SMQT Survey Process and Citations 4 — Questions and Answers
Question 1: A Plan of Correction (PoC) submitted by a facility must include which of the following elements?
- A signed admission of negligence by the administrator
- How the deficiency will be corrected, a completion date, and how compliance will be maintained (Correct answer)
- Payment of assessed civil monetary penalties before submission
- Surveyor approval signatures on each corrective action
Correct answer: How the deficiency will be corrected, a completion date, and how compliance will be maintained
A valid PoC must address correction of the specific deficiency, the completion date, and ongoing monitoring to maintain compliance.
Question 2: Which of the following triggers an Immediate Jeopardy (IJ) declaration during a survey?
- A documentation error found in a single resident's chart
- A situation where a facility's noncompliance has caused or is likely to cause serious injury or death (Correct answer)
- Three or more residents with the same care plan deficiency
- Failure to post the most recent survey results
Correct answer: A situation where a facility's noncompliance has caused or is likely to cause serious injury or death
Immediate jeopardy requires that noncompliance caused or is likely to cause serious harm, injury, impairment, or death.
Question 3: During a revisit survey, the surveyor's primary goal is to:
- Conduct a full standard survey of all care areas
- Verify that previously cited deficiencies have been corrected (Correct answer)
- Interview all residents about new complaints
- Reassess the facility's overall quality star rating
Correct answer: Verify that previously cited deficiencies have been corrected
A revisit is a targeted follow-up to confirm that deficiencies cited in the prior survey have been corrected.
Question 4: The closed record review task during a nursing home survey examines records of residents who:
- Refused to participate in the open survey sample
- Were discharged or died during a defined look-back period (Correct answer)
- Are currently receiving hospice services
- Have active grievances pending with the facility
Correct answer: Were discharged or died during a defined look-back period
Closed records are those of recently discharged or deceased residents and are reviewed to identify care issues not visible in current residents.
Question 5: Which regulatory tag is associated with nursing home residents' rights to be free from abuse, neglect, and exploitation?
- F600 (Correct answer)
- F684
- F758
- F812
Correct answer: F600
F600 covers the requirement that residents are free from abuse, neglect, misappropriation, and exploitation.
Question 6: A surveyor discovers that a facility failed to investigate and report an allegation of resident-to-resident abuse. The MOST appropriate action is to:
- Issue a courtesy warning and allow 30 days for self-correction
- Cite deficiencies under abuse prohibition and reporting requirements (Correct answer)
- Refer the matter solely to local law enforcement and take no survey action
- Document the finding but defer citation pending the facility's own investigation
Correct answer: Cite deficiencies under abuse prohibition and reporting requirements
Failure to investigate and report abuse allegations constitutes a citable deficiency independent of local law enforcement action.
Question 7: What is the significance of the 'kitchen sink' approach in surveying, and why is it discouraged?
- It refers to thorough documentation, which is encouraged
- It means citing every minor issue observed, which dilutes focus on serious deficiencies (Correct answer)
- It describes the food safety inspection portion of the survey
- It is the CMS-recommended method for large facilities
Correct answer: It means citing every minor issue observed, which dilutes focus on serious deficiencies
Citing trivial deficiencies alongside serious ones reduces the impact of significant findings and misallocates enforcement resources.
SMQT Survey Process and Citations 4
A Plan of Correction (PoC) submitted by a facility must include which of the following elements?