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140 Cards in this Set
- Front
- Back
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For certification a SNF and NF need to complete at least |
A life safety survey and A standard survey |
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Survey team size vary on what 4 factors |
Bed size of the facility whether the facility has historical patterns of serious deficiencies or complaints Whether facility has special care unit whether new surveyors are to accompany a team as part of their training |
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Composition of the team - what requirements must be met? |
Skilled nursing facility and nursing facility standard surveys must be conducted by multidisciplinary team of professionals at least one of them must be a registered nurse Surveyors be free of conflicts of interest surveyors successfully complete a training and testing program in the survey certification techniques Within these parameters state and feds can choose the team and what constitutes a professional |
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Length of survey based on person hoursp |
Dependent on the size and layout of facility and the complexity and number of concerns |
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Conflicts of interest for surveyors |
Federal employees are required to make a declaration of any outside interest and update CNS whenever such interests are acquired For state it’s not necessary to inform CMS of all potential conflict situation however if an over abuse requires correct of action regional office must be informed |
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Primary facie conflicts of interests |
Employee or former employee within the past two years financial interest in facility (indirect interest like broad based mutual fund doesn’t count) immediate family who has a relationship with facility immediate family who is a resident |
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Initial certification survey |
All initial service must verify substantial compliance with the regulatory requirements contained in the code |
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Post survey revisit |
When the state has cited deficiencies during a survey, they may conduct a post survey visit to determine if the facility is in compliance |
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Abbreviated standard survey |
Focuses on particular task that relate to complaints received or change of ownership management or director of nursing it does not cover all the aspects of the standard survey but concentrates on a particular area of concern the survey team investigate any area of concern And manner decisions regarding any regulatory requirement whether or not it’s related to the original purpose of the survey |
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Complaint investigation |
If State’s review of the complaint concludes that one or more violations may have occurred and only a survey can determine whether there is a deficiency Conduct a standard or abbreviated standard survey |
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Changes in management |
If facility notifies you of change in .org or management review changes to ensure compliance . If changes raise questions about continued compliance confirm through a survey |
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Extended survey/partial extended |
During standard or abbreviated standard survey the team suspects SQC, then must expand the survey. If expanded verses SQC then do an extended or partial extended survey |
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State monitoring visits |
Not part of state monitoring remedy. These visits may occur: During bankruptcy (with CNS authorization) after change of ownership (authorized by CMS RO) during or shortly after removal of IJ with the purpose of the visit to ensure welfare of residence by providing oversight and presence in other circumstances as authorized by CMS |
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Survey frequency for SNF and NF |
Not exceed 15 months from last survey and state average for intervals between survey should not exceed 12 months |
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Last day of survey |
Last day of observation regardless of when exit interview takes place |
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For purpose of computing 3 month and 6 months time frame what day do you use for both life safety and standard on the same traxk |
Use last day of the standard survey (last day do Resident observation), even if LS is second and citation was found during LS survey. Last day of the standard survey will always be used to compute number of noncompliance days. |
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For the purpose of first notice of noncompliance use the last day of the survey that found noncompliance. |
This means if life safety happens after health and life safety found the noncompliance count from last day of life safety |
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Extended surveys and abbreviated standard surveys are not counted in the calculation of survey interval or statewide average Revisits are not counted in the interval calculation Exception - when abbreviated standard survey turns into a standard survey |
The mandatory denial of payment for new admissions and termination time frames would be 3 and 6 months respectively for each separate portion |
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What is used to determine if a facility has not received a survey in 15months |
Certification and survey provider enhanced reporting system. CASPER |
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What date must survey info be submitted to CMS for the fiscal year? |
