State Operations Manual Appendix P - Survey Protocol for Long Term Care Facilities - Part I

Transcription

1 State Operatins Manual Appendix P - Survey Prtcl fr Lng Term Care Facilities - Part I (Rev. 21, ) Transmittals fr Appendix P I. Intrductin II. The Survey Prcess II.A The Quality Indicatrs Survey (QIS) 1. The QIS Standard Survey 2. The QIS Extended Survey 3. The QIS Pst-Survey Revisit (Fllw-up) 4. The QIS Cmplaint Survey Prcedures II.B The Traditinal Survey 1. Traditinal Standard Survey Tasks Task 1 - Offsite Survey Preparatin Task 2 - Entrance Cnference/Onsite Preparatry Activities Task 3 - Initial Tur Task 4 - Sample Selectin Table 1 - Survey Prcedures fr Lng Term Care Facilities - Resident Sample Selectin Task 5 - Infrmatin Gathering Sub-Task 5A - General Observatins f the Facility Sub-Task 5B - Kitchen/Fd Service Observatin Sub-Task 5C - Resident Review Sub-Task 5D - Quality f Life Assessment Sub-Task 5E - Medicatin Pass Sub-Task 5F - Quality Assessment and Assurance Review Sub-Task 5G - Abuse Prhibitin Review 1

2 Task 6 - Infrmatin Analysis fr Deficiency Determinatin Task 7 - Exit Cnference 2. The Traditinal Extended Survey and Partial Extended Survey 3. The Traditinal Pst Survey Revisit (Fllw-Up) 4. The Traditinal Abbreviated Standard Survey A. Cmplaint Investigatins B. Substantial Changes in a Facility s Organizatin and Management III. Writing the Statement f Deficiencies IV. Deficiency Categrizatin V. Cnfidentiality and Respect fr Resident Privacy VI. Infrmatin Transfer VII. Additinal Prcedures fr Medicare Participating Lng Term Care Facilities I. Intrductin (Rev. 20, Issued: , Effective: , Implementatin: ) Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required t be in cmpliance with the requirements at 42 CFR Part 483, Subpart B, t receive payment under the Medicare r Medicaid prgrams. T certify a SNF r NF, cmplete at least a: Life Safety Cde (LSC) survey; and Standard Survey. There are tw types f Standard Surveys: The Quality Indicatrs Survey (QIS), which uses the QIS prcedures and frms as cntained in the QIS Surveyr Training Manual. The QIS is nly used by a State Survey Agency upn apprval by CMS, and nly by the surveyrs wh have received QIS training; and The Traditinal Survey, which uses Frms CMS-670, CMS-671, CMS-672, CMS-677, and CMS-801 thrugh CMS-807 (see Exhibits 85, 86, and 88 thru 95). NOTE: CMS is beginning the prcess f a staged implementatin f a revised survey prcess, the Quality Indicatrs Survey (QIS) as a replacement fr the current (Traditinal) survey prcess. The QIS is a tw-staged, cmputer-assisted survey prcess with Stage 1 cnsisting f bth cmputer analysis f ffsite data frm the Minimum Data Set system as well as data cllected by surveyrs nsite frm bservatins, interviews, and recrd reviews f large cmputer- 2

3 selected resident samples. The infrmatin cllected thrughut Stage 1 is analyzed by cmputer t derive a set f apprximately 160 Quality f Care Indicatrs (QCIs) that are used t cmpare the facility being surveyed t natinal nrms. QCIs that scre beynd a statistical threshld are cmputerselected fr Stage 2 review, and the relevant residents are als cmputer selected. Stage 2 cnsists f systematic surveyr investigatins f triggered issues and residents using a set f detailed investigative tls knwn as critical elements prtcls. In additin t the Stage 1 and Stage 2 sample-based investigatins, the QIS als cntains several facility-level tasks that are unstaged and are cmpleted either n every survey r when triggered as areas f cncern. During this perid, as CMS cnducts pilt implementatin, CMS deems bth the QIS and Traditinal Survey as surveys-f-recrd t evaluate cmpliance f nursing hmes with the requirements at 42 CFR D nt annunce SNF/NF surveys t the facility. Cnduct standard surveys and cmplete them n cnsecutive wrkdays, whenever pssible. They may be cnducted at any time including weekends, 24 hurs a day. When standard surveys begin at times beynd the business hurs f 8:00 a.m. t 6:00 p.m., r begin n a Saturday r Sunday, the entrance cnference and initial tur shuld be mdified in recgnitin f the residents activity (e.g., sleep, religius services) and types and numbers f staff available upn entry. Use the standard survey prcedure discussed in this sectin fr all standard surveys f SNFs and NFs, whether freestanding, distinct parts, r dually participating. Fr surveys f facilities predminantly serving shrt stay residents, mdificatins f ffsite survey preparatin and sampling prcedures will be necessary. NOTE: D nt use this prcess fr surveys f intermediate care facilities fr the mentally retarded (ICFs/MR), swing-bed hspitals, r skilled nursing sectins f hspitals that are nt separately certified as SNF distinct parts. Survey Prtcls and Interpretive Guidelines fr these surveys are fund in Appendix J (ICFs/MR) and Appendix T (swing-bed hspitals and hspitals with nn-distinct part SNFs). When the survey team suspects substandard quality f care (SQC), expand the standard (r abbreviated) survey sample as necessary t determine scpe. If the existence f SQC is verified, then infrm the Administratr that the facility has SQC and an extended (r partial extended) survey will be cnducted. Surveys If a pssible nncmpliant situatin related t any requirement is identified while cnducting the infrmatin gathering tasks f the survey, investigate the situatin t determine whether the facility is in cmpliance with the requirements. 3

