1. Ohio Health Care Association District 2 August 15, 2017
New CMS Survey Process
Ohio Health Care Association
District 2
August 15, 2017
I am doing a very high level overview of the day to start us off. We need to establish the foundation so we all know what we are addressing and discussing today.
I will be doing the high overview.
Dusty will be doing on deeper dive into the processes and how ODH will use them.
Maureen was going to be doing practical application of the data as we have it to this point.
Maureen will not be here, so Dusty and I will be picking up her slides.
That will make me Maurane and Dusty will be Dusteen.
I appreciate Mandy’s introduction, but I am much more accustomed to being called Shane the Pain rather than Shane the Brain.

2. Contents Data sources: CMS Long-Term Care Survey Process Slides
CMS.gov Nursing Home Website
MLN Nursing Home Survey Process from July 25, 2017
CMS Survey and Certification Group Integrated Surveyor Training Website
CMS S&C Letters

3. CMS.Gov Nursing Home Page
Appendix PP [Effective through November 27, 2017] [PDF, 3MB]
Advance Appendix PP including Phase 2 [Effective November 28, 2017] [PDF, 3MB]
List of Revised FTags [Effective November 28, 2017] [PDF, 152KB]
S&C Memo: Revision to State Operations Manual Appendix PP for Phase 2 (Includes Training Information and Related Issues) [PDF, 121KB]
F-Tag Crosswalk [XLSX, 495KB]
Training for Phase 1 Implementation of New Nursing Home Regulations [PDF, 108KB]
New Long-term Care Survey Process – Slide Deck and Speaker Notes [PPTX, 8MB]
Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

4. Medicare Learning Network (MLN)
July 25th presentation.

5. CMS Survey and Certification Group
Integrated Surveyor Training Website
Next Slide Gives more detail. It zooms in on the picture in this slide.

7. The videos are brutal.
Do you remember the artist that was on PBS? The one with the ginormous Afro that spoke in soothing tones and painted landscapes.
It kind of reminded me of that, but with much less colorful and enjoyable material.

8. CMS S&C Letters List of Important S&C Notices:
Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool17-37-NH
Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues 17-36-NH
New Guidance for the Formatting of the Plans of Correction17-34-ALL
Reasonable Assurance Will Apply to Providers and Suppliers Who Voluntarily Terminate and Seek New Certification If a Termination Action by the State Agency Had Been Initiated17-35-ALL
Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures17-29-ALL
Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)17-30-Hospitals/CAHs/NHs

9. New Long Term Care Survey Process
Slides that look like this are directly from the CMS slide deck. We thought that these would provide the best training insight if you saw what it is that CMS is producing.

10. Disclaimer
The information provided within these slides are current as of May 15, It provides information related to the CMS' intent to implement the survey process on November 28, 2017 and the policies and procedures based on development to date.
This presentation will be updated as new information becomes available.

11. Overview Overview of Regulation Reform F-Tag Renumbering
New Interpretive Guidance (IG)
Current Survey Processes vs. New Survey Process
New LTC Survey Process
LTC Surveyor Training
State Preparation
Questions?

12. Overview of Regulation Reform

13. Overview of Regulation Reform
The regulation reform implements a number of pieces of legislation from the Affordable Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, including the following:
Quality Assurance and Performance Improvement (QAPI)
Reporting suspicion of a crime
Increased discharge planning requirements
Staff training section
There is a lot of legislation that has come together to get us to this place.
In truth it is almost staggering. In truth, it is too much.

14. Implementation Grid Implementation Date Type of Change
Details of Change
Phase 1:
November 28, 2016
(Implemented)
Nursing Home Requirements for Participation
New Regulatory Language was uploaded to the Automated Survey Processing Environment (ASPEN) under current F Tags
Phase 2:
November 28, 2017
F Tag numbering
Interpretive Guidance (IG) Implement new survey process
New F Tags
Updated IG
Begin surveying with the new survey process
Phase 3:
November 28, 2019
Requirements that need more time to implement
Requirements that need more time to implement
I don’t even want to talk about phase 3.

