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QUALITY INDICATOR SURVEY SURVEYOR TRAINING MANUAL

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1. Attempt to meet with the resident council president representative to announce the survey and set up a time to interview him her Ask permission to review the resident council minutes for the past three months In the rare case of a facility having more than one resident council group a representative from each group should be interviewed 5 Begin the Dining Observation if able to observe a full meal from start to finish Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 7 Quality Indicator Survey Procedures for Long term Care Facilities Task 3 Initial Tour The tour is an initial brief overview of the facility the residents and the staff The intent is to give the survey team an overall impression of the facility and the resident population being served The tour is not intended to be a method of sample selection or sample supplementation however if any egregious situations are observed that involve specific residents record the observation on a Surveyor Notes Worksheet Form CMS 807 and include the resident s name room number and date and time when the concern was observed Residents can be surveyor initiated automatically added to Stage II for an in depth review Ifa situation is observed that may indicate possible Immediate Jeopardy surveyors are to follow instructions provided in Appendix Q of the SOM e Begin the tour as soon as possible after entering the facility e Surveyors
2. Scope Severity A Scope Isolated Severity No Actual Harm with Potential for Minimal Harm Care Area Number of Residents Resident Funds l F164 PERSONAL PRIVACY CONFIDENTIALITY OF RECORDS Scope Severity A Scope Isolated Severity No Actual Harm with Potential for Minimal Harm Care Area Number of Residents Privacy l F242 SELF DETERMINATION RESIDENT MAKES CHOICES Scope Severity A Scope Isolated Severity No Actual Harm with Potential for Minimal Harm Care Area Number of Residents Choices l F248 ACTIVITY PROGRAM MEETS INDIVIDUAL NEEDS Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 56 Quality Indicator Survey Procedures for Long term Care Facilities The QIS Extended Survey When the survey team is conducting a QIS standard survey and they have determined there is substandard quality of care they will conduct QIS extended survey procedures Substandard quality of care is defined as one or more deficiencies with scope severity levels of F H I J K or L in any of the following regulatory groupings e 42 CFR 483 13 Resident Behavior and Facility Practices e 42 CFR 483 15 Quality of Life and or e 42 CFR 483 25 Quality of Care The purpose of the QIS extended survey is to gather further information unless already gathered during the standard survey concerning the facility s nursing and medical services and administration in order to evaluate systemic issues with t
3. Page 65 Quality Indicator Survey Procedures for Long term Care Facilities How to Calculate the MDS QCIs dl Primary Laptop only approx 15 25 minutes The team coordinator must run a utility on the primary laptop that will calculate the MDS QCIs using the MDS data imported into ASE After the MDS QCIs are calculated the surveyor must make a data backup of the MDS QCIs 1 Open the QIS DCT software from the Citation Manager in ASE 2 A QIS Collection Tool version 3 0 splash screen will appear for several seconds The Logon screen will then appear select highlight the current surveyor name from the Select Current Surveyor list and select Primary Laptop as the Laptop Type 3 Click the Select button A Please Wait while Survey Samples Are Drawn message box will appear for several seconds The MDS Data Form screen will then appear Click the Process MDS Data Now button Draw Sample Is Please Wait While Survey Samples Are Drawn 4 A warning message will appear which explains that this process can be lengthy depending on the size of the facility Click the Yes button to calculate run the MDS QCIs Once the calculations are complete th Stage I Sample screen will appear LENGTHY PROCESSING TIME REQUIRED Processing the MDS and all associated Transforms and QIs takes from 2 to 5 seconds per resident included in the ASPEN Data depending on the speed of the computer Are you sure you want to pro
4. Sample in the QIS DCT step 26 the survey team can view the Census Sample Report which contains the names of the sampled residents unit room numbers and surveyor assignments e The surveyor exports the Stage Sample from the primary laptop f The survey team imports the Stage Sample at all secondary laptops Surveyors can now begin Stage observations and interviews on their newly assigned Census Sample residents and if applicable continue observations and interviews on previously assigned Census Sample residents Importing the Stage Sample a second time does not affect data already entered for residents assigned during Step 1 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 13 Quality Indicator Survey Procedures for Long term Care Facilities Figure 5 Updated Census Sample Report with assignments NORTH STAR COMMUNITY MHZB11 08 01 2005 Census Sample hy Unit Room Name e pec Interview Status 3 2 CARR M 80 05 01 1924 03 25 2005 BROWN LAUREL Family Interview Candidate 4 2 STEVENSON L 27 05 01 1924 02 06 2005 BROWN LAUREL Resident Interview 5 2 STEVENSON J 50 05 01 1924 06 27 2005 BROWN LAUREL Resident Interview 6 1 JACKSON E 5 02 01 1921 04 04 2000 BROWN LAUREL Resident Interview 6 2 WILLIAMS B 33 05 01 1924 01 23 2004 BROWN LAUREL Resident Interview 8 1 WILLIAMS K 77 05 01 1924 02 11 2005 BROWN LAUREL Family Interview Candidate 9 1 STEVENSON A 67
5. 05 01 1924 10 22 2003 BROWN LAUREL Resident Interview 9 2 WILLIAMS R 36 05 01 1924 01 10 2005 BROWN LAUREL Resident Interview 10 1 SMITH E 2 04 01 1923 03 17 2000 BROWN LAUREL Family Interview Candidate 12 1 SMITH B 37 01 01 1920 11 14 2003 BROWN LAUREL Resident Interview 26 1 CARR T 78 05 01 1924 02 07 2005 CASIANO EVELYN Family Interview Candidate 26 2 CARR J 22 02 01 1921 11 11 2004 CASIANO EVELYN Resident Interview 31 2 SMITH E 45 05 01 1924 04 15 2002 CASIANO EVELYN Resident Interview 39 1 CARR L 65 05 01 1924 05 16 2005 CASIANO EVELYN Resident Interview 40 SMITH M 24 02 01 1921 05 05 2003 CASIANO EVELYN Resident Interview 43 CARR S 46 04 01 1923 04 14 2005 CASIANO EVELYN Family Interview Candidate 44 2 CARR T 79 05 01 1924 03 08 2005 CASIANO EVELYN Family Interview Candidate 45 1 STEVENSON G 10 05 01 1924 07 16 2001 CASIANO EVELYN Family Interview Candidate 48 1 WILSON J 15 05 01 1924 01 31 2005 CASIANO EVELYN Family Interview Candidate 3 Prepare two copies of the Admission Sample Report a Provide one copy of the Admission Sample Report to the facility for retrieval and provision of closed clinical records to the team within one hour b On the other copy of the Admission Sample Report the TC assigns Admission Sample residents who are also included in the Census Sample to the surveyor assigned to complete the resident s Census review Remaining Admission Sample residents reviews can be a
6. CE Pathways eeeeeeeeeeeeeeee eese eene eenn nenne nennen nn nnne nn nn nnns nn nnn 49 General Critical Element Pathway erret tee ro diet nare r od rone ri ca RE dene ncn 50 Critical Element Pathways torio ideae Tete tuere nhe Zeg 50 Using Critical Element Pathways when Reviewing a Care Area 50 Unnecessary Drug Review ease quien creronkr s eid das eon d rx x c Ho a Ea da ca CER CO a Ee CR 51 Systematic Review and Documentation of Critical Element Compliance 51 Completing Critical Element Documentation in the QIS DCT 52 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page ii Quality Indicator Survey Procedures for Long term Care Facilities Task 8 Stage Il Analysis Decision making and Integration of Information 53 Review Completion of Stage ll csssseccceesseeeeeeseeeeeeeesseneeeeesneeeeeeesseneeeseeseeeeeeeeseeeeeeenseenes 53 Import all Stage Il Data into the Primary Laptop eere 53 Review the Potential Citation Screen in the QIS DCT eee 53 Analysis Assignment of Scope and Severity and Team Decision making 54 Scope and Severity Matrix rere ec eae bs ace cde eia eee cece vee degens 54 ID 54 ele 55 Pre exit UE 55 Task 9 e ET 56 The ONS Extended Suey uncis
7. QCI Results Report Abuse QCIs Exceeded Threshold Quality Care Indicator Num Denom Rate Threshold QP253 C Abuse Resident Interview l 18 5 55 0 QCIs Did Not Exceed Threshold Quality Care Indicator Num Denom Rate Threshold QP236 C Abuse Family Interview 0 2 0 00 0 QP205 C Abuse Resident Oe ation 0 40 0 00 0 Accidents QCIs Did Not Exceed Threshold Quality Care Indicator Num Denom Rate Threshold QP092 C Dangerous Device Use 0 40 0 00 0 QP218 C Potential Accident Hazards Bed Side Rails 0 2 0 00 2 4 QP 01 M Incidence of New Fractures P MR 0 57 0 00 0 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 42 Quality Indicator Survey Procedures for Long term Care Facilities Exporting QCI Results to Secondary Laptops QCI Results after having been processed and reviewed for accuracy can be exported from the primary laptop and imported at the secondary laptops QCI Results for any Stage resident Care Area and or QCI can be viewed on any computer on the QCI Results screen of the QIS DCT during Stage ll investigation For example the QCI Results screen can be reviewed to see which QCls were met for a Stage ll resident in addition to those QCls that were not met and those QCls from which the resident was excluded Note The Stage data on the primary laptop determine the QCls representative of the survey Stage data on a secondary laptop should not be chan
8. e The Personal Funds worksheet references the Protection of Personal Funds tags F156 and F159 F162 Relevant F tags are referenced for each question so that the surveyor can refer directly to the regulation and Guidance to Surveyors when making compliance decisions Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 37 Quality Indicator Survey Procedures for Long term Care Facilities Task 6 Transition from Stage I to Stage Il After Stage data entry is complete and the Resident Pool has been updated in the QIS DCT on the primary laptop see Task 4 Update the Resident Pool the team will transition to Stage Il in depth investigation Prior to creating the Stage Il Sample the surveyors must focus on the following activities all of which are facilitated by the team coordinator The Stage to Stage II transition team meeting should be held after all Stage activities have been completed The meeting should be focused organized and with minimal extraneous conversation The team meeting encompasses the following activities e Confirm that all Census Sample and Admission Sample tasks are completed and entered into the QIS DCT e Merge the Stage data onto the primary laptop e Print the Relevant Findings Report for team discussion while QCI Results are processing in the QIS DCT e Process and review the QCI Results in the QIS DCT e Review surveyor initiated residents and or Care Areas as
9. provide the facility the opportunity to discuss and supply additional information that they believe is pertinent to the identified findings Because of the ongoing dialogue between surveyors and facility staff during the survey there should be few instances in which the facility is not aware of surveyor concerns or has not had an opportunity to present additional information prior to the exit conference e Conduct the exit conference with facility personnel e Invite the ombudsman and an officer of the organized residents group if one exists and additional residents who expressed interest in attending the exit conference e The team may provide an abbreviated exit conference specifically for residents after completion of the normal facility exit conference e f two conferences are held notify the ombudsman and invite him her to attend either or both conferences e Describe to the facility the team s preliminary deficiency findings and let the facility know that they will receive a written report of the survey results CMS 2567 e The Potential Citation Report see Figure 10 printed from the QIS DCT can be utilized by the surveyors to guide the exit conference If requested provide the facility a list of residents included in the Admission Census and Surveyor initiated Samples Figure 10 Potential Citation Report NORTH STAR COMMUNITY MHZB11 08 01 2005 Potential Citation Report F159 FACILITY MANAGEMENT OF RES FUNDS
10. 09 07 2006 Centers for Medicare amp Medicaid Services Page 5 Quality Indicator Survey Procedures for Long term Care Facilities 3 The survey team will be conducting a complaint investigation if applicable during the survey b Additionally 1 Provide the facility a copy of the OSCAR 3 2 Provide the Medicare Medicaid Application 671 and Resident Census and Conditions 672 3 Request the facility provide information identifying an emergency water source 4 Determine whether full time DON coverage is provided verbal confirmation is acceptable 5 Provide the CMS Quality Indicator Survey Demonstration Project brochure 2 Ask the administrator to provide the following information within one hour of the conclusion of the entrance conference a A list of key personnel and their locations b The name of the resident council president or an officer active council member if there is a resident council or equivalent group A schedule of meal times and the location of all resident dining room s d A schedule of Medication Administration pass times e All Admission Sample closed records Make arrangements for overnight safe storage of the records 3 Askthe administrator to provide the following information within four hours of the conclusion of the entrance conference a A list of residents who receive ventilator dialysis whether in or out of the facility or certified Medicare hospice services and or end o
11. 2006 Centers for Medicare amp Medicaid Services Page 68 Quality Indicator Survey Procedures for Long term Care Facilities those residents who are in the facility over those who have been discharged when selecting the Stage II Sample 10 To discharge a resident from the Admission Sample or Resident Pool select highlight the resident s name in the left vertical pane of the Stage I Sample screen and then click the Discharge Readmit Resident button Which Resident List do you want displayed Resident Pool C Admission Sample C Census Sample C Surveyor Initiated Sample C Facility d Initiated Care Areas For f CARR D 05 01 1924 Du CARR I 05 01 1324 mgeet CARR M 05 01 1924 i CARR M D 05 01 1924 lj CARR R 05 01 1924 77 CARR S L 04 01 1923 ip CARR T 05 01 1924 rff CARR T 05 01 1924 Wr FACILITY Tff JACKSON B 05 01 1924 rff JACKSON D B 05 01 1924 JACKSON D B 05701 1924 Update Census Residents Discharge Readmit Resident Add New Resident m JACKSON E 04 01 1923 E D JACKSON E 5 02 01 1921 Initiate Remove Care Area of New Admits m JACKSON G A 03 01 1922 Survey Steps JACKSON J 04 01 1923 D Resident In The Facility kl Resident Discharged From Facility JACKSON J 05 01 1924 7 Resident In Both Admission and Census Samples 83 Residents In List of All Residents NORTH STAR COMMUNITY MHZB11 08 01 2005 11 When a Confirm Residen
12. 54 Quality Indicator Survey Procedures for Long term Care Facilities Scope Isolated Pattern Widespread A D G J Scope is isolated when one or a very limited number of residents are affected B E H K Scope is a pattern when more than a very limited number of residents are affected and or the same resident s have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive in the facility C F I L Scope is widespread when the problems causing the deficiency are pervasive in the facility and or represent systemic failure that affected or has the potential to affect a large portion or all of the facility s residents Widespread refers to the entire facility not a subset of residents Pre exit Conference Upon completion of the team s deficiency decision making the facility administrator can be offered the option to attend a pre exit conference to discuss any issues of a sensitive confidential nature with the survey team The pre exit conference is distinct from the exit conference Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 55 Quality Indicator Survey Procedures for Long term Care Facilities Task 9 Exit Conference The general objective of the exit conference is to inform the facility of the survey team s observations and general preliminary findings During the exit conference
13. DCT will request that the surveyor enter the number of new admissions This information is found on the New Admission Information form completed by the facility amp New Residents How many residents are on the New Admit Form provided by the facility ins ee Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 67 Quality Indicator Survey Procedures for Long term Care Facilities 7 After the surveyor enters the number of new admissions the QIS DCT will randomly select a replacement resident and request that the surveyor enter that resident s information identified by the resident s number on the New Admission Information form Add Resident Please enter the following data for resident number 1 on the New Admissions list Admit Date Date Of Birth Last Name Gender First Name Unit Number Middle Init Room Number Close Form Skip Resident jw ji H If the surveyor attempts to add a resident who is already in the Census Sample or Resident Pool the QIS DCT will prompt the surveyor to select a different resident as a replacement H Each time a resident is discharged the QIS DCT will randomly select another resident from the New Admission Information form If there are no more new admits remaining to replace a discharged resident the QIS DCT will select a resident from the Resident Pool and prompt the surveyor to confirm that the replacem
14. Facilities decision to remove a resident should be based on progress towards completion of the Census Sample review Resident Observations The objective of the observation portion of the preliminary investigation is to collect resident specific information for the residents in the Census Sample During the entire survey process surveyors should be alert to staff resident interactions and the quality of life for all residents e When an observation suggests a concern consider the situation and time of day before making a final determination Multiple observations at various times of the day may be necessary to gather the required information Example a Resident Observation question is Based on general observations did you see any of the following skin is unclean i e food on face and hands If itis observed that the resident has food on his her face but the observation is made directly after a meal it is reasonable to make a second observation between meals to see if the condition persists e Surveyors using paper forms should enter Stage observation information in the QIS DCT promptly for greater accuracy and to avoid delay in the timely completion of Stage Document narrative notes on the Stage Relevant Findings screen Resident Interviews Surveyors will conduct Stage interviews with the Census Sample residents who are assessed as interviewable The QIS DCT uses a Cognitive Performance Scale CPS developed by Mo
15. II Critical Elements screen of the QIS DCT and compliance decisions are made during Stage Il Non staged Facility level Tasks The following seven non staged facility level tasks can be conducted during Stage and or Stage ll of the survey process Demand Billing The Demand Billing task is only completed for Medicare or Medicare Medicaid certified facilities and focuses on Medicare non coverage and compliance with relevant regulations Information is gathered by reviewing the denial notices and the requests for demand billing e Select one beneficiary from the facility provided list of Medicare beneficiaries who requested demand bills since the preceding survey period 9 15 months preferably a private pay resident if possible In addition to being asked to provide the demand bill list within 24 hours of the entrance conference the facility was asked to indicate the co payment source of each beneficiary i e private pay Medicaid or other insurance and provide the five most recently issued denial notices to beneficiaries e Request the denial notice issued to the beneficiary selected from the facility demand bill list Note The surveyor may have six notices to review Five of the notices are the most recently sent denial notices one notice is an actual request for a demand bill if there were any requests Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 25 Quality Indicator Survey
16. Procedures for Long term Care Facilities Use the Demand Billing worksheet Tab 8 to direct review of the notices and record information One surveyor should be assigned this task and be responsible for ensuring that all questions on the worksheet are reviewed Help text is available on the worksheet to assist in identifying concerns If any concerns are identified during review of the notices a No answer marked on the worksheet gather additional information as necessary from some or all of the sources identified on the last page of the worksheet The Demand Billing worksheet references tags F156 and F492 in the relevant General Indicator question to which the tags apply The surveyor should refer directly to the regulation and Guidance to Surveyors when making compliance decisions Dining Observation Dining observations begin with the first full meal that occurs after the team enters the facility Meal times and dining room locations should have been identified during the entrance conference The first full meal will allow the opportunity for observations to occur from the start of meal service until residents have finished eating Although it is necessary to choose the first full meal that allows observations to occur from start to finish it is not necessary to watch the meal in its entirety as long as all probes on the Dining Observation worksheet Tab 8 have been answered If concerns are identified at one meal e g breakfa
