1. QIS / ASE-Q QIS Onsite Revisits

2. Revisit Checklist Quality Indicator Survey 2

3. Revisit Steps Offsite Preparations Onsite Preparations Transition Revisit Investigation Revisit Stage 2 Analysis Post Revisit Activities Quality Indicator Survey 3

4. Offsite Prep for Revisit Gather supplies Obtain shell in ACO Import the shell into ASE Update Team Roster Verify complete Quality Indicator Survey 4

5. Obtain survey shell from ACO Contains MDS data Includes completion dates Obtain close to revisit start date Quality Indicator Survey 5

6. 6

7. 7

8. 8

9. Need screen shot Quality Indicator Survey 9

10. Need screen shot Quality Indicator Survey 10

11. Quality Indicator Survey 11

12. Quality Indicator Survey 12

13. Quality Indicator Survey 13

14. Quality Indicator Survey 14

15. Quality Indicator Survey 15

16. 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. Quality Indicator Survey 25

26. Quality Indicator Survey 26

27. Onsite Preparations Request upon arrival at facility: Alphabetical list of residents Info required to supplement sample Quality Indicator Survey 27

28. Quality Indicator Survey 28

29. Quality Indicator Survey 29

30. Quality Indicator Survey 30

31. Quality Indicator Survey 31

32. Quality Indicator Survey 32

33. Quality Indicator Survey 33

34. f Quality Indicator Survey 34

35. f Quality Indicator Survey 35

36. f Quality Indicator Survey 36

37. f Quality Indicator Survey 37

38. Quality Indicator Survey 38

39. Quality Indicator Survey 39

40. Quality Indicator Survey 40

41. Quality Indicator Survey 41

42. Quality Indicator Survey 42

43. Quality Indicator Survey 43

44. Quality Indicator Survey 44

45. Quality Indicator Survey 45

46. Quality Indicator Survey 46

47. Quality Indicator Survey 47

48. Quality Indicator Survey 48

49. Quality Indicator Survey 49

50. Quality Indicator Survey 50

51. Quality Indicator Survey 51

52. Quality Indicator Survey 52

53. Quality Indicator Survey 53

54. Quality Indicator Survey 54

55. Quality Indicator Survey 55

56. Quality Indicator Survey 56

57. Quality Indicator Survey 57

58. Quality Indicator Survey 58

59. Quality Indicator Survey 59

60. Quality Indicator Survey 60

61. Quality Indicator Survey 61

62. Quality Indicator Survey 62

63. Quality Indicator Survey 63

64. Quality Indicator Survey 64

65. Quality Indicator Survey 65

66. Quality Indicator Survey 66

67. Post Revisit Activities Finalize the CMS-2567 Import revisit survey into ACO Delete the survey from ASE Quality Indicator Survey 67