15. S&C 17-26-NH Survey Team Composition and Complaints
Notice of Proposed Rule Making (NPRM): The Centers for Medicare & Medicaid Services (CMS) published a proposed regulation Medicare Program; FY 2018 Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule which displayed on the Federal Register on April 27, 2017.
CMS Proposed Changes: CMS proposed four changes to the Survey Team Composition within the NPRM which, include revision of the definitions of “complaint survey” and “abbreviated standard survey,” relocation of requirements related to complaint surveys, and revision of survey team composition requirements as outlined below.
They are separating out survey types for better tracking. The Abbreviated Standard Survey process will now be different for a Complaint Survey versus a Change of Ownership Survey.
Survey Team Composition Requirements
The regulation under § (a)(1) requires that surveys be conducted by an interdisciplinary team of professionals, which must include a registered nurse. The proposed revision of this language will specify that these team composition requirements apply only to surveys under sections 1819(g)(2) and 1919(g)(2) of the Act, not to complaint surveys.

16. Phase 2 of LTC Regulations
Implement by November 28, 2017
Providers must be in compliance with Phase 2 regulations
All States will use new computer–based survey process for LTC surveys
All training on new survey process needs to be completed before go live date
Of course, Ohio is accustomed to using computer based survey processes. I can see some states struggling with this initially.

17. Phase 2 of LTC Regulations (continued)
Phase 2 includes:
Behavioral Health Services
Quality Assurance and Performance Improvements (QAPI Plan Only)
Infection Control and Antibiotic Stewardship
Physical Environment – smoking policies
Phase 2 will include:
Behavioral Health Services
Quality Assurance and Performance Improvements (QAPI Plan Only)
Infection Control and Antibiotic Stewardship
Physical Environment – smoking policies

18. Phase 2 of LTC Regulations, continued
Phase 2 includes, but is not limited to:
Resident Rights and Facility Responsibilities – Required Contact Information-
Freedom from Abuse, Neglect, and Exploitation – 1150B
Admission, Transfer, and Discharge Rights – Transfer/Discharge Documentation
Phase 2 will include, but is not limited to:
Resident Rights and Facility Responsibilities – Required Contact Information
Freedom from abuse, neglect, and exploitation – 1150B Requirements (reporting reasonable suspicion of a crime) See S&C Memo -Reporting Reasonable Suspicion of a Crime
Admission, transfer, and discharge rights – Transfer/Discharge Documentation

19. Phase 2 of LTC Regulations, continued
Phase 2 includes, but is not limited to:
Comprehensive Person-Centered Care Planning
Pharmacy Services – psychotropic medications
Dental Services – replacing dentures
Administration – Facility Assessment
Phase 2 includes, but is not limited to:
Comprehensive Person-Centered Care Planning – Baseline Care Plan
Pharmacy Services – Drug regimen review and reporting – review of medical chart, definition of psychotropic medications
Dental Services – replacing lost dentures
Administration – Facility Assessment – tied to sufficient and competent staff requirements

20. MLN Updates: July 25, 2017
I don’t want to spend a lot of time on these. My job was to just touch on the issues. We wanted to make sure you were aware of want is being mentioned by CMS.
Some of these will be more developed by Dusty in the detailed section.
Some, we will have to figure out as we go.

21. MLN Updates Resident Rights:
General Updates: Discussion of examples of non-compliance and survey procedures
Visitation Rights subject to reasonable restrictions
Advance directives
Advance Beneficiary Notices
Expanded discussion on role of resident representative and interested parties.
Freedom From Abuse, Neglect and Exploitation
F600 – Abuse and Neglect combined into a single tag
Additional Guidance Added for Clarity
What constitutes abuse and neglect
Assessing Consent
Involuntary Seclusion
Physical and Chemical Restraints
Policies to Prohibit Abuse and Neglect
Reporting Requirements
A moment of silence for the old F-Tags please…
May F323 Rest In Peace.
We will talk about a few specific examples, just to discuss the new IG’s.
F600
Example of “Assessing Consent”
Sexual Abuse is defined as “non-consensual sexual contact of any type…”
Generally, sexual contact is considered non-consensual if:
Appears to want the contact to occur, but lacks the cognitive ability to consent.
Does not want the contact to occur.
Areas that may be considered abuse:
Unsympathetic or negative attitudes towards residents.
Chronic staffing problems.

