#2 SMQT

Question 1

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?

Answer 1

The survey team must verify the actions taken by the entity to remove IJ and the point where IJ was removed.

Question 2

Which of the following must be documented on CMS-2567 when IJ is cited?

Answer 2

-Description of the noncompliance,
-specific regulatory requirements,
-and serious adverse outcome that occurred or likely to occur

Question 3

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.

Answer 3

-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.

Question 4

Difference between a removal plan and plan of correction in IJ

Answer 4

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.)

Question 5

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

Answer 5

State agency

Question 6

What an entity must do to have IJ removed

Answer 6

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

Question 7

What will the SA do once IJ has been removed and verified by surveyors?

Answer 7

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.)

Question 8

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?

Answer 8

The notice and /or Form CMS 2567 describing the IJ must be delivered within the time frame specified in Chapter3 section3010 in SOM.

Question 9

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?

Answer 9

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.

Question 10

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?

Answer 10

Nature and extent of non-compliance
Particular vulnerability of recipients

Question 11

Which term listed under “Definitions” in App Q means “failure to meet one or more federal health, safety, and or quality regulations”?

Answer 11

Noncompliance

Question 12

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.

Answer 12

The entity’s identified non compliance must be one contributing factor.

Question 13

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?

Answer 13

Provide preliminary fact analysis to support determination.

Question 14

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.

Answer 14

-Providing insufficient evidence
-Disregarding instructions
-Providing excessive documentation

Question 15

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.

Answer 15

(I don’t know. I answered first and second. the answer was given that it was partially correct only)

Question 16

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?

Answer 16

Summary of issue.
Identification of specific tag,
extent of non-compliance ( not sure about extent. )

Question 17

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.

Answer 17

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..

Question 18

Which authority must be involved in the evaluation and approval of an entity’s IJ removal plan?

Answer 18

SA with jurisdiction over entity.

Question 19

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.

Answer 19

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.

Question 20

Which document identifies immediate actions an entity will take to address IJ-level noncompliance:
-CMS-2567.
-IJ template.
-Plan of correction
-IJ removal plan

Answer 20

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…

Question 21

According to Chapter 2 SOM, what is “Form CMS-2567”?

Answer 21

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.

Question 22

All nursing home care, without exceptions, should be guided by what principles and care planning?

Answer 22

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.

Question 23

Offsite selected residents make up how much of the resident sample?

Answer 23

70%

Question 24

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?

Answer 24

3

Question 25

Which report can be used to assess whether a facility has sufficient staff to meet residents' needs, quality of life and care concerns

Answer 25

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.

Question 26

Why the QAPI and QAA Review task is done at the end of the survey after completion of all other requirements?

Answer 26

To make sure the survey team identified concerns independently of QAPI.

Question 26

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 -

Answer 26

-dining -infection control -sufficient and competent nursing staffing

Question 27

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?

Answer 27

26

Question 27

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

Answer 27

SOM appendix PP

Question 27

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

Answer 27

Matrix for new admissions in the last 30 days who are still in the facility

Question 27

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?

Answer 27

14

Question 28

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.

Answer 28

-Make sure there is sufficient information to support deficiency.

Question 29

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

Answer 29

Principle of Documentations

Question 30

Where in Title 42 can the specific requirements with which the entity must comply be found?

Answer 30

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.

Question 31

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

Answer 31

Isolated

Question 32

Scheduling and Conducting Surveys process...

Answer 32

- 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.

Question 32

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

Answer 32

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.

Question 33

During what time frame the facility must refer residents with lost or damaged dentures for dental services. F tag

Answer 33

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.

Question 34

What is the frequency of physician visits. F tag

Answer 34

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.

