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QIS The Survey Conundrum: Know the Answers to the Questions before the Surveyors


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Title: QIS The Survey Conundrum: Know the Answers to the Questions before the Surveyors

QIS - The Survey Conundrum Know the Answers to
the Questions before the Surveyors
  • Kelley Rice-Schild, NHA, Amina Dubuisson, DON,
    Floridean Nursing Rehab, Miami, FL
  • Connie ODonnell, NHA, All Saints Catholic
    Nursing Home, Jacksonville, FL
  • Alex Terentev, M.D., NHA, Rosewood Manor,
    Pensacola, FL
  • LuMarie Polivka West, MSP, Senior Vice President,
    Chief of Clinical Services, Florida Health Care
    Association, Tallahassee, FL
  • AHCA/NCAL 59th Annual Convention 2008 

Session Objectives
  • Learn about the QIS process and the use of
    interviews in the process. 
  • Understand how research supports the interview
    process in QIS. 
  • Learn how a facility that has had the QIS process
    has used interviews to improve the quality of
    care and also improve their survey outcome.

  • A revised survey process
  • Contract awarded in 2005 with University of
    Colorado to conduct demonstration
  • Independent evaluation of demonstration (Abt
  • Florida is participating with the statewide roll
    out of the QIS

2 Stages of the Quality Indicator Survey
  • Stage I Preliminarily investigate all
    regulatory areas and determine care areas for
    in-depth Stage II review
  • Stage II Determine if deficient practice, and
    document deficiencies including F tags, scope and

Stage I Entrance
  • Entrance Conference held during which necessary
    information is requested from facility (see
    Entrance Conference Facility Worksheet), i.e.
    alphabetical roster (this has been identified as
    a problem by AHCA)
  • Abbreviated Tour (concurrent to entrance
    conference) to provide orientation goals are
    different than traditional survey tour (no
    selection of resident sampling)

Within One Hour
  • Key personnel and locations
  • Name of resident council president
  • Meal time schedule and dining room location
  • All admission sample closed records
  • List provided to facility after entrance

Within Four Hours
  • Ventilator/Dialysis/Hospice Worksheet
  • Dialysis contract and related policies overview
    of how care is coordinated
  • For facility dialysis List of residents, room,
    and ESRD caregiver and who provides the service
    (internal or external provisions)
  • Day and times for dialysis treatment
  • Flu/Pneumococcal PP

Within 4 Hours cont.
  • Rooms with less than required square footage that
    have a variance
  • Lists of rooms 4 residents (variance)
  • Rooms below grade no window to outside or access
    to a corridor
  • QAA committee info Contact persons, members,
    frequency of meetings
  • PASSAR information
  • Any experimental research in the facility
  • Complaint/Abuse/Grievance info contact person
    and PP

Within 24 Hours
  • Medicare residents that have requested demand
    billing since last survey (9-15 mo)
  • Medicare/Medicaid application (671)
  • Resident Census and Condition (672)
  • Copy of the OSCAR 3
  • Query Is full time DON coverage provided?

Stage I Sampling
  • MDS sample drawn offsite and includes all
    residents with an MDS assessment within the past
    6 months of the survey
  • Census sample - random sample of current
    residents (n40)
  • Admission sample - random sample of new
    admissions (n30)

Stage I Resident Level Investigation
  • Resident Interviews
  • Resident Observations
  • Staff Interviews
  • Medical Record Reviews
  • Family Interviews

Stage I Facility Level Investigation
  • Resident Council Interviews
  • Observations of Dining and Kitchen
  • Infection Control Practices
  • Demand Bill Procedures
  • Quality Assessment and Assurance Program

Stage I Synthesis
  • Onsite data are combined with MDS data to
  • create resident-centered outcome and
  • process indicators, called Quality of Care
  • Indicators (QCIs)
  • QCIs and Facility-level Tasks
  • MDS (includes the 24 QI)
  • Census
  • Admission
  • Facility

Admission Sample Review
  • Prognosis
  • DX
  • LOS
  • Discharge info (if applicable)
  • Within 60 days of admit Any PT, OT, ST?
  • Pressure ulcer, weight loss, Terminal prognosis

Census Sample
  • Comatose
  • Bed mobility
  • Transfer
  • ICD 9 codes that focus on nutrition
  • Stability
  • Pressure Ulcers
  • Psycho tropics
  • Weight Loss

