Quality Indicator Survey ASPEN 10.2 (QIS Version 4.04) Have the QIS Tool opened and on Review Materials screen. (SHOW THE SLIDE) This is Glenna from CU and I will be doing the training. The goal of today’s presentation is to cover the changes to ASPEN 10.2, QIS Version 4.04. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS 4.04 Checklist (SHOW THE SLIDE) There is an updated QIS Checklist. For this presentation, I will first show the changes made to the tool using a training survey. At the end of the presentation I will discuss the changes to the Checklist. During this training, I will tell you which slide of the PPT handout we are on so you can take notes if you’d like. However, we would really like for you to watch the screen as I demonstrate the changes. At the end of the presentation, we’ll answer any questions you may have. We will take a quick break mid-way through the presentation so you’ll have time to jot down your questions during that quick break. Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 3. (Switch to QIS Tool) The first change is to the Review Material screen. As you can see the complaint section has been revised. You now only indicate whether a complaint will be investigated with the survey. You will include the complaint specific information during Reconciliation which we’ll talk about later. Quality Indicator Survey Quality Indicator Survey (QIS)

Entrance Conference Form Changes Now turn to Slide 4. The next change we want to talk about is to the Entrance Conference forms. (Go to Entrance Documents – open the Facility Copy). Both the facility and team copy of the Entrance Conference forms include a new probe to inquire about resident smoking. (Show #12) We’ll talk more about this addition when we cover the Stage 1 question changes. The facility copy was also revised to include the new language referring to Individuals with Intellectual Disability. (show page 3 – then close – open the team copy) The team copy also includes new probes regarding EHRs and the location of weight information. (show two probes above #6) The TC should get the information about smoking, EHRs and the location of weights prior to the initial team meeting. Close Offsite Prep – Expand Onsite Prep – Go to Initial Team Meeting Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 5. The next change we made was to Surveyor Notes. (open Surveyor Notes) You can now have surveyor notes opened while working on a different screen. If you document on another screen while Surveyor Notes are opened, the note will automatically be minimized. As you can see I’m on a team meeting screen with Surveyor Notes opened. I’m going to write on the screen, when I do you’ll notice the Surveyor Notes are automatically minimized. (type on screen) To get Surveyor Notes back you just have to click on it at the bottom. (pull Surveyor Notes back up) Let me show you that one more time in case you missed it. I’m going to type on the team meeting screen. (do this) Once I do, the Surveyor Notes is minimized but still opened. To pull the Surveyor Notes back up I just need to click on it at the bottom. (do this) Close Surveyor Notes by hitting OK Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 6. Let’s move to the Reconciliation screen. (Click on reconciliation). As you can see, the residency status is populated for everyone in the Resident Pool. The residency status is based on the most recent MDS submitted for each resident so it will be important for you to export the shell as close to the survey start date as possible to ensure the residency status is as accurate as it can be. Now you only have to verify the status of the Stage 1 Sample residents. This should be a huge time saver. You’ll also notice the instructions are opened. Hopefully, this encourages surveyors to follow the instructions, which were updated, since they are noticeably visible now. (expand the instructions slightly to show one more step) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 7. As I mentioned earlier, the other change that was made to the Reconciliation screen is the inclusion of complaint information. You can now include any complaint resident, who is in the facility, in your Census Sample. In addition, complaint residents will now be included in the Stage 2 sampling process which we’ll discuss later. If a complaint allegation is related to a facility task, even if a resident is named, you’ll investigate that with the task and the resident won’t be included in the Census Sample. Let me walk through and explain in detail how this works. As you can see, a new complaint column was added to the screen (point to it) and to the Census and Admission radio button (point to it). There is also a new Complaint Residents button. (point to it) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 8. The first two steps in the instructions have not changed. You’ll still update the New Admission Information form and then update the census number. Step 3 in the instructions now addresses complaints. (scroll down to Step 3 – expand to show 3bii) Step 3a says – if you are investigating a resident-specific complaint, click on the Complaint Residents button. Let’s do that now. (click on Complaint Residents) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 9 Step 3b in the instructions (move the screen to show Step 3b) says to determine whether the complaint residents are listed on the right side in the Resident Pool. You will add all complaint residents to this screen – even if they are discharged. For this exercise, let’s say we have three complaint residents: A. Opal, B. Isabelle, and Jane Doe. As you can see, A. Opal and B. Isabelle are listed in the Resident Pool; however, D. Jane is not so we know she’s a new admission and should be listed on the New Admission Information form. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 10. Step 3bi says if the resident is not listed on the right side – like D. Jane, click on the Add Resident button and enter the resident’s information. Let’s do that now. (click on Add Residents) We’ll enter Jane Doe’s information. Her admission date is 6/1/15. We’ll enter her last name as an initial so it matches our other de-identified training names (enter D for the last name) We’ll put her full first name (enter Jane) Her birthday is 1/1/1940 and she’s in room A-1. Once you’ve added all pertinent information, click on Save. (do this) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 11. After you add a new resident on the Complaint Residents screen, the resident will be listed under the Resident Pool. D. Jane is now listed in the Resident Pool. (point to D, Jane) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 12. Step 3bii says (move the screen to show 3bii) if the resident is listed on the right side, initiate all complaint care areas or F-tags for each complaint resident. For training purposes, the complaint allegations for A. Opal included Unnecessary Meds regarding an anti-hypertensive med and Accidents related to falls and unsafe smoking, and Participation in Care Plan. The allegations for B. Isabelle included Dignity and a concern that she could not choose her own physician. We know F163 isn’t mapped to a care area in QIS so we’ll have to initiate the F-tag directly for her. D. Jane’s complaint allegations included Accidents related to falls. Just as in the