QISMock SurveyGuideTheFrosini Rubertino, rn, c-ne, crnac

QISMock SurveyGuideTheFrosini Rubertino, rn, c-ne, crnac

The QIS Mock Survey Guide is published by HCPro, Inc.Copyright 2009 HCPro, Inc.All rights reserved. Printed in the United States of America. 5 4 3 2 1ISBN: 978-1-60146-642-6No part of this publication may be reproduced, in any form or by any means, without prior writtenconsent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediatelyif you have received an unauthorized copy.HCPro, Inc., provides information resources for the healthcare industry.HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and JointCommission trademarks.Frosini Rubertino, RN, C-NE, CRNAC, AuthorErika Bryan, CopyeditorJanie Krechting, RNC, BSN, MGS, LNHA, ReviewerAdam Carroll, ProofreaderAdrienne Trivers, EditorMatt Sharpe, Production SupervisorElizabeth Petersen, Executive EditorSusan Darbyshire, Art DirectorEmily Sheahan, Group PublisherJean St. Pierre, Director of OperationsJanell Lukac, Graphic ArtistAdvice given is general. Readers should consult professional counsel for specific legal, ethical, or clinicalquestions. Arrangements can be made for quantity discounts. For more information, contact:HCPro, Inc.P.O. Box 1168Marblehead, MA 01945Telephone: 800/650-6787 or 781/639-1872Fax: 781/639-2982E-mail: [email protected] HCPro at its World Wide Web and www.hcmarketplace.com9/200921721

ContentsContents on your CD-ROM. viIntroduction. viiiThe Long-Term Care Survey: The Big Picture. . viiiTypes of Surveys. ixScope and Severity of Findings.xSurvey Processes. . xiTransitioning to the QIS Survey Process. xiiiOverview of the QIS Process. xiiiGoal and Benefit of a Quality Indicator Mock Survey . . xvReview of the Quality Measures/Quality Indicators . . xviReview of the OSCAR 3 Report. xviiiLet’s Get Started: Begin with First Things First. xviiiUsing Your Regulation Manual as a Resource. xxTASK 1: Off-Site Survey Preparation & Initial Sampling.1Task 1 Team Goals.1Building the Resident Sample.2TASK 2: On-Site Survey Activities & Entrance ConferenceTask 2 Team Goals.13The Survey Team’s Arrival.14TASK 3: The Initial Tour.19Task 3 Team Goals.19Initial Tour.20TASK 4: Stage I Survey Tasks.23Task 4 Team Goals.23Finalizing Samples.24Information Gathering: Investigation and Relevant Findings.26Team Meetings.31The QIS Mock Survey Guide 2009 HCPro, Inc.iii

ContentsTASK 5: Facility-Level Survey Tasks (Non-Staged and Triggered).33Task 5 Team Goals.33Begin Non-Staged Tasks. .34Triggered Tasks.38TASK 6: Transition from Stage I to Stage II. .45Task 6 Team Goals.45Review of Stage I Completion and Resident Sample Update.47TASK 7: Stage II Survey Tasks.49Task 7 Team Goals.49Stage II. .49Team Meetings.50Stage II Sample Selection.51Staff Assignments. .53Information Gathering and Investigations.53Critical Element Pathways.54Unnecessary Drug Review.56TASK 8: Analysis and Decision-Making.59Task 8 Team Goals.59Integration of Facility-Level Information and Critical Element Pathways.59Analysis of Information. .60Scope and Severity Determination.61Substandard Quality of Care.63Past Noncompliance.64TASK 9: Exit Conference.67Task 9 Team Goals.67Writing a Plan of Correction.68How to Prepare for Your Annual Survey.68Regulatory Groupings, F-tags, and Associated Deficiencies.71Resident Rights.71Admission, Transfer, and Discharge Rights.72iv 2009 HCPro, Inc.The QIS Mock Survey Guide

