SMQT CORE PREVIEW QUESTIONS AND ANSWERS
SET A+
✔✔What is the Impact Act of 2014? - ✔✔Impoving Medicare Post-Acute Care
Transitions-effective 11/19/19. Includes Discharge Planning rule, Burden reduction and
Emergency Preparedness.
✔✔What is the survey process based on? - ✔✔Person centered care, resident centered
outcomes, QOC and QOL.
✔✔What are the 8 principles of Documentation? - ✔✔1. Entity Compliance or
Noncompliance
2. Using plain language.
3. Components of a Deficiency statement
4. Relevance of Onsite correction of findings
5. Interpretive guidelines
6. Citation of State or local code violations
7. Cross-referencing
8. Condition of Participation Deficiencies
✔✔What are the components of a deficiency statement? - ✔✔1. regulatory reference
2. deficient practice statement
3.relevance facts and findings
✔✔What are CMS core values? - ✔✔1.Public service
2.Integrity
3.Accountablity
4.Excellance
5.Respect
✔✔What are the LTC Survey Core skills? - ✔✔1. Resident-centered, outcome oriented
information gathering
2. Critical thinking
,3. Teamwork
✔✔What is the definition of Practicable - ✔✔capable regardless of circumstances or
resources available to support an individual, innate ability
✔✔What is iatrogenesis? - ✔✔a problem that is caused by a treatment
✔✔When should you export the survey shell from ACO? - ✔✔Export the shell as close
to the survey as possible but no more than 5 business days before.
✔✔When should you contact the RAI coordinator? - ✔✔If the number of residents is
unreasonable after exporting the survey shell
✔✔Which residents are included in the survey shell? - ✔✔1. Offsite selected who make
up 70% of the sample
2. Residents with at least 1 MDS in the last 120 days
3. Residents for closed record review
✔✔What is the CASPER report? - ✔✔Certification and Survey Provider Enhanced
Reporting
✔✔What items are required upon entrance - ✔✔1. Census excluding bed holds
2. Matrix for new admits in the last 30 days
3. Alphabetized list of resdients
4. List of resident who smoke
✔✔When screening residents, what other concerns should you pay attention to? -
✔✔resident behavior, staff-resident interactions, resident grooming and cleanliness,
strong urinary odors, evidence of abuse or neglect
✔✔How many compliant/FRI residents are in the initial pool? - ✔✔5 residents
✔✔What types of residents must you include in the initial pool? - ✔✔1. who smokes
2 dialysis
3.Hopsice
4. Ventilator
5. TBP
✔✔What are the types of interview status? - ✔✔1. intervieable
2.Noninterviewable
3.Refused
4. Unavailable
5. Out of facility.
,✔✔What should you do if a resident halts the interview midway? - ✔✔Attempt to
complete later, if you can't, leave the rest blank, complete RO/RR then mark the
resident as complete.
✔✔What is CFR Part 489.301? - ✔✔Jeopardy
✔✔What is the definition of Jeopardy? - ✔✔A providers noncompliance has caused, or
is likely to cause, serious injury, harm, impairment or death.
✔✔What do you do if the team has different information then the systemvpopulated
information? - ✔✔Enter it under notes field
✔✔What system provided information should be discussed at the end of Day 1
meeting? - ✔✔1. were any offsite selected residents d/c?
2. Was each newly admitted resident listed on the matrix screened by a team member?
3. Are there any harm, SQC, IJ or other concerns to discuss?
✔✔What should you use when selecting the sample size? - ✔✔Use the sample size
grid, and system calculated minimum.
✔✔Can the samlpe size exceed the sample size grid? - ✔✔Yes
✔✔How many residents does the system select for unnecessary medication review? -
✔✔5
✔✔What should you ask for if Abuse is being investigated based on a history of abuse
as noted on offsite prep screen? - ✔✔Ask facility for all allegations of abuse since the
last survey.
✔✔What should you consider when adding residents when the sample size is not met?
