Understanding the Critical Elements for Activities in the Quality Indicator Survey

Transcription

1 Understanding the Critical Elements for Activities in the QIS Understanding the Critical Elements for Activities in the Quality Indicator Survey Course Objectives This course will clearly explain the different aspects of the Critical Elements for Activities. Upon completion of this course, learners will understand and describe: The key federal tags that relate to and help surveyors assess compliance with Activities The role of resident, family and staff interviews and observations in Quality Indicator Surveys (QIS) The probes within the Critical Elements for Activities, which are used to guide investigations in Stage 2 of QIS Activities Participation in Activities is a key resident right, which directly impacts quality of life. Federal guidelines for Centers for Medicare & Medicaid Services (CMS) certified nursing homes require that every resident receive an individualized activity program. The intent of this requirement is ensure that the facility identifies each resident s interests and needs, and then involves the resident in an ongoing program of activities designed to appeal to those interests and to enhance the resident's highest practicable level of physical, mental and psychosocial well-being. i Some residents are independently capable of pursuing their own activities and selecting the structured or group activities offered by the facility that they would like to attend. Other residents may need assistance in uncovering activities of interest and/or require assistance from nursing home staff to participate in activities. When this area is investigated during a Quality Indicator Survey or traditional state survey, resident outcomes and experiences are critical to assessing if the Activities program is adequate for each resident, since the federal regulations specify that activities should be individualized. This course will explain the process by which surveyors should investigate how Activities are undertaken if this Care Area is triggered for further investigation in Stage 2 Page 1 of 16

2 of the QIS. What is the Quality Indicator Survey? The Quality Indicator Survey is a computer-based, two-staged investigative tool used by CMS to determine how well it s certified nursing homes comply with federal standards. Unlike traditional state surveys, each state and each surveyor follows the same structured process for assessing compliance with federal guidelines under the QIS. QIS is currently the state survey of record in numerous states, and all states plus the U.S. Virgin Islands and Puerto Rico will shift to QIS as their state survey of record as surveyors are trained. ii One main objective of the Quality Indicatory Survey is to improve consistency and accuracy in quality of care and quality of life problem identification by using a more structured process. Although the traditional state survey process draws from the same set of CMS regulations and interpretive guidance as the QIS, the conduct of traditional annual surveys has differed greatly from state to state and from surveyor to surveyor. In the traditional state survey process, surveyors have greater latitude in selecting Care Areas for investigation and surveyors do not always participate in all aspects of the annual state survey. These types of divergent practices have made it difficult for CMS and state agencies to accurately identify problem areas on a nationwide basis. QIS was designed to achieve several objectives: iii Improve the consistency and accuracy in quality of care and quality of life problem identification by using a more structured process Enable the systematic review of requirements and investigate regulatory problems objectively Enhance documentation through automation Focus survey resources on largest number of quality concerns Enable timely and effective feedback Provide tools for continuous improvement Stage 1 There are two stages to each Quality Indicator Survey. In Stage 1, surveyors will interview and observe residents, interview the family members or legal representatives of residents, as well as interview and observe staff members as they perform their duties. They will also conduct reviews of both on- and off-site documents and records and tour the facility to ensure that it is in compliance with federal regulations. QIS surveyors are rigorously trained to ensure consistent review and investigation of quality of care and quality of life across 51 Care Areas and 128 quality indicators. A Page 2 of 16

3 Care Area is a component of nursing facility care that is related to one or more qualityof-care and quality-of-life indicators (QCLIs), which are assessed in the Stage 1 preliminary investigation. iv There are four Quality Care Indicators associated with Activities, not including Surveyorinitiated or Facility-Level Tasks: v 1) Resident Interviews 2) Resident Observation 3) Family Interviews 4) MDS Sample There are seven Mandatory Facility-Level Tasks that surveyors will assess compliance against in Stage 1 of QIS. vi The seven Mandatory Tasks include: 1) Liability Notices & Beneficiary Appeal Rights Review 2) Dining Observation 3) Infection Control 4) Kitchen/Food Service Observation 5) Medication Administration Observation 6) Quality Assessment and Assurance Review 7) Resident Council President/Representative Interview The Mandatory Facility-Level Tasks are just what the name implies. These are seven tasks that CMS requires surveyors to complete at each facility when conducting a Quality Indicator Survey. For each of these seven tasks, surveyors may interview residents, their family or staff members, review documentation and observe care practices to better understand how the facility ensures that it is in compliance with the federal tags encompassed by the task. All the data gathered from Stage 1 and offsite information, such as complaints to state agencies which is gathered prior to the start of QIS, are entered into the Data Collection Tool (DCT). Many aspects of the QIS, like resident samples, resident, family and staff interviews and mandated facility-level tasked, are driven by the DCT. The DCT plays an important role is the QIS process and is a customized software platform, which surveyors also have access to during the course of surveys on their Tablet PCs. The DCT provides structured guidance for undertaking Quality Indicator Surveyors and helps calculate whether the data indicates that the facility meets or exceeds an established threshold for compliance. If the facility exceeds the threshold, surveyors will launch a Stage 2 investigation. Page 3 of 16

