Chapter 21 Federal Regulations ● Task 4: Sample Selection


● Task 5: Information Gathering ●


5A: General Observations of the Facility ● 5B: Kitchen/Food Service Observations ● 5C: Resident Review


● 5D: Quality of Life Assessment


● 5E: Medication Pass and Pharmacy Services 5F: Quality Assessment and Assurance Review ● 5G: Abuse Prohibition Review


● ●


Task 6: Information Analysis for Deficiency Determination


● Task 7: Exit Conference


The intent of the Off-site Preparation is to analyze various sources of information in order to identify and preselect potential residents for Phase 1 of the survey. This preselection may be amended after the facility tour, entrance conference, and the facility-provided Roster/Sample Matrix. To focus the survey, the follow- ing items are used: (3)


●


Quality Measure (QM) reports are used to iden- tify indicators of potential problems. (These reports were previously called Quality Indicator Reports.) The following are the three QM reports:


➤


Facility Characteristics Report: provides demographics about the resident population compared to state and national averages


➤


Facility QM Report: provides facility status for each of the MDS-based QMs as compared to state and national averages


➤


Resident Level QM Report: provides resident-specific information using current MDS data, the type of MDS assessment, and identifies the specific care area from MDS data


●


Statement of Deficiencies (CMS-2567) and Statement of Isolated Deficiencies (Form A)


●


Certification and Survey Provider Enhanced Reports (CASPER) Report 3, History Facility Profile, and CASPER Report 4: these reports contain the compliance history of the facility and information provided in the previous survey. Report 3 is used to determine if there is a pattern of repeat deficiencies in a particular tag or related tags and identifies the outcomes of complaint investigations and federal monitoring surveys. Report 4 contains information provided on the previous survey on the Resident Census.


●


Results of Complaint Investigations: review infor- mation from complaints investigated since the last survey, pattern of complaints as they relate to


●


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residents, staff, locations within the facility, or timing of the complaints (ie, night shift).


Information About Waivers or Variances: the survey team will review these on site to determine if a recommendation related to the waiver needs to be made to the State Agency (SA).


●


State Ombudsman Office reports: note any areas of concern that may need to be investigated.


●


Preadmission Screening and Resident Review Reports (PASRR): some states may have a way to report this information to the SA for evalua- tion of concerns.


It is the RDN’s due diligence to ask the facility admin- istrator for these forms either in hard copy or electronically.


The team that meets during the off-site preparation reviews all of the above information; in this meeting, the areas of potential concerns are identified along with which residents will be preliminarily selected for Phase 1. The facility’s QM report is used to preselect concerns that are flagged at the 75th or greater national percentile. In addition, based on the data, the team can decide to include areas of concern that may be at a lower percentile. The Resident Level QM report identi- fies each resident and care areas identified on the MDS. Residents who have the most care areas matching the areas of concern identified on the Facility QM report will be preselected as part of the sample. Approx- imately 60% of the residents are selected for inclusion in Phase 1 and the remaining 40% for Phase 2. The Roster/Sample Matrix is marked with each resident selected and the QM conditions for which each was selected. If there are concerns with weight loss, dehy- dration, and/or pressure ulcers (WHP), the minimum number of residents to be reviewed is identified in Appendix P, Table 1, “Resident Sample Selection,” and will be identified at this time as part of the Phase 1 sample (5). This preliminary selection may be modified once in the facility due to the status of a resident and/or other identified concerns from the initial tour and entrance conference, with the final selection made during Task 4, Sample Selection. Upon entry to the facility, the team is introduced and the facility’s administration is notified, if they are not on site. The team coordinator meets with the administrator, and the rest of the team begins the initial tour and kitchen observation. During the entrance con- ference, the following items are requested or discussed:


●


the current daily work schedules for licensed and registered nursing staff;


● list of the key facility personnel;


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