SMQT UPDATED EXAMS SCRIPT QUESTIONS AND
ANSWERS SET A+
✔✔1. only ONE INDIVIDUAL needs to be at risk
2. SERIOUS HARM, INJURY, IMPAIRMENT, OR DEATH does NOT HAVE TO
OCCURE BEFORE CONSIDERING immediate jeopardy. Requires HIGH potential for
those outcomes.
3. Individuals must not be subjected to abuse by ANYONE...staff, family, visitors,
volunteers
4. Serious harm can result from both abuse and neglect
5. Psychological harm is as serious as physical harm
6. When a cognitively impaired individual harmed another individual receiving care from
the entity due to the entity's failure to provide care and services to avoid physical harm,
mental anguish, or mental illness, this should be considered neglect.
7. any time a team cites abuse or neglect, it should consider IJ - ✔✔Principals of
Immediate Jeopardy
✔✔1. the entity either created a situation or allowed a situation to continue which
resulted in serious harm or a potential for serious harm, injury, impairment, or death to
individuals
2. the entity had an opportunity to implement corrective or preventive measures -
✔✔What points should be considered regarding entity compliance in regards to
immediate jeopardy?
✔✔1. screening
2. training
3. prevention
4. identification
5. investigation
6. protection
7. reporting/response - ✔✔Key components to prevent abuse and neglect?
,✔✔Entity compliance and noncompliance
-When an entity complies with the requirements applicable to the survey conducted, the
form CMS-2567 should consist of an explicit statement that the entity is in compliance.
- If an entity does not comply with one or more applicable requirements, the form CMS-
2567 includes corresponding citations of noncompliance - ✔✔Principles of
Documentation #1
✔✔Using Plain Language
- The deficiency citation is written clearly, objectively and in a manner that is easily
understood. - ✔✔Principles of Documentation #2
✔✔Components of a Deficiency Citation
- regulatory reference
- deficient practice statement
- relevant findings - ✔✔Principles of Documentation #3
✔✔Relevant onsite correction of findings
- if during the survey the entity corrects the situation that resulted in the deficiency, a
determination of "not met" must be documented on the 2567. The entity may indicate its
corrections in the right-hand column of the 2567. During IJ, if the facility initiates
corrective actions that abate a finding for IJ, follow the guidance in appendix Q -
✔✔Principles of Documentation #4
✔✔Interpretive Guidance
- the deficiency citation explains how the entity fails to comply with the regulatory
requirements, not the interpretation of those requirements. - ✔✔Principles of
Documentation #5
✔✔Citation of State or Local Code Violations
- state code are not cited on the 2567 - ✔✔Principles of Documentation #6
✔✔Cross-References
- Cross referencing from one citation to another is acceptable, but each deficiency must
stand by itself - ✔✔Principles of Documentation #7
✔✔Condition of Participation Deficiencies
- COP (requirements with which an entity must comply in order to participate in the
programs) citation includes deficient practice statements and findings to support the
determination of noncompliance with a condition level requirement. The finding may be
incorporated either by cross references to those which must be corrected to find the
COP in compliance or by narrative description of the individual findings - ✔✔Principles
of Documentation #8
, ✔✔ABUSE PROHIBITION REVIEW: Description - ✔✔The Abuse Prohibition Review is
a determination of whether the facility has both DEVELOPED & OPERATIONALIZED
policies and procedures designed to protect residents from the following:
- Abuse
- Neglect
- Involuntary seclusion
- Misappropriation of their property
This includes policies and procedures for:
- Hiring practices
- Training
- Ongoing supervision for employees and volunteers who provide services
- Reporting and investigation of allegations and occurrences that may indicate abuse
✔✔ABUSE PROHIBITION REVIEW: General Procedures - ✔✔General Procedures:
The review includes components of the facility's policies and procedures as contained in
the Guidance to Surveyors. These include policies and procedures for:
- Screening of potential hirees (or employees)
- Training of employees (both for new employees and ongoing training for all
employees)
- Prevention policies and procedures
- Identification of possible incidents or allegations that need (or require) investigation
- Investigation of incidents and allegations
- Protection of residents during investigations
- Reporting of incidents, investigations, and facility response to their investigations
- The general procedure for the Abuse Prohibition Review is to use/follow the Abuse
Prohibition Investigative Protocol to complete the task.
✔✔QUIZ QUESTION:
What is the general objective of the Abuse Prohibition Review? - ✔✔ANSWER:
The general objective of the Abuse Prohibition Review is to determine if the facility has
BOTH developed & operationalized policies & procedures that PROHIBIT
ANSWERS SET A+
✔✔1. only ONE INDIVIDUAL needs to be at risk
2. SERIOUS HARM, INJURY, IMPAIRMENT, OR DEATH does NOT HAVE TO
OCCURE BEFORE CONSIDERING immediate jeopardy. Requires HIGH potential for
those outcomes.
3. Individuals must not be subjected to abuse by ANYONE...staff, family, visitors,
volunteers
4. Serious harm can result from both abuse and neglect
5. Psychological harm is as serious as physical harm
6. When a cognitively impaired individual harmed another individual receiving care from
the entity due to the entity's failure to provide care and services to avoid physical harm,
mental anguish, or mental illness, this should be considered neglect.
7. any time a team cites abuse or neglect, it should consider IJ - ✔✔Principals of
Immediate Jeopardy
✔✔1. the entity either created a situation or allowed a situation to continue which
resulted in serious harm or a potential for serious harm, injury, impairment, or death to
individuals
2. the entity had an opportunity to implement corrective or preventive measures -
✔✔What points should be considered regarding entity compliance in regards to
immediate jeopardy?
✔✔1. screening
2. training
3. prevention
4. identification
5. investigation
6. protection
7. reporting/response - ✔✔Key components to prevent abuse and neglect?
,✔✔Entity compliance and noncompliance
-When an entity complies with the requirements applicable to the survey conducted, the
form CMS-2567 should consist of an explicit statement that the entity is in compliance.
- If an entity does not comply with one or more applicable requirements, the form CMS-
2567 includes corresponding citations of noncompliance - ✔✔Principles of
Documentation #1
✔✔Using Plain Language
- The deficiency citation is written clearly, objectively and in a manner that is easily
understood. - ✔✔Principles of Documentation #2
✔✔Components of a Deficiency Citation
- regulatory reference
- deficient practice statement
- relevant findings - ✔✔Principles of Documentation #3
✔✔Relevant onsite correction of findings
- if during the survey the entity corrects the situation that resulted in the deficiency, a
determination of "not met" must be documented on the 2567. The entity may indicate its
corrections in the right-hand column of the 2567. During IJ, if the facility initiates
corrective actions that abate a finding for IJ, follow the guidance in appendix Q -
✔✔Principles of Documentation #4
✔✔Interpretive Guidance
- the deficiency citation explains how the entity fails to comply with the regulatory
requirements, not the interpretation of those requirements. - ✔✔Principles of
Documentation #5
✔✔Citation of State or Local Code Violations
- state code are not cited on the 2567 - ✔✔Principles of Documentation #6
✔✔Cross-References
- Cross referencing from one citation to another is acceptable, but each deficiency must
stand by itself - ✔✔Principles of Documentation #7
✔✔Condition of Participation Deficiencies
- COP (requirements with which an entity must comply in order to participate in the
programs) citation includes deficient practice statements and findings to support the
determination of noncompliance with a condition level requirement. The finding may be
incorporated either by cross references to those which must be corrected to find the
COP in compliance or by narrative description of the individual findings - ✔✔Principles
of Documentation #8
, ✔✔ABUSE PROHIBITION REVIEW: Description - ✔✔The Abuse Prohibition Review is
a determination of whether the facility has both DEVELOPED & OPERATIONALIZED
policies and procedures designed to protect residents from the following:
- Abuse
- Neglect
- Involuntary seclusion
- Misappropriation of their property
This includes policies and procedures for:
- Hiring practices
- Training
- Ongoing supervision for employees and volunteers who provide services
- Reporting and investigation of allegations and occurrences that may indicate abuse
✔✔ABUSE PROHIBITION REVIEW: General Procedures - ✔✔General Procedures:
The review includes components of the facility's policies and procedures as contained in
the Guidance to Surveyors. These include policies and procedures for:
- Screening of potential hirees (or employees)
- Training of employees (both for new employees and ongoing training for all
employees)
- Prevention policies and procedures
- Identification of possible incidents or allegations that need (or require) investigation
- Investigation of incidents and allegations
- Protection of residents during investigations
- Reporting of incidents, investigations, and facility response to their investigations
- The general procedure for the Abuse Prohibition Review is to use/follow the Abuse
Prohibition Investigative Protocol to complete the task.
✔✔QUIZ QUESTION:
What is the general objective of the Abuse Prohibition Review? - ✔✔ANSWER:
The general objective of the Abuse Prohibition Review is to determine if the facility has
BOTH developed & operationalized policies & procedures that PROHIBIT