ContentsResident Behavior and Facility Practices.73Quality of Life.73Resident Assessment.74Quality of Care.75Nursing Services.79Dietary Services.80Physician Services.81Specialized Rehabilitative Services.81Dental Services.81Pharmacy Services. .82Infection Control. .82Physical Environment.82Administration.83Case Studies. .85Case Study 1: F329 Unnecessary Drugs, Scope and Severity of D.85Case Study 2: F309 Care and Services, Scope and Severity of E.87Case Study 3: F314 Substandard Quality of Care (SQC), Scope and Severity of H. .88Case Study 4: F323 Immediate Jeopardy, Scope and Severity of K.90Case Study 5: F505 Laboratory Services, Scope and Severity of D.92Glossary.95Appendix.99CMS-20044 Off-site Survey Preparation Worksheet.100CMS-20045 Entrance Conference (facility copy).101CMS-20046 Entrance Conference (team copy).104CMS-672 Resident Census and Condition Report. .106CMS-807 Surveyor Notes Worksheet.114Quality of Care Indicators and Facility-Level Tasks by Care Areas.116Quality of Care Indicators Mapped to Care Areas.125Quality of Care Indicators – Mapping to F-tags.129Quality of Care Indicators by Data Source.163Quality of Care Indicators – Mapping of F-tag to Care Area to Critical Element.167The QIS Mock Survey Guide 2009 HCPro, Inc.v

Contents on your CD-ROMEntrance Conference FormsTask 1 WorksheetsCMS-20044 Off-site Survey Preparation WorksheetTask 2 WorksheetsCMS-20045 Entrance Conference (team copy)CMS-20046 Entrance Conference (facility copy)CMS-672 Resident Census and Condition ReportCMS Quality Indicator Survey Demonstration Project BrochureStage I Forms and WorksheetsTask 3 Initial Tour WorksheetCMS-807 Surveyor Notes WorksheetTask 4 WorksheetsCMS-20047 Admission Sample Record ReviewCMS-20048 Census Sample Record ReviewCMS-20049 Family InterviewCMS-20050 Resident Interview and Resident ObservationCMS-20051 Staff InterviewTask 5 Facility Level WorksheetsCMS-20052 Liability Notice and Beneficiary Appeal Rights (Demand Billing)CMS-20053 Dining ObservationCMS-20054 Infection Control and ImmunizationsCMS-20055 Kitchen and Food Service ObservationCMS-20056 Medication Administration Observation and Drug StorageCMS-20057 Resident Council President/Representative InterviewCMS-20058 Quality Assurance & Assessment ReviewTask 5 Triggered Task WorksheetsCMS-20059 Abuse Prohibition ReviewCMS-20060 Admit, Transfer, Discharge ReviewCMS-20061 Environmental ObservationCMS-20062 Sufficient Nursing Staff Reviewvi 2009 HCPro, Inc.The QIS Mock Survey Guide

Contents on your CD-ROMCMS-20063 Personal Funds ReviewCMS-20084 Cognitive Performance Scale CalculatorStage II Worksheets: Critical Element Pathways (CEs) and Unnecessary Drug Review WorksheetTask 6 and 7 WorksheetsCMS-20065 ActivitiesCMS-20066 ADL-ROMCMS-20067 Behavioral/EmotionalCMS-20068 Bowel/Bladder/CatheterCMS-20069 Communication/Sensory ProblemsCMS-20070 DentalCMS-20071 DialysisCMS-20072 GeneralCMS-20073 HospiceCMS-20074 Hospital DeathCMS-20075 Nutrition/Hydration/Tube FeedingCMS-20076 Pain ManagementCMS-20077 Physical RestraintsCMS-20078 Pressure UlcersCMS-20079 Psych MedsCMS-20080 RehabilitationCMS-20081 VentilatorCMS-20082 Unnecessary DrugsStage II Care Area Investigation KeyQuality of Care Indicators (QCI) and mappingsQuality of Care Indicators and Facility Level Tasks by Care AreasQuality of Care Indicators Mapped to Care AreasQuality of Care Indicators – Mapping to F-TagsQuality of Care Indicators by Data SourceQuality of Care Indicators – Mapping of F-tag to Care Area to Critical ElementAdditional FormsAdmission SampleCensus SampleMDS SampleSurveyor Initiated SampleThe QIS Mock Survey Guide 2009 HCPro, Inc.vii

