#2 SMQT Flashcards
When your survey team has cited IJ, but the entity you are surveying alleges that the IJ was actually removed prior to the survey. What must the team verify?
The survey team must verify the actions taken by the entity to remove IJ and the point where IJ was removed.
Which of the following must be documented on CMS-2567 when IJ is cited?
-Description of the noncompliance,
-specific regulatory requirements,
-and serious adverse outcome that occurred or likely to occur
Your survey team has cited IJ at an entity, but the entity cannot implement its IJ removal plan before the team completes the survey’s exit conference.
-If a removal plan cannot be implemented prior to the exit conference of the original survey, the IJ continues until an on-site revisit verifies the date that IJ was removed.
-During onsite revisit survey, surveyors should verify that all elements of the removal plan have been implemented and actions taken were completed in a manner that eliminates the likelihood of serious injury, harm, or death.
-In addition to verifying that IJ was removed, when conducting the onsite revisit, surveyors should determine the date the entity’s removal plan was fully implemented
-Even when IJ is removed prior to the exit conference, an onsite revisit will be required to determine substantial compliance.
Difference between a removal plan and plan of correction in IJ
A removal plan is a short-term, urgent response designed to immediately eliminate the jeopardy situation. The primary goal is to protect the residents from harm as quickly as possible. Removal plan includes all actions the entity has taken or will take to immediately address noncompliance that resulted in or made serious injury, harm, or death. It must be provided to the SA as soon as an entity has identified steps it will take to ensure no recipients are suffering or likely to suffer. It is not necessary the removal plan completely correct all noncompliance associated with IJ, but rather it must ensure serious harm will not occur or recur.
It is not synonymous with the Plan of correction.
Correction Plan (Plan of Correction or POC): The correction plan is a longer-term strategy aimed at addressing the root causes of the IJ situation and preventing it from recurring. It’s about ensuring compliance with the regulations and improving overall care quality. The correction plan has a longer timeline, often requiring weeks or months to fully implement and ensure that the facility remains in compliance.
(Example : If the IJ was due to a critical staffing shortage, the removal plan might involve bringing in temporary staff immediately to ensure resident safety. For the same staffing shortage issue, the correction plan might involve revising the staffing policy, recruiting permanent staff, and implementing new training programs.)
If an interviewee seems hesitant to provide info or expresses concern about retaliation, make sure he/she knows who to contact if the facility retaliates, and how to notify:
- facility ombudsman office
-state agency
State agency
What an entity must do to have IJ removed
To have IJ removed, the entity must :
-implement the removal plan,
- and the survey team must verify through observation, interview, and record reviews all actions the facility took were effective in removing the likelihood that serious injury, harm impairment, or death would occur or recur
What will the SA do once IJ has been removed and verified by surveyors?
Once IJ has been removed the SA will issue a completed Form CMS-2567 and request a plan of correction that achieves substantial compliance. (Because just removing the IJ does not ensure that substantial compliance has been achieved.)
An entity has been surveyed, and the completed form CMS 2567 from the survey includes finding and description of IJ. Within what period must Form CMS 2567 be delivered to the surveyed entity?
-10 business days?
-30 days?
-Time frame documented in App Q ?
-The time frame specified in Chapter3 section3010 in SOM?
The notice and /or Form CMS 2567 describing the IJ must be delivered within the time frame specified in Chapter3 section3010 in SOM.
What will a CMS Location immediately do if it determines, during survey review that IJ exist and has not been identified by a State Survey Agency?
-Conduct onsite survey?
-Contact SA for further discussions to determine next steps?
-F/u with surveyed entity remotely?
-Notify surveyed entity by providing complete IJ template?
If the CMS/ RO determines that IJ exists and was not identified by the SA, the CMS will immediately contact the SA for further discussion and the appropriate next steps to take.
-Further, if SA agrees with CMS/RO that IJ exists, the SA will immediately notify the entity of the IJ by providing the IJ template.
- In addition, the SA may determine that more information is necessary and send a surveyor(s) to resume further investigation.
-If SA does not concur with CMS/RO’s determination of IJ, the CMS/ RO will notify the entity of the IJ noncompliance.
-If CMS/RO determines further investigation is needed, the CMS/RO will make the necessary arrangements to send a surveyor team for additional investigation before IJ notice is sent.
-When this occurs, the CMS/RO and SA will collaborate to determine who will conduct the onsite revisit to determine if IJ is removed and /or corrected.
Your survey team has determined that an entity is not in compliance with a particular regulatory requirement. Which of the following factors should the team consider determining whether a serious adverse outcome will likely occur if corrective action is not taken (select all that apply):
-Past history of non-compliance at level of IJ?
-Nature and extent of non-compliance?
-Particular vulnerability of recipients?
Nature and extent of non-compliance
Particular vulnerability of recipients
Which term listed under “Definitions” in App Q means “failure to meet one or more federal health, safety, and or quality regulations”?
