SMQT Survey Process and Citations 3 — Questions and Answers
Question 1: The 'universe' in the context of a nursing home survey refers to:
- All residents currently admitted to the facility
- The total population from which the resident sample is drawn (Correct answer)
- All deficiencies cited in the past three surveys
- The full list of applicable federal regulations
Correct answer: The total population from which the resident sample is drawn
The universe is the entire eligible population used to determine the appropriate resident sample size and selection.
Question 2: Which scope level indicates that a deficiency affects only a limited number of residents and is not a widespread pattern?
- Widespread
- Pattern
- Isolated (Correct answer)
- Systemic
Correct answer: Isolated
An 'isolated' scope means the deficiency occurred in one or a small number of instances without a pattern.
Question 3: During a survey, a resident tells a surveyor that staff skip her scheduled bath twice a week. This information is BEST classified as:
- Hearsay and therefore unusable
- Interview data to be corroborated with observation and records (Correct answer)
- Sufficient standalone evidence for an immediate citation
- Confidential and cannot be included in the survey record
Correct answer: Interview data to be corroborated with observation and records
Resident interviews are valid data sources that must be corroborated before a deficiency is cited.
Question 4: What is the purpose of an Informal Dispute Resolution (IDR) following a survey?
- To allow surveyors to add new citations after exit
- To give facilities a formal opportunity to dispute cited deficiencies before they are finalized (Correct answer)
- To determine the facility's fine amount for Immediate Jeopardy findings
- To schedule the next standard survey date
Correct answer: To give facilities a formal opportunity to dispute cited deficiencies before they are finalized
IDR is a post-survey process where facilities can present evidence challenging cited deficiencies.
Question 5: A surveyor notes a pattern of missed call-light responses across multiple residents. The scope assigned would most likely be:
- Isolated
- Pattern (Correct answer)
- Widespread
- Immediate jeopardy
Correct answer: Pattern
A 'pattern' scope is used when a deficiency affects more than a limited number of residents but is not ubiquitous throughout the facility.
Question 6: Which of the following BEST describes the purpose of the Quality Indicator Survey (QIS) trigger system?
- To randomly select which facilities are surveyed each year
- To identify areas of concern from MDS data that guide survey task focus (Correct answer)
- To automatically generate citations without on-site verification
- To score each facility's overall star rating
Correct answer: To identify areas of concern from MDS data that guide survey task focus
QIS uses MDS-derived quality indicators to help surveyors prioritize which areas to investigate during an on-site survey.
Question 7: When documenting an observation of a potential deficiency, surveyors should record:
- Only the conclusion that a regulation was violated
- Specific details including time, location, what was seen, and who was present (Correct answer)
- The resident's full name and Social Security number
- Staff disciplinary history for the persons involved
Correct answer: Specific details including time, location, what was seen, and who was present
Detailed, objective documentation including time, place, and observable facts is required to support any potential citation.
SMQT Survey Process and Citations 3
The 'universe' in the context of a nursing home survey refers to: