1. Long Term Care Survey Process
NFSU News Hour 7/20/17
Long Term Care Survey Process
Cynthia Vargo, Co-Manager
Nursing Facility Survey Unit
APD Safety, Oversight & Quality
9/07/17

2. NFSU News Hour 7/20/17
Picture bring memories of my two Portland Marathon completions in 1997 and 2007
Training preparations
Commitment
Desire or want to
Practice, practice, practice
One step at a time
No pain no gain
My running buddy, Leona
Rewards to follow

3. 1997 2007 NFSU News Hour 7/20/17 Training
Challenge not uphill but downhill
Ran backwards mile 19 to 26.2
Portland Marathon 1997 and 2007

4. Presentation Outline Regulation Reform F-tag Re-numbering
NFSU News Hour 7/20/17
Regulation Reform
F-tag Re-numbering
Long Term Care Survey Process (LTCSP)
Preparations

5. Regulation Reform

6. Regulation Reform Development Sources
NFSU News Hour 7/20/17
QIS/Traditional Processes
State Survey Agencies
Regional Offices
CMS Central Office
University of Colorado
Technical Expert Panel
Literature Review & Data Analyses

7. Regulation Reform Overview effective November 28, 2016
NFSU News Hour 7/20/17
Legislation revisions include:
Affordable Care Act (ACA), and
Improving Medicare Post-Acute Care Transformation (IMPACT) Act
Quality Assurance and Performance Improvement (QAPI);
Reporting suspicion of a crime;
Increased discharge planning;
Staff training section; and
Nursing facility requirements for participation.

8. Regulation Reform Implementation Grid
NFSU News Hour 7/20/17
Implementation Date
Type of Change
Details of Change
Phase 1:
November 28, 2016
LTC Requirements for Participation
Changes to current F-tag Regulatory Language
Phase 2:
November 28, 2017
F-tag re-numbering
Interpretive Guidance (IG)
LTC Survey Process (LTCSP)
New F-tags
New Interpretive Guidelines
New LTCSP begins
Phase 3:
November 28, 2019
More LTC Requirements
Requirements that need more time to implement

9. Phase 2 of LTC Regulations
NFSU News Hour 7/20/17
Effective November 28, 2017
Providers must be in compliance with Phase 2 regulations
All States use new LTCSP for surveys
Trainings completed before implementation date
Implement on November 28, 2017 (TUESDAY)

11. F-Tag Renumbering

12. F-tag Renumbering
NFSU News Hour 7/20/17

13. F-tag Renumbering Crosswalk provides original and associated new:
NFSU News Hour 7/20/17
Crosswalk provides original and associated new:
Regulatory grouping;
Regulation number; and
F-tag
The crosswalk is currently under development once finalized it will be distributed.

14. CMS release Fall 2017 F-tag re-numbering F-tag crosswalk
NFSU News Hour 7/20/17
F-tag re-numbering
F-tag crosswalk
Regulation appendices P and PP
Interpretive Guidance updates
(Surveyors will use the most recent version)
CMS is in the process of updating information for Appendices PP and P. Once the guidance is approved it will be available in the SOM.

15. Long Term Care Survey Process

17. Why change the Survey Process?
Improve efficiency and effectiveness;
Combine:
Quality of care/quality of life areas;
Traditional and QIS survey processes;
Best of both into one nationwide survey process.

18. New LTCSP Goals Same survey process entire country
NFSU News Hour 7/20/17
Same survey process entire country
Retain strengths from each process
New innovative approaches
Effective and efficient
Resident-centered
Balance between structure and surveyor autonomy
The New LTC Survey Process will replace both the Traditional and QIS processes,

19. Quality Indicator Survey (QIS)
Automation
NFSU News Hour 7/20/17
Quality Indicator Survey (QIS)
New LTCSP
Surveyor uses tablet PC;
Findings synthesized and organized;
QIS software
LTCSP software

20. Resident Sample Selection
NFSU News Hour 7/20/17
QIS
New LTCSP
Random resident selection for:
Admission sample (up to 30 current or discharged records);
Census sample (up to 40 current resident observations, interviews and record reviews);
Complaints can be included in census sample
Sample size determined by facility census;
Approximate selection:
70% MDS pre-selected;
30% surveyor-selected;
Maximum sample size 35;
Maximum complaint sample 5
Surveyor-selected residents based on observations, interviews and record review.
The sample size for the new survey process will be based on the facility census. The sample for the new survey process includes 70% of MDS pre-selected residents and 30% surveyor-selected residents.