Noncompliance
For IJ to exist which of the following statements must be true:
-The entity’s identified noncompliance must be sole contributing factor to actual or likely serious injury, harm, impairment or death.
-The entity’s identified noncompliance must not be a contributing factor.
-The entity’s identified noncompliance must be the predominant factor.
-The entity’s identified non compliance must be one contributing factor.
The entity’s identified non compliance must be one contributing factor.
Your survey team has answered “Yes” to one of the components of IJ outlined in the left-hand column of the IJ template. What must the team do in the corresponding space in the right-hand column?
Provide preliminary fact analysis to support determination.
Which of the following are potential errors that a survey team should avoid when filling out an IJ template?
-Providing insufficient evidence
-Disregarding instructions
-Making determination w/respect to each component of IJ.
-Providing excessive documentation.
-Providing insufficient evidence
-Disregarding instructions
-Providing excessive documentation
Which of the following is a survey team required to do when filling out the IJ template? select all that apply
-Provide a fact analysis do document each component of IJ.
-Document all evidence related to IJ.
-Ensure the info documented on IJ template is accurate
-Make determination w/respect to each component of IJ.
(I don’t know. I answered first and second. the answer was given that it was partially correct only)
Your survey team is providing a prelim fact analysis on the IJ template for the component of noncompliance. Which of the following must the team include in its documentation?
Summary of issue.
Identification of specific tag,
extent of non-compliance ( not sure about extent. )
Which part of Core App Q provides guidance on consulting supervisors at the State Survey Agency to confirm that each component of IJ exists?
-Part IV-Key components of IJ
-Part V analytic process for determination of IJ.
-Part VI-Calling IJ.
-Part VII- Removing IJ.
Part VI-Calling IJ.
When Survey team determines the entity’s noncompliance has caused a serious adv outcome or has made a serious adverse outcome likely, the team must consult with their SA for confirmation that IJ exists and seek directions..
Which authority must be involved in the evaluation and approval of an entity’s IJ removal plan?
SA with jurisdiction over entity.
When you determine that the same incident or entity practices has resulted in multiple violations, which of the following statements is true:
-You must have gathered sufficient evidence to ensure each violation can stand on its own on CMS-2567.
-You should identify deficiency the greatest negative outcome to the recipient
-The team must be able to articulate how the incident or practice represents a distinct violation or each regulation or tag.
not sure here. But in App Q, part V- analytic process for determining IJ it says:
If the survey team finds that the same incident or facility practice results in multiple violations, the team must be able to articulate how the incident or practice represents a distinct violation of each regulation or tag. Although a comprehensive statement may contain facts illustrating deficiencies at multiple tags, surveyors may not simply copy and paste from one tag to another. Even if multiple deficiencies share common facts, surveyors may need to conduct additional investigation to evaluate additional tags thoroughly.
Which document identifies immediate actions an entity will take to address IJ-level noncompliance:
-CMS-2567.
-IJ template.
-Plan of correction
-IJ removal plan
IJ removal plan-Immediate action includes all actions the entity has taken or will take to immediately address the noncompliance that resulted in or made serous injury,…harm…death…
According to Chapter 2 SOM, what is “Form CMS-2567”?
It is the official document used by CMS to record the results of surveys and inspections of healthcare facilities
Form CMS-2567 Overview:
It includes both the deficiencies identified by the surveyors and the facility’s response, including their Plan of Correction (POC).
It also documents the date IJ began, if known and presents official findings in writing.
Content:
Deficiency Citation: This section includes a detailed description of each deficiency found, citing the specific regulatory requirement that the facility failed to meet.
Facility’s Plan of Correction (POC): The facility must outline its plan to correct the deficiencies, specifying the steps it will take, who is responsible, and the timeframe for correction.
Completion Date: The form also includes the date by which the facility expects to have corrected the deficiencies.
Usage:
Surveyors: After a survey is completed, surveyors use Form CMS-2567 to formally document any non-compliance with federal regulations.
Facilities: The facility must respond to the documented deficiencies by submitting a Plan of Correction (POC) on the same form. This plan is critical for showing that the facility is taking steps to correct the issues and comply with regulations.
Public Record: Form CMS-2567 is part of the public record, meaning that it can be accessed by the public to see the compliance history of a healthcare facility.
All nursing home care, without exceptions, should be guided by what principles and care planning?
Person centered care is an approach to care that focuses on the individual needs, preferences, and values of the residents, rather than a one-size-fits-all model. It emphasizes respecting and responding to each resident’s unique identity, involving them in decision-making, and ensuring that their care plan reflects their personal desires and life goals.
Offsite selected residents make up how much of the resident sample?
70%
How many residents should you randomly select for the SNF Beneficiary Protection Notification Review from the list provided by the facility on the Entrance Conference Worksheet?
