CMS Study

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

1 matrix with instructions
1 entrance conference worksheet
3 beneficiary worksheets

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

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

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

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

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.

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

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.

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

greater than 5% weight loss

greater than 7.5% weight loss

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

greater than 10% weight loss

sample 3 residents for the care area.

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.

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

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

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

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

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

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

a problem that is caused by a treatment

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

Certification and Survey Provider Enhanced Reporting

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

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

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

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

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?

Yes

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

You will only investigate for the allegation

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

Environmental, Personal Funds, Resident Assessment

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

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.

used for information specific to the care area being reviewed

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

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

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

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

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

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

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

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)

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

verify notification to resident when Med A ends-
SNF-ABN and NOMNC
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.

above 41 degrees or below 135 degrees

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

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

41 degrees or lower

No

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

number of errors/opportunities X 100