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SMQT-DQA-2022
Study for SMQT
| Question | Answer |
|---|---|
| OFF site prep in ACO by Team Lead (coordinator) basically includes | create survey shell, add team members, assign self as team lead, 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? | This can result in no offsite-selected residents |
| 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 |
| 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 |
| 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? | Facility Matrix with instructions, Entrance Conference worksheet, Beneficiary Notices worksheet |
| 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 |
| 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 |
| 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)? | quick review of the MDS indicators (and Matrix information if available), quick head-to-toe observation, a few high level questions & anything to clarify noted concerns |
| 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 |
| 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) |
| Does a surveyor have to answer every care area for persons in the initial pool? | yes |
| 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 |
| 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 |
| 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 |
| 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 |
| How long should the team expect to meet to choose the final sample for investigation? | Anticipate at least an hour |
| 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? |
| 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 |
| 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 |
| 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 |
| During the medication administration observation how many medications should be observed? " | 25 |
| Who can observe medication administration? | Nurses or pharmacists are the best persons to be assigned to this task |
| Which team member should be assigned to do the beneficiary notification task? | Any team member can complete this |
| 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? |
| How does a surveyor know if all investigation work has been completed? | Review both the facility task screen and the investigation task screen |
| 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? |
| What are the three scope levels on the severity and scope grid? | isolated= 1 or very limit number of residents or staff involved Pattern= more than a very limited number or repeated occurrences of the same deficient practice 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 |
| 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 |
| 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 |
| How long should the exit conference last? | Allow enough time for the facility to discuss and supply additional information they may feel is pertinent |
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