Survey Process

Question 1

What are the main steps in the survey process?

Answer 1

1. Offiste prep
2. Facility entrance
3. Inital pool process
4. Sample selection
5. Investigation
6. Ongoing and other survey activities
7. Potential citations

Question 2

When is the QAA/QAPI task completed?

Answer 2

At the end of the survey, before the exit conference, with the TC.

Question 3

What software is the survey shell created in?

Answer 3

ASPEN Central Office (ACO)

Question 4

What software do you use to complete the survey?

Answer 4

ASPEN Survey Explorer (ASE-Q)

Question 5

Who preps the survey shell prior to the start of the survey?

Answer 5

Team Coordinator (TC)

Question 6

What should the TC have printed prior to entering the facility?

Answer 6

1. Facility matrix (1 set of instructions and multiple copies of a blank matrix)
2. Entrance conference worksheet (1 copy)
3. Beneficiary notices worksheet (3 copies)

Question 7

What should survey team members do prior to entering the facility?

Answer 7

Review the Offsite preperation screen.
* Review and FRIs assigned to you
* Review MDS indicator facility rate report
* Review offsite selected residents and their MDS indicators

Question 8

Who does the entrance conference with the facility administrator upon entering the facility?

Answer 8

The TC

Question 9

What information is needed from the facility immediately upon entrance?

Answer 9

• Census number
• Complete matrix for new admissions in the last 30 days who are still residing in the facility.
• ABC list of all residents (idnetify those that are out of the facility)
• A list of residents who smoke, designated smoking times, and locations

Question 10

What does the TC request during the entrance conference?

Answer 10

• Request that the Administrator inform the Medical Director that a surveying is happening.
• Information regarding full time DON coverage
• Information about the facility’s emergency water source
• Provide signs annoucing the survey and request they are posted in high-visibility areas
• Copy of updated facility floor plan if there has been changes including COVID-19 observation units.
• Name of Resident Council President
• Provide the facility with a copy of the CASPER 3
• Does the facility provide arbitration agreements? If so, provide TC with sample copy
• Has the facility asked residents/representatives to enter binding arbitration agreement?
• Name of the staff responsible for the agreements.

Question 11

What information is needed from the facility within one hour of entrance?

Answer 11

• Mealtime schedule, locations, copies of all current menus that will be served throughout the survey period and policy for food brought in by visitors.
• Med Administration schedule
• Number and location of med storage rooms and carts
• Working schedule for all staff seperated by departments during the survey
• List of key personnel, location, phone numbers including contract staff and DON
• Paid feeding assistant information including if they were provided through a State-approved training program min 8 hours training, list of staff who have completed paid feeding assistant trainings, list of residents who receive assistance from paid feeding assistants.
• Name of the facility’s infection preventionist, documentation of their training and evidence of specialized training in infection prevention and control.

Question 12

What information is needed from the facility within 4 hours of entrance?

Answer 12

• Completed matrix for all other residents
• Admission packet
• Dialysis contract/agreement/policy & procedure
• List of qualified staff providing hemodialysis or assistance for peritoneal dialysis treatments
• Does facility have onsite seperatly certified ESRD unit?
• Hospice agreement, P&P, and contact info
• Infection prevention and Control Program Standards, P&P, including surveillance plan, antibiotic stewardship program, and influenza, covid-19, pneumococcal immunization P&P.
• QAA committee information
• QAPI plan
• Abuse Prohibition P&P
• Description of experimental research occurring in the facility (if any)
• Facility assessment
• Nurse staffing waivers
• List of rooms meeting any one of the following conditions that require a variance:
  
  • Less than the required square footage
  • More than four residents

Question 13

What information is needed from the facility by the end of the first day?

Answer 13

• Provide each surveyor access to all residents’ EHR and complete the EHR information form
• Provide a list of residents, who are currently residing in the facility, that have entered a binding arbitration agreement on or after 9/16/2019
• Provide a list of residents who resolved disputes through arbitration on or after 9/16/2019

Question 14

What information is needed from the facility within 24 hours of entrance?

