survey readiness 24/7 toolkit

Survey Readiness 24/7 ToolkitA Guide to Survey Preparation

AADNS Survey Readiness 24/7 Toolkit

Copyright 2018, American Association of Post-Acute Care Nursing, d/b/a American Association of Directors of Nursing Services. All Rights Reserved | AADNS-LTC.org 2

Table of ContentsChapter 1: Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Long-Term Care Survey Process Seven Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Readiness Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2: Preparing Your Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Resident Selection Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Accessing Your Facility’s CASPER Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 3: Preparing Your Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Entrance Conference Preparation and Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Review of Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Staff Education and Competency Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Review of Abuse, Accidents, and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Quality Assurance Requirements and Process Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Chapter 4: Preparing Facility Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Staff Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Resident and Resident Representative Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Record Reviews—Minimum Data Set (MDS) and Care Plan Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Critical Element Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Notification of Change in Resident Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

QAA and QAPI Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Chapter 5: Preparing Your Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Mandatory Tasks and Triggered Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Rounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Medication Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Chapter 6: Preparing Your Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Plans of Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Action Steps to Correct Negative Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

QAA/QAPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Resources Cited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

AADNS Survey Readiness 24/7 Toolkit 3

chapter 1

Introduction


AADNS Survey Readiness 24/7 Toolkit Chapter 1: Introduction

The standard survey can be a time of uncertainty for facility leaders and staff. Surveyors arrive and within moments of entering the facility begin to observe and interview residents—and things can become stressful quickly. Survey outcomes can be improved by having a sound process in place for assessing and determining compliance with federal regulations before surveyors arrive.

The Long Term Care Survey Process (LTCSP) Procedure Guide, which will be used as the procedural and technical guide for conducting long-term care (LTC) standard surveys, was created by the Centers for Medicare & Medicaid Services (CMS) to walk surveyors through the various portions of the survey. Chapter 7 of the State Operations Manual (SOM) will also be revised in the future to include survey policy, according to CMS. Information can be found in Survey & Certification Memo 18-05-NH.

The standard survey process consists of seven tasks that surveyors must conduct during the survey.

Long-Term Care Survey Process Seven Tasks

1. Offsite survey preparation. Surveyors independently review the CASPER 3 report and other facility history information. Surveyors also review offsite-selected residents and the MDS Indicator Facility Rate Report.

2. Facility entrance. A brief conference with the administrator is conducted. No formal tour process with nursing facility staff takes place. Surveyors will go to their assigned areas to begin screening residents. Simultaneously, a brief kitchen observation is conducted.

3. Initial pool process. Surveyors spend an average of 8 to 10 hours onsite to complete the initial pool process. They will screen all residents who are present in the facility. Surveyors conduct observations, interviews, and limited record reviews during this time.

4. Sample selection. Determinations of residents to be reviewed are established from offsite selections and onsite sources of information.

5. Investigations. Systematic methods are used to make compliance determinations. For sampled residents, further investigations are conducted for all concerns that warrant them.

6. Ongoing and other survey activities. Surveyors carry out facility tasks and closed record investigations.

7. Potential citations/exit conference. Surveyors conduct an exit conference to relay potential areas of deficient practice.

Updated survey forms and manuals, along with the above-noted tasks, can be found here. Leaders in LTC facilities will need to review the information and develop a strategy to prepare all staff for the survey process. By creating an internal survey-readiness process, facility leaders can educate and prepare staff while evaluating survey readiness and compliance with federal regulations.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-05.pdf





Overview

This Survey Readiness 24/7 Toolkit provides tools and tips for developing an internal survey-readiness process. Chapter1 outlines the survey tasks that will be conducted during the standard survey. Chapter 2 outlines how and from where data is pulled and how it is used during the standard survey. Chapter 3 contains checklists to assist in reviewing specific elements that may be reviewed by surveyors to determine compliance. Chapter 4 offers tools and tips to assist in interviewing staff, residents, and/or resident representatives and managing the results. Chapter 5 has tools and tips for conducting checks of resident grooming and environmental cleanliness, auditing infection control practices, and reviewing medication storage and management processes. And chapter 6 reviews how to prioritize and address gaps and potential areas of risk. The toolkit resources can be printed, used electronically, or used to build user-defined assessments in your software system as part of a quality assurance module.

In preparation for survey, a timeline should be developed. The survey window remains open for facilities as little as 9 months and as much as 15 months after the last standard survey was conducted. And at any point, a complaint investigation could occur. This challenges facility leadership to maintain survey readiness throughout the year. This toolkit is intended to be part of your facility’s survey preparation process to promote optimal survey outcomes. To begin implementing the resources in this toolkit, it is suggested that at least six months after the previous survey was conducted you begin a methodical process of working through the components outlined in this guide. The implementation process includes planning, preparing, and performing audits and quality assessment/performance improvement (QAPI) activities.

Readiness Process

Establish a survey-readiness team: Identify who has the knowledge and skill and will be provided the time to complete elements of the survey. Consider selecting staff such as a nurse who has an eye for detail and a nursing assistant who keeps resident rooms impeccably clean. Include members from housekeeping, dietary, and other departments as needed by the process. In order for the survey-readiness review process to be successful, it needs to be launched by upper management (the administrator or governing body) to champion it and authorize the resources needed. Next the survey-readiness review project needs to be brought to the QAA committee and a project charter initiated so that the work can begin. Table 1.1 provides a checklist for the whole survey-readiness process.

The survey-readiness champion, called the Team Coordinator (TC—the assigned leader for implementing the Survey Readiness 24/7 Toolkit process) will ensure all tools to be used are current.

TheTC will review the toolkit elements and CMS survey tools to be sure they are the most currently posted forms and then assign members of the survey readiness team to assist in conducting the survey audits and documentation reviews. The TC should identify which tools will be completed when (see Table 1.2, “Survey Readiness Checklist”).



Train the team: Identify someone with an understanding of the survey process and tools who will train the team members conducting the survey-readiness process.

Schedule and conduct the reviews of residents and of the tasks the team will complete.

Conduct an analysis of the information collected during the survey-readiness process.

Create a follow-up action plan as needed for concerns identified during the survey-readiness process.

Schedule another review to ensure that all identified concerns have been corrected and the corrected measures have been sustained.



TABLE 1.1

Survey-Readiness Process ChecklistInstructions: Use this checklist to ensure the survey readiness team is assembled, is prepared, and completes the survey-readiness tasks that are necessary throughout the process.

Item Responsible PersonDate

Completed

Select corporate sponsor (administrator/upper management)

Develop survey-readiness (SR) charter (in QAA)

Select SR team coordinator (TC)

Select SR team members

(IDT—RN, LPN, nursing assistant, housekeeping, maintenance, dietary, activities, chaplain, etc.)

Set up SR binder/folders (electronic/hard-copy) to assemble documents in central location

Train team members on the SR process and expectations

Select start date of the SR review

Determine which forms you will use (CMS/facility defined, etc.) (Use Survey Readiness Checklist to select tools [Table 1.2])

Review CASPER 3D report for past survey concerns

Review CASPER QM reports for potential areas of concern

Review CASPER PBJ reports

Complete Entrance Form Checklist [Table 3.1]

Complete Policy-and-Procedure Audit [Table 3.2]

Complete Policy Risk-Management Review [Table 3.3]

Utilize facility-wide assessment and conduct In-Service Checklist audit [Table 3.4]

Conduct resident-selection process (pooling process)

Select high-risk, high-volume, problem-prone areas for resident review (Use CASPER reports/QM/facility-wide assessment, grievance logs, incident reports, and facility-reported incidents)

Assign the tasks (mandatory and triggered) to team members

Conduct Resident Personal Preferences Review [Table 4.1]

Conduct Care Planning and MDS QA Audit [Table 4.2]

Conduct Notification of Change in Resident Condition and Status Review [Table 4.3]



Item Responsible PersonDate

Completed

Assign each SR team member to a unit/neighborhood for the initial review of all residents

Schedule resident and resident representative interviews and assign SR team member

Conduct resident observations, interviews, and record reviews for the initial pool process using the identified tools

Review the Critical Element (CE) Pathways on selected residents using CE Pathway and toolkit resources

Review any CE Pathways that were not triggered and completed during the investigations portion of the survey

Conduct facility task review

Conduct facility-triggered task review

Organize, date, and place all information in the survey binder

Conduct a SR team meeting to discuss findings of audit process

Formulate a report of all potential deficiencies

Meet with facility leaders

Meet with the QAA committee to review SR findings

Schedule a follow-up review if potential survey deficiencies were identified during the SR process, to ensure compliance is established (QAA/QAPI process)



TABLE 1.2

Survey Readiness Checklist = Process should begin 3 months in advance of survey window opening

= Timeline in survey window

ITEM Action Y/NResponsible

PersonDue Date Result Y/N

Audit

CEP CMS-20059: Resident Abuse Protocols (include review of required action per minutes)

CEP CMS-20065: Activities

CEP CMS-20066: Activities of Daily Living

CEP CMS-20067: Behavioral-Emotional

CEP CMS-20068: Urinary Catheter or UTI

CEP CMS-20069: Communication and Sensory

CEP CMS-20070: Dental

CEP CMS-20071: Dialysis

CEP CMS-20072: General

CEP CMS-20073: Hospice and End of Life

CEP CMS-20074: Death

CEP CMS-20075: Nutrition

CEP CMS-20076: Pain Management

CEP CMS-20077: Physical Restraints

CEP CMS-20078: Pressure Ulcer

CEP CMS-20080: Rehab and Restorative

CEP CMS-20081: Respiratory Care

CEP CMS-20082: Unnecessary Medications

CEP CMS-20090: PASARR

CEP CMS-20091: Extended Survey

CEP CMS-20092: Hydration

CEP CMS-20093: Tube Feeding

CEP CMS-20120: Positioning, Mobility, ROM

CEP CMS-20123: Hospitalization

CEP CMS-20125: Bladder and Bowel Incontinence

CEP CMS-20127: Accidents

CEP CMS-20130: Neglect

Corrective Action Needed?

