This is [Synora Jones] from CMS and myself and [Kellie Jakaitis] will be doing the training.

The goal of today’s presentation is to cover the changes to ASPEN 11.2. In addition, we will highlight some of the areas that surveyors have asked about or have been struggling with.

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There is an updated LTCSP Procedure Guide. For this presentation, I will first show the changes made to the tool using a training survey. At the end of the presentation we will discuss the changes to the Procedure Guide.

During this training, we will tell you which step in the Procedure Guide we are covering so you can take notes if you’d like. However, we would really like for you to watch the screen as I demonstrate the changes.

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Turn to Step 5 in the updated LTCSP Procedure Guide.

One of the major changes included in this release is how the system handles complaints or FRIs being investigated with the survey. During offsite prep, the TC will link all outstanding complaints or FRIs with the system. This will allow the system to pull forward all complaint/FRI information throughout the survey.

On the Offsite Prep screen, you can see the complaint section has been revised. This is the section that lists any complaints or FRIs being investigated with the survey. I’ll first discuss the information included in the new active complaint/FRI section and then we will complete the steps for including the complaints and FRIs into our training survey.

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Each row will include a distinct complaint or FRI intake. For each intake, you will see the Intake ID which is pulled forward from ACTS.

When you click on the Intake ID you will see any notes entered by the State Agency in ACTS. As you can see, when I click on the first intake ID listed the ACTS note indicates the concern is regarding quarterly statements.

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The next column will show whether the intake is related to a complaint (COMP) or FRI. As you can see, for our training survey, we have two FRIs and five complaints that will be investigated with the survey.

Each intake will also pull forward the Complaint Resident Name from ACTS. You may see three possible scenarios under the Complaint Resident column. The first scenario is that the name may be blank like the first intake. This means that there is no resident associated with the complaint and the allegation is a general concern for the facility. The second possibility is that the intake person in the State added the name “Anonymous, Anonymous” in ACTs. The second intake is an example of that. Again, this means the complaint isn’t associated with a resident and the concern is generalized to the facility. If you find that a resident is identified but was not added in ACTS, add the resident in ACTS, export the shell, but do not override the data. If we found that a resident was identified when we read the intake note, we would want to go back to ACTS, remove the anonymous designation and add the resident’s name. The last scenario is that the complaint or FRI resident’s name was entered in ACTS and will be listed. The remaining complaints show the resident name entered in ACTS.

The column titled LTCSP Resident-Room displays the list of residents included in the survey shell when the shell was exported from ACO. In order for the system to

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know which complaint or FRI residents are being included in the survey, the TC will have to link the ACTS complaint or FRI resident with the resident name listed in the system. If there isn’t an ACTS resident name like the first intake, the system will automatically default the LTCSP resident to the general placeholder titled Facility, Facility. That way the system knows the complaint isn’t specific to a resident. If the ACTS complaint resident’s name is Anonymous, the TC will have to select the general Facility placeholder which is at the top of the drop down list. For any ACTS complaint or FRI resident listed, the TC will see if the resident is listed under the LTCSP resident list. If the resident is listed, the TC will select the resident’s name. If the resident isn’t in the LTCSP Resident List, you can add the resident with the Add New Resident button at the top right of the table.

There is also an indicator if the complaint or FRI resident is also an offsite selected resident. None of the complaint or FRI residents included in our training shell were also selected offsite.

Then you see a column where the TC can check which complaint or FRI residents will be included in the initial pool. Remember, the team can only include five complaint or FRI residents. If the complaint or FRI isn’t linked to a resident, then the box to include the resident in the initial pool is deactivated since the generalized complaint or FRI will apply to all of the residents in the initial pool and doesn’t impact the five residents that can be included.

The final column is where the TC will assign the surveyor responsible for the complaint or FRI resident in the initial pool.

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To review the allegations associated with each intake ID, expand the intake ID using the down arrow. If you click on the allegation you can read any notes that were entered in ACTS. You can see the complaint allegation is in regards to privacy and the residents being exposed when taken to the shower room.

So the system knows which area is linked to the allegation, the TC will add the specific area in middle column that is associated with the allegation. You will use the Add Initial Pool Care Area option for resident in the initial pool and the allegation is covered by the initial pool OR for general complaints covered by the initial pool. You will use the Directly Add New Investigation option, if the resident is not going to be included in the initial pool because there are more than five complaint/FRI residents or for an allegation area that isn’t covered by the initial pool such as an Ftag that isn’t mapped to the initial pool like self-administration of meds. The resident and any added investigation will be displayed on the assigned surveyor’s investigation screen. If the allegation is related to a Facility Task, add the applicable area which will be displayed on the facility task screen. Triggered facility tasks and sufficient staffing will also be displayed on the initial pool screens. Finally, if the allegation is related to a Closed Record, add the closed record area which will be displayed on the closed record screen. Once you add an area, it will be listed in the last column.

If a complaint is marked as a state-only, licensure complaint in ACTS, the complaint

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will be identified as such on the Offsite Prep screen. It is up to the State how they handle state-only complaints.

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Now let’s complete the steps for our outstanding complaints and FRIs. Let’s review the FRI allegation for the first intake. The concern is that residents are not getting quarterly statements as noted under the intake ID. There aren’t any allegation notes since there weren’t any notes entered in ACTS. For our training survey, we know the state has a system to document the full allegation details under the Intake ID so we will only review the intake ID notes.

This allegation is related to personal funds so we will add the triggered task under the Link or Add Facility Tasks option.

Since this concern isn’t linked to a specific resident, all of the initial pool residents will show this area of concern so you are reminded to review the area during the initial pool. In addition, the facility task screen will show that the personal funds task is related to a FRI allegation.

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Before we move to the next intake, you can see that Personal Funds is now listed next to the Facility Task label.

Let’s review the allegations for the next complaint. The allegation is around residents being taken down the hallway covered in a sheet and are exposed.

Before I add the facility placeholder since the allegation isn’t specific to a resident, notice that the initial pool indicator option is available.

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Once I add the general facility placeholder, you can see that the option to include the resident in the initial pool is gone.

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The complaint allegation is related to privacy which is covered by the initial pool. Let’s add privacy using the initial pool option.

Since this concern isn’t linked to a specific resident, all of the initial pool residents will show this area of concern so you are reminded to review the area during the initial pool.

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Once you add an initial pool area for a complaint that is not linked to a resident, the initial pool area will be listed for every non-resident specific intake next to the Care Areas label. As you can see Privacy is now listed for the first two complaints/FRIs.

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Let’s review the 3rd area which is related to a FRI. The resident, Charles Arnold, was just admitted to the facility and an aide on the day shift was rough during care.

First we need to link the ACTS resident name to the LTCSP resident name. As you can see Arnold isn’t in the resident list.

That means we will have to add the resident to the resident list.

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To add the resident to the resident list I’ll click on the Add New Resident icon above the table. I’ll add the resident’s name and mark FRI as the subgroup. Once you are onsite and confirm the resident is a new admission, you can add that subgroup on the Resident Manager screen. You will also identify the surveyor who will be assigned to the resident during the initial pool. I will leave the complaint resident assigned to Kelly. You do not need to add a room number or admission date if those pieces of information aren’t known. You can add them once you get onsite. Then click Save.

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Once you have added the resident, select the resident from the drop-down.

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The resident will be automatically included in the initial pool. If you do not want to include the resident in the initial pool deselect the checkmark in the In Pool column. For our training survey since we only have five complaint/FRI residents, we will leave Arnold in the initial pool and keep the resident assigned to Kelly. If you wanted to change the initial pool assignments, you would just designate the appropriate surveyor under the drop down option.

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Now we will add the initial pool area that addresses the allegation which is about abuse. I’ll select the Add Initial Pool Care Area option and put a checkmark next to abuse and then click on Save.

Now Abuse is listed next to the Care Areas label. Once we get to the initial pool, we will see the two general complaint/FRI areas of privacy and personal funds and Arnold will also display the complaint area of abuse.