Question 35

Can the DON serve as a charge nurse? F tag

Answer 35

The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. F 727

Question 36

F-812/813/814-Food source

Answer 36

1. 41F to 135F safe zone. 2. Rapid death of bacteria occurs at 165F or higher. 3. High temperature washer: Wash: 150F; Rinse: 180F 4. Low temperature washer: Wash: 120F; Rinse: 50ppm chlorine 5. “Wet-Nesting” – Water trapped between pans 6. 3 Days Emergency supplies – 1 Gallon Water/person/per day – Maximum capacity); 3 meals/day for 3 days

Question 36

Resident A's comprehensive assessment was completed on 1/1/2024. How many days does the facility have to develop the comprehensive care plan? -7 days after admission -14 days after admission -7 days after completion of the comprehensive assessment -14 days after completion of the comprehensive assessment

Answer 36

7 days after completion of the comprehensive assessment

Question 37

When surveyors cite an F tag, they are citing....

Answer 37

When surveyors cite an "F tag" in a long-term care facility, they are referencing a specific regulation that the facility must comply with to meet the federal requirements for participation in Medicare and Medicaid programs. Each F tag corresponds to a particular regulatory requirement, and a citation indicates that the facility is not meeting that requirement.

Question 38

When checking the food service walk in refrigerator unit, the outside thermometer read 40F, and the inside thermometer read 50 F. Which is the best method for the surveyor to tell if the temp are appropriate? -Leave the surveyor's thermometer inside the refrigerator for 10 min and recheck the temp. -Put another thermometer inside the refrigerator to be sure that the Temp was below 40 F -Take temp of samples of potentially hazardous foods inside the refrigerator to see if they are appropriate temps -Check the temp the next day to see if the temp is below 45 F.

Answer 38

-Take temp of samples of potentially hazardous foods inside the refrigerator to see if they are appropriate temps

Question 39

While observing a meal in the dining room, the surveyor notes the nursing staff are serving meals to the residents. Though they all use hand sanitizeer between each tray they serve, none of the nursing staff are wearing gloves or hairnets. Is this appropriate practice? -Yes, the nursing staff in the dining room can serve meals without gloves and hairnets on -No, the nursing staff should be wearing hairnets while serving meals in the dining room -No, the nursing staff should be wearing gloves to serve food in the dining room -No, only dietary staff should be serving meals.

Answer 39

Yes, the nursing staff in the dining room can serve meals without gloves and hairnets on

Question 40

During a tour of the kitchen, flies are seen. A surveyor could follow through by doing which of the following? (Select all that apply) -Checking the dumpster for refuse containers in good condition and was properly contained in dumpsters or compactors or otherwise covered. -Observing for flies and other pests during meal service Notifying team or observations and review other areas of the environment for pest concerns under the Environmental task -Nothing. You have enough evidence of non-compliance

Answer 40

-Checking the dumpster for refuse containers in good condition and was properly contained in dumpsters or compactors or otherwise covered. -Observing for flies and other pests during meal service Notifying team or observations and review other areas of the environment for pest concerns under the Environmental task

Question 41

Which of the following are examples of improper food-handling technique? Check all that apply -The hot foods on a steam table are 140 degrees F -Using tongs for serving bread and rolls -Storing leftover foods uncovered, undated, and unlabeled. -Completely submerging frozen chicken in a pan of cold water.

Answer 41

-Storing leftover foods uncovered, undated, and unlabeled. -Completely submerging frozen chicken in a pan of cold water.

Question 41

To sanitize in a three compartment sink, the following are needed: -Hot water immersion at 171 F for at least 60 seconds -100 PPM bleach or equivalent -10.5 ppm of iodine -Hot water immersion at 171 F for at least 30 sec or a chemical sanitizing solution used according to manufacturer's instructions.

Answer 41

-Hot water immersion at 171 F for at least 30 sec or a chemical sanitizing solution used according to manufacturer's instructions.

Question 42

Which statement is true about a dietary dep staffing? -The food service supervisor must have completed a correspondence course -The facility must employ a qualified dietician or other qualified nutrition professional either on a full time, part time, or consultant basis -The food service dep must have at least three employees The food service supervisor must be a Certified Manager

Answer 42

The facility must employ a qualified dietician or other qualified nutrition professional either on a full time, part time, or consultant basis

Question 43

Which of the following statements is incorrect? -Hand washing facilities should be located and properly equipped -Food preparation surfaces, equipment, and utensils should be sanitized to destroy potential disease caring organisms -Dietary employees must wear uniforms -Food containers should be stored off the floor and on clean surfaces

Answer 43

Dietary employees must wear uniforms

Question 44

Which of the following statements is not correct? -Menus for regular and modified diets must be prepared in advance -Menus must meet the nutritional needs of residents in accordance with established national guidelines -Menus must be updated monthly -Menus must be followed.