22. MLN Updates Admission, Transfer & Discharge:
Facility-Initiated Discharge vs. Resident-Initiated Discharge
F624 – Immediate Orientation and Planning for Discharge
Additional Guidance
Permitting Residents to Return and Right to Remain
Emergency Transfers
Documentation Requirements for Transfer and Discharge
Survey Review Procedures:
Review nursing notes and any other relevant documentation to see if appropriate orientation and preparation of the resident prior to transfer and discharge has occurred.
Through record review and interviews, determine if the resident received sufficient preparation prior to transfer or discharge, and if they understood the information provided to them.
Were the residents needed/requested possessions transferred with the resident to the new location?
Ask the resident or his/her representative if they understand why they transfer or discharge occurred.

23. MLN Updates Resident Assessments:
Integration with Resident Assessment Instrument (RAI) Manual
Assessment timing and completion
Care Area Assessment Process
Significant Change in Status Assessment
Using the RAI to develop, review and revise the resident’s comprehensive care plan
Coordination of PASARR screening, evaluation, determination and the RAI Assessment (Guidance and Survey Process)
Notification of the appropriate state authority when a resident with a mental disorder or intellectual disability has a significant change in status
Comprehensive Resident-Centered POC:
Baseline Care Plan
Integration with Resident Assessment Instrument (RAI) and Care Area Assessment (CAA) process
PASARR
Discharge Planning and Discharge Summary Process (New)
The focus of this plan is related to developing a Resident Centered Plan of Care.
You start with your baseline POC:
Then review all the data collection tools and add the key points to their POC.
RAI and CAA’s
PASARR
DC Planning and needs.

24. MLN Updates Quality of Life:
Quality of Life Definition- Noncompliance results from evidence demonstrate a pervasive disregard for the principles of quality of life.
Incorporation of Basic Life Support guidance
Quality of Care:
F684 Quality of Care Tag- Formerly F309 – Hospice, palliative care, other care issues
Guidance:
Dialysis
Respiratory Care
Fecal Incontinence
Position Change Alarms
Bed Rails
F684 Quality of Care. (May F309 RIP)
F684 Starts with the concept of “Highest practicable physical, mental and psychosocial well-being.” There was no definition change to this concept.
However, there is much guidance on:
Hospice Care
Palliative Care
Terminally Ill
Ulcers etc.
The Guidance then goes to a lengthy section on Coordinated POC‘s.
First, you have an obligation to individual addressed each of these issues to reach the highest practicable level of well-being.
Secondly, the guidance speaks to coordinate POC’s, “The Nursing Home retains primary responsibility for implementing those aspects of care…”

25. MLN Updates Nursing Services: Sufficient Staffing F725
Competent Staffing and Nurse Aide Proficiency F726
Except when related to provision of behavioral health services or non- nursing staff.
Behavioral Health Services:
Sufficient and Competent Staffing related to provision of behavioral health services.
Scope of services and coordination
Services for residents with dementia (F744)
Another moment for the old survey tags.
I just can’t get past this…
There are 10 questions that are listed in F725 that surveyors have to answer related to staffing. We will not go through all of them today, however, here are a few highlights:
Concerns voiced by residents, family and staff.
Does the staffing pattern match what the facility assessment says is required.
Diseases
Acuity
Functional/Cognitive limitations
Does the Workload or assignments of the nursing staff allow them time to participial in team meetings, care planning meetings, attend training, spend time caring for residents and take time for breaks?

26. MLN Updates Pharmacy Services: F757- Unnecessary Medications
F758- Psychotropic (Unnecessary and PRN Usage)
F756 Drug Regimen Review—new requirements related to reporting and documenting identified irregularities.
Food and Nutrition Services:
Qualifications of Personnel
Sufficient Staff
Policy regarding personal food items