21. Entrance Information Needed
NFSU News Hour 7/20/17
QIS
New LTCSP
Facility census number;
Alphabetical list of residents;
New admissions last 30 days
New admission Matrix last 30 days;
List of residents who smoke
Residents who smoke includes designated smoking times

22. Updated Facility Matrix (Draft) Residents Admitted within Past 30 days
NFSU News Hour 7/20/17
CMS has revised the matrix to more effectively capture those pieces of information needed for the survey.
Residents Admitted within the Past 30 days
The Revised Facility Matrix is still in draft and may change.
New Identifiers!

23. Initial Entry to Facility
NFSU News Hour 7/20/17
QIS
New LTCSP
No sample selection (random only);
Initial tour of facility, resident population and staff/resident interactions;
30–45 minutes average initial tour;
Dining & kitchen review
No initial tour process;
Full observation/interview of all residents;
Limited record review for initial pool process:
Offsite selected residents
New admissions
Vulnerable residents
Other identified concerns
8 hours average initial pool process;
Reminder: Facility Floor Plans requested from all facilities.
Unlike the current survey processes, there is no formal tour for the new survey process.
Surveyors will begin observing every resident.

24. Survey Structure QIS New LTCSP
NFSU News Hour 7/20/17
QIS
New LTCSP
Stage 1: Preliminary investigation of regulatory areas in the admission and census samples and mandatory facility tasks started;
Stage 2: Completion of in-depth investigation of triggered care areas and/or facility tasks based on Stage 1 identified concerns
Resident sample about 20% of current census;
Initial pool observation, interview and limited record reviews;
Surveyors select up to 50% sample;
Investigations continue for each sampled resident;
Facility tasks and closed record reviews completed

25. Group Interviews QIS New LTCSP
NFSU News Hour 7/20/17
QIS
New LTCSP
Interview Resident Council President or Representative;
Resident Council minutes review
Resident Council Meeting with active members;

26. Facility Tasks Dining; Infection Control; Beneficiary Notification;
NFSU News Hour 7/20/17
QIS
New LTCSP
Dining;
Infection Control;
Beneficiary Notification;
Kitchen;
Medication Administration;
Medication Storage;
Resident Council;
QAA/QAPI
QAA/QAPI;
Nurse Staffing
Nurse Staffing (sufficient & competent)
Triggered only Tasks:
Personal Funds
Environment
Resident Assessments

27. Preparations

29. State Agency Preparations
NFSU News Hour 7/20/17
August 2017
State survey train the trainers
September 2017
State surveyor webinar trainings
November 2017
LTCSP Phase 2 National Implementation
Phase 2 of LTC regulations required for implementation
January 2018
New CMS training material for LTC

30. Training Layers CMS and State Agency
NFSU News Hour 7/20/17

32. Provider and Public Preparations
NFSU News Hour 7/20/17
CMS National Calls and Q&As – Fall 2017
Surveyor Training Materials
Interpretive Guidance Videos
Survey Forms and Critical Element Pathways
Integrated Surveyor Training Website (ISTW)

33. Integrated Surveyor Training Website (ISTW)
Web-based training
Video webcasts
Archived webinars
Surveyor training videos
More CMS online training platforms . . .

35. ISTW – Currently two Provider specific trainings

36. ISTW filter by: Long Term Care

37. ISTW: Surveyor Training Videos Filter: LTC>search course>SME
NFSU News Hour 7/20/17
SME – Subject Matter Expert

38. Subject Matter Expert (SME) videos:
Admission, Transfer and Discharge
Appendix PP Overview of Revised Interpretive Guidance
Behavioral Health
Facility Assessment
Freedom form Abuse, Neglect and Exploitation
Infection Control
Person Centered Care
Pharmacy Services
Quality Assurance and Process Improvement Plan – The Basics
Quality of Life and Quality of Care
Nursing Services

40. Questions?