Qtips

In an effort to assist our facility members in preparing for this survey process, LeadingAge Indiana will provide you with monthly tips for QIS preparation – or as we like to call them, “Q-Tips.”

Get the latest overview of recent surveys. Frequently cited tags and their severity can be extremely helpful with your survey preparation! [click here]

Get all of the QIS forms and guides here.

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I. Getting Started

II. Reviewing Admissions

III. The Family Interview

IV. Resident Interviews and Observations

V. Review Staff Interview Forms

VI. Liability Notice & Beneficiary Appeal Rights Review

VII. Dining Observation Review

VIII. Infection Control & Immunizations

IX. Kitchen & Food Service Observation

X. Medication Administration

XI. Resident Council President Interview

XII. Quality Assessment and Assurance (QA&A) Review

XIII. Medication Storage

XIV. Abuse Prohibition Review

XV. Admission, Transfer, and Discharge Review

XVI. Environmental Observations

XVII. Sufficient Nursing Staff Review

Overview -

QIS is a two stage process to systematically review nursing home requirements and investigate any regulatory areas triggered. The survey process has been revised, but the Federal Regulations and interpretive guidance remain unchanged. The QIS uses customized software to guide surveyors through a structured investigation.

The process begins with offsite survey preparation including review of prior deficiencies, current complaints, ombudsman information, and existing waivers/variances.

Upon entry at the facility, an entrance conference is conducted during which time facility information is requested. (Click here for entrance conference worksheet.) Concurrently, surveyors will conduct a brief tour.

3 Distinct Stage I samples are selected:

Census sample with focus on Quality of care and life. Includes 40 residents.
Admission sample with focus on recent admissions. Includes 30 residents both current and discharged.
MDS data is used to create the resident pool from which the Stage I samples are randomly selected and to calculate the MDS-based Quality of Care and Life (QCLIs) for use in Stage II.

Stage I includes a review of residents and includes: residents and family interviews, staff interviews and resident observation as well as clinical record reviews. Mandatory tasks are started including:

Resident council president interview
Observation of dining and kitchen areas
Infection control practices
Medication administration
Review of the Medicare Demand billing process
Quality assurance Programs

After the Stage I review is complete, computer collection tool uses the surveyors findings along with the MDS data to determine what exceeds the national threshold and consequently triggers care areas and/or triggered facility-level tasks for further investigation in Stage II.

Stage II investigation includes:

Care area investigations using a set of investigative protocols
Completion of mandatory facility-level tasks
Triggered facility-level tasks which include abuse prohibition, environment, nursing services, sufficient staffing, personal funds and admission, transfer, discharge.

After all investigations have been completed, the team analyzes the results to determine whether noncompliance exits. (QIS uses the same process to determine noncompliance, including scope and severity, as is used in the traditional survey.) An exit conference is conducted, during which the nursing home is informed of the survey findings.

Keep an eye on the Education Calendar for Compliance Update Training!

Questions? Contact us for support!