IntroductionThe Long-Term Care Survey: The Big PictureOn July 30, 1965, former President Lyndon Johnson signed the Medicare and Medicaid bills of theSocial Security Act. Former President Harry Truman, who had initially proposed a prepaid healthinsurance plan through the Social Security system in 1945, received the first Medicare card.Medicare is a Federally funded insurance program, and Medicaid is a State program that is fundedby both the state and a percentage of funds by the federal government. Both programs requirenursing facilities to comply with specific regulations to receive reimbursement and funding.The Secretary of the U.S. Department of Health and Human Services (HHS) has designated theCenters for Medicare & Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), to administer the standards and compliance aspects of these programs. CMS servesthe Medicare and Medicaid beneficiary by strengthening healthcare services and creating a cultureof healthcare responsiveness.Organizationally, CMS is a branch of the HHS. The CMS regulations can be found in the Code ofFederal Regulations (CFR) in Title 42: Public Health, Chapter IV: CMS, Subchapter G: Standards andCertification, Part 483: Requirements for States and Long Term Care Facilities, Subpart B: Requirementsfor Long Term Care Facilities. Fifteen regulatory groupings are listed in Subpart B with more than180 F-tags that identify a portion of each requirement needed to maintain compliance for CMScertification. Any F-tag found to be in noncompliance, even for one resident, results in a deficiency,or citation. A deficiency is defined as a facility’s failure to meet requirements to participate in theMedicare and Medicaid program. Some deficiencies may have monetary consequences, such asfines, denial of payment, or termination of the provider agreement, depending on the severity ofthe noncompliance.Enforcement of the regulations is conducted through survey inspections by a team of surveyors.These surveyors are responsible for determining compliance and ensuring that beneficiaries arereceiving quality healthcare in a safe environment. There are two main groups of surveyors thatconduct surveys for CMS:viii 2009 HCPro, Inc.The QIS Mock Survey Guide

Introduction1. State surveyors who are employed by a State agency that is contracted by the Federal government to perform Federal surveys.2. Federal surveyors who are employed by CMS directly or with a government contractedcompany. Federal surveyors complete Federal monitoring surveys called “look-behinds/comparative,” which are conducted after your State agency has already conducted a survey,and “oversight” surveys, in which the Federal surveyors accompany the State surveyors during the survey.The activities related to the survey process can be viewed in the Social Security Act under TitleXVIII, Section 1864 (a) and in Title XIX, Section 1902 (a) (9) (A) and (a) (33) (B).Types of SurveysAll surveys are required by law to be unannounced. There is a penalty for giving prior notice to afacility of up to 2,000. There are several types of surveys.The standard surveyThis is an annual provider survey. It is a resident-centered, outcome-oriented inspection. The Traditional Standard Survey process is composed of seven tasks, and the Quality Indicator Standard (QIS)Survey process is composed of nine tasks. Ten percent of standard surveys must begin either on theweekend or off-shift. Standard surveys are unannounced, and are routinely conducted every nineto 15 months from the date of the last annual survey exit. Facilities within a geographic area arenot surveyed in the same order as in the previous survey. The time, day, and week is varied from theprevious year.The abbreviated standard surveyAn abbreviated standard survey is usually called a “complaint survey.” This survey focuses on aparticular issue brought to the surveyors’ attention in the form of a complaint. Abbreviated surveysusually begin during the time frame the allegation is made. The survey team will focus on a particular area of concern. The timing, scope, and duration of an abbreviated survey are at the discretionof the surveyor State agency. An exception is when a complaint is made that is an allegation of anImmediate Jeopardy to health and safety. In this case, the allegation must be investigated withintwo working days.The QIS Mock Survey Guide 2009 HCPro, Inc.ix

