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Can You Simulate the Survey Team’s Offsite Prep?

The survey team’s offsite preparation is integral to the new long-term care survey process (LTCSP), says Amy Stewart, RN, RAC-MT, DNS-MT, QCP-MT, curriculum development specialist for AADNS. As part of the offsite prep, the survey team coordinator reviews and documents findings from the facility’s CASPER 3 report for patterns of repeat deficiencies, the results of the last standard survey, and complaints and facility-reported incidents since the last standard survey, as well as any facility history of abuse, federal waivers or variances for onsite review, active enforcement cases that shouldn’t be investigated, and information provided by the ombudsman.

In addition, all survey team members independently review the following offsite prep information, according to the LTCSP Procedure Guide:


·         The Facility Rate Report. This report provides a facility-level picture of how many residents and which MDS indicators are potential concerns. The report looks at an array of 32 MDS-based clinical indicators, such as Alzheimer’s or dementia, constant pain, depression, hospice, major infections, pressure ulcers – facility-acquired, and wandering. It lists the total number of MDS assessments included in the report, the number of residents with each indicator, and the percent of residents with each indicator. See a sample MDS Indicator Facility Rate Report here. See a list of the 32 MDS indicators below.


· Alzheimer’s or Dementia

· Anticoagulant with Internal Bleeding

· Anticoagulant without Internal Bleeding

· Bowel & Bladder

· Catheter with UTI

· Catheter without UTI

· Constant Pain

· Decline in ADLs

· Dehydration

· Depression

· Dialysis

· Falls with Major Injury

· Feeding Tube / NO Dehydration

· Feeding Tube with Dehydration

· Four (4) or More Re-Hospitalizations

· Frequent Pain

· Hospice

· Insulin

· Major Infections

· One (1) Re-Hospitalization

· Preadmission Screening and Resident Review (PASARR)

· Pressure Ulcers Facility Acquired

· Pressure Ulcers Worsening

· Restraints

· ROM Limitation / NOT Receiving Therapy

· ROM Limitation / Receiving Therapy

· Tracheostomy

· Two (2) or Three (3) Re-Hospitalizations


· Ventilator

· Wandering

· Weight Loss


·         Offsite-selected residents list. This list drills down to the resident level, giving surveyors the list of offsite-selected residents (complete with MDS-provided room numbers) and their MDS indicators.

·         Discharged residents list. This list details discharged residents who were selected for a closed record review during the investigation phase of the LTCSP in three categories: unexpected death, hospitalization, and community discharge. “The team can use these residents for the closed record review or choose offsite-selected residents that have been discharged,” notes the LTCSP Procedure Guide.

CMS has not released information about how the MDS indicators used in the Facility Rate Report and the offsite-selected residents list are calculated—and facilities don’t have access to these documents themselves. “However, these MDS indicators appear to hone in on several conditions that help to determine the quality of care that was delivered,” points out Stewart.

“When the survey team enters your facility, they will have the list of off-site selected residents with MDS-driven triggers, who will account for approximately 70 percent of the expected initial pool,” says Stewart. “This list will eventually lead the surveyors to their sample of residents for investigations. So a big takeaway for the director of nursing services (DNS) is that your MDSs will be used to help surveyors identify areas of concern; accuracy is vital.”

Stewart recommends that DNSs pull the following CASPER reports to obtain a similar landscape of their facilities:


·         Facility characteristics report;

·         Facility-level QM report;

·         Resident-level QM report; and

·         0003D/0004D package report.


Note: For information about accessing the first three reports listed above, see Section 11, “MDS 3.0 Quality Measure Reports,” of the CASPER Reporting User’s Guide for MDS Providers. For information about the last report, see Section 6, “Nursing Home Provider Reports,” of the CASPER Guide.

“These reports offer a lot of information about the conditions associated with your residents, help pinpoint potential areas of concerns (e.g., pressure ulcers, weight loss), and provide surveyors with historical data on past survey deficiencies,” says Stewart. “These reports can assist nurse leaders in identifying residents who may be included in the final resident sample.”


Other offsite prep that could impact you

In addition, the DNS needs to realize that typically every surveyor is already assigned to where they are going and what they are doing upon facility entrance, says Stewart. “The surveyors have their unit assignments, and they usually know which of the nine mandatory facility tasks they are assigned to conduct. This means they will immediately begin to gather data required for the survey.”

Note: For additional information, review the “Offsite Prep” lesson of CMS’s online surveyor training course Long-term Care Survey Process Review. Also see the new CMS document, Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training


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