Facility Self-Assessment (Mock Survey) Tool
FacilitySelf-Assessment(Mock Survey)Tool
SECTION 5 - FACILITY SELF-ASSESSMENT (MOCKSURVEY TOOLS)Facility Self-Assessment - Mock surveys are an opportunity to look at systems,procedures and processes of care and to identify potential survey-risk areas.Mock surveys should be performed on a scheduled basis and shared withnursing home staff. The most important part of the survey process is what youdo after it is over with the results. F-tags are used in this section. Be advisedthat CMS makes revisions to the F-tags on a regular basis.SECTIONAdministrationArticle: Mock Survey: An Important ComponentSelf-Assessment/Mock SurveyGuide to F-Tag NumbersLong Term Care Survey Process (LTCSP) Procedure GuideSurvey Scope & Severity GridOffsite Preparation WorksheetInitial Pool Care AreasResident ObservationLimited Record ReviewResident Representative InterviewResident InterviewMandatory Facility TaskCMS 20053 Dining ObservationCMS 20054 Infection Prevention, Control,& ImmunizationsCMS 20055 Kitchen ObservationCMS 20052 Beneficiary Protection Notification ReviewCMS 20056 Medication Administration ObservationCMS 20089 Medication Storage and LabelingCMS 20058 QAA & QAPICMS 20057 Resident Council InterviewCMS 20062 Sufficient & Competent Nurse StaffingFirst Impressions ChecklistAdministration ChecklistContract Book ChecklistPersonnel File ChecklistCritical Element PathwaysCMS-20059 AbuseCMS-20063 Personal FundsCMS-20091 Extended SurveyCMS-20130 NeglectEnvironmentPhysical Plant Rounds-Initial TourFire Drill GridCMS-20061 Environmental 8-183184185-205206207-210
NursingMDS Audit ToolChart Audit ToolCMS 20054 Infection Prevention ControlCMS 20056 Medication Administration ObservationCMS 20059 AbuseCMS 20062 Sufficient & Competent Nurse StaffingCMS-20066 Activities of Daily LivingCMS-20067 Behavioral-EmotionalCMS-20068 Urinary Catheter or UTICMS-20069 Communication-SensoryCMS-20071 DialysisCMS-20072 GeneralCMS-20073 Hospice and End of LifeCMS-20074 DeathCMS-20075 NutritionCMS-20076 Pain ManagementCMS-20077 Physical RestraintsCMS-20078 Pressure UlcerCMS-20080 Rehab and RestorativeCMS-20081 Respiratory CareCMS-20082 Unnecessary MedicationsCMS-20089 Medication Storage and LabelingCMS-20092 HydrationCMS-20093 Tube FeedingCMS-20120 Positioning, Mobility, ROMCMS-20123 HospitalizationCMS-20125 Bladder and Bowel IncontinenceCMS-20127 AccidentsCMS-20130 NeglectCMS-20131 Resident AssessmentCMS-20132 DischargeCMS-20133 Dementia CareMatrix with InstructionsCMS 672 - Resident Census and Conditions of ResidentsInitial Certification Tag Review ToolPsychosocial Severity 00-406DietaryDietary ObservationsMonthly Meal Quality ReviewMonthly Sanitation/Infection Control ReviewMeal Audit ToolCMS-20053 DiningCMS-20055 KitchenCMS-20075 Nutrition407408409410411412-418419-425426-431
Social ServicesLTCSP Resident Interview Care AreaLTCSP Resident Representative Care AreaLTCSP Resident Observation Care AreaPsychosocial Outcome Severity GuideCMS 20052 Beneficiary NoticeCMS 20057 Resident CouncilCMS 20059 AbuseCMS 20063 Personal FundsCMS 20065 ActivitiesCMS 20067 Behavioral-EmotionalCMS 20069 Communication-SensoryCMS 20073 Hospice-End of LifeCMS 20090 PASARRCMS 20130 NeglectCMS 20132 DischargeCMS 20133 Dementia CareUpdated June 9-534535-538539-542
ADMINISTRATION5
Mock Survey: An Important Component of Survey PreparationMany long-term care providers strive to be ‘survey-ready’ all year round. But just like many of us schedulethe big spring cleaning some time in advance of company arriving for their annual summer visit; some LTCproviders opt to conduct a Mock Survey in anticipation of their annual licensure/certification visit.Mock Surveys can serve several purposes: A Mock Survey can be an opportunity to take a fresh look at systems, procedures and processes ofcare, and identify potential survey-risk areas. And survey-risk can translate into litigation-risk. A Mock Survey also can reveal how staff will function under stressful circumstances.Taking that fresh and objective look is essential in order to reap the maximum benefit from the MockSurvey process. LTC providers are discovering the hard way that the procedures, protocols andmonitoring/QA systems that served them well enough in the past are no longer sufficient to avoid surveydeficiencies. ‘But we’ve always done it this way; the surveyors never cited us on this in the past; wethought we were doing this correctly; we’ve always done well on our surveys before – how could this behappening?’ It is hard to stay current with new standards and the more stringent application of existingstandards like F314 Pressure Ulcers, F315 Continence/Catheters, F323 Accidents, etc. It is hard to look atone’s own organization and see its shortcomings.One way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Surveyprocess conducted by someone external to your organization. This ‘someone’ could be a consultant or anexperienced and well informed professional from a neighboring LTC community. If, however, you elect tomanage the process using your own personnel, incorporating the following approaches can facilitateobjectivity: Assign department heads to ‘survey’ departments other than their own. In nursing, have chargenurses/unit managers, supervisors, etc., assigned to audit other units and/or aspects of care for whichthey are not usually responsible. It is often hard to see your own forest for the trees. Although obviously the internal ‘surveyors’ will know that a Mock Survey will be taking place atsome point, it could be more beneficial if direct care staff and other workers were notinformed. This maximizes the surprise and stress factor. Even though the internal ‘surveyors’ know that the process is planned, the Mock Survey should beunannounced. The Administrator walks in one morning and proclaims it to be Mock SurveyDay. This simulates ‘real life’ conditions.The most important part of the Mock Survey process is what you do after it’s over. If you have about threemonths between the Mock Survey and the earliest likely date of the next survey, then I recommend the‘Systems’ approach. The Systems approach includes a broader review and analysis of organizationalpolicies, procedures, protocols and practices that may be contributing to Quality Indicator Report flagsand/or to the ‘findings’ of the Mock Survey ‘survey team.’ If you have one month or less between the MockSurvey and the earliest likely date of the next survey, then I recommend you go into ‘Manage the DamageMode.’ What are your high-risk areas, which residents have experienced negative outcomes, how can therisk be lessened and/or the negative outcome be explained and/or otherwise addressed?In either scenario, “Systems” or “Manage the Damage Mode” develop a Corrective Action Roadmap that6
assigns responsibility, targets timeframes and breaks down the plan into operational steps.Pre-survey preparation and risk management are the two most effective tools we have to weather today’sregulatory climate. Most LTC providers, if they haven’t endured it already themselves, know of a providerin their area- good reputation, well respected in their community, satisfactory survey history – that has beenblown out of the water during their last survey. Wouldn’t you rather have a ‘friendly outsider’ or your ownteam discovers the dust-bunnies before the surveyors do?Reprint from The Edge, April 29, 2009The Edge is provided to members of the Kansas Association of Homes and Services for the Aging in partnership with Life ServicesNetwork, the Illinois AAHSA affiliate. Authored by Dorrie J. Seyfried, Vice President of Method Management, Risk Management& LTC Consultants based in St. Charles, Illinois.7
