314 ● ●

Part III Standards for Compliance

Kitchen/Food Service Observation Infection Control Policies and Practices ● Demand Billing Review ● Abuse Prohibition Review

●

Quality Assessment and Assurance (QAA) Review

Task 6: Transition From Stage I to Stage II ●

Update the Resident Pool

● Review Completion of Stage I ●

●

Review Surveyor-Initiated Residents and/or Care Areas

Import All Data into the Primary Laptop ● Review the Relevant Findings Report ● Review the QCI Results Report

Task 7: Stage II Survey Tasks ●

Introduction

● Team Meetings ●

●

Stage II: Sample Selection Substituting Residents

● Supplementing the Sample Staff Assignments

● ● ● ●

Stage II: Information Gathering Stage II: Critical Element Pathways

Medication Administration Observation and Unnecessary Drug Review

Facility-Level Investigations Environmental Observation ● Resident Funds

● ● ● ●

Admission, Transfer, and Discharge Review Sufficient Staff

Task 8: Analysis and Decision-Making: Integration of Information

Integration of Facility-Level Information Integration of Critical Element Pathways ● Analysis of Information Gained

● ● ●

Analysis of Scope and Severity and Team Decision-Making

Task 9: Exit Conference ●

Exit Conference

The most current Appendix P, related to the QIS, does not yet include all aspects of the QIS process, required components, or a detailed description of the guidance to surveyors in completing this survey. Rather, the forms and process are updated periodically and the information is provided via teleconferences to the state agency that performs the QIS (5). The most up-to-date

Stage 2 Analysis The objective of the off-site preparation meeting is to review the facility’s past history, using the CASPER reports and ombudsman reports, and to note any waivers/variances of the facility. Additionally, the team determines who will be assigned to the eight manda- tory tasks, to the initial tour, and to the census reconcil- iation. This information is gathered on CMS Form 20044. The team lead gathers forms for the facility (new admissions; the entrance conference worksheet, CMS Form 20045) and for the team (CMS Form 20046; CMS QIS brochure; CMS-671, the Long-Term Care Facility Application for Medicare and Medicaid; Form CMS-672, the Resident Census and Conditions of Residents; and a copy of the CASPER 3 report). Additionally, there are various state-required forms to give to the facility. At this team meeting, the team also downloads the QIS shell containing resident informa- tion and MDS data. Each surveyor is instructed to initi- ate the Dining Observation Task (Form 20053) and Infection Control Task (Form 20054) on his or her computer.

Once the team enters the facility, staff will imme- diately begin their assigned tasks. The team lead will pass on the form for new admissions and the signs indicating that the survey has begun. One person will go to the kitchen for the initial kitchen check and will complete at least the first three questions on Form 20055. Other surveyors will begin the initial tour. The entrance conference will not be held until the New Admission form is returned. (This form is filled out by the facility with the names and demographic informa- tion on residents admitted within the past 30 days and who are still residing in the facility.) At that time, the

information can be found at the CMS website (www. cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/QIS-Survey- Forms.html). The following is a summary of the process:

Offsite Survey Preparation Entrance Conference On-site Preparation Stage 1

Mandatory Tasks Transition Stage 1 to Stage 2 Stage 2

Critical Element Pathways (CEs) Triggered Facility Task