11/15 |
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All CMS surveys must be unannounced including |
Standard Complaint surveys and Onsite revisit |
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How should state notify LTC Ombudsman regarding survey? |
According to state protocol developed between state and LTC Ombudsman office |
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When a extended or partial extended survey is conducted, what happens to the nurse aide training and competency program in the facility |
Must be withdrawn |
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IDR |
States and CMS a must have in writing an IDR process |
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Mandatory elements of IDR |
Upon receipt of 2567 facilities offered IDR Facilities Must not use the IDR to delay remedies or to challenge any other aspect of the survey process including: Scope and severity assessments (except for IJ and SQC) Remedies imposed Alleged failure of the survey team to comply with a required survey process Alleged inconsistency of the survey team in citing among other facilities Alleged inadequacy of inaccuracy if IDR process |
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Request for IDR must happen when |
Within the 10 calendar days given to prepare PoC. |
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Will the failure to complete and IDR delay enforcement action? |
No |
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When Facilty is unsuccessful in IDR |
Surveying entity notifies facility |
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When facility successful in IDR |
Surveying agency correct 2567 and annoyed deficiency as deleted Adjust any scope and severity assessments for deficiencies Promptly notify CMS regarding changes to the enforcement actions if the deleted or altered deficiencies were the sole CSU’s rod the actuon |
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When should IDR requests be entered into ASPEN and the ASPEN informal dispute |
Within 10 calendar days of receiving the request CASPER aid not updated until IDR is complete |
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To keep surveys unannounced state and feds should follow these guidelines |
Facilities in same geographical area should not be surveyed in the same order Time of day, time of week and time of month should vary. Weekend entry and early morning early evening entries should also occur. |
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What percent of surveys should occur on weekend or off hours? |
10% |
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What happens when an individual announces a standard survey to the faciltiy |
Must be reported to CMS And CMS determjnes if a CMP should be imposed. Can be up to $2000 |
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What is the only time that extended or partial extended survey occurs |
When a SQC has been identified |
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When is expansion or expanded survey used |
When during a standard or abbreviated survey the state suspects SQC but does not have sufficient information to confirm. |
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If SQC aid identified during an expanded survey what happens? |
Either a extended survey or Partial extended survey occurs. |
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If expanded survey does not find SQC? |
Then proceed with preparing 2567 and following procedures |
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An extended of partial extended survey should occur in what time frame of standard or abbreviated? |
Immediately after or no later than 14 days |
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When a extended survey is conducted what additional notices must the state provide |
State board responsible for the licensing of the nursing home administrator and Attending physician if each resident who was identified as having been subject to the substandard quality of care |
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When facility successful in IDR |
Surveying agency correct 2567 and annoyed deficiency as deleted Adjust any scope and severity assessments for deficiencies Promptly notify CMS regarding changes to the enforcement actions if the deleted or altered deficiencies were the sole CAuse of the enforcement action |
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Facilities are able to request Independent IDR when? |
CMS imposes CMP against facility and penalties are subject to being collected |
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Denial for purpose of starting Medicare reasonable assurance |
Denial for purpose of starting Medicare reasonable assurance |
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End |
End |
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Are all CMP funds subject to eacros |
Yes |
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Core requirements of an acceptable Independent IDR process |
Opportunity for independent IDR is provided within 30 calendar days of the notice of impositions of CMP Independent IDR will be completed in within 60 days of facilities request. Generate a written record prior to collection of the penalty Opportunity for resident (involved) input Be approved by CMS and conducted by the state |
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State conduct a survey for the regional office certifies compliance or non-compliant and determines whether facility will participate in Medicare or Medicaid programs |
State conduct a survey for the regional office certifies compliance or non-compliant and determines whether facility will participate in Medicare or Medicaid programs |
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Non-state operated skilled nursing facility |