Answer 44

Menus must be updated monthly

Question 45

Resident Smith had a recent CVA and is observed feeding himself using regular utensils. He is dropping his food before he is able to reach the mouth. What portion of his chart will you review to determine if the facility assessed his ability to eat independently. Check all that apply: -The resident's comprehensive plan for ability to eat independently -Activity record -Recommendations by therapist about eating -Dietary notes

Answer 45

-The resident's comprehensive plan for ability to eat independently -Recommendations by therapist about eating -Dietary notes

Question 46

During a survey, you discover a reasonable suspicion of a crime was committed against a resident and it has not been reported by a covered individual. How should you proceed: -Report the potential criminal incident to law enforcement immediately -Consult with your team and report the potential criminal incident to law enforcement immediately -Remind the facility of the covered individual's obligation to report suspected crimes within the required timeframes -Consult with your supervisor and report the potential criminal incident to law enforcement immediately.

Answer 46

-Remind the facility of the covered individual's obligation to report suspected crimes within the required timeframes (reference 42. DFR&483.12 (b)-(c) Reporting of Alleged Violations, F609

Question 46

The decision to apply physical restraints should be based on the comprehensive assessment, which include which of the following justifications? (check all that apply) -The reason for restraint is being used as discipline -Symptoms that are being treated -The presence of a specific medical symptom that would require use of restraints -How the use of restraints will assist the resident in reaching his highest level of physical and psychosocial functioning.

Answer 46

Symptoms that are being treated -The presence of a specific medical symptom that would require use of restraints -How the use of restraints will assist the resident in reaching his highest level of physical and psychosocial functioning.

Question 47

Which of the following resident to resident altercations would not constitute abuse? -A cognitively impaired resident strikes another resident within their reach -Infrequent arguments or disagreements that occur during the course of normal social interactions -A resident pushed or strikes another resident who is rummaging through their possessions -None of the above.

Answer 47

-Infrequent arguments or disagreements that occur during the course of normal social interactions

Question 47

A resident in a locked area would not be considered to be involuntarily secluded if placement in a secured area is NOT: -Based on a request from the resident's representative without clinical justification -Based on the resident's diagnosis alone -Used for staff convenience or discipline -Based on a request from the resident's representative, placement meets clinical criteria, and is in the best interest of the resident, but the resident refuses placement.

Answer 47

Based on a request from the resident's representative, placement meets clinical criteria, and is in the best interest of the resident, but the resident refuses placement.

Question 47

The resident has the right to be free from physical or chemical restraints for which reasons: check all that apply -Imposed for purposes of discipline -Unnecessarily inhibits a resident's freedom of movement or activity -Used as a therapeutic intervention justified through care planning and chosen by the resident -Imposed for purposes of convenience

Answer 47

-Imposed for purposes of discipline --Imposed for purposes of convenience

Question 48

F 867 QAPI/QAA

Answer 48

QAPI & QAA Review Critical Elements Pathway), the survey team should request and review the facility’s QAPI Plan and program policies and procedures after the investigation into all other requirements is completed. Additionally, CMS-20058 states that “disclosure of documents generated by the QAA committee may be requested by surveyors only to determine compliance with QAPI regulations. Surveyors must not use documentation provided by the facility during the QAPI/QAA review to identify additional concerns not previously identified by the survey team during the current survey.”

Question 48

Which of the following is NOT an example of misappropriation of a resident's property? -A nurse who uses a resident's med for personal use -A nurse who uses a resident's med for personal gain -A nurse who borrows another resident's med due to a failure to order the med -None of the above.

Answer 48

-A nurse who borrows another resident's med due to a failure to order the med

Question 49

During a survey, you discover a reasonable suspicion of a crime was committed against a resident, and that the covered individual reported the suspected crime to local law enforcement. In this situation, you MUST verify that the covered individual made the report. What information would help you verify that the report was made? Check all that apply: -The case number of the report -Name of the person who received the report -Name of the person included in the report -The date and time of the report.

Answer 49

The case number of the report -Name of the person who received the report -The date and time of the report.

Question 50

On any finding of abuse, neglect, or misappropriation of property by a nurse aide, the SA must include all of the following information in the State's nurse aide registry within 10 working days of the findings EXCEPT: -Documentation of the State investigation, including the nature of the allegation. -Documentation of the facility's investigation, including the nature of the allegation. -Evidence that led the State to conclude that the allegation was valid -The date of the hearing, its outcome, and a statement by the individual disputing the allegation, if applicable

Answer 50

Documentation of the facility's investigation, including the nature of the allegation Reference 42 CFR & 483.12(a) (3) Not employe/engage staff with adverse actions, F 606

Question 51

You have just observed a CNA perform incontinence care for a resident soiled with urine and feces. To prevent transmission of infection, nursing employee must always follow which type of precautions for all residents? -Transmission Based precautions -Standard precautions -Contact precautions Droplet precautions

Answer 51

Standard precautions

Question 52

How often infection prevention and control program (IPCP) must be reviewed

Answer 52

Annually and as necessary F 880

Question 53

Review of the facility's "Infection Control Logs" revealed a newly admitted resident obtained a UTI within 48 hr of their admission. Further review revealed the IP classified the UTI as a community acquired infection. Community accquired infections refer to infections that are present or incubating at the time of admission and which generally develop withi how many hours of admission? -36 hours of admission -72 hours of admission -24 hours of admission -48 hours of admission

Answer 53

72 hours of admission

Question 54

In alcohol-based hand rub what is the percentage of ethanol or isopropyl must be to reduce the number of viable microorganisms

Answer 54

60-95%

Question 55

What are the specific qualifications for an IP. Check all that apply: -Has primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field -Enrolled in specialized training in infection prevention and control -Is qualified by education, training, experience, or certification -Works at least part time at the facility.

Answer 55

Has primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field --Is qualified by education, training, experience, or certification -Works at least part time at the facility.

Question 56

How do NH facilities track communicable diseases and whom they report outbreaks?

Answer 56

NH facilities must establish a system for surveillance, based on national standards, including the resident population. The surveillance system must include a data collection tool and the use of the nationally recognized surveillance criteria, such as but not limited to the CDC's Nation Healthcare Safety Network (NHSN), or updated McGeer criteria. The facility must know when and to whom to report communicable diseases, healthcare associated infections, and potential outbreaks. The facility must document follow up activity in response to important surveillance findings.

Question 57

What is Spaulding classification system

Answer 57

Spaulding classification system identifies three risk level associated with medical and surgical instruments: critical, semi-critical, and noncritical items. -Critical items (needles IV, indwelling Cath) enter sterile tissue or the vascular system. Items should be sterile -Semi-critical items (dental, podiatry equipment, electric razor) contact mucous membranes or non-intact skin. Items require cleaning followed by high level disinfection treatment using and FDA approve high level chemical disinfectant, or maybe sterilized. -Non-critical items are those that come in contact with intact skin but not mucous membranes (blood pressure cuffs, stethoscopes, wheelchairs). Need to clean, followed by either low or intermediate level disinfection following manufacturer's instructions. Disinfection must be performed with EPA-registered disinfectant labeled for use in healthcare setting)

Question 58

Low level of disinfectant vs intermediate level of disinfectant

Answer 58

Low level disinfection includes EPA registered hospital disinfectants with HBV and HIV label claim. Appropriate for most noncritical equipment. Intermediate level disinfection destroys all bacteria, including TB, viruses, fungi, but not bacterial spores. EPA registered hospital disinfectant with a TB claim. Maybe used for non-critical equipment that is visibly contaminated with blood. (However, a low level disinfectant with a label against HBV and HIV could also be used.

Question 59

What are three categories of transmission-based precautions

Answer 59

Contact precautions, droplet precautions, and airborne precautions. For some diseases that have mutliple routs of transmission, more than one transmission-based precautions category may be required. Whether used singly or in combination, they must always be used in addition to standard precautions.

