CIF Form
This is the name of the form used to document the investigation for standalone complaints.
What is a Complaint Investigation Form (CIF)?
The purpose of a revisit is to determine this.
What is to ensure that the facility has corrected identified substantial noncompliance and is now in substantial compliance.
The state Regional Directors.
Who is .......
Leanna Bonner (Southern Region),
Robbie Dunbar (Northwest Region),
Kenya Pledger (Central Region),
Cheryl Dean (Northeast Region).
This document must remain confidential.
Response to providers when asked what the concern is.
(2 answers)
What is a complaint and Care and Services.
All information for completed complaints (including any citations written) should be completed in ACTS no later than this.
What is the Wednesday following the investigation by noon.
This date MUST be accurate as civil money penalties or other remedies may be impacted by this date.
What is the date the facility alleges compliance/POC date?
These are the areas in ACO to review to determine the facility's history that should be documented on the CIF form.
What is the last standard survey and complaints since the last standard survey for the facility?
This is the time frame when a revisit must occur.
What is between the last correction date on the plan of correction and the 60th day from the survey exit date.
Must be done upon completion of a Recertification Survey, Complaint Survey, and Revisit Survey and prior to exiting the facility. (There are 2 answers).
What is QAPI and call the RD for the facility.
Investigation consists of this.
(There are 3 answers)
What are observations, interviews, record reviews?
This should ONLY be on the first allegation of each complaint.
What is a narrative?
670 hours are important in determining this.
What is how CMS/Federal Government determines payment to the State of Georgia for contracted services?
The two people who must be notified once the entrance conference is over and the surveyor has set up in the conference room.
Who is the Ombudsman and the Complainant.
Documents required from the facility upon entrance for a revisit.
What is the Alpha Census, Roster Sample Matrix (802), 2-Week Facility Staffing Grid, and a list of staff working upon entrance to the facility with their names and titles.
The State Agency has _____ Business days to get a 2567 out to a facility and the facility has _____ Calander days to respond with their POC once they receive the 2567.
What is 10 and 10?
This form is used to provide resident ID and care concerns and must be filled out and sent in with the TC Packet.
What is the Complaint Roster Sample Matrix.
This should be written per the POD and GA writing guide. It should be specific to the allegation and must answer every concern mentioned in the allegation so that it is clear a thorough investigation was completed. Each allegation should have this.
What is a summary?
Required for all survey types (except the State Survey’s) and if there is a complaint attached to the survey these hours should be split 70/30 between the complaint and the survey.
What are 670 hours?
1. __________ residents must be sampled for each allegation.
2. Must be part of the sample for an allegation if mentioned in the complaint.
1. What is 3?
2. Who is the resident mentioned in the complaint.
When an active complaint with a resident named is added to the revisit survey, this is when it is appropriate to add that resident to the sampled residents for the revisit.
What is when the complaint is related to a deficiency cited on the original survey.
Name of the Long-Term Care Director.
Who is Andrea Sanders?
Investigated on a complaint as done on a standard survey.
What are allegations (or care areas)?
You have identified a serious concern while on survey alone. This is the first thing you should do.
What is call the RD for the facility immediately to discuss and get further guidance.
Review of complaint intake forms and allegation(s)/care areas, FRI’s, photographs, and/or other information attached to the survey shell or provided prior to the investigation. Review the related regulatory requirements or standards that pertain to the complaint. Review last standard survey outcome in ACO and complaints since last standard survey to determine facility history. Determination of observations to be made, interviews to conduct, and records to be reviewed is referred to as this on the CIF.
What is Offsite Prep?
These should be used for staff, and during certain situations for residents, when adding the summary into ACO.
What is an identifier?
Used to document the investigation for a revisit survey.
What are Surveyor Notes (807)?
Upon completion of the revisit survey, you have this many hours to send in your TC Packet. (This is all the information gathered that is required upon entrance).
Who do you send this information to? (3 people)
What is 72 hours?
Who is Letitia Mason, QA Specialist for the facility, and the RD for the facility?
This is determined based on the information you have obtained in your complaint investigation.
(There are 2 answers)
What is if the allegation is substantiated or unsubstantiated AND if you will need to write a citation.
Citations for complaints are entered here.
What is ACO?
When determining a sample size on a revisit for a level three (harm) and above, your sample size should include ...........
What are all residents for whom the outcome rose to level three or above?