27. MLN Updates QAPI: QAPI Plan Disclosure of QAA Information
Good Faith Attempts to Correct
Patient Safety Act
Potentially Preventable Adverse Events
Infection Control:
Infection Control Program – discussion of minimum components
Antibiotic Stewardship Program – minimum antibiotic use protocols and a system for monitoring antibiotic use – describes other core components based on CDC guidance
F865 is the QAPI Plan
The plan has to “reflect the complexities, unique care and services that the facility provides.”
A QAPI plan is the written plan containing the process that will guide the nursing home’s efforts in assuring care and services are maintain at acceptable levels of performance and continually improved.
Disclosure of Information and Good Faith Attempts:
The survey process is intended to be an objective assessment of facility compliance with the requirements of participation….
The surveyor task to review the QAPI Plan/QAA is intended to occur at the end of the survey, after completion of investigation into all other requirements to ensure that concerns are identified by the survey team independently of the QAPI Plan/QAA review.
“Surveyors may only require facilities to disclose QAA committee records if they are used to determine the extent to which facilities are compliant with the provisions for QAA.“
“Information gleaned from disclosure of QAA committee documents will not be used to cite new issues (not already identified by the survey team) or to expand the scope or severity of concerns identified by the current survey.”

28. MLN Updates Administration: • Facility Assessment Guidance
Technical Assistance
Expanded Discussion of Role of Medical Director
Facility Closure
Hospice Agreement
Other Regulatory Sections:
Physician Services
Lab, Radiology and Other Diagnostic Services
Dental Services
Physical Environment
Training
F838 Facility Assessment
The resident Population
Number of residents and capacity of residents
The care required by your population based on diseases, conditions, physican and cognitive limitations and overall acuity.
Staff competencies
Physical Environments
Ethnic, cultural or religious factors
The Facilities Resources
Building, physical structures and vehicles
Equipment (Medical and Non-Medical)
Services Provided (Therapy, Pharmacy)
All personnel and their education requirements
Contracts, MOA’s or other agreements for normal and emergency operations.
Health Information Technologies resources (EHR and Sharing of Electronic Data)

29. F Tag Renumbering

30. F Tag Renumbering The image above is the F Tag Crosswalk showing:
The original regulatory grouping and the new associated grouping
The original regulation number and the new associated regulation number
The original F Tag and the associated new F Tag
The crosswalk is currently under development once finalized it will be distributed. This job aid will be available in the fall of 2017.
The image above is the F Tag Crosswalk showing:
The original regulatory grouping and the new associated grouping
The original regulation number and the new associated regulation number
The original F Tag and the associated new F Tag

31. F Tag Renumbering, continued
This is a larger view of the crosswalk. The crosswalk is currently under development once finalized it will be distributed. This job aid will be available in the fall of 2017.

32. New Interpretive Guidance (IG)

33. New Interpretive Guidance (IG)
CMS is in the process of updating information for Appendices P and PP. Once the guidance is approved it will be available in the SOM.
States should ensure surveyors use the most recent version of the regulation and IG
CMS plans to release the Guidance in early summer 2017
These have been produced and can be found on the CMS S&C website.
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.
States should ensure surveyors use the most recent version of the regulation and IG

34. CMS S&C Letters List of Important S&C Notices:
Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool17-37-NH
Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues 17-36-NH
New Guidance for the Formatting of the Plans of Correction17-34-ALL
Reasonable Assurance Will Apply to Providers and Suppliers Who Voluntarily Terminate and Seek New Certification If a Termination Action by the State Agency Had Been Initiated17-35-ALL
Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures17-29-ALL
Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)17-30-Hospitals/CAHs/NHs

35. Surveyor Minimum Qualifications Test (SMQT) and the New Regulations
SMQT will not reflect any new regulations/guidance at this time  
SMQT will be suspended November and December 2017
The test is scheduled to be updated to reflect new guidance/regulations for January 2018
SMQT will not reflect any new guidance/regulations at this time  
SMQT will be suspended November and December 2017
The test is scheduled to be updated to reflect new regulations and guidance for January 2018
It appears from this slide, that surveyors will be surveying with training but without testing in November and December. Good luck if you have a survey during those 2 months.
Let us know how it goes….
If it happens, you just got lucky and should go buy a lottery ticket.

36. Current Survey Processes vs. New Survey Process
Now let’s switch topics and discuss the survey process. I’m first going to give a high level overview of the key differences between the current survey processes as compared to the new survey process.

