THE QIS POST SURVEY REVISIT PSR Courtney Hamilton

THE QIS POST SURVEY REVISIT (PSR) Courtney Hamilton MSN, RN Director Health Care Education & Quality ISDH

INTRODUCTION TO THE NEW PSR PROCESS The PSR application is fully integrated into the QIS software Can be used for each revisit The PSR follows the same tasks as in the QIS annual recertification surveys Offsite Preparations Onsite Preparations Transition Revisit Investigation Revisit Stage 2 Analysis Post Revisit Activities

PSR SAMPLE SELECTION & THE MDS The PSR survey data includes updated MDS data The MDS data is used to automatically update the status of the residents and is used by the software to select a sample of three residents for each care area. The PSR sample may include residents who were cited on the annual survey as well as resident’s who met the QCLI criteria on the annual survey but were not part of the sample. Only includes residents currently in the facility

OFFSITE PREPARATIONS During Offsite Preparations, the Team Coordinator (TC) reviews the F-tags cited during the annual recertification survey. Software displays F-tags with a S/S of D or higher Displays the POC dates if entered. Allows for the TC to make any pertinent notes about the revisit survey.

ONSITE PREPARATIONS – REVIEWING THE SAMPLE SELECTIONS The survey team will ensure three residents were sampled for each care area or F-tag direct cite If three residents are not sampled – the survey team will request additional information from the facility. For example – if three residents were not sampled for pressure ulcers, the survey team will ask the facility for a list of residents with pressure ulcers. If the F-tag was a result of a facility task – no residents will be selected. If the med error rate was 5% or greater, then the Medication Administration task will need to be initiated.

ONSITE PREPARATIONS When the survey team enters the facility they will request: An alphabetical resident census List of any residents needed to supplement the sample. The Resident Pool information is updated from the MDS and reflects admissions and discharges since the annual survey. The TC will ensure that all sampled residents are still in the facility Residentifiers are the same for both annual survey and the PSR. No duplication of sample numbers

WHAT QCLI DATA IS AVAILABLE DURING THE PSR? On the PSR screens the QCLI data from both the annual survey and the PSR are available for review. The QCLI data for the PSR only includes current MDS data. Provides additional information if another resident is needed for a sample.

REVISIT INVESTIGATIONS The QA&A facility task is ALWAYS conducted on a PSR During the PSR investigations, the surveyor has access on their computers to the following information: The F-tag cited The applicable care area related to the F-tag The completion date POC information documented prior to entrance to the facility Text from the annual survey’s 2567 Regulations Interpretive Guidance The Critical Element Pathway

REVISIT TEAM MEETINGS As with the QIS annual survey, team meetings should be held at least daily to discuss pertinent findings, possible IJ’s, or any concerns with the high likelihood of rising to the level of harm. The team should discuss any possibilities of Substandard Quality of Care If the three sampled residents for an F-tag from one of the big three Regulatory Groupings (Resident Behavior & Facility Practices, Quality of Life and Quality of Care) have the potential for noncompliance – the team MUST determine whether SQC possibly exists. Determine the need for a supplemental sample

REVISIT ANALYSIS Potential Citations Includes any potential citations from NEW concerns List of citations that have been corrected List of deficiencies that are being recited on the PSR. There must be a decision documented on every tag listed as potential or re-cite Correction dates are entered on this screen Exit Conference

QUESTIONS ? ?