Survey Prep Boot CampSM - Long-Term Care Version
Course Outline
Long-Term Care Boot Camp — Survey Prep Version is an intensive, four-day course outlining how to survive
the new Quality Indicator Survey (QIS) process, compliance with new and upcoming F-Tags, strategies for
coping with surveyors, and how to avoid or fight deficiencies under this difficult regulatory environment.
Module 1: Overview of OBRA '87 and how it began the current era of nursing home regulation
- History of events leading up to the implementation of OBRA of 1987
- Purpose of the survey process and history of the development of the current day survey process
- Conclusions from the Institute of Medicine Report from 1986
- Recommendations from the IOM Study implemented in OBRA of 1987
- Implementation and monitoring of OBRA 1987
- Overview of current nursing home regulation
- Implementing the State Operations Manual, authority to survey
- Organizational components and Resident Assessment Instrument process
- Surveyor objectivity, training, and experience requirements
- Benchmarking progress toward the goals of OBRA 1987
- The CMS Action Plan for 2007
- Federal monitoring agencies and their impact
- Research validating impending changes and trends in survey
- Learn to navigate the web to locate for sruvery informaiton
- Identifying and locating key sources of authority
- Dealing with updates
- Additional sources
Module 2: What is a Quality Indicator Survey (QIS)?
- Summary of the QIS Evaluation Project
- Impetus behind the new survey project
- Project timelines and anticipated changeover to QIS
- Goals of the Evaluation project
- Outline of the QIS Process
- Description of the stages, tasks, and new terms related to the standard QIS process
- Review of Tasks, including computer-assistance provided
- Use of QIS beyond the Standard Survey
- Examination of the QCIs and Critical Elements
- Major differences between the QIS and Traditional Survey Process
- Brief review of the Training Manual and materials
- Understanding the data collection and use of computers for analysis of the data collection
- Identifying the structure and process differences
Module 3: Types of Surveys
- Brief overview of the types of Surveys
- Overview
- Types: Standard Survey, Extended Survey, Abbreviated Standard Survey (includes complaint surveys
not handled during the Standard Survey), Partial Extended Survey, Post-Survey revisit; Initial
Certification Survey
- Complaint Surveys (usually Abbreviated Surveys)
- Minimum required elements of a complaint survey
- Federal database tracking system: ACTS
- Federal Oversight Surveys
- Types of oversight surveys: Comparative and Observational
- The FOSS Survey and performance review standards
- Trends and recommendations
- Managing and minimizing complaints and complaint surveys
- Understanding the scope of the problem
- Prevention techniques
- Facility communication and teamwork, or getting the key players on the same page
Module 4: The Survey Process
- The Traditional Survey Process
- Importance of Offsite, or preparatory, survey endeavors including review of prior survey
history, OSCAR reports, QM/QI review, and any complaints not yet investigated
- Onsite Survey Tasks and Phases of the Survey
- Entrance Conference and Initial tour
- Sample selections (and predictive ability)
- Information Gathering Task and Sub-Tasks
- Information Analysis for Deficiency Determination
- Exit Conference
- Statement of Deficiency (CMS-2567)
- Deficiency Categorization: Scope and Severity
Module 5: Offsite Survey Preparation Task, or "How are surveyors armed when they arrive at your facility?"
- Quality Measurement Overview
- History and development of Quality Measures/Quality Indicator (QM/QI) Review
- QM/QI key concepts and terms
- Review of chronic care measures
- Review of post acute care measures
- Making sense of the QM/QI Reports
- Which assessments count?
- Facility Characteristics Report
- Facility QM/QI Report
- Monthly Trend Report
- Resident Level Reports
- Analyzing the Reports
Module 6: Comprehensive Care Review includes observations, interviews, and a record review.
- Introduction
- Comprehensive Care Review
- Intent of RAI
- Development of RAI
- Common MDS Acronyms
- Overall review of the facility's completion of the RAI process and MDS Accuracy
- Regulatory Review
- RAI and Interdisciplinary Process
- MDS Basics
- MDS Components
- Types and Timing of RAI Assessments
- Dating Sequences
- Coding Guidelines
- Problematic Coding Areas
- RAPS
- Implementation of the care plan and resident response
- Based on MDS
- Other Care Challenges
- Medical Record Review is used to validate the MDS coding to ensure accurate assessment
Module 7: Focus on F-Tags
- Overview of nursing home deficiency requirements and patterns
- Deficiency determination
- National patterns and trends
- OHIO QIS results as of November 2006
- Focus on recent Quality of Care F-Tag revisions
- F309 Quality of Care
- Current uses
- Planned use for pain citations
- F314 Pressure Ulcers
- F315 Urinary Incontinence
- F329 Unnecessary Drugs
- Focus on recent Quality of Life Changes
- F248 Activities
- F249 Activities Director
- Psychosocial Outcome Severity Guide
- Citation Justification
Module 8: Responding to Citations, Immediate Jeopardy
- Overview of nursing home deficiency requirements, patterns, and terms
- Writing the Statement of Deficiency, delivery, and timeframes
- Review documentation guidelines and work an example
- Facility response options and the plan of correction
- PoC Exercise
- IDR Process
- Definition and requirements for the process
- Exercise and determining when to invoke an IDR
- Determination of Immediate Jeopardy
- Principles
- Triggers
- Procedures
- Example
- Enforcement Process and Penalties
- Basis and overview
- Revisit/Date of Compliance Policy
- Remedies
- Scope and severity and Civil money penalties
Module 9: Mock Survey or Making Sure Your Facility is Survey-Ready
- Overview of Survey Preparation Techniques
- Purpose and Timing
- External Mock Surveys: Benefits and Drawbacks
- Internal Mock Survey: Benefits and Drawbacks
- Process and Problem Identification
- Traditional Survey Process
- QIS Survey Process and Use of Thresholds
- Interviews and Observation
- Record Reviews
- Policy and Procedure Update
- Ensuring Your Facility is Always Survey-Ready
- Preparing Staff, Residents and Family
- Problem Identification
- Process Update
- Get Ready, Stay Ready
Module 10: Life Safety Code® and Disaster Planning
- Life Safety Code Overview
- History
- Authority and survey and Appendix I
- Who performs the survey
- FSES
- Life Safety Inspection and Deficiencies
- Survey Procedures and Tasks
- Complaint Investigations
- Revisits
- Enforcement Issues and Timing
- Disaster Planning and Emergency Preparedness
- Recent GAO Study results and Recommendations
- F-Tag Impact
Module 11: Q&A and Continuous Quality Improvement
- Overview
- The Deming influence
- Later work (Six Sigma, TQM)
- Important new definitions
- Q&A Committee
- Composition and timing
- Purpose
- Non-Compliance Findings
- Adopting CQI Principles
- Leadership and Driving Forces
- Customer-Focus
- Philosophy
- Creative Approaches
- Practical Applications
- Types of issues for consideration
- Initiating Proactive approaches
- Critical Thinking
- Innovation
- Staff Satisfaction
- Audit Processes
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