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Let’s move on to the next complaint. Reviewing the intake ID note, we can see that the dad called and said the resident needs help going to the bathroom. They never have enough staff and they've left him in the bathroom twice now. This last time he fell and had to go to the hospital. Now he has a fracture and is declining. This resident has two allegations listed – staffing and falls. However, reading the actual allegation details we can see that the allegation really covers three areas: sufficient staffing which is under Facility Tasks and falls and hospitalization which are under the initial pool. You should make sure you read through the details of the allegation and not just rely on the allegation titles since you may identify additional areas of concern that are directly related to the complaint.

After we review the allegation details, we need to select the resident from the LTCSP resident list. Durrette isn’t included in the list so we will add him.

Once he’s added to the list, we have to select him in the drop down.

Again, once you select an added resident, the resident will automatically be included in the initial pool. We’ll keep the resident assigned to Kelly.

The final action you have to take for each allegation is to identify the areas in the

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system that are related to the allegation. Let’s add them now. Notice the warning message in the header when you go to add an initial pool area. The warning is reminding you that the Accident Hazards option in the initial pool is only related to physical hazards. Falls, smoking, resident-to-resident altercations and unsafe wandering/elopement are separate initial pool areas. For our training, we will select falls and hospitalization.

I will also select sufficient staffing under the Link or Add Facility Tasks option.

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Let’s move on to the next complaint. Reviewing the intake ID note, we can see that the resident's blood sugar drops every morning. They have spoken to staff but nothing has changed. The allegation concerns are related to the resident’s insulin which is covered by the initial pool.

Let's first link the resident to the resident list. This is the first example of the ACTS resident being included in the resident list.

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When you select a resident that is already included in the resident list, the resident will not automatically be included in the initial pool. Before I include the resident in the initial pool, I will add insulin under the Add Initial Pool Care Areas option.

For medication related complaint allegations, try to include the resident in the initial pool for the medication area so there is a greater possibility that the resident will be selected by the system for the full unnecessary medication review.

For medication related allegations not covered by the initial pool, you will also add the Unnecessary Medication area under the Directly Add to Investigations option. Let’s say there was also an allegation that the resident’s blood pressure has been really low and the facility said they ran out of the resident’s blood pressure medications. In addition to adding insulin, we’ll also add the unnecessary medication area that will go directly to the investigation screen to cover the blood pressure concern. This will ensure the resident’s complaint medication allegation is pulled forward to the Investigation screen. When adding a complaint that goes directly to the investigation screen, you can select the surveyor who should be assigned to the investigation. We will leave Kelly as the assigned surveyor.

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Then I will place a checkmark in the Initial Pool column and keep the resident assigned to Kelly.

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Let’s move on to the next complaint for McCloud. Reviewing the intake ID note, we can see that the resident can’t get money on the weekend. The allegation concerns are related to the personal funds task.

Let's first link the resident to the resident list.

Let’s add the resident to the initial pool. This time we will change the initial pool assigned surveyor to Metcalf.

The final action is to add personal funds. Even though we’ve already added personal funds as a general complaint area, we will still add the task to this resident so the system knows to pull forward the complaint for this resident as well as the general complaint issue.

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Let’s look at our final complaint. Since there isn’t any notes under the Intake ID, we’ll check the allegation notes. Based on the allegation notes, the resident declined rapidly and was sent to the hospital and died. This is an example of an allegation that is related to a closed record.

The resident isn’t listed in the resident list so we will have to add the resident. Since we know the resident is no longer in the facility, when you add the resident, remove the surveyor assignment so the resident will not be included in the initial pool. It is okay to mark the complaint subgroup.

Then we will select the resident from the resident list. Then we will add the Hospitalization closed record area. Make sure you remove the IP indicator checkmark.

The complaint resident will be listed on the closed record sample screen.

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To summarize the complaints and FRIs for our training survey, we have a general and resident-specific complaint regarding personal funds. We have a general complaint around privacy. We have resident-specific complaints regarding falls, hospitalizations, and insulin. And we have a complaint for the hospitalization closed record.

We have included four complaint/FRI residents in the initial pool. You will receive a warning if you add more than five complaint/FRI residents in the initial pool.