17. The QIS DCT may select more than three residents who triggered for a Care Area because surveyor initiated residents are included and some CE Pathways combine Care Areas For example Nutrition Hydration and Tube Feeding are three Care Areas within one Critical Element Pathway Therefore in this case a minimum of three residents will be selected for each triggered Care Area within the combined CE Pathway Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 45 Quality Indicator Survey Procedures for Long term Care Facilities If the Ventilator Dialysis and Certified Medicare Hospice End of Life services list delivered during the entrance conference and completed by the facility indicates that the facility has residents who are ventilator dependent or on dialysis or hospice the surveyor should select one resident from each of the three categories to review in Stage Il From zero to three residents could be added to the Stage Il Sample for review of Ventilator Dialysis and Certified Medicare Hospice End of Life services one resident could possibly meet criteria for more than one of the combined categories The TC should surveyor initiate any residents that the team determined during the transition from Stage to Stage II that should be added to the Stage II Sample based on additional information gathered during Stage or from offsite information i e complaints Stage Il Staff Assignments The
18. assigned to complete the Medication Administration task should surveyor initiate the residents observed during the Medication Pass See the QIS Checklist for instructions to surveyor initiate a resident and a Care Area If errors were Observed the surveyor should indicate that the facility was not in compliance with the requirement and choose the appropriate citation and The surveyors assigned the Medication Administration Observation task should confer and calculate the error rate as follows see Figure 7 1 Combine all surveyor observations into one overall calculation for the facility Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 29 Quality Indicator Survey Procedures for Long term Care Facilities 2 Medication Administration Error Rate Number of Errors divided by Opportunities for Errors doses given plus doses ordered but not given multiplied by 100 Figure 7 Medication Error Rate Calculation Total Number of Errors X 100 Total Doses Given Total Doses Ordered but Not Given After the overall error rate is determined the team will determine whether a facility citation is appropriate during the team meetings If the Medication Administration Error Rate is 5 or greater cite F332 If any one medication error is determined to be significant cite F333 Quality Assessment and Assurance QAA Review Part 1 of the worksheet is completed at all facilities The surveyo
19. c or o dee ORE IR AU RR EEN URE Teese vo ER stabs dU ER ARR ER RAINER den 41 Care Area List View nci e XR RR XR EXER RM ERN RN duces XXE RE XR XE EA VEA CRM de Y dex ES 41 K eeler Example ee ee e ep trop eb dn de eere adole LUE ds 41 Print the QCI Results HepDOLL en oer e Leere EEN 42 Exporting QCI Results to Secondary Laptops eere 43 Review th QCI Hesults en eek arsi tdi ecd ae 43 Make Note of Residents and or Care Areas to Surveyor Initiate in Stage ll 43 Task 7 Stage Il Survey Tasks eeeeeeeeeeeeeeeeeeeeeeeeeee eene nnne nnn nnn 45 at ECACC EE 45 Stage ll Sample Selectlonh hae tes eee imei luc eiua 45 Stage II Staff Assignments eiii rotae cea scene sec ccu excu eeu accu cabane cL FA SBEER ada PpE e gps 46 Stage ll Team MGGtings T 46 Removing and Replacing Residents in Stage ll eee 47 Supplementing the Stage Il Sample lceeeeeeeeeeeeeeeeeeee nennen nennen nnne nnn 48 Stage Il In depth Investigation 1ceeeeeeeee eee eeeeesee eere eene e nennen nnne nnne nnn 48 Stage Il Forms that Facilitate Gathering of Information sssseesessesssss 48 Stage II Information Validation eeeeeeeeeeeeeeee eese ee eese eren ne nennen nennen nennen nnn nnns 49 Critical Element
20. concerns noted during the interview should be shared with all team members Triggered Facility level Tasks The following five facility level survey tasks are completed in Stage II only if triggered by offsite information e g complaints or by Stage interviews observations or record review 1 Abuse Prohibition Review 2 Admission Transfer and Discharge Review 3 Environmental Observations 4 Nursing Services Sufficient Staffing and 5 Personal Funds Abuse Prohibition Review The Abuse Prohibition Review is completed only if triggered from Stage issues related to potential abuse and or neglect obtained through observation and or interviews issues identified offsite and or any concerns identified during any part of the survey The Abuse Prohibition Review is not required on every QIS survey If Stage investigation results in triggering of the Abuse Care Area for a resident the facility level Abuse Prohibition Review will also trigger for completion If Abuse at the resident level is brought to the attention of the survey team offsite complaints etc surveyor initiate the resident for the Abuse Care Area and surveyor initiate the facility for the Abuse Prohibition Care Area The investigation is conducted as currently outlined in the SOM Appendix P Abuse Prohibition Investigative Protocol per the SOM Objective To determine if the facility has developed and operationalized policies and procedures that prohibit ab
21. information gained during the survey When a deficiency exists determine if F225 or F226 provides the best regulatory support for the deficiency e 483 13 c F226 Staff Treatment of Residents The facility is compliant with this requirement if it has developed and implemented written policies and procedures that prohibit mistreatment neglect and abuse of residents and misappropriation of resident property If not cite F226 e 483 13 c 1 2 3 and 4 F225 Staff Treatment of Residents The facility is compliant with this requirement if it has taken appropriate actions in the areas of screening reporting protecting investigating and taking appropriate corrective actions If not cite F225 Admission Transfer and Discharge Review The Admission Transfer and Discharge Review task is completed only if triggered from Stage information e Prior to the review determine which residents caused this task to trigger e Request the Resident Rights information and an admission packet for all payer sources of the facility e Use the Admission Transfer and Discharge Review worksheet Tab 9 to direct the review and to record information Questions 1 5 relate to information obtained during Stage resident and or family interviews Complete the follow up only for interview questions identified as a concern in Stage I Questions 6 and 7 are completed if information is gathered or provided either during or before t
22. items If additional information must be entered the surveyor must enter the information on the secondary laptop and repeat the export to flash drive The team coordinator must import the completed secondary Stage Survey Data to the primary laptop The team coordinator should also review residents who were surveyor initiated to ensure that they were imported After importing all of the Stage Data and verifying its completion the team coordinator will backup export the merged Stage Data to flash drive Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 38 Quality Indicator Survey Procedures for Long term Care Facilities Print the Stage Relevant Findings Report After the team coordinator has merged imported and backed up the secondary Stage data the team coordinator should print the narrative documentation of findings entered in QIS DCT during Stage to facilitate discussion of potential problems The Stage Relevant Findings Report can be printed from the QIS DCT at any time to facilitate discussion of potential problems during team meetings How to Print the Relevant Findings Report 1 From the QIS DCT menu bar select Reports Stage I Relevant Findings report 2 When the resident list displays select to display All other options are Admission Census Surveyor Initiated or Stage II 3 Use the mouse to highlight select all listed residents select a Sort Order and cl
23. more survey team nurse s or pharmacist s One surveyor will be assigned responsibility for organizing and ensuring completion of the task The surveyor assigned this task will also be responsible for review of the drug storage areas on the units where the Medication Administration Observation is conducted The surveyors will observe a combined total of at least 50 medication administrations to at least 10 randomly observed residents from different units The surveyor responsible for this task must ensure that the surveyors number of observations of administered medications total at least 50 AND that at least 10 residents were observed to achieve the total of 50 medications Surveyors should attempt to observe medications by multiple routes Observe the staff nurse during the medication pass and query the staff on the routes of administration Adjust observations to include other routes as possible Observations need not all be done in one day Multiple medication administration times can be observed for each resident Refused medications are observable medications and can be counted Document observations on the Medication Administration Review worksheet Determine whether medications were administered appropriately If not determine the significance of each error by considering the following Resident s condition Medication category Frequency of the error Data entry into the QIS DCT is completed in Stage II Surveyors
24. need to be surveyor initiated to be further evaluated during Stage Il Critical Element Pathways Each Critical Element Pathway follows the same basic format Sections include probes that guide the surveyor through the process of determining if the Critical Elements are in place In turn the Critical Elements assist the surveyor in determining if the facility is in compliance with the specific regulation The probes suggest avenues for inquiry and assist the surveyor through the investigative process The probes do not directly reflect the language of the relevant regulation Each pathway identifies F tags that should be considered for citation A Critical Element Pathway CE should be reviewed for each Care Area to be investigated in Stage Il e Because the elements are considered critical to compliance in a particular regulatory area the facility s failure to meet a Critical Element suggests the facility s failure to meet a participation requirement e Documentation on the CE summary form should be specific enough so that compliance decisions can be made and supportable deficiencies can be written if the facility has been determined to be noncompliant e Brief notes can be recorded next to specific probes or Surveyor Notes Worksheets can be used for documentation of interviews and observations and information and quotes taken from the clinical record Using Critical Element Pathways when Reviewing a Care Area While the format f
25. prior to the end of Stage II data collection Note Any unsafe situations that relate to the life safety codes i e concerns with use of extension cords improper storage of oxygen and blocked fire doors should be referred to the Life Safety Code surveyor Nursing Services Sufficient Staffing The Nursing Services Sufficient Staffing task is completed only if triggered from Stage family or resident interviews observations identification of concerns and from facility provided staffing information e Request a copy of the actual staffing schedule for the licensed nursing staff LVN LPN and RN for the most recently completed pay period with the resident census for the period and any staffing waivers e Verify that the staffing schedule reflects 24 hour licensed coverage 8 hour registered nurse coverage and full time director of nursing coverage The review of Nursing Services Sufficient Staffing will be conducted as it is outlined in the current protocol from the SOM which is reproduced below Nursing Services Sufficient Staffing Protocol per the SOM Objectives e To determine if the facility has sufficient nursing staff available to meet the residents needs e To determine if the facility has licensed registered nurses and licensed nursing staff available to provide and monitor the delivery of resident care Use Note This protocol is not required during the standard survey unless it is triggered in the even
26. should tour individually as assigned by the team coordinator It is not necessary to have a facility staff person accompany the surveyor on tour e Attempt to meet as many staff and residents family as possible e If the tour is being conducted during a time when there is an opportunity to observe a full meal begin the Dining Observation task see the section titled Dining Observation e While on tour document any concerns with the general environment for example common bathing areas lighting and noise levels odors general cleanliness and safety etc e To gain information about the facility and the resident population focus on the following Staff resident interactions related to residents privacy and dignity including the manner in which the staff responds to resident requests mood and behavioral symptoms and indications of need for staff attention Staff availability by identifying the licensed and registered nursing staff currently on duty The activities in which residents are engaged including both in room and structured group activities The characteristics of the resident population such as the presence of special care units for residents with dementia sub acute rehabilitation units or Medicare wings and the presence of residents with clinically complex special care needs such as feeding tubes ventilators intravenous therapies tracheostomy tubes and oxygen therapy Note The team coordinator
27. tiaa an Ove naonin uda Cds Cuv DU Ve ho uian koania ioeina 57 Nursing ServiDBS EE 57 lla c M 57 Pd 58 The QIS Complaint Survey Procedures eese 59 The QIS Post Survey Revisit Follow up eeeeeeeeerrerreeeeeeeeeennnnnnn 60 QIS DCT Software Procedures eee 61 EI DT iraani arin eieaa ariaa ria a aiaiai isasara addaa Na annia ia didien ia a G 1 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page iii Quality Indicator Survey Procedures for Long term Care Facilities Introduction The Quality Indicator Survey QIS process is designed to guide surveyors through the federal survey in a two stage process Stage involves an initial quality assessment of targeted residents selected randomly by the QIS Data Collection Tool DCT on a wide range of Care Areas covered by the regulations Resident assessment is conducted based on resident observations interviews and from reviewing clinical records These onsite assessment data are used together with Minimum Data Set MDS data to construct 160 resident centered outcome and process indicators called Quality of Care Indicators QCls When compared with national norms QCls are used to focus the more detailed quality investigation during the Stage Il review Stage II involves the in depth review of residents within Care Areas that exceeded thresholds as ide
28. to MDS resident and assessment information historical and current regulatory and interpretive guidelines and the Quality Indicator Survey Data Collection Tool QIS DCT via the Citation Manager Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page G 1 Quality Indicator Survey Procedures for Long term Care Facilities Care Area A Care Area refers to a critical component of nursing home care that in the QIS process is defined by one or more related resident centered outcome and process indicators called Quality of Care Indicators QCls If Stage information gathering identifies residents whose QCI data exceeded rate thresholds for Care Areas or triggers Care Areas Stage II will involve in depth investigation of the residents using Critical Element Pathway s CEs to systematically review information and document concerns Census Sample The Census Sample consists of 40 residents currently residing in the survey facility who are randomly selected by the QIS DCT for information gathering by surveyors through interview observation and record review during Stage of the QIS process Critical Element Pathway Investigative Protocol A Critical Element CE Pathway corresponds to an associated Care Area identified in Stage and provides information to guide Stage II QIS process investigation A CE Pathway assists surveyors to determine whether a facility undergoing survey meets the associated regu
29. to Surveyor Initiate in Stage Il The survey team should determine whether any residents should be added to the Surveyor initiated Sample based on additional information gathered during Stage or from offsite information i e complaints These residents and or Care Areas can be added to the Stage II Sample see the section titled Supplementing the Stage II Sample which contains QIS DCT instructions on adding residents to the Stage Il Sample The following examples illustrate the types of potential concerns that may lead a surveyor to select a resident for inclusion in the Stage Il Sample or if the resident is already included in the Stage Sample may direct the surveyor to surveyor initiate a particular Care Area or F tag for further review e Ventilator dialysis hospice residents listed by the facility on the Ventilator Dialysis and Certified Medicare Hospice End of Life Services worksheet on the back of the last page of the Entrance Conference Facility Worksheet Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 43 Quality Indicator Survey Procedures for Long term Care Facilities e Observations of an uncovered inflamed surgical wound e Observations of a resident with a leg ulcer vascular or neuropathic that causes discomfort or is malodorous or e During the resident interview the resident offers information about treatment or medications that were ordered but not received Qua
30. to a prescribed Care Area review or facility level review Relevant findings can be entered as narrative text in the QIS DCT and subsequently printed as a report for review to facilitate team discussions of potential problems and to assist in Stage II information analysis decision making or deficiency writing as appropriate Relevant findings not included in the prescribed review can be used to determine whether to surveyor initiate a particular Care Area for in depth review in Stage Il Resident Council President Representative Interview The Resident Council President Representative Interview which replaces the Group Interview is a facility level task that focuses on resident rights facility rules and facility responsiveness to council concerns If there is no resident council leader or officer the interview questions can be asked of a resident who is active in the council as indicated by the facility As part of the Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page G 3 Quality Indicator Survey Procedures for Long term Care Facilities interview surveyors can review resident council minutes to become familiar with issues that have been discussed before the interview Secondary Laptop A secondary laptop is the survey laptop used by a team member other than the team coordinator to enter gathered information for assigned sample residents and facility level tasks When information gathering is co
31. well as the list of residents who receive dialysis services Medicare certified hospice services or are ventilator dependent Verify the Completion of Stage Each surveyor needs to confirm that all resident specific information from the Census Sample and Admission Sample tasks has been gathered and entered in his her laptop A surveyor can determine at a glance which questions remain unanswered for any given resident by the color of the text of each displayed item in the Survey Tree of the Stage Data Entry screen Black text refers to information that has been completed red text refers to incomplete information After completing their Stage data entry all surveyors must export their Stage data to flash drive Import merge all Stage Data into the Primary Laptop The team coordinator must import the Stage Survey Data from each secondary laptop flash drive to the primary laptop Once the import of data to the primary laptop is completed the team coordinator can determine at a glance which questions remain unanswered for any given resident or Care Area by the color of the text of each displayed item in the Survey Tree of the Stage Data Entry screen Black text refers to information that has been completed red text refers to incomplete information If any items text displays in red the team coordinator should consult the members of the survey team to ensure that all information has been entered and the reason for any missing
32. with residents or their families legal representatives Request a copy of the facility s floor plan Request a copy of the staffing schedules for licensed and registered nursing staff for the survey time period Provide a copy of the Facility Entrance Conference Worksheet 2 The surveyor assigned to complete the Stage Sample should do the following a b Set up the primary laptop Begin the sampling task as soon as the alphabetical resident census is provided follow the Primary Laptop responsibilities as listed on the QIS Checklist Entrance Conference 1 After the administrator or designee has provided the resident census and the New Admission Information form or has arranged for these items to be provided to the team the team coordinator will meet with the administrator or designee to briefly review the QIS process and answer any questions a Inform the administrator of the following 1 Privately conducted interviews will take place with family members and individual residents unless the interviewees request the presence of a facility staff member 2 The survey team will be communicating with facility staff throughout the survey and will ask for facility assistance when needed Advise the administrator or designee that he she will have the opportunity to provide the team any information that would clarify an issue brought to his her attention but there will be no daily conference Quality Indicator Survey
33. 5 Casiano Evelyn l 66666 Elder Martha _ lg Residents as of 08 01 2005 4 At the Team Roster window click Update Team Roster 22222 Brown Laurel 55555 Casiano Evelyn 66666 Elder Martha 44444 Morley Young Staci Leader Delete Done Help Ds Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 62 Quality Indicator Survey Procedures for Long term Care Facilities 5 The Select Surveyors window will appear Add members to the survey team by clicking in the box to the left of their names a To add a new surveyor click the New button and add the surveyor information in the dialog box that appears b To modify an existing record select highlight the surveyor name click the Modify button and update the surveyor information in the dialog box that appears When updating of the information is complete click OK Select Surveyors ao ee 14 22222 Brown Laurel Lbrown 1 55555 Casiano Evelyn Ecasiano Bd 66665 Elder Martha Melder 1 44444 Morley Y oung Staci Syoung Help Cancel Modify Morley Young Staci Information Staff Identification Federal Surveyor ID 44444 State Personnel ID 44444 m Name l First STACI Middle Last MORLEY YOUNG Title Code os Generalist Surveyor D E Mail Address Login Detail Network Login SYOUNG Oracle Login Oracle SE tea deb Quality Indicator Survey 09 07 2006 Centers f
34. 8 2005 Family Interview Candidate CARR T 78 05 01 1924 02 07 2005 Family Interview Candidate JACKSON E 5 02 01 1921 04 04 2000 Resident Interview JACKSON G 14 03 01 1922 03 11 2002 Family Interview Candidate JACKSON J 11 05 01 1924 03 22 2004 Resident Interview SMITH B 37 01 01 1920 11 14 2003 Resident Interview SMITH E 66 05 01 1924 05 19 2005 Family Interview Candidate SMITH E 45 05 01 1924 04 15 2002 Resident Interview SMITH E 2 04 01 1923 03 17 2000 Family Interview Candidate SMITH G 62 03 01 1922 06 21 2004 Resident Interview SMITH G 19 05 01 1924 04 12 2005 Resident Interview SMITH J 72 05 01 1924 10 04 2004 Family Interview Candidate SMITH M 24 02 01 1921 05 05 2003 Resident Interview Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 3 Quality Indicator Survey Procedures for Long term Care Facilities 5 The team coordinator is responsible for gathering and carrying all necessary QIS supplies a Laptop Tablet PC and peripherals any external disk drives power cords extra battery packs and carrying case b Power strip s with surge suppressor Portable printer and extra ink cartridges for printer Flash drive diskettes prepared as indicated on the Storing QIS Data document in Tab 2 of the Surveyor Resource Manual e Printer paper about half a ream f All Stage and Stage II survey worksheets according to your state procedures g Completed survey an
35. Assign dining observations based on the number and location of dining areas and for any residents who eat in their room 6 The team coordinator will determine and communicate to the survey team a target day and time for completion of Stage I Stage Team Meeting End of First Day At the end of the first day a brief meeting should be held to e Determine the workload remaining in Stage I e Discuss team progress e Determine whether any assignment adjustments are necessary e Discuss pertinent findings both resident and facility level tasks Determine whether there are any egregious situations that need to be brought to the facility s attention e Determine how many family interviews have been completed who has been interviewed and who might be available for interview Schedule family interviews for completion prior to the end of the Stage I Stage Resident level Preliminary Investigation Stage consists of a cursory review of the initial quality assessment of sampled residents and the facility as a whole using a set of prescribed questions This process is systematic and covers a full range of critical Care Area reviews Stage tasks include gathering sample resident specific information by observation interview and record review Information gathered in Stage is used to determine which care areas will be comprehensively reviewed in Stage ll Stage II includes in depth observations interviews and record reviews related to the
36. Care Areas identified during Stage l Tips on How to Organize Stage Preliminary Investigation e Once a surveyor becomes familiar with the Stage interview questions the surveyor should conduct all interviews using their tablet pc All relevant findings can be entered into the tablet pc by using the handwriting recognition software e Begin Stage preliminary investigation in a manner most efficient to the time of day and the activities occurring in the facility e Upon finalization of the Stage Sample begin making arrangements for family and staff interviews see the section titled Family Interviews and the section titled Staff Interviews e Regardless of the task being performed the surveyor should be alert at all times to the care environment and activities occurring such as staff resident interactions activities infection control practices and care provisions Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 16 Quality Indicator Survey Procedures for Long term Care Facilities e Attempt to complete as many resident observations and resident interviews as possible before beginning record reviews Complete record reviews when residents are unavailable for observation or interview e For sample residents currently in the facility attempt to conduct the record reviews on the unit so that observations can be completed at the same time e Findings concerning residents who are not
37. DR Hawes C Phillips C Mor V Lipsitz A MDS Cognitive Performance Scale Journal of Gerontology Medical Sciences 1994 49 4 M174 M182 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 20 Quality Indicator Survey Procedures for Long term Care Facilities e tis extremely rare for the CPS to find that someone is interviewable when they are not so you can almost always proceed with the interview if the resident meets the CPS interviewable criteria If it is clear that the person is giving you misinformation then mark him her as non interviewable and stop the interview e Ifa resident identified as non interviewable based on the CPS score provides reasonable answers to the sample questions then continue the interview If at any point you have concerns that the information you are receiving is not accurate then you can stop the interview at this point and mark them as not interviewable If you are comfortable the resident is interviewable then complete the interview and change them to interviewable Use the Resident Interview amp Resident Observation worksheet Tab 7 to guide the resident interview Once a surveyor becomes familiar with the interview questions the surveyor should conduct all interviews using their tablet pc To ensure survey consistency ask the interview questions as they are written on the worksheet However in order to ensure a quality conversation the following tips may be hel
38. QIS DCT allows the surveyors to make assignments in three ways by Surveyor Care Area and Resident The team coordinator usually assigns the Stage Il Sample to the team by Resident It is convenient in some cases to switch to the Care Area view during assignment so that assignments can be made to surveyors with expertise in the relevant Care Area to complete those reviews In the process of determining surveyor assignments and workload distribution the team coordinator should consider the following points e Surveyor expertise in specific Care Areas e The number of Care Areas triggered e The number of residents assigned to each surveyor e The facility level tasks assigned to individual surveyors e Touse time efficiently attempt to assign a surveyor to residents in the same or neighboring units e The QIS DCT automatically assigns surveyor initiated residents to the surveyor who initiated the resident into the sample The team coordinator can reassign the resident to another surveyor as necessary e Assigning residents to the surveyor who reviewed them in Stage I allows surveyors to follow residents through the entire survey Additionally the QIS DCT offers an automatic assignment button on the Stage II Assignment screen that distributes and balances the workload across all surveyors on the team see the QIS Checklist After the assignments have been made print the Stage Il Report sort by Surveyor after assigning all r
39. QUALITY INDICATOR SURVEY SURVEYOR TRAINING MANUAL Quality Indicator Survey Procedures for Long term Care Facilities Table of Contents irit 1 Task 1 Offsite Survey Preparation e eeeeeeeeeeeeeeeeeeeeenne nennen nnn 2 Task 2 Onsite Preparatory Activities and Entrance Conference 5 Immediately Upon Entrance to the Facility essere nnn 5 EMELIE 5 Concurrent Activities uoce eee ni ae ree ene ea tees 7 Task 3 Initial TOUE ducendo r rest ne Peer ARX P cere tree err reer cece re EXx YR XRY XR Y EXE X EXRNEXRY ERN KXR X EXx V EXRx rer rerr 8 Task 4 Stage T Survey TasK8 ceiontioriiiieioao uo Depe ve Ca eege 9 Stage Sample OvervieW 2 2595 0 etico Me cir eet 9 PRESIGEALIPOOM ins att rs t 9 MDS Sample x t rer OB teu det ipd E 9 Admission Samples rrna e tu vae tee av Gates eye ved euo deben dei a d e E e De n 9 Census Samples se ecd ehe re De ERREUR EXTR EERE ARENE EEFE EaR Eea EN 10 Surveyor initiated Sample icol rb Hr EEe t e EORR EIER EXER ER Rue dA PR Uer x tere encke 10 Reconciling the Census Sample sccccessseeeceeeeeeeeeeseseeeeeesseneeeeseseeeeeseenseeeeeeeseeeeesenseseees 11 Update the Resident PO0l chiede Ga baia daa enue seins Da Ee pau deck rbd veis da C CE CON M UN Eua 14 Stage I Team Meellrgs coim ere Ee osi ce e 15 initial Team Meeting EE 15 Stage Team Meeti
40. Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 41 Quality Indicator Survey Procedures for Long term Care Facilities Print the QCI Results Report After the team coordinator has run the QCI results print the QCI Results Report see Figure 9 to review the following e The Care Areas to be investigated in alphabetical order e The QCls and their reference number that exceeded or did not exceed their threshold within each Care Area e The source data A for Admission C for Census M for MDS for the each QCI e The Numerator number of residents who met the QCI Criteria or who had a negative outcome Denominator number of residents included in the rate computation Rate for the facility and the Threshold of the QCI The QCI Results Report is the only source that shows QCI thresholds in the QIS DCT When a Care Area has QCls that exceeded the threshold that Care Area will be included in the Stage Ill Sample The QIS DCT will automatically select one or more residents for each triggered Care Area during the Stage Il Sample selection process see Task 7 Stage II Sample Selection How to Print the QCI Results Report 1 From the QIS DCT menu bar select Reports QCI Results Report 2 Click the Print icon on the preview screen menu bar 3 Change the Number of Copies to 4 number of surveyors on the team and click OK Figure 9 QCI Results Report NORTH STAR COMMUNITY MHZB11 08 01 2005
41. The QIS DCT will randomly select residents whose MDS excluding discharge or re entry MDS assessments was submitted to the state within the 180 days prior to the MDS extraction date The second step in selecting the Census Sample is performed onsite on the primary laptop and involves verifying that each of the residents selected in the first step via the MDS assessments continue to reside in the facility The current residency status must be verified because there is lag time between MDS extraction and the start of the survey Surveyor initiated Sample This sample is not randomly selected by the QIS DCT but rather at a surveyor s discretion The Surveyor initiated Sample is comprised of residents specifically chosen by a surveyor to be further evaluated during Stage II The surveyor may choose a resident for inclusion in this sample based on resident specific information obtained during other tasks i e offsite such as complaints or ombudsman information or onsite information from random observations and or interviews These residents are automatically added to the Stage II investigation The procedures to surveyor initiate a resident are listed in the section titled Supplementing the Stage Il Sample How to Add Residents to the Stage II Sample see the QIS Checklist Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 10 Quality Indicator Survey Procedures for Long term Care Facilities Rec
42. a discrepancy In some cases information overlaps between data sources For example the staff interview includes the question Does the resident currently have one or more pressure ulcers The clinical record review includes the same question e Multiple data sources are reviewed to ensure that information available only in one source is accessed i e information that is observed but not documented and to validate information from all available sources e If it is determined that one of the sampled residents refuses to be interviewed is out of the facility or has been discharged the resident can be removed from the Census Sample see the Reconciling the Census Sample section titled How to Discharge a Resident If the Census Sample review has not been started remove and replace the resident If some portion of the review has been started but you have not interviewed the resident you can record Resident refused or is unavailable for an interview on the Resident Interview amp Resident Observation worksheet and in the Resident Interview section of QIS DCT for the Is the resident able to be interviewed question Document the reason the resident was unavailable on the Relevant Findings screen It is not necessary to replace or substitute the discharged resident with another resident The Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 19 Quality Indicator Survey Procedures for Long term Care
43. cator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 33 Quality Indicator Survey Procedures for Long term Care Facilities Observations Worksheet Tab 9 to direct observations and record information Completion of the worksheet will primarily involve observations of the general facility environment e For any negative answer marked on the worksheet investigate further using the probes and guidance Narrative documentation should be made in the Comments section for all areas of concern Consider corroborative information such as interviews with residents family members resident representatives staff and review of resident records etc e Each team member is responsible for sharing with the surveyor assigned the Environmental Observation task throughout the survey and at daily team meetings identified concerns and observations e The surveyor assigned to complete this task should confirm that all necessary information has been gathered to answer the questions on the Environmental Observations worksheet including findings comments and observations provided by all team members as well as information from daily team meetings and discussions applicable data from the Infection Control worksheet and other information as appropriate e The surveyor should enter all the data from the Environmental Observations worksheet into one laptop and ultimately if entered on a secondary laptop import it to the primary laptop
44. cess the MDS data now Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 66 Quality Indicator Survey Procedures for Long term Care Facilities How to Reconcile the Census Sample Admission Sample and Resident d Pool 1 Usethe facility provided resident census to verify that the residents on the Census Sample list are still residing in the facility If a sampled resident has been discharged use the QIS DCT to replace the discharged resident with a resident who is currently in the facility 2 To discharge a resident select highlight the resident s name in the left vertical pane of the Stage I Sample screen and then click the Discharge Readmit Resident button 3 If the Resident is in the Census Sample a Discharge Census Sample Resident message box will appear click OK Discharge Census Sample Resident AN The selected resident is in the Census Sample 4 When a Confirm Resident Discharge message box appears click Yes Confirm Resident Discharge The selected resident CARR T 05 01 1924 will be marked as discharged in the survey Are you sure you want to discharge this resident 5 A Below Required Sample Size message box will appear click OK Below Required Sample Size i Thesize of the Census sample has slipped below the required size Another resident must be added to the Census M sample 6 The first time a resident is discharged the QIS
45. compliance for requirements cited as deficiencies For all QIS revisits the surveyor s will review offsite the Statement of Deficiencies and conduct a focused review of the summary information from the QIS standard survey Once onsite the surveyor s will ask the facility to provide a alphabetical resident census The surveyor s will use the QIS software as well as information from the QIS standard survey such as residents investigated to surveyor initiate the Care Areas and or Tags and residents to be investigated The surveyor s will use Stage II Critical Element Pathways CEs protocols as applicable to the Tags that have been cited or the general CE for aspects of care not covered by the other CEs For example if deficiencies were cited for pressure ulcers and medication errors the surveyor s would use the Pressure Ulcers CE and the Medication Administration Review form to conduct these investigations The surveyor s will input findings into the QIS software and proceed through QIS deficiency decision making and scoring of scope and severity for any deficiencies that are cited Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 60 Quality Indicator Survey Procedures for Long term Care Facilities QIS DCT Software Procedures How to Update the Team in ASPEN 1 After importing the MDS extraction into ASE locate the facility under the Alpha tab or the Survey tab Use the mouse to expand and co
46. ct a Stage II investigation in a particular Care Area The prevalence rate consists of a defined numerator and denominator for each OC Thresholds established for each QCI are based on distribution data from numerous facilities or concerns based absolute standards Trigger The term trigger refers to the initiation of Stage II investigation of a Care Area whose threshold has been exceeded based on Stage findings from observation interviews or record reviews and MDS data for specific residents Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page G 4
47. ctions or mood changes of the resident in response to what may seem to be minimal stimuli e g bathing dressing having to go to the bathroom a question asked of the person that can be characterized by weeping blushing anger agitation or stubbornness If staff are knowledgeable regarding what when and to whom to report according to the facility policies e Interview at least three front line supervisors of staff who interact with residents Nursing Dietary Housekeeping Activities Social Services Determine how they monitor the provision of care services the staff resident interactions deployment of staff to meet the resident s needs and the potential for staff burnout which could lead to resident abuse e Obtain a list of all employees hired within the previous 4 months and select five employees from this list Ask the facility to provide written evidence that the facility conducted pre screening based on the regulatory requirements at 42 CFR 483 13 c Swanson EA Maas ML Buckwalter C Catastrophic reactions and other behaviors of Alzheimer residents Special unit compared to traditional units Archives of Psychiatric Nursing 1993 VII 5 292 299 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 32 Quality Indicator Survey Procedures for Long term Care Facilities Determination of Compliance Take account of all information gained during this review as well as all other
48. d includes the names of residents who were excluded from the QCI calculation e QCI Did Not Exceed Threshold includes the QCIs that did not trigger the actual facility rate and the number of residents who make up the denominator of the QCI calculation QCI Criteria Not Met includes the names of residents who make up the denominator but not the numerator of the QCI calculation Excluded includes the names of residents who were excluded from the QCI calculation QCI Results Example The Admission Sample QCI Weight Loss Since Admission includes in the numerator any resident who lost 596 or more any time within 60 days as compared to their admission weight Residents in the numerator are said to have met the criteria for the QCI or had a negative outcome This QCI includes in the denominator any resident who has been at the facility for at least 15 days The QCI excludes from the numerator and denominator those residents who were on a planned weight loss program or who have a terminal prognosis If the facility rate for Weight Loss Since Admission exceeds the threshold which is set at 21 796 the QCI will trigger for further investigation in Stage Il The relationship between QCls and Care Areas can vary one or more QCls may trigger just one Care Area For example the QCls Abuse from the family interview and Abuse from resident observation and Abuse from resident interview trigger the Care Area Abuse Quality Indicator
49. dents information e The second copy of the report is used by the survey team when marking record reviews as being completed Aspen Automated Survey Processing Environment Central Office ACO ASPEN Automated Survey Processing Environment Central Office is a Windows based program that enables State Agencies SAs to implement information based administration of the health care facilities under their supervision ACO stores data about certified facilities regulated by the Centers for Medicare amp Medicaid Services CMS and the regulations pertinent to those facilities ACO includes full survey operations support which enables agencies to centralize survey event planning and team assignment in addition to providing access to MDS resident and assessment information historical and current and regulatory and interpretive guidelines ACO provides survey performance reporting and integration with Quality Measure Indicator QM QI statistics which facilitates inclusion of survey findings in the State Standard System Aspen Survey Explorer ASE ASPEN Automated Survey Processing Environment Survey Explorer is a Windows based program that enables State Agencies to implement information based administration of the health care facilities under their supervision ASE stores data about certified facilities regulated by the Centers for Medicare amp Medicaid Services CMS and the regulations pertinent to those facilities ASE provides access
50. dents at immediate risk of harm e Discuss the need to substitute a sampled resident or to supplement the Stage II Sample discussed in the next section e Discuss the progress and results of the facility level tasks to determine which issues may need further review in Stage ll Since some facility level tasks are not staged while others require completion in Stage ll these tasks will be at various levels of completion Any currently identified potential concerns issues should be shared with the team Removing and Replacing Residents in Stage Il Rarely a resident in the Stage Il Sample may need to be removed from a particular Care Area review and replaced by a different resident in the Resident Pool if the Care Area cannot be completed for the resident or is not relevant to the resident The surveyors should discuss removal of the resident from the Stage II Sample at the team meeting A resident may be considered for removal in the following circumstances e Stage information was recorded incorrectly due to a data entry error or an observation being recorded for the wrong resident e Incorrect information was provided during the staff interview e The resident is transferred or discharged from the facility and observations are essential to completion of the Care Area review e The resident representative does not want observations essential to completion of the Care Area Review to occur To remove a resident from the Stage Il Samp