State conduct survey and certifies compliance regional office determines whether a facility is eligible to participate in Medicare |
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Non-state operated nursing facility |
They conduct a survey at certified appliance state certification is final state Medicaid agency determines whether facility is eligible to participate |
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Don state operated Dually participating facility |
State conducted a survey and certified compliance state certification of compliance to state Medicaid agency for nursing facility and to the regional office for skilled nursing in the case where the state and regional office disagree with the certification look to Rules |
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For initial certification who is responsible |
State conduct a survey and determine whether a prospective provider is in substantial compliance if in compliance date recommend the regional office of the Medicaid agency enter into agreement with the 30 |
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When can the survey agency confirm substantial compliance through documentation in Lieu of an on-site revisit |
Deficiencies fall at the level D E or F without a finding of substandard quality of care |
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If noncompliance falls at level F with finding of SQC or any level higher than F the option to except evidence of a correction in Lieu of an on-site revisit? |
Doesn’t apply |
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Criteria for no opportunity to correct |
IJ is identified in current survey Any at level G H I that fall under SQC Double G or above in consecutive surveys either Heath or LSC SFF if F or above in Health or F or above in LSC |
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When must a CMP be imposes |
When IJ arhat resulted in serious harm impairment or death May be used when there is an IJ which doesn’t result in harm serious impairment or death |
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State is authorized to recommend and impose category 1 remedies which include |
Directed plan of correction State monitoring And directed inservice training |
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Remedies should be chosen how? |
By the remedy that will best achieve the purposes of attaining and sustaining compliance |
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Who has the authority to impose a CMP |
Only CMS RO and must go through CMP analytic tool |
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Directed inservice training |
Appropriate where there are sufficient use that point to knowledge gaps and staff competency |
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Directed plan of correction |
Directed actions or process from state or CMS RO that facility must take to correct root cause of noncompliance |
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Temporary management |
Temporary appointment of manager or administrator to oversee correction or over see closure Temp managers term Can be extended past date of correction May be imposed at any time is not in substantial compliance but also when there is an IJ or widespread harm and an alternative remedy to termination has been proposed |
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DPNA |
Must be imposed when facility is not in compliance if not in compliance by 3 months of last survey day or when the facility has been found to have SQC in last three surveys |
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DPAA |
Denial of all payments for Medicare and caid Only CMS has authority to impose Severe penalty - criteria to use: Seriousness of current survey Noncompliance history Use of other remedies that have failed |
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Notice requirements when IJ exists |
Nature of IJ Request an allegation of removal Consequences of failure to submit an allegation of removal Remedies recommended with effective dates Opportunity for IDR Opp for independent IDR if CMPs Disapproval of nurse aide CEP If SQC list of physicians servings residents involved When no formal notifications of remedies are being provided must clearly indicate that the notice does not serve as a formal notice May serve as a final notice for category 1. May also serve as formal notice for DPNA if authorized by CMS |
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Who sends formal notice of remedies? |
For category 1 and DPNA - state survey agency For other than category 1 - CMS RO for medicare and dually participating and for NF where TO is handling enforcement By state Medicaid for other than category 1 and DPNA for NF not included above |
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Notice of remedy requirement for IJ and no IJ |
2 calendar days - except for CMP and State monitoring 15 calendar days |
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Notification requirements when IJ is found |
If IJ is identified during survey must share with team and determine whether IJ Then discuss with Survey team management If IJ is determined must notify facility administration while onsite |
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When IJ found survey team must notify who else besides facility |
CMS RO or state Medicaid agency |
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When IJ what happens with PoC deadline |
PoC deadline deferred until revisit is conducted and verified IJ is removed |
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5th - 21st calendar day |
Except when already given by state, CMS RO or state Medicaid agency issue a formal Notification |
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Who is also given notice of pending termination |
General public |