current initiate screen, you can initiate multiple areas at the same time. Let’s initiate Accidents for both A. Opal and D. Jane. (do this). Then we’ll initiate Participation in Care Plan and Unnecessary Meds for A. Opal. (do this). Finally, we’ll initiate Dignity and then F163 for B. Isabelle. (do this) Notice you can initiate the resident from under the complaint list or the pool. As you can see, the complaint residents and their associated areas are now listed under Complaint Residents on the right side. (point to this) Before we leave this screen let me show you one thing. (move the screen to show the status and Census column) As you can see A. Opal and B. Isabelle have a residency status of In Facility from their most recent MDS and neither are included in the Census Sample. (point to them) Any resident who is added to the Resident Pool – like D. Jane – will have a residency status of In Facility once you exit this screen. You won’t have to check this on a survey, I just wanted to show you their original status and that they weren’t included in the Census Sample for training purposes. Now that we’ve initiated all complaint residents and their associated allegations, we can exit the screen. (click OK) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 13. Steps 3biii and 3biv just say that the complaints will be listed under Complaint Residents and you can exit the screen once all complaint residents are added. (show these instructions) Step 4 in the instructions is new. Step 4 says to click on the Census, Admission and Complaint radio button to verify the status of your sample and complaint residents. (click on the radio button) As you can see, A. Opal, B. Isabelle, and D. Jane have a checkmark in the complaint column and in the Census Sample column. If you add a complaint resident who is in the facility, another randomly sampled resident will be removed so your sample size stays the same. This enhancement addresses the concern expressed by States about investigating complaints during a QIS. Now the complaint resident will be integrated into your workload. Let’s say we verified the status of everyone listed on the Census, Admission and Complaint radio button. We determined that B. Isabelle and C. Danny were actually discharged so I’ll update their status. (do this) As I do this, notice that our sample number is reduced by 2 and B. Isabelle who is a complaint resident was removed from the Census Sample. If a complaint resident is discharged, they won’t be in the Stage 1 sample, but they will be included in the Stage 2 sampling process which we’ll discuss later so it’s crucial you add all complaint residents, discharged or in facility, to this screen. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 14. You’ll finish reconciliation as you currently do. We’ll run through this quickly just so we can get a completion check. For training purposes we will click on the residency status to display all of our in-facility residents to expedite assigning room #s. (click on Replace Census Discharges – enter 0 – click save – add room number – exit screen – then double click on status column and enter room number for In) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 15. You’ll complete Stage 1 assignments as you currently do. The in facility complaint residents will be included on this screen since they are a part of the Census Sample. We’ll manually assign A. Opal and D. Jane to Sayuri and then auto assign the rest. (do this) Once Stage 1 assignments have been made, if a complaint comes in, the complaint resident won’t be included in the Census Sample since we don’t want to risk removing a resident that you may have partially completed. However, you should still add the complaint to the reconciliation screen since they will be included in the Stage 2 sample. Now that we’ve made all Stage 1 assignments, let’s go to the new Complaint Assignments screen. The purpose of this screen is to assign the complaint residents to you if you want access to their Stage 2 care areas or tags. This screen works just like the Stage 2 Assignment screen – so the complaint resident will be listed under the surveyor who was assigned the resident in Stage 1. As you can see, Opal and Jane are listed under Sayuri since we assigned them to her on the Stage 1 assignment screen. Any discharged complaint resident will be listed under the No Stage 1 Surveyor – so Isabel is listed there since we changed her residency status to discharged. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 16. One change that was made to both the Complaint and Stage 2 Assignment screens is how the auto-assign button works. Now, if you push auto-assign anything listed under No Stage 1 Surveyor is excluded. Let’s push auto-assign. (do this) As you can see, Sayuri was assigned Opal and Jane since they were assigned to her in Stage 1, while Isabel is still listed on the unassigned pane. There’s no completion requirement for this screen, so you don’t have to assign the complaint residents if you don’t need access to their Stage 2 areas during Stage 1. Assignments can be made on this screen, or later with Stage 2 assignments. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 17. If you assign the complaint residents on the new Complaint Assignments screen, you can begin your investigative documentation during Stage 1, if necessary. Let’s enter a note for Accidents for Opal (expand, Stage 2, click on Opal – enter a note) We’ll come back to this once we get to the Stage 2 assignment screen. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 18. (close Onsite Prep – expand Stage 1 - Census) Now let’s talk about the changes that were made to the Stage 1 questions. We’ll first cover the changes to the Resident Interview. These same changes were made to the Family interview as well. Let’s go to section F, Care Planning. We revised this question since the previous wording was confusing. (click on Opal – expand Resident Interview – answer A as interviewable – go to section F) Read the question on the screen and the additional guidance. As you can see, the question now includes being invited to care planning meetings and being included in day to day decisions that impact the resident’s treatment and care. When we reviewed the data, we found that surveyors’ continued to ask about care plan meetings even though that wasn’t the intent of the current question. About 55% of the tags were cited for not inviting residents to care plan meetings and 27% were cited for a failure to include the resident in day-to-day decisions. This finding and a review of the regulation underscored the need to address residents’ opportunities to be involved in decisions about their treatments both outside of and during care planning meetings. During our testing of the new questions we came across one scenario we wanted to address. If a resident responds that his/her care decisions are up to the physician or other staff, the surveyor should follow up to ask whether the resident has any concerns about their care that are not being addressed. If the resident indicates there are no concerns, then the question should be answered Yes. As you may have noticed, the Relevant Findings are now on the screen. This will enable you to enter a relevant finding before answering the question which will be especially helpful for observations, and make