Although the guidance and regulations have not changed, the new Quality Indicator Survey (QIS) process changes the methods by which outcomes are measured and data collected.

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or many years, I have heard many persons working in long-term care say they wished state surveyors would be “consistent and more organized.” Sometimes you better be careful for what you wish for, because it may come true. That is just the case with the survey process in the long-term care industry. The Centers for Medicare & Medicaid Services (CMS) heard those voices loud and clear and developed a revised long-term care survey process, the Quality Indicator Survey (QIS). It was designed as a two-stage process for surveyors to use to systematically and objectively review all regulatory areas and subsequently focus on selected areas for further review.
       The QIS provides a structure for an initial review of a larger sample of residents based on the Minimum Data Set (MDS), resident and family interviews, observations, and medical record reviews. Although the survey process has been revised under the QIS, the federal regulations and interpretive guidelines have not changed.

Table 1

To follow are objectives that CMS hoped to achieve under the new process:
       • Improve consistency and accuracy of the quality of care and quality of life problem identification using a more structured process
       • Comprehensively review the full range of regulatory care areas within current survey resources
       • Enhance documentation by organizing survey findings through automation
       • Focus survey resources on the facilities with the largest number of quality concerns.
       If you review the conclusions of initial testing, you see that this revised survey process has yielded increased consistency and has improved documentation of survey findings. Given the promising results from the testing, CMS now plans to evaluate the QIS on a larger scale, using surveys of record through a demonstration with an independent evaluation.

The Development of the Quality Indicator Survey

       The University of Colorado’s Division of Health Care Policy and Research and the University of Wisconsin-Madison’s Centers for Health Systems Research and Analysis developed the QIS with information systems support provided by Mavericks Systems, Inc., and Alpine Technologies, through a contract from CMS for which RTI International was the prime contractor.
       The QIS process, tools, software, and training materials have undergone extensive revision and refinements over the years through pilot, feasibility, alpha, and beta tests led by teams of researchers, state surveyors, and CMS staff, in many facilities across the United States. The QIS Demonstration enabled CMS to further refine and improve upon the process before determining whether to proceed with national implementation.
       For purposes of the demonstration, CMS designed the QIS as a standard survey. Some facilities in the demonstration states were surveyed using the QIS as the survey of record; however, most facilities in these states were surveyed using the current survey process, known as the traditional survey. The demonstration and evaluation of the QIS was held in five states: California, Connecticut, Kansas, Louisiana, and Ohio. These five states were selected from among 25 states based on several criteria, including geographic balance, representation of rural areas, citation history, use of technology, and average survey time. One state was selected based on its primarily rural population.
       The QIS began in October of 2005. It was only used by a state survey agency upon approval of CMS and by surveyors who had received QIS training. The demonstration project lasted one year. National rollout is planned for late 2007 and 2008. Some states, including Florida and Connecticut, have already started second-phase statewide rollout.
       The QIS process uses customized software called the QIS Data Collection Toll (QIS DCT) to guide surveyors through a structured, two-staged investigation. The process begins with offsite preparation similar to that completed during the traditional federal long-term care survey process. This includes preparation of team assignments and review of available information regarding prior deficiencies, complaints, ombudsman information, and existing waivers and variances. Unlike the traditional survey process, the QIS does not require surveyors to review the Quality Indicator/Quality Measure (QI/QM) and Online Survey Certification and Reporting (OSCAR) reports on pre-selected potential residents for review prior to the survey. MDS data is requested and loaded off site into the surveyors’ computers and used to calculate the MDS-based Quality of Care Indicators (QCIs). This information is used to create the list of residents from which the Stage 1 samples are selected.

The Stages of the Quality Indicator Survey

       The purpose of the initial tour is not to select a sample of residents nor to gather detailed information regarding specific concerns. Concurrent to the entrance conference that is held upon entry to the facility, another surveyor conducts an abbreviated tour of the facility to become orientated to the facility layout, resident population, and staff.
       There are three distinct Stage 1 samples that are selected: the MDS sample (which is selected off site), the census sample, and the admission sample. The MDS sample includes facility-reported information on residents who have had an MDS assessment at any time during the past six months. This does not include discharge or reentry assessments. The census sample is made up of 40 randomly selected residents who reside in the facility at the time of the on-site visit. The admission sample includes 30 residents who were recently admitted to the facility. An emphasis is placed on skilled nursing facility (SNF) post-acute residents and long-stay admissions with critical issues (eg, rehospitalization, functional loss, or death). We cannot forget that, in addition to these samples, the surveyors can select other residents for the sample based on their observations. This is referred to as the surveyor-initiated sample.
       Stage 1 includes a preliminary investigation of all regulatory areas and the process of determining care areas for in-depth Stage 2 review. It also consists of both computer analysis of offsite data from the MDS system as well as data collected by surveyors on site by observation, record review of the large computer-selected resident samples, and interviews. The on-site data gathered is used together with the MDS data to build resident-centered outcome and process QCIs.
       Stage 2 is a more in-depth and systematic resident-level investigation of care areas. Investigations of triggered residents are conducted using investigative protocols, which serve as probes that guide the surveyor to investigate and determine whether the facility is in compliance with the regulations. Also during Stage 2, the surveyors will determine the deficiencies, including the Federal Tags (F-Tags) and scope and severity.

