352 CHAPTER 22 | Federal Regulations
However, the survey team can expand an abbreviated survey or complaint or facility reported survey to a standard survey if they find evidence that warrants more extensive review.
In addition to the initial, recertification, and complaint or facility reported incident surveys that the state agency conducts, CMS must also conduct federal monitoring surveys to review state agency performance. These surveys include the health, life safety code, and emergency preparedness parts of the survey. There are two types of federal monitoring sur- veys under the standard survey process11
:
• Long-term care health federal monitoring surveys are composed of three survey processes aimed at advising and evaluating state agency surveys. Fed- eral surveyors may accompany state agency sur- veyors on a focused concern survey, conduct an independent investigation of identified concern areas, or conduct a full survey after a standard survey is conducted by the state agency in the same facility.
• Long-term care life safety code federal monitoring surveys are composed of two survey processes aimed at advising and evaluating state agency surveyors. The federal surveyors may conduct a federal oversight and support survey to observe and assess the state survey team performance or a life safety code comparative survey, which is a full survey conducted after a standard survey is conducted by the state agency in the same facility.
The Survey Process
The standard survey process is described in the LTCSP.2
The survey process includes off-site prepa- ration, facility entrance, initial pool process, sample selection (a minimum of eight residents per surveyor are selected to begin the survey), investigation for sampled residents, and ongoing and other survey activities. Off-site preparation consists of conducting computer analysis of off-site data (results of the last standard survey, complaint surveys, facility reported incident or self-reports, quality measure reports, cer- tification and survey provider enhanced reports, and other reports) and making facility and task assign- ments to the team. It is the RDN’s due diligence to
ask the facility administrator for the reports, either in hard copy or electronically, that relate in any way to the nutrition and dining services department. Once at the facility, the entrance conference takes place with the administrator. RDNs and NDTRs should help provide the information required that relates to nutrition and dining services. This informa- tion can be found on the CMS Entrance Conference Worksheet.9
Facilities must be aware of the most cur-
rent worksheet, as these are frequently revised. Information required within 1 hour of the survey- ors’ entrance includes the following9
:
• schedule of mealtimes • location of dining rooms • copies of all menus, including therapeutic menus, that will be served for the duration of the survey
• policy for food brought in from visitors • RDN name and telephone number as part of key personnel
• information on paid feeding assistants, if employed by the facility
− whether training for paid feeding assistants was provided through a state-approved training program by qualified professionals as defined by state law, with a minimum of 8 hours of training
− a list of staff (including agency staff) who have successfully completed training as paid feeding assistants and are currently assisting selected residents with eating meals and snacks
− a list of residents who are eligible for assis- tance and are currently receiving assistance from paid feeding assistants
Information required within 4 hours of the sur- veyors’ entrance includes the Completed Matrix Form. This form includes individuals with weight changes. The nutrition practitioner must keep this form current and all staff need to know (1) who is responsible for updates and (2) the process that keeps this form up to date.
Information that may be requested within 24 hours
of the surveyors’ entrance include form CMS-672 documenting individuals with weight changes, those receiving texture modified diets, and those needing adaptive eating devices. This information should be kept current at all times.
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