Self-Assessment/Mock SurveyToday, more than ever, nursing facilities must be prepared to demonstrate compliance with federalregulations not only at survey time, but all year long. Survey teams can arrive at facilities as soonas nine months after the last annual survey. They can appear at any time to conduct complaintinvestigation surveys. And, these days, they are likely to begin surveys at nontraditional times andon weekends. These changes in the frequencies, times and types of surveys make it imperative thatfacilities be prepared at all times.Nevertheless, with rapidly increasing turnover rates for nursing staff and managers, facility staffmight not be familiar with surveyors' procedures, care observations, interviews, and record reviewsand could be unprepared to meet these challenges.To adequately prepare staff to succeed at survey time, and to ensure that the facility complies withregulations at all times, periodic self-assessments or mock surveys can be an important feature of afacility's quality assurance process. A mock survey can be performed by facility staff, by corporateadvisors or by outside consultants. In whatever manner your facility chooses to provide theseservices, there are a few guidelines to bear in mind.1. Enlist "fresh eyes" to see existing problems clearly. Be sure to include new employees, an"outsider" or other mock surveyors who are not overly familiar with the facility's staff andresidents. If using facility staff, ask them to review areas outside their direct span of control.2. Replicate "real" survey procedures as faithfully as possible. Use precise observation methods,select a sample of residents according to survey guidelines and interview the same staff that realsurveyors are likely to interview.The following pages include a variety of tools for you to use for your own self-assessment—use allor some of them. Remember, if you find any deficient practices be sure you bring it to yourQuality Assurance Meetings/QAPI, document your findings, and come up with a workable plan tocorrect the problem.8
Long‐Term Care Rule F‐Tag: Job AidFederal Regulatory Groups for Long Term Care Facilities* Substandard quality of care one or more deficiencies with s/s levels of F, H, I, J, K, or L in RedF540Definitions483.10 Resident ident Rights/Exercise of RightsRights Exercised by RepresentativeRight to be Informed/Make Treatment DecisionsRight to Participate in Planning CareResident Self‐Admin Meds‐Clinically AppropriateRight to Choose/Be Informed of Attending PhysicianRespect, Dignity/Right to have Personal Property*Reasonable Accommodations of Needs/Preferences*Choose/Be Notified of Room/Roommate ChangeRight to Refuse Certain Transfers*Self DeterminationImmediate Access to ResidentRight to Receive/Deny VisitorsInform of Visitation Rights/Equal Visitation Privileges*Resident/Family Group and ResponseRight to Perform Facility Services or RefuseProtection/Management of Personal FundsAccounting and Records of Personal FundsNotice and Conveyance of Personal FundsSurety Bond ‐ Security of Personal FundsLimitations on Charges to Personal FundsNotice of Rights and RulesRight to Access/Purchase Copies of RecordsRequired Notices and Contact InformationRequired PostingsRight to Forms of Communication with PrivacyRight to Survey Results/Advocate Agency InfoRequest/Refuse/Discontinue Treatment;Formulate Adv DiPosting/Notice of Medicare/Medicaid on AdmissionNotify of Changes (Injury/Decline/Room, Etc.)Medicaid/Medicare Coverage/Liability NoticePersonal Privacy/Confidentiality of Records*Safe/Clean/Comfortable/Homelike EnvironmentGrievancesResident Contact with External EntitiesReport‐30: LTC‐Rule Job Aid483.12 Freedom from Abuse, Neglect, and 10*Free from Abuse and Neglect*Free from Misappropriation/Exploitation*Free from Involuntary Seclusion*Right to be Free from Physical Restraints*Right to be Free from Chemical Restraints*Not Employ/Engage Staff with Adverse Actions*Develop/Implement Abuse/Neglect, etc. Policies*Reporting of Reasonable Suspicion of a Crime*Reporting of Alleged Violations*Investigate/Prevent/Correct Alleged Violation483.15 Admission, Transfer, and DischargeF620F621F622F623F624F625F626Admissions PolicyEqual Practices Regardless of Payment SourceTransfer and Discharge RequirementsNotice Requirements Before Transfer/DischargePreparation for Safe/Orderly Transfer/DischargeNotice of Bed Hold Policy Before/Upon TransferPermi ng Residents