51. dication regimen Use one review form for each resident reviewed 1 Review all medications ordered not just those observed and not just psychopharmacological drugs 2 Review physician orders physician progress notes history and physical laboratory reports consultant reports the Resident Assessment Instrument care plan and other appropriate interdisciplinary notes for information addressing the resident s total medication regimen 3 Forthe selected resident sample the total medication regimen will be reviewed to ensure that it is free from unnecessary medications An unnecessary medication is any drug given a In excessive dose including duplicative therapy or b For excessive duration or c Without adequate monitoring or d Without adequate indications for its use or e In the presence of adverse consequences which indicate the dose should be reduced or discontinued or f Forany combination of the reasons above e Ifthe facility did not provide the appropriate monitoring duration dose or indication for the use of each medication ordered cite F329 If F329 is cited and the consulting pharmacist did not identify the problem and bring it to the attention of the attending physician and director of nurses cite F428 Systematic Review and Documentation of Critical Element Compliance After a surveyor has gathered all available information through observations interviews and record reviews for a specific resid
52. e amp Medicaid Services Page 11 Quality Indicator Survey Procedures for Long term Care Facilities The assigned surveyor will begin the sample reconciliation task on the primary laptop as listed on the QIS Checklist Task 4 Finalize Stage Sample Selection as soon as the alphabetical resident census is provided by the facility it is not necessary to wait for the New Admissions Information form Other surveyors will be completing the tour and the team coordinator will be conducting the entrance conference 1 2 When the facility provides the alphabetical resident census the surveyor may make assignments for Census Sample residents currently residing in the facility a The surveyor compares the facility provided resident census with the residents on the Census Sample Report printed offsite marking on the Census Sample Report any Census Sample residents who have been discharged b Ifa resident is not on the facility s resident census the surveyor marks the resident as discharged on the printed Census Sample report see Figure 2 Do not discharge the resident in the QIS DCT until Step 2 below c In the QIS DCT s Update Census Residents window accessible by clicking the Update Census Residents button on the Stage Sample screen the surveyor enters Unit if applicable and Room Number for each Census Sample resident who is also on the resident census Note If the facility provides the New Admission Information form anytime a
53. e team meetings The report can be printed from any laptop connected to the printer The report also can be used to assist the surveyors in the Stage II information analysis and decision making process and as appropriate for deficiency writing Stage Admission Sample Review The Admission Sample review focuses on the quality of care within the first six months for short stay residents Surveyors should complete record reviews throughout Stage at times when residents and staff are unavailable for observations and or interviews The review encompasses four different areas e Rehabilitation e Emergent Care e Skin Care and e Nutrition The Admission Sample review is completed via record review only using the sampled resident s record from the admission designated by the QIS DCT and listed on the Admission Sample Report The team coordinator oversees progress towards completion of the Admission Sample review taking into consideration the workload of each team member Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 17 Quality Indicator Survey Procedures for Long term Care Facilities Information from the clinical record is entered directly no paper forms in the QIS DCT When an Admission Sample resident s clinical record review is completed the survey team member should mark the review as complete on the team copy of the Admission Sample Report Record Review Guidance The followi
54. e to requests for assistance and the timeliness of call lights being answered and e Determine if the problems are facility wide cover all shifts or are limited to certain units or shifts or days of the week This can be based on information already gathered by the team with additional interviews of residents families and staff as necessary Determination of Compliance Note Meeting the State mandated staffing ratio if any does not preclude a deficiency of insufficient staff if the facility is not providing needed care and services to residents e Compliance with 42 CFR 483 30 a F353 Sufficient Staff The facility is compliant with this requirement if the facility has provided a sufficient number of licensed nurses and other nursing personnel to meet the needs of the residents on a 24 hour basis If not cite F353 e Compliance with 42 CFR 483 30 b F354 Registered Nurse The facility is compliant if a registered nurse is provided at least eight consecutive hours a day seven days a week and a DON is provided on a full time basis If not cite F354 Personal Funds The Personal Funds task is completed only if triggered from information obtained during offsite data review or during Stage family or resident interviews The Personal Funds review focuses on the protection of resident s personal funds Information gathering is completed through an interview with the personal funds manager financial record review and closed record
55. en unsuccessful select another resident from the list of Census Sample residents who have been assessed as Family Interview candidates e Family members of residents from various units should be selected if possible It may be helpful to ask staff on different units if there are family members or resident representatives who visit the facility on a regular basis and who might be willing to be interviewed Ask staff the best way of contacting these individuals and or when time of day day of week the person visits e Use the screening questions on the Family Interview worksheet to determine whether the interviewee knows the resident well enough to complete the rest of the interview Based on answers to the first screening question decide whether the interview can be completed or partially completed if the family member representative has knowledge of some areas of the resident s care Note Concerns identified during the Family interview may need to be immediately investigated while the family member or representative is available Staff Interviews Staff interviews are conducted with licensed staff either the RN or LPN using the Staff Interview worksheet Tab 7 to record the responses to interview questions Once a surveyor becomes familiar with the interview questions the surveyor should conduct all interviews using their tablet pc e tis important to arrange an interview with the nurse who has frequent and direct contact with the
56. ent a systematic review of the information for each critical element should be completed to determine whether the critical element is met e The Guidance to Surveyors should be used as a reference to assist the surveyor in understanding the regulation The QIS DCT provides Interpretive Guidelines and Regulations for each potential citation accessible through the Document button e The Critical Element compliance decision should be documented on the CE Pathway worksheet and then entered in the Stage II Critical Elements screen of the QIS DCT Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 51 Quality Indicator Survey Procedures for Long term Care Facilities e A citation should be considered if one Critical Element for one resident is not in place A deficient practice decision should be made for each Critical Element e The analysis of information gathered and decision making builds on discussions during the daily team meetings which should include discussions of observed problems areas of concern and possible failure to meet requirements e The Critical Element Pathways and survey procedures are designed to assist the surveyor in gathering investigating organizing and analyzing information about the quality of services provided by the facility in order to determine whether the facility is meeting long term care requirements e n some instances surveyors may find noncompliance under addit
57. ent Regulations REG button and Interpretive Guidelines IG button are available for viewing and copying and pasting into the documentation When the surveyor is ready to assign severity he she should click the Review Severity button at the bottom of the Documentation Form screen The Resident Care Area Severity form provides the following Severity of Potential Citation selections O Level 4 Immediate jeopardy O Level 3 Actual harm O Level 2 No actual harm with the potential for more than minimal harm O Level 1 No actual harm with the potential for no more than minimal harm When the surveyor has entered documentation and assigned severity click the close button icon of an open door to return to the Stage II Critical Elements screen The F tag text remains red until documentation and severity have been entered Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 52 Quality Indicator Survey Procedures for Long term Care Facilities Task 8 Stage ll Analysis Decision making and Integration of Information Review Completion of Stage ll Ensure that all resident specific information from Stage Il has been gathered and entered on each surveyor s laptop It can be determined at a glance which questions remain unanswered for any given resident or Care Area by the color of the text of each displayed item in the Survey Tree of the Stage II Critical Elements screen Black text
58. ent is a current resident 8 After the surveyor has verified that all residents in the Census Sample are currently residing in the facility click the Update Census Resident button and enter Room Numbers Units and assign surveyors to residents using the drop down list or by typing the first letter s of a surveyor name and pressing the down arrow Update Census Residents Sort By Name C Unit Name D D B Unit Room Assigned Surveyor CARR D ELDER MARTHA CARR D CARR I 05 01 1924 CARR J 02 01 1921 CASIANO EVELYN CARR L 05 01 1924 CASIANO EVELYN CARR M 05 01 1924 BR WN LAUREL CARR S 04 01 1923 JACKSON G 03 01 1922 JACKSON J 04 01 1923 JACKSON P 01 01 1920 JACKSON R STEVENSON F STEVENSON G STEVENSON J STEVENSON L STEVENSON M STEVENSON P STEVENSON P 0520171924 ELDER MARTHA Close 9 The Admission Sample and Resident Pool must also be reconciled to accurately reflect any recent discharges The surveyor assigned the sampling task will use the facility provided resident census to make sure that the residents listed in the Resident Pool are appropriately identified as a current resident or as being discharged from the facility This activity should be performed on the Primary laptop anytime during the Stage I activities The Resident Pool needs to be updated before advancing to Stage II because the QIS DCT prioritizes Quality Indicator Survey 09 07
59. esidents and Care Areas Distribute the applicable pages of the report to each surveyor pages break so that when the last of one surveyor s assignments is listed a new page begins with the next surveyor s assignments Stage Il Team Meetings The survey team should meet daily to discuss progress and findings related to individual residents as well as facility level findings During team meetings the team should accomplish the following tasks e Assess each surveyor s progress Make workload adjustments as necessary Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 46 Quality Indicator Survey Procedures for Long term Care Facilities e Discuss the progress and results of the facility level tasks to determine which issues may need further review in Stage ll Since some facility level tasks are not staged while others require completion in Stage ll these tasks will be at various levels of completion Any currently identified potential concerns issues should be shared with the team e Determine what information should be shared with the facility to allow staff an opportunity to provide additional information before making compliance decisions Information should not be shared with the facility if information gathering needs to occur over time to determine a trend However the team should consider the seriousness of the information gathered and appropriately inform the facility of situations placing resi
60. ey 09 07 2006 Centers for Medicare amp Medicaid Services Page i Quality Indicator Survey Procedures for Long term Care Facilities Quality Assessment and Assurance QAA Review ceeceeeeeeeeeeetnneeeeeeeeeeeeeeneneeneeeeees 30 Resident Council President Representative Interview seeeseeeeeeeeeeeeeeeeeeeeeeeeeeees 30 Triggered Facility level Tasks ais cerro rans timi tecrasenncntacectedantsnatas aiaseadencanvavsateciuceeasinnes 31 Abuse Prohibition Hevlew eee en nnn n nnn nn nennen enne 31 Abuse Prohibition Investigative Protocol per the SOM sse 31 Admission Transfer and Discharge RevieW ne 33 Environmental Observatons sss sensn enne ennemis 33 Nursing Services Sufficient Staffing eeeeeieieeessssseeecessee nennen nnn 34 Nursing Services Sufficient Staffing Protocol per the GON 34 Ee e e cM 36 Task 6 Transition from Stage I to Stage ll eese 38 Verify the Completion of Stage I cccssseeeeeeseseeeeeeeseneeeeeeseeneeeeenseeeeeeeeseeeeeeeseseneeeesseneaees 38 Import merge all Stage Data into the Primary Laptop eee 38 Print the Stage Relevant Findings Report eese nnne nnn 39 Process and Review the QCI Results eeeeeeeeeeeeeeeeeeeeee nennen ennt nnns 39 GCI List Vi Mc c M ei 40 Resident List View c
61. f life services provide the facility the Ventilator Dialysis Certified Medicare Hospice and or End of Life Services worksheet on the last page of the Entrance Conference Facility Worksheet b Ifthere are residents receiving dialysis within the facility alert the State Survey Agency s SA ESRD survey team that home dialysis is being provided within this LTC facility informing them of identified home dialysis concerns The facility should provide the following 1 Access to the written contract agreement arrangement policies procedures and or plan of care specifying how care is coordinated 2 List of Residents names room numbers and name of the End stage Renal Disease ESRD assigned caregiver technician and identify whether this caregiver is provided by the ESRD facility the Durable Medical Equipment DME supplier or the LTC facility 3 Days and times each resident will receive his her dialysis treatment c The Influenza Pneumococcal Vaccination Policy amp Procedures Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 6 Quality Indicator Survey Procedures for Long term Care Facilities d A list of rooms that are less than required square footage and or rooms that have more than four residents requires a variance Ask the administrator whether there are rooms below grade that have no window to the outside or that have no access to an exit corridor e Quality Assu
62. for all surveyors are combined to display multiple authors and associated findings on the QIS DCT Potential Citation screen This task assignment includes ensuring that all questions have been answered and entered in the QIS DCT The data will then be used by the team to make compliance decisions about Infection Control The following tasks should be completed Confirm that the information necessary to answer the questions on the worksheet has been gathered Ensure that identified concerns and observations are shared with team members throughout the survey and at daily team meetings After the team has discussed the information and reached consensus each team member may enter his her data from the Infection Control worksheet in the Stage II Critical Elements screen after surveyor initiating the task at the facility level Kitchen Food Service Observation The Kitchen Food Service Observation worksheet Tab 8 should be used to direct Observations record information and mark any areas of concern Some of the General Indicators e g Storage Temperatures Food Storage include follow up questions that need to be answered to complete the investigation Additional documentation should be made in the Comments section of the worksheet for all areas of concern The Kitchen Food Service Observation task should begin with a brief visit to the kitchen as part of the initial tour to observe general sanitation practices cleanliness of the ki
63. fter Step 1c is completed skip ahead to Step 2 d When the team coordinator completes the entrance conference he she assists the surveyor who is reconciling the sample in assigning the Census Sample residents to the survey team The Update Census Residents window can be sorted by Unit defaulting to sort by Room Number if no Units are entered to equally distribute the workload sample by location of the residents e The surveyor prints four 4 copies of the Census Sample Report Figure 3 after units room numbers and surveyor assignments have been completed Alternately in the QIS DCT after importing the Stage Sample next step the survey team can view the Census Sample Report which contains the names of the sampled residents unit room numbers and surveyor assignments f The surveyor exports the Stage Sample from the primary laptop g The survey team imports the Stage Sample at all secondary laptops Surveyors can now begin Stage observations and interviews on their assigned Census Sample residents When the facility provides the New Admission Information form the surveyor can complete the Census Sample reconciliation a b Compare the New Admission Information form with the Resident Pool view of the Stage Sample screen in the QIS DCT Cross off any residents who are already listed in the QIS DCT and renumber the residents on the New Admission Information form It may be that MDS Data for newly admitted
64. ged and QCls subsequently recalculated on the secondary laptop Instead import the changed data at the primary laptop recalculate the QCls and re export the QCIs to the secondary laptop Review the QCI Results The QCI Results screen displays residents according to whether their data comprises the numerator and the denominator of each QCI and identifies residents whose data has been excluded from the QCI calculations see Tab A for Quality of Care Indicators OCI and Facility level Tasks It is useful for the survey team to review the QCI Results screen and printed QCI Results Report for a number of reasons e To identify which QCls exceeded the threshold for inclusion into Stage II e To identify all residents who met the QCI criteria or QCls that exceeded the threshold for a particular Care Area e To identify all the QCls that triggered for an individual resident e To access the specific questions and responses that define each QCI e To note whether a resident or Care Area may need to be surveyor initiated for inclusion in the Stage Il Sample see Task 7 and e To detect a Stage data entry error for example a resident is selected for a condition Care Area that is not applicable to the resident After the Stage Relevant Findings the QCI Results and residents identified for surveyor initiation into the Stage II Sample have been reviewed the team can begin Stage II activities Make Note of Residents and or Care Areas
65. group of residents being asked about by the surveyor e Interviews with staff can be arranged so that they are conducted at a time convenient for the staff member e Since resident assignments are organized by unit room number it is likely that the same nurse will be able to answer questions about all residents assigned to one surveyor This eliminates the need for one surveyor to complete multiple staff interviews e Document the staff member s response to the interview question even if the information may contradict what the surveyor has obtained from other data sources i e observation and record review The surveyor should document that a discrepancy was recognized in Relevant Findings for the relevant question on the Stage Data Entry screen of the QIS DCT The documentation will be saved and listed with other findings comments in Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 22 Quality Indicator Survey Procedures for Long term Care Facilities the Relevant Findings Report and will be available for further investigation during the Stage II process Note One question in the staff interview will require the staff member to show the surveyor documentation from the clinical record to support the information response given Question B1 Nutritional supplement requires facility documentation of a recording and monitoring system to support a Yes answer This documentation may include a chec
66. he MDS based QCls will be reviewed in Stage Il Admission Sample The Admission Sample includes up to 30 residents who had an Admission MDS submitted within six months 180 days prior to the extraction date and were admitted to the facility more than 30 days prior to the extraction date The sample is randomly drawn offsite by QIS DCT from the Resident Pool Stage information is obtained from record review for each of the Admission Sample residents The extraction date refers to the date the MDS data was downloaded from the state server Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 9 Quality Indicator Survey Procedures for Long term Care Facilities Census Sample The Census Sample is selected randomly by the QIS DCT from the Resident Pool Offsite 40 residents were randomly drawn in the QIS DCT as the Stage Census Sample Onsite sample reconciliation ensures that the sample only includes residents who are currently residing in the facility When discharged residents are replaced during the reconciliation process newly admitted residents from the New Admission Information form are added to the sample as replacements these residents likely will not have MDS data in the QIS DCT Stage information is obtained from resident family interviews staff interviews surveyor observations and record review The first step in selecting the Census Sample is performed offsite on the primary laptop