- ✔✔Residents with the most concerns
Residents with concerns R/T QOL and RR
Residents selected for unnecessary med review
prior survey and complaint results
underrepresented areas of facility.
✔✔What is investigated when more than 5 complaint/fri residents are added to the
sample? - ✔✔You will only investigate for the allegation
✔✔When finalizing the sample you must ensure that a surveyor is assigned to which
residents? - ✔✔every resident in the sample, additional complaint/fri residents, non
sampled unnecessary medication review residents
, ✔✔What are the 9 mandatory facility tasks - ✔✔1. Beneficiary Protection Notification
review
2.Dining observation
3. Infection control
4. Kitchen
5. Medication Administration
6. Medication Storage
7. QAA/QAPI
8. Resident Council Meeting
9. Sufficient and Competent Nurse Staff
✔✔What 3 task are assigned to all surveyors? - ✔✔Dining observation, infection
control, sufficient and competent nurse staff. (One surveyor is assigned primary
responsibility for completion of each task)
✔✔Which facility tasks are triggered tasks? - ✔✔Environment, Personal Funds,
Resident Assessment
✔✔483.24 - ✔✔Quality of Life- pertains to all care and services provided. Facilities must
provide necessary care and services to attain or maintain highest practicable physical,
mental, and psychosocial well being.
✔✔483.25 - ✔✔Quality of Care-facility must ensure residents receive care and
treatment in accordance with professional standards of practice, person centered care
and resident choice
✔✔What is included on a baseline care plan? - ✔✔Initial goals based on admission
orders
MD orders and dietary orders
Therapy and social Services
PASARR
✔✔What is a PASARR - ✔✔Pre-Admission Screening and Resident review -screening
to ensure that the facility coordinates with the appropriate, State designated authority, to
ensure that individuals with a mental disorder, intellectual disability or a related
condition receive care and services in the most integrated setting appropriate to their
needs.
✔✔What pathway is used to investigate QOC concerns that have no pathway? -
✔✔General CE pathway
✔✔When should you use "Investigation Notes"? - ✔✔used for information specific to the
care area being reviewed
SET A+
✔✔What is the Impact Act of 2014? - ✔✔Impoving Medicare Post-Acute Care
Transitions-effective 11/19/19. Includes Discharge Planning rule, Burden reduction and
Emergency Preparedness.
✔✔What is the survey process based on? - ✔✔Person centered care, resident centered
outcomes, QOC and QOL.
✔✔What are the 8 principles of Documentation? - ✔✔1. Entity Compliance or
Noncompliance
2. Using plain language.
3. Components of a Deficiency statement
4. Relevance of Onsite correction of findings
5. Interpretive guidelines
6. Citation of State or local code violations
7. Cross-referencing
8. Condition of Participation Deficiencies
✔✔What are the components of a deficiency statement? - ✔✔1. regulatory reference
2. deficient practice statement
3.relevance facts and findings
✔✔What are CMS core values? - ✔✔1.Public service
2.Integrity
3.Accountablity
4.Excellance
5.Respect
✔✔What are the LTC Survey Core skills? - ✔✔1. Resident-centered, outcome oriented
information gathering
2. Critical thinking
,3. Teamwork
✔✔What is the definition of Practicable - ✔✔capable regardless of circumstances or
resources available to support an individual, innate ability
✔✔What is iatrogenesis? - ✔✔a problem that is caused by a treatment
✔✔When should you export the survey shell from ACO? - ✔✔Export the shell as close
to the survey as possible but no more than 5 business days before.
