Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

SMQT > Survey Process > Flashcards

Survey Process Flashcards

1
Q

What are the main steps in the survey process?

A
  1. Offiste prep
  2. Facility entrance
  3. Inital pool process
  4. Sample selection
  5. Investigation
  6. Ongoing and other survey activities
  7. Potential citations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

When is the QAA/QAPI task completed?

A

At the end of the survey, before the exit conference, with the TC.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What software is the survey shell created in?

A

ASPEN Central Office (ACO)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What software do you use to complete the survey?

A

ASPEN Survey Explorer (ASE-Q)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Who preps the survey shell prior to the start of the survey?

A

Team Coordinator (TC)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What should the TC have printed prior to entering the facility?

A
  1. Facility matrix (1 set of instructions and multiple copies of a blank matrix)
  2. Entrance conference worksheet (1 copy)
  3. Beneficiary notices worksheet (3 copies)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What should survey team members do prior to entering the facility?

A

Review the Offsite preperation screen.
* Review and FRIs assigned to you
* Review MDS indicator facility rate report
* Review offsite selected residents and their MDS indicators

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Who does the entrance conference with the facility administrator upon entering the facility?

A

The TC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What information is needed from the facility immediately upon entrance?

A
  • Census number
  • Complete matrix for new admissions in the last 30 days who are still residing in the facility.
  • ABC list of all residents (idnetify those that are out of the facility)
  • A list of residents who smoke, designated smoking times, and locations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What does the TC request during the entrance conference?

A
  • Request that the Administrator inform the Medical Director that a surveying is happening.
  • Information regarding full time DON coverage
  • Information about the facility’s emergency water source
  • Provide signs annoucing the survey and request they are posted in high-visibility areas
  • Copy of updated facility floor plan if there has been changes including COVID-19 observation units.
  • Name of Resident Council President
  • Provide the facility with a copy of the CASPER 3
  • Does the facility provide arbitration agreements? If so, provide TC with sample copy
  • Has the facility asked residents/representatives to enter binding arbitration agreement?
  • Name of the staff responsible for the agreements.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What information is needed from the facility within one hour of entrance?

A
  • Mealtime schedule, locations, copies of all current menus that will be served throughout the survey period and policy for food brought in by visitors.
  • Med Administration schedule
  • Number and location of med storage rooms and carts
  • Working schedule for all staff seperated by departments during the survey
  • List of key personnel, location, phone numbers including contract staff and DON
  • Paid feeding assistant information including if they were provided through a State-approved training program min 8 hours training, list of staff who have completed paid feeding assistant trainings, list of residents who receive assistance from paid feeding assistants.
  • Name of the facility’s infection preventionist, documentation of their training and evidence of specialized training in infection prevention and control.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What information is needed from the facility within 4 hours of entrance?

A
  • Completed matrix for all other residents
  • Admission packet
  • Dialysis contract/agreement/policy & procedure
  • List of qualified staff providing hemodialysis or assistance for peritoneal dialysis treatments
  • Does facility have onsite seperatly certified ESRD unit?
  • Hospice agreement, P&P, and contact info
  • Infection prevention and Control Program Standards, P&P, including surveillance plan, antibiotic stewardship program, and influenza, covid-19, pneumococcal immunization P&P.
  • QAA committee information
  • QAPI plan
  • Abuse Prohibition P&P
  • Description of experimental research occurring in the facility (if any)
  • Facility assessment
  • Nurse staffing waivers
  • List of rooms meeting any one of the following conditions that require a variance:
    • Less than the required square footage
    • More than four residents
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What information is needed from the facility by the end of the first day?

A
  • Provide each surveyor access to all residents’ EHR and complete the EHR information form
  • Provide a list of residents, who are currently residing in the facility, that have entered a binding arbitration agreement on or after 9/16/2019
  • Provide a list of residents who resolved disputes through arbitration on or after 9/16/2019
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What information is needed from the facility within 24 hours of entrance?

A
  • Completed Medicare/Medicaid application
  • Completed census and condition information
  • Beneficiary Notice - Residents discharged within the last six months
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

True or False:

The facility should exclude bed holds from the facility census number

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

When you receive the Facility Assessment report, what are you reviewing?

A

Review for systemic concerns identified in resident-specific areas or if there is a systemic concern with lack of adequate resrouces.

17
Q

What facility task must be done immediately upon entering the facility?

A

The kitchen task

18
Q

How many residents should you include in your inital pool?

A

8

19
Q

How many residents will you need to screen in your assigned area?

A

All of them

20
Q

What should a surveyor do to screen residents for the sample pool?

A
  • Observations
  • Interviews
  • Limited Record Reviews
21
Q

Which residents should be included in the initial pool?

A

All offsite selected residents (unless discharged) and any compliant/FRI residents (see attachment A for max # of FRI residents). These residents do not need to be screened as they will already be included in the inital pool.

22
Q

True or False:

Before a surveyor enters a resident’s room, they should review the MDS indicators and matrix information (if available) for a more complete picture of the resident.

A

True

23
Q

If there are no concerns based on MDS indicators and matrix information, what should the surveyor do?

A

Conduct a head-to-toe observation of the resident. If there are no additional concerns, screening is completed.

24
Q

What two additional subgroups should be included in the initial pool?

A

Newly admitted residents and Vulnerable residents

25
Q

What questions and tools can you use to conduct the initial screening?

A

None- you will need to rely on your knowledge and critical thinking skills.

26
Q

True or False:

When screening residents, you should be documenting your notes on the RI, RO, and RR screens.

A

False- It’s up to you how and where to document your screening notes, but it cannot be done in the RI, RO, or RR screens.

27
Q

Which residents should be included in the initial pool, if available?

A
  • Resident who smokes
  • Resident who is receiving dialysis
  • Resident on Hospice
  • Resident on a ventilator
  • Two residents who are on Transmission-Based Precautions
28
Q

If a resident refuses an interview, what should the surveyor do?

A

Do not attempt to interview the resident again. Complete the record review and you still may be able to complete the resident observation unless the resident refused to be observed or participate in the survey.

29
Q

If a resident is unavailable for interivew, what should a surveyor do?

A

Make a few more attempts throughout the day or try to schedule an interview before determinig this status. If the resident is still unavailable, proceed with a limited record review and complete the resident observation.

30
Q

True or False:

If a resident is out of the facility during the initial pool process, mark the resident as “Out of Facility” and nothing more needs to be done.

A

False- You will still need to complete the record review.

31
Q

True or False:

When interviewing a resident, ensure that there is at least one staff in the interview room.

A

False- this allows the resident to speak more freely.

32
Q

When interviewing residents during the initial pool process, what tool can guide you through the interview process?

A

The care areas CE pathways

33
Q

True or False:

Each care area must be covered when interviewing residents during the initial pool process.

A

True- if a care area is not applicable, check the “No Issues/NA” checkbox.

34
Q

How will you know that a care area has been covered for a resident?

A

A green checkmark will pop up next to the care area on the screen.

35
Q

What does it mean when a surveyor selects the FI checkbox?

A

It identifies that the specific resident has a care area that needs to be further investigated.

36
Q

True or False:

A surveyor is permitted to make an observation of a resident’s genitals, rectal area, and for females, the breast area.

A

False- This can only be done by a licensed nurse, physician’s assistant, or a physician.

37
Q

When should you do RRI/Family interviews?

A

For non-interviewable residents

SMQT (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions