5. “Negative” Responses by Data Source A “negative” response is a response that includes a resident in the “QCLI Criteria Met” category of the QCLI calculation results, or is part of a set of questions that includes a resident in the “QCLI Criteria Met” category. Rate (one for each data source) = Numerator: Number of negative responses by data source for each surveyor. Denominator: Number of responses by data source for each surveyor. Outlier rules Low outlier- Half or less than the national average (Except for FI and CR: a low outlier is =0%). High outlier- Double or more than the national average (Except for SI: a high outlier is ≥20%). None Identify any low or high outliers by data source for the report and state average compared to the national average. Review the surveyor rates to determine whether any surveyor has a low or high rate of negative responses by data source compared to the national average. Survey-level: Counts are made within a survey and across surveyors. Counts are made across surveys for individual surveyors. Report-level: Survey-level rates are averaged across surveys. Determine whether a surveyor has an unusual occurrence of 0% for Stage 1 negative responses or has a considerably lower/higher average rate of negative responses compared with the state or national average for each data source. If concerns are identified, examine QIS process steps that are associated with negative response rates. Ensure surveyors: Understand the intent of the questions, Ask the questions accurately, Do not ask leading questions, Do not repeat the question to elicit a positive response, Ask all of the questions, Answer the questions correctly, Conduct appropriate observations, and Conduct appropriate clinical record reviews. Ensure surveyors discuss pertinent findings for both resident and facility task assignments during team meetings. Ensure the team coordinator documents concerns during team meetings. 6. Census Sample Interview Rate
Lists all care areas and facility tasks that can be triggered. Identifies triggered care areas and tasks (T), cited care areas and tasks (C), and surveyor-initiated care areas and tasks (S). Survey totals for Triggered, Triggered and Cited, and Triggered and Not Cited are given at the end of each survey column. Looking across the report, the Totals column shows the number of times each care area was triggered and cited, the number of times each care area triggered, and the percentage of times each care area was triggered and cited. Outlier Low Outlier- If the national average is <26%, then the low outlier is ½ or less than the national average. If the national average is ≥26% and <61%, then the low outlier is 15 or more points less the national average. If the national average is ≥61%, then the low outlier is 20 or more points less than the national average. High outlier- None Identify the care areas and tasks that were triggered and not cited (0%) for the report (Totals) and state. Identify whether the report and state have a low or high citation rate for triggered care areas and tasks compared to the national average. When evaluating the citation rate, also consider the number of the care area or task triggered. A citation rate of 0% when the care area only triggered once may not have as much significance for this item as a care area that triggered on all ten surveys but was only cited once for a 10% rate. Determine trends or patterns regarding whether a particular care area or task continues to have a low/high citation rate when triggered. If is a low citation rate for a triggered care area or task, examine the QIS process steps that are associated with citations. Ensure surveyors: Follow the guidance on the facility task and CE pathway when conducting the investigation. Conduct a comprehensive and thorough investigation. Discuss pertinent findings with the team to assess the potential for noncompliance and determine the need for additional investigation. Make accurate compliance decisions.
If the national average is >11% then the high outlier is 40 points or more than the national average. If national average is ≤11%, then quadruple the national average. Note: Social Service has no high outlier and is an exception to the above rule. 20. Removed Care Areas/Tasks/Tags and Reason for Removal Identifies care facility tasks, and F-tags that were removed along with the reason for the removal. If the surveyor marked “8=other,” the documented rationale for the removal is provided. The surveyor who removed the care area, task, or F-tag is identified. No outlier rule Surveyor-Initiated F-tags with Mapping to a Care Area/ Task Report in and the F-tag Report in FTagReport.pdf Review the documented rationale and determine whether the rationale seems appropriate. If a care area or task was removed because Stage 1 information was recorded incorrectly or the resident was transferred or discharged from the facility (codes 1-5 and 7), review the Surveyor Initiated and Removed Care Areas and F-tag report to ensure another resident who met the criteria was initiated for the care area, as available. Determine trends or patterns regarding whether there is a particular care area, task, or F-tag being removed. If the surveyor selects reason 8=other, ensure that the documented rationale does not indicate that the assignment was removed since it is reassigned to another surveyor. To make workload adjustments in Stage 2, the original owner of the assignment should not remove the care area or task. The surveyor assuming responsibility of the assignment should initiate the care area or task. This will ensure that the reassigned area is actually completed when the surveyors synchronize their Stage 2 data. For example: Surveyor 1 surveyor 2 to complete the activity care area investigation for resident #3. Surveyor 1 leaves the activity care area incomplete on his/her tablet. Surveyor 2 initiates the activity care area for resident #3 on his/her tablet and completes the investigation. When surveyors 1 and 2 synchronize their Stage 2 data to the TC, the activity care area will display as complete provided surveyor 2 completed the investigation. 21. Rate of CE Responses of “No”
Count of QIS potential citations. This is the total number of potential citations determined onsite by the survey team during the analysis and decision-making meeting. Report calculation: An average of all QIS potential citations across the set of surveys being reviewed. Outlier rules Low outlier- 2 or less than the national average. High outlier- 4 or more than the national average None Determine whether a district office or team has a considerably lower/higher average count of QIS potential citations over time compared with the state and national average. If concerns are identified, examine the QIS process steps associated with Stage 2 investigations and compliance decisions. Ensure surveyors: Follow the guidance on the facility task and CE pathway when conducting the investigation. Conduct a comprehensive and thorough investigation. Discuss pertinent findings with the team to assess the potential for noncompliance and determine the need for additional investigation. Make accurate compliance decisions. 28. Number of Actual CMS-2567 Citations Count of Citations on the CMS-2567. Report calculation: The average count of actual citations across the set of surveys Outlier rules Low outlier- 2 or less than the national average. High outlier- 4 or more than the national average None Determine whether a district office or team has a considerably lower/higher average count of CMS-2567 citations over time compared with the state and national average. Determine whether surveyors add or delete deficiencies after the team has made compliance decisions during the analysis and decision-making meeting. (See DAR-SA item #27) Determine whether supervisors/reviewers add or delete deficiencies during the internal QA review process. Determine whether the CMS-2567 indicates numerous changes made to the QIS potential citations. If there are numerous differences between the QIS potential citations identified during the survey and the final CMS-2567, determine the underlying reasons for the differences (e.g., is the deletion due to an inadequate investigation or insufficient documentation, are supervisors adding F-tags that the team should have identified, is training warranted)? 29. Number of Tags with No Citation Decision