67. he count of new admissions from the New Admissions Information form completed by the facility 6 After the surveyor enters the count of new admissions the QIS DCT will randomly select a replacement resident identified by the resident s numbered position on the New Admission Information form and request that the surveyor enter the resident s information e If the surveyor attempts to add a resident who is already in the Census Sample the QIS DCT will indicate that the surveyor must use a different resident as a replacement e Each time the Census Sample falls below 40 each time a resident is discharged the QIS DCT will randomly select another resident from the New Admissions Information form If there are no more new admissions to replace discharged residents the QIS DCT will randomly select a resident from the Resident Pool and ask the surveyor to confirm that the replacement is a current resident c The team coordinator assists the surveyor in assigning Census Sample residents or if applicable assigning the remaining unassigned residents The Update Census Residents window can be sorted by Unit defaulting to sort by Room Number if no Units are entered to equally distribute the workload sample by location of the residents d The surveyor prints four 4 copies of the Census Sample Report Figure 5 after units room numbers and surveyor assignments have been completed After importing the Stage
68. he facility s provision of services and management that may be non complaint with the long term care requirements and may have contributed to problems cited in the substandard quality of care deficiency ies The survey team shall document their findings about these Tags on Surveyor Notes Worksheets Form CMS 807 and shall input their findings into the QIS software If the QIS Staffing Review protocol was not already completed during the standard survey the survey team will complete this protocol At the discretion of the State Survey Agency the QIS extended survey can be conducted either e Prior to the exit conference in which case the facility will be provided with findings from the standard and extended survey or e Subsequent to the standard survey but no longer than 2 weeks after the completion of the standard survey if the survey team is unable to complete the extended survey prior to the exit conference When conducting the QIS extended survey the team coordinator will surveyor initiate the Care Area titled Extended Survey All F tags associated with an extended survey will then need to be answered on the Stage II Critical Element screen as to whether compliance was met The team will document compliance within the following regulatory groupings Nursing Services F353 Sufficient nursing staff F354 RN and DON requirements Physician Services F385 Supervision of medical care F386 Review care write progress
69. he survey that suggests a concern with facility initiated transfers discharges If so request a list of residents transferred or discharged to another SNF NF an assisted living group home acute care facility or psychiatric care unit and follow worksheet procedures e Help text is available on the worksheet to assist in identifying concerns Each question should be answered with either No the regulation is not met or Yes the regulation is met e The Admission Transfer and Discharge Review worksheet references Resident Rights and Admission Transfer and Discharge requirements Relevant F tags are referenced for each question so that the surveyor can refer directly to the regulation and Guidance to Surveyors when making compliance decisions Environmental Observations The Environmental Observations task is completed only if triggered during Stage family or resident interviews or resident observations A current complaint s about the facility s environment received by the state survey agency or during Stage investigation determines the need to complete the environmental observation Stage investigation includes the Census Sample family and resident interview questions e g Is this a comfortable building in which to live and Is the facility clean resident room observations and any other environmental observations of concern during the initial tour or during Stage I Use the Environmental Quality Indi
70. ialysis General Critical Element Pathway see details below Hospice and Palliative Care Hospitalization or Death Nutrition Hydration and Tube Feeding Status Pain Management Psychoactive Medications Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 49 Quality Indicator Survey Procedures for Long term Care Facilities 14 Physical Restraints 15 Pressure Ulcers 16 Rehabilitation and Community Discharge 17 Ventilator Dependent Residents General Critical Element Pathway CE Pathways relate to specific Care Areas The exception is the General Critical Element Pathway which is available for a resident with a care issue not addressed in one of the CE Pathways developed for a specified Care Area The QIS DCT Stage II Report directs you to use the General CE Pathway to investigate concerns related to the following QCls e Accidents such as falls fractures and hazards related to the use of assistive devices and supervision e Fecal impaction e Other skin conditions such as abrasions bruises skin tears or burns and e Non urinary tract related infections such as respiratory or wound infections The General CE Pathway is also used for other quality of care concerns not related to an existing CE Pathway such as diabetes mellitus chronic obstructive pulmonary disease congestive heart failure and non pressure related wound care venous arterial or neuropathic ulcers which will
71. ic residents who do not appear to be receiving services to meet their needs e g lack of adequate assistance or residents who have positioning or dignity concerns should be recorded on the Dining Observation worksheet for possible inclusion in the Stage Il sample and for further in depth observation in Stage II If the team determines that the resident should be included in Stage II the surveyor will initiate the resident into the sample The name of the resident and the specific area of concern should be documented Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 26 Quality Indicator Survey Procedures for Long term Care Facilities Any resident resident representative or family concerns should be documented for further follow up Request the resident or family member s name If that person indicates he she would like to provide more information about dining concerns schedule a time and place for another more in depth interview e Use the Dining Observation worksheet to direct your observations record information and mark any areas of concern Document the location date and time of the meal observation Some of the General Indicators include follow up questions that need to be answered to complete the investigation During the first full meal observed mark all areas of concern and follow up as needed with subsequent meal observations e Dining observations will continue th
72. ick the Preview Report button 4 Click the Print icon on the preview screen menu bar 5 Click OK Process and Review the QCI Results After merging and verifying all data on the primary laptop the team coordinator needs to calculate the QCI Results Calculating the QCI results uses on information extracted from the MDS data and all data collected on Stage Sample residents The QCI Results screen displays residents according to whether their data comprises the numerator and the denominator of each QCI and identifies residents whose data has been excluded from the QCI calculations see Tab 4 for Quality of Care Indicators OCI and Facility level Tasks It is useful for the survey team to review the QCI Results screen and printed QCI Results Report for a number of reasons e To identify which QCls exceeded the threshold for inclusion in Stage II e To identify residents who met the QCI criteria or QCls that exceeded the threshold for a particular Care Area e To identify all the QCls that triggered for an individual resident e To access the specific questions and responses that define each QCI e To note whether a resident or Care Area may need to be surveyor initiated for inclusion in the Stage Il Sample see Task 7 and e To detect a Stage data entry error for example a resident is selected for a condition Care Area that is not applicable to the resident If data entry errors are found see the QIS Checklist for instructi
73. idents The Family Interview applies in cases in which the resident is unable to be interviewed e g due to cognitive difficulties MDS Sample The MDS Sample consists of a facility s residents who have had completion of an MDS Assessment except discharge or re entry assessments within the 180 days before the survey Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page G 2 Quality Indicator Survey Procedures for Long term Care Facilities Residents who have only an Admission Discharge or Re entry MDS Assessment within the 180 days before the survey are excluded The MDS Sample is drawn offsite in the QIS DCT which then uses the MDS Sample data for QCI calculations that will identify residents to be further investigated during Stage II of the QIS process New Admission Information Report The New Admission Information Report is generated by the QIS DCT and is provided to the facility to record all residents who have been admitted within the 30 days before the survey date The survey team uses the information to update the Admission Sample and the Census Sample in the QIS DCT Primary Laptop The primary laptop refers to the survey laptop used by the team coordinator and designated to process the MDS QCls draw the Stage Sample calculate QCls based on merged Stage data from all survey laptops create the Stage II sample report and assign Stage II Critical Elements and import the potential citat
74. in the Census Sample should be recorded on Surveyor Notes Worksheets Include resident names and specific details for team discussion The survey team has the prerogative to surveyor initiate residents into the Stage Il sample for further investigation e Attempt to stagger closed record reviews so that some members of the survey team can be on the resident units as much as possible e Surveyors should enter Stage information interviews observations and clinical record data in the QIS DCT at regular intervals to avoid delay in the completion of Stage l Stage Relevant Findings In addition to answering the prescribed questions in Stage surveyors can document by entering narrative text observed problems areas of concern and the sources of their findings for any question in the QIS DCT Appropriate information could include source or person interviewed position title date and time Relevant Findings are entered by clicking the Relevant Findings button at the bottom of the top right pane for any question in the Stage Data Entry screen The relevant finding can be entered into the tablet pc by using the handwriting recognition software or by typing Relevant findings for a surveyor initiated resident may also be documented when the applicable Care Area is initiated for that resident Surveyors can view the Stage I Relevant Findings Report from any QIS DCT laptop as necessary to facilitate discussion of potential problems during th
75. ional F tags listed on a Critical Element Pathway If an F tag is not listed but surveyors determine that a facility is out of compliance needs to be cited the F tag should be surveyor initiated and appropriate documentation completed on the Stage II Critical Elements screen The individual severity level for the F tag must also be assigned Completing Critical Element Documentation in the QIS DCT During the investigation of a Care Area for a particular resident the surveyor must mark each Critical Element in the QIS DCT as either Yes Met or No Unmet To mark an F tag as Not Applicable mark No Unmet select the F tag and click the Not Applicable button The QIS DCT will prompt the surveyor to enter relevant findings and to assign severity for the F tag at the resident level each time a Critical Element is marked as No Unmet e The severity level for each Critical Element marked as No should be determined independently of any severity levels assigned to other unmet Critical Elements within the Care Area e To enter documentation and severity the surveyor should select No next to the appropriate Critical Element in the QIS DCT select highlight the F tag in the Possible Citations list bottom right pane beneath the Critical Elements pane and click the Document button On the Documentation Form that appears the surveyor should enter findings utilizing Principles of Documentation POD Stage findings for the resident curr
76. ions into ASE Quality Indicator Survey QIS The Quality Indicator Survey QIS process is a standardized computer assisted systematic two stage process using large random samples and a threshold data base to compare the facility under survey to all others in a large set of subject areas QCls Quality Indicator Survey Data Collection Tool QIS DCT The Quality Indicator Survey Data Collection Tool QIS DCT is the software used to facilitate data collection during the QIS process The QIS DCT processes MDS data draws the Stage I and Stage II samples is used to input survey information document relevant findings for Stage and Stage Il data merges Stage and Stage II data collected at all survey laptops calculates QCls and provides review of potential citations and assignment of each citation s scope and severity The QIS DCT is accessed through the Citation Manager of ASPEN Survey Explorer Quality of Care Indicators QCI Quality of Care Indicators QCls are resident centered outcome and process indicators constructed from calculations of downloaded MDS Data and data collected onsite during a survey i e observations interviews and clinical records review Once compared with national and or state norms QCls focus the Stage Il review of Stage findings Relevant Findings Relevant findings are surveyors documentation of additional findings related to observed problems areas of concern and sources of findings related
77. kbox or checklist that indicates the supplement was given provides a percentage of supplement consumed or lists the amount consumed Any of these methods are acceptable Clinical Record Review The record review for the Census Sample residents encompasses the following areas e Pressure Ulcers e Psychotropic Medications and e Weight Loss Additionally some quality indicators for the Census Sample use imported MDS items for risk adjustment and exclusion from calculations i e comatose state ADL function and certain diagnosis codes e Information from the clinical record is collected for all residents in the Census Sample and is entered directly no paper forms in the QIS DCT The QIS DCT data collection screens contain help text guidance to assist the surveyor in collecting the necessary data e Surveyors may conduct the record review on their assigned residents any time throughout Stage preferably at times when residents and staff are unavailable for observations and or interviews e The records can be brought to the surveyor s workspace or the laptop can be taken directly to the floor unit Attempt to conduct the record reviews on the unit if possible so that general observations of the unit activities and staff resident interactions can be conducted at the same time Record Review Guidance The following guidance lists some of the reliable sources not all inclusive to review in completing the Stage Census Sample Rec
78. latory requirements by incorporating each step of the resident care process reflected in the regulations e Assessment e Care planning e Implementation of care that meets professional standards and e Monitoring of care A General Critical Element Pathway is available for a resident having a care issue not addressed in one of the specific CE Pathways The Critical Element Summary Form documents investigation results for use during team discussion decision making or documentation in the QCI DCT Facility level Tasks Facility level tasks are not specific to any one resident and are completed by the survey team throughout Stage and or Stage II of the QIS process The six facility level tasks completed on every survey include Resident Council President Representative Interview Dining Observation Kitchen Food Service Observation Infection Control Demand Billing and Quality Assessment and Assurance Review The survey team completes task specific worksheets from which information is entered in QIS DCT during Stage Il Five additional facility level tasks are assigned and completed during Stage II only if triggered during Stage These triggered tasks are Environmental Observation Resident Funds Admission Transfer and Discharge Review Sufficient Staff and Abuse Prohibition Review Family Interview A family interview is conducted during Stage of the QIS process for each of three families or representatives of Census Sample res
79. ld attempt to use as many information sources as possible staff resident and family interviews observations and record reviews to strengthen the validity of the information gathered The focus should be on obtaining information through observation and interviews using record review to validate those information sources It is recommended that a copy of the care plan should be obtained if possible to assist with directed observations and interviews Observations and interviews should begin as soon as possible do not wait for the care plan copy and should occur over several shifts to ensure consistent application of interventions Begin information gathering in a manner most efficient to the time of day and the Care Areas being reviewed For example if it is midmorning and a resident being reviewed for the Care Area Activities is attending an activity it would be most beneficial to start with observing the activity Critical Element CE Pathways The following 17 Critical Element Pathways including the General Critical Element Pathway are available for use in Stage ll investigation 1 2 e SOS Ee ae 10 11 12 13 Activities Activities of Daily Living and or Range of Motion includes Cleanliness Grooming and Positioning Behavioral and Emotional Status Bowel or Bladder Function Use of an Indwelling Catheter Communication and Sensory Problems includes Hearing and Vision Dental Status and Services D
80. le the team coordinator must go to the QCI Results screen in the QIS DCT find another resident who triggered the same Care Area s as the resident being removed if one exists and surveyor initiate the replacement resident into the Stage II Sample See the QIS DCT Software User Manual section titled Maintain Stage II Care Area for instructions on removing a Care Area Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 47 Quality Indicator Survey Procedures for Long term Care Facilities Supplementing the Stage Il Sample If the review of residents selected for the Stage Il Sample does not provide enough information to make deficiency determinations concerning specific requirements or to determine that there is substandard quality of care supplement the Stage Il Sample with residents representative of the area s of concern Focus the review for these residents only on the concern being investigated and any other concerns discovered during the review How to Add Residents to the Stage II Sample 1 From the QIS DCT menu bar select View Screen Stage I Sample 2 From the Stage I Sample screen select the option to display the Resident Pool 3 In the Resident List left pane find and select the relevant resident s name using the mouse 4 Click the Initiate Remove Care Area button in the bottom right pane 5 When the Initiate Remove Care Area screen appears select either th opti
81. lity Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 44 Quality Indicator Survey Procedures for Long term Care Facilities Task 7 Stage ll Survey Tasks Introduction Stage ll involves the in depth review of residents whose related Quality Care Indicators QCls exceeded thresholds in Care Areas as identified through the completion of the Stage process The QIS DCT has identified the Care Areas to investigate in Stage Il Additionally during Stage Il facility level tasks must be completed and compliance decisions made Stage Il data gathering includes a review of specific Care Areas based on Stage results As in Stage the team should always be alert to staff resident interactions related to dignity privacy and respect in Stage ll Care Areas identified in Stage II have a set of associated Critical Element CE Pathways see Tab 10 which have been developed to provide information to guide the investigation and to assist surveyors in completing a consistent organized and systematic review of triggered Care Areas The CE Pathways have a format similar to CMS current investigative protocols Sixteen of the Stage II CE Pathways pertain to a specific Care Area and provide information to guide the investigation and help surveyors determine whether a facility meets the associated regulatory requirements A General CE Pathway is available for a resident with a care issue not addressed in one of the CE Pathwa
82. ll F tags documented by the team during Stage Il e The pane on the right side of the Potential Citation screen displays by F tag an aggregation of the documentation created during Stage Il see the QIS Checklist The survey team will review all potential citations and accompanying documentation that resulted from the Stage ll investigations to determine whether a deficiency exists based on the evidence gathered If cited the team will select the final severity for each deficiency and then select the scope and the severity using the Scope and Severity Matrix Once all citation decisions have been made the Potential Citation Report is printed to assist in presenting the preliminary findings during the Exit Conference The F tags selected for citation by the team and the associated documentation will be loaded into ASE and used in the 2567 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 53 Quality Indicator Survey Procedures for Long term Care Facilities Analysis Assignment of Scope and Severity and Team Decision making Surveyors should refer to Deficiency Categorization part V in Appendix P of the SOM in addition to referring Appendix PP guidance for making severity decisions related to selected tags Scope and Severity Matrix SCOPE SEVERITY Isolated Pattern Widespread Level 4 Immediate Jeopardy J K L Level 3 Actual Harm G H Level 2 No Actual Harm with Pote