Now [KELLIE] will discuss the changes made to the initial pool.

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Turn to Step 12 in the Procedure Guide.

I first want to clarify a few areas regarding the initial pool process. The first area we want to discuss is the initial pool workload.

Attachment A in the Procedure Guide has been updated and now shows the expected initial pool size according to the recommended survey team size. If the recommended survey team size is four surveyors, then each surveyor is expected to have about eight residents in their initial pool, which results in an initial pool of about 32 residents across the survey team.

If a State decides to send more than the recommended number of surveyors on a survey, then it is acceptable for the team to split unit assignments and distribute the expected initial pool size across the larger team. For example, if a State sends a team of six surveyors when the recommendation is four surveyors, then the expected initial pool size remains 32 residents. These residents can be distributed across the team which means four of the six surveyors will have about five residents in their initial pool and the other two surveyors will have about six residents in their initial pool).

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If a State sends fewer than the recommended number of surveyors, the smaller team also must adjust their initial pool numbers. For example, if a State sends three surveyors when the recommendation is four surveyors, then the three surveyors must still include about 32 initial pool residents across the team, or two surveyors with about 11 initial pool residents and one surveyor with about 10 initial pool residents.

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Now let’s clarify the screening process. The purpose of briefly screening all residents in your assigned area is to identify residents to include in the initial pool. All offsite selected residents (unless discharged) and any complaint/FRI residents (maximum of five) are to be included in the initial pool, and therefore do not need to be screened. You will screen all other residents to determine if they should be in the initial pool.

Before you enter each room, review the MDS indicators and matrix information (if available) for the residents you will be screening in the room to give you a more complete picture. You also will know ahead if they are newly admitted residents.

If you have no concerns based on the MDS indicators and matrix information, conduct a quick head-to-toe observation of the resident. If you don’t have any observation concerns, move on.

If you identify a concern during your quick observation such as staff ignoring a resident yelling out in pain or a resident who has facial bruising OR if you have a concern based on your review of the MDS indicators or matrix, introduce yourself and ask a few high level questions – like How long have you lived here? Do you have any concerns with your care? and then ask the resident about your identified concern to help decide if the resident should be included in the initial pool.

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Interactions should be quick to allow time to complete full interviews and observations with initial pool residents. There are no initial screening questions or screening tool included in the system. Conduct the screening based on your knowledge and critical thinking skills.

Here are two examples for the brief screening:

Resident A has an MDS indicator for depression and no other MDS indicators. The matrix shows the resident is receiving an antidepressant. I observe the resident in her room, well groomed, dressed appropriately, and playing cards. I have no observation concerns. My screening is complete and I would not include this resident in the initial pool.

Resident B, who is not vulnerable, new admission, offsite selected or complaint, has an MDS indicator for weight loss. I have not received the matrix yet. The resident is in her room at 8:30 am with her breakfast meal on the over-the-bed table. The resident consumed 100% of her breakfast. After introducing myself, I ask a few high level questions (e.g., do you have any concerns?). I would then ask about the food and weight loss. The resident says she likes the food. The resident says she had a cold and lost her appetite a couple months back but has gained the weight back. My screening is complete after a couple of minutes and I would not include this resident in the initial pool.

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You are not required to document the results of your screening. However, if you would like to document your screening results or take notes for the residents in your assigned area to help keep you organized, document these notes under Surveyor Notes.

Do not document your screening results on the RI, RO, RR screens or mark the Complete box for any resident who isn’t a part of the initial pool. You should not be completing the RI, RRI, RO, or RR areas when screening – these are to be completed only for residents that are included in the initial pool.

Do not enter an interview status for any resident not included in the initial pool.

Ensure you are not assigned to any resident who is not included in the initial pool.

If you determine that one of the residents you have screened will be in the initial pool and you have notes in the Surveyor Notes section, you can copy and paste those notes into the correct Initial Pool Care Area.

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We wanted to ensure it was clear what areas you should complete for your initial pool residents. If you are assigned to a resident, that means the resident is included in the initial pool. If you pre-assign yourself to all residents before screening –ensure you remember to remove your assignment once you know the resident will not be a part of the initial pool.

