Survey and Compliance
The survey team reviews these reports to assess patterns of care.
What are Quality Measure reports?
This F-Tag is cited when a resident is not free from abuse, neglect, or exploitation.
What is F600 (Free from Abuse and Neglect)?
This staff member is responsible for overseeing the facility’s Infection Prevention and Control Program.
Who is the Infection Preventionist (IP)?
These 3 main domains determine the overall Five-Star Rating
What are Health Inspections, Staffing, and Quality Measures?
This team member is responsible for coordinating the MDS assessment and Care Plan process.
Who is the MDS Coordinator?
If a facility has poor QM outcomes, this CMS status may be applied.
What is Special Focus Facility (SFF)?
This F-Tag pertains to the Infection Prevention and Control Program.
What is F880 (Infection Control)?
This type of infection must be reported to the local health department and tracked internally.
What is a reportable communicable disease (e.g., COVID-19, flu, C. difficile)?
This tool is used by CMS to calculate the Quality Measure domain of Five-Star.
What is MDS data (Minimum Data Set)?
This team is responsible for reviewing resident goals, progress, and care planning.
What is the Interdisciplinary Team (IDT)?
Regular review of QM data helps this type of committee ensure quality.
What is the QAPI Committee?
This F-Tag mandates that residents be free from unnecessary psychotropic medication
What is F758 (Unnecessary Psychotropic Medications)?
This CMS-required program includes surveillance, prevention, and antibiotic stewardship components.
What is the Infection Prevention and Control Program (IPCP)?
This system is used to report staffing data to CMS.
What is PBJ (Payroll-Based Journal)?
These meetings are required under OBRA and usually occur quarterly or after significant changes.
What are Care Plan Meetings?
This document outlines survey deficiencies and must be submitted by the SNF to correct issues.
What is a Plan of Correction (POC)?
This F-Tag is related to the comprehensive care plan process
What is F656 (Develop/Implement Comprehensive Care Plan)
This term refers to isolating residents to prevent the spread of certain infections.
What is Transmission-Based Precautions?
This percentage of long-stay residents receiving antipsychotics affects the QM domain.
What is the Long-Stay Antipsychotic QM?
This IDT role ensures safe medication use and monthly drug regimen reviews.
Who is the Pharmacist?
These 3 things are reviewed by surveyors during the entrance conference.
What are census, staffing, and current active residents with issues?
This F-Tag relates to ensuring discharge planning and a safe transition.
What is F660 (Discharge Planning Process)?
This routine documentation tracks infection trends across residents.
What is an Infection Surveillance Log?
These types of surveys are unannounced and can heavily influence your Five-Star rating.
What are State Health Inspections?
IDT collaboration helps ensure these two CMS priorities: resident ___ and care ___ .
What are resident outcomes and care coordination?