83. llapse tree nodes 2 After locating the facility expand the facility node and then expand to display the Survey ASPEN Explorer File view Quality gystem Help et E Ej toa E Config EJ Local E Filters Facility Name Provider Number Facility Type and City ASPEN Desktop Alpha View 8 My Surveys Brown Laurel 0 9 A C D F G K L N E North Star Community 020413 SNF NF SR Face 08 05 2005 Open Survey ID Survey Date and f Team Survey Status Brown Laurel 44444 Mortsy Young Staci 55555 Casiano Ey S g Team Members assigned to this Survey Resident Pool for this Survey 2e S x x 66666 Elder Martha amp Residents as of 08 01 2005 OO R T LA X Z Regulations H Surveyors Internet my Recycle FE ES Tabs Alpha Tree View sorted alphabetically by facility name Type Tree View sorted by facility type and Survey Tree View all imported facility data sorted by facility name 54 Alpha Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 61 Quality Indicator Survey Procedures for Long term Care Facilities 3 Beneath the Survey right click the Team node and select Update Team from the pull down menu to update and edit the survey team E ui Bi North Star Community 020413 SNF NF SR BMHzBIi 08 05 2005 Open Update Team Input 67RA Hours Staci 5555
84. mplete at the end of Stage and Stage Il the data is exported to disk from the secondary laptops and then imported or merged on the primary laptop Stage Stage is the portion of the survey process in which Census Sample and Admission Sample residents are randomly selected and assigned in the QIS DCT software subsequently the survey team using QIS process worksheets conducts resident family and staff interviews and makes and records observations Stage findings are the basis of QCI calculations which focus the Stage Il in depth review of Care Areas that exceeded QCI thresholds Stage Il Stage ll is the portion of the survey process in which an in depth directed review is conducted of residents within Care Areas that exceeded thresholds identified during the Stage process Surveyor initiated Care Areas are investigated and facility level tasks are completed during Stage ll Compliance decisions are made at the completion of Stage Il Surveyor initiated Sample The surveyor initiated sample consists of residents specifically chosen by surveyors not randomly selected by the QIS DCT to be further evaluated during the Stage II Care Area in depth review This sample can be based on resident or facility specific information obtained from ombudsman information off site complaints surveyor observation or interviews Threshold The term threshold refers to the prevalence rate established to govern the decision whether to condu
85. names of residents who make up the denominator but not the numerator of the QCI calculation e Excluded includes the names of residents who were excluded from the QCI calculation Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 40 Quality Indicator Survey Procedures for Long term Care Facilities Resident List View When the Resident List view is selected on the QCI Results screen the QIS DCT displays the names of all residents Beneath each resident name are three subheadings e QCI Criteria Met includes the QCls for which the resident was included in the numerator of the QCI calculation e QCI Criteria Not Met includes the QCIs for which the resident was included in the denominator but not the numerator of the QCI calculation e Excluded includes the QCls for which the resident was excluded from the QCI calculation Care Area List View When the Care Area List view is selected on the QCI Results screen the QIS DCT displays the Care Areas to be further investigated in Stage Il Beneath each Care Area are two subheadings e QCI Exceeded Threshold includes the triggered QCls the actual facility rate and the facility s prevalence rate QCI Criteria Met includes the names of residents who make up the numerator of the QCI calculation QCI Criteria Not Met includes the names of residents who make up the denominator but not the numerator of the QCI calculation Exclude
86. ng End of First Day cccc cece eeeceeeceeeeeeneeneseeeeceeeeeeeeeseeeeeseeneeeeeees 16 Stage Resident level Preliminary Investigation esee 16 Tips on How to Organize Stage Preliminary Investgaton 16 Stage Relevant Findlfitjs eene rece EEN eege 17 Stage Admission Sample Review eeseeeeeeeeeeeeee eene eene ennt nennen nnn nnne nnns 17 Record Review Guidance 18 Stage I Census Sample Review cesses esses eeeeeeee eene ntnn nnne nnn nannten nns 19 Completing the Census Sample Review 19 Resident Observations noes eet ee eee ek eet teed 20 Resident IBtervigWS 5 gege EENEG EERSTEN NEE ege 20 Family Interview FERME 22 Staff A OV EE M 22 Clinical Record BeVvleW cic ei epi ei ette etai cta punte i e ai da cna e nnne 23 Record Review Guidance 23 Task 5 Facility level Survey Tasks eeeeeeeeeeeeeeeeeeeeeeeneennennn nnne 25 Non staged Facility level Tasks sees essences eene eene nennen nnne nennen 25 Demand BiG e e c 25 Dining ODSERV ej Mm 26 Gelee e EE 28 Kitchen Food Service Observation ccccceeecececeeeeceeeeeeeeeeeceeeeeeeeeeeeeeeeeeeeeeeeeeeeeseeeneeeeeeess 28 Medication Administration Observation ccecccecceeeceeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeereees 29 Quality Indicator Surv
87. ng guidance lists some of the reliable sources not all inclusive to review in completing the Stage Admission Sample Review Exclusions 1 Terminal Prognosis physician orders physician progress notes 2 Length of Stay the facility face sheet Community Discharge 1 Currently residing depends on whether you have a closed or open record 2 LOS 60 days a Closed record face sheet discharge summary b Openrecord face sheet and current date 3 Discharge Location face sheet discharge summary social service notes physician orders Receipt of Therapy PT ST OT evaluation and progress notes 5 Admitted from face sheet reliable if the resident came from the hospital admission H amp P social service admission notes nursing admission notes 6 LTC prior to hospital SNF stay face sheet if resident is a readmit social service admission notes admission H amp P nursing admission notes Death 1 Death within 30 days face sheet discharge summary physician orders nursing notes Hospitalization 1 Hospitalized within 30 days physician orders physician progress notes nursing progress notes Pressure Ulcer 1 2 3 Admission skin assessment subsequent skin assessments treatment records nursing progress notes and MDS which should be the last source type reviewed Weight Loss To obtain weights use an appropriate source that covers the time period reflected in the date prompts Use the same charting or doc
88. notes and sign orders F387 Frequency of physician visits F388 Physician Assistant Nurse Practitioner visits F389 Availability of physicians for emergencies F390 Delegation of tasks in SNFs and NFs Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 57 Quality Indicator Survey Procedures for Long term Care Facilities Administration F490 Administration uses resources effectively and efficiently F491 Facility licensed F492 Compliance with federal state and local laws F493 Governing body F494 NA employed gt 4 months non permanent employees F495 NA employed lt 4 months competency F496 Registry verification F497 CNA in service training F498 Proficiency of CNAs F499 Staff qualifications F500 Use of outside resources written agreements F501 Medical Director F502 Laboratory Services F503 Requirements for the facility s lab services F504 Obtaining lab services when ordered F505 Notification of lab results F506 Transportation arrangements for lab services F507 Filing lab results dating of lab results lab address F508 X ray services F509 Requirements for facility s own x ray services F510 Obtaining x ray services when ordered F511 Notification of x ray results F512 Transportation arrangements for x ray services F513 Filing x ray results dating reports F514 Clinical records and c
89. nouncement signs for the facility h Facility folder or notebook to hold all forms provided by the facility and reports created in the QIS DCT Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 4 Quality Indicator Survey Procedures for Long term Care Facilities Task 2 Onsite Preparatory Activities and Entrance Conference Immediately Upon Entrance to the Facility 1 The team coordinator must do the following listed in order of priority Request that the person in charge be notified of the team s entrance Introduce the survey team Request an alphabetical resident census with room numbers units Request that the facility note residents on the census who are not in the facility such as in the hospital home visit etc Provide the facility the New Admission Information form The facility should record on this form all residents who were admitted within the 30 days prior to the date listed on the report and who still reside in the facility Review the instructions on top of the form Emphasize that the date of birth must be provided Request a workspace for use by the survey team and briefly explain that electrical connections are required due to use of computers and printers Provide signs announcing the survey Ask the facility to post the signs in areas easily observable to residents and visitors announcing that a survey is being performed and that surveyors are available to privately meet
90. ntial for D E F More than Minimal Harm Level 1 No Actual Harm with Potential for A B C No More than Minimal Harm Severity Level 4 Level 3 Level 2 Level 1 Immediate jeopardy to resident health or safety J K L Noncompliance that results in immediate jeopardy a situation in which immediate corrective action is necessary because the facility s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury harm impairment or death to a resident receiving care in a facility Actual harm that is not immediate jeopardy G H Noncompliance that results in a negative outcome that has compromised the resident s ability to maintain and or reach his her highest practicable physical mental and psychosocial well being No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F Noncompliance that results in no more than minimal physical mental and or psychosocial discomfort to the resident and or had the potential not yet realized to compromise the resident s ability to maintain and or reach his her highest practicable physical mental and or psychosocial well being No actual harm with potential for minimal harm A B C A deficiency that has the potential for causing no more than a minor negative impact on the resident s Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page
91. ntified through the Stage process Probes within Critical Element Pathways are utilized to guide the investigation and help determine whether regulatory requirements are met Team meetings should be conducted daily during the survey and any time the team deems it necessary to monitor the investigative process and adjust assignments If a situation suggests possible Immediate Jeopardy the team will follow the instructions in Determining Immediate Jeopardy Appendix Q of the State Operations Manual SOM Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 1 Quality Indicator Survey Procedures for Long term Care Facilities Task 1 Offsite Survey Preparation Select the team coordinator TC The team coordinator will direct the survey activities and all primary laptop computer responsibilities see The QIS Checklist in Tab 2 of the QIS Surveyor Resource Manual Use the Offsite Survey Preparation Worksheet Tab 2 of the QIS Surveyor Resource Manual to record the following 1 Review and record survey information from the following sources a Review the OSCAR 3 report to determine whether the facility has any patterns of repeat deficiencies b Review any complaints filed with the survey agency recording areas of concern and resident names in order to investigate the complaint s during the survey c Contact the ombudsman s office in accordance with state policy to provide notification of appr
92. oaching survey and request any state ombudsman office information that will need to be reviewed during the survey d Review any information from the State ombudsman s office to be investigated during the survey Record areas of concern with any resident names to be included in the survey e Note any federal waivers or variances for onsite review 2 Prepare team assignments a Assign a surveyor other than the team coordinator to reconcile the Stage Census Sample The remaining survey team members will complete the Initial Tour Note The team coordinator will assist the team with completing the tour after the entrance conference ensuring all activities are completed in a timely manner b Assign the review of any waivers variances c Assign surveyors the following facility level tasks 1 Demand Billing 2 Dining Observation 3 Infection Control 4 Kitchen Food Service Observation 5 Medication Administration Observation 6 Quality Assessment and Assurance Review 7 Resident Council President Representative Interview Complete the following steps outlined on the QIS Checklist 1 Obtain the survey shell and facility information according to your state s procedures and import the data into ASPEN Survey Explorer ASE on the primary and secondary laptops 2 Start the QIS Data Collection Tool DCT software on the primary laptop The QIS DCT software is used to randomly select samples input survey information and document relevan
93. on to display Care Areas QCI Based or the option to display F tags Ftag Direct Cite 6 Select highlight the relevant Care Area F tag and click the Include button 7 Click the Relevant Findings button to document comments relevant findings 8 After entering findings click on the Close Form button 9 Click the Close button to return to the Stage I Sample screen Stage Il In depth Investigation Stage ll in depth investigation includes completion of resident level Care Area reviews and completion of facility level tasks Before beginning the Stage II investigation surveyors should review any notes written during Stage I including the Stage Relevant Findings Report about those residents included in their Stage Ill assignments Additionally surveyors should review the QCI Results screen for pertinent information related to the admission date and the reason for the review Stage ll Forms that Facilitate Gathering of Information e A Critical Element Pathway CE should be reviewed for each Care Area to be investigated in Stage Il The CE guides the surveyors through the process of determining if the Critical Elements of care are in place e The Critical Element Summary Forms Tab 10 should be used in conjunction with the CEs to document their Stage II Care Area investigation prior to team discussion decision making or entering documentation in the QIS DCT e A Stage ll Resident Face Sheet Tab 10 should be completed p
94. onciling the Census Sample Upon entrance into the facility the team coordinator asked the provider to immediately provide the survey team A copy of the resident census with room numbers units in alphabetical order by resident name noting which residents are on not in the facility e g in the hospital home visit etc Figure 3 Figure 3 Example of a Facility provided Resident Census North Star Community Daily Census 08 05 05 Last Name First Name MI DOB Room Admit CARR D 10 01 1915 90 1 10 14 2002 CARR D 05 01 1924 53 2 07 07 2003 CARR I eee 90 2 07 21 2003 CARR J M 02 01 1921 26 2 11 11 2004 05 01 1924 9 acson p w J os70171924 2 2 1071872004 The completed New Admissions Information form 1 Figure 4 which was soie offsite prior to the start of the survey with the names of residents who were admitted to the facility within the last 30 days and that continue to reside in the facility Figure 4 Completed New Admission Information Form NORTH STAR COMMUNITY MHZB11 08 01 2005 New Admission Information Please provide the following information for residents admitted to the facility after 07 02 2005 Only include residents that are still residing in the facility Admission Last First Mid Date Of Unit Room Date Name Name Init Birth Gender 1 07 26 05 Spencer Cena 07 14 22 F 85 2 2 le Quality Indicator Survey 09 07 2006 Centers for Medicar
95. ons on correcting them How to Process the QCI Results 1 From the QIS DCT menu bar on the primary laptop select View Screen QCI Results A message will display Please wait while QCI Results Are Loaded indicating the QCIs are being processed Do not interrupt the process the process will take several minutes 2 After the QCI processing is complete the QCI Results screen see Figure 8 will appear Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 39 Quality Indicator Survey Procedures for Long term Care Facilities Figure 8 QCI Results Screen QCI List Displayed Select the view to be displayed QCIList Resident List C Care Area List CARR L HAS MET the criteria because this resident E QCls Exceeded Threshold 5 TEST E M TT A Lack of Community Discharge 21 uestion 1 Do you feel that staff treats your relative friend wi 4 19 respect and dignity For example do they treat her him politely 4 Pressure Ulcer Incidence or Worsening Answer Yes Provided By 55555 On 04 11 2005 12 58 16 PM 7 7 1 13 C Abuse Resident Interview 5 6 1 18 Td C Activities Family Interview 502 1 2 Question 2 Does the staff take time to listen to her him E C Choices Family Interview 50 172 Answer No Provided By 55555 On 04 1 1 2006 12 58 16 PM E C Choices Resident Interview 11 8 2 17 Question 3 Is the staff understanding abo
96. ontents F515 Retention of medical records F516 Safeguarding medical records confidentiality F517 Emergency and Disaster plans F518 Staff training in emergency procedures F519 Transfer agreement with hospital F520 Quality assessment and assurance F521 QA meets quarterly develops plans of action F522 Disclosure of ownership Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 58 Quality Indicator Survey Procedures for Long term Care Facilities The QIS Complaint Survey Procedures The QIS is used for investigation of complaints during a QIS standard survey The team coordinator will surveyor initiate the care area s that relate to the complaint allegation s for the resident s involved in the complaint or at the facility level as appropriate The team coordinator will add the allegations to the list of issues and residents evaluated during the QIS standard survey No Stage activities are required for the complaint investigation The complaint area s of concern and the resident s involved will be investigated in Stage II of the QIS standard survey The team coordinator will surveyor initiate the complaint area s of concern and the resident s involved in the complaint during the transition from Stage to Stage Il dl How to Add Residents to the Stage II Sample 1 From the QIS DCT menu bar select View Screen Stage I Sample 2 From the Stage I Sample
97. or Medicare amp Medicaid Services Page 63 Quality Indicator Survey Procedures for Long term Care Facilities 6 Once the Team Roster is modified assign the team coordinator by right clicking on the Team icon and selecting Update Team from the drop down menu 7 At the Team Roster dialog box select the surveyor s name and click the Leader button to designate the selected surveyor as the team coordinator indicated by the blue diamond To remove the Leader designation simply select the surveyor and click the Leader button or select a different surveyor to serve as the team coordinator and click the Leader button Team Roster Brown Laurel Casiano Evelyn Elder Martha Morley Young Staci Delete Done Help Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 64 Quality Indicator Survey Procedures for Long term Care Facilities How to Start the QIS Software Once the survey and MDS extract is imported into ASE start the QIS DCT software to perform the survey tasks 1 At the main screen in ASPI red cross 2 At the Citation Manager screen At the drop down menu sel h Find m HO E E EE EE FUE ASPEN Desktop Alpha View SJ My Surveys Brown Laurel 0 9 4 C D F GK L N By North Star Community 020413 SNFJNF e Citation Manager bh Res Survey Properties Surveyors Internet Recycle Team Roste
98. or each CE Pathway is similar each one of the CE Pathways is unique and directs the surveyor to specific actions In some cases a Critical Element Pathway will direct the surveyor to complete a related Care Area review using a different Critical Element Pathway For example when reviewing the Hospice CE Pathway the Pressure Ulcers CE Pathway or the Dental CE Pathway the surveyor may be directed to also complete the Pain CE Pathway Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 50 Quality Indicator Survey Procedures for Long term Care Facilities The Hospitalization or Death CE Pathway will usually be conducted via closed record reviews In each case the surveyor should carefully follow the directions provided for successful completion of the Critical Element Pathway review Although the surveyor is free to organize information gathering as desired it is not necessary to work through one Critical Element Pathway before moving on to the next one Unnecessary Drug Review The QIS DCT selects Stage ll residents currently residing in the facility and who have the most Care Areas identified for Stage Il review to undergo an Unnecessary Drug Review The intent of this sampling selection process is to include review of residents with more complex clinical needs The surveyor s review of medication use is not intended to constitute the practice of medicine and does not empower the reviewer to dictate the me
99. ord Review MDS items for risk adjustment and exclusions 1 Comatose MDS nursing assessment physician progress notes 2 Bed Mobility MDS therapy notes nursing notes 3 Transfer MDS therapy notes nursing notes 4 ICD 9 CM codes physician diagnosis list on the physician orders nutrition assessment 5 Terminal illness physician orders physician progress notes as listed on the worksheet Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 23 Quality Indicator Survey Procedures for Long term Care Facilities Pressure Ulcers 1 Current pressure ulcer current skin assessment treatment records nursing progress notes MDS Psychotropic Medications 1 and 2 Currently receiving Antipsychotic or Benzodiazepine physician orders medication administration record consultant notes 3 Diagnosis physician diagnosis listing physician progress notes consultant notes Weight Loss To obtain weights use an appropriate source that covers the time period reflected in the date prompts Use the same charting or documentation source for all of the weights if possible Weight information may be collected from the following sources Medication Administration Records Treatment Administration Records Dietary notes Nursing notes Weight and height records Se ON E O Vir The charting or documentation source that includes the weights recorded when the resident was actually weighed e g bath