IntroductionThe extended surveyAn extended survey is conducted if substandard quality of care (SQC) is found during a standardsurvey. Nursing services, physician services, and administration are reviewed, and there is a focus onpolicies and procedures that may have produced the SQC. SQC is defined as any deficiency in theregulatory grouping of Quality of Care, Quality of Life, or Resident Behavior/Facility Practices, witha scope and severity of either F, H, I, J, K, or L. The QIS extended survey may be conducted priorto the exit conference of the standard survey, or after the standard survey if the team is unable tocomplete it, as long as it is no longer than two weeks after the standard survey completion. WhenSQC is validated, the facility loses its ability to train nurse aides for a specified period of time.The partial extended surveyThis survey is conducted after SQC is found during an abbreviated standard (complaint) survey.Surveyors will review nursing services, physician services, and administrative policies and procedures that focus on the concerned area that was identified in the abbreviated survey. For example,if SQC is found during this survey, a partial extended survey is conducted. When a SQC is validatedduring this survey, the facility loses its ability to train nurse aides for a specified period of time.The postsurvey revisit or follow-up surveyThis is an on-site visit by the surveyors to verify correction of the specific deficiencies that wereidentified on a prior survey. The plan of correction will help in directing the surveyors toward determining compliance.The OSHA surveyThe Occupational Safety and Health Administration (OSHA) conducts surveys to ensure compliance with safety in the workplace. This survey looks at workplace accident and injury, bloodbornepathogens, and the Americans with Disabilities Act.Scope and Severity of FindingsEach identified deficient practice or noncompliance during any survey is assigned a scope and severity. The severity assignment is either a level 1, 2, 3, or 4 and is based on the following criteria: Level 4: Immediate Jeopardy to resident health or safety. If the facility is determinedto have an Immediate Jeopardy, the survey team will stop the survey process and informthe Administrator or the designee in charge. An immediate plan of correction is thenx 2009 HCPro, Inc.The QIS Mock Survey Guide

Introductionimplemented to remove the Immediate Jeopardy situation before the survey continues. Inaddition, the facility will be required to submit a plan of ongoing compliance. Level 3: Actual harm that is not Immediate Jeopardy. Level 2: No actual harm, with potential for more than minimal harm that is not ImmediateJeopardy. Level 1: No actual harm with potential for minimal harm.The scope assignment is considered isolated, patterned, or widespread and is based on the following criteria: Isolated: The scope of noncompliance is considered isolated when one or a very limitednumber of residents are affected. Pattern: 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 samedeficient practice, but the effect of the deficient practice is not found to be pervasive inthe facility. Widespread: Scope is widespread when the problems causing the deficiency are pervasivein the facility and/or represent systemic failure that affects or has the potential to affect alarge portion or all of the facility’s residents. Widespread refers to the entire facility, not asubset of residents.Survey ProcessesThere are two processes that are used to conduct surveys: the Traditional Survey process and theQIS process. Both processes are resident-centered, outcome-oriented, and rely on a sample ofresidents to gather information about the facility’s compliance with the CMS Federal regulations.Deficiency determination is focused on actual and potential negative outcomes.The QIS Mock Survey Guide 2009 HCPro, Inc.xi

IntroductionDifference Between the QIS and Traditional Survey ProcessQuality Indicator Survey ProcessTraditional Survey ProcessData collection, findings, synthesizing of informationTablet computer with Data CollectionTool (DCT) software is used to recordfindings and synthesize information.The survey team collects the data andrecords its findings on paper. The computeris only used at the end of the process toprepare the deficiencies that the facility willlater receive on the Deficiency Statement(CMS-2567).Off-site preparationThe OSCAR 3 report is reviewed withcurrent complaints. The information isdownloaded into the DCT.The OSCAR 3, reports, and QualityMeasures/Quality Indicator report (QM/QI) are reviewed and a sample of residentsis selected, along with identifying areas ofconcern.Entrance informationAn alphabetical Resident Census isobtained with room numbers and units,along with a list of new admissions overthe past 30 days.The Roster/Matrix (CMS-802) is obtainedand reviewed.Initial tourThere is no initial overview of the facility.Information is gathered about the sampleselected during off-site preparation and itis determined whether the sample is stillappropriate.Resident Sample selectionThe DCT provides a random ResidentSample.Sample size is determined by the FacilityCensus. The Resident Sample is based onthe QM/QI percentiles and issues identifiedoff-site and during the tour.Survey structureStage I: There is a preliminary investigation and mandatory facility-level tasks areinitiated.Stage II: This is an in-depth investigation of triggered Care Areas from StageI findings and more facility tasks areconducted.Sample is 20% of census for observations,interviews, and clinical record reviews.Phase I: Focused on comprehensive reviews based on QM/QI reports and issuesidentified from off-site info and facility tour.Phase II: Focused reviews are conducted.Additional facility and environmental tasksare completed during the entire surveyprocess.Resident group interviewInterview with Resident Council Presidentor representative is conducted.xii 2009 HCPro, Inc.A meeting with the Resident Group Councilis conducted, including reviewing meetingminutes to identify concerns.The QIS Mock Survey Guide