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Once survey agency’s verifies that the IJ is removed it send a statement of deficiencies for 2567 and PoC is due when |
10 calendar days from notice |
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23rd for IJ |
Termination takes effect if IJ has not been removed |
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State monitoring |
No notice requirement Oversee correction to prevent against further harm When situation has potential to worsen or facility seems unwilling to correct MUST Abe used when received SQC on last 3 surveys |
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Criteria for alternative remedies (to termination of agreement) when no IJ exists If any one is not met then recommendation for alternative is denied |
Termination Termination with alternate remedies Alternate remedies instead of term Mandatory DPNA |
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End |
Wnd |
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Termination of provider agreement |
May be used at anytime but MUST ave used when IJ is not removed within 23 days and facility not in compliance 6 months from last survey day |
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When must remedies be entered into ASPEN |
Wishing 5 Bds of notice to facility |
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Who can ban payments from private pay residents |
Only state of remedy was approved by CMS |
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Remedy becomes effective when? |
Once imposed remedy is effective as of the date in the notice |
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Remedies continue until? |
Datebof substantial compliance as determined by state survey agency |
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For IJ removal of the jeopardy has what effect on remedies? |
Stops 23 day termination remedy Per day CMP must be lowered once survey agency determines IJ has been removed Other CMPs May continue Other remedies stay in effect until substantial compliance is found |
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When fed remedies are immediately imposed (no opp for correction) what is the responsibility of the State? |
Notify CMS RO within 5 business days CMS RO make final determination with 5 bds if receipt Survey agency must enter into ASPEN No opportunity to correct within 5bds of notice to facility |
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When no IJ the state and CMS should give an opportunity to correct before remedies are imposed. What is process? |
Survey agency sends out an initial notice to facility with copy to CMS and State Medicaid agency Transmits deficiencies cited Provides notice of mandatory remedy of termination if facility fails to be in substantial compliance by 6 months from date of last survey Provides approved plan of correction will establish outside date of when correction must be Madelyn serve as final notice for category 1 remedies (effective no less than 15 days from Notice) Informs facility that comply is sent to CMS and state Medicaid agency Right to IDR 10 calendar days to submit plan of correction |
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DPAA |
Denial of all payments for Medicare and caid Only CMS has authority to impose Severe penalty - criteria to use: Seriousness of current survey Noncompliance history Use of other remedies that have failed |
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Notice requirements when IJ exists |
Nature of IJ Request an allegation of removal Consequences of failure to submit an allegation of removal Remedies recommended with effective dates Opportunity for IDR Opp for independent IDR if CMPs Disapproval of nurse aide CEP If SQC list of physicians servings residents involved When no formal notifications of remedies are being provided must clearly indicate that the notice does not serve as a formal notice May serve as a final notice for category 1. May also serve as formal notice for DPNA if authorized by CMS |
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Who sends formal notice of remedies? |
For category 1 and DPNA - state survey agency For other than category 1 - CMS RO for medicare and dually participating and for NF where TO is handling enforcement By state Medicaid for other than category 1 and DPNA for NF not included above |
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Notice of remedy requirement for IJ and no IJ |
2 calendar days - except for CMP and State monitoring 15 calendar days |
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Notification requirements when IJ is found |
If IJ is identified during survey must share with team and determine whether IJ Then discuss with Survey team management If IJ is determined must notify facility administration while onsite |
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When IJ found survey team must notify who else besides facility |
CMS RO or state Medicaid agency |
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When IJ what happens with PoC deadline |
PoC deadline deferred until revisit is conducted and verified IJ is removed |
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5th - 21st calendar day |
Except when already given by state, CMS RO or state Medicaid agency issue a formal Notification |
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Who is also given notice of pending termination |
General public |
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Once survey agency’s verifies that the IJ is removed it send a statement of deficiencies for 2567 and PoC is due when |
10 calendar days from notice |
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23rd for IJ |
Termination takes effect if IJ has not been removed |
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State monitoring |
No notice requirement Oversee correction to prevent against further harm When situation has potential to worsen or facility seems unwilling to correct MUST Abe used when received SQC on last 3 surveys |
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Criteria for alternative remedies (to termination of agreement) when no IJ exists If any one is not met then recommendation for alternative is denied |
Termination Termination with alternate remedies Alternate remedies instead of term Mandatory DPNA |
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When are onsite revisits mandatory? |
SQC deficiencies 1st onsite revisit finds deficiencies that qualify as SWC harm or IJ. Onsite revisits must continue for these even if they lessen to lower levels Second onsite revisit finds any noncompliance State needs to seek approval fromCMS TO for 3 rd onsite revisit or recommend termination (for mediacsr or dually participating) Not a guarantee |
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Termination of provider agreement |
May be used at anytime but MUST ave used when IJ is not removed within 23 days and facility not in compliance 6 months from last survey day |
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When must remedies be entered into ASPEN |
Wishing 5 Bds of notice to facility |
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Who can ban payments from private pay residents |
Only state of remedy was approved by CMS |
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Remedy becomes effective when? |
Once imposed remedy is effective as of the date in the notice |
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Remedies continue until? |
Datebof substantial compliance as determined by state survey agency |
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For IJ removal of the jeopardy has what effect on remedies? |
Stops 23 day termination remedy Per day CMP must be lowered once survey agency determines IJ has been removed Other CMPs May continue Other remedies stay in effect until substantial compliance is found |
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When fed remedies are immediately imposed (no opp for correction) what is the responsibility of the State? |
Notify CMS RO within 5 business days CMS RO make final determination with 5 bds if receipt Survey agency must enter into ASPEN No opportunity to correct within 5bds of notice to facility |
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When no IJ the state and CMS should give an opportunity to correct before remedies are imposed. What is process? |
Survey agency sends out an initial notice to facility with copy to CMS and State Medicaid agency Transmits deficiencies cited Provides notice of mandatory remedy of termination if facility fails to be in substantial compliance by 6 months from date of last survey Provides approved plan of correction will establish outside date of when correction must be Madelyn serve as final notice for category 1 remedies (effective no less than 15 days from Notice) Informs facility that comply is sent to CMS and state Medicaid agency Right to IDR 10 calendar days to submit plan of correction |
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DPAA |
Denial of all payments for Medicare and caid Only CMS has authority to impose Severe penalty - criteria to use: Seriousness of current survey Noncompliance history Use of other remedies that have failed |
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Notice requirements when IJ exists |
Nature of IJ Request an allegation of removal Consequences of failure to submit an allegation of removal Remedies recommended with effective dates Opportunity for IDR Opp for independent IDR if CMPs Disapproval of nurse aide CEP If SQC list of physicians servings residents involved When no formal notifications of remedies are being provided must clearly indicate that the notice does not serve as a formal notice May serve as a final notice for category 1. May also serve as formal notice for DPNA if authorized by CMS |
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Who sends formal notice of remedies? |
For category 1 and DPNA - state survey agency For other than category 1 - CMS RO for medicare and dually participating and for NF where TO is handling enforcement By state Medicaid for other than category 1 and DPNA for NF not included above |
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Notice of remedy requirement for IJ and no IJ |
2 calendar days - except for CMP and State monitoring 15 calendar days |
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Notification requirements when IJ is found |
If IJ is identified during survey must share with team and determine whether IJ Then discuss with Survey team management If IJ is determined must notify facility administration while onsite |
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When IJ found survey team must notify who else besides facility |
CMS RO or state Medicaid agency |
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When IJ what happens with PoC deadline |
PoC deadline deferred until revisit is conducted and verified IJ is removed |
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5th - 21st calendar day |
Except when already given by state, CMS RO or state Medicaid agency issue a formal Notification |
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Who is also given notice of pending termination |
General public |
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Once survey agency’s verifies that the IJ is removed it send a statement of deficiencies for 2567 and PoC is due when |
10 calendar days from notice |
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23rd for IJ |
Termination takes effect if IJ has not been removed |
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State monitoring |
