Chapter 21 Federal Regulations


person who is assigned to reconciliation will use the team lead’s computer to do the resident reconciliation (identifying who is in the facility at the time of entry), and the team lead will conduct the entrance conference. After the initial tour, the entrance conference, and the reconciliation completion, a brief team meeting will be held to identify licensed staff in the facility and the type of residents (eg, dementia, rehab, younger popula- tion), and to report on any information from the entrance conference. The assignment of residents for Stage 1 will be made and will be downloaded on each surveyor’s computer. Surveyors are instructed to observe dining at the first meal served upon entry to the facility; therefore, the dining observation could happen during this initial time frame in the facility, depending upon the time of entry.


Stage 1 is designed to gather information on a preselected group of residents. The QIS program uses the MDS data from the past six months to determine who should be reviewed during Stage 1 for the census sample and for the admission sample. During recon- ciliation, residents who were discharged will be ran- domly replaced in a computer-driven manner by a new admission resident. The number of residents in the census sample is based on the facility census and can be up to 40 residents. The admission sample can be up to 30 residents. For the census sample, the QIS program directs the surveyor on what to observe, what information to gather from the record, and what questions to ask of the resident and the staff about the resident. During Stage 1, three family interviews are conducted for residents who are not interviewable. The QIS system is very specific on this number—only three families are to be interviewed at this time, and the residents must be determined to be noninterview- able by the surveyor. Admission records are primarily for residents who are discharged from the facility, and specific information is gathered from the medical record.


Once all information is collected for the census and admission sample, the team gathers for a transi- tion meeting. Each surveyor’s information is passed to the team lead’s computer, and the QIS program cal- culates the thresholds for each care area and deter- mines the Stage 2 sample. The system selects three residents for any of the 38 care areas that meet the predetermined threshold for further investigation. In addition to these preselected residents, the team initi- ates a review for one resident in each of these catego- ries: Hospice, Dialysis, Ventilator Use, and Preadmission Screening and Resident Review (PASRR). After the analysis, the team will discuss if there are any residents left out of the sample who may need to be added due to the critical nature of their condition. Additional residents and the associated


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care areas may be brought into the sample due to MDS data, not from surveyor-entered Stage 1 data. Residents from Stage 1 who have a low BMI and do not receive a prescribed high-protein, high-calorie supplement may be identified to be part of the Stage 2 sample for investigation. At this time, residents who have been marked as dehydrated in Section J of the MDS or whose weights from Section K of the MDS reflect weight loss will be identified as Stage 2 sample residents. These residents may or may not have been part of the Stage 1 sample and oftentimes will be dis- charged residents.


All residents in Stage 2 represent a care area or resident right area that could mean a failed practice exists. It is the surveyor’s job to go through the Critical Element (CE) pathway or triggered task to determine whether or not the facility is in compliance with the regulation. This is done by interviews, observations, and record reviews based on the CE pathway, the regu- lation for those areas without CE pathways, and/or the specific task directives. Policies and procedures will be reviewed in relationship to these areas as well. Mandatory and triggered tasks are completed throughout the survey. The first questions on the quality assessment and assurance (QAA) review are asked during the entrance conference. Through out the survey, the team discusses if there are issues that should have been addressed by the QAA team, and during the final phase of Stage 2, the team lead will complete the QAA task with the administrator. The kitchen task is started immediately upon entry into the facility during Stage 1 and is completed during Stage 2. Data from resident interviews and dining observa- tions help to focus the completion of this task. Dining observations are made in Stage 1, the first meal upon entry into the facility. If there are no concerns on that observation, the dining task is complete. However, if there are concerns in a specific area, that area will be revisited during Stage 2 but not in every dining room. The infection control task is ongoing throughout the whole survey, with all surveyors initiating infection control on their computer, noting any concerns. One surveyor is assigned to complete all aspects of the task, with other surveyors primarily watching for infection control issues during resident observations, walkthrough of the facility, and dining service. Surveyors watch the distribution of meals in the dining rooms and in the hallways for room trays. Special attention is paid as to how residents are served in their rooms, whether or not staff wash their hands between resident rooms, and the setup of residents and trays in each room. The other mandatory tasks— Medication Administration, Medication Storage, Resident Council Chair interview, and Liability Notices and Appeals—may be started during Stage 1


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