Food Service Regulation #
800 to 814
Refrigerator temp and cold food
under 41 deg
Hot Food
135 degrees or higher
Grey scoop
#8. = 1/2 cup
145 degrees
Cooking Temperature for: Fish, seafood, eggs, steak, pork
155 degrees
Cooking Temperature for Ground meat
165 degrees
The internal temp of turkey, chicken, duck
Food Danger Zone
41-135 degrees
practicable
capable regardless of circumstances or resources available to support an individual determined by the comprehensive resident assessment
person centered interventions
person centered care, resident centered outcomes, quality of care, quality if life
Team coordinator offsite duties
create and import survey shell, reviews facility info and completes offsite prep screen, assigns mandatory tasks, makes unit assignments shares data with team, prints survey docs
Create survey shell in ACO
not more than 5 days before the survey
Survey shell
70% offsite selected, preselected residents for closed record reviews
Mandatory Tasks assigned to all surveyors
dining, infection control, sufficient and competent nurse staffing
Mandatory Tasks assigned to individuals
SNF beneficiary protection notification review, kitchen observation, medication administration, resident council interview, QAA/QAPI
Closed record review categories
unexpected death, hospitalization, community discharge
information within 4 hrs on entrance
dialysis, antibiotic stewardship, QAPI, facility assessment
access to EHR
by the end of the first day
initial pool should include
a smoker, dialysis, hospice, ventilator, transmission based precautions
offsite residents must be selected for the initial pool t/f
true
Components of an IJ
noncompliance, serious harm as a result of noncompliance, need for immediate action
# of people for the unnecessary medication review?
5
What significant medication error?
Error which causes the resident discomfort or jeopardizes health and safety
F 921
Safe, functional, sanitary environment-if triggered need to complete entire pathway on applicable section
Sections of Environmental Pathway?
Accommodation of need, call system, sound, temp, lighting, clean equipment in good repair, water temp, bed/bath linens clean-in good repair, pest control, ventilation, handrails, other concerns
What is the square footage of a single room?
100 square feet
What is the footage of a multiple room?
80 square feet per resident
What is a comfortable temperature?
71-81 degrees
How should privacy curtains be hung?
Must be hung from the ceiling and extend around the bed to provide total visual privacy.
What is the window requirement for residents room?
Must have an outside window or outside door in every sleeping room, sill height must not exceed 36 inches above the floor.
What is the requirements for bathroom facilities?
Each resident room must have its own bathroom equipped with a commode and sink (built after 2016)
How often use a resident receive a financial statement?
Quarterly and upon request
What amount of money must be kept in an interest bearing account?
$50
When must a facility notify a Medicaid resident of the amount of money in their account?
When the account reaches $200 of the eligibility limit.
How can the software help determine the new admission?
Any residents on the alphabetical list from the facility that are not in the software should be the admissions in the last 30 days
When should QAPI/QAA tasks be completed?
At the end of the survey
What should be discussed at End of Day meetings?
were offsite concerns validated?
were new systemic concerns validated?
has more than 1 surveyor identified and validated the same concern?
Make a list of the concerns that facility should be aware of.
What does an Extended Survey further evaluate?
Physician services (483.30)
Nursing Services (483.35)
Administration (483.70)
QAPI (483.75)
Infection Control (483.80) if applicable
Training (483.90) if applicable
Resident Assessment (483.20) if def. in QOC triggered
What is Extent?
prevalence or frequency
What is universe?
total number affected or at risk from deficient practices
What is disputed in and IDR?
Provider cam dispute factual accuracies with state agency
What is disputed in an IDDR?
Provider can dispute with an entity separate from the state agency when CMPs are imposed
What is a For Appeal?
An appeal heard with Administrative Law Judge. Both sides use lawyers, it is adversarial. CMS and provider
are subject to cross-examination. If either side is unsatisfied with results it can be appealed to the DAB (Departmental Appeals Board).
What is Judicial Review?
A provider may request (CMS may not) if unsatisfied with DAB.
During a formal appeal, does CMS have the responsibility of showing why the provider should have enforcement?
Yes
What area trigger an extended survey?
