Survey Prep Boot Camp - Long Term Care Version
Course Outline
Module 1: Your Survey Data
- Introduction to the Nursing Home Compare Website
- Implementation of OBRA and the current era of nursing home regulation
- Details of the Five-Star Quality Rating System-The public display of your survey data
- Regulatory research: End your confusion of the CMS website and find what you need
Module 2: Types of Surveys and Managing Complaints
- Brief overview of the types of surveys
- Complaint surveys (usually abbreviated surveys)
- Federal oversight surveys
- Managing and minimizing complaints and complaint surveys
Module 3: QIS Stage I Processes
- Review of the QIS Stage I process and associated survey forms
- Description of the tasks and new terms related to the standard QIS process
- Sample types and sizes
- Interviews, record reviews
- Review of computer-assistance provided
- Examination of the QCLIs and relationship to QM/QIs
- Review of the facility-level survey tasks
Module 4: QIS Stage II Processes
- Review of the QIS Stage II process and associated survey forms
- Description of the tasks and completion of the facility-level tasks
- MDS' and QCLI's control over the direction, scope, length of Stage II
- In-depth review of computer-selected care areas by a survey team
- Teaching staff how to respond during the survey process
- Critical element pathways and relationship to investigative protocols
Module 5: The Traditional Survey Process
- Off-site preparation
- On-site survey tasks and phases of the survey
- Surveyor tools for the traditional survey
- Major differences between the QIS and traditional survey process
- How to prepare for survey when you are unsure whether you will have a QIS, traditional, or blended survey
Module 6: Determining Scope and Severity
- Statement of deficiency (CMS-2567)
- Deficiency categorization
- Understanding the scope and severity grid
- Application of the psychosocial scope and severity
- Impact on your facility's Five-Star rating
Module 7: Writing Your Plan of Correction
- Understanding the format
- Answering the four questions
- Submission time frames
- When to ask for help
Module 8: Responding to Citations and the Appeals Process
- The informal dispute resolution (IDR) process
- Additional appeals process
- Enforcement process and penalties
Module 9: What to Do If You Are Placed in Immediate Jeopardy
- Determination of Immediate Jeopardy
- Enforcement process and penalties
Module 10: Focus on Survey Deficiencies (F-tags)
- Overview of nursing home deficiency requirements and patterns
- Focus on recent Quality of Care F-tag revisions
- Focus on recent Quality of Life changes
- Review of nursing home deficiency requirements, documentation, patterns, and terms
Module 11: Conducting Mock Surveys as a Quality Control Tool
- Overview of survey preparation techniques
- Process and problem identification
- Ensuring your facility is always survey-ready
Module 12: Operational Focus Required for Good Survey Outcomes and Quality Care
- Auditing current processes
- CQI requirements and process to relationship to the Five-Star Quality Rating System
- Staffing changes to yield best results
- Benchmarking and implementing changes
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