4 Standard Survey The QIS Standard Survey is cmpsed f Tasks 1 9 and the Traditinal Standard Survey is cmpsed f Tasks 1 7. Bth versins f the survey prcess are resident-centered, utcme-riented inspectins that rely n a case-mix stratified sample f residents t gather infrmatin abut the facility s cmpliance with participatin requirements. Outcmes include bth actual and ptential negative utcmes, as well as failure f a facility t help residents achieve their highest practicable level f well-being. Based n the specific prcedures detailed in this Appendix, a standard survey assesses: Cmpliance with residents rights and quality f life requirements; The accuracy f residents cmprehensive assessments and the adequacy f care plans based n these assessments; The quality f care and services furnished, as measured by indicatrs f medical, nursing, rehabilitative care and drug therapy, dietary and nutritin services, activities and scial participatin, sanitatin and infectin cntrl; and The effectiveness f the physical envirnment t empwer residents, accmmdate resident needs, and maintain resident safety, including whether requested rm variances meet health, safety, and quality f life needs fr the affected residents. Extended Survey The extended survey is cnducted after substandard quality f care is determined during a standard survey. If, based n perfrming the resident-centered tasks f the standard survey it is determined that the facility has prvided substandard quality f care in 42 CFR , Resident Behavir and Facility Practices; 42 CFR , Quality f Life; and/r 42 CFR , Quality f Care, cnduct an extended survey within 14 days after cmpletin f the standard survey. (See Sctin II.A.2. fr further infrmatin abut the QIS extended survey and Sectin III fr further infrmatin abut the Traditinal Extended Survey. Abbreviated Standard Survey This survey fcuses n particular tasks that relate, fr example, t cmplaints received r a change f wnership, management r directr f nursing. The abbreviated standard survey des nt cver all aspects cvered in the standard survey, but rather cncentrates n a particular area f cncern(s). Fr example, an abbreviated standard survey may be cnducted t substantiate a cmplaint. The survey team can expand the abbreviated standard survey t cver additinal areas, r t a Traditinal Standard Survey if, during the Abbreviated Standard Survey, 4

5 evidence is fund that warrants a mre extensive review. (See als Chapter 5 f this manual fr additinal administrative prcedures related t cmplaints.) At this time, the QIS is nt used t cnduct an abbreviated standard survey. See II.A.4. belw fr investigatin f cmplaints during the QIS standard survey. Partial Extended Survey A partial extended survey is always cnducted after substandard quality f care is fund during an abbreviated standard survey r during a revisit, when substandard quality f care was nt previusly identified. If, based n perfrming the abbreviated standard survey r revisit it is determined that the facility has prvided substandard quality f care in 42 CFR , Resident Behavir and Facility Practices; 42 CFR , Quality f Life; and/r 42 CFR , Quality f Care, cnduct a partial extended survey. (See Sectin III fr further infrmatin abut the partial extended survey. At this time, the QIS is nt used fr partial extended surveys.) Pst-Survey Revisit (Fllw-Up) The pst-survey revisit is an nsite visit intended t verify crrectin f deficiencies cited in a prir survey. See 2732 and Appendix P, Part I, Sectin VI, Writing the Statement f Deficiencies. (See Sectin II.A.3. fr further infrmatin abut the QIS revisit and Sectin VI. fr further infrmatin abut the Traditinal revisit.) If substandard quality f care is determined during a revisit, cmplete a partial extended survey, if a partial extended r extended survey had nt been cnducted as the result f the prir standard r abbreviated standard survey. Initial Certificatin Survey In a survey fr initial certificatin f SNFs r NFs, perfrm the tasks f bth the Traditinal Standard and Extended Surveys. During the initial survey, fcus bth n residents and the structural requirements that relate t qualificatin standards and resident rights ntificatin, whether r nt prblems are identified during the infrmatin gathering tasks. Gather additinal infrmatin t verify cmpliance with every tag number. Fr example, during an initial survey, verify the qualificatins f the scial wrker, dietitian, and activities prfessinal. Als, review the rights ntificatin statements n admissins cntracts. Cmplete the Statement f Deficiencies and Plan f Crrectin (Frm CMS-2567) in Exhibit 7. Specialty Surveyrs All members f a survey team need nt be nsite fr the entire survey. Specialty surveyrs participating in surveys (e.g., a pharmacist, physician, r registered dietitian) must be nsite during that prtin f the survey dealing with their area f expertise. Hwever, they must cnduct that prtin while the rest f the team is present. All members f the survey team shuld enter the facility at the same time, if pssible. Befre leaving the facility, at the cmpletin f his/her prtin f the survey, the specialty 5