Family Interview
  • Want to understand why it is like to live in
    this nursing home
  • Determine through screening the level of
    resident knowledge
  • Prior Hx
  • Preferences Are they honored?
  • Choices
  • Activities
  • Dignity Interactions

Family Interviews
  • Staffing - Is it sufficient?
  • ADL
  • Oral Health
  • Abuse
  • Personal property
  • Environment
  • Rights
  • Costs/Funds
  • Admission
  • Notice of changes
  • Care plan participation

Resident Interview
Openers How long have you been here, are you
from around here, what is the food
like? Cognitive determination If cognitively
appropriate the questions entail quality of life
and care
Resident Interview Cont.
  • Abuse Do you ever feel afraid
  • Personal property
  • Skin condition
  • Potential restraints device in place that may
    potentially restrict movement or access to ones
  • Pain observations also done
  • Food

Resident Interviews
  • Staffing
  • Oral Health
  • Positioning
  • Privacy
  • Exercise of rights
  • Funds
  • Room

Staff Interviews
  • Catheter use reason diagnosis
  • Neurogenic bladder must be verified in medical
  • Nutrition supplements and reasons for
  • Skin Care Protocols

Facility Survey Tasks
  • Demand Billing
  • Dining
  • Frequency of meals
  • Assistance
  • Meal service and proper handling
  • Dignity and independence
  • Adequate time
  • Positioning (maximized eating ability)

Facility Survey Tasks cont.
  • Atmosphere
  • Substitutes
  • Furnishing/space
  • Food quality and sufficient liquids adequate
    assist as needed

Infection Control
  • Observations for hand washing (Competency tool)
  • Glove use
  • Staff with lesions?
  • Soiled laundry process
  • Isolation
  • Functioning infection control program
  • Staff adherence to PP

Kitchen/Food Service
  • Tour
  • Storage
  • Food Infection control guidelines
  • Storage temperatures and process
  • Food prep and service includes snacks, leftover
    storage, etc.
  • Sanitization
  • Equipment

Stage II Sampling
  • Computer identifies sample such that all
    triggered care areas are included with as few
    residents as possible
  • The more care areas triggered, the larger the
  • All sentinel events and complaints

Stage II Resident Level Investigation
  • Each surveyor evaluates care process in relation
    to Stage I findings
  • Both resident-level and facility-wide
  • Use of Critical Elements Pathways to structure
    investigative process
  • Rate severity for each resident where deficient
    practice is found

Stage II Facility Level Investigations
  • If triggered in Stage I
  • Abuse Prohibition
  • Environment
  • Nursing service
  • Sufficient staff
  • Resident funds
  • Admission, transfer, and discharge

Stage II Synthesis
  • Combine Stage II findings across residents into
    single computer by F tag
  • Integrate survey team findings into single
  • Use documentation recorded in Stage I and Stage
  • Identify deficiencies and determine severity and
  • Upload directly to 2567

Surveyor Initiative
  • At any time in the process,
  • surveyors can initiate the addition
  • of
  • Residents
  • Care areas
  • F tags

Medication Observation
  • Medication administration observation is assigned
    to specific surveyors during offsite preparation
  • Medication administration observation is
    conducted throughout the survey
  • Documentation is completed during Stage II

  • 10 resident sample
  • Preparation
  • Administration correct dose, order, and given
    per appropriate technique and order
  • Storage
  • Staff need a working knowledge of medications
  • Beyond the med cart survey success

CMS QIS Process Strengths
  • Larger Sample Sizes
  • To identify patterns of poor care
  • Different samples (e.g., admission and census)
    emphasize different types of residents.
  • Comprehensive
  • Past studies demonstrated that some surveyors
    targeted only selected deficiencies while missing
    the big picture
  • Staged approach requires surveyors to examine all

Structured Approach
  • Systematic observations and questions are
    comparable across sites and replicable
  • Providers could use the tool to reliably assess
    and improve quality on an ongoing basis

Learn the QIS process
  • Read and Learn
  • the Manual !