The Nine Survey Tasks

       Not only is the QIS process broken into two distinct stages, but there are nine tasks that are completed both off and on site.
       Task 1 includes gathering offsite data; processing the MDS data in the QIS DCT software used to randomly select samples, input survey information, document relevant findings, calculate QCIs, and provide review of potential citations; reviewing the facility history by reviewing OSCAR data for patterns, complaint history, and ombudsman reports; and printing a New Admission form and Census Sample Report to take to the facility.
       Task 2 begins when they walk in your front door. This is when an entrance conference will be held with the Administrator and Director of Nursing (DON). The surveyor will request an alphabetical resident census with room numbers and units identified. You will be required to identify at this point who is not in your facility. The New Admission form will be completed to include residents admitted 30 days prior to the date on the form and who are still in the facility. Date of birth will be required.
       The surveyor will also ask for a copy of the facility floor plan, staffing schedules for licensed nursing staff for the survey time period, and an established work place with electrical outlets for the computer(s). You will be asked to complete forms 671 (Medicare/Medicaid Application) and 672 (Resident Census and Conditions). No longer will you be asked to complete form 802.
       The surveyor will ask for information regarding the emergency water source and determine whether full-time DON coverage is provided. This will be a verbal response. Facility staff will be provided a QIS brochure. The surveyor will conduct private interviews with family and residents (unless they require staff present) and ask facility staff for assistance if needed. There will not be daily conferences.
       While the entrance conference is going on, the other surveyor(s) will begin the initial tour and the kitchen/food service observation. They will try to meet with the resident council president to set up a time to meet with him/her and ask permission to review resident council meeting minutes for the past three months. The dining observations will begin if it is mealtime. Some of the things they will be watching during the dining observations include releasing restraints, serving all residents at one table at a time, the interaction between staff and residents, asking to apply clothing protectors (which should never be used to wipe a resident’s mouth and/or face), and the overall dining experience.

Table 2

       Task 3 involves the initial tour. Gone will be the days on which your “most knowledgeable nurse” accompanies the surveyor on the tour. The surveyor will walk your halls. He/she will gather information about your facility. Observations will be made to assess staff-resident interaction, staff availability, call-light response, and activities the residents are engaged in both in their rooms and in supervised and structured activities. Special attention will be paid to the presence of residents with clinically complex and/or special needs as well as your special care units. The intent is to get an overall impression of the facility and a brief overview of residents and staff. The initial tour is not intended to add to the resident sample, and it is not necessary for staff to accompany the surveyor on the tour. Observations will be made on general environment.
       Task 4 is when the surveyors will finalize the resident sample selection, update the census sample to reflect current residents, and add assessments to the sample. The admission sample will be selected, and you will be given the name of residents whose closed records are requested. Keep in mind that the admission sample targets up to 30 new admissions (ie, those who have had an admission MDS submitted within 180 days prior to the extraction date). Surveyors will have a high interest in those residents who have been rehospitalized, sustained a loss of physical function, and died. This is a period when residents are extremely vulnerable to such issues as hospitalization.
       The surveyor-initiated sample is for those residents selected at the surveyors’ discretion and may be selected for inclusion based on complaints, ombudsman information, on-site information from random observations, and/or interviews. These residents are automatically added to the Stage 2 investigation. They will also finalize the census sample, which includes up to 40 residents in the facility at the time of the survey. Because direct observations, interviews, and record reviews are conducted for the census sample in Stage 1, the sample does not rely on staff-reported data and can address other quality of care areas. Emphasis is placed on long-stay residents. The QIS process will encompass a larger resident sample.

       Editor’s note: Part 2 of this article, which begins with Task 5 of the QIS process, will run in the October issue of ECPN.