Question 60

Temperatures for laundry in hot water and cold water

Answer 60

Recommendations for laundry processed in hot water: temp 160F for 25 min For laundry that is not hot water compatible, low temp washing at 71-77F plus chlorine or oxygen activated bleach. (the facility is not required to monitor water temp during laundy processing cycles. A chlorine bleach rinse is not required for all laundry items process in low tem

Question 61

All facilities must develop, implement, and permanently maintain an Inservice training program for nurse aids that is appropriate and effective as determined by which of the following: - the facility assessment -nurse aid performance reviews and resident grievances -nurse aid performance review -nurse aid performance review and the facility assessment

Answer 61

Nurse aid performance review and the facility assessment

Question 62

Which of the following are NOT considered under the nurse aide training provision and are not required to take the 12-hour nurse aid training? Check all that apply -Any individual providing nursing or nursing related services to residents in a facility -Private duty nurse aids who are not employed or utilized by the facility on a contract, per diem, leased or other basis. -Individuals who furnish services to residents only as paid feeding assistants -Volunteers who provide nursing or nursing related services to residents in a facility

Answer 62

-Private duty nurse aids who are not employed or utilized by the facility on a contract, per diem, leased or other basis. -Individuals who furnish services to residents only as paid feeding assistants

Question 63

Nurse is about to administer Dilantin (anticonvulsant) to a resident who receives enteral nutrition via feeding tube. To minimize interactions, the surveyor should consider which of the following as a mediation error? -Simultaneous administration of Dilantin and enteral nutrition formula -Separating the administration of Dilantin and enteral nutrition formula -Administration of Dilantin followed by flushing the feeding tube with water -None of the above

Answer 63

-Simultaneous administration of Dilantin and enteral nutrition formula

Question 64

Examples of anticholinergic side effects of antipsychotics include which of the following: Check all that apply -Excessive laughing and crying Tachycardia -Dry mouth and blurred vision -Urinary retention and constipation

Answer 64

Tachycardia Dry mouth and blurry vision -Urinary retention and constipation

Question 65

Which of the following is NOT a true statement regarding rooms designated for resident dining and activities? -They must be well-ventilated -They must be adequately furnished -They must be equipped with a nurse call system -They must be well-lighted.

Answer 65

They must be equipped with a nurse call system. (F920-Dining and resident activities. Aso they must have sufficient space to accommodate all activities.

Question 66

Which of the following is not required in facilities already certified prior to 3/31/1992 -Each bed must have ceiling-suspended curtains extending around the bed to provide total visual privacy. -Each room must have at least one window to the outside. -Each room must ensure full visual privacy. -Rooms must have direct access to a corridor

Answer 66

Each bed must have ceiling-suspended curtains extending around the bed to provide total visual privacy. (In facilities certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy)

Question 67

The facility must be adequately equipped to allow residents to call assistance through a communication system which relays the call directly for staff member for assistance, in all cases except (select all that apply): -Dining and activities areas -Each resident's room -the rehab unit -Toilet and bathing facilities

Answer 67

Except dining and activities, and rehab F 919. Each resident's bedside and Toilet and bathing facilities. Please note that the requirement is met only if all portions of the system are functioning (e.g., system is not turned off at the nurses 's statin, the volume too low to be heard, the light above a room or rooms is not working, no staff at nurses' station) and calls are being answered.

Question 68

In the event normal electrical supply is interrupted, the facility emergency electrical power system must supply power adequate at least for lighting for: -Bathrooms -Medication rooms - Kitchen -Entrances and exits

Answer 68

-Entrances and exits (F 906. An emergency electrical power system must supply power adequate at least for lighting all entrances and exits, equipment to maintain the fire detection, alarm, and extinguishing systems, and life support systems in the event the normal electrical supply is interrupted. When life support systems are used, the facility must provide electrical power with an emergency generator that is located on the premises.