No notice requirement Oversee correction to prevent against further harm When situation has potential to worsen or facility seems unwilling to correct MUST Abe used when received SQC on last 3 surveys |
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Criteria for alternative remedies (to termination of agreement) when no IJ exists If any one is not met then recommendation for alternative is denied |
Termination Termination with alternate remedies Alternate remedies instead of term Mandatory DPNA |
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When are onsite revisits mandatory? |
SQC deficiencies 1st onsite revisit finds deficiencies that qualify as SWC harm or IJ. Onsite revisits must continue for these even if they lessen to lower levels Second onsite revisit finds any noncompliance State needs to seek approval fromCMS TO for 3 rd onsite revisit or recommend termination (for mediacsr or dually participating) Not a guarantee |
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Are initial complaint surveys counted in revisit count? |
No unless they occur at the time of another onsite revisit. Any revisits associated with complaint survey are ccounted towards revisit count |
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When initial complaint survey is conducted after the Third onsite revisit but befor the 6-month term date how does surveyor proceed? |
Cannot do revisit without approval from CMS or state Should be used to consider term |
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When revisits are for specifically the health or life safety but not both then revisit counts are separate |
When for both counts are the same |
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Are visits to determine if IJ has been removed count towards revisits? |
Yes |
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Are state monitoring or drop by visits of SFF count towards revisits |
No |
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Is PoC required when facility is in compliance but has isolated deficiencies of no actual harm and potential for only minimum harm |
No. But facility are expected to correct them |
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Termination of provider agreement |
May be used at anytime but MUST ave used when IJ is not removed within 23 days and facility not in compliance 6 months from last survey day |
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When must remedies be entered into ASPEN |
Wishing 5 Bds of notice to facility |
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Who can ban payments from private pay residents |
Only state of remedy was approved by CMS |
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Remedy becomes effective when? |
Once imposed remedy is effective as of the date in the notice |
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Remedies continue until? |
Datebof substantial compliance as determined by state survey agency |
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For IJ removal of the jeopardy has what effect on remedies? |
Stops 23 day termination remedy Per day CMP must be lowered once survey agency determines IJ has been removed Other CMPs May continue Other remedies stay in effect until substantial compliance is found |
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When fed remedies are immediately imposed (no opp for correction) what is the responsibility of the State? |
Notify CMS RO within 5 business days CMS RO make final determination with 5 bds if receipt Survey agency must enter into ASPEN No opportunity to correct within 5bds of notice to facility |
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When no IJ the state and CMS should give an opportunity to correct before remedies are imposed. What is process? |
Survey agency sends out an initial notice to facility with copy to CMS and State Medicaid agency Transmits deficiencies cited Provides notice of mandatory remedy of termination if facility fails to be in substantial compliance by 6 months from date of last survey Provides approved plan of correction will establish outside date of when correction must be Madelyn serve as final notice for category 1 remedies (effective no less than 15 days from Notice) Informs facility that comply is sent to CMS and state Medicaid agency Right to IDR 10 calendar days to submit plan of correction |
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Reassurance concept |
If a Medicare provider was terminated it may not be reinstated until it has been verified through a reasonable assurance process to determine that the provider is capable of compliance and sustaining compliance |
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Is there a reassurance process for medicaid |
No. States are not required to do so but may. |
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What is the requirement for the reassurance process |
Must be surveyed and find substantial requirement at the beginning and at the end of the reassurance process |
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If non compliance is found during either reassurance survey then? |
Reentry is denied with not right to appeal |
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If only deficiencies at A B C then facility is found to be at |
Substantial compliance |
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2nd assurance visit |
Usually full survey. If survey finds only A B C deficiencies then facility is acceptable for program participation. PoC for deificiencies greater than A must be submitted If D E F in any area grouped with deficiencies that lead to term then denial If D E F and SQC then denial If D E F with no SQC and not related to previous then CMS May accept this survey with a approved PoC as ok to participate. Must wait till received approved PoC If above level F then denial |
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End |
End |