Take to QAA/QAPI?





CEP CMS-20132: Discharge

CEP CMS-20133: Dementia Care

MAND TASK CMS-20052: Beneficiary Notices Review

MAND TASK CMS-20053: Dining

MAND TASK CMS-20054: Infection Prevention, Control and Immunization

MAND TASK CMS-20055: Kitchen

MAND TASK CMS-20056: Medication Administration

MAND TASK CMS-20057: Resident Council

MAND TASK CMS-20058: QAA and QAPI

MAND TASK CMS-20062: Sufficient and Competent Staff

MAND TASK CMS-20089: Medication Storage

TRIG TASK CMS-20061: Environment

TRIG TASK CMS-20063: Personal Funds

TRIG TASK CMS-20131: Resident Assessment

Other

Admission packet/posted: Inform residents of facility grievance policy

Admission packet/posted: Inform residents of how to file complaint with State Survey Agency

Admission packet/posted: Notice of Medicaid eligibility, rights, and obligations

Admission packet/posted: Resident rights

Admission packet: Facility policies (e.g., visitation, smoking, etc.)

Admission packet: Right to access his/her personal and medical records

Employee personnel files compliance review

Medication administration audit

Ombudsman: Provide list of facility-initiated transfers

Oxygen in-use signs posted

Resident personal funds management review


Take to QAA/QAPI?





Policies and Procedures

Abuse/neglect/misappropriation of resident property/staff screening & training (see State Operations Manual [SOM] for full details)

Admissions (specifics in federal regulations)

Advance directives and how resident preferences related to CPR/advance directives are communicated

Bed-hold policy

Compliance and ethics (due 11/29/19)

Dentures: lost and damaged (when facility is responsible for paying)

Dialysis: Transport to and from dialysis treatments

Electronic signature and protecting use of an electronic signature (specifics in federal regulations)

Elopement (see SOM for details)

Emergency water supply

Facility closure

Food: Personal food storage and use (includes food brought in from visitors)

Food: Storage/prevention of food-borne illness

Gardening (if facility has its own garden)

Grievance (how grievances are processed; specifics in federal regulations)

Hospice/end-of-life care

Infection control and prevention/antibiotic stewardship (several policies are mentioned; see SOM for details)

Infection control: Equipment care following injections

Influenza and pneumococcal immunization administration

Influenza/pneumococcal immunization follow-up after injections

Laboratory, radiology, and other diagnostics (including notification of physician)

Pharmacy: Controlled medication count process


Take to QAA/QAPI?





Pharmacy: Destruction of medications process

Pharmacy: Drug regimen reviews

Pharmacy: How to handle discrepancies in amounts of controlled medications

Pharmacy: Self-administration of medications process

Physicians allowed to delegate writing of orders to dietitian if state law allows

QAA/QAPI (see SOM for details; a number of policies are listed)

Readmission: Permit residents' return after discharge or leave of absence

Reporting a possible crime

Resident care: Catheter use

Resident care: Dialysis (see SOM for full details)

Resident care: Feeding tubes (including how to check placement)

Resident care: IVs/parenteral therapy

Resident care: Mechanical ventilation

Resident care: Pressure injury/ulcer treatment (SOM mentions treatment protocols)

Resident care: Respiratory care therapy and staff training

Resident care: Restorative/rehabilitation

Resident privacy and confidentiality

Resident property safeguards

Resident rights

Restraints (including who can initiate)

Room changes

Secured/locked areas and criteria for placement within

Smoking

Transfer/discharge

Transfusion (if facility staff provide on-site)

Visitation

Other—based on facility-wide assessment (FWA)

Other—based on FWA


Take to QAA/QAPI?





Posted

Contact information for Aging and Disability Resource Center

Contact information for state and local advocacy agencies (including State Survey Agency)

Employee rights

Local contact agency information

Medicaid Fraud Unit information

Medicare and Medicaid benefits and how to receive refunds

Staffing data required by regulations

State long-term care ombudsman information

Survey data and plans of correction for past 3 years

Staff Competencies and Education

Abuse, neglect, exploitation, and misappropriation (including identification, prevention, and reporting requirements)

Approaching a resident who may be agitated, combative, verbally or physically aggressive, or anxious

Assistive devices and their use

Behaviors: dealing with difficult behaviors

Blood (or blood product) transfusions: monitoring residents afterward

Changes in condition: how to identify

Cognitively impaired residents: care protocols

Communication

CPR training, hands-on

Crime: reporting a reasonable suspicion

Cultural competency

Dementia management

Dialysis (if hemodialysis or peritoneal dialysis is performed on-site by staff)

Emergency preparedness (table top drill and community drill)

Emergency respiratory care and treatment of complications


Take to QAA/QAPI?





Equipment: training on new equipment

Fire prevention and safety

Foot care

Infection control and prevention (including preventing spread of food-borne illness)

In-service training on continued competency that addresses areas of weakness as determined in nurse aides’ performance reviews: no less than 12 hours

Medication equipment

Medication management

Nursing skills, basic

Pain management

Person-centered care

Resident care processes and policies and those identified through the FWA

Resident rights and facility responsibilities

Restorative services, basic

Restraint use alternatives

Safety

Skin and wound care

CMS Forms

Census and Condition Information (CMS-672), completed

Matrix of all residents (CMS-802) (within 4 hours)

Matrix of new admissions in last 30 days (CMS-802)

Medicare/Medicaid Application (CMS-671), completed (staffing information not required)

Copy of

Activities calendar

Admission packet sample

Census number (note residents out of facility)

Clinical Laboratory Improvement Amendment (CLIA) certificate

Dialysis: Agreement with dialysis vendor(s)


Take to QAA/QAPI?





Dialysis: List of qualified staff providing hemodialysis or assistance for peritoneal dialysis treatments

Dialysis: Policies and procedures for transport to and from dialysis treatments

Dining: Current menus

Dining: Location of dining rooms

Dining: Scheduled mealtimes

Documented Programs: Antibiotic stewardship program

Documented Programs: Emergency preparedness/disaster drills (table top and community-based)

Documented Programs: Facility-wide assessment

Documented Programs: Fire safety and recorded drill(s)

Documented Programs: Management of grievance process (past 3 years)

Documented Programs: QAA committee information and frequency of meetings

Documented Programs: QAPI plan

EHR access: Medical records access and use instructions for surveyors

Experimental research: Describe if occurring in the facility

Facility floor plan

Feeding assistants: Evidence of staff training

Feeding assistants: List of residents receiving assistance from paid feeding assistants

Hospice: Agreements with hospice vendor(s)

Hospice: Policies and procedures for hospice program

List: Alphabetical resident roster (note residents who are out of the facility)

List: Key personnel, locations, and phone numbers (note any contract staff)

List: Medicare beneficiaries who were discharged and had days remaining in the past 6 months

List: Residents who smoke, designated smoking times and locations


Take to QAA/QAPI?





Medication: Number and location of medication storage rooms and medication carts

Medication: Schedule of medication administration

Policies and Procedures: Abuse

Policies and Procedures: Care of equipment following injections

Policies and Procedures: Emergency water supply

Policies and Procedures: Infection prevention and control program standards

Policies and Procedures: Influenza/pneumococcal immunization follow-up after injections

Resident Council president contact info

Staffing: Work schedule for RN/LPN/LVNs during survey

Surety bond

Waivers: List rooms with less than required square footage and/or housing more than 4 residents

Waivers: Staffing waivers (if applicable)


Take to QAA/QAPI?


chapter 2

Preparing Your Data


AADNS Survey Readiness 24/7 Toolkit Chapter 2: Preparing Your Data

Resident Selection Process

Chapter 1 described the survey process and provided a Survey Readiness Checklist to assist the survey preparation team to conduct an overview of the facility staff and system readiness. Chapter 2 provides a guide to gathering and preparing the available data to begin implementing the survey preparation process. When considering which data to review, the terms high risk, high volume, and problem prone are a place to start.

The SOM (Definitions §483.75[g][2][ii]) defines these terms.

