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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