37. Why is CMS Changing the LTC Survey Process?
Two different survey processes existed to review for the Requirements of Participation (Traditional and QIS)
Surveyors identified opportunities to improve the efficiency and effectiveness of both survey processes.
The two processes appeared to identify slightly different quality of care/quality of life issues.
CMS set out to build on the best of both the Traditional and QIS processes to establish a single nationwide survey process.

38. Goals of New Process Same survey for entire country
Strengths from Traditional & QIS
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, which means everyone in the country will use the same process. When designing the New LTC survey Process, they took into account the strengths from both the Traditional and QIS. One strength of the Traditional process was that surveyors could ask residents questions as they would like, which was retained in the New LTC Survey Process to promote surveyor autonomy. Having a computer-based process and using pathways as investigative tools were strengths of the QIS process that were used for the New LTC Survey Process. They also included many innovative ways of conducting various components of the survey.
The overarching goal for the New LTC Survey Process is to have one unified survey process that effectively identifies survey outcomes in an efficient manner that accounts for survey resources for both time spent onsite and the number of surveyors. The New LTC Survey Process is resident-centered, which means resident-specific concerns identified through resident observations and resident or representative interviews are emphasized. The New LTC Survey Process provides as much structure as possible to ensure consistency while allowing surveyors the autonomy to make decisions based on their expertise and judgment.

39. Quality Indicator Survey (QIS)
Automation
Traditional
Quality Indicator Survey (QIS)
New Survey Process
Survey team collects data and records the findings on paper
The computer is only used to prepare the deficiencies recorded on the CMS-2567
Each survey team member uses a tablet PC throughout the survey process to record findings that are synthesized and organized by the QIS software
Each survey team member uses a tablet or laptop PC throughout the survey process to record findings that are synthesized and organized by new software
The Traditional survey process is completed on paper while the QIS process is automated. The new survey process will be an automated process.

40. Sample Selection Traditional QIS New Survey Process
Sample size determined by facility census
Residents are pre-selected based on QM/QI percentiles (total sample)
Sample may be adjusted based on issues identified on tour
Maximum sample size is 30 residents
Includes complaints
The ASE-Q provides a randomly selected sample of residents for the following:
Admission sample is a review of up to 30 current or discharged resident records
Census sample includes up to 40 current residents for observation, interview, and record review
With QIS 4.04, complaints can be included in census sample
Sample size is determined by the facility census
70% of the total sample is MDS pre-selected residents and 30% of the total sample is surveyor-selected residents. Surveyors finalize the sample based on observations, interviews, and a limited record review.
Maximum sample size is 35 residents
The sample size for the new survey process will be based on the facility census. The sampling approach for the new survey process is different than either current process. The sample for the new survey process includes 70% of MDS pre-selected residents and 30% surveyor-selected residents.
35 Residents:
70% equals 25 residents from the MDS
30% equals 10 residents from the Surveyor Selection
One of the things that I have always said regarding the QIS, was to never allow yourself to be in a position where a surveyor has to make a subjective call.
However, in the new survey process, you are placed in that position from the beginning.
“Surveyors finalize the sample based on observations, interviews, and a limited record review.” In essence, this is based on surveyor discretion. It is based on what they discovered in interviews and observation.

41. Offsite Traditional QIS New Survey Process
Review Casper 3 and 4 reports
Survey team uses QM/QIs report offsite to identify preliminary sample of residents areas of concern
Review the Casper 3 report and current complaints
Download the MDS data to PCs
ASE-Q selects a random sample of residents for Stage 1 from residents with MDS assessments in past 180 days
Each team member independently reviews the Casper 3 report and other facility history information
Review offsite selected residents and their indicators and the facility rates.
All of the survey processes review facility history information to prepare for the survey. In addition, surveyors will review the offsite selected residents and facility rates during offsite preparation which is similar to the Traditional process.

42. Information Needed Upon Entrance
Traditional
QIS
New Survey Process
Roster Sample Matrix Form (CMS-802)
Obtain census number and alphabetical resident census with room numbers and units
List of new admissions over last 30 days
Completed matrix for new admissions over the last 30 days
Facility census number
Alphabetical list of residents
List of residents who smoke and designated smoking times
Similar to the other processes, there will be information requested immediately after entering the facility which we’ll discuss in detail later.