“High risk”: Refers to care or service areas associated with significant risk to the health or safety of residents, e.g., tracheostomy care; pressure injury prevention; administration of high risk medications such as warfarin, insulin, and opioids.

“High Volume”: Refers to care or service areas performed frequently or affecting a large population, thus increasing the scope of the problem, e.g., transcription of orders; medication administration; laboratory testing.

“Problem-prone”: Refers to care or service areas that have historically had repeated problems, e.g., call bell response times; staff turnover; lost laundry.

When considering which residents, systems, and tasks to review for a survey-readiness process, a good place to start is with a review of form CMS-672; the matrix for new admissions and long-term residents (CMS-802); the facility-wide assessment (FWA); the CASPER reports; Quality Measure (QM) information; Payroll-Based Journal (PBJ) staffing information; and past survey deficiencies.

To create a pool (or list) of residents to include in the survey-readiness process, it may be helpful to ensure there is a system in place for completing and reviewing the CMS-672 (“Resident Census and Conditions of Residents”) and “Matrix for Providers” with instructions. It is best for these forms to be kept survey ready at all times, updated at least weekly with admissions and discharges. This can be done by having the team members responsible for maintaining them turn them in to a central location where all items for the survey process are kept in a survey-readiness binder. By reviewing these forms, the team can begin to identify high-risk, high-volume, problem-prone care processes to review during the survey-readiness process. Additionally, the team can compare the information on the above-mentioned forms with the data collected and analyzed as part of the facility-wide assessment process. Integrating the FWA and survey-readiness processes ensures that the unique characteristics of the facility population are captured and that staff are educated in these areas. For more information on the requirements of the facility-wide assessment, see AADNS’s Facility Assessment Workbook. The team can further break down the CASPER report information, QM information, and past survey outcomes. It is also helpful to review past PBJ submissions and look at staffing patterns.

When reviewing the resident population, please consider any residents determined to be “vulnerable” according to CMS’s LTCSP Procedure Guide. Examples of vulnerable residents include but are not limited to those with Alzheimer’s or quadriplegia who are dependent on staff. Additionally, the Guide includes residents admitted within the last 30 days and those with concerns, for example, those included on facility-reported incidents (FRI) documents. The Guide has more detail; however, this is a place to start to gather a pool of residents to be reviewed by the internal survey-readiness team.

https://www.aadns-ltc.org/Landing-Pages/Facility-Wide-Assessment-Workbook





Accessing Your Facility’s CASPER Data

One often-overlooked source of critical information and facility data is the Certification and Survey Provider Enhanced Reporting (CASPER) system. The CASPER reports assist in further identifying residents to include in an internal survey-readiness review. The MDS 3.0 QM package report provides the following reports: Facility Characteristics, Facility QMs, and Resident-Level QMs. By running the package report, the TC can work with the team to identify which additional residents to include. The Facility Characteristics report will provide additional information that may be relevant in determining whether a resident care practice falls into the category of high risk, high volume, and/or problem prone. By reviewing this report, survey-readiness team members deepen their understanding of the facility’s resident population. In addition to using the report to help them identify residents for review, the team members should compare it to the FWA to ensure these two items are aligned and capture the facility’s resident profile.

The next report is the Facility QM report. Fundamentally, this report compares the facility with others in the state and nationwide. When reviewing this report, the team should consider those areas that are flagged and scoring at the 75th percentile or greater in the comparison group national percentile. The reviewer should not assume there is a problem if there is a flag. Rather, the reviewer should understand that the area needs further investigation to determine whether there is an actual problem or a potential problem or whether effective systems are in place but the facility has a specialty population. The Facility QM report is updated monthly, with a two-month delay. CASPER data is also updated on Monday mornings with the previous week’s MDS submissions.

After the Facility QM report is broken down, the team should review the Resident-Level QM report to further drill down to which residents are triggering the QMs and may be included in the pool for review. In addition to using this report to help assess residents according to triggered QMs, team members should review the report resident by resident to determine the number of triggered areas per resident. During this phase, the team should determine whether a correlation exists between triggered QMs that creates a high-risk, high-volume, or problem-prone area in need of further investigation, and include the triggered residents in the pool. Additionally, the team should average the number of triggered QMs by resident and determine by number of QMs which additional residents to add to the pool of residents for review. For example, if there are on average five QMs per resident, all residents triggering five QMs who are not already in the pool



should be added. Additionally, the team should include a couple of residents who do not trigger any QMs, to ensure that data collected and reported from the MDS is accurate and reflective of the resident.

It is important to understand that data obtained through the QM reports is not the most current data available, as it reports on MDS submissions that could have occurred nearly 12 months earlier (for example, reported QMs for falls with major injury have a look-back of 275 days); however, it is useful information that helps team members see a snapshot of what the surveyors will be reviewing prior to entering the facility. For more technical information, please refer to CMS’s CASPER Reporting User’s Guide for MDS Providers.

In addition to the CASPER MDS Provider reports is the CASPER 3 report. Reviewed by surveyors, it shows the facility’s survey history over the last three years. Studying this report enables the survey-readiness team to understand risk areas previously identified; the report should be considered when selecting residents and tasks for review during the internal survey-readiness process.

09/2016 v1.04 Certification And Survey Provider Enhanced Reports MDS 3.0 NH 6-3CASPER Reporting MDS Provider User’s Guide PROVIDER

GENERAL INFORMATIONMDS 3.0 Nursing Home (NH) Provider reports are requested on the CASPER Reports page (Figure 6-1).

Figure 6-1. CASPER Reports Page – MDS 3.0 NH Provider Reports Category

1. Select the MDS 3.0 NH Provider link from the Report Categories frame on the left. A list of the individual MDS Nursing Home Provider reports you may request displays in the right-hand frame.

NOTE: Only those report categories to which you have access are listed in the Report Categories frame.

2. Select the desired underlined report name link from the right-hand frame. One or more CASPER Reports Submit pages are presented providing criteria options with which you specify the information to include in your report. These options may differ for each report.

3. Choose the desired criteria and select the Submit or Next button.

Once the data has been collected and reviewed, the survey-readiness team will determine how many residents should be included in the survey-readiness process. A rule-of-thumb could be the same as the surveyors’ guidance in Attachment A (p. 41) of the CMS LTCSP Procedure Guide, using the current facility census. Additionally, consideration could be given to the type of issues being reviewed and the number of residents with those issues. For example, if there were four residents with facility-acquired pressure injuries, the team would review all these residents to ensure that all elements of the system are working and that all causes are being thoroughly addressed.

Now that the survey preparation team has been selected, the data has been reviewed, and a resident pool has been selected, it is time to address additional steps for completing an internal survey-readiness process.

https://qtso.cms.gov/mdstrain.html



chapter 3

Preparing Your Documentation


AADNS Survey Readiness 24/7 Toolkit Chapter 3: Preparing Your Documentation

After you have gathered your data as described in chapter 2 of this toolkit, you will begin preparing your documentation. Chapter 3 assists the survey-readiness team to conduct system audits for the purpose of identifying areas of concern that need to be addressed as part of the facility’s QAA process.

To ensure that care provided to residents meets the minimum regulatory standards outlined in the CMS Requirements of Participation (RoP) for skilled nursing facilities, the internal survey-readiness team will review both resident-level information and facility systems. A number of forms can help guide the team in this review: the same forms that surveyors will use during the standard survey process, and other forms specific to the facility characteristics. A process for reviewing these forms and conducting targeted audits will need to be developed as part of the internal survey-readiness procedure.

Entrance Conference Preparation and Process

The entrance form provided by CMS, “Entrance Conference Worksheet,” lists information that surveyors will request from facility leadership upon arrival and at specific intervals throughout the survey. There are items due immediately upon entrance, at the entrance conference, within 1 hour, within 4 hours, by the end of the first day, and within 24 hours. It is recommended to facility leaders that, for the sake of efficiency, this information be compiled in advance and organized in a survey-readiness binder that is centrally located and can be easily reviewed. Wherever this survey-readiness binder is located, facility leadership across all shifts will need to have access to it to ensure the information is available should a survey commence after regularly scheduled business hours or on weekends. The information should be reviewed and updated on a routine schedule established by the team, such as weekly. During an internal survey-readiness audit, it may be the role of the facility’s TC to review and audit all information detailed on the entrance form to ensure it is both accurate and up to date. Please review a sample Entrance Form Checklist (see Table 3.1).

Review of Policies and Procedures

The internal survey-readiness process should include a review of systems or parts of systems. During an actual survey, surveyors may review a facility’s policies and procedures in the course of looking at facility systems. For example, there may be a concern with how pressure injury care is provided by a staff member, and so a surveyor may request to review the facility’s policy and procedure addressing pressure injuries. During the internal survey-readiness process, if a team member finds a similar concern, the team member should request and review the policy and procedure to determine whether there is a process of care in place and whether staff are able to follow it. Furthermore, the survey-readiness review should include observation of staff carrying out the procedure, as applicable. Additionally, the internal survey-readiness team should conduct a proactive review of all policies and procedures related to high-risk, high-volume, problem-prone care areas (see the discussion of resident pool selection in chapter 2). The review should include interviewing and observing staff to determine their knowledge of the appropriate policy and procedure. Finally, policies and procedures should be reviewed at least annually to ensure they meet standards of practice and remain relevant. Please review an example of a Policy and Procedure Audit (Table 3.2) and a Policy and Procedure Risk-Management Checklist (Table 3.3).

