New Survey System, New Guidelines

Edition: November 2008 - Vol 16 Number 11
Article#: 3061
Author: Repertoire

This fall, your nursing home customers must make sense of a new set of guidelines, and those with some computer savvy will be ahead of the curve. The Centers for Medicare and Medicaid Services (CMS) has implemented its Quality Indicator Survey (QIS), a computer-assisted long-term care survey process used by selected State Survey Agencies and CMS to determine if Medicare-and Medicaid-certified nursing homes meet federal requirements. The new survey was scheduled to be launched in October.

This is a very different survey process, and providers must not only learn it, but become accustomed to the results as well, according to sources at the American Health Care Association. For instance, some nursing homes may have a higher number of deficiencies cited under QIS, but at a lower scope and severity compared with the traditional survey. However, although the survey process under QIS is new, the Federal regulations and interpretive guidance remain the same, according to CMS.

The Quality Indicator Survey was designed to achieve the following objectives:

Improve consistency and accuracy of care and quality-of-life problem-identification through a more structured survey process.

Enable timely and effective feedback on survey processes for surveyors and managers.

Systematically review requirements and objectively investigate all regulatory areas within current survey resources.

Provide tools for continuous improvement.

Enhance documentation by organizing survey findings through automation.

Focus survey resources on facilities, and areas within facilities, with the greatest number of quality concerns.

How it works

The Quality Indicator Survey is a two-stage process, which relies on customized software, or a data collection tool (DCT), on personal computers to guide surveyors through a more structured inspection. First, the surveyors review a facility's prior deficiencies, current complaints, ombudsman information and existing waivers and variances. Minimum data set (MDS) information for a particular facility is loaded offsite into the surveyors' PCs.

Next, the surveyors visit the nursing home and conduct an "entrance conference," during which they request facility information. They also conduct a brief tour of the nursing home to develop an overall impression. At this time, they collect three Stage I samples:

1. A census sample, which focuses on quality care and quality of life and includes randomly selected residents in the nursing home at the time of the survey.

2. An admission sample, which includes 30 recent admissions and focuses on such issues as re-hospitalization, death and functional loss. This sample includes current and/or discharged residents.

3. The minimum data set, which is used to create a resident pool from which stage I samples are randomly selected, as well as to calculate MDS-based quality of care and quality of life indicators (QCLI) for use in stage II.

Other residents and issues may also be selected at the surveyors' discretion. Stage I includes an initial review of large samples of residents, and includes resident, family and staff interviews, resident observations and clinical record reviews. Using onsite automation, surveyors may combine the results of these investigations to provide a comprehensive set of QCLIs. In addition, surveyors observe facility-level tasks, such as dining and kitchen provisions, infection control practices and medication administration, as well as the facility's Medicare demand billing process and quality assessment and assurance program.

Once Stage I is complete, the data collection tool combines the surveyors' findings with MDS data to determine which QCLIs exceed a national threshold, suggesting further investigation of certain care areas or facility-level tasks in Stage II.

Stage II involves the following steps:

Care area investigations using a set of investigative protocols that assist surveyors in completing an organized, systematic review of triggered care areas.

Completion of mandatory facility-level tasks.

Triggered facility-level tasks, which include abuse prohibition, environment, nursing services, sufficient staffing, personal funds and admission/transfer/discharge.

Once all investigations are complete, the surveyors analyze results to determine whether a facility is in noncompliance with federal requirements. The surveyors inform the nursing home of their findings during an exit conference.

Implementation and training

CMS is implementing the QIS on a state-by-state basis, depending on its resources for training surveyors. The training and implementation process may take between one and three years, depending on the number of surveyors who require training and other issues relevant to that state. Until all nursing home surveyors in a selected state have received training in the QIS process, some nursing homes in that state will continue to receive the traditional survey.

To ensure that QIS training is delivered in a consistent manner, CMS has opted to employ a contractor to conduct initial QIS training, as well as subsequent training of each state's designated QIS trainers. Training requirements include completion of Web-based lessons, classroom training, participation in a mock survey and achievement of two successful compliance assessments during surveys of record. QIS trainers must complete four additional QIS surveys of record, participate in a "Train-the-Trainer" workshop, deliver classroom training to surveyors, observe and evaluate surveyors during a mock survey and evaluate surveyor performance during a survey of record.

The University of Colorado is responsible for surveyor training and technical support, as well as QIS implementation, under the QIS Demonstration Project. Questions regarding the project may be directed to Fred Gladden at (410) 786-3033 or

To compare traditional surveys with the new QIS process, visit