The QIS Mock Survey Guide

What could be better than knowing what’s wrong BEFORE a survey?
The QIS Mock Survey Guide helps you develop a survey team, conduct a mock survey, and ultimately test your facility’s survey-readiness.

The best way to be prepared for a Quality Indicator Survey (QIS) is to know what you should expect. The only true way to gain that knowledge is to conduct mock surveys using the actual materials used by surveyors in the field.

The new HCPro resource The QIS Mock Survey Guide is a book and CD-ROM that provides you with a step-by-step outline of what happens during a survey under the revised process. It simplifies the differences between the traditional survey and the QIS and provides educational tools to complete the survey process.

This solution-based guide:

• Includes an overview of the QIS and how to transition into the QIS from the traditional survey process
• Offers instructions on how to perform both Stage I and Stage II of the QIS at your organization
• Provides a detailed outline of everything you need to do to prepare before the arrival of surveyors
• Includes case studies that look at five separate instances where facilities were found deficient under F-tags 329, 309, 314, 323, and 505
• Outlines the best way to develop a survey team, conduct a mock survey, and troubleshoot any potential problems
• Contains the actual forms and worksheets used by surveyors in the field today

Each tool below is included in the book and on the companion CD-ROM:

APPENDIX A:  Entrance conference forms

Task 1 Worksheets
CMS-20044 Offsite Survey Preparation Worksheet

Task 2  Worksheets
CMS-20045 Entrance Conference (team copy)
CMS-20046 Entrance Conference (facility copy)
CMS-672 Resident Census and Condition Report
CMS Quality Indicator Survey Demonstration Project brochure

APPENDIX B:  Stage I Forms and Worksheets

Task 3 Initial Tour Worksheet
CMS-807 Surveyor Notes Worksheet

Task 4 Worksheets
CMS-20047 Admission Sample Record Review
CMS-20048 Census Sample Record Review
CMS-20049 Family Interview
CMS-20050 Resident Interview and Resident Observation
CMS-20051 Staff Interview

Task 5 Facility Level Worksheets
CMS-20052 Liability Notice and Beneficiary Appeal Rights (Demand Billing)
CMS-20053 Dining Observation
CMS-20054 Infection Control and Immunizations
CMS-20055 Kitchen and Food Service Observation
CMS-20056 Medication Administration Observation and Drug Storage
CMS-20057 Resident Council President/Representative Interview
CMS-20058 Quality Assurance & Assessment Review

Task 5 Triggered Task Worksheets
CMS-20059 Abuse Prohibition Review
CMS-20060 Admit, Transfer, Discharge Review
CMS-20061 Environmental Observation
CMS-20062 Sufficient Nursing Staff Review
CMS-20063 Personal Funds Review
CMS-20084 Cognitive Performance Scale Calculator

APPENDIX C:  Stage II Worksheets: Critical Element Pathways (CEs) and Unnecessary Drug Review Worksheet

Task 6 and 7 Worksheets
CMS-20065 Activities
CMS-20066 ADL-ROM
CMS-20067 Behavioral/Emotional
CMS-20068 Bowel/Bladder/Catheter
CMS-20069 Communication/Sensory problems
CMS-20070 Dental
CMS-20071 Dialysis
CMS-20072 General
CMS-20073 Hospice
CMS-20074 Hospital death
CMS-20075 Nutrition/Hydration/Tube Feeding
CMS-20076 Pain Management
CMS-20077 Physical Restraints
CMS-20078 Pressure Ulcers
CMS-20079 Psych meds
CMS-20080 Rehabilitation
CMS-20081 Ventilator
CMS-20082 Unnecessary Drugs

Stage II care area investigation key

APPENDIX D: Quality of Care Indicators (QCI) and mappings
Quality of Care Indicators and Facility Level Tasks by Care Areas
Quality of Care Indicators Mapped to Care Areas
Quality of Care Indicators – mapping to F tags
Quality of Care Indicators by data source
F tags to Care Areas to Critical Element Pathways

Table of Contents:

This resource is organized by task so you can find what you need FAST!

Introduction: The Long Term Care Survey: The Big Picture
Types of Surveys
Scope and Severity of Findings
Transitioning to QIS Survey Process
Overview of the QIS Process
Goal and Benefit of a Quality Indicator Mock Survey
Review of the Quality Measures/Quality Indicators (QM/QI)
Review of the Oscar 3 Report
Let’s Get Started:  Begin With First Things First
Using Your Regulation Manual as a Resource
Glossary of Terms

Task 1: Off Site Survey Preparation and Initial Sampling

Task 2: On Site Survey Activities and Entrance Conference

Task 3: Initial Tour

Task 4: Stage I Survey Tasks

Task 5: Facility Level Survey Tasks

Task 6: Transition from Stage I to Stage II

Task 7: Stage II Survey Tasks

Task 8: Analysis and Decision Making

Task 9: Exit Conference

Case Studies
Regulatory Groupings

About the author:

FROSINI RUBERTINO, RN, CRNAC, C-NE, CDONA/LTC, is a registered nurse with more than 30 years of experience in the healthcare industry. Former president of an Ohio-based long-term care consulting and education firm, and a former member of the Arkansas Healthcare Association's Education Committee, she is currently a clinical services consultant for an Arkansas-based clinical consultant group. She received her executive management certificate from the Weatherhead School of Management at Case Western Reserve University and her Continuous Process improvement training in Cleveland, OH. As an HCPro faculty member, she brings her experience in risk management, Medicare and regulatory compliance, clinical systems, and education into the classroom for this program.

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