For every initial pool resident, remember to select at least one subgroup and an interview status.

You should answer every initial pool area listed under the interview, observation, and record review sources. We have found quite a few areas left blank with or without the complete box being checked. The only acceptable reason you should mark the Complete box is if a resident halts an interview and you are unable to complete the interview.

When the team meets, the TC should confirm the accuracy of the initial pool on the team meeting screen under the section titled “How many residents did each surveyor include in the initial pool?” If a resident shouldn’t be listed, the surveyor should remove their assignment on the Resident Manager screen to remove the resident from the initial pool.

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Now I’ll go to the resident manager screen to discuss how the complaint/FRI information is pulled forward from the Offsite Prep screen. Any complaint/FRI resident added to the initial pool on the Offsite Prep screen will be listed with the applicable subgroup and assigned surveyor. You will also see the dot under the Investigate column since any complaint or FRI resident will be investigated for the complaint allegation.

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Let’s take a look at Durrette’s initial pool screens. Let’s first make Durrette interviewable.

You will now see a new Complaint indicator in the header at the top right and next to all applicable complaint or FRI initial pool areas.

If the environment is a complaint allegation, just realize that the complaint indicator will be next to every initial pool area that is mapped to the environment task. For example, if the allegation is related to not being able to access the closet – the complaint indicator will be next to the accommodation of needs, environment, and the call light areas.

If you click on the Complaint indicator you will have access to all of the information that was on the Offsite Prep screen for each applicable complaint/FRI area that is associated with the resident. For Durrette, you will see the general complaint areas regarding personal funds and privacy and you will see the complaint areas specific to Durrette which includes falls, hospitalization and sufficient staffing.

We recommend you copy and paste the details of the complaint from the intake ID or allegation notes and into the applicable initial pool area. That way, the information

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will be pulled forward to the investigation screen and you won’t have to keep clicking on the intake or allegation notes.

Let’s set up our example and just respond to a few areas.

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When you click on the complaint indicator you will also see the complainant information. The complainant may be anonymous or will display the name of the complainant that was added in ACTS. Any contact information entered in ACTS will also be displayed so you can quickly get in touch with the complainant.

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To set up a sampling example, I will assign Bond, Brea and Brooks to Kelly and mark the residents as vulnerable.

When we select James Bond you will only see the two generalized complaint areas listed for the resident.

I will mark Bond as interviewable. I will mark no issue for privacy and will mark FI for personal funds and falls.

Now let’s set up Brea. I will mark Brea as non-interviewable. I will mark no issue for privacy and FI for falls.

Now let’s go to Brooks. I’ll mark him as interviewable. For Brooks, I’m going to mark no issue for privacy and I’m only going to mark an observation concern with falls. I just want to make sure everyone realizes that you won’t see the outcome for your observation responses when you are on the RI/RO screen. The green checkmark is related to the interview. You have to click on the RO option to see the orange ! For falls.

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We have one more resident to set-up. Let me change my filter to just display my residents and we’ll complete Fletcher. Let’s first make Fletcher interviewable. Then we’ll mark insulin as a concern for Fletcher. Remember Fletcher is the complaint resident who had her blood sugars dropping in the morning. And then we will mark Yes for insulin under the record review.

Let me summarize what we did in the initial pool for the complaint areas. We marked four residents with a fall concern which was a complaint allegation. We didn’t mark anyone as having a concern for hospitalization, including the complaint resident. For the general complaint area related to privacy – we marked No Issue for the initial pool residents. We marked a non-complaint resident with a personal funds concern. Finally, we marked insulin as a concern for the complaint resident.

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If a complaint is called into the State Agency and added to the survey during the initial pool process, the team should discuss whether to include the complaint resident in the initial pool as long as there are fewer than five complaint/FRI residents and there is enough time left in the initial pool to complete the interview, observation and record review.

To include the complaint resident in the initial pool: The SA should attach the complaint to the survey shell. Everyone should re-import the shell and answer No to the warning message (do not overwrite the data) so only complaints are updated. Then you will complete the complaint steps on the Offsite Prep screen and share the data with the team.