4 Stage 2 In Stage 2, surveyors will conduct in-depth reviews of residents whose related Quality Care Indicators exceed the thresholds set for that Care Area. The DCT helps to identify Care Areas to investigate in Stage 2 of QIS. In addition to these in-depth reviews, triggered facility-level tasks are conducted and compliance decisions are determined. vii There are five different triggered tasks that surveyors may investigate based on Stage 1 data. Surveyors will only investigate these tasks if data collected in Stage 1 of the survey exceeds the threshold set by CMS for a particular care area. In other words, these five tasks are only performed if enough QCLIs in Stage 1 trigger these tasks for investigation in Stage 2. 1) Abuse Prohibition 2) Admission Transfer & Discharge 3) Environmental Observations 4) Personal Funds 5) Sufficient Staffing Requirements Care Areas identified in Stage 2 have a set of associated Critical Elements (CE), developed to guide the surveyor and the investigation in a consistent, organized and systematic review of the triggered Care Area and the associated regulatory requirements. The CE Pathways are similar in format to CMS current investigative protocols used for traditional state surveys. For Stage 2 investigations, there are 16 CE Pathways pertaining to specific Care Areas and a General CE Pathway to assist surveyors in investigating a resident with a care issue not addressed in the other 16 CE Pathways. According to CMS, the CE Pathway incorporates each step of the resident care process reflected in the regulations: assessment, care planning, implementation of care that meets professional standards of quality, Care Plan revision, and provision of care and services to meet the needs of the resident. viii The Care Area Investigation Key (see Figure 1) lists the 16 different Critical Element Pathways available to QIS surveyors. Where no specific CE Pathway exists, surveyors may use the general CE Pathway to investigate that Care Area. Figure 1: Stage 2 Care Area Investigation Key ix Page 4 of 16

5 Guidance to Surveyors General CE Pathway CE Pathway Facility Worksheet Abuse Accidents Activities Abuse Prohibition Choices Colostomy, Ureterostomy, Illeostomy Dignity Fecal Impaction General Critical Element Pathway Infections (non-uti) ADL, ROM, Grooming & Positioning Behavior and Emotional Status Bowel & Bladder/Use of Catheter Admission, Trasfer and Discharge Review Demand Billing Review Dining Observation Communication / Sensory Environmental Enteral Feedings Skin Conditions / Hearing / Vision Observations Food Quality Dental Extended Survey Foot Care Notification of Change Parenteral Fluids Participating in Care Planning Personal Property Privacy Prosthesis Resident Room - Access to Corridor Resident Room - # of Residents per Room Resident Room - Size Resident Room - Window to Outside Respiratory Care Social Services Tracheal Suctioning Tracheostomy Unnecessary Drug Use Dialysis Hospice and End of Life Hospitalization and Death Nutrition, Hydration and Tube Feeding Pain Management Physical Restraints Pressure Ulcers Psychoactive Medications Rehabilitation and Community Discharge Ventilator Unnecessary Drug Use Infection Control & Immunizations Kitchen/Food Service Observations Medication Administration Observation / Drug Storage Personal Funds Review Quality Assessment & Assurance Review Resident Council President / Representative Interview Sufficient Nursing Staff Review Page 5 of 16

