Assessments
Based on CMS Requirements, identify which pts require a New Patient Pre-Tx Evaluation by the RN (P&P 01-03-07, 05-02-28, 12-03-03)
What is any pt treating or training for the first time at the facility (new admissions, transfers, patient visitors)?
Although not included in DQI score, this item was added as a new Ancillary Metric
What is Covid-19 vaccinations?
The surveillance tests (and in what frequency) needed for a pt who is Antigen Negative, Core Positive, Antibodies >/= 10
What is monthly antigen and annual antibody testing?
Title of report found in FHR and given to surveyors
What is the Core Survey Report?
Frequency of which the Covid-19 Infection Control Audits are to be completed
What is weekly?
Identify which patients require an Initial Assessment and Plan of Care (P&P 01-14-01, 05-15-02, 12-16-01)
Who are patients new to dialysis, patients with a modality change and patients post-failed transplant?
In PD, this metric was removed and its points were reallocated to this other metric
What is Patient Satisfaction Survey and what is Uncorrected Calcium?
For a new patient admission, this is the timeframe allowed for Hep B Surface Antigen results
What is within 30 days prior to first treatment or training date?
Identify 4 items provided to surveyors within 3 hours of a Core Survey
What is list of...?
CMT: Weekly utilization goals for Facility Log-In and Care Activity Assignment
What is 90% for facility log-in and 80% for Care Activity Assignment?
Identify the timeframe for Initial, 90-Day, Stable and Unstable Assessments and Plan of Care are completed (P&P 01-14-01, 05-15-02, 12-16-01)
What is: Initial Assessments and POC in 30 days or 13 tx; 90-Day, Stable, Unstable in 30 days for assessment and within 15 days of completion of assessment for the POC?
Metric that was added to ICHD DQI
What is CVC in Use % Improvement?
Required ongoing surveillance if a new patient has a negative TST (one-step) completed within 3 months prior to admission
What is administer a second TST 1-3 weeks after admission and an RAQ and then re-administer a TST and RAQ annually?
Identify 1 item provided to surveyors by the end of Day 1?
What is...?
CMT: IKC Monthly Risk Rating adherence goal
What is 80%?
In PD, this is the expectation of the RN if patient does not submit or complete Daily Home Treatment Records/Flowsheets (P&P 05-01-29)
What is the RN will review with the patient the importance of home records and the patient's responsibility to provide them, issue new record sheets and document intervention in Falcon?
These 2 metrics were removed from HHD's DQI
What is Patient Satisfaction Survey and Uncorrected Calcium?
Vaccinations offered to patients
What are Hep B, Pneumococcal, Influenza and Covid-19 vaccines?
Timeframe of Infection Control/Clean Sweep audits submitted to surveyors
What is 12 months worth of audits?
Teammate(s) required to attend Governing Body meetings
Who are FA, Medical Direcotr, ROD, CC/CNM (if FA is not an RN)?
Intervention if the ICHD prescription is not met and identify what components this may include (P&P 01-03-08)
What is document the reason why prescription was not met and notify RN? And what is DFR, BFR, treatment time?
What is 25 points?
Vaccination steps for any adult patient without evidence of pneumococcal vaccinations
What is 1) Administer Prevnar (PCV-13), 2) Administer first dose of Pneumovax (PPSV23) atleast 8 weeks after Prevnar, 3) Administer second dose of Pneumovax five or more years after second dose for pts ages 19-64 or Administer a final dose of Pneumovax at 65 years old (at least 5 years since most recent Pneumovax dose)
Identify the 3 triggers for a Recertification Survey
What is 1) Facility due for recertification, 2) Complaint(s) reported to CMS, 3) Publicly reported data (QIP score, Star Rating)?
The steps to take if a TM Advanced Screening indicates: TM asymptomatic, had close contact with a confirmed Covid positive person and not up-to-date with Covid vaccinations
What is 1) TM is permitted to work; 2) TM tested ASAP, 1-4 days after exposure and re-tested 5-7 days following exposure?