to Return to Facility483.20 Resident 5F646Admission Physician Orders for Immediate CareComprehensive Assessments & TimingComprehensive Assmt A er Significant ChangeQuarterly Assessment At Least Every 3 MonthsMaintain 15 Months of Resident AssessmentsEncoding/Transmi ng Resident AssessmentAccuracy of AssessmentsCoordina on/Cer fica on of AssessmentCoordina on of PASARR and AssessmentsPASARR Screening for MD & IDMD/ID Significant Change Notification483.21 Comprehensive Resident Centered Care PlansF655F656F657F658F659F660F661Baseline Care PlanDevelop/Implement Comprehensive Care PlanCare Plan Timing and RevisionServices Provided Meet Professional StandardsQualified PersonsDischarge Planning ProcessDischarge SummaryPage 1 of 2483.24 Quality of LifeF675F676F677F678F679F680*Quality of Life*Ac vi es of Daily Living (ADLs)/ Maintain Abili es*ADL Care Provided for Dependent Residents*Cardio‐Pulmonary Resuscita on (CPR)*Ac vi es Meet Interest/Needs of Each Resident*Qualifica ons of Ac vity Professional483.25 Quality of 95F696F697F698F699F700*Quality of Care*Treatment/Devices to Maintain Hearing/Vision*Treatment/Svcs to Prevent/Heal Pressure Ulcers*Foot Care*Increase/Prevent Decrease in ROM/Mobility*Free of Accident Hazards/Supervision/Devices*Bowel/Bladder Incon nence, Catheter, UTI*Colostomy, Urostomy, or Ileostomy Care*Nutri on/Hydra on Status Maintenance*Tube Feeding Management/Restore Ea ng Skills*Parenteral/IV Fluids*Respiratory/Tracheostomy care and Suc oning*Prostheses*Pain Management*Dialysis*{PHASE‐3} Trauma Informed Care*Bedrails483.30 Physician ServicesF710F711F712F713F714F715Resident's Care Supervised by a PhysicianPhysician Visits‐ Review Care/Notes/OrderPhysician Visits‐Frequency/Timeliness/Alternate NPPsPhysician for Emergency Care, Available 24 HoursPhysician Delega on of Tasks to NPPPhysician Delega on to Die an/Therapist483.35 Nursing ServicesF725F726F727F728F729Sufficient Nursing StaffCompetent Nursing StaffRN 8 Hrs/7 days/Wk, Full Time DONFacility Hiring and Use of NurseNurse Aide Registry Verifica on, RetrainingFriday, July 14, 20179
Federal Regulatory Groups for Long Term Care Facilities* Substandard quality of care one or more deficiencies with s/s levels of F, H, I, J, K, or L in RedF730F731F732Nurse Aide Perform Review – 12Hr/Year In‐ serviceWaiver‐Licensed Nurses 24Hr/Day and RN CoveragePosted Nurse Staffing Informa on483.40 Behavioral Health ServicesF740F741F742F743F744F745Behavioral Health ServicesSufficient/Competent Staff‐Behav Health Needs*Treatment/Svc for Mental/Psychosocial Concerns*No Pattern of Behavioral Difficulties Unless Unavoidable*Treatment /Service for Dementia*Provision of Medically Related Social Services483.45 Pharmacy ServicesF755F756F757F758F759F760F761Pharmacy Svcs/Procedures/Pharmacist/RecordsDrug Regimen Review, Report Irregular, Act On*Drug Regimen is Free From Unnecessary Drugs*Free from Unnec Psychotropic Meds/PRN Use*Free of Medica on Error Ratesof 5% or More*Residents Are Free of Significant Med ErrorsLabel/Store Drugs & Biologicals483.50 Laboratory, Radiology, and Other Diagnostic ry ServicesBlood Blank and Transfusion ServicesLab Services Not Provided On‐SiteLab Svs Physician Order/No fy of ResultsAssist with Transport Arrangements to Lab SvcsLab Reports in Record‐LabName/AddressRadiology/Other Diagnostic ServicesRadiology/Diag. Svcs Ordered/No fy ResultsAssist with Transport Arrangements to RadiologyX‐Ray/Diagnos c Report in Record‐Sign/Dated483.55 Dental ServicesF790F791Rou ne/Emergency Dental Services in SNFsRou ne/Emergency Dental Services in NFsF806F807F808F809F810F811F812F813F814Resident Allergies, Preferences and Subs tutesDrinks Avail to Meet Needs/Preferences/ Hydra onTherapeu c Diet Prescribed by PhysicianFrequency of Meals/Snacks at Bed meAssistive Devices ‐ Ea ng Equipment/UtensilsFeeding Asst ‐Training/Supervision/ResidentFood Procurement, Store/Prepare/Serve ‐ SanitaryPersonal Food PolicyDispose Garbage & Refuse Properly483.65 Specialized Rehabilitative ServicesF825F826Provide/Obtain Specialized Rehab ServicesRehab