6 Critical Elements of Care The five Critical Elements of Care that are assessed by a CE Pathway are: x Comprehensive assessments: Did the facility conduct an assessment regarding the risks and/or problems the resident has related to the diagnosis and/or condition? (F-tag 272) Comprehensive care plan: Did the facility develop a care plan to address the care and treatment related to the clinical diagnosis and/or the identified condition? (F-tag 279) Care and services meet professional standards: Did the facility implement practices that meet professional standards of quality? (F-tag 281) Care plan revisions: Did the facility revise the plan of care as needed? (F-tag 280) Provision of care and services: Did the facility provide care and services in accordance with the comprehensive assessment and plan of care that meet Care Area regulation? (Various F-tags that are specific to a Care Area) The objective of the CE Pathways is to help assess whether a facility meets the five Critical Elements of Care for Care Areas that have exceeded the threshold in Stage 1. xi A facility can assess their own five Critical Elements in a Care Area by using the CE Pathways and following the structured protocol themselves. Resident Assessment Instrument Signed into law in 1987 by President Ronald Regan, the Nursing Home Reform Act mandates that nursing homes to take numerous measures aimed at sustaining a high quality of care and meeting the psychosocial well-being needs of the residents. Among other things, the Nursing Home Reform Act requires that nursing homes use the Resident Assessment Instrument (RAI), which is a standardized and comprehensive assessment tool aimed at helping clinical staff identify residents strengths, weaknesses, preferences and needs in key areas of functioning. xii This assessment then becomes an important part of the resident s medical record and should be updated frequently to reflect changes in the resident s condition and needs over time. Nursing homes are required to complete the RAI within 14 days of admission to the facility. The Minimum Data Set (MDS) is also a component of the resident assessment. Triggers from MDS help identify areas for additional assessment and review. The assessment guides nursing home staff as they develop individualized Care Plans for each resident at their facility. Care Plans aids staff in helping to maintain or improve the resident s condition and their level of involvement in Activities of Daily Living (ADLs). However, Activities should not be confused with Activities of Daily Living. According to CMS, Activities refer to: Page 6 of 16

7 .. to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. xiii Activity Programs Many nursing homes offer no-cost structured group or program activities for residents at regularly scheduled times, such as book club meetings, knitting circles or card games. There are also many special structured activities, such as dining at a local restaurant or attending a play, offered by many nursing homes that require the resident to pay a fee. Non-structured social interactions are also important in helping the resident obtain a high level of psychosocial well-being. Activities Non-structured activities could include, setting a table for dinner or watering plants. CMS considers non-structured activities, like sitting on the patio, surfing the Internet or engaging in conversations with friends, as Activities, and states that these types of informal activities are preferable to typical facility group activity programs. Surveyors are instructed to adapt their investigation of compliance to include informal activities in their reviews. xiv If Activities is triggered for Stage 2 investigation, surveyors will review the RAI, including documentation regarding the assessment of the resident s interests in activities, Page 7 of 16

8 preferences and needed adaptations. Based on a review of the RAI, as well as observations and interviews, surveyors will assess whether the RAI reflects the resident s: Current physical, mental and psychosocial health and how that impacts their interests and customary routine Special information about the resident s preferences Changes in activity pattern prior to admission Special needs or adaptations in order to participate in desired activities Desired daily routine and availability Particular group, one-on-one or self-directed activities in which he or she desires to participate. xv Some facilities may not have a completed RAI, if the resident has been at the facility for less than 14 days. They may have instead completed a 5-day assessment for Medicare beneficiaries. If this was completed and utilized Resident Assessment Protocols (RAPS), surveyors may utilize the 5-day assessment if an RAI has not yet been completed for the resident. xvi Care Planning As explained earlier, the Critical Element Pathway provides a structured process for the surveyor to investigate whether the facility is in compliance with associated regulatory requirements. Before starting the investigation, surveyors will briefly review the comprehensive assessment and interdisciplinary care plan, to identify facility interventions and to guide their observations. Care Plans must be completed 7 days after the comprehensive assessment. Surveyors are instructed to review the Care Plan to ascertain if the resident s goals, interests and preferences are reflected in the Care Plan and if a lack of sufficient care planning is an issue. Surveyors will review Care Plans to determine if the resident or their representative participated in the plan and if it was revised, as needed, to reflect changes in the resident s interests, abilities or health, cognitive state or if some aspects of the original plan were not successful. Resident & Family Interviews The Quality Indicator Survey relies heavily on direct interviews and observation of residents to help assess whether facilities are meeting regulatory requirements. Studies have shown that asking residents directly about their condition and preferences helps to show respect for the individual and promotes a high quality of life. It is hoped that the Page 8 of 16