6 surveyr must meet with the team r team crdinatr t discuss his/her findings and t prvide supprting dcumentatin. The specialty surveyr shuld als share any infrmatin he/she btained that may be useful t ther team members. If he/she is nt present at the infrmatin analysis fr deficiency determinatin, the specialty surveyr shuld be available by telephne at that time and during the exit cnference. Team Cmmunicatin Thrughut the survey prcess, the team (including specialty surveyrs nsite at the time) shuld discuss amng themselves, n a daily basis, bservatins made and infrmatin btained in rder t fcus n the cncerns f each team member, t facilitate infrmatin gathering and t facilitate decisin making at the cmpletin f the standard survey. II. The Survey Prcess II.A. - The Quality Indicatrs Survey (QIS) The QIS survey is used as the survey-f-recrd nly fr states that have received CMS apprval, and nly by surveyrs wh have cmpleted QIS training. Sectins II.A belw describe the use f the QIS fr standard surveys, extended surveys, pst-survey revisits, and cmplaint investigatins. 1. The QIS Standard Survey The QIS standard survey cnsists f the fllwing Tasks (details are cntained in the QIS Surveyr Training Manual, which is incrprated by reference): Intrductin Task 1: Offsite Survey Preparatin: Offsite Survey Preparatin and Initial Sampling Task 2: Onsite Preparatry Activities and Entrance Cnference Prir t the Entrance Cnference Entrance Cnference Pssible Off Hurs Activities Task 3: Initial Tur Tur 6

7 Task 4: Stage I Survey Tasks Finalize Sample Selectin Stage I Sample Selectin Prcedures Stage I Team Meetings (first meeting) Stage I Infrmatin Gathering Stage I Admissin Sample Review Medical Recrd Review Stage I Census Sample Review Resident Interviews Resident Unavailable fr Interviews Resident Observatins Staff Interviews Medical Recrd Review Family Interviews Task 5: Nn-Staged Survey Tasks Resident Cuncil President/Representative Interview Dining Observatin Kitchen/Fd Service Observatin Infectin Cntrl Plicies and Practices Demand Billing Review Abuse Prhibitin Review Quality Assessment and Assurance (QA&A Review) Task 6: Transitin Frm Stage I t Stage II Update the Resident Pl Review Cmpletin f Stage I Review Surveyr-Initiated Residents and/r Care Areas Imprt All Data int the Primary Laptp Review the Relevant Findings Reprt Review the QCI Results Reprt Task 7: Stage II Survey Tasks 7

8 Intrductin Team Meetings Stage II Sample Selectin Substituting Residents Supplementing the Sample Staff Assignments Stage II Infrmatin Gathering Stage II Critical Element Pathways Medicatin Administratin Observatin and Unnecessary Drug Review Facility-Level Investigatins Envirnmental Observatin Resident Funds Admissin, Transfer, and Discharge Review Sufficient Staff Task 8: Analysis and Decisin-Making: Integratin f Infrmatin Integratin f Facility-Level Infrmatin Integratin f Critical Element Pathways Analysis f Infrmatin Gained Analysis f Scpe and Severity and Team Decisin-Making Task 9: Exit Cnference Exit Cnference 2. The QIS Extended Survey When the survey team is cnducting a QIS standard survey and they have determined there is substandard quality f care, they will cnduct QIS extended survey prcedures. Substandard quality f care is defined as ne r mre deficiencies with scpe/severity levels f F, H, I, J, K, r L in any f the fllwing regulatry grupings: 42 CFR , Resident Behavir and Facility Practices; 42 CFR , Quality f Life; and/r 42 CFR , Quality f Care. 8