Services‐ Physician Order/Qualified Person483.70 ly w/Fed/State/Local Law/Prof StdGoverning BodyFacility AssessmentStaff QualificationsUse of Outside ResourcesResponsibili es of Medical DirectorResident Records ‐ Identifiable InformationTransfer AgreementDisclosure of Ownership RequirementsFacility closure‐AdministratorFacility closureHospice Services*Qualifications of Social Worker 120 BedsPayroll Based Journal483.75 Quality Assurance and Performance ImprovemF865F866F867F868QAPI Program/Plan, Disclosure/Good Faith Attempt{PHASE‐3} QAPI/QAA Data Collec on and MonitoringQAPI/QAA Improvement Ac vi esQAA Committee483.60 Food and Nutrition Services483.80 Infection vided Diet Meets Needs of Each ResidentQualified Dietary StaffSufficient Dietary Support PersonnelMenus Meet Res Needs/Prep in Advance/FollowedNutri ve Value/Appear ,Palatable/Prefer TempFood in Form to Meet Individual NeedsReport‐30: LTC‐Rule Job AidInfection Prevention & ControlAntibiotic Stewardship Program{PHASE‐3} Infec on Preven onist Qualifica ons/Role*Influenza and Pneumococcal Immuniza onsPage 2 of 2483.85 {PHASE‐3} Compliance and Ethics ProgramF895{PHASE-3} Compliance and Ethics Program483.90 Physical ency Electrical Power SystemSpace and EquipmentEssen al Equipment, Safe Opera ng Condi onResident BedResident RoomBedroom Number of ResidentsBedrooms Measure at Least 80 Square Ft/ResidentBedrooms Have Direct Access to Exit CorridorBedrooms Assure Full Visual PrivacyResident Room WindowResident Room Floor Above GradeResident Room Bed/Furniture/ClosetBedrooms Equipped/Near Lavatory/ToiletResident Call SystemRequirements for Dining and Activity RoomsSafe/Func onal/Sanitary/Comfortable EnvironmentProcedures to Ensure Water AvailabilityVentilationCorridors Have Firmly Secured HandrailsMaintains Effec ve Pest Control ProgramSmoking Policies483.95 Training 49{PHASE‐3} Training Requirements ‐ General{PHASE‐3} Communication Training{PHASE-3} Resident’s Rights TrainingAbuse, Neglect, and Exploitation Training{PHASE‐3} QAPI Training{PHASE‐3} Infection Control Training{PHASE-3} Compliance and Ethics TrainingRequired In‐Service Training for Nurse AidesTraining for Feeding Assistants{PHASE-3} Behavioral Health TrainingFriday, July 14, 201710
Long Term Care Survey Process (LTCSP) Procedure GuideEffective May 6, 2018I. OFFSITE PREP . 1Step 1: Create survey shell in ASPEN Central Office (ACO) . 1LTCSP Application HELP. 1Step 2: Export shell from ACO . 1Step 3: Import shell into ASPEN Survey Explorer (ASE-Q). 2Step 4: Add team members in ASE-Q (if team composition changes) . 3Step 5: Access the survey . 3Step 6: TC completes offsite prep screen. 3Step 7: TC makes facility unit assignments . 5Step 8: TC makes mandatory facility task assignments . 6Step 9: TC prints documents . 6Step 10: TC shares offsite prep data with team members . 7DATA SHARING METHODS . 7Using the File method . 7Using Secured Wireless method or using Wired method with a switch . 8Using Secured Wired method using a cable to connect two machines . 9Step 11: Team reviews offsite information . 9II. FACILITY ENTRANCE . 10Step 12: Enter the facility and go to your assigned area . 10III. INITIAL POOL PROCESS. 11Step 13: Briefly screen all residents in your assigned area and observe, interview, and complete alimited record review for initial pool residents . 11Overview: . 11Initial Pool Workload. 12Screening. 12Initial Pool Residents: . 14Organizational Options for Screening and Initial Pool Residents: . 15Process Steps for Initial Pool Residents . 18Additional Initial Pool Process Information . 24Step 14: Share data at the end of each day and team composition changes . 25Step 15: End of Day 1 team meeting. 26IV. SAMPLE SELECTION. 28Step 16: Share Completed Initial Pool Data and TC Confirms Initial Pool Data is Completed . 2811