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending


https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Entrance-Conference-Worksheet-Facility-Copy.pdf



Staff Education and Competency Review

Staff training and competency is another area for the internal survey-readiness team to review. The review of staff training may include, at a minimum, in-services based on the facility-wide assessment to ensure staff are skilled, knowledgeable, and competent in caring for residents in those care areas identified as high risk, high volume, or problem prone. Additional training topics are cited in the RoP. And the SOM, under F726, states the following:

Competency in skills and techniques necessary to care for residents’ needs include but is not limited to competencies in areas such as:

• Resident Rights

• Person centered care

• Communication

• Basic nursing skills

• Basic restorative services

• Skin and wound care

• Medication management

• Pain management

• Infection control

• Identification of changes in condition

• Cultural competency

(Note that this is not an all-inclusive list; other areas are noted elsewhere in the SOM.)

The team will need to proactively organize areas that will be reviewed based on additional information found in the SOM, the facility-wide assessment (FWA), and the resident pool review (discussed in chapter 2). When reviewing the residents in the pool, the residents’ behavioral, assessment, and care-planning needs should be used to determine what training needs to be included in the in-service–review portion of the survey-readiness process. For example, if the review indicates residents are subject to wandering, staff should be trained on how to respond to wandering residents. The review of in-service training records should also ensure that the appropriate staff members were trained based on their roles and responsibilities. Please review an example of an In-Service Training Checklist (Table 3.4).



Review of Abuse, Accidents, and Neglect

An internal survey-readiness process should include a systematic review of abuse, accidents, and neglect (including incidents, policies, and staff training related to prevention and mandatory reporting requirements). Tools that help assist in the review are in the LTC Survey Pathway folders on the LTC survey website. The tools are CMS-20059, “Abuse”; CMS-20127, “Accidents”; and CMS-20130, “Neglect.” The internal survey-readiness team should be trained in how to use these tools to review incidents and assess regulatory compliance.

Quality Assurance Requirements and Process Review

Both the Quality Assessment and Assurance (QAA) committee functions and the Quality Assurance and Performance Improvement (QAPI) process are key facility components requiring evaluation. Whenever care concerns are identified, the findings must be brought to the QAA/QAPI committees so the issues can be both resolved and monitored for further occurrences. The internal survey-readiness team should include a review of QAA/QAPI processes and compliance as part of its process. The team has access to LTC Pathway CMS-20058, “QAA and QAPI Plan Review,” which will assist in reviewing elements of the QAA committee and the QAPI plan.

QAA committee meeting minutes must also be reviewed to ensure that identification of quality issues is in place and that appropriate follow-up is continuous. If a quality deficiency is identified, the team will need to consider whether an appropriate plan of correction has been developed and whether the committee has overseen the process, according to F867 in the SOM. The guidance at F867 suggests that a corrective action plan be written that includes:

• A definition of the problem—which, depending on the severity and extent of the problem, may require further study by the committee to determine contributing causes of the problem (Root Cause Analysis)

• Measurable goals or targets

• Step-by-step interventions to correct the problem and achieve established goals

• A description of how the QAA committee will monitor to ensure changes yield the expected results

These specific elements can be developed as a checklist for the team to use.

The activities discussed in this chapter may occur at any time throughout the survey-readiness process. The reviews may be triggered by findings made during the survey-readiness review, or the team may have preplanned areas of review based on the information discovered when identifying the resident pool.


https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-Pathways.zip



TABLE 3.1

Entrance Form Checklist

Items

In place and staff are knowledgeable

If no, action takenY N N/A

Information Needed From the Facility Immediately Upon Entrance

1. Census number.

2. Complete matrix for new admissions in the last 30 days who are still residing in the facility (CMS-802).

3. Alphabetical list of all residents (note any resident out of the facility).

4. List of residents who smoke, designated smoking times and locations.

Entrance Conference

5. Conduct a brief Entrance Conference with the administrator (or the person in charge at the time of the survey preparation who would be responsible for answering the questions) and ascertain the leader’s knowledge by asking questions 6, 7, and 8.

6. Information regarding full-time DON coverage (verbal confirmation is acceptable).

7. Information about the facility’s emergency water source (verbal confirmation is acceptable).

8. Signs announcing the survey that are posted in high-visibility areas.

9. A copy of an updated facility floor plan.

10. Name of Resident Council president.

11. The facility copy of the CASPER 3.

Within an Hour

12. Schedule of mealtimes, locations of dining rooms, copies of all current menus, including therapeutic menus, that will be served for the duration of the survey, and the policy for food brought in from visitors.

13. Schedule of medication administration times.

14. Number and location of med storage rooms and med carts.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/CMS-802.pdf



Items



15. The actual working schedules for licensed and registered nursing staff for the survey time period. (Note: Interview administrator/designee regarding knowledge of how to attain information and update information in survey binder.)

16. List of key personnel, location, and phone numbers. Note contract staff (e.g., rehab services).

17. If the facility employs paid feeding assistants, provide the following information:a) Whether the paid feeding assistant training

was provided through a state-approved training program by qualified professionals as defined by state law, with a minimum of 8 hours of training;

b) The names of staff (including agency staff) who have successfully completed training for paid feeding assistants, and who are currently assisting selected residents with eating meals and/or snacks; c) A list of residents who are eligible for assistance and who are currently receiving assistance from paid feeding assistants.

Within 4 Hours

18. Complete the matrix for all other residents. (Check for accuracy.)

19. Admission packet.

20. Dialysis contract(s), agreement(s), arrangement(s), and policies and procedures, if applicable.

21. List of qualified staff providing hemodialysis or assistance for peritoneal dialysis treatments, if applicable.

22. Agreement(s) or policies and procedures for transport to and from dialysis treatments, if applicable.

23. Does the facility have an on-site, separately certified ESRD unit?

24. Hospice agreement, and policies and procedures for each hospice used (name of facility designee[s] who coordinate[s] services with hospice providers).



Items



25. Infection Prevention and Control Program standards, policies and procedures, and Antibiotic Stewardship Program.

26. Influenza/pneumococcal immunization policies and procedures.

27. QAA committee information (name of contact, names of members, and frequency of meetings).

28. QAPI plan.

29. Abuse Prohibition policies and procedures.

30. Description of any experimental research occurring in the facility.

31. Facility assessment.

32. Nurse staffing waivers.

33. List of rooms meeting any one of the following conditions that require a variance: • Less than the required square footage • More than four residents

By the End of the First Day

34. Provide each surveyor with access to all resident electronic health records—do not exclude any information. (Use and review specific form provided by CMS; ensure IT designee is identified and informed.)

Within 24 Hours of Entrance

35. Completed Medicare/Medicaid application (CMS-671).

36. Completed Census and Condition information (CMS-672).

37. Beneficiary Notice—Resident Discharged Within Last Six Months (use and review specific form provided by CMS).

Form last updated:

Reviewed by:



TABLE 3.2

Policy-and-Procedure Audit

Name of Policy:

Date of Review:

Reviewer:

Policy-and-Procedure Criteria

Criteria Met

Recommendations Responsible PartyY N

The policy is relevant to a specific problem, condition, clinical practice, target population, or regulation.

The policy reflects best practices, current standards with an aim to improve clinical practice.

Policies provide common-sense, user-friendly, well-defined procedures.

The policy exceeds regulatory requirements—the intent is to improve clinical practice. Other alternatives have been evaluated.

The policy supports the intent of the regulation.

The policy and/or procedure is evidence based.

The policy incorporates resident-directed preferences from literature, research, regulation, and/or facility populations.

Any exclusions are defined in the policy.

Policies are current and reflect ongoing review dates.

Observed staff performing procedure or, if unable to observe staff, staff were interviewed to assess knowledge of procedure steps, as applicable.

A brief summary of significant changes, including reference, research, or training material, is attached to the policy review summary (if applicable).



TABLE 3.3

Policy Risk-Management Review

Key Policy, Process, or Practice:

In Place If no, action plan and time frame ResultY N

Is consistent with the organization’s philosophy and standards

Is consistent with state and federal requirements

Reflects current standards of practice and is evidence based

Provides common-sense, user-friendly, well-defined procedures

In practice, each step is realistic and functional

In practice, there are no steps that are interrupted, inadequate, or omitted due to: • The policy or process itself • Assessment structure • Equipment needs• Education needs • Employee competency • Staffing ratios • Environmental issues • Oversight needs • Insufficient time to complete task, etc.

