Survey Process and Citations Flashcards

When a surveyor cites a facility for a deficiency, the citation must include which of the following?

Answer: The regulatory tag number and scope/severity level

Every citation must reference the applicable regulatory tag number and be assigned a scope and severity level.

Which term describes a deficiency that causes no actual harm but has the potential for more than minimal harm?

Answer: No actual harm with potential for more than minimal harm

Deficiencies are classified as 'no actual harm with potential for more than minimal harm' when residents are not yet hurt but could be.

During an entrance conference, what is the primary purpose of the surveyor's opening statement?

Answer: To explain the survey process and team composition to facility leadership

The entrance conference orients facility leadership to the survey team, purpose, and general process.

Under CMS guidelines, which survey task involves reviewing a sample of residents' comprehensive assessments and care plans?

Answer: Resident sample selection and care planning

The resident sample task includes reviewing MDS assessments and care plans to evaluate individualized care.

A surveyor observes a resident being repositioned without following the documented care plan. This finding is BEST documented as:

Answer: A potential deficiency to be corroborated with interview and record review

Initial observations must be corroborated through interviews and records before a deficiency is cited.

Which CMS document outlines the specific tasks surveyors must complete during a standard nursing home survey?

Answer: State Operations Manual (SOM)

The State Operations Manual provides the procedural guidance surveyors follow for all standard survey tasks.

If a facility disputes a citation during the exit conference, the surveyor's appropriate response is to:

Answer: Explain the basis of the finding and note the dispute for the record

Surveyors explain their findings' evidentiary basis; formal dispute resolution occurs through the IDR/IIDR process after the survey.