9 increased emphasis on resident interviews will provide a broader picture of what the residents are experiencing in the home and what problems or concerns they may have. In Stage 1 of QIS, cognitive residents should be asked about activities, choices, abuse, personal property and a number of other subjects. Cognitive residents are asked five different yes and no interview questions that relate to activities: Page 9 of 16 1) Do you participate in any of the activity programs here? No Yes Do not wish to participate 2) Do the organized activities meet your interests? No Yes 3) Do you receive assistance for things you like to do, such as supplies, batteries, books? (Facility should have items available for residents to use). No Yes 4) Are there activities offered on the weekends, including religious events? No Yes 5) Are there activities available in the evenings? No Yes Surveyors will also observe residents, who are not interviewable due to their cognitive status. They are instructed to observe these residents during Stage 1 of QIS to ascertain whether they also participate in activities at the nursing home, and also to observer whether their participation is active and/or encouraged by staff members. The Family interviews conducted as part of the QIS will also factor into whether Activities are investigated further in Stage 2. During Stage 1, surveyors are instructed to interview three family members, who know the resident well and visit the facility often. During those interviews, surveyors will ask family members whether staff encourage the resident to attend activities and provide assistance to the resident as needed to attend these activities. Additionally, MDS information may also come into play if it s indicated that the resident selected for review spends little or no time in activities. xvii If Activities are investigated in Stage 2, surveyors will interview the resident or their legal representative as appropriate to determine compliance. During these interviews, surveyors will want to ensure that the resident/representative was involved in the development of their Care Plan and if the planned activities that stem from that Care

10 Plan reflect the resident s preferences. Additionally, they will want to determine how often the resident participates in activities if at all and what type of assistance the facility provides to facilitate participation in activities of choice when the resident does participate. Assistance can take many forms, such as providing transportation, accommodating the resident by rescheduling therapy or other services when possible, making equipment available to complete activities and providing ADL assistance during activities as needed. For example, the RAI may show that a particular resident enjoys playing cards, and is interested in joining a weekly game of Bridge at the facility. The RAI may also indicate that a resident is scheduled for physical therapy at 2 pm on Wednesday each week, which is coincidently the same day and time that the nursing home sets up a weekly game of Bridge. The surveyor may then investigate whether the facility assists the residents in participating by scheduling their physical therapy at another time. In some cases the resident may not want to participate in activities, which is a choice that the nursing home is obligated to respect. If this is the case, the surveyor will want to understand why the resident does not want to participate and also whether the resident desires activities that the facility does not provide. Federal Tags There are several federal tags that help make up the overall regulations for activities. Let s review F248, F279, F280 and F248, which figure into the Critical Elements for Activities. CMS considers F248 a key outcome tag within Quality of Life. This federal tag directs facilities to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident. While many facilities have an Activities department, the provision of activities is the duty of the facility overall, as it is not possible to one department to provide individualized activities for the entire population of a nursing home. According to CMS, Activities refer to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. xviii The new CMS interpretive guidelines for F248 Activities also states that goals identifying how many group activities residents will attend are outdated and old fashioned. An example would be indicating that a resident will set the dinner table twice per week. Instead, F248 seeks to have the resident set goals for themselves with the assistance of nursing home staff. Page 10 of 16

11 F279 involves the development of an individualized Care Plan for each resident, which is prepared by an interdisciplinary team and includes measurable objectives and timetables to meet the resident s medical, nursing, mental and psychosocial needs. To the extent possible, the resident and the family or legal representative should participate in the development of the care plan. Surveyors will determine if what is documented in the care plan for a resident is what they see happening. When Care Plans are developed, residents, or their representative, should be involved. F280 covers revisions to the care plan, requiring that nursing staff make updates as needed to addresses the changing needs and changing condition of nursing home residents. When a resident refuses some or all of the activities suggested in a care plan, facilities are required to work with the resident, or their representative, to determine why the resident refuses to participate or if there are any issues that are causing them to not participate. F272 address the individual activity preferences and interests of each resident, and requires the facility to provide adaptations as needed to assist the resident in participating in activities of choice. During the Stage 2 investigation, the surveyor may encounter concerns with processes and requirements relating to Activities. Surveyors are cautioned to examine these concerns before assessing non-compliance. Some of the federal tags that may come into play are listed below (see Figure 2). xix If the surveyor determines that the facility is not in compliance with any of these related requirements, the surveyor is instructed to initiate the appropriate F tag. Figure 2: Related Federal Tags Related Federal Tags F164, Privacy and Confidentiality F172, Access and Visitation Rights F242, Selfdetermination and Participation F246, Accommodation of Needs Surveyor Instructions Determine whether the facility has accommodated the resident s need for privacy for visiting with family, friends, and others, as desired by the resident. Determine whether the facility has accommodated the resident s family and/or other visitors (as approved by the resident) to be present with the resident as much as desired, even round-the-clock. Determine whether the facility has provided the resident with choices about aspects of his or her life in the facility that are significant to the resident. Determine whether the facility has adapted the resident s physical environment (room, bathroom, furniture, etc.) to accommodate the resident s individual Page 11 of 16

