Survey Process and Citations Flashcards

Which of the following BEST describes 'actual harm' as a severity level in the CMS citation framework?

Answer: A deficiency that has resulted in a negative outcome that compromises the resident's ability to maintain or reach their highest practicable well-being

Actual harm means the deficiency caused a measurable negative outcome affecting the resident's physical, mental, or psychosocial well-being.

When a surveyor conducts a medication administration observation, they are specifically looking for:

Answer: Adherence to the 'five rights': right resident, drug, dose, route, and time

The five rights of medication administration are the standard framework for evaluating safe medication practices.

A surveyor finds that a resident's care plan was not updated after a significant change in condition. This could constitute a deficiency under which regulatory area?

Answer: Comprehensive care planning

Failure to revise care plans after a significant change in condition violates the comprehensive care planning requirements.

Which of the following is an example of a 'widespread' scope deficiency?

Answer: The facility's hand hygiene protocol is not being followed by most staff throughout the building

Widespread scope applies when a deficiency affects the majority of residents or reflects a systemic problem throughout the facility.

During a survey exit conference, which information must the surveyor provide to the facility?

Answer: A verbal summary of deficiencies found and the basis for each citation

The exit conference must include a summary of deficiencies and the evidentiary basis, but penalty amounts and resident confidentiality are protected.

A facility's administrator asks a surveyor to share the names of residents who made complaints. The surveyor should:

Answer: Refuse, as resident interview information is confidential and must not be disclosed

Surveyor guidelines strictly protect resident confidentiality — informant identities are never disclosed to facility management.

Which of the following is the correct order of steps when a surveyor identifies a potential Immediate Jeopardy situation?

Answer: Notify the team coordinator, confirm IJ criteria are met, inform facility leadership, and require immediate removal of jeopardy

IJ protocol requires team consultation to confirm criteria, followed by immediate notification to facility leadership so jeopardy is removed as quickly as possible.