3
Which report can be used to assess whether a facility has sufficient staff to meet residents’ needs, quality of life and care concerns
Payroll-Based Journal (PBJ) Staffing Report) is used to assess whether a nursing facility has sufficient staff to meet residents’ needs.
Key components of the Staffing Report include:
Staffing Levels: The report provides data on the number of RNs, LPNs, CNAs, and other direct care staff. It can be used to determine whether the facility meets state and federal staffing requirements.
Staffing Hours: It details the number of hours each type of staff member is on duty. This helps assess whether there are enough staff on hand to provide adequate care to residents at all times.
Staffing Ratios: By analyzing the data, one can calculate the staff-to-resident ratio, turnover and Retention Rates: Some reports also include information on staff turnover and retention rates, which can impact the quality of care and consistency of services provided to residents.
Why the QAPI and QAA Review task is done at the end of the survey after completion of all other requirements?
To make sure the survey team identified concerns independently of QAPI.
Which of the following mandatory facility tasks is assigned to all surveyors?
-QAPI and QAA
-Medication administration
-Kitchen
-Infection Control
-dining
-sufficient and competent nursing staffing
-
-dining
-infection control
-sufficient and competent nursing staffing
When conducting the med administration observation, you observed 25 meds administered with 1 error related to the medication not being administered on an empty stomach per order. Reconciliation also showed that 1 medication was omitted. What is the total number of opportunities?
26
What resource should you routinely consult to help you fully understand the regulations and specific language in which those regulations are written:
-SOM appendix PP
-LTCSP procedure guide
SOM appendix PP
As specified on the Entrance Conference Worksheet, which of the following is required immediately upon entering the facility:
-Facility assessment
-QAA assessment
-Complete matrix for new admissions in the last 30 days who are still in facility
Matrix for new admissions in the last 30 days who are still in the facility
The federal regulations, Resident Assessment require facilitiies to use the CMS-specified Resident Assessment Instrument (RAI) process to complete a comprehensive assessment of each resident within how many days after admission?
14
When the team meets to make final compliance determinations, why you should conduct a sequential review of all regulatory requirements, evaluating each regulatory section, in order to: (choose one)
-Verify that you ‘ve investigated every care are for potential citation.
-Make sure there is sufficient info to support deficiency.
-Make sure there is sufficient information to support deficiency.
What document provides guidance to surveyors about how to properly structure statements on Form CMS-2567, Statement of Deficiencies and Plan of Correction:
-SOM
-LTCSP procedure guide
-POD
Principle of Documentations
Where in Title 42 can the specific requirements with which the entity must comply be found?
Title 42 covers a broad range of topics, including public health, social welfare, and civil rights.
Specific regulatory requirements, these are often detailed in the Code of Federal Regulations (CFR), particularly in 42 CFR (Title 42 of the CFR), which provides detailed regulations implementing the statutory provisions of Title 42 of the U.S. Code.
During resident screening you observe 2 residents in bed staring at the doorway. Both residents are on isolation for infuenza. They tell you they’ve complained about boredom to the Activity Director, but nothing has been done and they won’t be able to leave their rooms until they are symptom free. What is the scope?
- Not enough information
-Isolated
-Pattern
Isolated
Scheduling and Conducting Surveys process…
- The State must complete a standard survey of each skilled nursing facility and nursing
facility not later than 15 months after the previous standard survey.
Facilities with excellent histories of compliance may be surveyed less frequently to
determine compliance, but no less frequently than every 15 months and the State-wide
standard survey average must not exceed 12 months.
If the State is concerned that a change of ownership, management, administrator, or
DON may have caused a decline in the QOC or services furnished
by a facility, it may conduct a standard or abbreviated
standard survey within 60 days of the change.
Facilities with poor histories of compliance may be surveyed more frequently to ensure
that residents are receiving quality care in a safe environment.
The State may conduct surveys as frequently as necessary to determine if a facility
complies with the participation requirements as well as to determine if the facility has
corrected any previously cited deficiencies. There is no required minimum time which
must elapse between surveys.
What is significant weight loss in one month? three months? 6 months?
What is severe weight loss in one month? three months? six months?
F tag
Significant weight loss in one month: 5%, three months: 7.5%, six months:10%.
Severe loss: greater than 5%, greater than 7.5%, greater than 10%.
F 692 Assisted nutrition and hydration. Maintaining acceptable parameters of nutritional status. Sufficient fluid intake. Therapeutic diet.
During what time frame the facility must refer residents with lost or damaged dentures for dental services.
F tag
The facility must assist R in obtaining routine and 24 hr. emergency dental care.
Must promptly within 3 days, refer R within lost or damaged dentures for dental services. Facility must document of what they did to ensure the R could still eat and drink adequately while awaiting for an appt.
F tag 790.
What is the frequency of physician visits.
F tag
F712. The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.
Can the DON serve as a charge nurse?
F tag
The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
F 727