Long Term Care Survey Process (LTCSP) Procedure GuideEffective May 6, 2018Step 17: Select the Sample . 28V. INVESTIGATION . 32Step 18: Conduct investigations for sampled residents. 32VI. ONGOING AND OTHER SURVEY ACTIVITIES . 36Step 19: Complete closed record reviews. 36Step 20: Complete facility task assignments . 37 Dining . 38 Infection Control . 38 SNF Beneficiary Protection Notification Review . 38 Kitchen . 38 Med Admin. 39 Med Storage . 39 Resident Council Meeting . 40 Sufficient and Competent Nurse Staffing . 40 Personal Funds . 41 Environment. 41 Resident Assessment . 41 Extended Survey . 41Step 21: End of the day meeting . 41Step 22: Complete QAA/QAPI . 42VII. POTENTIAL CITATIONS . 42Step 23: Share Completed Investigation Data, Confirm Investigation Data is Complete, and TeamDeficiency determination. 42Step 24: Exit Conference with Facility . 44Step 25: Load Cites . 45Step 26: Save and Delete Completed Survey . 46Attachment A: Sample Size, Recommended Team Size, and Initial Pool Size . 47Note on Survey Team Size. 48Note on Onsite Time . 48Attachment B: Complaints and Facility Reported Incidents with Standard Survey . 49Enforcement Considerations . 4912
Long Term Care Survey Process (LTCSP) Procedure GuideEffective May 6, 2018I. OFFSITE PREPStep 1: Create survey shell in ASPEN Central Office (ACO)Create a survey shell in ACO according to your state practice. Add team members in ACO and designate the team coordinator. o Expand the facility’s name.o Right click on the Event ID.o Select Team Roster from the list.o Select Update.o Check the box for each team member that will participate in the survey. Ensureeach person has a check next to his or her name. Select OK.o Highlight the surveyor that is Team Coordinator (TC). Select Leader. The TC willhave a diamond in front of their name.o Select Done.Link any complaints and Facility Reported Incidents (FRIs) to the survey according toyour state practice. LTCSP Application HELPContact the designated state technical lead according to your state procedures for anyhardware or software difficulties. If an “unhandled exception” error message occurs while using the LTCSP applicationOR you are having technical issues, make a print screen of the message or technicalconcern. While still on the screen, press the Function [Fn] key and the Print Screen[Prnt Scrn] key. Open a Word document and paste the print screen [Ctrl V]. Describein the Word document the actions being completed just before the error message ortechnical concern. Send the document to your state technical lead. If the designated state technical lead is not available and the technical difficulty stopsthe survey process, contact
the big spring cleaning some time in advance of company arriving for their annual summer visit; some LTC providers opt to conduct a Mock Survey in anticipation of their annual licensure/certification visit. Mock Surveys can serve several purposes: A Mock Survey can be an opportunity to take a fresh look at systems, procedures and processes of
Mock Assessment Test Paper 1 1-79 Mock Assessment Test Paper 2 80-167 Mock Assessment Test Paper 3 168-247 Mock Assessment Test Paper 4 248-303 Mock Assessment Test Paper 5 304-383 Mock Assessment Test Paper 6 384-448 Mock Assessment Test Paper 7 449-526
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AP Calculus AB Name_ Mock AP Exam #3 Review The Mock AP Exam Thursday- Multiple Choice There will be 5 Calculator Multiplice Choice Questions and 15 Non-Calculator Multiple Choice Questions. This portion of the Mock AP Exam
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Mock Trial Preparation Background Before beginning this lesson, the teacher must pre-pare for the mock trial: Prepare the packets of information for the witnesses (prosecution and defense) and the defendant. Continue gathering courtroom materials needed for the mock trial
Cambridge IGCSE ACCOUNTING 0452/22 Paper 2 May/June 2020 MARK SCHEME Maximum Mark: 120 Published Students did not sit exam papers in the June 2020 series due to the Covid-19 global pandemic. This mark scheme is published to support teachers and students and should be read together with the question paper. It shows the requirements of the exam. The answer column of the mark scheme shows the .