Employees who are required to participate are actively apprised of the policy, process, or practice

Is readily available for review by staff who need to know

Is incorporated into employee competencies

Includes internal controls that adequately monitor and identify variations

Variations are promptly evaluated and resolution strategies are developed and implemented timely

There is a process in place to consistently evaluate functionality and compliance

Is reviewed by the QAA committee for value added or needed

Is reviewed, at a minimum, annually



TABLE 3.4

In-Service Checklist

Topic:

Date:

Location:

Instructor:

Lesson Plan Characteristics: Y N Recommendations Responsible Party

Objectives are measurable.

Teaching methods are appropriate based on topic content and identified need.

Content summary is comprehensive.

Evaluation methods are appropriate to measure learning.

References are included (evidence based, regulation).

Time frames are identified for content.

Appropriate staff received training.

Topic was added to orientation as indicated.

Competency checklist was included or developed as indicated.

Additional comments as needed:


chapter 4

Preparing Facility Stakeholders


AADNS Survey Readiness 24/7 Toolkit Chapter 4: Preparing Facility Stakeholders

Chapter 3 walks the survey preparation team through a process of evaluating facility processes and care systems. In chapter 4, the focus will be on conducting resident-specific evaluations and preparing staff for the survey process.

Taking time to conduct the individual resident and family member reviews helps to determine whether the residents’ quality of care and quality of life are achieving the goals of helping them attain and maintain their highest practicable level of well-being and promotes readiness for the upcoming survey. Interviewing staff about the care they provide to their residents is essential to survey readiness. This process has the added benefit of preparing staff to understand and be ready for the survey process.

Using the resident-selection process outlined in chapter 2, the internal survey-readiness TC creates a list of the residents in the selected pool to be reviewed during this compliance audit. The review consists of interviews with staff members about the care they provide and their knowledge of the residents, and with residents and their representatives about the care they receive. Additionally, during this part of the survey-readiness process, the team will complete a review of the CMS-issued forms for the Critical Element (CE) Pathways. While tools have been developed in many facilities and corporations to aid in these reviews, it is also important to use the tools CMS has provided. By using the CMS tools, staff members will become familiar with the information that surveyors will be asking and observing for. CMS tools also allow staff to learn about any resident issues and systems gaps that may need to be addressed before the surveyors arrive.

Additionally, thought must be given to how the survey-readiness interviews, pathways, and tasks will be set up. For each resident to be reviewed, the survey-readiness team should set up a grid that identifies the resident, team members assigned to conduct the interviews, tasks the assigned staff will complete, and completion dates. Here is an example:

Resident (from pool selection)

Staff to be interviewed

(using Resident

Record Review forms)

Team member assigned to

interview staff

Team member to interview

resident and/or

representative

Team member to review MDS and care plan

Team member to conduct CE

PathwaysDate to be completed

The TC may also choose to use the Survey Readiness Checklist (Table 1.2) to complete and track the audits for the CE Pathways.




Staff Interviews

The survey-readiness TC organizes staff interviews to be completed, identifying which members of the team will conduct interviews and which staff members will be interviewed based on residents selected in the pool process (see chapter 2). For example, the residents may be assigned by unit, neighborhood, or living section based on how they were chosen in the initial selection process. These pooled groups then become the focal point for primary staff to be interviewed on those units. The TC must ensure there are adequate numbers of interviewers to interview staff who know the selected residents, across all three shifts. There are many tools that could be reviewed with staff. The survey-readiness team can use the Staff Interview sections of the same forms surveyors will use, including the mandatory task observation forms and the CE Pathways. These forms are in the LTC Survey Pathway and Survey Resource folders. The TC will need to assign the appropriate CE Pathways based on the resident triggers, and the assigned interviewer will use the staff interview questions to gather the information. (See below for information on CE Pathways.) This requires planning and preparation.

Resident and Resident Representative Interviews

In addition to organizing staff interviews, the TC reviews the pool of residents and identifies those residents who will be interviewed and those whose representatives will be interviewed, as well as the staff members who will conduct the interviews. The TC may work with team members who know the residents best to determine interviewable residents, keeping in mind that there is no threshold to be used when selecting these residents. Caution should be used when choosing to exclusively interview a resident’s representative instead of the resident him- or herself, as valuable information may be missed. If doubt exists about whether a resident is interviewable, both the resident and the representative should be interviewed. The forms used for interviewing residents and their representatives are on the LTC survey website cited above, in the LTC Survey Pathway, Survey Resources, and LTCSP Initial Pool Care Area folders.

In addition to using the forms provided by CMS, team members can use the “Resident Personal Preferences” audit tool included in this toolkit (Table 4.1). This tool helps measure whether residents’ personal preferences are being honored in support of a person-centered approach to caregiving.

Record Reviews—Minimum Data Set (MDS) and Care Plan Review

Record reviews are conducted to review the documentation regarding care delivery and advance directives and to identify any other resident concerns. During record reviews and interviews, another component requiring the survey-readiness team’s focus is the MDS. The MDS is the clinical assessment tool that guides the resident assessment, and its accuracy is crucial because it is a key source of information used to develop the resident’s plan of care. Surveyors are trained to review each resident’s MDS and care plan for accuracy.

To audit the MDS for each resident in the pool, the team will want to use the Resident Assessment Critical Element Pathway. After the team member reviews the MDS, the care plan must be reviewed for compliance. The tool “Care Planning and MDS Quality Assurance Audit” (Table 4.2) can help the team review whether care plan elements are in place.






Critical Element Pathways

Next, the TC must identify and instruct reviewers in completing CE Pathways appropriate to triggered areas shown on the CASPER Quality Measure report for the selected residents. If there is no specifically applicable CE Pathway, the TC and reviewer must choose another resource with which to determine regulatory compliance—whether the General CE Pathway, a State Operations Manual “Investigative Protocol” or “Key Elements of Noncompliance” section (note that not every F-Tag has these sections), or a combination. The Investigative Protocol portion walks surveyors through a series of questions or scenarios to help them determine compliance with the regulation and can be used as well to determine compliance during the facility survey preparation process. The Key Elements of Noncompliance portion, provided to surveyors, has examples of what noncompliance looks like, and can assist facility staff to evaluate their own care practices.

There are 29 CE Pathways located on the LTC survey website cited previously. The survey-readiness team should review residents impacted by an area outlined in these 29 pathways. If none of the residents in the pool has a condition outlined by a particular pathway, the TC must select additional residents to review. The goal is to review residents representing all of the CE Pathways in order to identify issues prior to the surveyors’ doing so.

Notification of Change in Resident Condition

Change in resident condition has become an area of focus for surveyors. As team members conduct resident reviews in their assigned audit sections, it is important that they assess whether changes in condition have been identified timely and the appropriate notification has been completed. The tool “Notification of Change in Resident Condition or Status” (Table 4.3) is designed to assist the team member conducting the review.

QAA and QAPI Action

After conducting the interviews of staff, residents, and resident representatives, and reviewing the residents’ MDSs and care plans, the auditors will have gathered information that needs to be turned into QAPI action. Using the facility’s QAPI protocols, the TC will meet with the survey-readiness team and then will meet with the QAA team to review the audit findings and begin the process of correcting any issues noted during the reviews. To support findings and actions taken, all information should be compiled into an organized, easily accessible file or survey binder. (This will be discussed further in chapter 6.)




TABLE 4.1

Resident Personal Preferences Review

Date: Unit: Completed by: Instructions: Indicate Y for yes or N for no for each question for each resident interviewed. If question is not applicable to resident, indicate with an asterisk (*). Select residents to audit from the facility pool selection process, or at least 20% of the resident population.

QuestionsResident Corrective Action

(Identify Resident #)#1 #2 #3 #4 #5

1. Do you eat and enjoy bedtime snacks?

2. Can you eat other than during scheduled mealtimes?

3. Can you choose whom you sit with when eating?

4. Do you usually get up in the morning and go to bed at night at a time of your choosing?

5. Can you choose what you wear?

6. If you want to visit another resident here, can you do it?

7. Has there ever been any problem in someone who wanted to visit you, and whom you wanted to see, getting to see you?

8. If you want to leave the facility for short periods of time, can you do so?

9. Can you spend your time around here pretty much the way you like?

10. Do you like the activities that are offered?

11. Is your mail still sealed when you get it?

12. Is there some means by which you can make private phone calls?

13. If you have moved from one room to another, did the staff inform you in advance about the move and why you were being moved?

14. If you asked to move because you wanted to, did the staff enable you to do so?

15. Did you choose your physician?

16. Have you wanted to see a particular physician and been unable to do so?

17. If you need help in the bathroom, or washing up, or dressing, do you get help?

18. If you have ever complained formally about anything here, was your complaint resolved?

19. Can you make choices about your care?





20. Are you invited to attend meetings with staff to discuss and plan your care and treatment?

21. Are you asked for your consent before treatment or drugs are started or stopped?

22. Do you know what the rules are here?

23. Do you know what your rights are as a resident here?

24. Does the staff address you by your name of choice?

To QA Committee:Yes No

Comments:

Compliance Score

Number of residents/charts reviewed:

Number of residents/charts without issues (compliant):

Compliance rate: (Divide number of compliant charts by number of charts audited and multiply by 100, e.g., 12 charts audited, 5 charts compliant = 41.6% compliance. 5 ÷ 12 = 0.416 × 100 = 41.6%)



TABLE 4.2

Care Planning and MDS Quality Assurance Audit

Auditor: Date:

Instructions: Indicate Y for yes or N for no for each question for each resident interviewed. If question is not applicable to resident, indicate with an asterisk (*). Select residents to audit from the facility pool selection process, or at least 20% of the resident population.



