Survey Prep Boot Camp - Long Term Care Version
Learning Objectives
Module 1: Survey Data, Rationale, and Your Five-Star Quality Rating Survey
- Navigate the Nursing Home Compare website
- Define how OBRA '87 changed how nursing homes are operated
- Describe the purpose of survey and the survey reporting system in long-term care
- Define the survey window and survey frequency
- Differentiate the major components of the Five-Star Quality Rating System and identify the relative weight of each component
- Explain the different components of the State Operations Manual
- Demonstrate how to find survey regulations in the State Operations Manual
Module 2: Types of Surveys and Managing Complaints
- Describe the types of surveys that are performed in long-term care
- Distinguish between the roles of state surveyors and federal surveyors
- Discuss at least one method to manage complaints in your facility
- Explain the purpose of a federal oversight survey
- Review prior survey history using OSCAR reports and the Nursing Home Compare
website
Module 3: QIS Stage I Processes
- Identify the main challenges during the transition process from traditional survey to QIS
- Identify the QIS Stage I survey tasks
- Describe the types and purpose of the Stage I samples
- Discuss the impact of the resident interview on the QIS outcomes
- Examine the relationship between QCLIs to quality measurements
- Differentiate between triggered and non-triggered facility-level tasks
Module 4: QIS Stage II Processes
- Identify the QIS Stage I survey tasks
- Explain the relationship between and critical element pathways and investigative protocols
- Discuss how the MDS sample and coding impact the scope and length of Stage II
- Discuss one method for staff to respond positively during Stage II of the survey
- Demonstrate one of CMS' new quality measurement tools for the survey
Module 5: The Traditional Survey Process
- Differentiate how the resident sample selection process works under the traditional survey
- Name the distinct phases of a typical nursing home traditional survey
- Describe the elements of the resident assessment instrument and how they link to the traditional survey process
- Define the objective of the medical record review to the survey process
- Discuss how to analyze a quality indicator report to determine where the survey team will focus its efforts
- Recognize the main differences between the QIS process and the traditional survey process in the CMS nursing home health inspection
Module 6: Determining Scope and Severity
- Explain how to read a Statement of Deficiency
- Define the different deficiency scope and severity levels
- Describe how prior survey history can affect your current survey
- Discuss the impact of the psychosocial severity grid
- Define the possible remedies associated with substandard quality of care tags
- Discuss the impact of survey on the facility's Five-Star rating
Module 7: Writing Your Plan of Correction
- Discuss the relevance of the CMS-2567 format to writing the plan of correction
- Demonstrate how to write an acceptable Plan of Correction
- Summarize the submission time frames
- Discuss the four questions that need to be answered as part of the plan of correction
- Devise a strategy to preemptively fight deficiencies before surveyors cite your facility
Module 8: Responding to Citations and the Appeals Process
- Use IDR process
- Recognize other types of survey appeals
- Define trends in civil money penalties that 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: What to Do If You Are Placed in Immediate Jeopardy
- Describe the basis of how surveyors make the determination of Immediate Jeopardy
- Explain the rights of the facility in an Immediate Jeopardy situation
- Determine how to clear the immediate jeopardy
- Discuss the enforcement process and associated penalties linked to Immediate Jeopardy
Module 10: Focus on Survey Deficiencies (F-tags)
- Recall at least two recently revised F-tags by CMS
- List two upcoming F-tags that will be revised within the next few years
- Discuss the difficulty of complying with F209, Quality of Care
- Demonstrate how to look up deficiencies in the Compendium
- Devise a strategy to preemptively fight deficiencies before surveyors cite your facility
Module 11: Conducting Mock Surveys as a Quality Control Tool
- Construct a staff education strategy to train different levels of staff for survey
- Determine how to evaluate your facility vulnerabilities through mock survey, and define a process to link deficiencies to improved care
- Perform follow-up to quality issues
- Summarize how you can use the forms to manage your own survey process
Module 12: Operational Focus Required for Good Survey Outcomes and Quality of Care
- Define a monitoring process for auditing current care processes related to survey compliance
- Explain the frequency necessary to perform benchmarking
- Describe which team members must be involved in the process
- 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 Five-star rating
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