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What is severity level 2

Noncompliance that has potential to cause more than minimal harm that is not IJ resident has no more than minimal discomfort, their is a potential to compromise residents ability to reach highest practicable level, shame/embarrassment without loss of interest minimal episodic pain, facility has no system to prevent problems

The TC must complete which tasks during offsite prep?

Create/export shell from ACO
Import shell into ASE-q
Add team members
Complete offsite prep screen
Make unit assignments
Make mandatory task assignment
print documents
Share offsite prep with team

What documents are printed by the TC during offsite prep?

1 matrix with instructions
1 entrance conference worksheet
3 beneficiary worksheets

What is the purpose of the initial pool process?

To briefly screen all residents and observe, interview and complete initial record review.

When should you share data?

At the end of each day and when the team composition changes.

What must be done prior to Sample Selection

The completed I.P data is shared and the TC confirms that the data is complete.

What are the 7 LTSCP steps?

1. Offsite prep
2. Facility entrance
3. Initial Pool Process
4. Sample Selection
5. Investigation
6. Ongoing and other survey activities
7. Potential Citations

How wide must an exit corridor be?

8 feet

Name 3 antipsychotics

Thorazine (chlorpromazine) Haldol (haloperidol) Abilify (aripiprazole) Clozaril (clozapine) Zyprexa (olanzapine) Latuda (lurasidone) Seroquel (quetiapine) Risperdal (risperidone)

Indications of unnecessary medication include?

Excessive dose
excessive duration
without adequate monitoring
without adequate indication for use
use in the presence of adverse consequences

What is psychotropic drug?

Any drug that affects brain activates associated with mental processes and behavior-include anti-psychotic, antidepressant, anti-anxiety and hypnotic medications

What is "anticholinergic side effect"?

an effect of a medication that may cause dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, hallucinations, flushed and increased blood pressure

What is"Extrapyramidal symptoms" (EPS)?

a neurological side effect that may occur within a few day or years of treatment with antipsychotics. Includes various syndromes such as; akathisia, medication-induced Parkinsonism, and dystonia.

What is akathesia?

a distressing feeling of internal restlessness that may appear as constant motion, the inability to sit still, fidgeting, pacing or rocking.

What is Medication-induced Parkinsonism?

Syndrome of symptoms like Parkinson's; tremor, shuffling gait, slowness of movement, expressionless face, drooling, postural unsteadiness and rigidity of muscles.

What is dystonia?

acute, painful, spastic contraction of muscle groups (commonly the neck, eyes and trunk) that often occurs soon after initiating treatment.

What is Neuroleptic Malignant Syndrome (NMS)?

Syndrome related to the use of antipsychotics that presents with a sudden onset of diffuse muscle rigidity, high fever, labile blood pressure, tremor, and cognitive dysfunction. Potentially fatal if not treated immediately, including stopping the offending medication.

What is serotonin syndrome?

Serious clinical condition resulting from overstimulation of serotonin receptors. Commonly related to the use of SSRI's, SNRI's, triptans, and antibiotics. Restlessness, hallucinations, confusion, loss of coordination, fast heartbeat, rapid changes in blood pressure, increased temperature, overactive reflexes, NV&D.

What is Tradive dyskinesia?

abnormal, recurrent involuntary movements that typically present as lateral movements of the tongue or jaw, thrusting, chewing, frequent blinking, bro arching, grimace and lip smacking. May be irreversible

Significant weight loss in 1 month?

5% weight loss

Severe weight loss in 1 month?

greater than 5% weight loss

Significant weight loss in 3 months?

7.5% weight loss

Severe weight loss in 3 months?

greater than 7.5% weight loss

Significant weight loss in 6 months?

10% weight loss

What are signs and symptoms of digoxin toxicity?

anorexia, nausea, vomiting, visual changes, cardia arrhythmia, low heart rate

When must a Gradual Dose reduction (GDR) occur?