100. pful e Interviews are conducted in a private setting to allow residents to speak freely e Surveyors should explain the purpose of the interview and obtain resident permission to be interviewed e After asking the question paraphrase as necessary to make sure the resident understands the question Be careful to paraphrase in a manner that does not change the intent of the question e Go through the questions in the order they are provided except as necessary to maintain a sensible flow If the resident brings up a subject that goes with questions not yet addressed the surveyor may skip to those questions and then return to where the skip occurred e Probe for further information if an answer the resident has given is incomplete or unclear and you are unable to score his her response e Itis preferable to complete the interview at one sitting when possible but surveyors may break the interview into more than one session if the resident becomes fatigued or is scheduled for an activity e Following the interview if the surveyor questions the validity of the interview additional information about the resident s cognitive status can be obtained from record review or staff interview Manual calculation of the CPS score can be done by the surveyor if the resident s cognitive status is questioned or the QIS DCT did not have the MDS information to calculate the score see Tab 11 for calculating instructions e Surveyors should document inte
101. play multiple authors and associated findings on the QIS DCT Potential Citation screen This task assignment includes ensuring that all questions have been answered and entered in the QIS DCT The data will then be used by the team to make compliance decisions about the overall dining experience Infection Control Each team member should use the Infection Control worksheet Tab 8 to direct observations record information and mark any areas of concern Questions 1 7 Narrative documentation of all areas of concern should be recorded in the Comments section If concerns with infection control practices are observed then the surveyor assigned responsibility for this task will review the infection control program using the probes on the worksheet to determine whether there is a functioning infection control program in place Question 8 One surveyor will be assigned responsibility for coordinating completion of the Infection Control task although the entire team will be making Infection Control observations Any surveyor s not assigned the Infection Control task can surveyor initiate Infection Control at the facility level should he she have significant or detailed findings The surveyor answers and documents critical elements relevant to his her observations and records the data on the QIS DCT Stage II Critical Elements screen When the Stage II data from all secondary laptops is imported to the primary laptop the Infection Control findings
102. played Which Resident List do you want displayed Resident Pool Admission Sample C Census Sample C Surveyor Initiated Sample C Facility dei 8 s CARR D 05 01 1924 CARR I 05 01 1924 f CARR J M 02 01 1921 I CARR L 05 01 1924 CARR M 05 01 1924 rf CARR M D 05 01 1924 rfj CARR A 05 01 1824 Th CARR S L 04 01 1823 Initiated Care Areas for Residency Status Icons Laer ied T 05 01 1924 Wr FACILITY JACKSON B 05 01 1924 JACKSON D B 05 01 1924 JACKSON D B 05 01 1924 JACKSON E 04 01 1923 ACKSON ES 02 01 1921 JACKSON G A 03 01 1922 JACKSON J 04 01 1823 ACKSON J 05 01 1324 Update Census Residents 1 Discharge Readmit Resident Add New Resident Initiate Remove Care Area of New Admits Survey Steps iF Resident In The Facility m Resident Discharged From Facility i Resident In Both Admission and Census Samples Sh Sh Si Sh Sap Sh 83 Residents In List of All Residents NORTH STAR COMMUNITY MHZB11 08 01 2005 Stage Team Meetings The survey team should meet briefly at least on a daily basis to monitor the investigative process and to make assignment adjustments as needed If an observed situation suggests possible Immediate Jeopardy the team should follow the instructions in Determining Immediate Jeopardy Appendix Q of the SOM Initial Team Meeting The initial team meeting should be held after the tour and
103. r Print Forms Print Letters CMS 670 Workload CMS 1539 C amp T Change Event ID Send To Create Followup Survey 0 Q R T LAN Doct eadera X Z Regulations Create LSC Survey EN select and right click the relevant Survey ct Citation Manager S Citation Manager for North Star Community 08 01 2005 08 05 2005 Citations Team Roster Regulations click the QIS Tool button Long Term Care Facilities FED F 07 02 X 0000 fA men Exercise Of Rights 483 10 a 1 amp 2 fA 0152 fA 0153 Q 0154 fA 0155 fA 0156 fA 0157 fA 0158 Lead fA 0151 Brown Laurel Casiano Evelyn Elder Martha Morley Young Staci I Roster Activate r Survey Information D Event ID MHZB11 Medicare ID 065274 Fac ID 020413 Active Surveyor Brown Laurel 22222 Mode Normal Survey Dates 08 01 2005 08 0 Initial Comments Definition Of Ltc Facility 483 5 Exercise Of Rights 483 10 a 3 amp 4 Notice Of Rights And Services 483 10 b 2 Notice Of Rights And Services 483 10 b 3 483 10 d Notice Of Rights And Services 483 10 b 4 Notice Of Rights And Services 483 10 b 5 10 48 Notification Of Changes 483 10 b 11 Protection Of Resident Funds 483 10 c 1 gt Pea ea ee Find Forms Letters Attach Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services
104. r assigned the QAA Review task will determine through interview with the administrator whether the facility has a functioning QAA committee who participates on the committee who leads the committee and how often the committee meets Part 2 is initiated if the survey team has identified actual or probable quality deficiencies during Stage or Stage ll The survey team conducts this investigation using the Quality Assessment and Assurance QAA Review worksheet Tab 8 The goal of Part 2 is to determine whether the facility s QAA committee effectively identifies quality deficiencies and deals with them and that staff know how to access the QA process Note The surveyor should not conduct a review of the minutes of the QAA committee as the regulation does not require the facility to disclose these records The facility may choose to provide these records however it should not be used as the source for the surveyor to identify concerns for investigation Resident Council President Representative Interview The Resident Council President Representative Interview focuses on resident rights facility rules Note and facility responsiveness to council concerns If there is not a resident council or equivalent group this task will not be conducted If no organized group exists the surveyor should determine whether residents have attempted to form one and have been unsuccessful and if so why If a resident council or equivalent gro
105. rance and Assessment QAA committee information contact person name member names and meeting frequency f Location of Pre admission Screening and Resident Review PASRR information Some states may have formal mechanisms to share with the survey agency the results of PASARR screens for residents with mental illness or mental retardation If this information is available evaluate whether there are any potential concerns and note names of residents for possible inclusion in the sample A description of any experimental research occurring in the facility h Name of contact person for Complaint Abuse Grievance 4 Ask the administrator to provide the following information within 24 hours of the conclusion of the entrance conference a If the facility is Medicare or Medicare Medicaid certified a list of Medicare residents who requested demand billing since the preceding survey 9 15 months with identification of the residents payment source s b A list of the five most recent denial notices with the payment source sent to the residents by the facility c Medicare Medicaid Application 671 and Resident Census and Conditions 672 Concurrent Activities During the entrance conference and while waiting to receive the requested information the following onsite activities should be initiated 1 Complete the Initial Tour 2 Begin the process of finalizing the Stage Sample 3 Begin the Kitchen Food Service Observation 4
106. re plans services not provided as needed by the resident focus the discussion with supervisory staff on the situations that led to using the protocol how do they ensure that there is adequate staff to meet the needs of the residents how do they ensure that staff are knowledgeable about the needs of the residents and are capable of delivering the care as planned how do they assure that staff are appropriately deployed to meet the needs of the residents how do they provide orientation for new or temporary staff regarding the resident needs and the interventions to meet those needs and how do they assure that staff are advised of changes in the care plan Determine if nursing assistants and other nursing staff are knowledgeable regarding the residents care needs e g the provision of fluids and foods for residents who are unable to provide these services for themselves the provision of turning positioning and skin care for those residents identified at risk for pressure sores ulcers and the provision of incontinence care as needed Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 35 Quality Indicator Survey Procedures for Long term Care Facilities e f necessary review nursing assistant assignments in relation to the care and or services the resident requires to meet his her needs e In interviews with residents families and or other resident representatives inquire about the staff s respons
107. record Certified Nurse Aide flow sheets weight books etc 7 Minimum Data Set use only as the source of last resort Note The source used can be recorded under Relevant Findings in the QIS DCT to facilitate any weight review if nutritional concerns are triggered for Stage ll review Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 24 Quality Indicator Survey Procedures for Long term Care Facilities Task 5 Facility level Survey Tasks There are 12 facility level survey tasks to be completed see Tab 8 and 9 for facility level survey worksheets seven of which are not staged meaning information can be gathered for these tasks during Stage and or Stage ll of the survey process Note The last five facility level survey tasks marked with an asterisk below are completed in Stage II only if triggered by offsite information e g complaints or by Stage interviews observations or record review 1 Demand Billing Dining Observation Infection Control Kitchen Food Service Observation Medication Administration Observation Quality Assessment and Assurance QAA Review Resident Council President Representative Interview GOP Ov OTs ER Abuse Prohibition Review 9 Admission Transfer and Discharge Review 10 Environmental Observations 11 Nursing Services Sufficient Staffing and 12 Personal Funds All facility level information is data entered in the Stage
108. refers to information that has been completed red text refers to incomplete information Some facility level tasks will remain red if not all questions needed to be answered Import all Stage Il Data into the Primary Laptop e All survey data from the secondary laptops must be exported to disk flash drive and then imported to the primary laptop e Once the import of data to the primary laptop is completed the team coordinator can determine at a glance which questions remain unanswered for any given resident or Care Area by the color of the text of each displayed item in the Survey Tree of the Stage II Critical Elements screen If any items text displays in red the team coordinator should consult the members of the survey team to ensure that all information has been entered and the reason for any missing items Review the Potential Citation Screen in the QIS DCT Once the Stage II activities are complete and all data have been imported to the primary laptop the QIS DCT will aggregate on the Potential Citation screen all Care Areas and residents within an F tag The QIS DCT will show the maximum individual severity of all residents and facility Care Areas reviewed in Stage ll for that F tag The team coordinator will use the QIS Checklist as a guide while leading a team discussion of the aggregated Care Areas and residents showing on the Potential Citation screen e The pane on the left side of the Potential Citation screen lists a
109. res for Long term Care Facilities Note The investigation of 2 3 alleged violations takes place as part of the QIS process Any findings related to the investigation are entered into the QIS DCT as documentation to the overall Abuse Prohibition Review Determine if the facility implemented adequate procedures o For reporting and investigating o For protection of the resident during the investigation o For provision of corrective action Note The reporting requirements at 483 13 c specify both a report of the alleged violation and a report of the results of the investigation to the State survey agency Determine if the facility reevaluated and revised applicable procedures as necessary e Interview several residents and families regarding their awareness of to whom and how to report allegations incidents and or complaints This information can be obtained through the resident group and family interviews e Interview at least five direct care staff representing all three shifts including activity staff and nursing assistants to complete the following f staff are trained in and knowledgeable about how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions Note Catastrophic reactions are extraordinary reactions of residents to ordinary stimuli such as the attempt to provide care One definition in current literature is catastrophic reactions are defined as rea
110. residents has already been transmitted and included in the QIS DCT Complete the update of the Census Sample on the primary laptop by discharging residents and replacing them with newly admitted residents The QIS DCT randomly selects replacement sample residents based on the count of residents on the New Admission Information form The surveyor will add a newly admitted resident as directed by the QIS DCT from the New Admission Information form Follow the instructions below on How to Discharge a Resident Also see the QIS Checklist If there is not a Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 12 Quality Indicator Survey Procedures for Long term Care Facilities sufficient number of residents on the New Admission Information form to replace residents discharged from the Census Sample the QIS DCT will randomly pull into the Census Sample a current resident from the Resident Pool How to Discharge a Census Sample Resident 1 From the QIS DCT menu bar select View Screen Stage I Sample 2 Select highlight the resident s name in the left vertical pane of the Stage I Sample screen 3 Click the Discharge Readmit Resident button 4 If the resident is in the Census Sample the QIS DCT will display a warning message that the selected resident is in the Census Sample Click OK to continue 5 The first time a resident is discharged the QIS DCT will request that the surveyor enter t
111. review e Prior to beginning the review verify that the resident has a personal funds account e Request a list of residents who expired over the last three to six months and for whom the facility managed personal funds Note Adjust the timeframe of three to six months accordingly in an attempt to obtain a list of at least three residents who expired and had their personal money managed by the facility e Use the Personal Funds worksheet Tab 9 to direct your review and to record information The worksheet includes a series of questions to be answered For the review of questions 1 8 the resident sample will be composed of the resident s whose data triggered the task Interview the person who manages personal funds for questions 1 8 After completing questions 1 8 complete one Closed Record Review If concerns are noted with the Closed Record Review supplement the sample to review a total of three closed records e Help text is available on the worksheet to assist in identifying concerns If any concerns are identified during interview of the personal funds manager or review of the financial record s a No answer to any of the Personal Funds questions gather additional information from some or all of the sources identified on the last page of the worksheet Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 36 Quality Indicator Survey Procedures for Long term Care Facilities
112. rior to initiation of the CE Pathways to provide an overview of the condition of the resident at the time of the review Substandard quality of care is defined as one or more deficiencies related to participation requirements under 42 CFR 483 13 Resident Behavior and Facility Practices 42 CFR 483 15 Quality of Life or 42 CFR 483 25 Quality of Care which constitute either immediate jeopardy to resident health or safety pattern or widespread deficiencies at severity level 3 or widespread deficiencies at severity level 2 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 48 Quality Indicator Survey Procedures for Long term Care Facilities A listing of the Care Areas that have an associated CE Pathway can be found at the beginning of Tab 10 followed by a listing of the Care Areas that require use of the General CE Pathway Additionally The QIS DCT Stage II Report directs the surveyor to use the General CE Pathway in relevant Care Areas To review a Care Area not covered by an associated CE Pathway or the General CE Pathway use the current Guidance to Surveyors protocol As noted previously the Surveyors Notes Worksheets should be used for documentation of additional concerns identified throughout Stage Il Stage Il Information Validation Stage Il in depth investigation for each triggered Care Area will vary somewhat based on the regulatory requirement being investigated but surveyors shou
113. roughout the survey process to follow up on concerns identified during the first full meal observation if necessary There may also be instances in which dining observations will be conducted for residents who are surveyor initiated into the Stage II sample because of concerns identified during the first full meal observation Dining observations will also be conducted during Stage Il for sample residents with nutrition related concerns e g weight loss decline in eating ability or dehydration The appropriate Critical Element Pathway will be used for documenting concerns for these Stage II residents e f surveyors identify concerns about dietary services e g the residents complain of cold unpalatable food meals are not consistent in quality or there is a high prevalence of residents with unintended weight loss the surveyor assigned to dining observations may request a sample tray Request that the meal be sent to the unit that is the greatest distance from the kitchen or to the affected unit or dining room Check food temperature and palatability of the test meal at about the time the last resident on the unit is served and begins eating Maintain the tray in a similar condition to that of the last resident served For example if trays are kept inside a heated holding cart do not remove the sample tray from the cart until the last resident is served fa sample tray is requested and concerns are identified documen
114. rris et al 1994 to automatically calculate a CPS score for each Census Sample resident who has an MDS assessment in ASE e Residents with a CPS score of 1 3 on a scale of 1 7 will be identified on the Census Sample Report as Interviewable e Residents with a CPS score of 4 7 will be identified on the Census Sample Report as a Family Interview Candidate However surveyors should talk with all residents in the Census Sample to determine whether they are able to answer the questions on the Resident Interview amp Resident Observation worksheet Suggested approaches for initiating a discussion are noted on the worksheet e fthe resident does not have an MDS assessment the computer will not calculate a CPS score and the resident will be listed as interviewable see Tab 11 for Instructions for Completing the Cognitive Performance Scale and for using the Cognitive Performance Level Calculator For the QIS process a resident is determined to be interviewable largely based on the CPS score determination We have found the CPS scores to accurately determine who is interviewable in four of five residents To establish rapport with the resident make a determination about whether a resident is interviewable in the absence of an MDS and or confirm the CPS determination the interview form contains four simple questions for initiating the discussion Please bear the following in mind when using these four questions Morris JN Fires BE Mehr
115. rview responses while they are conducting the interview and enter the responses in the QIS DCT at regular intervals to avoid delay in the completion of Stage l Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 21 Quality Indicator Survey Procedures for Long term Care Facilities Family Interview During Stage I three family members or resident representatives who know the resident well and visit the facility often enough to provide information about services provided by the facility will be interviewed The three family interviews must be completed and data entered in the QIS DCT prior to the end of Stage The purpose of the family interview is to obtain information from the interviewee about whether the facility is honoring the preferences of a sub sample of non interviewable residents in areas such as schedules activities and choices e Ask the interview questions as they are written on the Family Interview worksheet Once a surveyor becomes familiar with the interview questions the surveyor should conduct all interviews using their tablet pc Adjust the questions and probes as necessary to make them applicable to the resident and the individual being interviewed e Family interviews should be conducted only with family or representatives of non interviewable Census Sample residents e Ifan interviewee is not appropriate for an interview or two attempts to reach the family member friend have be
