1. Quality Indicator Survey ASPEN 10.1.7 (QIS Version 4.03) Quality Indicator Survey 1

2. QIS 4.03 Checklist

3. Quality Indicator Survey 3

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7. Updated Kitchen Pathway Cracked or unpasteurized eggs that are used in foods that are not fully cooked (per observation or interview); If staff is preparing resident requests for soft cooked and undercooked eggs (i.e. sunny side up, soft scrambled, soft boiled), determine if pasteurized shell eggs, liquid pasteurized eggs or unpasteurized shell eggs were used; If there is an outbreak of food borne illness and the facility’s primary food service has been ruled out as the cause of the outbreak, review the policies and procedures for maintaining nursing home gardens, if applicable. Quality Indicator Survey 7

8. Updated Kitchen Pathway Ask staff: Are you aware of current CDC and FDA nursing home egg handling and preparation policies? Does the facility have written egg storage and preparation policies that honor resident preferences safely? If a food borne illness outbreak occurred: Did you report the outbreak to the local health department? Unit Refrigerators 14. Are snack/nourishment refrigerators on the unit maintained so as to prevent the potential for food-borne illness? Yes No F371 15. Are proper refrigerator (snack/nourishment) temperatures maintained and are food items dated/labeled? Yes No F371 Quality Indicator Survey 8

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11. Quality Indicator Survey 11

12. Stage 2 Auto Save QIS automatically saves Stage 2 investigative documentation every 5 minutes Report any instance of Stage 2 data loss to the QTSO Help Desk (1-888- 477-7876) Quality Indicator Survey 12

13. Quality Indicator Survey 13

14. Ctrl D and Ctrl N Shortcuts work in Surveyor notes, team meetings, Stage 1 and 2, facility tasks and potential citations. EXCEPTION: Ctrl N does not work in team meeting screens. Quality Indicator Survey 14

15. Quality Indicator Survey 15

16. Revisit Sampling Revisit Sampling Changes Exclude discharged residents No longer duplicate residents Quality Indicator Survey 16

17. Quality Indicator Survey 17

18. Quality Indicator Survey 18

19. Quality Indicator Survey 19

20. Quality Indicator Survey 20

21. Quality Indicator Survey 21

22. Quality Indicator Survey 22

23. Quality Indicator Survey 23

24. Quality Indicator Survey 24

25. QIS Checklist – Steps 25, 26, 37, Addendum Quality Indicator Survey 25

26. QIS Checklist – Step 37 Quality Indicator Survey 26

27. QIS Checklist – Revisit Step 6 Quality Indicator Survey 27

28. QIS Checklist – Revisit Step 7 Quality Indicator Survey 28

29. QIS Checklist – Revisit Step 11 Quality Indicator Survey 29

30. QIS Checklist – Revisit Step 12 Quality Indicator Survey 30

31. QIS Checklist – Revisit Step 13 Quality Indicator Survey 31

32. Implementation 9/21/14 Roll-out Date QIS and Revisit Checklist updated –http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/SurveyCertificationGenInfo/index. html?redirect=/surveycertificationgeninfo/http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/SurveyCertificationGenInfo/index. html?redirect=/surveycertificationgeninfo/ Quality Indicator Survey 32