it easier to enter a relevant finding since you don’t have to click on a button. The initial date and time functionality works the same as before. We’ll enter a relevant finding and answer the question as Yes to illustrate a point later. (enter a RF – then answer the question as Yes) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 19. Now we’ll go to section K which used to be Food Quality. (go to K1 - click on the question) Food Quality was removed from the resident interview since it was already covered in Dining. This change is in accord with other efforts to reduce duplication, such as with the previous removal of resident interview questions on food preferences because the issue was already addressed in Dining. We looked at all QIS surveys in 2013 and found that about 95% of the surveys with a F364 citation from Food Quality, was also cited from Dining. So there was significant overlap between the two areas. We have replaced Food Quality with a new question regarding ADLs. Read the question on the screen and the additional guidance. Dressing and oral care are mapped to ADLs and toileting is mapped to the Urinary Incontinence care area. We’ll mark this question as a positive. (mark None of the above) Quality Indicator Survey Quality Indicator Survey (QIS)

Resident Interview - Dental N1 Do you have any problems with your teeth, gums, or dentures? N2 Are staff taking care of these problems to your satisfaction Now turn to Slide 20. Now we’ll discuss the changes to the Dental questions. (go to N1 - click on the question) There is now one question that asks about their dental status. Read the question on the screen and the additional guidance. If the resident says they have dental issues, (mark Yes) then you’ll ask the next question. (go to N2) Read the question on the screen. CMS is aware that surveyors were having to investigate dental concerns that were known non-issues because the resident said their concern was taken care of. This new question will eliminate those unnecessary investigations. Let’s say the resident says staff are taking care of their dental issues. (mark Yes) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 21. (close RI) We are now going to discuss the changes in the Resident Observation section. (expand RO) Let’s first look at Dental. (Go to Q1) As you can see the Dental question was teased out from Section A. This is because there is now a link between the dental observation and interview. If a resident says the facility is addressing their dental concerns, the observation section is skipped. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 22. (go to a different resident – RO – Q1) The other change that was made to the dental observation question was to the response. We added missing teeth to the response options which is response option C. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 23. (stay on the same resident – not Opal) Now let’s talk about a new question that was added to the Incontinence section. (click on B2) Read the question on the screen and the additional guidance. During Stage 1, you are going to observe for incontinence care for high risk residents only. Who are we talking about when we say high risk. It’s the residents who are cognitively impaired and noticeably dependent on staff. There is a skip pattern in place – so if you mark the resident as interviewable, refused or unavailable, this question is skipped. To identify a concern with this question, you should do rounds for these residents, along with the rounds you should be doing to see if they are repositioned. You do not have to observe them continuously in Stage 1 to identify a potential concern. For example, you should have a red flag when you walk onto a unit and you see a resident who is cognitively impaired and sitting in a Geri-chair and is left in the common area for hours on end. If every time you walk by, the resident is in the same place and it’s been 3 or 4 hours…you should ask the aide to observe incontinence care. If the resident is soiled, you would mark this question as Yes which is a concern. The reason you are being asked to observe incontinence care during Stage 1, only if you identify a potential concern, is that we want quality issues being triggered into Stage 2. Since you aren’t doing continuous observations during Stage 1, we don’t want you triggering a lot of residents who may not have been provided incontinence care but weren’t wet. However, I want to stress the importance of documenting a relevant finding for negative responses because that is the basis of a potential deficiency. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 24. (go back to Opal) Now let’s go to Positioning. (click on K1) The only change made to this question was the addition of a response option of Other which is response option L. (show) Quality Indicator Survey Quality Indicator Survey (QIS)

Resident Observation – Side Rails L1 – Are there side rails? L2 – Do the side rails fit the bed properly so the resident can't get caught between the side rails and the mattress? Turn to Slide 25. Now let’s talk about Accident Hazards. (click on L1) We revised this question since it was easy for surveyors to answer it incorrectly because of how it was worded. Read the question on the screen and the additional guidance. If you say the resident has side rails, then you’ll have to answer the next question. (click on L2) Read the question for L2 on the screen and the additional guidance. Quality Indicator Survey Quality Indicator Survey (QIS)

Resident Observation - Smoking P1 – Is the resident observed smoking during the two days of Stage 1 (surveyor must observe smoking area at designated smoking times? P2 – Is the resident smoking safely? Now turn to Slide 26. The final change made to the Resident Observation is to section P. (click on P1) We added a smoking observation during Stage 1 for your sample residents. The reason we asked for a list of smokers and smoking times during the Entrance, is because you will need to know that before you start Stage 1. If one of your sample residents is on the list, make sure to observe smoking during the designated smoking time. If you happen to observe your resident smoking outside of a designated time, you’ll still want to ensure the resident is safely smoking. Read the question on the screen. Let’s say your resident was observed smoking. (answer Yes) Now we’ll go to the next question. (down arrow to P2) Read the question on the screen and the additional guidance. For our training, we’ll say the resident was not safely smoking. Remember we initiated this resident for a complaint regarding unsafe smoking. (mark No and enter a RF) Quality Indicator Survey Quality Indicator Survey (QIS)