This method is preferable to just adding the complaint or FRI subgroup on the Resident Manager screen. If you just add the complaint/FRI subgroup on the Resident Manager screen the system won’t know which areas are associated with the allegations. Knowing the specific complaint areas is important since the system will now ensure you have sampled adequately for each complaint area.

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Now turn to Step 14 in the Procedure Guide and we are going to move on to the team meeting screen.

When the team comes together for the team meeting, the TC should receive everyone’s data before the team meeting so the TC has consolidated information for the pre-populated items.

If the team included a resident who is on transmission-based precautions or who smokes, the TC should document the name of the resident on the screen.

Now turn to Step 16 in the Procedure Guide. Once the initial pool is completed and all surveyors share their data with the TC the TC should confirm the initial pool is actually complete. At the bottom of the team meeting screen, you will see a list of initial pool residents who have incomplete data. The TC should ensure there aren’t any residents listed and if there are – there is an acceptable reason for the incomplete data which should be documented in the Notes field.

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Now we are on Step 17 in the Procedure Guide. We are ready to move on to the sample screen.

The first change made to the sample screen is that the facility census number can now be updated prior to clicking on the Start Sample Finalization button. We believe the TC may have tried to update the facility census number prior to completing the initial pool and receiving all surveyors’ data which was causing issues during the sample meeting. Now the TC can update the facility census number at any time.

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Let’s begin the sample meeting.

Let’s see who was selected for the full medication review. Jessica Fletcher was the resident who had the complaint regarding medications. She was not selected for the unnecessary medication review. If that occurs, you will complete the unnecessary medication review for the five system selected residents and just focus on the medication of concern for the complaint resident.

If you want to know the reason the resident was selected for the medication review you can click on the Yes link.

Make sure you confirm the residents selected for the medication review are still in the facility. If a resident that was selected for an Unnecessary Medication review has been discharged you will need to replace the discharged resident. To remove the resident, click on the red “x,” and a pop up will appear with the name of the individual that will replace the discharged resident.

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If you happen to click on the Start Sample Finalization button before you receive every team member’s completed initial pool data – if you click on ALT+U the screen will refresh.

Once you select the Finalize Sample button you can no longer refresh the screen. At that point if you notice any mistakes – they will have to be corrected on the Investigation screen.

You may have noticed that an initial pool resident would sometimes appear on the screen but the resident had no FIs marked and they weren’t a complaint/FRI resident or selected for the unnecessary medication review. The system was incorrectly bringing these residents forward if you said the resident wasn’t receiving hospice services during the record review. This has been fixed so when you answer No to the record review hospice question the resident will no longer appear on the sample screen if they do not have any FIs marked and they have been removed from the FI report.

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Let’s discuss how you are guided to conduct the sample meeting using the residents that we partially completed. Kelly has six initial pool residents who had concerns identified. Kelly has two system-selected residents and three complaint/FRI residents.

The system will now show you the complaint areas added on the offsite prep screen.

One nice feature added to this release is that the system will now ensure you have sampled adequately for each complaint area which I’ll show you in a minute.

When you meet as a team to select your sample, the first step is to discuss the system selected residents to determine if the team wants to replace any of the residents. As a team we discuss Arnold and Bond. We decide to keep both residents – Arnold is a FRI resident with an allegation regarding abuse. Bond was our offsite selected resident who had falls which is our complaint area for another resident so we’ll keep him.

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The next step when selecting the sample is to have each surveyor identify additional residents they want to include in the sample and the reason why. These residents should be comprised of:

• Residents who have the most concerns.

• Up to five complaint/FRI residents for the team.

• At least one resident for hospice, dialysis, ventilator, and transmission-based precautions, if available, even if there were no potential concerns identified in the applicable area during the initial pool process.

When completing this step, Kelly says she wants to include the two complaint residents in the sample. Durrette has three issues – hospitalization, falls and other concerns. If you remember, we marked No Issue for hospitalization. Since this is a complaint area specific to Durrette even if you mark No Issue during the initial pool you are still required to complete an in-depth investigation for that complaint area so the system will pull that area forward.