12 needs in relation to the pursuit of individual activities, if any. F249, Qualifications of the Activities Director F250, Social Services Determine whether the activities director is qualified to lead the activities program. Determine whether the facility is providing medicallyrelated social services related to assisting with obtaining supplies/equipment for individual activities (if any), and assisting in meeting the resident s psychosocial needs related to activity choices including: Meeting the needs of the resident who is grieving; Maintaining contact with family; Providing or arranging for provision of needed counseling services; Supporting preferences, customary routines, concerns and choices; and Assisting residents/families in decision-making. F353, Sufficient Staff Determine whether the facility had qualified staff in sufficient numbers to assure the resident was provided activities based upon the comprehensive assessment and care plan. F464, Dining and Activities Rooms F499, Staff Qualifications Determine whether the facility has provided sufficient space to accommodate the activities and the needs of participating residents and that the space is well lighted, ventilated, and adequately furnished. Determine whether the facility has employed sufficient qualified professional staff to assess residents and to develop and implement the activities approaches to its comprehensive care plans. Staff Interviews & Observations To determine whether the regulatory requirements for activities are met, surveyors may interview Activities Staff, CNAs, Social Services and Nursing Staff, as well as observe staff member interactions with residents. Surveyors are instructed to take into account whether a resident has special cognitive or physical needs, and determine whether he or she is receiving activities according to their comprehensive assessment and interdisciplinary care plan. For example, there Page 12 of 16

13 may be numerous residents within a nursing home who are confined to their room due to a medical condition. For these residents, surveyors will look for signs that activities, such as reading or listening to music are accommodated. Signs of Accommodation Signs of accommodation might include providing books, music or proper lighting. If a resident is constantly mobile, for example, the surveyor will observe whether the facility which incorporates all staff and not just the Activities team accommodate that resident s need or desire to move about the facility in a safe and supervised manner. If observing a resident, who is medically compromised, surveyors may determine if the activities offered by the facility accommodate that resident s need for time-limited or lowenergy activities, which also allow staff to administer relevant medical, nursing or dietary needs. Surveyors are instructed to take the special needs of the resident into account when assessing this Care Area. If an investigation is triggered, and the Care Plan calls for group activities, surveyors will observer whether staff attempts to accommodate specific resident needs in order to participate. Adaptations should be based on the needs of the resident. Actions such as informing the resident of program schedules, proving transportation or assuring that the activities are compatible with the resident s interests are examples of adaptations, as well ensuring that thea activity is age appropriate. Page 13 of 16

14 The facility should be aware of the numerous adaptations available to assist residents in participating in activities of choice and should make these available to residents. Some environment adaptations or modifications include eliminating glare, reducing extraneous noise or selecting/making available tables with sufficient height for wheelchair users to get the arms of their wheelchairs under the table to participate in an activity taking place at the table. Nurse Interview In the nursing staff interview, surveyors are instructed to interview a nurse responsible for the resident to determine how nursing home staff members assist them in activities in which the resident is interested in participating. Assistance can take many forms, including coordinating schedules medications or therapy to the extent possible to make it easier for the resident to attend an activity or making staff available to assist with activities in and out of the facility. If the resident refuses to participate in activities, the surveyors may ask the nurse what they believe are the reasons for nonparticipation. Surveyors will also observe nursing staff to ensure that interview responses and observations are compatible. Activity Staff As explained early, fulfilling the activities requirements of federal regulations, involves more than just the Activity Staff. All departments should work together to ensure that this requirement is met. Still, surveyors will interview members of this team to determine if they are aware of the resident s activities and goals, if they provide assistance in providing activities in accordance with the resident s Care Plan and if they make sure the resident has sufficient supplies to participate in different activities. Activity staff may also be asked if they know whether the resident participates in activities and if they do not participate, if they have determined the reason for non-participation. Surveyors will also observe activity staff to ensure that interview responses and observations are compatible. Social Services Interview In the social services interview, surveyors are instructed to determine what contributions this team makes to help the resident participate in activities of choice. This includes actions the social services staff takes to assist the resident with their psychosocial needs. It also includes the role that social services plays in obtaining equipment or supplies to help the resident participate in activities. For example, if the resident enjoys reading, surveyors may seek to determine if social services provides audio books for residents or assists the residents in obtaining new glasses or hearing aids for such activities, if their current glasses or hearing aids are not adequate. Funds may also have a role to play in activities. And as such, surveyors may determine what roles social services plays in helping to obtain sufficient funds for a resident to participate in activities of choice that require funds, like outing to local restaurants or other dining Page 14 of 16

