The QIS Survey Process: How to Prepare Faculty: Diane Atchinson, RN- BC, MSN, ANP DPA Associates, Inc Kansas City, MO 800-245-0372 E mail: diane@dpaassociates.com
Access the QIS manual KDOA web site License and certification Scroll down to manuals www.nursinghomequality.com Click on resources Download manual, brochure and all forms
Two staged process Stage I Collection of off site data Oscar 3 reports Complaint investigations Ombudsman contact-any issues Waaivers or variances Collection of data on site This information is compared to national norms Information is gathered from: Observations Clinical record reviews Resident/family interviews Staff interviews This information identifies sets of care areas for further investigations
Stage II Systematic investigation of issues flagged from Phase I Organized around Critical Element Pathways Investigative probes for the care areas triggered
Initial tour Give an overall view of the facility Not intended to be a method of sample selection Facility staff not needed for the tour Note environmental issues (see checklist) Focus areas: Staff/resident interactions Staff availability Activities provided and who is attending Characteristics of the residents
Sample selection-minimum of 40 residents MDS sample Admission sample Record review only and focuses on first six months in the facility Rehabilitation Emergent care Skin care Nutrition Census sample Report generated states who should be reviewed and if they can be interviewed Ability to be interviewed is base on CPS score
Other tasks Demand billing Dining observation Infection control Kitchen/food service observation Medication Administration QA review Resident council leader interview
Task reviewed if triggered from Phase II reviews Abuse review Admission, transfer and discharge review Environmental observations Nursing services, sufficient staffing Personal fund
Tools to use Every area noted above in task 5 have specific tools for surveyor completion. Answers determine deficiencies
Medication observation Drug storage Medication passes-10 residents/50 passes Multiple routes Eye G tubes
Phase II_Process review Triggered from data in Phase I when inputted into the computer The computer will tell the surveyor who to do a more indepth review and for what reason Use of the Critical Element Pathways (17) General pathway for those who do not fit the other 17 pathways
Pathways include Assessment Care planning Interviewing Observation Care plan followed Dose reductions Monitoring for side affects Behavior monitoring
Analysis, decision making and integration of information Data input Pre exit conference ( concerns conference)
Exit conference Invite ombudsman Residents can come or a separate meeting with the residents can occur Deficiencies found No written report at exit
QIS extended survey will occur for the following reasons Scope/severity of levels F, H, I J, K L In any of the following areas Resident behavior and facility practices Quality of life Quality of care
How to prepare Complete a notebook that includes all the information needed from checklist attached Review each Critical element pathway and update your QA process to include these areas Interview residents and families routinely using the same questions the surveyors will use Educate staff regarding their role through interviews in the survey process and what they need to know Pull the forms and manual for the QIS process
Outcomes of mock QIS surveys P and P for influenza and pneummoccal does not include educational materials Preferences big area for resident interviews Get up Bathing Meals Preferences become an issue with residents who are dependent on staff- whenever the staff can get to me Family interviews-invitation to care plan meetings Resident council-ombudsman role and facility data (survey posting etc) Denial letter info
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES ENTRANCE CONFERENCE WORKSHEET (QIS Facility Copy) INFORMATION TO PROVIDE IMMEDIATELY UPON ENTRANCE 1. An alphabetical resident census, with room numbers/units. Note residents on the census who are not in the facility (e.g., in the hospital, home visit, etc.). 2. A completed New Admission Information form. Please list all new admissions after the date listed (roughly the last 30 days) on the form. Include only residents still residing in the facility. Please include Admission Date, Date of Birth, and Room Number/Unit for each resident. 3. Post survey announcement signs in high-visibility areas. 4. A copy of the facility floor plan. 5. A copy of the staffing schedules for licensed and registered nursing staff for the survey time period. INFORMATION TO PROVIDE WITHIN ONE (1) HOUR OF ENTRANCE CONFERENCE 6. List of key personnel and their locations. 7. Name of resident council president or an officer/active council member. 8. Schedule of meal times and location of dining room(s). 9. Schedule of Medication Administration times. 10. All Admission Sample closed records (to be brought to survey team work area). A list of required records will be provided after the Entrance Conference. Make arrangements for overnight storage of the records in a secure location; the survey team will need to access them throughout the survey. INFORMATION TO PROVIDE WITHIN FOUR (4) HOURS OF ENTRANCE CONFERENCE 11. A list of residents who receive ventilator, dialysis (whether in or out of the facility), certified Medicare hospice and/or end of life services (see page 2 of this worksheet). 12. If there are residents receiving dialysis within the facility, provide the following information (see the last page of this worksheet): List containing residents names, room numbers, name of ESRD assigned caregiver/technician (and identify whether this caregiver is provided by the ESRD facility, the DME supplier, or the LTC facility); Days and times each resident will receive his/her dialysis treatment. Provide access to the written contract, agreement, arrangement, policies/procedures, and/or plan of care, specifying how the care is coordinated, to assist with the evaluation of care. 13. Influenza / Pneumococcal Immunization - Policy & Procedures. 14. List of rooms meeting any one of the following conditions that require a variance: Less than the required square footage More than four residents Below ground level No window to the outside No direct access to an exit corridor 15. Quality Assessment and Assurance (QAA) committee information (name of contact, names of members and frequency of meetings). FORM CMS 20045 (01/09)
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES ENTRANCE CONFERENCE WORKSHEET (QIS Facility Copy) 16. Location of Preadmission Screening and Resident Review (PASRR) information. 17. Description of any experimental research occurring in the facility. 18. Name of contact person for Abuse Prohibition Policies and Procedures/Complaints/- Grievance information. INFORMATION TO PROVIDE WITHIN 24 HOURS OF ENTRANCE 19. For Medicare or Medicare/Medicaid certified facilities: a list of Medicare residents who requested demand billing in the past six months and a list of Medicare beneficiaries discharged from the SNF in the past six (6) months. 20. Medicare/Medicaid Application (CMS-671), and Resident Census and Conditions (CMS-672). FORM CMS 20045 (01/09) 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES ENTRANCE CONFERENCE WORKSHEET (QIS Facility Copy) VENTILATOR, DIALYSIS, CERTIFIED MEDICARE HOSPICE AND/OR END OF LIFE SERVICES Please return the completed worksheet to the survey team within four hours of entrance. Resident Room # Ventilator Dialysis Hemo- Dialysis Peritoneal Certified Medicare Hospice and/or End of Life If there are residents receiving dialysis within the facility, provide the following: Resident Room # ESRD Assigned Caregiver/Technician Caregiver/Technician Provider: ESRD Facility DME Supplier LTC Facility ESRD Facility DME Supplier LTC Facility ESRD Facility DME Supplier LTC Facility ESRD Facility DME Supplier LTC Facility Dialysis Treatment Days and Times FORM CMS 20045 (01/09) 3