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3 Mandatory Facility Tasks assigned to all surveyors
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9 Mandatory Facility Tasks
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SMQT
Study cards for SMQT exam 2020
| Question | Answer |
|---|---|
| 3 Mandatory Facility Tasks assigned to all surveyors | Dining Infection Control Sufficient and Competent Nurse Staffing |
| 9 Mandatory Facility Tasks | Dining Infection Control Sufficient and Competent Nurse Staffing Kitchen SNF Beneficiary Protection Notification Review Med Administration Med Storage Resident Council QAA/QAPI |
| 3 Triggered Facility Tasks | Personal Funds Environment Resident Assessments |
| As a representative of CMS , what should you do to earn the respect of the Stakeholders? | Accept, and then act upon , CMS core values |
| An outcome-oriented approach to information gathering should only consider actual and not potential oucomes True or False | False outcome-oriented approach evaluates whether the facility's care and services have contributed to an actual or potential decline in resident well-being |
| Which term below refers to the resident's innate capability or level of funtioning as determined through comprehensive resident assessement Practicable Practical | Practicable |
| The LTC survey process uses person-centered interventions to focus on: | Person-centered care Resident-centered outcomes Quality of care and Quality of Life |
| Team Coordinator Completes which 6 Offsite Prep Tasks | Creates/imports shell Reviews facility information and completes offsite prep screen Assigns mandatory facility tasks Makes facility unit assignments Shares Data with team members Prints survey Documents |
| When should the survey shell be exported | As close to the survey date as possible but never more than 5 business days before |
| What information is obtained from the CASPER report? | Patterns of repeat deficiencies |
| What information should be documented when the TC contacts the Ombudsman? | Name Contact information Date contacted Any concerns identified by Ombudsman |
| When making team assignments what 2 units should not be assigned to the same surveyor? | Rehab and Memory Care |
| What 3 types of residents are chosen for closed record review? | Hospitalized Discharged to the community Death |
| Immediately after the TC informs the administrator about the survey what should the TC and Team members do? | TC-entrance conference Team member assigned to Kitchen Facility task should head to kitchen for brief tour All other team members go directly to assigned units |
| What is the timeline for the facility to complete the facility Matrix? | Immediately for residents admitted during last 30 days 4 hours for all other residents |
| What should the TC do once the new admission Matrix is completed? | Deliver a copy to each surveyor on the floor |
| Which 4 items are needed immediately upon entrance? | Census number Alpha Resident Roster Matrix for residents admitted last 30 days Residents who smoke, smoking time and locations |
| Facility Assessment; when should it be requested and when should it be reviewed | Requested at Entrance Conference Reviewed only if systemic care issues are identified |
| What information is to be provided within 1 hour of entrance: | Schedule meal times, location dining, menus, Policy food brought in by visitor Schedule med admin times, # &location of med storage rooms and med carts Nursing staff schedules List of key staff, location and phone number Paid Feeding Assistants? |
| Items needed within 4 hours of entrance | Dialysis information Antibiotic Stewardship Information QAPI plan Facility Assessment |
| When should the facility provide surveyors access to EHR? | By the end of the first day |
| Which resident are included in initial pool? | Offsite Selected Newly Admitted Complaint/FRI Vulnerable Identified Concerns |
| According to IJ Triggers in Appendix Q, would a lack of diabetic monitoring resulting or likely to result in serious hypoglycemic or hyperglycemic reaction potentially trigger an IJ investigation | Yes-failure to protect from undue adverse medication consequences or failure to provide medications as prescribed |
| Would failure to complete a resident assessment and develop a care plan be an IJ trigger? | No |
| How many residents does the system select for Unnecessary Medication Review? | 5 |
| System selected residents include: | 1) Offsite with 1 care area marked further investigate 2) Marked IJ or harm 3) Abuse |
| Sample should include which residents: | Hospice Dialysis Transmission Based Precautions Vent/Trach Smoking if marked further investigate |
| Where do you find guidance to help identify potential interviewees? | CE Pathway |
| Which questions are best to ask at the start of the interview since they allow respondents to answer as fully as they choose? | Open ended questions |
| When observing the first full meal, what should the team do if there are fewer surveyors than dining areas? | Prioritize the dining areas with the most dependent residents |
| What are 3 objectives of the SNF Beneficiary Protection Notification Review Task? | 1. Verify that facility provided appropriate notice 2. Verify that facility billed MCR within time frame after the resident requested demand bill 3. Verify that facility did not bill the resident while decision was pending |
| How many residents are selected for SNF Beneficiary Protection Notification Review Task? | 3 |
| The medication observations should include which 3 things? | 1. Minimum of 25 opportunities 2. Variety of residents, staff, units 3. Multiple routes of administration |
| Define a significant medication error | One which causes the resident discomfort or jeopardizes the resident's health and safety |
| What FTag addresses Significant Medication Errors? | F760 |
| Can you cite a significant medication error that is found on record review but not observed during medication pass? | Yes |
| What should you do when in the locked medication storage area to ensure the validity of your observations and drug security? | Have a staff member present at all timess |
| If a resident or representative chooses to deposit a resident's funds with the facility, how often must the facility provide statements? | Quarterly and when requested by resident or legal representative |
| When should the comprehensive assessment be complete? | 14 days after admission and annually |
| The Life Safety survey should never precede the health survey? True or False | True |
| How many days must an extended survey be copleted after the standard survey? | 14 |
| When a complaint is received what type of survey is completed? | Abbreviated |
| Who is responsible for posting the sign announcing the survey? | Either the survey team or the facility at the request of the survey team |
| Interviews and observations during the survey will direct your ______________________ | Record Review |
| The objective of the kitchen task is to determine: | if the facility is acting accordingly to prevent food borne illnesses |
| If a resident who is receiving hospice care is not recieving the necessary care and services by the hospice agency the team should: | Contact the state agency to decide if a survey of the hospice agency is necessary |
| When does the surveyor document on the CMS 677 (Med Pass Form) the purspose of the physician's actual order? | Only if the order differs from the observation of the administration of the medication |
| The QAA/QAPI committee must have a minimum of : | DON, physician and 3 staff members |
| How is medication error calculated? | # errors/#opportunities x 100 |
| How is weight loss calculated? | Pounds lost/starting wt= ___x100 |
| Identify one category of medication that should be avoided with DX of Glaucoma | Decongestants |
| What 3 guidelines determine if a medication error is significant? | 1. Type of medication 2. Condition of the resident 3. Frequency of the error |
| When do quantitative behaviors have to be documented for the use of anti-psychotic drugs? | Alzheimer's/Dementia DX |
| List two hypnotic drugs? | Halcion, Restoril and Dalmane |
| Which class of drugs can cause high fever/muscular rigidity aka neuroleptic malignant syndrome | Anti-psychotics |
| List two anti-anxiety drugs? | Serax, Ativan, Xanax |
| Identify two significant side effects of anti-psychotic drug therapy? | Parkinsonism Tardive Dyskinesia |
| List one anti-convulsion drug? | Dilantin, Tegretol, Phenobarbitol |
| List 2 classes of drugs that cannot be crushed | Time Released medications Enteric Coated |
| List 2 anti-hypertensive drugs | Procardia Vasotec |
| How often are facilities required to conduct drug regimen review? | Monthly |
| What is the movement disorder characterized by puckering the mouth and tongue? | Tardive Dyskinesia |
| What are Macronase, Orinase, Diabinese? | Oral Hypoclycemics |
| What is the time frame for the provider requesting an IDR? | 10 Calendar Days |
| How does the provider requesting an IDR affect the providers requirements to provide POC and implement corrective Action | The IDR process does not impact need to provide POC, implement corrective actions or delay any enforcement actions |
| In the appeal process what is the primary evidentiary document? | 2567 |
| In a formal appeal, who has the responsibility of showing why the provider should or should not be subject to the enforcement remedy? A) CMS has the responsibility to show why they should B) Provider has the responsibility to show why they should not | A) CMS has the responsibility to show why the provider should be subject to the enforcement remedy |
| If a resident is receiving anti-psychotic medications and the medications are not adequately monitored is this an unnecessary medication? | Yes |
| The facility is required to: 1. Make appointments for vision services 2. Purchase eyeglasses when needed by resident 3. Arrange for transportation for hearing services 4. Conduct comprehensive audiological evaluations | 1 & 3 |
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