Please use the reading material to answer the following:

In your OWN words, what would you do to ensure that your organization is in compliance with the various regulatory standards if you were a nursing facility administrator?

Task 1: Offsite Preparation

Offsite preparation before the actual visit to the facility includes potential areas of concern at the targeted facility based on the facility's compliance history. During the actual visit, surveyors will initially focus on determining whether the previously identified concerns indeed exist.

Offsite preparation is based primarily on reports generated by the state's database. Each facility is required by law to use a patient assessment instrument called the minimum data set (MDS), and to electronically transmit the MDS information to the state in which the facility is licensed. The MDS information is used by the state to compile three main facility-specific reports that are available to the surveyors:

1. Facility Characteristics Report, which provides demographic information about the patient population in the facility. It includes information on gender, age, payment source, diagnostic characteristics, type of assessment, stability of conditions, and discharge potential.

2. Facility Quality Measure/Indicator (QM/QI) Report, which ranks the facility on quality indicators that apply to both chronic care (long-stay) and postacute care (short-stay) patients in the facility. The percentile ranking of the facility indicates how it compares with other facilities in the state.

3. Resident Level QM/QI Report, which provides resident-specific information. The report indicates whether a given resident has a particular condition, such as pressure ulcers or behavioral problems, or whether a given resident is at a high or low risk of developing a condition.

Other sources of information include (1) areas of noncompliance on the previous survey, (2) any patterns of noncompliance based on the past four surveys (OSCAR Report 3, where states are required to maintain comprehensive information about past and current surveys and complaint investigations in CMS's OSCAR database), (3) findings from complaints that were investigated and complaints that have not been investigated, and (4) any areas of concern reported by the State Ombudsman Office. Information about any other potential areas of concern, such as events reported in the news media, may also be included.

Task 2: Entrance Conference

The survey team coordinator has an on-site meeting with the administrator (or other person in charge of the facility in the administrator's absence) to provide introductions and explain the purpose of the visit. The surveyors depend on the administrator for various types of information that would help facilitate the survey. For example, surveyors will need copies of the actual work schedules for licensed and registered nursing staff; a copy of the written information that is provided to patients regarding their rights; copies of admission contracts for all patients; whether the facility has any special care units, such as dementia care units; and where the surveyors could find key personnel when needed. The administrator is given copies of the QM/QI and other reports used in the off-site preparation. Signs are posted in the facility to notify the residents, employees, and the general public that a survey is in progress and that the surveyors are available to meet with any concerned individual.

Task 3: Initial Tour

In an average-size nursing home of approximately100 beds, the tour may take about 2 hours. Members of the survey team may go around independently, with or without members of the facility's staff accompanying them. However, the suggested protocol is to have a facility staff person accompany the surveyors to answer questions and provide introductions to residents or family. The surveyors talk to residents, employees, and visitors in the facility; visit some patient rooms and key departments, such as the kitchen; and make general observations. The purpose is to make a general assessment in conjunction with the information compiled during off-site preparation. Information is gathered about concerns identified in Task 1 and any new concerns observed during the tour are added. During the tour, the main areas of focus are quality of care, quality of life, the emotional and behavioral conduct of patients and the reactions and interventions by staff, and any environmental and safety issues.

Task 4: Resident Sample Selection

Information gathered during off-site preparation and the tour is used to develop a resident sample for detailed investigation of patient care. A "case mix stratified" sampling method is used. It is designed to include patients who require heavy care as well as those who require light care and patients who have sufficient memory and comprehension to be interviewed as well as those who cannot be interviewed. To the extent possible, the sample includes patients who may be particularly vulnerable, such as those who have indwelling catheters, are tube fed, are mentally impaired, or have speech or hearing disorders. Patients who have sustained a weight loss, those at risk of dehydration, those with pressure ulcers, or those with other associated risk factors are also included in the sample.

Task 5: Information Gathering

Most of the surveyors' time in the facility is spent on the investigative phase of the survey process. Some main areas of investigation include patient care, medication errors, food preparation and dining services, residents' quality of life, facility environment and safety, procedures for protecting residents against abuse and neglect, and an evaluation of the facility's quality improvement program.

The process includes direct observations; interviews with the facility's residents, staff, and visitors; and a review of records. Close observations are made of meal preparation; dining services; medication pass; care being given; staff interactions with patients; infection control practices; and the condition of the environment such as cleanliness, sanitation, presence of any pests, safety hazards, functioning of equipment, and the proper and safe storage of drugs and biologics, and housekeeping chemicals and equipment. Record review particularly includes a review of patient assessments, plans of care, and outcomes of clinical interventions. The main purpose of record review is to obtain information necessary to validate or clarify information obtained through observation and interviews. Formal structured interviews are conducted for quality of life assessment.

Even though Task 5 is investigative in nature, the State Operations Manual recommends an open and ongoing dialogue with facility staff members. This gives the facility the opportunity to provide additional information if there are questions about compliance.

Task 6: Determination of Compliance

The surveyors determine the facility's compliance with each of the standards; a deficiency is cited when a standard is not met. The survey team must evaluate the evidence documented during the survey to determine whether a deficiency exists. Any negative patient outcomes resulting from a failure to meet a requirement must also be documented.

Deficiencies are characterized as resident centered or facility centered. Resident-centered requirements must be met for each resident, and a violation affecting any single resident is cited as a deficiency. Facility-centered violations refer to the operational systems such as staffing, food preparation, and infection control. Deficiencies are also evaluated in terms of their severity and scope. Severity is determined by the extent of actual or potential harm and negative health outcomes as a result of not meeting a standard. Scope describes the number of patients that are potentially or actually affected as a result of not meeting a standard. Severity is rated according to four levels and scope is categorized in three types.

Task 7: Exit Conference

In the exit conference, the surveyors meet face to face with facility officials to present their findings. The administrator may request a copy of the patient sample, provide additional information that may have been overlooked, or ask for further clarifications. Information provided during the exit conference enables the nursing home staff to start remedial action and address the most critical areas of deficiency.

Attachment:- Regulation and Enforcement.rar