43. Initial Entry to Facility
Traditional
QIS
New Survey Process
Gather information about pre-selected residents and new concerns
Determine whether pre-selected residents are still appropriate
1 – 3 hours on average
No sample selection
Initial overview of facility, resident population and staff/resident interactions.
30 – 45 minutes on average for initial overview
No formal tour process
Surveyors complete a full observation, interview all interviewable residents, and complete a limited record review for initial pool residents:
Offsite selected residents
New admissions
Vulnerable residents
Identified Concern that doesn’t fall into one of the above subgroups
8 hours on average for interviews, observations, and screening.
Unlike the current survey processes, there is no formal tour for the new survey process. Surveyors will begin observing every resident in their assigned area to identify about eight residents for the initial pool process and then will spend about eight hours completing the observations, interviews and record review for the residents selected for the initial pool process.
8 HOURS OF OBSERVATION!!
“Interview all interviewable residents.”

44. Survey Structure Traditional QIS New Survey Process
Resident sample is about 20% of facility census for resident observations, interviews, and record reviews
Phase I: Focused and comprehensive reviews based on QM/QI report and issues identified from offsite information and facility tour
Phase II: Focused record reviews
Facility and environmental tasks completed during the survey
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 concerns identified during Stage 1
Resident sample size is about 20% of facility census
Interview, observation and limited record review care areas are provided for the initial pool process; surveyors can ask the questions as they would like
Surveyors meet to discuss and select sample, may have more concerns than can be added to the sample; may need to prioritize concerns
The surveyors meet at the end of every day. So, theoretically, they should have information to share at the end of each day.
In truth, I will appreciate this. The one thing I could not stand was sharing on Thursday and not having time to do anything about it.
The new survey process took into account the strengths of both the Traditional and QIS processes and tried to balance consistency with surveyor autonomy. For the new survey process, surveyors are completing thorough observations, interviews and a limited record review for the residents selected during the initial pool process. Part of that review consists of covering a number of quality of life and care areas and during interviews the surveyor can ask the questions as they would like as long as they maintain the intent of the area.
For the new survey process, the survey team will select the residents for the sample.

45. Survey Structure, continued
Traditional
QIS
New Survey Process
Investigations are then completed during the remainder of the survey for each sample resident using CE pathways
Facility tasks and closed record reviews are completed during the survey
Once the sample is selected, the remainder of the survey is spent conducting investigations for residents, facility tasks and closed records.

46. Group Interviews Traditional QIS New Survey Process
Meet with Resident Group/Council
Includes Resident Council minutes review to identify concerns
Interview with Resident Council President or Representative
Resident Council Meeting with active members
Resident Council minutes seem to be coming up a lot lately. We have seen surveyors try and count suggestions and recommendations made by the residents in the resident council as Grievances.
Have a template built to address all concerns from the Resident Council. Read the minutes prior months resident council meeting in the current meeting. You should have already dealt with any issues, but you can count this as a secondary monitoring phase to ensure they all were brought to conclusion.
The new survey process includes a group
interview with residents who are active members of the resident council; however, the questions asked during the group are different from both current processes.

47. New LTC Survey Process Overview
Now let’s discuss the new LTC survey process.

48. New Survey Process
The new survey process builds on the best of both survey processes.
Process is computer software-based
Input from various stakeholders
Survey process and software are in testing and development and validation
CMS is currently working with their internal IT department and outside contractors to develop software for the new survey process. CMS is also working to gather input from various resources within the SA and RO to develop new reports from the survey tool that will inform State and RO review (similar to the Desk Audit Report (DAR), but simpler).

