MISC
This is a systematic method for collecting information.
Investigation
This appendix of the SOM contains guidance to Surveyors for LTC facilities.
Appendix PP
This form is used to document photos or digital recordings.
Form 6339
This department is responsible for receiving and triaging complaints.
Complaint and Incident Intake (CII)
This should be the first interview conducted in an investigation.
Complainant
Reviewing the facility's account information in ASPEN and TULIP occurs during this part of the survey or investigation.
Offsite Prep/Pre-survey Activities
These two types of pathways will walk you through the investigation or survey.
Facility Task and Critical Element Pathways
This form is filled out to gain consent before photographing a resident.
6340-A, Consent to Photograph
This triage level requires a 24-hour response.
Immediate Jeopardy (P1)
Name at least two things the surveyor will do during the entrance conference.
1. Document on the on-site worksheet entrance dates and times.
2. State and document the general nature of the allegations
3. Request documents (census, resident roster, incident reports, facility staff list etc.)
4. Confirm the administrator information on file is current.
IMs, internal forms, and handbooks can be found on this department's SharePoint page.
Policy and Rules (PAR)
This facility task is used when looking at dry food storage.
Kitchen
This form is used to capture a witness statement.
4825-A, Witness Statement
This is done when an incident or complaint does not warrant an onsite investigation.
Regional Offsite Review
When conducting interviews, avoid these types of questions
Leading questions
Remember these three things when reviewing conflicting evidence.
Credibility, reliability, and verifiability (CRV)
This folder contains many resources for Surveyors to use when surveying or investigating LTC facilities.
Survey Resources Folder (CMS)
This is the document used when a surveyor summarizes what they did to determine if the facility was in compliance.
Investigation Report
Regional Staff review these intakes for tracking of trends to determine if there are common themes that suggest areas for focused attention when the next onsite survey occurs.
Non-immediate Jeopardy (P4 Low)
This should be initiated immediately after the entrance conference.
Initial Tour
Surveyors should notify this person if facility staff are being hostile or creating an adversarial environment.
Program Manager
These are guidance for determining compliance.
Investigative Protocols
A referral is completed for these three types of substantiated allegations.
This is the response time for non-immediate jeopardy (P2 high) intakes.
On-or-before 18 business days within an annual average of 15 business days.
Other residents are added to the sample because they share this with the resident identified in the complaint.
Similar characteristics or care areas