SMQT Survey Process and Citations 2 — Questions and Answers
Question 1: When a surveyor cites a facility for a deficiency, the citation must include which of the following?
- The name of the staff member responsible
- The regulatory tag number and scope/severity level (Correct answer)
- The administrator's signature of receipt
- The proposed corrective action
Correct 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.
Question 2: Which term describes a deficiency that causes no actual harm but has the potential for more than minimal harm?
- Immediate jeopardy
- Actual harm
- No actual harm with potential for more than minimal harm (Correct answer)
- Isolated deficiency
Correct 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.
Question 3: During an entrance conference, what is the primary purpose of the surveyor's opening statement?
- To collect staff signatures on disclosure forms
- To explain the survey process and team composition to facility leadership (Correct answer)
- To review the previous survey's Plan of Correction
- To conduct the initial medication pass observation
Correct 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.
Question 4: Under CMS guidelines, which survey task involves reviewing a sample of residents' comprehensive assessments and care plans?
- Closed record review
- Resident council interview
- Beneficiary protection notification review
- Resident sample selection and care planning (Correct answer)
Correct answer: Resident sample selection and care planning
The resident sample task includes reviewing MDS assessments and care plans to evaluate individualized care.
Question 5: A surveyor observes a resident being repositioned without following the documented care plan. This finding is BEST documented as:
- A complaint requiring separate investigation
- A potential deficiency to be corroborated with interview and record review (Correct answer)
- An immediate jeopardy situation requiring facility lockdown
- An administrative note outside the survey record
Correct 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.
Question 6: Which CMS document outlines the specific tasks surveyors must complete during a standard nursing home survey?
- State Operations Manual (SOM) (Correct answer)
- Conditions of Participation (CoP) handbook
- Federal Register preamble
- OSHA compliance guide
Correct answer: State Operations Manual (SOM)
The State Operations Manual provides the procedural guidance surveyors follow for all standard survey tasks.
Question 7: If a facility disputes a citation during the exit conference, the surveyor's appropriate response is to:
- Remove the citation immediately to avoid conflict
- Explain the basis of the finding and note the dispute for the record (Correct answer)
- Escalate the dispute to the CMS regional office on the spot
- Allow the facility 24 hours to provide counter-evidence before the exit
Correct 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.
SMQT Survey Process and Citations 2
When a surveyor cites a facility for a deficiency, the citation must include which of the following?