We Earned a Deficiency Free QIS Survey!
  • All Saints Story

All Saints History
  • Independent
  • Non-Profit
  • 53 years of caring
  • 6.2 years average employment (range 1 week 29
  • 120 Residents
  • 87 long term care
  • 19 Bed Secured Alzheimer Unit

Survey History
Opportunity to host a Mock Survey
Pre-Mock Preparations
  • Read QIS Manual
  • Reviewed systems in place
  • Questioned residents
  • Explained QIS process to residents, staff,
  • Prepared Survey Book

Pre-Mock Expectations
  • Learn about QIS process
  • Survey-prep
  • Positive outcome

Mock Reality
  • Little communication with management
  • If didnt find info, often assumed not there
  • Staff not ready for questions asked
  • Residents didnt always understand questions
  • EVERYONE uncomfortable with process!
  • 18 mock federal citations state crossovers

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Staff Education
  • Supervisors must understand Critical Pathways
    how they impact care
  • All staff must understand intent of QIS
  • Explain QIS process and what their role is
  • Prepare for use of computers
  • Prepare for questions that may be asked
  • Establish a communication plan for Survey

Resident Interviews
  • Use questions from QIS Manual
  • Familiarize residents with what the questions are
  • Lets you know what they really think
  • Good basis for CQI projects
  • Gives residents a voice in their care
  • Act on the answers! Care plan issues that arise
    from questions

Care Plan Adjustments
  • Software changes
  • Highlighted key approaches that meet regulation
  • Verbiage modification
  • Bring Nursing Aide Care Plan to Care Plans
  • Verify MDS info is actually located in chart

Quality Indicator Review
  • Great QIS Tool!
  • Review residents who trigger in multiple areas
    for QIS concerns.
  • Review flagged areas for QIS concerns.
  • Incorporate QIS-related concerns into your CQI
    process. Be able to address all areas of concern
    before QIS Survey.

Find the Key
  • The key to the QIS puzzle is different for each
  • It is the one thing that brings everything
    together in your building.
  • You dont need to reinvent your systems.
  • Just find the key.
  • Its already there.
  • Look for it!

All Saints Key
  • The Nursing Aide Care Plan

Nursing Aide Care Plan
  • Located 2 places CNA Book inside resident
    closet door
  • Verify both Care Plans match
  • Verify Nursing Aide Care Plan matches resident
    care plan
  • Quiz CNAs

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Survey Day Tips
  • Have info ready when they come in!
  • Admission List
  • Resident Census
  • HCFA 672
  • Survey Book (use surveyor checklist)
  • Let your staff know you trust them
  • Use your communication systems

Same Old, Same Old
  • Facility appearance odor important
  • Happy, smiling residents staff
  • Interactions activities observed
  • Dining observed (intensely!)
  • Personal items stored labeled
  • Weights Skin Sheets easy to find

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  • Improvement Process
  • Rosewood Manor

Quality of Life Activities
Psychosocial Aspect
  • Sensitivity Training for employees
  • Enhancing activities
  • - 15 minutes per C.N.A.
  • - Train CNA in activities for low cognition
  • - Quality of Life activities (tea party,
    band, aromatherapy, etc.)

Department Specific Tasks
  • Stage 1 Forms Survey Tasks (from manual) copied
    and distributed to departments Business Office,
    Nursing, Dietary, etc
  • Critical element pathways reviewed by Department

Our Focus
  • To improve residents quality of care and quality
    of life by enhancing
  • Associate and residents interactions
  • Resident and residents interactions
  • Associate and associate interactions

Central Command
  • Administrators office for high visibility
  • Wall charts progress of specific tasks,
    resident/family interview concerns, dining
    observations, etc
  • Standing flip chart - rounds results / follow-up

  • Weekday Department Managers
  • Every morning at 630
  • 3 department managers / one a nurse
  • Specific things to observe - guidelines
  • Daily report at stand up (flip chart)
  • Follow up on issues and concerns at next stand up
    (most important)
  • Evening, Night, Weekend - Supervisors

  • Thank you Thursday (wall tracking chart)
  • Department Heads offered opportunity each
    Thursday in Stand Up to write thank you notes
  • Goal to improve the associate to associate and
    manager to associate interaction / relationships
  • QIS Survey looking for teamwork and comfortable
    working relationships among staff as well as
    between residents and associates.

