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HCPro Boot Camps
200 Hoods Lane,
Marblehead, MA 01945
Phone: (800) 780-0584
Fax: (800) 738-1553
Copyright 2000-2008,
HCPro, Inc., All Rights Reserved
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Five-Star Quality Rating Boot CampSM for Long-Term Care
Learning Objectives
Module 1: Overview of the Five–Star Quality Rating System
- Describe the purpose of the Five–Star Quality Rating System
- Navigate the Nursing Home Compare web site
- Define how OBRA '87 changed how nursing homes are operated
- Explain the different components of the State Operations Manual
- Find the nursing home survey and certification letters on the CMS Web site
- Demonstrate how to find survey regulations in the State Operations Manual
Module 2: Details of the Five–Star Quality Rating System
- Differentiate the major components of the Five–Star Quality Rating System and identify the relative weight of each component
- Describe the types of surveys that are included in the Five–Star Quality Rating System
- Distinguish between the roles of state surveyors and federal surveyors
- Explain the impact to the nursing homes when surveyors cite for seemingly minor infractions
- Describe the specific staffing requirements necessary to increase your rating
- Explain how the quality measures (QM) impact your Five–Star rating
Module 3: The Traditional Survey Process
- Define the survey window and survey frequency
- Illustrate how the resident sample selection process works
- Name the distinct phases of a typical nursing home survey
- Explain how to read a Statement of Deficiency
- Illustrate the different deficiency severity levels
Module 4: Quality Indicator Survey (QIS)?
- Recognize the main differences between the Quality Indicator Survey and the traditional survey process in the CMS nursing home health inspection
- Conclude why CMS felt it was necessary to update the survey process
- Identify the main challenges during the transition process from traditional to QIS
- Identify the QIS survey tasks
- Demonstrate one of CMS' new quality measurement tools for the survey
Module 5: Offsite Survey Preparation Tasks
- Review prior survey history using OSCAR reports and the Nursing Home Compare web site
- Analyze a quality indicator report to determine where the survey team will focus their efforts
- State what might cause a quality indicator score to be inflated, though not an effect of poor resident care
- Review transmitted Minimum Data Set (MDS) records to determine nursing home compliance and accuracy
Module 6: Comprehensive Care Review includes observations, interviews, and a record review
- Demonstrate how to staff should conduct themselves during surveyor interviews
- Describe the elements of the resident assessment instrument and how they link to quality of care
- State the importance of the Minimum Data Set to the Survey process
- Review transmitted Minimum Data Set records to determine nursing home compliance
- Devise a strategy to preemptively fight deficiencies before surveyors cite your facility
Module 7: F-Tag Fun
- Recall the recently revised F-Tags by CMS
- List two upcoming F-Tags that will be revised within the next few years
- Explain the difficulty of complying with F-Tag #314, Pressure Ulcers
- Discuss the difficulty of complying with F-Tag #315, Incontinence
- Demonstrate how to look up deficiencies in the Compendium
Module 8: Responding to Survey Citations and Immediate Jeopardy
- Demonstrate how to write an acceptable Plan of Correction
- Use the informal dispute resolution (IDR) process
- Recognize other types of survey appeals
- Define trends in civil money penalties CMS surveyors are awarding
- Describe how to recover from a Denial of Payment for New Admissions
- Explain the timeline for termination from the Medicare program
Module 9: Mock Surveys and Role Playing
- Construct a staff training strategy to train different levels of staff for survey
- Define how to evaluate your facility deficiencies through mock survey and define a process to link deficiencies to improved care
- Classify the survey forms by their different uses
- Summarize how you can use the forms to manage your own survey process
Module 10: Operational Focus Required for Optimal Five–Star Rating
- Describe a process to monitor the accurate capture staffing hours
- Define a monitoring process for auditing performance in the Five–Star Quality Rating
- Explain the frequency necessary to perform benchmarking
- Describe which team members need to be involved in the process
Module 11: CQI and the Five–Star Nursing Home Ratings
- Define what constitutes a continuous quality improvement program
- State CMS' latest guidance for quality assessment and assurance
- Construct a plan to improve or maintain your 5–star rating
- Perform follow up to quality issues
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