Answer 14

• Completed Medicare/Medicaid application
• Completed census and condition information
• Beneficiary Notice - Residents discharged within the last six months

Question 15

True or False:

The facility should exclude bed holds from the facility census number

Answer 15

True

Question 16

When you receive the Facility Assessment report, what are you reviewing?

Answer 16

Review for systemic concerns identified in resident-specific areas or if there is a systemic concern with lack of adequate resrouces.

Question 17

What facility task must be done immediately upon entering the facility?

Answer 17

The kitchen task

Question 18

How many residents should you include in your inital pool?

Answer 18

8

Question 19

How many residents will you need to screen in your assigned area?

Answer 19

All of them

Question 20

What should a surveyor do to screen residents for the sample pool?

Answer 20

• Observations
• Interviews
• Limited Record Reviews

Question 21

Which residents should be included in the initial pool?

Answer 21

All offsite selected residents (unless discharged) and any compliant/FRI residents (see attachment A for max # of FRI residents). These residents do not need to be screened as they will already be included in the inital pool.

Question 22

True or False:

Before a surveyor enters a resident’s room, they should review the MDS indicators and matrix information (if available) for a more complete picture of the resident.

Answer 22

True

Question 23

If there are no concerns based on MDS indicators and matrix information, what should the surveyor do?

Answer 23

Conduct a head-to-toe observation of the resident. If there are no additional concerns, screening is completed.

Question 24

What two additional subgroups should be included in the initial pool?

Answer 24

Newly admitted residents and Vulnerable residents

Question 25

What questions and tools can you use to conduct the initial screening?

Answer 25

None- you will need to rely on your knowledge and critical thinking skills.

Question 26

# True or False: When screening residents, you should be documenting your notes on the RI, RO, and RR screens.

Answer 26

False- It's up to you how and where to document your screening notes, but it cannot be done in the RI, RO, or RR screens.

Question 27

Which residents should be included in the initial pool, if available?

Answer 27

* Resident who smokes * Resident who is receiving dialysis * Resident on Hospice * Resident on a ventilator * Two residents who are on Transmission-Based Precautions

Question 28

If a resident refuses an interview, what should the surveyor do?

Answer 28

Do not attempt to interview the resident again. Complete the record review and you still may be able to complete the resident observation unless the resident refused to be observed or participate in the survey.

Question 29

If a resident is unavailable for interivew, what should a surveyor do?

Answer 29

Make a few more attempts throughout the day or try to schedule an interview before determinig this status. If the resident is still unavailable, proceed with a limited record review and complete the resident observation.

Question 30

# True or False: If a resident is out of the facility during the initial pool process, mark the resident as "Out of Facility" and nothing more needs to be done.

Answer 30

False- You will still need to complete the record review.

Question 31

# True or False: When interviewing a resident, ensure that there is at least one staff in the interview room.

Answer 31

False- this allows the resident to speak more freely.

Question 32

When interviewing residents during the initial pool process, what tool can guide you through the interview process?

Answer 32

The care areas CE pathways

Question 33

# True or False: Each care area must be covered when interviewing residents during the initial pool process.

Answer 33

True- if a care area is not applicable, check the "No Issues/NA" checkbox.

Question 34

How will you know that a care area has been covered for a resident?

Answer 34

A green checkmark will pop up next to the care area on the screen.

Question 35

What does it mean when a surveyor selects the FI checkbox?

Answer 35

It identifies that the specific resident has a care area that needs to be further investigated.

Question 36

# True or False: A surveyor is permitted to make an observation of a resident's genitals, rectal area, and for females, the breast area.

Answer 36

False- This can only be done by a licensed nurse, physician's assistant, or a physician.

Question 37

When should you do RRI/Family interviews?

Answer 37

For non-interviewable residents