Staff Interview - Falls E1 – How many falls has the resident had in the last 30 days? E2 – Did any fall result in an injury? Now turn to Slide 27. (Close RO – expand SI) Now we’ll move to the changes made to the Staff Interview. As you can see the Nutrition section is gone. It has been moved to the Census Record Review since we found that surveyors were conducting numerous investigations for inaccurate information provided by the staff. Staff often times said the resident was not getting a supplement. Then when the surveyor got into Stage 2, they documented that the resident was receiving a supplement. Because there was a high incidence of inaccurate information from the staff, we moved this question to the record review – which we’ll look at in a second. The only other change made to the Staff Interview was to the Falls section. The trigger rate was 70% and citation rate was only 22%. We revised the fall questions to hopefully identify a better candidate for an in-depth investigation. (click on E1) Read the question on the screen. You’ll still only include falls that occurred in the facility. If the resident had a fall, you’ll answer the next question. (go to E2) Read the question on the screen and the additional guidance. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 28. (close SI – expand CR) Now let’s talk about the changes to the Census Record Review section. (click on C1) For Unnecessary Meds, we added to the additional guidance a notation about mood stabilizers being the exception. Read the exception. For this training, remember we initiated Unnecessary Meds for this resident for a complaint regarding an antihypertensive med. When we completed her Stage 1 med review we identified that the resident was also receiving Coumadin. (mark anticoagulant) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 29. (click on D2) Now let’s look at the supplement question which was removed from the staff interview. The question has not changed and you’ll still have to verify the supplement is monitored in order to answer the question. As you can see, the responses have been broken out. If there isn’t an order for a supplement, you’ll mark No, not ordered. If there is an order but you find the resident is consistently refusing the supplement or there are holes in the documentation, you’ll mark the second No option. If the resident is getting the supplement as ordered, mark Yes. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 30. (close SI – expand FI) There were two changes made that were specific to the Family Interview. As you can see all of the questions that used to be under section O are gone. The questions about being told how to apply for Medicare or Medicaid, third party guarantee and being informed about resident rights were deleted and will no longer trigger the AT&D task. Based on our analysis, we found that these questions were rarely triggered (less than 7%) and were rarely cited. Now the only two areas that will trigger AT&D are room change and bed hold. We are going to mark room change as an issue so we can look at the revised pathway later. (go to RI – P1 = Yes and P2 = No, add a RF – go back to RO, question O1). Instead of the AT&D questions, there is now a new pain question. (go to O1 for a different resident) Read the question from the screen and the additional guidance. That’s all the changes to the Stage 1 questions. Now we’ll talk about one more change to Stage 1. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 31. (go to a different resident) When you change the family or resident interview status from interviewable to non-interviewable you will now get a warning saying interview responses will be deleted. Hopefully, this prevents you from losing information in case you are on the wrong resident. (RI – Interviewable, answer one Choices question, change the status to Non-interviewable – show the warning – say No) Before we move on, we need to answer a few questions to demonstrate something later in the training. We’ll answer the Dignity, Resident Observation, question N1 as an issue for four residents. (do this for the last 4 residents in the list – mark Option D for one resident) While Alicia does that, I want to mention the items that were added to the Fact or Fiction document. As I read the statement, think about whether you think the answer is Fact or Fiction. Here’s the first statement - In a large facility with numerous med storage rooms and carts, you have to check every single room and cart. That is Fiction. In a large facility with numerous carts and rooms, it is not necessary to check all medication carts and storage. Randomly check a few and only expand if concerns are identified to determine scope. Here’s the second statement - During Stage 1, the staff tells you the resident has not fallen in the last 30 days. As you complete your record review, you happen to notice a fall that occurred 3 weeks ago. You should clarify the discrepancy with the nurse and then change your answer? That is Fact. During Stage 1 if you happen to discover that the staff provided incorrect information, you should clarify the discrepancy with the staff and then change your response. It’s important for the team to have accurate stage 1 information to identify potential areas of concern. The last item added to the document says - During Stage 1, the resident has a bandage on his/her arm. The surveyor should ask the resident or family, if applicable, what type of wound is under the bandage. This is Fact. If you are unsure what type of wound is under the bandage, ask an interviewable resident or family during the family interview. If the resident is non-interviewable and a family interview is not performed, ask staff or refer to the medical record so you know how to respond to the Resident Observation, Skin Conditions question. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 32. (Close Stage 1 – Expand Mandatory Tasks – click on Dining) Now let’s move on to Dining. As I mentioned, Food Quality was removed from Stage 1 since it was duplicative. Since the questions were removed from Stage 1, the Food Quality care area was also removed. In addition, the only change made to the Dining screen is the removal of the resident sample box for CE6. If you identify specific resident concerns for CE6, you’ll include the resident just like you would for any other facility task CE. Since you aren’t asking residents about food quality during Stage 1, it will be critical to ask a reasonable number of residents about the food quality and temperature during Dining. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Threshold Changes QP208 Activities Small: from 40% to 30% QP212 Dignity Not Small: from 5.8% to 6.6% QP204 Privacy Small from 34.9% to 24% QP250 Exercise of Rights Not Small from 1% to 6.8% Now turn to Slide 33. (show this slide) Let’s move on to discuss the changes made to the QCLI Results screen. Discuss slide Just a note to remind you--The QCLI thresholds are reviewed periodically by CMS to ensure there is sufficient sensitivity to trigger the applicable Care Areas when there are concerns that warrant further investigation. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 34. (Close Mandatory Tasks – expand Transition – calculate QCLIs) The QCLI Results screen now allows you to update Stage 1 responses during the team review. You can also customize how you would like your right display to look. There are two options – either the QCLI Detail view (show) which is the current read only view or the Edit Response view. (show) You can also customize how you’d like to see the Edit Response view. Your two options are either Collapsed (show) or Expanded (show) We recommend you use the Expanded view so you can see everything without having to open the response or relevant findings. If you use the QCLI Display as your default, you will need to use the Change View button in order to make data entry changes. So, we’ll select the QCLI Display, Expanded to show you how you would make data entry errors. (do this) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 35. The Change View button will display the other option. So in this case, when we push the Change View, we’ll see the Edit Response option. (do this – hit Close) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 36. Now, we’ll change our right display to the Edit Response option, expanded. (do this) With this option, the TC can see and edit all of the responses and relevant findings and change a response, if needed, without pushing the Change View option. The only exception is to MDS QCLIs – they are in a read only view regardless of the display option that is selected. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 37. You can change any response – from a negative to a positive or the reverse. For example, let’s say we answered the smoking question incorrectly for Opal. We didn’t see her smoking during Stage 1. (expand Accidents – Criteria Met – Opal) Let’s change the response for P1 to No (do this) Once you’ve finished discussing all care areas, you’ll recalculate QCLIs if a data entry change was made, just as you do now. Since we changed smoking, let’s recalculate. (do this – go to smoking, Opal) As you can see, smoking is now under the Did Not Exceed category and P2 was skipped. Once you customize your right display, all future surveys will display the same customized screen unless you elect to change it, thus you can change it whenever you want. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 38. Now I want to discuss the new Staff Interview fall QCLIs. There are now four fall QCLIs. The first QCLI is one fall, no injury. The second QCLI is one fall, with injury. The third QCLI is multiple falls, without injury. The last QCLI is multiple falls, with injury. The reason we created a QCLI for each area was to try and sample better candidates for falls by creating different thresholds for these QCLIs. Since multiple falls with injury indicate the greatest concern, we assigned a 0% threshold to ensure all of these residents are investigated. We assigned the highest threshold to a single fall without injury. Since these are new QCLIs and thresholds, it will be important for the team to discuss the residents who triggered for falls and use your critical thinking to decide which residents have the greatest concern. We also added a new QCLI from the MDS for elopement. The new MDS-based QCLI will identify residents whose wandering places them at significant risk of getting to a potentially dangerous place. (show all Accident QCLIs) As you can see there are many different areas that are mapped to Accidents such as falls, smoking and elopement. It will be critical for the team to discuss the sampled residents for this care area since the system will only select three residents. You want to ensure all significant concerns are addressed. Before we move on, I just wanted to highlight some of the other QCLI changes that were made: We remapped a couple QCLIs. We remapped improper foot coverings from ADLs to Accidents (show QCLI) and we remapped a lack of repositioning from Positioning to Pressure Ulcers. (show QCLI) We deleted the QCLI that used to trigger Rehab. Now there are no Stage 1 or MDS QCLIs that trigger the Rehab pathway. The care area is still available so if you identify an issue you can still initiate the care area. During our analysis, we found that the majority of the Rehab related cites came from initiations and not from the care area being triggered. Finally, we removed the Community Discharge care area entirely. If you identify concerns, look at social services, 283, 284 or other Federal regulatory areas. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 39. (go to transition meeting) Now we’ll take a look at the Transition Meeting screen. We changed the last probe from data entry errors to a reminder about the status and plan for mandatory facility tasks. Let’s take a 5 minute stretch break. This is your chance to jot down any questions you may have up to this point. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 40. (go to Stage 2 Sample) Now we’ll take a look at the new Stage 2 Sample screen. This screen will be familiar to you since it’s similar to the Revisit Sample screen. The purpose of this screen, is to allow the TC to adjust the Stage 2 sample. Before, if a resident with a serious concern wasn’t sampled, you had to add that resident to the sample of 3. Now you can remove one of the sampled residents and replace them with a resident with an egregious concern. This enhancement will save time and will hopefully lead to better outcomes. We’ll walk through an example of this after we talk about how complaints are handled on this screen. All triggered care areas and complaints that were initiated on the Reconciliation screen will be displayed on this screen. Let’s first look at Accidents. As you can see our two complaint residents are listed. You can tell they are complaint residents since there is a Y under the complaint column. Any complaint resident that is added to the Reconciliation screen, will automatically be included in the Stage 2 sample. That is why it’s so important to add all complaints to the Reconciliation screen. You’ll only see a staff ID in the staff column if a complaint was assigned on the Complaint Assignments screen – otherwise, that column will be blank. Let’s look at Dignity. Isabel was our complaint resident who was discharged. As you can see, she was still included in the Stage 2 sample, as one of the 3 sampled, since you have to complete an in-depth investigation for her complaint. Now look at Care Planning. As you can see only the complaint resident is listed. Care Planning was not triggered. (go back to QCLI Results and show) If a complaint related Care Area isn’t triggered, you now only have to complete an in-depth investigation for the complaint resident. This is a change because in the past you had to have a sample of 3 for any complaint. Now, if a care area doesn’t trigger, you do not have to add 2 additional residents, even if there are additional residents in the Criteria Met category, since you completed a preliminary review of the area for your entire sample. Again, this enhancement should save you time. In addition, the complaint resident will be included in the Stage 2 sample regardless of whether they were in the Criteria Met. We marked the care planning question for Opal as a positive, but since she was a complaint resident for this care area, she’ll still be included in the Stage 2 sample. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 41. Let’s look at the last section on the screen which is our complaint tag. Even complaint tags will be displayed on this screen. As you can see, Isabel was a complaint for F163. The tags you initiate for a complaint should not be mapped to any care area in QIS which means you aren’t completing a review of the area during Stage 1 across the entire Census Sample. Because of that, you will have to initiate additional residents for a tag so you have a sample of 3. Let me just summarize how the complaint sampling works to make sure we’re all on the same page. If a care area triggers, the complaint resident will be included in the sample of 3. If a care area doesn’t trigger, you just have to investigate the complaint since you’ve already completed a review of that care area for the entire Census Sample. If the complaint is related to a tag, you have to have a sample of 3 since the area isn’t reviewed during Stage 1. A complaint sampling table along with the Q&A’s from all of the 10.2 training sessions will be posted to CU’s website once all 10.2 related sessions are completed. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 42. Now let’s talk return to the topic of adjusting your Stage 2 sample. This is a huge enhancement because the TC, along with team input, can now alter the Stage 2 sample to include residents who have the most serious concerns without adding to your workload. This enhancement will save time and will hopefully lead to better outcomes. Let me show you how to adjust your Stage 2 sample. Let’s use Dignity as our example. You cannot remove a complaint since you have to complete and in-depth investigation. (demo) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 43. However, for Dignity we had four additional residents in the Criteria Met. Let’s say one of the residents sampled for Dignity was observed in a hospital gown but you knew that was by the resident’s choice. While a resident who wasn’t sampled had a serious issue. During Stage 1 you observed staff providing care to the resident who wasn’t sampled and who had Alzheimer’s. During the care observation, staff didn’t explain what they were doing with the resident and the resident became extremely agitated. We would remove the resident with the non-issue (put a check in the Remove column next to one resident) and then add the resident who had the serious issue by selecting the Replace/Add Resident button. (do this) Using your critical thinking will be important to make these decisions and having strong Stage 1 observations and documentation will help. As you can see, the residents in the Criteria Met category who weren’t sampled are listed. If you wanted to add someone from the Resident Pool that’s an option as well. (point to it) Let’s add our egregious resident. (pick a resident and say OK) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 44. Whenever you initiate an area, you will now be required to document the reason. If a complaint was called in during Stage 2, any surveyor could initiate the complaint. If that’s the situation, you’d use Complaint resident as your reason. Now that you are only verifying the status for your Stage 1 sample residents, there may be a possibility that a discharged resident is sampled for an MDS item. If that’s the case and you know there are residents in the Criteria Met who are in the facility, you would replace the discharged residents using the second option. If you need to add residents to a Care Area to rule out SQC, you’d use the 3rd option. You’d use the Newly identified concern option if you identify a new issue in Stage 2. During Stage 2, if you come across a related area that needs to be investigated you’d use this option. For example, if you’re investigating pressure ulcers and come across a significant weight loss, you’d initiate Nutrition and mark this reason. If you are initiating a tag that isn’t mapped to a care area, you’ll use the No Care Area available option. If during the Stage 2 sample adjustments, you want to replace a sampled resident with a resident who had an egregious concern who wasn’t sampled you’d use this option. For our example, we’ll pick the second to last option. (do this – exit the screen) We still have a sample of 3 for Dignity and we’ve replaced our resident with the non-issue with the resident who had an egregious concern. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 45. The only areas excluded from this screen are facility tasks and Unnecessary Meds since you cannot alter those samples. You will now initiate all additional areas like dialysis and hospice as you’ve done before but you will initiate them on the Stage 2 Sample screen. Let’s initiate Hospice. (do this) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 46. Now we are moving on to the Stage 2 Assignments screen. (go to Stage 2 assignment) The only complaint related area we haven’t followed through with is Unnecessary Meds. There’s two possible sampling situations that can occur: The first sampling scenario is that you initiate a complaint resident for Unnecessary Meds and the resident’s Stage 1 meds gives the resident a high enough score to be included in the sample of 5. If this is the case, the complaint resident will not show up on the QCLI results screen due to a software design limitation. That resident will however show up on the Stage 2 assignment screen for investigation; however, the Append Text feature won’t work for the complaint resident so you’ll have to copy their medication information. This is strictly an issue with Unnecessary Meds. The second sampling scenario is that the same complaint resident’s Stage 1 meds does not give the resident a high enough score to be included in the sample of 5. If that is the case, the complaint resident will be added as the 6th resident. The other complaint sampling exception is for MDS-only care areas like Behaviors. In that case, if you initiate a complaint the resident will be in addition to the sample of 3. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 47. Back on the Complaint Assignments screen, we assigned the complaint areas for Opal and Jane to Sayuri. If you assign the complaint areas on the Complaint Assignments screen, they will already be assigned to that surveyor on the Stage 2 assignment screen. If you remember, we didn’t assign the complaint areas to anyone for Isabel. As you can see Isabel is still on the unassigned pane. Let’s now talk about reassigning complaints. If you assigned complaint residents to a surveyor on the Complaint Assignments screen and want to make reassignments at this point, do not reassign them using the Stage 2 assignment screen. You should follow the current procedures for handling reassignments in Stage 2 which is to have one surveyor initiate the area and the other surveyor leave it alone. If you tried to reassign the areas via this screen, the areas will be removed from the originally assigned surveyor’s computer along with their documentation. Let’s show you what happens. (demo – show Opal in Stage 2 again with doc in Accidents – go back to assignment screen – reassign to Glenna – show Stage 2 again and Opal is gone) So, let me emphasize this point again. Just like with mandatory task reassignments that may need to occur at this point, don’t reassign complaints, just simply initiate. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 48. There’s one last change I want to talk about that was made to the assignment screens. In the past, if the TC accidently initiated the same resident and care area twice and then tried to assign the area to the same surveyor, they’d get an unhandled exception message. You cannot assign the same resident and care area to the same surveyor in QIS. If this happens to you, instead of an unhandled exception message, you’ll get a warning message telling you to follow the addendum instructions to fix the problem. (Options/Initiate – Accidents for Opal – Unassign SK - Assign to GM) Now we are ready to talk about the changes made in Stage 2. (assign AT&D to SK) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 49. (close Transition – expand Stage 2 – click on AT&D) We have added the Append Text feature to all non-mandatory facility tasks. Once you push the button, the QCLI info will be populated in the applicable CE. (push Append Text) As you can see, the QCLI info was populated in CE1 since CE1 is the critical element related to room change concerns. In addition, you can see that we’ve updated the AT&D task since we deleted a few of the Stage 1 triggers. CE1 is now room change. CE2 deals with bed hold. CE3 through CE9 are related to the Stage 1 questions that were deleted like third party guarantee. Now you’ll only investigate CE3 through CE9 if you identify an issue from complaints or the ombudsman or you’re made aware of an issue during the survey. So for our training example, we’d investigate and answer CE1 as Yes or No. If we didn’t have any other issues brought to our attention, we’d mark CE3 through CE9 as N/A. (do this) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Updated Pathways Revised pathways ADL, Death, Hospitalization, Positioning, ROM, Rehab & Restorative, Urinary Incontinence New pathways Accidents and Nutrition Partially separated combined pathway UTI and Catheters Now turn to slide 50. Show this slide We have converted a number of pathways into the new format so they are similar to Pressure Ulcers and Unnecessary Meds. The care areas that are now condensed includes: ADL Death Hospitalization Positioning ROM Rehab and Restorative Urinary Incontinence We also developed two new pathways for Accidents and Nutrition using the new format. Since we teased out Urinary Incontinence from the combined pathway, we updated the combined pathway for UTI and Catheters. To develop these revised pathways, we had input from numerous states who reviewed them and provided comments regarding the content, ease of use, and structure. In addition, we had the CU and CMS QIS team and state surveyors rigorously test the pathways in the field. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 51. I want to highlight a few points about the overall formatting of the pathways and some specifics for a few care areas. (initiate Death, Positioning, Rehab, and Urinary Incontinence for Jane D) Notice we have to provide a reason for initiation for each CA. Since our reason is the same for all 4 residents we can click OK 4 times. We’ll work our way up from the bottom. Let’s talk about Urinary Incontinence first. (open – Full Screen Display) We tried to make these pathways as user friendly and useful as possible. For the MDS section, we identified the areas that should be reviewed and the section the area can be found in. That’s not to say, based on your investigation, you may need to review additional MDS-related areas. Again, you should do a quick review of the MDS, care plan, orders and diagnosis and then start your observations. Observations are the most critical component to any investigation so you should begin those for all of your residents as soon as possible. For the interview sections, we created questions that could be asked as written. You don’t have to ask them as written, but they have been provided to you in a format that you can use. Depending on whether you have concerns from your observations and interviews with the resident or family, you may or may not need to interview staff. Even if you do have to interview staff, all of the probes may not be applicable. That’s also true for the record review section. As you work through these pathways, you may come across probes that can be related to other areas. For example, in the this pathway there’s a probe under the Observation section asking breaks in Infection Control. If you identify infection control as a concern, that issue would be considered an independent but associated area and you should document the issue under the Infection Control task. We have included a question about refusals in all interview sections. That question should only be asked of the resident or staff, if you are aware that the resident has refused. If there’s no indication that the resident refuses, you do not need to ask that question. As I mentioned during the Stage 1 review, we have included an interview question asking if the resident receives assistance with toileting. If the resident says they don’t – you’ll investigate the concern under this pathway. The SOM indicates F315 should be investigated if a resident is incontinent because they don’t get the necessary help to the bathroom. In addition, we have added a new CE to the pathway which is CE6 (F312) for any resident who is on a check and change program but didn’t get the assistance they needed. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 52. Let’s talk about the Rehab pathway. (open Rehab – Full Screen Display) I wanted to explain one specific detail in this pathway. If you look in the staff interview section you’ll notice some brackets that tell you to ask about your specific concerns. That means you should insert your area of concern. For example, if you initiated the Rehab pathway for a concern about ambulation – when you get to a probe with a bracket you’d say…what is restorative doing to address the resident’s ambulation. In addition, we added an N/A option to F311 and F406 since you may not be investigating both areas. (scroll to CE5 and CE6) Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 53. Now we’ll open Positioning. (do this – Full Screen Display) We provided quite a few observation probes to help guide you with potential positioning related concerns. The second probe under observations is addressing what some of you may have heard referred to as a Merry Walker and whether they are sized correctly. If we scroll down to the interview section, another enhancement we made to these pathways, was to divide up the interview probes by discipline so you wouldn’t have to sift through all the probes and try and decide which probe pertained to which staff. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 54. Now we’ll discuss one part of the Death pathway. (open to Full Screen Display) I just wanted to ensure everyone understood the Note at the top of the pathway. Typically, you’ll investigate a resident for this pathway if they died within 30 days of admission and had not elected the hospice benefit. However, if during your Stage 2 review you find out that the resident had a rapid decline after admission and then elected the hospice benefit and subsequently died – you should still determine if there were any concerns during the resident’s rapid decline. If there were, you should investigate the resident’s death even though they went on hospice. This is assuming you didn’t identify that the resident did not elect the hospice benefit during your Stage 1 review. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 55. The final pathway I want to discuss is Accidents. (open – Full Screen Display) The structure of this pathway is different from the others since there are so many different areas that map to Accidents such as smoking, falls, and elopement. Under each investigatory section, the specific areas are broken out and have individualized probes. For example, under observation you’ll see one general probe that applies to any area of concern. Then you’ll see the different areas of concern broken out such as specific probes for smoking, entrapment, resident-to-resident-altercation, and so on. I want to discuss one probe in this pathway. Under the record review section, there’s a probe asking if a personal alarm was only used on a temporary basis to identify the resident’s routine. Personal alarms should not be used as a long-term intervention to prevent falls. The purpose of an alarm is to identify, during a short period of time, when the resident tries to get up so staff can implement more appropriate long-term measures to prevent falls during those key times. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Now turn to Slide 56. The last change made for 10.2 is to the Stage 2 Team Meeting screen. To help remind you of any outstanding complaint work, we’ve added a complaint reference to the first two probes regarding findings for residents and facility tasks. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 7 Start Showing Slides To wrap up, I want to summarize the 10.2 changes using the QIS Checklist. Step 7 now refers to the new Skills Assessment process which has replaced Compliance. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 13 Step 13 – we’ve included the reconciliation instructions in both the Checklist and in the QIS Tool. The instructions were updated and we added two notations to reflect the new reconciliation and complaint process. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 14 Step 14 – now includes the complaint assignment information. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 15 Step 15 – We included the complaint info in the Stage 1 synch point. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Steps 18 and 21 Step 18 – We removed reference to the complaints that was in the example from the Review Materials screen. Step 21 – We added to start the complaint with your Census Sample, if feasible. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 21 Step 21 – We removed the reference regarding the monitoring of the nutritional supplement from the staff interview. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Steps 22 and 23 Step 22 – We updated the reconciliation steps for replacing a resident during Stage 1. Step 23 – We added Complaints to the daily back-up. If you are in Stage 1 and you’ve started to enter investigative documentation for your complaint resident, it is very important to back up the Stage 2 synch point. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Steps 25 and 26 Step 25 – Under Mandatory Facility Tasks, we updated the Dining instructions and removed any reference to the Food Quality care area. Step 26 - Under Non-mandatory facility tasks, we added the Append Text feature and removed reference to the View Stage 1 Info button. We also updated the procedures for AT&D since we deleted a few of the family interview questions that were mapped to this task. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 30 Step 30 – We updated the last probe on the transition meeting screen. We also updated the instructions to correct data entry errors. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Steps 32 - 35 Steps 32 through 35 – The entire Stage 2 Sample review and finalization steps were updated to reflect the new Stage 2 sample screen. You will now update your Stage 2 sample on the new Stage 2 Sample screen. You will only make Stage 2 assignments on the Stage 2 assignment screen. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 39 Step 39 – The added the complaint reminder to the Stage 2 Team Meeting probes. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey QIS Checklist – Step 58 Step 58 – The instructions for deleting a survey were updated. If you are deleting the entire facility you no longer have to delete the residents first. You can just delete the entire survey. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Addendum Addendum – We added a new section titled Customize the QCLI Results screen. This is where you’ll find detailed instructions regarding how to customize your right screen display on the QCLI Results screen. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Addendum Addendum – We included a note to document the reason for initiation which is a new requirement. We also included complaints under the section titled Reassigning Facility Tasks. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Addendum Addendum – If you try to assign the same resident and care area to the same surveyor twice, you’ll get a warning referring you to this section for instructions on how to fix the problem. Your three options are to assign the resident to a different surveyor, remove one of the initiated areas, or leave the extra initiated area unassigned. If you leave the extra initiated area unassigned, you may not get a completion check on the assignment screen. Quality Indicator Survey Quality Indicator Survey (QIS)

QIS Checklist – Addendum Addendum – The Surveyor Notes section was updated to reflect the new functionality. Quality Indicator Survey Quality Indicator Survey (QIS)

Revisit and Comparative Revisit (additions) Reason for initiation Add a complaint to Resident Pool Comparative All standard survey changes, excluding complaint Reconciliation now has completion check (still must verify accuracy!) There were two 10.2 changes made to the Revisit. One was the inclusion of the reasons for initiation and the ability to add a complaint to the Resident Pool screen. For the comparative, all of the same changes that were made to the Standard survey were also made in the comparative, excluding the ability to add complaints to the Reconciliation screen. If you ever investigated a complaint during a comparative, we have different steps for you to follow since we don’t want any of the States Census residents removed from your sample. There’s one additional change to the comparative instructions that I want to mention. Because the residency status is now populated on the Reconciliation screen, you will have a completion check when you first access the screen. However, you are still required to verify the accuracy of the residency status for all Stage 1 sample residents. This information is reflected in the updated Comparative Checklist. Quality Indicator Survey Quality Indicator Survey (QIS)

Quality Indicator Survey Implementation 7/12/15 Roll-out Date QIS and Revisit Checklist updated All QIS related materials (e.g., Fact or Fiction, Forms) http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/index.html?redirect=/surveycertificationgeninfo/ 8/24/15 Training materials available (Comparative, Classroom, and Skills Assessment) Finally, the roll-out date is 7/12. The QIS and Revisit Checklist, along with other QIS related materials such as the Stage 1 forms and pathways and Fact or Fiction have been updated and is posted on the S&C website. The training materials which includes the comparative, classroom and Skills Assessment approach will be available on 8/24. There is a new approach used for the classroom and Skills Assessment which used to be compliance. You’ll receive additional training once the materials are released. Quality Indicator Survey Quality Indicator Survey (QIS)

Evaluation and Questions Any questions? We’d greatly appreciate it if each of you could take a minute to complete the evaluation of this training. The link is on the slide. We’ll now open it up for questions. Quality Indicator Survey Quality Indicator Survey (QIS)