116. screen select the option to display the Resident Pool In the Resident List left pane find and select the relevant resident s name using the mouse Click the Initiate Remove Care Area button in the bottom right pane When the Initiate Remove Care Area screen appears select either th option to display Care Areas QCI Based or the option to display F tags Ftag Direct Cite Select highlight the relevant Care Area F tag and click the Include button Click the Relevant Findings button to document comments relevant findings After entering findings click on the Close Form button Click the Close button to return to the Stage I Sample screen Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 59 Quality Indicator Survey Procedures for Long term Care Facilities The QIS Post Survey Revisit Follow up A QIS post survey revisit is conducted in accordance with 7317 to confirm that the facility is in compliance and has the ability to remain in compliance The purpose of the revisit is to reevaluate the specific care and services that were cited as noncompliant during the QIS standard and or extended survey The specific procedures for each revisit depend on the deficiencies that were cited during the QIS standard survey For each QIS revisit the surveyor s will use portions of the QIS standard survey only as applicable to their need to evaluate the facility s return to
117. should make sure that both the tour and the Stage Sample reconciliation are completed in a timely manner helping others when necessary in order to complete the process as quickly as possible Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 8 Quality Indicator Survey Procedures for Long term Care Facilities Task 4 Stage Survey Tasks Stage Sample Overview The Quality Indicator Survey Data Collection Tool QIS DCT was developed in part to provide a systematic automated resident sampling process On the primary laptop the QIS DCT randomly selects residents from the MDS data that were imported into ASPEN Survey Explorer ASE offsite before the survey by the team coordinator The QIS DCT generates three Stage samples from the resident pool 1 the MDS Sample 2 the Admission Sample and 3 the Census Sample The surveyors can also generate a non random sample of residents called the Surveyor initiated Sample to investigate in Stage II there are no Stage activities for the Surveyor initiated Sample the residents will be reviewed in Stage Il The MDS Admission and Census samples have different purposes in the Stage quality assessment activities The MDS sample reflects quality of care data on all residents treated in the facility within a certain time period This sample is limited to facility reported MDS data The Admission Sample targets up to 30 new admissions to the facility during
118. ssigned equally amongst the team Leave this copy near the records so survey team members can mark off completed Admission Sample reviews To facilitate record location for Admission Sample residents currently residing in the facility write the resident s room number on the report Each surveyor will data enter the Admission Sample record review in the QIS DCT and mark his her record review as completed Update the Resident Pool The surveyor assigned the sample reconciliation task will use the resident census and the New Admissions Information form to appropriately identify all residents in the Resident Pool Figure 6 as currently residing in the facility or discharged Perform this activity on the primary laptop anytime before Transition from Stage to Stage II Task 6 as it is very important to the Stage II Sample selection process the QIS DCT selects Stage ll residents based on their residency status see the QIS Checklist The residency status icon should be green residing in the facility or yellow in both the Admission and Census Sample in the QIS DCT for residents listed on the resident census and New Admission Information form the status icon should be blue discharged for all other residents in the Resident Pool Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 14 Quality Indicator Survey Procedures for Long term Care Facilities Figure 6 Stage Sample Screen Resident Pool List Dis
119. st it is recommended that the team watch a different meal e g the evening meal to determine whether the problem s also exist s during that mealtime This procedure should be followed unless there are specific reasons the same meal needs to be observed more than once Subsequent meal observations for concerns identified during the first full meal can occur any time during the survey but will most likely be done during Stage Il If the facility has more than one dining room or residents are eating in their rooms observations should occur in all of these areas The surveyor assigned to observe meal service in resident rooms needs to be especially cognizant of meal set up and can then return periodically to the resident rooms to observe progress The majority of time should be spent watching residents who require the most assistance Dining observations conducted during Stage are general observations of dining and food service and should not be limited to observation of specific residents This review will concentrate primarily on whether necessary staff are available to assist residents and if the facility promotes a positive dining experience The review should include observations of staff resident interactions resident positioning and the overall dining room atmosphere including furnishings and available space see the Dining Observation worksheet Based on general observations made during this meal names of specif
120. t Discharge message box appears click Yes 12 The icon next the resident s name will change to blue to indicate that the resident has been discharged from the facility Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 69 GLOSSARY Quality Indicator Survey Procedures for Long term Care Facilities Glossary Admission Sample The Admission Sample consists of 30 residents randomly selected by the Quality Indicator Survey QIS Data Collection Tool DCT to undergo clinical record review by the survey team during Stage Residents are eligible for inclusion in the Admission Sample if they have had completion of an admission MDS Minimum Data Set within the 180 day period before the beginning date of the survey Admission Sample Report The Admission Sample report lists the residents selected by the QIS DCT for inclusion in the Admission Sample during which clinical record review is completed for 30 residents e One copy of the Admission Sample report is provided to the facility for use when gathering discharged residents clinical records for review by the survey team clinical records for Admission Sample residents who are currently residing in the facility are reviewed on the unit Before providing the report to the facility the survey team will use the facility s resident census to reconcile residency discharge status for residents on the Admission Sample report blacking out current resi
121. t findings calculate QCls and provide review of potential citations 3 Calculate the MDS QCls using the QIS DCT on the primary laptop The samples will be drawn on the primary laptop and exported later to the secondary laptops Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 2 Quality Indicator Survey Procedures for Long term Care Facilities 4 Print the New Admission Information Form Figure 1 and the Census Sample Report Figure 2 from the QIS DCT on the primary laptop Figure 1 Blank New Admission Information Form NORTH STAR COMMUNITY MHZB11 08 01 2005 New Admission Information Please provide the following information for residents admitted to the facility after 07 02 2005 Only include residents that are still residing in the facility mission Last First Mid Date Of Unit Room te Name Name Init Birth Gender Figure 2 Census Sample Report printed offsite NORTH STAR COMMUNITY MHZB11 08 01 2005 Census Sample Admission Assigned Unit Room Name X Date Surveyor Interview Status CARR D 30 05 01 1924 07 07 2003 Family Interview Candidate CARR J 22 02 01 1921 11 11 2004 Resident Interview CARR L 65 05 01 1924 05 16 2005 Resident Interview CARR M 80 05 01 1924 03 25 2005 Family Interview Candidate CARR M 26 05 01 1924 03 29 2005 Family Interview Candidate CARR S 46 04 01 1923 04 14 2005 Family Interview Candidate CARR T 78 05 01 1924 03 0
122. t of care concerns or problems that may be associated with sufficiency of nursing staff It is required to be completed for an extended survey Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 34 Quality Indicator Survey Procedures for Long term Care Facilities This protocol is to be used when Quality of care problems have been identified e g residents not receiving the care and services to prevent pressure sore ulcer s unintended weight loss and dehydration and to prevent declines in their condition as described in their comprehensive plan of care such as bathing dressing grooming transferring ambulation toileting and eating and Complaints have been received from residents families or other resident representatives concerning services e g care not being provided call lights not being answered in a timely fashion and residents not being assisted to eat Procedures Determine if the registered licensed nursing staff is available to Supervise and monitor the delivery of care by nursing assistants according to residents care plans Assess resident condition changes Monitor dining activities to identify concerns or changes in residents needs Respond to nursing assistants requests for assistance Correct inappropriate or unsafe nursing assistants techniques and Identify training needs for the nursing assistants If problems were identified with ca
123. t those concerns under the Additional Notes section of the Dining Observation worksheet Surveyor initiate the appropriate F tag e g F364 for food that is unpalatable unattractive or not at the proper temperature F371 for failure to distribute food under sanitary conditions etc and document your concerns in the QIS DCT under the documentation button of the Stage II Critical Elements screen e While most of the information is obtained through observation the surveyor should ask residents questions to confirm or validate observations and to assess food palatability and temperature If concerns are identified they should be shared during the daily team meetings e One surveyor will be assigned responsibility for coordinating completion of the Dining Observation task although the entire team will be making dining observations Any surveyor s not assigned the Dining task can surveyor initiate Dining at the facility level Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 27 Quality Indicator Survey Procedures for Long term Care Facilities should he she have significant or detailed findings The surveyor answers and documents critical elements relevant to his her observations and records the data on the QIS DCT Stage II Critical Elements screen When the Stage II data from all secondary laptops is imported to the primary laptop the Dining Observation findings for all surveyors are combined to dis
124. tchen and any practices that might indicate potential for food borne illness The surveyor should focus on the tasks that are naturally occurring in the kitchen at the time and that might indicate a potential for food borne illness The initial brief visit should be Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 28 Quality Indicator Survey Procedures for Long term Care Facilities used to complete as much as is possible of the section titled Initial Brief Tour of the Kitchen on the Kitchen Food Service Observation worksheet and may also help identify additional areas of concern listed on the worksheet Repeated focused visits to the kitchen will be used to complete the rest of the worksheet and answer any remaining questions in the Initial Brief Tour of the Kitchen section that may not have been completed during the initial visit These repeated visits to the kitchen should be unannounced and should occur as necessary to make observations and conduct staff interviews to identify possible areas of concern for each of the General Indicators on the worksheet These visits can occur any time throughout Stage or Stage ll of the survey and can be brief and directed The surveyor assigned to this task will want to plan visits to the kitchen during food service preparation and clean up Medication Administration Observation The Medication Administration Observation task is conducted on every survey by one or
125. the entrance conference are completed and after the Census Sample has been updated 1 Briefly discuss information gathered during the tour and entrance conference a Information about staff resident interactions b Availability of staff and staffing characteristics patterns c Activities in which residents are engaged d Characteristics of the population e Meal times scheduled activities medication pass times and f Any observed situations of concern 2 Compare the observed staff with the staffing schedule provided by the facility If discrepancies exist between the duty roster and the staff observed onsite ask the person in charge to explain the discrepancies This information will be used in conjunction with information about the DON hours to help determine whether the facility is compliant with the requirements for licensed and registered nursing staff per 42 CFR 483 30 a 2 F353 and 42 CFR 483 30 b 1 F354 Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 15 Quality Indicator Survey Procedures for Long term Care Facilities 3 The team coordinator will assign the residents from the Census Sample to each surveyor 4 Determine Admission Sample assignments Census Sample residents who are also in the Admission Sample should have the Admission Sample review completed by the same surveyor Those residents in both samples are marked with an asterisk on the Census Sample Report 5
126. the period when residents are extremely vulnerable to issues such as hospitalization The Admission Sample facilitates the Stage review of specific post admission care and maximizing function before functional decline occurs The Census Sample includes up to 40 residents in the facility at the time of the survey Because direct observations interviews and record reviews are conducted for the Census Sample in Stage I the sample does not rely on staff reported data and can address other quality of care areas Resident Pool The Resident Pool consists of residents from which the random samples are drawn and is comprised of residents who had at least one MDS assessment transmitted to the state within the 180 days prior to the extraction date MDS assessments in the Resident Pool can include all assessment types except Discharge assessments The Admission Census MDS and Surveyor Initiated Samples are subsets of the Resident Pool MDS Sample The MDS Sample includes those residents who had an MDS assessment excluding Discharge or Re entry assessments anytime within the 180 days prior to the extraction date The MDS Sample also excludes residents who had only an Admission assessment in the 180 day period The sample is drawn offsite from the MDS extraction imported into ASE The sample cannot be viewed from the Stage Sample screen in the QIS DCT There are no Stage activities for the MDS Sample residents the residents whose data trigger t
127. umentation source for all of the weights if possible Weight information may be collected from the following sources 1 Medication Administration Records 2 Treatment Administration Records 3 Dietary notes 4 Nursing notes Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 18 Quality Indicator Survey Procedures for Long term Care Facilities Weight and height records The charting or documentation source that includes the weights recorded when the resident was actually weighed e g bath record Certified Nurse Aide flow sheets weight books etc 7 Minimum Data Set use only as the source of last resort Note The source used can be recorded under Relevant Findings in the QIS DCT to facilitate any weight review if nutritional concerns are triggered for Stage II review Stage Census Sample Review The Census Sample review focuses on the care of residents currently residing in the facility and consists of three components e Resident observations e Interviews with residents families and staff e Clinical record review The Census Sample review encompasses the following areas e Activities of Daily Living ADLs e Nutrition e Drug Use e Elimination Incontinence e Resident Room e Oral Health e Quality of Life e Skin Care Completing the Census Sample Review e Surveyors should complete each review in entirety and document exactly what each data source describes even if there is
128. up exists the president or an officer will be interviewed In the rare event that there are multiple groups within a facility a representative from each group should be interviewed If there is no resident council leader or officer the interview questions can be asked of a resident indicated by the facility to be active in the council The surveyor should obtain permission from the resident council president or officer to review the resident council minutes Prior to the interview the surveyor should become familiar with some of the issues that have been discussed This interview may be conducted any time during the survey but should be completed early enough in the process to allow time for follow up of any identified concerns Use the space provided on the Resident Council President Representative Interview worksheet Tab 8 to record comments negative responses and or any additional information that may be helpful in determining the exact nature of the concern Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 30 Quality Indicator Survey Procedures for Long term Care Facilities e Follow up on any concerns that are within the scope of the long term care requirements Further investigation should include interviews with appropriate staff members to determine how concerns are resolved Team meetings will provide opportunities to share concerns and focus on particular problematic areas Any potential
129. use neglect involuntary seclusion and misappropriation of property for all residents Procedures e Obtain and review the facility s abuse prohibition policies and procedures to determine that they include the key components i e screening training prevention identification investigation protection and reporting response see Guidance to Surveyors at F226 It is not necessary for these items to be collected in one document or manual e Interview the individual s identified by the facility as responsible for coordinating the policies and procedures to evaluate how each component of the policies and procedures is operationalized if not obvious from the policies How do you monitor the staff providing and or supervising the delivery of resident care and services to assure that care service is provided as needed to assure that neglect of care does not occur How do you determine which injuries of unknown origin should be investigated as alleged occurrences of abuse How are you ensuring that residents families and staff feel free to communicate concerns without fear of reprisal e Request written evidence of how the facility has handled alleged violations and select 2 3 alleged violations if the facility has this since the previous standard survey or the previous time this review has been done by the State Quality Indicator Survey 09 07 2006 Centers for Medicare amp Medicaid Services Page 31 Quality Indicator Survey Procedu
130. ut dignity issues during E leet siehe Funds Family bathing and when assisting with toileting E C Dignity Family Interview 50 1 2 Answer Yes Provided By 55555 On 04 11 2006 12 58 16 PM IOC Criteria Met CARA L DC Criteria Not Met Additional Information About This Quality Indicator 5 C Oral Health Status Resident Observation 2 5 1 40 C Personal Funds Resident Interview 25 4 15 C Personal Property Family Interview rane 4 NORTH STAR COMMUNITY MHZB11 08 01 2005 The QCI results are reported as a rate for the facility for each QCI This rate is then compared to an established threshold which is based on the distribution of rates across facilities for each QCI The prevalence rate of a QCI for a facility is compared to the prevalence rate of other facilities If the facility rate exceeds the threshold rate the QCI is triggered The QIS DCT displays the QCI Results in three views e QCIList e Resident List found to be most helpful to surveyors and e Care Area List QCI List View When the QCI List view is selected on the QCI Results screen the QIS DCT displays the triggered QCls beneath the QCI Exceeded Threshold heading and displays the QCls that did not trigger beneath the QCI Did Not Exceed Threshold heading Beneath each QCI are three subheadings e QCI Criteria Met includes the names of residents who make up the numerator of the QCI calculation e QCI Criteria Not Met includes the
131. ys developed for a specified Care Area Although CE Pathways have been developed for particular Care Areas it is worth noting that a common link exists between pathways the CE Pathway incorporates each step of the resident care process reflected in the regulations assessment care planning implementation of care that meets professional standards of quality care plan revision and provision of care and services to meet the needs of the resident The surveyor may be reviewing just one Care Area for one resident while looking at a number of Care Areas for another resident Regardless of the Care Areas being reviewed general observations of the care environment that suggest concerns with staff resident interactions should be noted and reported to the team during the daily team meetings Stage Il Sample Selection Stage II Sample selection is performed in the QIS DCT and consists of residents who triggered through the Stage process and residents selected through surveyor initiation The QIS DCT identifies Stage II Sample residents and Care Areas for further review Stage Il Sample residents are selected in the following order 1 All surveyor initiated residents 2 A minimum of three residents if available from triggered Care Areas are selected in the following order a Residents from the Census Sample or the Admission Sample b Residents currently residing in the facility and c Residents who have been discharged from the facility

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