Standard, Abbreviated and Revisit Survey Offsite Preparation

Michelle Roepke, BS, MT (ASCP)Director-Federal Survey and Certification DivisionLARA-Bureau of Community and Health Systems

Alicia Kuehn-Moore MA, BAA, RN, NHA, C.H.E.S.Nurse Consultant

Standard Survey Offsite Preparation

Quality Measure/Indicator Reports, are used as indicators of potential problems or concerns and are downloaded from the State database.

1. Facility Characteristics Report (CASPER Report MDS 3.0 Facility Characteristics)2. Facility Quality Measure/Indicator Report (CASPER Report MDS 3.0 Facility Level Quality Measure Report)3. Resident Level Quality Measure/Indicator Reports (CASPER Report MDS 3.0 Resident Level Quality Measure Report)4. CMS 2567 (Statements of Deficiencies)

Standard Survey Offsite Preparation Continued

5. CASPER Report 0003D Provider History Profile (CMS OSCAR Computer System)6. CASPER Report 0004D Provider Full Profile-Resident Characteristics (CMS OSCAR Computer System)7. Complaint investigation results 8. Waivers or variances9. Ombudsman office concerns 10. Other pertinent information

1. Facility Characteristics Report (CASPER Report MDS 3.0 Facility Characteristics)

Demographic information about: Resident population Gender Age Payment source Diagnostic characteristics Type of assessment Stability of conditions Payment source

2. Facility Quality Measure/Indicator Report (Casper Report MDS 3.0 Facility Characteristics)

Status for each MDS based quality measures/quality indicators compared to state & national averages.

Denominator

Observed Percentage & Adjusted Percentage

Comparison Group State Average

Comparison Group National Average

Comparison Group National Percentile

3. Resident Level Quality Measure/Indicator Reports (CASPER Report MDS 3.0 Resident Level Quality Measure Report)

Generated from the facility MDS data base; what conditions residents may have.PainPressure Ulcer, New/worse Pressure UlcerRestraintsFalls, Falls with injuryAntipsychotic MedicationsAntianxiety Medications

3. Resident Level Quality Measure/Indicator Reports (CASPER Report MDS 3.0 Resident Level Quality Measure Report) ContinuedBehaviorDepressionUrinary Tract Infection (UTI)Urinary CatheterBowel/BladderWeight (Loss or Gain)Increased Activity of Daily Living (ADL’s)

4. CMS 2567-Statements of Deficiencies

Citations from the previous survey during the prior year.Enables survey to look for possible areas of

concern.

5. CASPER Report 0003D (from CMS OSCAR Computer System)

The facility 4 year compliance history.

Four years of compliance history; The citations (the F-tag) obtained during past four years, with scope and severity.

Complaint investigation and Federal monitoring surveys during the past 4 years.

Repeated deficiencies/patterns.

6. CASPER Report 0004D Provider Full Profile-Resident Characteristics (from CMS OSCAR Computer System)

Information provided from the facility during the previous survey from the Resident Census (CMS 672).

Compares population characteristics to state, CMS region, and national averages.

7. Complaint Investigation Results

Four years of the facilities compliance history, the citation (the F-tag), the scope and severity.

Also has the dates of any complaint investigation and Federal monitoring survey data from the past 4 years.

Repeated deficiencies, any patterns.

8. Waivers or Variances Information

Staffing waiverThe CMS/Federal guidelines for staffing variances.

Room varianceThe CMS/Federal guidelines for resident room

space. Do the waivers or variances have any negative

effects on resident care or quality of life?

9. Ombudsman Office Information

Information of potential concerns reported by the ombudsman.Concerns or complaints reported from the

ombudsman generated from residents, family members/visitors.

10. Other Pertinent Information

Special potential concerns reported from the media or other sources.

Abbreviated (Complaint/FRI) Survey Offsite Preparation

Complaint InvestigationsThe Complainant

The complainant is contacted for additional information regarding the intake received (complaint).

Other pertinent informationAny other information obtained relevant to the

complaint.

Revisit Survey Offsite Preparation

Revisits for standard and complaint/FRI surveysTo confirm the facility has implemented their

plan of correction (POC).To confirm the facility is in compliance with

CMS regulatory requirements.

Are You Ready for the Standard Survey?

Be Prepared

Daily census.

Staff members to tour with surveyors.

Computers for surveyors with passwords.

Are You Ready for the Standard Survey?Continued

Survey BookUp to date facility Roster.Items from the Entrance Conference Checklist.Examples: Admission packet, medication and meal

schedules, alphabetical list of residents, residents receiving Hospice and dialysis services, residents under age 55, facility key personnel and their locations, policies and procedures related to resident rights, abuse, neglect, and the Elder Justice Act.

Thank you!

Any questions?

Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems Federal Survey and Certification Division

LARA-BCHS-FSCD 02-13-2017

FACILITY ENTRANCE CONFERENCE CHECKLIST

CCN# 23_______________ Provider Name: _______________________________________________

Survey Manager: __________________________ Manager’s Phone Number: _____________________

Bed Capacity: ___________ Census: __________Team Leader: _________________________________ ____________________________________________

Please provide the following documents as soon as possible:

_____ Must have within 1 hour. A numbered copy of the Facility Roster/Sample Matrix (CMS-802 Form) for each survey team member. _____ Completed LTC Facility Application for Medicare and Medicaid (CMS-671 Form). Electronic version preferred. _____ Resident Census and Conditions Form (CMS-672 Form). Electronic version preferred. _____ Copy of the current actual daily work schedules for licensed and registered nursing staff. (for all shifts) that are scheduled to work during the week of the survey. _____ List of residents with in-house acquired pressure ulcers and a list of residents with unplanned weight loss. _____ List of all residents with a diagnosis of Dementia who are receiving or have received antipsychotic medications within the last 30 days. _____ Alphabetical List of residents. _____ List of residents receiving Hospice Care and the name(s) of the hospice provider. _____ List of residents receiving dialysis services and the name(s) of the dialysis provider. _____ List of residents under the age of 55. _____ List of any residents who communicate with non-oral communication device, sign language or who speak a language other than the dominant language of the facility. _____ Copy of the facility’s building layout indicating the location of the nurses’ stations, individual resident rooms, storage and common areas and additional storage areas including outlying buildings. (Copies for each survey team member). _____ A copy of the facility admission packet/contract including payment sources and all written information provided to the residents regarding their rights and facility policies. _____ Schedule of medication pass by unit (including insulin injections, inhalers, IV’s or nebulizers). _____ Schedule of meal times, dining locations, and copies of all current menus including therapeutic menus that will be served during the duration of the survey by unit. _____ List of residents admitted during the past month. _____ List of residents transferred/discharged during the past three (3) months with destinations. _____ Activity calendar for the past three (3) months. _____ QAPI Committee personnel and meeting schedule. Include the contact person and who leads the committee. _____ Fire Drill records since the last annual survey.

Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems Federal Survey and Certification Division

LARA-BCHS-FSCD 02-13-2017

_____ The facility Disaster Plan Manual. _____ List of residents in the facility during the previous flu season (10/1-3/31). _____ Copy of the facility’s vaccination policy/procedure and any authorization forms. _____ Copy of the Trust Fund Policy/Procedures and all forms for completing transactions and giving authorizations. _____ Copy of current Surety Bond and current proof of payment. _____ Minutes from the last six (6) months of Resident Council meetings and the name of the Council President. _____ List of key facility personnel, their job titles, phone numbers and their locations. _____ Alphabetical list of all employees (including contracted individuals) including dates of hire, and job titles (RN, LPN, CNA and HSKP). _____ List of Medicare residents who received notice of non-coverage in last six (6) months. _____ Current CLIA Waiver _____ Registration as a Producing Facility of Medical Waste License. _____ Copy of smoking policy, list of current residents who smoke, and their smoking assessment form. _____ Complete files of three (3) past abuse/neglect investigations that the State did not investigate. Include your notes and interviews conducted. _____ Copy of facility policies/procedures to prohibit/investigate abuse, neglect, misappropriation of property, prohibition of staff taking/using photographs or recordings in any manner that would demean or humiliate a resident. This includes any equipment to take, keep, or distribute photographs and recordings on social media and the policies and procedures that relate to the Elder Justice Act. Identity of person who is responsible for coordinating and evaluating each Component. Include a copy of the Criminal Background Check Policy/Procedure. Survey Monkey https://www.surveymonkey.com/r/RSP7DXN

Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems Federal Survey and Certification Division

LARA-BCHS-FSCD 02-13-2017

SURVEYOR ENTRANCE CONFERENCE CHECKLIST

CCN# 23______________ Provider Name: _______________________________________________ Bed Capacity: __________________ Census: _________________________ Sample: Phase I-Comprehensive Reviews _________ Focused Reviews _______________ Phase II-Focused Reviews _________ Closed Records _________________ Resident/Family Interviews _________ _____ Does the facility have special care units for residents with heavy clinical needs, people with Dementia, or those receiving specialized rehabilitation services? _____ Make arrangements for staff to accompany team and initial tour. _____ Has the facility had an abbreviated survey prior to this survey? If yes, were there any concerns? _____ Inform the facility of exit conference guidelines in regards to citation findings. Minimally the President of the Resident council, as well as other cognitively intact residents should be invited to attend the Exit conference. _____ Clarify communication channels and expectations for the survey. Inform the facility that the survey team will be communicating with the facility staff throughout the survey and will ask for assistance when needed. Also, advise the facility; your staff will have the opportunity to give the survey team members any information that would clarify an issue brought to the facility staff’s attention. _____ Inform the facility that no documents that were requested during the survey will be accepted once the exit conference starts. _____ Provide the facility with copies of the survey signs to be posted. _____ Provide CASPER 3 and 4, Quality Measures (QM) and Facility Characteristics reports with explanation of how reports are used in TASK 1. Request explanation of discrepancies between quality Measures characteristics report and special features described by the facility. _____ Inform the administrator that there will be interviews with individual residents, groups of residents, family members, visitors, and legal representatives and that these interviews are conducted privately, unless the interviewees request the presence of an Ombudsman or staff member. _____ Ask the administrator to ensure that during the survey, there are times when residents, families or resident representatives may contact the survey team without facility staff present and without having to ask facility staff to leave or to allow access to the team. _____ Is there at least one (1) window to the outside in each room? (F461) _____ Do all bedrooms have access to an exit corridor? (F459) _____ Which, if any, rooms have less square footage than required? Do you have a variance in effect? are you prepared to continue to request a variance for such rooms? (F457)

Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems Federal Survey and Certification Division

LARA-BCHS-FSCD 02-13-2017

_____ Which bedrooms, if any, are not at or above ground level? (F461) _____ Does the facility have air conditioning? If so, is the facility fully air conditioned or partial? If partial, show what areas are air conditioned on the facility’s floor plan. (i.e. dining room, hallways, resident rooms, day rooms) (F257 and/or F467). EMR ACCESS/WIRELESS NETWORKS _____ Do you use any electronic medical records? _____ What portion of the clinical record is electronic? Inform the facility that each surveyor needs access to the electronic portion of the resident’s medical records within two (2) hours of the start of the survey. _____ Please provide the name(s) of the Health Information Person/responsible staff person designated to provide assistance to the survey team for the Electronic Medical Records. _____ Do you have a wireless network password available for survey staff? If so, please provide. ONSITE PREPARATORY ACTIVITIES _____ Call Ombudsman _____ Contact resident Council President or other council designee and make preparations for group interview.

Facility Survey Prep

Survey Preparation

• Be open and honest with them– Be sure that they understand the process.

• Requirements of participation in Medicaid/Medicare• Ramifications of citations• Citation scope and severity levels • How citations are corrected and re-survey process• What are common citations this year

If they understand the process, they can be a better participant.

Staff Education

• Let them know what surveyors will look at– They look back from the last survey year– They will look at resident charts– They will look at resident rooms– They will look at facility cleanliness and upkeep– They will observe resident care and med pass

What we do every day mattersWe don’t have a survey plan, we have an every day plan

Staff Education

• Review Abuse policies, Elder Justice Act, Disaster Plans

– Quiz staff frequently throughout the year, not just survey time.

– Remind them where to find pertinent information (necessary postings etc)

– All staff should know where staffing information is posted, survey information, how to help a resident or family member with a complaint.

– Give staff reminders every shift, every day.

Staff Education

• Staff should understand the stress level that the Administrator and DON and other key personnel are under during survey time.– This is not the time to talk about a schedule change or minor issue

that can wait– Also reassure them that you understand their stress level as well

Staff Education

• Give them tips for speaking with a surveyor

– It is ok to ask a surveyor to repeat or rephrase a question if you don’t understand what they are asking

– It is ok to take a minute to think about your answer and response

– It is ok to ask to reference a chart or resident information if necessary to answer a question

Staff Education

• Binder set up with current documentation requested on Facility Entrance Conference Checklist.

• Binder has tabs to easily access information. Updated monthly during the year and weekly during survey window (anyone can access in case of Administrator absence)

• If information needs to be updated when surveyors arrive, have a note as to who provides the updated information.

• House Supervisor or Shift Leader has same binder with same information or has immediate access to Administrator’s copy.

• Facility Information sheet is already filled out and ready to go. Information on that sheet doesn’t often change.

Administrator Preparations

• Binder set up with current documentation requested on Facility Entrance Conference Checklist.

• Binder has tabs to easily access information. Updated monthly during the year and weekly during survey window (anyone can access in case of Administrator absence)

• If information needs to be updated when surveyors arrive, have a note as to who provides the updated information.

• House Supervisor or Shift Leader has same binder with same information or has immediate access to Administrator’s copy.

• Facility Information sheet is already filled out and ready to go. Information on that sheet doesn’t often change.

Administrator Preparations

• Build a knowledgeable team – send staff to educational programs to help them understand the regulatory process (RN Boot Camp, Dementia Education, Infection Control Education, Joint Provider sessions)

• Know your residents – use CASPER/PEPPER reports • Use your Quality Assurance Processes and QA everything! Any resident/family

complaint goes through the QA process. • Educate your physicians. Be sure they are aware of new regulation changes,

current frequently cited citations.• Network with other facilities. Share survey results with those in your area or

regions.• Work with your surveyors, not against them. It is a benefit to get them what they

are asking for promptly to allow them to complete their job. Remember they are under stress and time constraints just as you are.

Administrator Preparations

• Know who the surveyors are looking at. Who are they asking questions about and what rooms are they going in.

• What staff are they talking to. Report what questions they asked.• Double check everything every day and every shift

• Med Carts• Dietary Carts• Kitchen• Pantry areas• Utility rooms

During the Survey

• Binder with pertinent information regarding citation–Correction of citation–Any QA’s that were derived from the citation–Staff education and documentation of such–Policies if any were updated due to citation

Re-Survey