IntroductionTransitioning to the QIS Survey ProcessAs the survey process transitions from the Traditional Survey to the QIS, state-by-state implementation will take place as training resources become available. Once a state is selected by CMS toimplement the QIS, they are given one to three years to implement the process statewide.Overview of the QIS ProcessThe QIS is a systematic and structured two-staged process, utilizing computerized Data CollectionTool (DCT) software to identify care issues. Only the process of reviewing and investigating haschanged with the QIS. The Federal regulations and interpretive guidance have remained the same.During the QIS process, more information about the facility and its residents is obtained throughmore comprehensive observation, interviews, and clinical records. Both Stage I and II includesampling, investigation, and synthesis of information that provides the survey team with consistentconclusions to determine whether there is a deficient practice.Stage IStage I is the initial quality assessment to identify care areas and facility-level systems that will needa more thorough investigation in Stage II. The DCT contains a comprehensive set of more than 150Quality of Care Indicators (QCI) used in Stage I to assist with identifying which care area will needthe more thorough investigation, as evidenced by the QCI rate exceeding an established threshold.When a QCI exceeds the established threshold, it “triggers” a specific care area, which is then addressed in a Critical Element Pathway during Stage II. A Critical Element Pathway may be triggeredduring observations, interviews, and clinical record reviews using QIS review worksheets and taskforms. The Stage I review and facility task review forms and task forms indicate which F-tag may bea possible deficiency, pending analysis of the information that was gathered. These forms include: Stage I Review Forms–– Admission Sample Review Worksheet–– Census Sample Review Worksheet–– Family Interview–– Resident Interview and Observation–– Staff InterviewThe QIS Mock Survey Guide 2009 HCPro, Inc.xiii

Introduction Facility-Level Mandatory Tasks–– Liability Notice and Appeal–– Dining Observation–– Infection Control–– Kitchen and Food Observation–– Medication and Drug Storage–– Resident Council President–– Quality Assessment and Assurance (QA&A) Facility-Level Triggered Tasks (only completed if triggered)–– Abuse Prohibition–– Admit-Transfer-Discharge–– Environment–– Sufficient Staffing–– Personal FundsStage IIDuring Stage II, State surveyors use the Critical Element Pathways for each triggered care area, triggered by exceeding the threshold, to guide them systematically through a more in-depth review.This, in turn, will determine the associated F-tags for noncompliance. The Critical Element Pathwayworksheets and the Unnecessary Drug worksheet are located on the CD-ROM and indicate whichF-tags may be cited for noncompliance. They include the following:xiv CMS-20065 Activities CMS-20066 ADL/ROM CMS-20067 Behavioral/Emotional Problems CMS-20068 Bowel/Bladder/Catheter CMS-20069 Communication/Sensory Problem CMS-20070 Dental 2009 HCPro, Inc.The QIS Mock Survey Guide

Introduction CMS-20071 Dialysis CMS-20072 General CMS-20073 Hospice & Palliative Care CMS-20074 Hospitalization or Death CMS-20075 Nutrition/Hydration/Tube Feeding CMS-20076 Pain Management CMS-20077 Physical Restraints CMS-20078 Pressure Ulcers CMS-20079 Psychoactive Medication CMS-20080 Rehabilitation and Community Discharge CMS-20081 Ventilator CMS-20082 Unnecessary DrugsGoal and Benefit of a Quality Indicator Mock SurveyThe goal of the Quality Indicator Mock Survey is r

CMS Quality Indicator Survey Demonstration Project Brochure Stage I Forms and Worksheets Task 3 Initial Tour Worksheet CMS-807 Surveyor Notes Worksheet Task 4 Worksheets CMS-20047 Admission Sample Record Review CMS-20048 Census Sample Record Review CMS-20049 Family Interview CMS-20050 Resident Interview