The Long Term Care Survey Process Procedure Guide that is used by surveyors under the LTCSP has been updated as of May 6, 2018. The updated procedure guide and other changes are also outlined in a new CMS Surveyor Training that is also available to providers.
Some highlights from the training that explain changes to the procedures includes:
- Complaints/FRIs – The LTCSP system software has been updated to address complaints/facility-reported incidents that are investigated during the survey, which allows the system to pull forward all complaint information throughout the survey. Complaints can be associated with a specific resident or be general to the facility. If a concern is not linked to a specific resident, all of the initial pool residents will show the specific area of concern so that surveyors are reminded to review that area during the initial pool review/selection.
- Screening Process – The training clarifies that the screening process during the LTCSP is for surveyors to identify residents to be included in the initial pool. This does not include offsite selected residents who still remain in the facility and any complaint/FRI residents because these two groups are already included in the initial pool. The screening is for all other residents to see if they should also be included in the initial pool. If no concerns based on MDS indicators and/or matrix information are found, then the surveyor is supposed to “conduct a quick head-to-toe observation of the resident.” If there are no concerns, then the surveyor should move on to the next person.
- If a concern during the screening process is identified based on surveyor observation, the surveyor is instructed to ask the resident “high level” questions such as if they have had any concerns with their care, and to ask the resident about the identified concern to see if that resident should be included in the initial pool.
- Initial Pool – Surveyors are instructed to review every initial pool area listed under the interview, observation and record review sources, with CMS noting that so far, there have been many areas left with blanks or checked off as completed without additional information. Further, CMS states that the only reason the “completed” box next to interview should be marked “complete” is if the resident chooses to stop the interview and it cannot be completed.
- General Facility Placeholder – The updated version of the software, as mentioned above, now allows surveyors to select a general facility placeholder if there are complaints or concerns that are not associated with a specific resident but should be investigated, or if the surveyor wants to cite a tag that wasn’t part of a facility task.
- Updates to Facility Tasks, CE Pathways and Matrix – CMS notes in the training that several facility tasks, Critical Element Pathways and the Matrix have been updated. (We’ll be covering these changes in another CMSCG Blog post).
- Updates to Recommended Sample Size/Team Size/Initial Pool Size – The table that provides recommendations for the number of residents, surveyors and initial pool size has been updated.
These changes and others are reflected in the May 6, 2018 LTCSP Procedure Guide, which can be downloaded here. You can launch the CMS ISTW training course, LTCSP 11.2 Software and Other Updates (LTCSP11.2) by visiting the Integrated Surveyor Training Website and selecting “I am a Provider” to view the course catalog.
Need help preparing for your facility’s upcoming survey? CMS Compliance Group’s interdisciplinary team of quality improvement and compliance consultants can work with you to achieve good survey outcomes. Contact us to learn more about how we can work together.
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