9 The purpse f the QIS extended survey is t gather further infrmatin (unless already gathered during the standard survey) cncerning the facility s nursing and medical services and administratin, in rder t evaluate systemic issues with the facility s prvisin f services and management that may be nn-cmplaint with the lng term care requirements, and may have cntributed t prblems cited in the substandard quality f care deficiency(ies). When cnducting the QIS extended survey, the survey team crdinatr will surveyr-initiate all Tags within the fllwing regulatry grupings int the QIS survey sftware: 42 CFR , Nursing Services; 42 CFR , Physician Services; and 42 CFR , Administratin. There are n specific QIS frms t assist this review. The survey team shall dcument their findings abut these Tags n Surveyr Ntes Wrksheets (Frm CMS-807) and shall input their findings int the QIS sftware. If the QIS Staffing Review prtcl was nt already cmpleted during the standard survey, the survey team will cmplete this prtcl. At the discretin f the State Survey Agency, the QIS extended survey can be cnducted either: Prir t the exit cnference, in which case the facility will be prvided with findings frm the standard and extended survey; r Subsequent t the standard survey, but n lnger than 2 weeks after the cmpletin f the standard survey, if the survey team is unable t cmplete the extended survey prir t the exit cnference. 3. The QIS Pst-Survey Revisit (Fllw-up) A QIS pst-survey revisit is cnducted in accrdance with 7317 t cnfirm that the facility is in cmpliance and has the ability t remain in cmpliance. The purpse f the revisit is t reevaluate the specific care and services that were cited as nncmpliant during the QIS standard and/r extended survey. The specific prcedures fr each revisit depend n the deficiencies that were cited during the QIS standard survey. Detailed prcedures are fund in the QIS Surveyr Training Manual. Fr each QIS revisit, the surveyr(s) will use prtins f the QIS standard survey, nly as applicable t their need t evaluate the facility s return t cmpliance fr requirements cited as deficiencies. Fr all QIS revisits, the surveyr(s) will review ffsite the Statement f Deficiencies and cnduct a fcused review f the summary infrmatin frm the QIS standard survey. Once nsite, the surveyr(s) will ask the facility t prvide a rster f residents. The surveyr(s) will use the QIS sftware as well as infrmatin frm the QIS standard survey (such as residents investigated) t surveyr-initiate the Care Areas and/r Tags and residents t be investigated. The surveyr(s) will use Stage 2 Critical Element Pathways (CEs) prtcls as applicable t the Tags that have been cited, r the general CE fr aspects f care nt cvered by the ther CEs. Fr example, if deficiencies were cited fr pressure ulcers and medicatin errrs, the surveyr(s) wuld use the pressure ulcer CE and the QIS Medicatin Administratin and Unnecessary Drug Review frm t cnduct these investigatins. The surveyr(s) will input findings int the QIS sftware 9

10 and prceed thrugh QIS deficiency decisin making, and scring f scpe and severity fr any deficiencies that are cited. 4. The QIS Cmplaint Survey Prcedures The QIS is used fr investigatin f cmplaints during a QIS standard survey. The survey team crdinatr will surveyr-select the cmplaint area(s) f cncern and the resident(s) invlved in the cmplaint and add them t the list f issues and residents evaluated during the QIS standard survey. The QIS Surveyr Training Manual cntains further details cncerning the manner in which these surveyr-selected cncerns and issues are added t the standard survey fr investigatin, determinatin f whether they are substantiated r unsubstantiated, and cnveying f findings int the CMS ASPEN data system. At this time, the QIS is nt used fr investigatin f cmplaints during an abbreviated standard survey. Surveyrs shuld use the prcedures cntained in VII.A. belw fr these investigatins. II.B. - The Traditinal Survey II.B.1 - Traditinal Standard Survey Tasks (Rev. 20, Issued: , Effective: , Implementatin: ) Task 1 - Offsite Survey Preparatin A. General Objectives The bjectives f ffsite survey preparatin are t analyze varius surces f infrmatin available abut the facility in rder t: Identify and pre-select cncerns fr Phase 1 f the survey, based n the Facility Quality Measure/Indicatr Reprt (see descriptin belw at B.3.a.). This preselectin is subject t amendment based n the results f the tur; Pre-select ptential residents fr Phase I f the survey based n the Resident Level Quality Measure/Indicatr Reprts (see descriptin belw at B.3.a.) This pre-selectin is subject t amendment based n the results gathered during the tur, entrance cnference, and facility Rster/Sample Matrix; Nte cncerns based n ther surces f infrmatin listed belw and nte ther ptential residents wh culd be selected fr the sample; and Determine if the areas f ptential cncerns r special features f the facility require the additin t the team f any specialty surveyrs. 10