Residents rights 483.10
Abuse 483.12
QOL 483.24
QOC 483.25
Behavioral Health 483.40
Pharmacy 483.45
Administration 483.7
Infection Control 483.80
Which level of severity should the team choose if several residents had a severity of 2 but I resident had a severity level of 3 for the same tag?
A. The severity should always be documented at the highest level; the scope should match the scoring for the highest severity (if their was a pattern at 2, but only one at 3, then it is isolated)
B. Update the team roster in ASE-0 under the facility name and correct Event ID. Do NOT remove a team remember to prevent data los
C. 1. create survey shell 2. add team members 3. assign self as team leader 4. link any complaints and FRIs
D. one copy of the instructions and multiple blank matrix copies
During the final sample selection the team should sample how many residents per complaint care area, if able.
A. Try again later, but if unable, leave the rest of the interview blank. If you completed the RO and RR areas place a check mark next to "COMPLETE" on the resident’s interview screen OR move the resident to the “Complete” folder (you will get a warning)
B. There are two areas: “investigations notes" which should be used to document information that is specific to a care area OR “resident notes” where you can document general information that may apply to all care areas
C. Three should be chosen if there are enough marked under that care area as "further investigation"
D. One person should be assigned, but all surveyors should watch for concerns where staffing may be related to resident complaints or quality of life or care concerns. These surveyors should answer any corresponding CE
During the investigation phase of the survey, can a surveyor investigate a resident not listed in the final sample?
A. Yes. however. the team should be consulted regarding additions. The surveyor can click on "add new investigation" icon to add them to their work load.
B. False: interview in each care area except for those areas that may not be applicable to all residents (such as catheter)
C. one copy of the instructions and multiple blank matrix copies
D. The universe is the number of residents investigated for each care area as noted on the Sample Finalization screen.
OFF site prep in ACO by Team Lead (coordinator) basically includes
A. When every item has been marked on each screen a green check mark will show on the icon to indicate completeness
B. 1. create survey shell 2. add team members 3. assign self as team lead 4. link any complaints and FRIs
C. The severity and scope grid is located in the survey resources folder.
D. The matrix should be completed within four hours.
What does the letter "|" stand for on the severity and scope grid?
A. Actual harm that is not immediate but is widespread exists
B. Change the small initial pool indicator (icon) from "unknown" (U) to "yes" (Y)-make sure to select the appropriate subgroups"
If immediate jeopardy is a concern what should the team do immediately?
A. Mark the curnt to as don't cte and select the reason to not cite as move to another tag and then select the correct to
B. The facility administrator or designee should begin immediately
C. False: only the team lead (coordinator) will attend the enternece conference
D. Confer, go to Appendix Q and use the immediate jeopardy decision making tool; contact supervisor
Should the survey team give a list of the citations to the facility during the exit conference?
A. False: team members should review the offsite prep information independently after receiving the shell from the team lead
B. You must assess and mark the "interview status" of each person in your pool
C. True: the survevor may choose to interview and observe offsite selected and/or complaint/FRI residents during the screening phase.
D. It is best to give general information but a tag may be given IF the facility directly requests. Remind them that these are preliminary.
Who should be "screened" during the initial pool process?
A. Simply do not complete the closed record review for that area/category
B. Generally, the entire team takes part in dining observations. If any one surveyor has a concern they should mark the corresponding tag and document. One person should be assigned to complete the reminder.
C. ALL residents should be screened EXCEPT offsite selected and complaint/FRI residents who are already included and do not require screening
D. A brief screening of ALL residents in your assigned area and narrowing down residents to a pool of about eight (8) per surveyor.
There are three major methods of investigating, observation, interview and record review. In what order should these occur?
A. 1. create survey shell 2. add team members 3. assign self as team lead 4. link any complaints and FRIs
B. Observations are critical and should occur on going throughout the investigation. Record review, such as looking at resident charts, may be done along with observations. Survevors will likely want to wait to do interviews until later.
C. A brief screening of ALL residents in your assigned area and narrowing down residents to a pool of about eight (8) per surveyor.