✔✔When should you contact the RAI coordinator? - ✔✔If the number of residents is
unreasonable after exporting the survey shell
✔✔Which residents are included in the survey shell? - ✔✔1. Offsite selected who make
up 70% of the sample
2. Residents with at least 1 MDS in the last 120 days
3. Residents for closed record review
✔✔What is the CASPER report? - ✔✔Certification and Survey Provider Enhanced
Reporting
✔✔What items are required upon entrance - ✔✔1. Census excluding bed holds
2. Matrix for new admits in the last 30 days
3. Alphabetized list of resdients
4. List of resident who smoke
✔✔When screening residents, what other concerns should you pay attention to? -
✔✔resident behavior, staff-resident interactions, resident grooming and cleanliness,
strong urinary odors, evidence of abuse or neglect
✔✔How many compliant/FRI residents are in the initial pool? - ✔✔5 residents
✔✔What types of residents must you include in the initial pool? - ✔✔1. who smokes
2 dialysis
3.Hopsice
4. Ventilator
5. TBP
✔✔What are the types of interview status? - ✔✔1. intervieable
2.Noninterviewable
3.Refused
4. Unavailable
5. Out of facility.
,✔✔What should you do if a resident halts the interview midway? - ✔✔Attempt to
complete later, if you can't, leave the rest blank, complete RO/RR then mark the
resident as complete.
✔✔What is CFR Part 489.301? - ✔✔Jeopardy
✔✔What is the definition of Jeopardy? - ✔✔A providers noncompliance has caused, or
is likely to cause, serious injury, harm, impairment or death.
✔✔What do you do if the team has different information then the systemvpopulated
information? - ✔✔Enter it under notes field
✔✔What system provided information should be discussed at the end of Day 1
meeting? - ✔✔1. were any offsite selected residents d/c?
2. Was each newly admitted resident listed on the matrix screened by a team member?
3. Are there any harm, SQC, IJ or other concerns to discuss?
✔✔What should you use when selecting the sample size? - ✔✔Use the sample size
grid, and system calculated minimum.
✔✔Can the samlpe size exceed the sample size grid? - ✔✔Yes
✔✔How many residents does the system select for unnecessary medication review? -
✔✔5
✔✔What should you ask for if Abuse is being investigated based on a history of abuse
as noted on offsite prep screen? - ✔✔Ask facility for all allegations of abuse since the
last survey.
✔✔What should you consider when adding residents when the sample size is not met?
- ✔✔Residents with the most concerns
Residents with concerns R/T QOL and RR
Residents selected for unnecessary med review
prior survey and complaint results
underrepresented areas of facility.
✔✔What is investigated when more than 5 complaint/fri residents are added to the
sample? - ✔✔You will only investigate for the allegation
✔✔When finalizing the sample you must ensure that a surveyor is assigned to which
residents? - ✔✔every resident in the sample, additional complaint/fri residents, non
sampled unnecessary medication review residents
, ✔✔What are the 9 mandatory facility tasks - ✔✔1. Beneficiary Protection Notification
review
2.Dining observation
3. Infection control
4. Kitchen
5. Medication Administration
6. Medication Storage
7. QAA/QAPI
8. Resident Council Meeting
9. Sufficient and Competent Nurse Staff
✔✔What 3 task are assigned to all surveyors? - ✔✔Dining observation, infection
control, sufficient and competent nurse staff. (One surveyor is assigned primary
responsibility for completion of each task)
✔✔Which facility tasks are triggered tasks? - ✔✔Environment, Personal Funds,
Resident Assessment
✔✔483.24 - ✔✔Quality of Life- pertains to all care and services provided. Facilities must
provide necessary care and services to attain or maintain highest practicable physical,
mental, and psychosocial well being.
✔✔483.25 - ✔✔Quality of Care-facility must ensure residents receive care and
treatment in accordance with professional standards of practice, person centered care
and resident choice
✔✔What is included on a baseline care plan? - ✔✔Initial goals based on admission
orders
MD orders and dietary orders
Therapy and social Services
PASARR
✔✔What is a PASARR - ✔✔Pre-Admission Screening and Resident review -screening
to ensure that the facility coordinates with the appropriate, State designated authority, to
ensure that individuals with a mental disorder, intellectual disability or a related
condition receive care and services in the most integrated setting appropriate to their
needs.
✔✔What pathway is used to investigate QOC concerns that have no pathway? -
✔✔General CE pathway
✔✔When should you use "Investigation Notes"? - ✔✔used for information specific to the
care area being reviewed