Within the first year in which a resident us admitted or med is prescribed the facility must attempt a GDR in two separate quarters (with at least one month in between the attempts) unless clinically contraindicated.

Severe weight loss in 6 months?

greater than 10% weight loss

What drugs are review for unnecessary medications?

Insulin, anticoagulant, antipsychotics with dementia

When finalizing the sample, what do you do if other residents are marked Fl for the complaint allegation care area?

sample 3 residents for the care area.

What residents are system selected?

any offsite selected with at least one care area marked FI, any resident a surveyor marked as include in sample, any identified abuse concern from IP or history of abuse citation or allegation since last survey.

What areas are reviewed for non-interviewable residents?

Pressure ulcers, dialysis, infections, nutrition, falls in last 120 days, ADL decline, low risk B&B, unplanned hospitalization, elopement, change of condition in last 120 days.

All residents are reviewed for which areas?

Advanced directives, confirm specific information based on RI/RO, other concerns.

What act established Medicare and Medicaid

Social Security Act of 1965 signed by Johnson established Medicare for aged over 65 and Medicaid health insurance for low income.

What was created in 1977 to combine Medicare and Medicaid?

Health Care Financing Administration (HCFA), the predecessor if CMS

Who does Medicaid provide services for?

low income, needy elders, blind, disabled getting SSI, certain infants and low income pregnant women.

What is Title XVIII(18)?

Regulations for Medicare.Covers hospital, post hospital, home health services and hospice.

What is Title XIX(19)?

Regulations for Medicare for families with children, aged, blind or disabled with low income.

What is the Impact Act of 2014?

Improving Medicare Post-Acute Care Transitions-effective 11/19/19. Includes Discharge Planning rule, Burden reduction and Emergency Preparedness.

What is the survey process based on?

Person centered care, resident centered outcomes, QOC and QOL.

What are the 8 principles of documentation?

1. Entity Compliance or Noncompliance
2. Using plain language
3. Components of a Deficiency statement
4. Relevance of Onsite correction of findings
5. Interpretive guidelines
6. Citation of Sate or local code violations
7. Cross-referencing
8. Condition of Participation Deficiencies

What are the components of a deficiency statement?

1. regulatory reference
2. deficient practice statement
3. relevance facts and findings

What are CMS core values?

1. Public service
2. Integrity
3. Accountability
4. Excellence
5. Respect

What are the LTC Survey Core skills?

1. Resident-centered, outcome oriented information gathering
2. Critical thinking
3. Teamwork

What is the definition of Practicable?

capable regardless of circumstances or resources available to support an individual, innate ability

What is iatrogenesis?

a problem that is caused by a treatment

When should you export the survey shell from ACO?

Export the shell as close to the survey as possible but no more than 5 business days before.

When should you contact the RAI coordinator?

If the number of resident is unreasonable after exporting the survey shell

Which residents are included in the survey shell?

1. Offsite selected who make up 70% of the sample
2. Residents with at least 1 MDS in the last 120 days
3. Residents for closed record review

What is the CASPER report?

Certification and Survey Provider Enhanced Reporting

What items are required upon entrance?

1. Census excluding bed holds
2. Matrix for new admits in the last 30 days
3. Alphabetized list of residents
4. List of residents who smoke

When screening residents, what other concerns should you pay attention to?

resident behavior, staff-resident interactions, resident grooming and cleanliness, strong urinary odors, evidence of abuse or neglect

How many compliant/FRI residents are in the initial pool

5 residents

What types of residents must you include in the initial pool

1. who smokes
2. dialysis
3. Hospice
4. Ventilator
5. TBP

What are the types of interview status?

1. Interviewable
2. Non-interviewable
3. Refused
4. Unavailable
5. Out of facility

what should you do if a resident halts the interview midway?

Attempt to complete later, if you can't, leave the rest blank, complete RO/RR then mark the resident as complete.

What is CFR Part 489.301?


What is the definition of Jeopardy?

