study for CMS surveyor test- Nursing Home Survey Procedure
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
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| show | 1. create survey shell
2. add team members
3. assign self as team lead
4. link any complaints and FRIs
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| show | As close to survey start date as possible but NO MORE than FIVE business days so MDS data is up-to-date
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| What affect will there be on the survey shell if a facility has not submitted MDS assessment data? | show 🗑
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| show | 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
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| show | Data loss may occur. Leave team members on the list even if they leave a survey
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| show | Include up to five in the initial pool and the sample.
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| show | 1.Facility Matrix with instructions
2. Entrance Conference worksheet
3. Beneficiary Notices worksheet.
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| How many copies of the Facility Matrix with instructions should be printed before facility entrance? | show 🗑
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| How many Entrance Conference worksheets should be printed before facility entrance | show 🗑
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| show | three copies (Beneficiary Notification Review)
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| When sharing data with a "stick" (jump drive, thumb drive, flash drive) what must be done with any wi-fi connection | show 🗑
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| show | False: team members should review the offsite prep information independently after receiving the shell from the team lead
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| True or False: Upon entrance the entire team will be present for an Entrance Conference. | show 🗑
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| 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 | show 🗑
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| show | False: residents may have been admitted, discharged or moved so the surveyor should ask for a roster for his/her assigned area upon entrance
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| After entrance, how many residents should each surveyor screen in his/her assigned area? | show 🗑
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| show | A brief screening of ALL residents in your assigned area and narrowing down residents to a pool of about eight (8) per surveyor.
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| Who should be "screened" during the initial pool process? | show 🗑
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| What does "screening" consist of (basic)? | show 🗑
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| Initial pool subgroups include: offsite selected, complaint/FRI, new admission and________________ | show 🗑
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| show | Notes should be written on "Surveyor Notes" but at this step should not be included on the RI, RO or RR screens
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| show | Discuss this with the team. Work loads can be adjusted or time for the pool process may need to be increased.
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| True or False: a surveyor is allowed to do interview and observations during the screening phase of the initial pool process | show 🗑
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| show | The resident manager in LTCSP may not match the roster and may need correcting
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| show | Change the small initial pool indicator (icon) from "unknown"(U) to "yes" (Y)--make sure to select the appropriate subgroups"
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| show | The matrix should be completed within four hours.
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| How many residents of the following categories should be included in the total initial survey pool: smokes, dialysis, hospice, ventilator, transmission-based precautions? | show 🗑
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| show | False: there is the ability to "transfer Interview Answers to Other Resident" using the button found under the "Add/Update Resident" icon
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| show | You must assess and mark the "interview status" of each person in your pool
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| True or False: Not all persons in your initial pool have to be interviewed | show 🗑
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| True or False: only interview in the Care Areas that match a resident's MDS indicators during the initial pool | show 🗑
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| True or False: the interview questions provided by CMS are required and the surveyor must ask each one during the initial pool interview | show 🗑
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| show | yes, each area should either indicate "Further investigation" is needed OR there is "No Issue/NA"
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| show | When every item has been marked on each screen a green check mark will show on the icon to indicate completeness
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| show | 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)
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| show | The team should try to complete three interviews to be better informed for sampling decisions
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| True or False: it is ideal to stay on the unit while doing record review instead of working in the conference room | show 🗑
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| show | False: the record review areas will be based on interview status, certain MDS indicators and whether or not the person is a new admission
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| show | Confer, go to Appendix Q and use the immediate jeopardy decision making tool; contact supervisor
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| When team and supervisor agree about the presence of an IJ who should inform the facility? | show 🗑
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| show | The facility administrator or designee should begin immediately
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| What information should the facility be given when IJ has been determined in order for them to take corrective action | show 🗑
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| show | All team members need to share their data with the team lead (coordinator)
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| During the end of the day team meeting, what should the rest of the surveyors consult? | show 🗑
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| When does the survey team need to expand the sample during the day one team meeting? | show 🗑
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| show | 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
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| What does an "extended survey" look for? | show 🗑
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| How long should the team expect to meet to choose the final sample for investigation? | show 🗑
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| During the final sample selection the team should sample how many residents per complaint care area, if able. | show 🗑
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| If the sample size is not met, what should the team consider to increase the sample number | show 🗑
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| What must the team lead (coordinator) do to assure the workload is distributed evenly before finalizing the sample? | show 🗑
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| What type of records are needed for the "closed record review"? | show 🗑
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| What should be done if the team is unable to find a resident that fits the categories for closed record review? | show 🗑
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| What should a surveyor do if there is no available pathway for an investigative area? | show 🗑
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| There are three major methods of investigating, observation, interview and record review. In what order should these occur? | show 🗑
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| When doing interviews, is there a "correct" order in which to do them? | show 🗑
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| show | 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.
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| During the investigation phase of the survey, can a surveyor investigate a resident not listed in the final sample? | show 🗑
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| show | 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.
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| When should facility task assignments be completed? | show 🗑
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| show | 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.
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| During the medication administration observation, how many medications should be observed? | show 🗑
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| show | 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
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| show | Any surveyor can perform this task; however, consider that nurses and pharmacists may have a higher comfort level and training for this task
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| Who can complete the kitchen task? | show 🗑
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| show | 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.
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| show | 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.
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| show | 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.
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| show | 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
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| show | 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
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| Why should the QAA/QAPI task be completed towards the end of the survey? | show 🗑
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| show | The team should make sure to have someone complete the Personal Funds facility task
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| If anyone on the team has concerns related to the environment should the team complete the entire environmental review task? | show 🗑
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| show | 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.
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| show | 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
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| How does a surveyor know if all investigation work has been completed? | show 🗑
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| When discussing potential citations, if the team makes a determination noncompliance. Then what? | show 🗑
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| show | The severity and scope grid is located in the survey resources folder.
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| What is the lowest level of deficiency on the severity grid? | show 🗑
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| show | This is severity level "4" that states there is "immediate jeopardy to resident health or safety"
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| What does severity level 2 on the severity grid stand for? | show 🗑
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| On the severity grid, what would level 3 stand for? | show 🗑
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| What does "scope" mean when talking about deficiencies? | show 🗑
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| show | 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
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| show | 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)
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| What does the letter "K" stand for on the severity and scope grid? | show 🗑
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| show | Actual harm that is not immediate but is widespread exists
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| show | 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
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| show | The universe is the number of residents investigated for each care area as noted on the Sample Finalization screen
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| show | 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
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| show | 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.
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| show | It is best to give general information but a tag may be given IF the facility directly requests. Remind them that these are preliminary.
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| show | The only time this should be provided is in the case of "immediate jeopardy"
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| What should be done if the provider specifically asks if a deficiency is isolated, pattern or widespread? | show 🗑
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| Should the team reveal the identity of any residents noted in the citations? | show 🗑
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| How long should the exit conference last? | show 🗑
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