Section A. Assessment

1. Comprehensive MDS completed: • within 14 days of admission

• within 14 days of a significant change

• at least every 12 months

2. MDS completed every 92 days.

3. RN certification signature and date (Z0500).

4. Disciplinary certification signatures and dates are present (Z0400).

5. Most recent quarterly review of resident’s condition is consistent with progress notes and plan of care.

Section B. Problem Identification

6. All triggered problems have been addressed by the IDT via Care Area Assessments (CAAs).

7. A CAA summary has been written for each triggered care area problem. Each summary contains: risks and complications, need for referral, reason why/why not proceeding to care plan, inclusion of resident/resident representative.

8. Justification of the lack of need for further care planning is evident by the IDT.

9. Problems/strengths have been prioritized by the IDT, and affected disciplines have signed.

Non-pharmacologic interventions have been included as indicated.

10. IDT is involved in the process. This includes an RN with responsibility for the resident; attending physician; nurse aide with responsibility for the resident; member of food and nutrition services staff; to extent practicable, resident and resident’s representative; other appropriate staff.

11. Plan of care is developed within 7 days of completion of MDS.





12. Plan of care includes all problems and strengths noted on MDS.

13. Each problem/strength has measurable goal.

14. Approaches are individualized, specific, and include all disciplines involved.

Section C. Plan of Care

15. Problems, goals, strengths approaches are integrated and are not contradictory by discipline.

16. Each goal has a determined target date for achievement.

17. Care plan is current as it reflects the current status of the resident, progress notes, MDS, and interview (if possible).

18. Therapists are involved in planning care when applicable.

19. Charge nurses, nurse assistants, and other direct care staff are knowledgeable of the plan of care and changes.

20. Communication system is in place among care planners.

21. Direct caregiver(s) attend team meeting.

22. Functional abilities have not changed since the previous care plan review date.

23. If yes to #22, documentation reflects the medical/clinical reasons for the change.

24. If yes to #22 and there has been a decline, alternative approaches to assist the resident to attain/maintain individual function have been tried.

25. All risk factors for decline are identified and planned for on plan of care.

Section D. Outcome/Documentation

Progress notes by discipline reflect resident’s: 26. care needs

27. care provided

28. response to and outcomes of care

29. ability/potential to participate further in or manage own care

30. status and progress toward goals




Compliance Score






TABLE 4.3

Notification of Change in Resident Condition or Status Review

Date: Completed by: Instructions: Indicate Y for yes or N for no for each question for each resident interviewed. If question is not applicable to resident, indicate with an asterisk (*). Select residents to audit from the facility pool selection process, or at least 20% of the resident population.

Please note: Notifications must occur promptly (within 24 hours) of the event, or immediately if the event is life-threatening or a serious injury occurred.

StandardResident Corrective Action


1. Physician notified by nursing when:

a. Resident was injured during an incident

b. Resident has injury of unknown cause

c. Resident has significant change in mental status

d. Resident has significant change in physical status

e. Resident has significant change in psychosocial/behavior status

f. Resident has need to have treatment altered

g. Resident refused treatments 2 or more consecutive times (or per facility policy)

h. Resident refused medications 2 or more consecutive times (or per facility policy)

i. Resident refused treatments/medications at least 2 times during a week (or per facility policy)

j. Resident is being discharged without proper medical authority

2. Staff notified appropriate family/resident representative when:

a. Resident involved in incident/accident and injured

b. Resident has injury of unknown cause

c. Resident has significant change in mental status

d. Resident has significant change in physical status

e. Resident has significant change in psychosocial/behavior status



StandardResident Corrective Action


f. Resident has a need to have treatment altered significantly

g. Resident has a change in room assignment

h. Resident is to be discharged from the facility

i. Resident is to be transferred to the hospital

3. Resident and/or resident representative notified by nursing staff when:

a. A change in medical care or nursing treatment occurred

b. A change in room assignment occurred

c. Transfer to the hospital occurred

d. Discharge from facility occurred


Comments:

Compliance Score





chapter 5

Preparing Your Environment


AADNS Survey Readiness 24/7 Toolkit Chapter 5: Preparing Your Environment

Chapter 4 focused on identifying areas of concern and/or regulatory compliance through interviews and resident record reviews. The team can now begin to focus on another technique used during survey: observing residents and the environment. This is where the survey-readiness team observes resident care and interactions between staff and residents, and observes the environment that impacts residents. How residents and the environment appear to an observer could be used to interpret quality-of-care and quality-of-life issues that lead to survey deficiencies. Chapter 5, then, will describe how the team will gather data and identify areas of concern that must be addressed prior to the actual survey.

Mandatory Tasks and Triggered Tasks

In addition to the resident record reviews and the CE Pathway reviews discussed in chapter 4, there are nine mandatory tasks developed by CMS that must be completed. The review of tasks uses detailed forms that surveyors must use during a standard survey; it is important that the survey-readiness team use the same versions of these forms during their review. The TC must identify team members with the skills to complete the mandatory tasks and then charge those individuals with completing them. For example, the medication storage area review will need to be conducted by a nurse, while the dining room observation may be completed by a member of dining services. All nine tasks should be addressed.

In addition to mandatory tasks, there are three triggered tasks to be completed. During the standard survey process, these tasks are triggered when surveyors identify concerns with these specific areas. However, the team will want to complete all the triggered tasks so all areas are assessed for concerns. Again, the TC must identify and assign one or more skilled team members these tasks.

The nine mandatory tasks are as follows:

• Beneficiary Protection Notification Review

• Dining Observation

• Infection Control

• Kitchen Observation

• Medication Administration

• Medication Storage

• Resident Council Meeting



• Sufficient and Competent Nurse Staffing

• QAA/QAPI

The three triggered tasks are:

• Environment

• Personal Funds

• Resident Assessment

The CMS forms for the tasks can be found at the LTC survey website, in the LTC Survey Pathways folder.

As the survey-readiness team will complete many assignments, it may be helpful to develop tracking systems. For example, when the TC assigns a mandatory or triggered task, the assigned team member’s name will be listed along with a completion due date on a tracking log.

Rounding

In addition to the mandatory and triggered task review, another technique the team can use to gather data is rounding. Rounding allows the survey-readiness team to hear firsthand the concerns of residents and staff and address them before the actual survey. Several types of rounding can be used to help identify areas of concern: leadership, clinical, customer-satisfaction, resident, and employee rounding. Furthermore, many rounding tools are available for use; an example is the QAPI Leadership Rounding Guide, available at the end of this chapter (see Table 5.1). This tool can be customized according to the specific area of care being reviewed. For example, clinical and care delivery reviews might focus on residents with high-risk, high-volume, problem-prone care issues, along with specialty populations identified in the facility-wide assessment. The team might focus its rounding on residents on hospice; using restraints or alarms; receiving intravenous fluids, enteral feedings, or wound care; on isolation; or on dialysis, to name a few. The rounding tool would be amended to reflect the facility’s policies and procedures as well as regulatory components.

Another review the team should conduct is the environmental rounds audit, which includes housekeeping and infection-control reviews. CMS tools for environmental and infection-control review are available on the LTC survey website in the LTC Survey Pathway folder. In addition to the CMS tools, the audit tools “Housekeeping Review: General Cleaning” and “Universal Precautions Review” are included in this toolkit for the team to use (Tables 5.2 and 5.3). These tools can assist team members in assessing the environment and practices that could pose risks to residents, families, and staff.

Rounding specific to grooming and care delivery may assist team members in determining resident concerns about quality of life and quality of care. The “Grooming and Care Delivery Review” audit tool included in this toolkit may be useful in this review (Table 5.4).


https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPILeadershipRoundingTool.pdf




Medication Review

An important function completed multiple times a day is medication administration. By conducting a medication review that includes an audit of medication storage areas as well as administration, the team will be able to identify potential errors and reduce administration-associated risks. Surveyors will complete two triggered tasks, “Medication Storage” and “Medication Administration.” AADNS has created an audit tool (Table 5.5) to help the survey-readiness team prepare; this can be used in addition to the CMS tools.



TABLE 5.1

Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.

Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse managers) are out in the building with staff and residents, talking with them directly about care and services provided in the organization including QAPI initiatives. Rounding with staff and residents is an effective method for leaders to hear firsthand what is going well and what issues need to be addressed within the organization. It serves as an important signal of leadership’s commitment to performance improvement, and promotes a culture of QAPI in the organization. Use this to guide your rounds to monitor the progress of QAPI initiatives. Questions to Consider Before Rounding 1. Which leader(s) will conduct rounds? 2. How frequently will rounds take place? 3. What questions do you want to ask? What do you want to learn? (See sample questions below.) 4. What barriers/issues have already been identified that employees should be asked about in order to

gather input on solutions? Rounding 1. Leaders conduct rounds as planned, maintaining a positive tone, building relationships with staff by taking

the time to listen and respond to employees’ and residents’ needs. 2. Ask questions and document key points. See optional rounding form below. 3. When employees raise issues or ask for help, assure them you will follow up. 4. Follow up on previous issues or requests —share with staff how the issues were addressed or resolved. To Do After Rounding 1. Identify frequently noted issues/themes. 2. Prioritize issues (e.g., by level of urgency, threat, ability to resolve). 3. Conduct follow-up to show responsiveness to the issues raised (note: this may involve following up with

employees individually, developing an organizational report that outlines the input collected and proposed solutions—potentially utilizing the priority levels developed in step #2—or including the findings as a component to be communicated during the next rounding session).

4. Consider ways to acknowledge outstanding employee/unit efforts (e.g., thank you notes or other rewards/recognition).

5. Identify training or coaching opportunities for employees/units. Plan next rounding session.

QAPI Leadership Rounding Guide




Rounding Form PERSON CONDUCTING ROUNDS: DATE: UNIT(S):

BACKGROUND: (to be completed prior to rounding) TOPIC ___Specific PIP(s): ___Specific aspect of care (e.g., bathing, medication reconciliation) ___Specific work place or workflow issue ___Other Information needed prior to rounding: What is your organization trying to achieve? How will improvement be recognized? Current data or description of performance: Improvements made to-date: BARRIERS/ISSUES ALREADY KNOWN: (sharing these may be an opportunity to ask for staff input on solutions)

PREVIOUS BARRIERS/ISSUES THAT HAVE BEEN ADDRESSED BY LEADERSHIP: (reporting these back to staff shows responsiveness)

Questions for leaders to ask staff (include any qualitative and quantitative information obtained). What things are going well around this initiative or this aspect of care or service? What evidence do you see of success?

Notes:

What is frustrating you with the work around this initiative or this aspect of care or service? What barriers/issues do you see threatening this initiative or aspect of care or service? How should they be addressed?

Notes:




What additional resources/tools/equipment are needed?

Notes:

Are there any colleagues who deserve special recognition for their efforts on this initiative or this aspect of care or service?

Notes:

Are there any colleagues who could be helped through coaching/training to make this initiative or aspect of care or service more successful?

Notes:

What feedback, if any, have you heard from residents and families about changes taking place as part of this initiative or this aspect of care or service?

Notes:

What else would you like the leadership to know about this initiative or this aspect of care or service?

Notes:

Leaders –summarize notes from conversations you had with residents or families on this topic:



TABLE 5.2

Housekeeping Review: General Cleaning

Date: Time: Unit:

Completed by:

Instructions: Check YES or NO for each standard. If standard is not applicable, place an asterisk (*) in the YES column.

Standards Yes No Corrective Action/Comment

1. Maintenance Storage Areas/Closet:

a. Kept locked at all times.

b. Chemicals labeled and stored off floor.

c. Dilution of chemicals posted.

d. Floor, walls, ceiling, and vents clean.

e. Sinks clean and no water leakage observed.

2. Resident Rooms:

a. Floors clear of spills, stains, and debris.

b. Corners and edges clean and free of wax buildup.

c. Bed frames free of dust and lint.

d. Cubicle curtains present, clean, properly hung, and not torn.

e. No evidence of dust on window sills, blinds, lights, furniture, behind beds.

f. Over-bed tables clean.

g. Bathroom clean, free of odors; towel, toilet paper, and soap dispensers filled.

h. Trash receptacles lined with plastic bags and emptied per schedule.

i. Resident room free of odors.

k. Closet floors clean.

3. Hallways:

a. Floors clean and dry.

b. When floors are being washed, “Wet Floor” signs evident.

c. One-half floor mopped at a time.

d. Water changed per policy, or more frequently if indicated.

e. Corners and edges clean and free of wax buildup.




4. Garbage/trash:

a. Stored in designated areas.

b. Kept in covered receptacles.

c. Receptacles clean.

d. Collected according to schedule.

5. Cleaning of Wheeled Equipment:

a. Wheelchairs/geri-chairs cleaned according to schedule, or more frequently if indicated.

b. Carts and med carts cleaned according to schedule, or more frequently if indicated.

Comments:



TABLE 5.3

Universal Precautions Review

Date: Time: Completed by:

Employee: Department:

Instructions: Check YES or NO for each standard.


1. Gloves are readily available on the unit.

2. Hands are washed for the appropriate amount of time per facility policy before and after each resident contact.

3. Gloves are changed after contact with each resident.

4. Gloves are used for pericare, oral care, changing incontinent briefs.

5. Gloves are used for trash and laundry disposal.

6. Gloves are used for accuchecks, injections, and/or venipunctures.

7. Gloves are used for emptying bedpans/Foley catheter bags/emesis basins.

8. Gloves are used for treatments and/or dressing changes.

9. Needles are not recapped by hand.

10. Needles are not removed from disposable syringes.

11. Needles are deposited uncapped into needle/sharps box.

12. Needle/sharps box has room for more needles.

13. Needle/sharps containers are readily available.

14. Sharps containers are capped when filled and placed in the red infectious waste bag/box/container.

15. Solutions for cleaning up blood/body fluid spills are available.

16. All soiled linen is bagged at the location where it was used.

17. Linen soiled with blood/body fluids are transported in impervious bags.

18. Equipment is available for universal precautions:

a. gloves




b. soap, towels, trash cans

c. gowns/aprons

d. masks

e. goggles

19. Disposable infectious wastes are discarded in red plastic bags no less than 3 mil thickness.

20. Soiled dressings/wastes are discarded in plastic bags while in the resident’s room and the bag is then placed in the appropriate trash receptacle.

Additional comments/corrective action by reviewer:



TABLE 5.4

Resident Grooming and Care Delivery Review

Date: Unit: Completed by: Instructions: Indicate Y for yes or N for no for each question for each resident interviewed. If question is not applicable to resident, indicate with an asterisk (*). Select residents to audit from the facility pool selection process, or at least 20% of the resident population.



Grooming:

Resident’s appearance is generally clean and neat.

Resident’s hair is groomed neatly and styled according to resident wishes.

Resident’s face is clean.

Male resident’s facial hair is maintained according to known preferences in the care plan.

Female resident’s face is without facial hair unless care-planned.

Resident’s glasses are clean and well fitting.

Resident’s hearing devices are in place, clean, and work.

Resident’s teeth are clean; if dentures, clean and well fitting.

Resident’s nails are trimmed and clean, without ragged edges.

Clothing is neat, clean, and wrinkle free.

Clothing is properly fitting and appropriate according to preferences.

Clothing is appropriate for the weather/temperature.

No names are visible on resident’s clothing.

Shoes are clean and in good repair.

Shoes are appropriate for safe mobility.

Wheelchair and other aids according to plan of care are clean and in good repair.

Cushions are in place, clean, and in good repair according to plan of care.

Music and television are appropriate content according to resident wishes and volume is appropriate for hearing ability.

Lighting is appropriate for resident preference and ability.

Resident is observed in a location appropriate for time of day and plan of care.





Care Delivery Review:

A review of resident’s plan of care and MDS was completed prior to observing resident care.

Resident care was observed and provided according to the resident’s plan of care and MDS:

a. Bathing

b. Dressing/grooming

c. Toileting—including catheter care, as appropriate

d. Transferring

e. Bed mobility/turning and positioning

f. Assisting with meals


Resident #1:

Resident #2:

Resident #3:

Resident #4:

Resident #5:

Compliance Score






TABLE 5.5

Medication Storage Review

Date: Unit: Completed by: Instructions: Check YES or NO for each standard for each resident audited. If standard is not applicable to resident, place an asterisk (*) in the YES column.

Standards Y N Corrective Action/Comment

1. Med carts are locked at all times when the nurse is not using the cart.

2. Schedule II medications are maintained within a separately locked, permanently affixed compartment.

3. Discontinued and expired meds are removed on a timely basis.

4. Proper procedures are followed when meds are discontinued:

a. Meds are destroyed.

b. Narcotic destruction is safe, secure, and prevents diversion.

c. Meds are returned to pharmacy.

5. External and internal meds are separated.

6. Multidose medications are dated when first opened.

7. All drugs have an expiration date.

8. Medication containers meet labeling requirements.

9. Med carts are stored under 77° F.

10. No evidence of pre-pouring or pre-preparing meds prior to a med pass.

11. Cart is neat, clean, free of spills, and loose medications are in the bottom of the drawers.



chapter 6

Preparing Your Plan


AADNS Survey Readiness 24/7 Toolkit Chapter 6: Preparing Your Plan

There are many activities that staff carry out and residents experience in a 24-hour period. By observing residents in their environment and completing system reviews, the team will more deeply understand concerns that need to be addressed as well as matters of compliance. Chapters 2 through 5 have looked at how the team collects data. It is important to systematically review the data and determine how it should be addressed. Chapter 6 will discuss what to do with the results of all the data collected throughout the survey-readiness review.