15 events. Surveyors will also observe social services staff to ensure that interview responses and observations are compatible. CNA Interview In the CNA interview, surveyors will seek to understand what role the CNA plays in assisting the resident to participate in activities of choice. The CNAs play a critical role in helping residents perform many important tasks, like helping them to get out of bed and dress, helping to get them to transportation or helping to provide ADL assistance to the resident while they participate in activities. Surveyors will also observe CNA staff to ensure that interview responses and observations are compatible. After completing interviews, observations and document reviews, surveyors will enter their findings into the DCT to determine compliance with respect to four specific federal tags: F272, F279, F280 and F248. 1) Did the facility adequately assess to identify individual activity preferences and interests, and needed adaptations? No Yes F272 2) Did the facility develop a Care Plan with input from the resident and/or representative, as appropriate, that provides to the extent possible for the resident s participation in activities of choice? No Yes F279 3) Did the facility revise the plan of care as needed with input of the resident (or representative, as appropriate)? No Yes F280 4) Did the facility provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well being of the resident? No Yes F248 Surveyors may find that the facility is in compliance, even if the Activities Care Area is triggered for Stage 2 investigation. A facility is in compliance with Activities if they: xx Recognized and assessed for preferences, choices, specific conditions, causes and/or problems, needs and behaviors Defined and implemented activities in accordance with resident needs and goals Monitored and evaluated the resident s response Revised the approaches as appropriate Page 15 of 16

16 i CMS Manual System, Department of Health & Human Services, Centers for Medicare & Medicaid Services, Pub State Operations Provider Certification, Transmittal 19, June 1, 2006, p. 74. ii Priority Order of Quality Indicator Survey (QIS) National Implementation in States, Centers for Medicare & Medicaid Services, Ref: S&C-09-05, August 7, 2009, p. 1. iii Updated Brochure Describing the Quality Indicator Survey, Centers for Medicare & Medicaid Services, Ref: S&C-08-21, May, 16, 2008, p. 1. iv The QIS Expert: Pathways Standardize Stage 2 Assessments, Provider Magazine, April 10, 2010, p. 18. v QCI Breakdown by Data Source, Quality Indicator Study, August 6, 2007, p. 1. vi Updated Brochure Describing the Quality Indicator Survey, Centers for Medicare & Medicaid Services, Ref: S&C-08-21, May, 16, 2008, p. 1. vii Quality Indicator Surveyor Training Manual, Centers for Medicare & Medicaid Services, Quality Indicator Survey - 09/07/2006, p.51. viii Ipid, p. 51. ix Stage II Care Area Investigation Key, Department of Health and Human Services, Centers for Medicare & Medicaid, CMS Form (08/07), p. 1. x The QIS Expert, p. 18. xi The QIS Epert, p. 18. xii Nursing Home Resident Assessment Quality of Care, Department of Health and Human Services, Office of Inspector General June Gibbs Brown, January 2001, OEI , p. 3. xiii CMS Manual System, Department of Health & Human Services, Centers for Medicare & Medicaid Services, Pub State Operations Provider Certification, Transmittal 19, June 1, 2006, p. 74. xiv Stage 11 Care Area Investigation Key, p.1. xv Stage II Critical Element for Activities, p.9. xvi Stage II Critical Element for Activities, p. 10. xvii Stage II Critical Element for Activities, Department of Health and Human Services, Centers for Medicare & Medicaid, CMS Form (06/07), p. 1. xviii CMS Manual, p. 74. xix Stage II, Critical Elements for Activities, p. 13. xx CMS Manual, p. 92. Page 16 of 16