Question 69

What is "Essential Electrical System"

Answer 69

A system of alternate sources of power and all commercial distribution systems and ancillary equipment, designed to ensure continuity of electrical power

Question 70

Toilet facilities mean a space that contains a lavatory with: -Grab bars and a toilet -A toilet/commode -A mirror and a toilet -Towels and a toilet

Answer 70

-A toilet/ commode (F 918 Each resident room must be equipped with or located near toilet and bathing facilities. For facilities that receive approval of construction plans from State after 2016, each resident room must have its own bathroom equipped with at least a commode or sink.}

Question 71

For facilities built, receive approval of construction or reconstruction prior to November 2016, bedrooms must accommodate no more than: -Two residents -Five residents -Four residents -Three residents

Answer 71

-Four Residents (F 911. For facilities that receive approval of construction after November 28, 2016, bedrooms must accommodate no more than two residents.

Question 72

Each resident is to have functional furniture appropriate to the resident's needs. Functional furniture appropriate to the resident needs is defined as which of the following: check all that apply -A lavatory with mirror and toilet, with single use hand towel -A place to put personal effects, such as pictures and bedside clock, as well as suitable furniture, such as a chair -A place to put personal effects on shelving that is accessible to the resident -Contributes to the resident attaining or remaining his or her highest practicable level of independence and well-being.

Answer 72

-A place to put personal effects on shelving that is accessible to the resident -Contributes to the resident attaining or remaining his or her highest practicable level of independence and well-being. (F 917 In addition to functional furniture also, private closet space in each resident room, separate bed, clean mattress, bedding appropriate for weather/climate

Question 73

The state included one complaint in the recert survey. Review of the complaint intake revealed an anonymous complaint resident. If complaint resident is listed as anonymous, the TC should select which of the following from the LPCSP Resident-room column dropdown on the offsite prep screen? -Resident, Resident -Anonymous, Anonymous -Unknown, Unknown Facility, Facility

Answer 73

Facility, Facility

Question 74

If a care area does not have a pathway, the surveyor should refer to what document for the investigation? -State Operations Manual, Appendix A -State Operations Manual, Appendix B -State Operations Manual, Appendix PP -State Operations Manual, Chapter 5

Answer 74

State Operations Manual, Appendix PP

Question 75

To certify a skilled nursing facility or nursing facility, which of the following must be completed? Check all that apply: -A standard health survey -A standard life safety code survey -A complaint investigation -A monitoring survey

Answer 75

A standard health survey -A standard life safety code survey

Question 76

Skilled nursing facilities and nursing facilities must be in compliance with which of the following requirements to receive payment under Medicare and Medicaid? -42 CFR Part 484, Subpart B -42 CFR Part 484, Subpart C -42 CFR Part 483, Subpart B -42 CFR Part 483, Subpart B

Answer 76

-42 CFR Part 483, Subpart B This federal regulation sets the standards for nursing facilities, including requirements for quality of care, staffing levels, resident rights, and safety measures.

Question 77

SOM appendixes mainly about: -State Operations Manual, Appendix A -State Operations Manual, Appendix B -State Operations Manual, Appendix PP -State Operations Manual, Chapter 5

Answer 77

Appendix A: Focuses on Medicare Conditions of Participation for hospitals. Appendix B: Covers Medicare Conditions of Participation for home health agencies. Appendix PP: Provides interpretive guidelines for long-term care facilities. Chapter 5: Details the procedures for beneficiary complaint investigations and survey and certification processes

Question 78

Who can attend a resident council meeting during survey? -The ombudsman, if the Resident Council Presidents approves it -Any facility staff so they know what the problems are -The ombudsman, an no approval is needed -Residents

Answer 78

The ombudsman if the Resident Council President approves it and Residents

Question 79

According POD#6, citation of State or local code violations: (select the best anser) -Viloations of any code, Local, State, or Federal, must be documented on the form CMS-2567 -Violations of State and Federal laws and codes must be documented on the Form CMS 2567.Documenting violations of local codes is left to the surveyor's discretion. -Viloations of State and local laws and codes must be documented in the language of the Federal regulations explicity requires such compliance. -Violation of State and local laws and codes do not need to be included on the form CMS 2567

Answer 79

Viloations of State and local laws and codes must be documented in the language of the Federal regulations explicity requires such compliance. (*The entity's failure to comply with State or local laws or regulations is not documented on Form CMS 2567 except when Federal regulation requires compliance with State or local laws)*

Question 80

What is the highest level of severity for F561 (self determination)? 1? 2? 3? 4?