D. All surveyors will observe throughout the survey for breaks in infection control; however, one main person should interview related to the facility plan for infection prevention & antibiotic stewardship
What are the three scope levels on the severity and scope grid?
A. 1. Isolated= 1 or very limit number of residents or staff involved 2. Pattern= more than a very limited number or repeated occurrences of the same deficient practice, but not pervasive. 3. Widespread= pervasive or represents systemic failure
B. As close to survey start date as possible but NO MORE than FIVE business days SO MDS data is up-to date
C. There are two areas: "investigation notes" which should be used to document information that is specific to a care area OR "resident notes" where you can document general information that may apply to all care areas.
D. Actual harm that is not immediate but is widespread exists
Data loss may occur. Leave team members on the list even if they leave a survey
C. What might happen if a team member's name is removed from a survey team in ASE-Q?
D. Does a surveyor have to answer every care area for persons in the initial pool?
No, this only needs to be done if there are MDS discrepancies for care areas not marked for further investigation or there have been delays in completion or submission of MDS assessment.
A. True or False: the interview questions provided by CMS are required and the surveyor must ask each one during the initial poor interview
B. Who can complete the medication storage task?
C. Should the resident assessment task be completed by all surveyors?
D. What are the three scope levels on the severity and scope grid?
This is not necessary. Review the specific concerns that have been noted. Remember, Emergency Preparedness is not part of this task.
A. There are three major methods of investigeting, observation. interview and record review. In what order should these occur?
B. Should the survevor consider the facilities five star rating when doing a survey?
C. How long should the exit conference last?
D. If anyone on the tom bae concerns related to the environment should the team complete the entre environment review task?
Mark the current tag as "don't cite and select the reason to not cite as "move to another tag" and then select the correct tag
A. Who should respond the the sufficient and competent nurse stating task?
B. The team may decide that a particular problem fits better under a different tag, what then?
C. True or False: If you accidentally enter information under the wrong pool resident you will have to cut and paste to the correct person for each care area.
D. How many copies of the Facility Matrix with instructions should be printed before facility entrance?
All surveyors will observe throughout the survey for breaks in infection control; however, one main person should interview related to the facility plan for infection prevention & antibiotic stewardship
A. When should Team Lead export survey shell from ACO?
B. How many surveyors should work on the infection control task?
C. True or False: it is ideal to stay on the unit while doing record review instead of working in the conference room
D. What should be done if the team is unable to find a resident that fits the categories for closed record review?
Anticipate at least an hour
A. How long should the team expect to meet to choose the final sample for investigation?
B. During the end of the day team meeting, what should the rest of the surveyors consult?
C. Should the resident assessment task be completed by all surveyors?
D. What might happen if a team member's name is removed from a survey team in ASE-Q?
As close to survey start date as possible but NO MORE than FIVE business days so MDS data is up-to-date
A. True or False: Surveyors do not noted a roster because all persons will be listed in the LTCSP Resident Manager
B. When should Team Lead export survey shell from ACO?
C. If there are concerns with sampled residents related to having trouble accessing their funds in their facility account or not receiving a quarterly statement what should be done?
D. If immediate jeopardy is a concern what should the team do immediately?
A pattern of immediate jeopardy to resident health or safety exists
A. Who can complete the medication storage task?
B. What does the letter "K" stand for on the severity and scope grid?
C. On the severity grid, what would level 3 stand for?
D. How many Beneficiary Notices worksheet copies should be printed before facility entrance
This will vary, depending on the task; however, is should not interfere with completing the initial pool activities.
A. When should facility task assignments be completed?
B. What is involved in the "initial pool process" (basics)?
C. How soon should the facility take action related to the removal of immediate jeopardy?
D. The Team Lead (coordinator) should print what documents in preparation for facility entrance?
Include up to five in the initial pool and the sample.
A. How long should the team expect to meet to choose the final sample for investigation?
B. Should the survey team give a list of the citations to the facility during the exit conference?
C. How many complaints or FRIs should Team Lead (coordinator) include when completing the "offsite prep screen"?
D. What does the letter "K" stand for on the severity and scope grid?