A providers noncompliance has caused, or is likely to cause, serious injury, harm, impairment or death.

What do you do if the team has different information than the system populated information?

Enter it under notes field

What system provided information should be discussed at the end of Day 1 meeting?

1. Were any offsite selected residents d/c?
2. Was each newly admitted resident listed on the matrix screened by a team member?
3. Are there any harm, SQC, IJ or other concerns to discuss?

What should you use when selecting the sample size?

Use the sample size grid, and system calculated minimum.

Can the sample size exceed the sample size grid>


How many residents the system select for unnecessary medication review?


What should you ask for if Abuse is being investigated based on a history of abuse as noted on offsite prep screen?

Ask facility for all allegations of abuse side the last survey.

What should you consider when adding residents when the sample size is not met?

Residents with most concerns
Residents with concerns R/T QOL and RR
Residents selected for unnecessary med review
prior survey and complaint results underrepresented areas of facility.

What is investigated when more than 5 complaint/FRI residents are added to the sample?

You will only investigate for the allegation

When finalizing the sample you must ensure that a surveyor is assigned to which residents?

every resident in the sample, additional complaint/FRI residents, non sample unnecessary medication review residents

What are the 9 mandatory facility tasks?

1. Beneficiary Protection Notification review
2. Dining observation
3. Infection control
4. Kitchen
5. Medication Administration
6. Medication Storage
8. Resident Council Meeting
9. Sufficient and Competent Nurse Staff

What 3 task are assigned to all surveyors?

Dining observation, infection control, sufficient and competent nurse staff. (One surveyor os assigned primary responsibility for completion of each task)

Which facility tasks are triggered tasks?

Environmental, Personal Funds, Resident Assessment


Quality of Life- pertains to all care and services provided. Facilities must provide necessary care and services to attain or maintain highest practicable physical, mental, and psychosocial well being.


Quality of Care-facility must ensure residents receive care and treatment in accordance with professional standards of practice, person centered care and resident choice

What is included on a baseline care plan?

Initial goals based on admission orders
MD orders and dietary orders
Therapy and social services

What is a PASARR?

Pre-Admission Screening and Resident Review-screening to ensure that the facility coordinates with the appropriate, State designate authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receive care and services in the most integrated setting appropriate
to their needs.

What pathway is used to investigate QOC concerns that have no pathway?

General CE pathway

When should you use "Investigation Notes"?

used for information specific to the care area being reviewed

When should you use "Resident Notes"?

when you have information about the resident you would like to have for all care areas

What must you do prior to observing resident care?

Have consent from the resident or resident rep., and facility nurse staff must be available during the observation.

How should you determine who to interview?

Use the critical element pathway

What do you do if an interviewee says you cannot use the information they revealed?

You cannot use the revelation but you can investigate the issue with other residents

Can an interviewee's identity be revealed if the facility appeals a cited deficiency and the deficiency is based on information from the interview?


What should be discussed at the end of day 1 team meeting?

Any newly identified harm or IJ concerns?
Need to expand sample to r/o SQC?
Status of information for complaint/FRI
Pertinent findings
Work left to complete
Need to adjust workload
Whether 3 resident rep interviews are done
Concerns indicative of system failure

What is the importance of record review?

Determine bow negative outcomes are r/t the facilities failure to provide adequate care
Determine if the facility has enabled the resident to reach their highest practicable level

What is reviewed during the Infection Control task?

All surveyors observe for breaks in infection control throughout the survey.
Assigned surveyor reviews IPCP, AB Stewardship, and the influenza/pneumococcal vaccination (5 residents), sample of 3 staff including at least 1 that was COVID 19 positive, and 3 residents for TBP(1 covid + or suspected) as well as screening, testing and reporting of COVID 19

What is reviewed for compliance with the Antibiotic Stewardship program?

1. AB use protocol on prescribing
2. Protocols to determine if AB is indicated
3. A process for review of AB use by prescribers
4. Protocols to ensure resident are prescribed the appropriate AB
5. A system for feedback reports

What is avoidable decline?

The facility failed to do 1 or more of the following;
1. evaluate resident clinical condition and risk factors
2. develop and implement interventions consistent with resident needs, goals, and standards of practice
3. Monitor and evaluate impact of interventions
4. revise interventions as appropraite

What are the factors in determining Non-compliance?

1. Specific action or lack of action relative to requirement
2. Practice the facility implemented or failed to implement
3. What the facility did or did not do to cause the non-compliance
4. The actual or potential outcome that resulted from the noncompliance

What factors should you consider in determining severity when harm has occurred?

How likely is it that a resident could suffer harm, impairment, death or compromise/deterioration?
Does the deficient practice require immediate correction?
Could the noncompliance have an impact on many residents?
Use the psychosocial outcome grid and the reasonable person concept

What factors should you consider in determining severity when there is no actual harm?

how likely is it that a resident could suffer harm, impairment, death or compromise/deterioration?
Does the deficient practice require immediate correction?
Could the noncompliance have an impact on many residents?
Use the psychosocial outcome grid and the reasonable person concept

What is the psychosocial outcome grid?

guide designed to identify each residents psychosocial response to noncompliance as the basis for determining psychosocial severity of a deficiency

What is reasonable person concept?

Used when a resident's psychosocial outcome may not be readily determined through the investigative process. The team should determine the severity of the psychosocial outcome that the deficient practice would have had on a reasonable person in a similar situation.

What factors drive decisions on severity?

residents condition
whether staff followed P&P
duration of event
facility and staff response to the problem
impact on the resident (condition after the event)

What does Widespread scope refer to?

The entire population, not a subset, not a hall, but ALL

How do you classify the severity when the evidence includes incidents of varying severity and cope?

Classify the deficiency at the highest level of severity. Ex. 1 resident. severity level 3, there were widespread finding of same deficiency at severity level 2-classify as severity level 3-scope isolated

How do you determine SQC?

Deficiency designated under CoP
1 or more def. that poses IJ
A pattern of, or widespread def. at severity level 3
A widespread deficiency a severity level 2
(F,H,I,J,K, or L)

What does the Beneficiary Protection Notice Review verify?

verify notification to resident when Med A ends-
verify the facility billed medicare within the required time frame after the resident requested a demand bill verify that the facility did not bill the resident while a decision was pending.

What is 483.60?

Kitchen-store, prep, distribute food under sanitary conditions to prevent food-born illness. F812

What is the danger zone?

above 41 degrees or below 135 degrees

What are the 3 types of contamination?

Biological, chemical, physical

What is Critical Control Point (CCP)

a specific point, procedure, or a step in food preparation and serving at which control can be exercised to reduce, eliminate or prevent the possibility of a food safety hazard.
Cooking, cooling, holding, reheating

What foods are PHF/TCS

ground beef, poultry, fish, cut melon, unpasteurized eggs, cottage cheese

How should PHF foods be cooked?

Cool from 135 degrees to 70 degrees in 2 hours then 70 degrees to 41 degrees or lower within 6 hours.

What temperature should hot foods be held at?

135 degrees or higher

What temperature should cold foods be held at?

41 degrees or lower

What temperature should food be re-heated to?

165 degrees for 15 seconds within 2 hours

Should ABHS be used in food Service?


What is the purpose of medication administration observation?

Verify that the facility meets the requirements of error rate of 5% or less, and residents are free from significant medication errors.

What should a medication administration observation include?

25 opportunities
variety of residents, staff on different shifts and units
variety of routes (PO, SC, ophthalmic etc.)

What does a med observation assess for?

MD orders-reconcile observed meds with the MD orders
manufacturers specifications
professional standards
verify med expiration date

How do you calculate med error rate

number of errors/opportunities X 100


5% or more medication error rate


Significant medication error