Answer 80

For 561 , the hightes level of severity is a 2.

Question 81

Upon entering the facility, the TC discusses with the administrator the information needed from the facility immediately. When the TC asks for that information, he should be asking the administrator to do which of the following: -Exclude bed holds from the facility census number -Include bed holds from the facility census number -Include respite resident in the report -Exclude respite residents from the report

Answer 81

Exclude bed holds from the facility census number

Question 82

The state included one complaint in the recert survey. Review of the complaint intake revealed an anonymous complaint resident. If a complaint resident is listed as anonymous, the TC should select which of the following from the LTCSP Resident -Room column dropdown on the offsite prep screen? -Anonymous, Anonymous -Facility, Facility -Resident, Resident -Unknown, Unkown

Answer 82

-Facility, facility

Question 83

After selecting the Start Sample Finalization button, an unnecessary med review selection message appears. The message identifies the five residents the system selected for the unmed. Why the system might select non-initial pool residents for an unnecessary medication review: -Non-initial pool residents take less medications than initial pool residents. -There are not five residents in the initial pool with medication concerns. -Non-initial pool residents take more medications than initial pool residents. -A resident does not exist in the initial pool to cover the four required medications.

Answer 83

-There are not five residents in the initial pool with medication concerns. -A resident does not exist in the initial pool to cover the four required medications.

Question 84

During sample selection, the system will identify the residents that should be included in the sample, even if the sample number is exceeded. The system selected residents include which of the following residents? Check all that apply: -Any identified residents with abuse concerns from the initial pool. -Any offsite selected resident who had at least one care are marked as further investigation. -Any complaint/FRI residents not linked to the LTCSP on the Offsite Prep screen -Any resident that a surveyor marked as Include in Sample (i.e., harm or IJ)

Answer 84

-Any identified residents with abuse concerns from the initial pool. -Any offsite selected resident who had at least one care are marked as further investigation. -Any resident that a surveyor marked as Include in Sample (i.e., harm or IJ)

Question 85

The facility 's census upon entrance was 13, however, two offsite selected residents were discharged, during the initial pool process. The team completed the initial pool process and included a total of 11 residents in the initial pool. When the TC reviews the Finalize Sample screen, the number of residents listed in the Facility Census filed is 16 (i.e., the number of residents exported into the survey shell) How should the TC proceed? -Change the number of residents in the facility census filed to 11 -Change the number of residents in the facility census filed to 13 Do not change the census number and keep the number of residents listed as 16 -None of the above.

Answer 85

Change the number of residents listed in the Facility Census field to 13. (Facility Census field to 13, as this reflects the correct number of residents at the time of entrance (before any discharges occurred). This aligns the census with the actual number of residents when the survey began.

Question 85

What effect will there be on the survey shell if a facility has not submitted MDS assessment data? Check all that apply: -There will be no effect to the shell -No MDS info will show in the shell, and there will be no offsite selected residents -There will be no offsite selected residents -An error message will appear directing the SA call the facility and determine why

Answer 85

No MDS information will show in the shell, and there will be no offsite selected residents

Question 85

When should the survey shell be exported from ACO for a survey that is planned 10 days from today's date -as close to the survey start day as possible but no more than five business days prior to the survey. -as close to the survey start day as possible but no more than five calendar days

Answer 85

as close to the survey start day as possible but no more than five business days prior to the survey.

Question 86

Protecti0n from disclosure is generally afforded documents generated by the QA and QAA committee. Which of the following documents are not protected from disclosure? Check all that apply? -Reports/records used to track adverse events -Meeting minutes, internal papers, or conclusions. -Wound logs and infection control logs -Incident and accident reports

Answer 86

-Reports/records used to track adverse events -Wound logs and infection control logs -Incident and accident reports