample Finalization screen
The team may decide that a particular problem fits better under a different tag, what then? Mark the current tag as "don't cite' and select the reason to not cite as "move to another tag" and then select the correct tag
Who should be invited to attend the exit conference? The facility leadership, ombudsman and officer of any organized resident group. One or two residents can be invited or a separate conference can be held just for residents.
Should the survey team give a list of the citations to the facility during the exit conference? It is best to give general information but a tag may be given IF the facility directly requests. Remind them that these are preliminary.
When should the provider be given the scope and severity for the deficiencies? The only time this should be provided is in the case of "immediate jeopardy"
What should be done if the provider specifically asks if a deficiency is isolated, pattern or widespread? Let them know how many residents for a particular problem
Should the team reveal the identity of any residents noted in the citations? No. A sample list of with R numbers can be provided for use with the CMS-2567 form but resident identity should not be discussed at the exit conference.
How long should the exit conference last? Allow enough time for the facility to discuss and supply additional information they may feel is pertinent.
Created by: Ruthef100