The TC and other members of the team have used interviews, observations, and record reviews to assess whether care delivery complies with regulations. During the process, the team may identify areas of concern requiring action. The team will need to coordinate addressing and monitoring areas of concern. This may require facility leaders to develop and implement an internal plan of action to correct potentially deficient practices.

Plans of Correction

A place to start, as introduced in chapter 2, is with past survey deficiencies. Because the surveyors will review the facility’s survey history, so should the facility team. To prepare, the facility’s TC will need to review the past three years of the facility’s statements of deficiencies and plans of correction to confirm that issues are managed according to the monitoring system identified and accepted through the plan-of-correction process. For example, there should already be binders, files, or electronic folders in place that contain the statements of deficiencies and corresponding plans of correction with supporting detail. The supporting information should provide evidence that the monitoring and auditing system put in place sustained the plan-of-correction elements. Additionally, the TC should review newly collected data to ensure that no issues from past surveys are reoccurring that could trigger repeat deficiencies.

Action Steps to Correct Negative Findings

Once the data is collected at each phase, the team should assemble all the information in an organized manner, creating a binder, file, or electronic folder. The binder should be organized in the order in which the information was collected, sorted by resident or task as appropriate. Once the information is organized the team should conduct a systematic review and determine whether an action plan is required to correct any negative findings. In some cases, the team may choose to correct negative findings as it collects and reviews information. If so, this action should be documented and added to the binder, to be available for review by the QAA/QAPI committee to ensure there is not a trend or systems issue that may need deeper exploration to prevent reoccurrence.

For other negative findings not corrected at the time of discovery, the team should meet and discuss setting up an action plan that includes what the issue is, how and by whom it will be addressed, by what date corrective action will be



completed, and how that action will be monitored. Though the actual surveyors may still find the issue during a standard survey, an action plan will be in place, providing evidence that the team was aware of and attended to resolving the negative findings. (A sample action plan from LeadingAge Michigan is available on the following pages). During the survey-readiness team review, team members may find that further exploration of the negative findings is required and determine that a Performance Improvement Project is required.

QAA/QAPI

A written summary of findings, along with actions and recommendations, should be presented to the QAA/QAPI committee to assist in determining what follow-up or monitoring will be put in place. The written summary should include these elements from the SOM guidance at F867:

• A definition of the problem—which, depending on the severity and extent of the problem, may require further study by the committee to determine contributing causes of the problem (Root Cause Analysis)

• Measurable goals or targets

• Step-by-step interventions to correct the problem and achieve established goals

• A description of how the QAA committee will monitor to ensure changes yield the expected results

Additionally, if the survey-readiness team has determined that a PIP is required, the findings should be presented to the QAA/QAPI committee so a PIP team can be formed and corrective action completed. A sample PIP charter from CMS is included in this toolkit.

Conclusion

Once a team decides to design and perform a survey-readiness process, team members must choose from among the many ways this process can be conducted. The goals of survey readiness should be to identify areas that require improvement, ascertain survey compliance, provide staff an opportunity to learn and build confidence, and improve resident care. Time, resources, and administrative support are needed to be successful in conducting an internal survey-readiness process. In addition, in order to be survey ready 24/7, facility leaders need an ongoing plan to complete an internal survey-readiness review at specific and regular intervals. It is hoped that the information and tools in this toolkit will be useful in the development of an internal survey-readiness team and a successful readiness strategy.

https://cdn.ymaws.com/www.leadingagemi.org/resource/resmgr/2015_AC_Handouts/4B-Supervison_for_Accident_P.pdf

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/pipcharterwkshtdebedits.pdf


QAPI ACTION PLAN

Location: Facility Name

Unit or population: Date: Team Members

Concern (Use data) Root Cause Analysis:

Goals & Objectives (Measurable, compare to concern data) Action Items (corresponding to Root Cause Analysis)

Responsible Team Member(s)

Start Date

Estimated Completion Date

Actual Completion Date

Comments

CONFIDENTIAL FOR QA PURPOSES ONLY


Note: This resource was created by LeadingAge Michigan. Used with permission.


QAPI ACTION PLAN

Action Items (corresponding to Root Cause Analysis)

Responsible Team Member(s)

Start Date

Estimated Completion Date

Actual Completion Date

Comments

CONFIDENTIAL FOR QA PURPOSES ONLY


Note: This resource was created by LeadingAge Michigan. Used with permission.




What is a project charter? A project charter clearly establishes the goals, scope, timing, milestones, and team roles and responsibilities for an Improvement Project (PIP). The charter is typically developed by the QAPI team and then given to the team that will carry out the PIP, so that the PIP team has a clear understanding of what they are being asked to do. The charter is a valuable document because it helps a team stay focused. However, the charter does not tell the team how to complete the work; rather, it tells them what they are trying to accomplish. Use this worksheet to define key charter components. PROJECT OVERVIEW Name of project: Example: Reduction in use of position change alarms

Problem to be solved: Example: Alarms going off frequently detract from a homelike environment and may give staff a false sense of security. Background leading up to the need for this project: Example: Residents and families have complained about the sound of alarms going off frequently. Staff feel pressure to do “something” when a resident falls. [Tip: Reference specific background documents, as needed.]

The goal(s) for this project: Example: Decrease the percentage of residents with position change alarms used on XX unit by 25% by XX/XX/XX. [Tip: See Goal Setting Worksheet]

Scope—the boundary that tells where the project begins and ends. The project scope includes: Example: Use of position change alarms on XX unit.

Worksheet to Create a Performance Improvement Project Charter

Note: This resource was created by CMS and is in the public domain.




PROJECT APPROACH Recommended Project Time Table: PROJECT PHASE START DATE END DATE

Initiation: Project charter developed and approved

Planning: Specific tasks and processes to achieve goals defined

Implementation: Project carried out

Monitoring: Project progress observed and results documented

Closing: Project brought to a close and summary report written

Project Team and Responsibilities: TITLE ROLE PERSON ASSIGNED Project Sponsor Provide overall direction and oversee

financing for the project

Project Director Coordinate, organize and direct all activities of the project team

Project Manager Manage day-to-day project operations, including collecting and displaying data from the project

Team members*

*Choice of team members will likely be deferred to the project manager based on interest, involvement in the process, and availability. Material Resources Required for the Project (e.g., equipment, software, supplies):





Barriers What could get in the way of success? What could you do about this? Example: A resident could fall and staff could automatically blame the lack of an alarm.

Example: Educate staff on the lack of relationship between alarms and falls; collect data on removal of one alarm at a time.

Example: Staff complaints of need for additional staff to watch everyone if alarms are removed.

Example: Focus on anticipation of resident needs, and assess if additional hands-on-deck are needed during busy times on unit.

PROJECT APPROVAL The signatures of the people below relay an understanding and approval of the purpose and approach to this project. By signing this document you agree to establish this document as the formal Project Charter and sanction work to begin on the project as described within. TITLE NAME SIGNATURE DATE Administrator

Project Sponsor

Project Director*

Project Manager*

*May not always have both roles.



Resources Cited

AADNS Survey Readiness 24/7 Toolkit


AADNS’s Facility Assessment Workbook https://www.aadns-ltc.org/Landing-Pages/Facility-Wide-Assessment-Workbook

CASPER Reporting User’s Guide for MDS Providers https://qtso.cms.gov/mdstrain.html

Critical Element (CE) Pathways https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ GuidanceforLawsAndRegulations/Downloads/LTC-Survey-Pathways.zip

Entrance Conference Worksheet https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/ Downloads/Entrance-Conference-Worksheet-Facility-Copy.pdf

Long Term Care Survey Process (LTCSP) Procedure Guide https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ GuidanceforLawsAndRegulations/Nursing-Homes.html

LTC Survey Website https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ GuidanceforLawsAndRegulations/Nursing-Homes.html

Matrix for Providers (CMS-802) https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/CMS-802.pdf

QAPI Leadership Rounding Guide https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ QAPI/downloads/QAPILeadershipRoundingTool.pdf

Requirements of Participation (RoP) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/ CMS1201984.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

Sample Action Plan from LeadingAge Michigan https://cdn.ymaws.com/www.leadingagemi.org/resource/resmgr/ 2015_AC_Handouts/4B-Supervison_for_Accident_P.pdf

Sample PIP Charter https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/pipcharterwkshtdebedits.pdf

Survey & Certification Memo 18-05-NH https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-05.pdf


https://qtso.cms.gov/mdstrain.html


https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Entrance-Conference-Worksheet-Facility-Copy.pdf



https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/CMS-802.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPILeadershipRoundingTool.pdf


https://cdn.ymaws.com/www.leadingagemi.org/resource/resmgr/2015_AC_Handouts/4B-Supervison_for_Accident_P.pdf

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/pipcharterwkshtdebedits.pdf


survey readiness 24/7 toolkit

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