49. New Survey Process (continued)
Three parts to new Survey Process:
Initial pool process
Sample Selection
Investigation
The new survey process is computer-based with three parts:
The initial pool process
Sample selection
The investigative process

50. Development Sources Current QIS/Traditional Processes
State Survey Agencies
Regional Offices
CMS Central Office
University of Colorado
Technical Expert Panel
Literature review & data analyses
The New LTC Survey Process developed by CU under CMS’ direction was designed based on careful consideration from numerous sources, relevant data, and multiple rounds of testing.
CU reviewed the pros and cons of both the QIS and Traditional processes that were submitted by State and Regional representatives at the April 2015 SETI conference.
CU conducted interviews with CMS staff who had expertise in both the QIS or Traditional processes or survey-related policy development. The interviews addressed strengths and weaknesses of the Traditional and QIS approaches and suggestions for a new and more effective survey process.
A survey process Technical Expert Panel, or TEP, was held in July 2015, where four diverse groups of RO and State Surveyors developed components of their ideal survey process. As a part of that TEP, information from a questionnaire the participants completed prior to the meeting was included , which included input from the surveyors in their respective State or Region.
CU also took into account information obtained through a literature review. CU reviewed literature on the effectiveness of the LTC Survey Process to obtain additional perspectives on survey effectiveness and areas for improvement.
Whenever possible during developmental activities, CU conducted quantitative and qualitative data analyses to help inform decisions on the design of the New LTC Survey Process. In addition, the CU project team contributed input on the new survey process based on a blend of expertise in QIS and the Traditional processes, including research, testing, and redesign.
Although it is not possible to design a survey process that incorporates all opinions, they attempted to consider as many perspectives and factors as possible. Throughout the planning process, they considered how various design approaches would affect survey outcomes and resources.

51. Testing and Validation
Testing and validation is ongoing
Diverse selection criteria
Small & large facilities
Urban & Rural facilities
Variations in 5-star ratings
Geographically diverse facilities
Use of broad group of RO, SA, and
contract surveyors to test process and software
Equal use of QIS and traditional states
Use of analytic teams
Once the process was developed, testing began using CU, CMS Central Office, HMS, ROs and State surveyors. To date, they have had eight ROs and 12 SAs test the survey. Accounting for all testers, they have tested the survey, thus far, in 16 States and 24 facilities. CMS plans to do more testing to test revisions that were made to the process so the material presented today may undergo minor changes.
To test the process, they wanted to ensure they had as much diversity as possible. During testing, they represented States from around the country, including both QIS and Traditional. They tested in facilities of various sizes with teams of various sizes. They tested in urban and rural facilities. They tested in facilities both with and without rehabilitation units and/or locked Alzheimer’s units. They tested in facilities with various ratings—both facilities with good and poor performance.
For some of the test surveys, an analytic team also reviewed facility quality issues to determine if those areas of concern were identified through the survey process.
Following each round of testing, CU and CMS analyzed the data from each survey and reviewed surveyor feedback on the process. Based on the testing results and feedback, the process and materials were refined for the next round of testing.

52. Overview Initial Pool Process Sample size based on census:
70% offsite selected
30% selected onsite by team:
Vulnerable
New Admission
Complaint
FRI (Facility Reported Incidents- federal only)
Identified concern
I want to give a really high level overview of the entire survey process before going into more detail.
There are three main parts to the New LTC Survey Process: the initial pool process, sample selection, and investigation.
The sample size is based on the facility census. Generally, the sample size is about 20% of the facility census. In some cases, the sample size is slightly higher than the numbers included in the Traditional sample size grid but lower than the sample size for QIS. One example is the cap for facilities with a census at or above 175 residents. The cap for the Traditional is set at 30 and the cap for QIS is set at 40. The New LTC Survey Process has a cap of 35 residents for larger facilities.
One of the most critical components to any survey is the sample. For the new survey process, 70% of the residents will be MDS pre-selected. The team will select 30% of the residents onsite, including vulnerable residents who are dependent on staff, new admissions within the last 30 days, complaints or facility-reported incidents or FRIs—which would cover any alleged violation involving mistreatment, neglect, abuse, injuries of unknown origin, and misappropriation of property—and any resident who has a significant concern but does not fall into any of the sub-groups I just mentioned.
The first day of the survey, or about eight hours, depending on when the team enters, is spent conducting observations, interviews, and a limited record review for the residents in the initial pool.

53. Overview, continued Select Sample Survey team selects sample
Investigations
All concerns for sample residents requiring further investigation
Closed records
Facility tasks
At the end of the first day or beginning of the second day, the survey team will identify the sample. Once the sample is selected, the remainder of the survey is spent investigating all concerns requiring further investigation for the residents in the sample. Facility tasks and closed-record investigations will also be conducted.

54. Thank You!!