New IJ Process
This is when the Surveyor should notify the TC of an identified, serious concern.
What is immediately?
This Surveyor is responsible for writing any citation, directed by the RD to be written related to the Extended Survey.
Who is the Surveyor assigned to that area of the Extended Survey by the TC?
A legally enforceable contract where parties agree to settle disputes outside of court via a neutral third-party arbitrator rather than a judge or jury.
What is Arbitration?
The immediate action(s) a facility takes to stop, eliminate, or correct a serious threat to patient safety, health, or life, preventing further harm or recurrence. The imminent risk of serious harm, impairment, or death no longer exists, allowing the facility to continue operations while a full Plan of Correction (POC) is finalized.
What is an Abatement?
The resident has a right to choose or refuse to perform services for the facility and the facility must not require a resident to perform services for the facility.
What is F566?
True or False
The Surveyor who identified the Immediate Jeopardy (IJ) is solely responsible for investigating and writing all citations related to the IJ.
False.
IJ is the responsibility of the entire team. During the IJ process all other survey activity will cease until the TC informs the team they may resume regular survey activities.
The purpose of this is to explore the extent to which structure and process factors may have contributed to systemic problems caused by substandard quality of care.
What is an Extended Survey?
This nursing home facility task has had the most immediate jeopardy's cited.
*Infection control remains the most frequently cited task for Immediate Jeopardy (IJ) in nursing homes, often triggered by failings in staff adherence to protocols.
What is Infection Control?
IJ removal plan sent to the RD by the facility?
What is a Credible Allegation of Compliance?
The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
What is F554?
This resource is used by the team to determine when IJ is present.
What is Appendix Q?
An extended survey can be conducted at these times. (2-part answer)
What is Prior to the exit conference, in which case the facility will be provided with findings from the standard and extended survey; or After the standard survey but no later than 14 calendar days after the completion of the standard survey.
*For the second option, if the extended survey is completed after the standard survey, documentation of non-compliance should be completed in the same survey shell.
Ensures that the facility has an adequate number of qualified nursing staff on duty 24/7 to meet resident care needs, comply with regulations, and operate within budgetary limits.
What is Sufficient and Competent Staffing?
Number of days the facility has to produce a credible AOC during an ongoing IJ.
What is 23 days?
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider.
What is F628?
This is who the team must notify of the serious concern after sufficient investigation by the team shows a serious concern has occurred.
Who is the Regional Director (RD) for the facility?
True or False
It is ok to only choose "yes" or "no" when answering the CE questions under the Extended Survey topics without documenting specific investigative data.
False
*Documentation for any record review and interviews should be documented in the notes section in iQIES. If you are citing, do not forget to get supporting documents to attach to the shell.
A comprehensive requirement under federal regulations that mandates the facility provide a safe, clean, comfortable, and homelike environment tailored to the individual physical, social, and psychological needs of each resident. It requires moving away from institutionalized, "one-size-fits-all" care to personalized living arrangements that foster dignity, independence, and comfort.
What is Environment?
These are the items included in the AOC binder for each citation. (6 items)
What is are the specific actions to fix the systemic failure, identification and documentation of affected residents, staff education/training, monitoring plan to include audit tools, the facility Quality Assurance Performance and Improvement (QAPI) committee meetings, and the exact date compliance was achieved.
The intent of this tag is to assure that ALL services, as outlined by the comprehensive care plan, being provided meet professional standards of quality.
What is F658?
These are the only people who are allowed to be present during the telephone meeting with the RD and QA Specialist.
Who is Facility Staff?
*No Regional staff may be on or involved in the call.
The Extended Survey requires these specific trainings based on staff job title. These include new and existing staff and direct care staff.
What is Abuse, Neglect, Exploitation, Infection Control, Resident Rights, Resident Behavioral Health Care Needs, and Dementia Care
Ensures compliance with federal regulations regarding the management, protection, and accountability of residents' personal money.
What is Personal Funds?
This is specifically numbered by citation and must be scanned and labeled in direct correlation to the original documents.
What is the AOC Binder?
The intent of this tag is to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs.
What is F645?
The steps to be taken once the RD has confirmed, after review of the team's investigation, that IJ exists.
Hint: There are 5 steps.
What is.....
1. The RD/QA Specialist, will conduct a brief conversation with the facility to discuss the identified concern.
2. Following the call, if the facility presents sufficient evidence or explanation, the RD or QA Specialist will instruct the team in writing to either:
3. If the facility DOES NOT present sufficient evidence or explanation, the RD or QA Specialist will notify the Administrator and the survey team of the IJ investigation status and the survey team will proceed with the formal LTCSP IJ investigation process and will, at this time, fill out the IJ Template.
4. The team will notify the RD of the facility that the IJ Templates are completed and ready for review. Once the RD has reviewed and approved the IJ Templates, the TC will print the IJ Templates and go to Administration to officially call the IJ notifying the facility that the outcome may change following completion of the Survey State Agency (SSA)/Centers for Medicare and Medicaid Services (CMS) QA review.
5. The TC will return to the conference room and under “Facility Tasks” trigger the Extended Survey. During this time all other survey activities will stop. The TC will notify the team when they may resume regular survey activities.
Determines the specific resources and staff competencies necessary to provide competent care to residents, both during daily operations and emergencies. It aligns staffing, equipment, and services with the specific acuity, cultural, and psychosocial needs of the resident population.
What is the Facility Assessment?
This facility task discusses the facility overall response to Resident concerns.
What is Resident Council?
Interviews to be conducted during the Abatement Process?
Who is everyone in the facility that is directly, or may directly, be involved in the IJ situation?
Review the impact of the physical, mental, and/or psychosocial aspects of the resident’s ability to maintain, improve or prevent avoidable decline in range of motion and mobility, the surveyor must review the provision of care and services and implementation of interventions under this tag.
What is F688?