Principles of Documentation

Question 1

What is a CMS 2567?

Answer 1

Statement of Deficiencies

Question 2

What is a Deficiency Citation?

Answer 2

Record of the survey that documents and justifies whether or not a facility is in compliance. It also informs the facility of its compliance status and allows them to develop a Plan of Correction (PoC) to address deficiencies.

Question 3

A deficiency citation consists of what?

Answer 3

• Survey tag number
• CFR or LSC reference
• Language that specifies noncompliant aspect of requirement
• Explicit statement that the requirement was “NOT MET”

Question 4

What is included in the Deficiency Citation?

Answer 4

• Specific action, error, or lack of action (deficient practice)
• When possible, resultant outcome relative to deficient practice
• Description of extent of deficient practice or number of deficient cases relative to total number of such cases.
• Code of individuals or situations referenced in extent of practice
• Reference to source of information through which evidence was obtained

Question 5

True or False?

If a deficiency is found and corrected onsite during the survey, it must still be determined that it was “NOT MET” on the CMS-2567.

Answer 5

True

Question 6

When can you cross-reference another F Tag?

Answer 6

When it is applicable and provides stregnth to linked citations.

Question 7

What is a Deficiency Practice Statement?

Answer 7

A statement at the begining of the evidence that sets out why the entity was not in compliance with a regulation.

Question 8

What term describes pertinent facts that illustrate a problem that exists at a specific entity and that are listed immediately after the condition of participation?

Answer 8

Findings

Question 9

What is “Extent of Deficient Practice”?

Answer 9

The prevalence or frequency of a deficient entity practice.

Question 10

What is “Outcome”?

Answer 10

A result or consequence of entity practices (e.g., development of avoidable pressure sore or ulcer; reaction due to receipt of wrong blood type).

Question 11

What is “S/S”?

Answer 11

Severity/Scope

Question 12

What is Scope and Severity?

Answer 12

(A-L) which illustrates the effect of the noncompliance on the nursing home resident (severity) and the number of residents actually or potentially affected (scope) by the provider’s noncompliance.

Question 13

What is “Universe”?

Answer 13

The total number of individuals, records, observations, and objects related to the entity practice or recipients at risk as a result of a deficient practice. Use as the denominator when determining the extent of a deficient practice.

Question 14

What is “Appendix P”?

Answer 14

Survey Protocol for Long Term Care.

Question 15

What is “Appendix Q”?

Answer 15

Guidelines for Determining Immediate Jeopardy

Question 16

Providers and suppliers under the Social Security Act or laboratories that participate in the CLIA program are referred to as:

Answer 16

Entities

Question 17

True or False:

The extent of a deficient practice indicates the prevalence or frequency of a deficient entity practice.

Answer 17

True

Question 18

What are the 8 Principles of Documentation (POD)?

Answer 18

1- Entity Compliance and Noncompliance
2- Using Plain language
3- Composition of a Deficiency Citation
4- Relevance of Onsite Correction of Findings
5- Interpretive Guidelines
6- Citation of State or Local Violations
7- Cross References
8- COP Deficiencies

Question 19

What is the 1st POD?

Answer 19

Entity Compliance and Noncompliance
- If compliant, include explicit statement of compliance.
- If not compliant, include corresponding citations.

Question 20

True or False:

If an entity complies with the requirements applicable to the survey conducted, Form CMS-2567 should consist of an explicit statement that the entity is in compliance for that particular survey.

Answer 20

True

Question 21

True or False:

The Principle of Entity Compliance and Noncompliance addresses how a deficiency citation is to be written objectively and in a manner that is easily understood.

Answer 21

False

Focuses on the issue of whether or not an entity is in compliance.

Question 22

What is the 2nd POD?

Answer 22

Using plain language
* The deficiency citation is written clearly, objectively, and in a manner that is easily understood.

Question 23

What is the 3rd POD?

Answer 23

Components of a Deficiency Citation
* Regulatory Reference
* Deficient Practice Statement
* Relevant Findings (Use concise and logisitcal sequence. Support/Show the entity’s noncompliance w/a requirement (who, what, where, when, how). Include outcomes, descriptions, identifiers, sources)

Question 24

What is the 4th POD?

Answer 24

Relevance of Onsite Correction of Findings
* If a deficiency is found and corrected onsite during the survey, it still must be determined that it was “NOT MET” on CMS-2567

Question 25

What is the 5th POD?

Answer 25

Interpretive Guidelines
* Can assist a surveyor with clarifying and interpreting the regulations.
* Supports surveyors with determination of compliance

Question 26

What is the 6th POD?

Answer 26

Citation of State or Local Code Violations
* Only recorded on the CMS-2567 when federal requirements state that entities must follow State/Local laws to obtain payment for services.

Question 27

What is the 7th POD?

Answer 27

Cross References
* Acceptable if it is applicable to the current citation AND provides stregnth to the linked citation.
* More effective if linked citation has a cause-and-effect relationship.
* Each deficiency must be able to stand by itself.

Question 28

What is the 8th POD?

Answer 28

COP Deficiencies
* Condition of Participation which includes a statement of deficient entity practices and findings to support determination of noncompliance.