Dining Room SupervisionNurses
  • Schedule of nursing supervision posted
  • Guidelines updated and posted at Nurses station
    Dining Room
  • - Focus on interactions between associates and
  • - Include all areas that meals were served
    (including resident room)

Dining Room CQI
  • Use Dining Room Observation Form
  • CNA, Nurse, or Supervisor
  • Observer to meal, documenting observations
  • Involved staff in PI process
  • Better than in-services for staff education

Nurses Weekly Audit
  • Nurse Managers Unit Managers
  • Assigned to an area of 16 20 residents
  • Same assignment for survey
  • Specific audit tool developed
  • (from ideas/forms obtained from other
  • Completed audits to DON
  • Issues identified and addressed

Nurses Audit Tool
  • Revised from original to be more manageable with
    weekly tasks
  • Week 1 Med rooms, diets, chart audit
  • Week 2 Restraints/alarms, ADL log, interviews
  • Week 3 Skin, treatments, labs
  • Week 4 Med Pass, MARs, medications

Standards of Care Meetings
  • Weekly with Care Plan Team
  • Focus each week on different area Skin,
    Restraints, Psychotropic, Weight, Catheters
  • Charts brought to meeting
  • Specific audit tools for each topic
  • Documentation in department notes, appropriate
    forms completed and care plan updated during

What does this resident want???
Activities Questionnaire
  • Goals Focus on a psychosocial aspect
  • Staff learn more specifics about resident
  • Completed by Staff nurses and CNAs
  • Interviewed resident / or family
  • Each nurse/C.N.A. completed 1-2 interviews
  • Became a great resource for Care Plans

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Resident Council President Interview
  • Completed by Administrator
  • Surveyors only interview Resident Council
    President, no longer conduct group interview

Residents Interview
  • Social Service identified interviewable residents
    (using QIS form)
  • Interviewed all appropriate residents using
    Resident Interview Resident Observation form.
  • Interviewed selected family members using Family
    Interview form
  • Reviewed in Stand Up and follow up on any

  • Reasons for a
  • Deficiency Free Survey

We Knew Our Residents
  • Told us the information from every CNA they
    interviewed matched what was in chart. (CNA
    interviewing residents helped a lot)
  • Nurses able to talk about residents during nurse
    interview with minimal time searching through
    chart and MAR (also comfortable with where
    information located in chart)

Resident Information Matched
  • Part of computer analysis is comparing similar
    data from resident interview, family interview,
    chart audit (notes, MDS, care plan). The
    computer highlights areas that do not match.
  • We had no highlighted areas. All our data

Resident and Associate Morale
  • Residents and families for the most part happy
  • Residents wanted facility to do well
  • Staff would go the extra mile for residents
    sewing, fixing meals in therapy, making hats for
    tea party
  • Staff gave positive statements to surveyors about
  • Team work CNAs, nurses managers all working

  • All shifts involved in rounds and knew we were
    consistently observing what we were expecting.
    Staff complimented immediately as improvements
  • ALL Department Heads involved and on the same
  • Non-nursing Department heads learned what to
    observe. Sometimes saw things nursing too close
    to see.
  • Staff and residents saw a Department Head daily
    opportunity to address concerns immediately.

More Accurate Charts
  • Standards of Care Meeting with charts audit for
    Dr.s order, nurses notes, restorative note,
    dietary note, justification (catheter), consent
    (restraints, psychotropics), MDS, Care Plan
  • Falls/Incidents Reviewed daily with chart at
    Nurse Management Meeting. Checked for
    documentation, appropriate interventions, orders,
    and care plan updated,
  • Care Plans Something very resident specific so
    you could recognize resident without name on care
    plan. (this is where Activity Questionnaire also

Med Pass
  • Aimed for every nurse manager to observe 1 nurse
    weekly, occurred every 2-3 weeks
  • Pharmacy a big problem had to have nurses
    checking all meds and documenting missing on 24hr
    report for ADON/DON follow-up

Closed Charts Organized
  • Easy for surveyors to find what they are looking
    for without looking through entire chart.
  • Note Be sure skin sheets, weekly wound forms
    and weights are easy to find

  • We have a lot of areas for improvement at
    Rosewood and the surveyors observed many of them,
    BUT the residents were happy, involved and the
    associates had good relationships with the
    residents and each other
  • This was reflected in the data entered into the
    computer first 2 days (Stage 1), resulting in
    very few areas they needed (or were allowed) to
    dig deeper into during Stage 2
  • They did not ask for infection control, skin
    books, or any policies or procedures. None of
    these areas triggered in Stage 1
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