Any time you mark Other Concerns – during the sample meeting – you should remove Other Concerns and commit to a care area. Our issue was related to falls which we already have so we just have to remove Other Concerns.

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Fletcher was our other complaint resident with an allegation concerning her insulin and blood pressure so we definitely want to include the resident in the sample. As you can see only the insulin area is listed. Any complaint care area added directly to the investigation screen during offsite prep will not be listed on the sample screen.

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However, when you click on the Workload button you will see any complaint care area that was added directly to the investigation screen so the TC can consider those investigations when ensuring the workload is distributed evenly. Now let’s go back to the sample screen.

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Once the team has reviewed the system selected residents and included any other residents, the third step to sampling is to go to the Sample by Care Area screen to ensure:

• Enough residents have been sampled for the complaint areas.

• A resident has been sampled to cover all care areas marked as further investigation.

• Enough residents are sampled to adequately investigate the scope of each area.

Let’s discuss the complaint sampling rules:

• If there are other residents who had further investigation marked for the complaint care area, the team is required to sample three residents. To help make the complaint sampling easier, a COMP abbreviation has been added to the screen so you can easily identify the complaint related areas. Falls is an example where there were other residents who had concerns in addition to the complaint resident. We have four residents with fall concerns and we have only included two residents in our sample; therefore, we should include one more resident so we have three residents for the complaint allegation for falls. We aren’t going to add a resident yet since I want to show you the warning message you’ll receive if you don’t sample enough residents for a complaint area.

• If there weren’t any other residents who had concerns regarding the complaint allegation, the team is only required to investigate the complaint resident. Abuse

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and Hospitalization are examples of this. Only the complaint resident had a concern so that is the only resident we’ll investigate.

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• For general complaint areas not associated with a resident, if there weren’t any concerns identified during the initial pool for the complaint area, the area does not require any further investigation, with the exception of abuse.

Privacy was our general complaint area. We marked No Issue for our initial pool residents. If that is the case, then your complaint investigation is completed. If you have a general complaint or FRI about abuse and there were no concerns identified during the initial pool, the abuse care area will automatically be initiated for the facility and will be listed on the TC’s investigation screen once the sample is finalized. Since there isn’t a resident to review, you will complete a review of the facility’s policy and procedures and QAA system for monitoring reported allegations of abuse unless a concern is identified with abuse for a resident during your investigation.

• If the complaint allegation is not covered by the initial pool process (e.g., record keeping), then the team is required to sample three residents to investigate the area.

• Any complaint related to medications will be investigated in addition to the five system selected residents for the Unnecessary Medication Review if the complaint resident isn’t picked as one of the five residents. If this is the case, you

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only have to investigate the complaint-specific medication. Fletcher is an example of this that we discussed earlier.

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Let’s go back to the sample screen By Resident. I want to point out two areas regarding complaints before we look at the new warning messages. Notice that McCloud is a complaint resident who hasn’t been included in the sample and remember we’ve only sampled two residents for the complaint area for falls. Let’s look at the new warning you’ll receive if you don’t sample the five complaint/FRI residents allowed for the team if available or if you don’t sample three residents for complaint areas if warranted.

On an actual survey of record you would correct these issues. We’ll move on for the training survey since we only have partial data for one surveyor.

Now we are ready to move on to discuss the changes to the facility task screen.

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The Extended Survey is no longer listed when you click on the Facility Task screen. We thought having this task listed on the screen may have been confusing since we found that surveyors were conducting the extended even though SQC wasn’t identified.

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Now if you identify SQC and need to conduct the extended survey, you will initiate the task.

You will also notice a complaint indicator next to the facility tasks that were added on the offsite prep screen. The complaint indicator will be displayed on everyone’s machine to remind you that there is a complaint related to that task. Let’s take a look at personal funds.

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Once you click on the complaint task, you will see the complaint indicator at the top right corner of the screen.

If there were any complaint residents associated with a facility task, you will also see a complaint indicator next to the resident. As you can see James McCloud is displayed in the resident box with the complaint indicator since he was our complaint resident who couldn’t get money on the weekends. You will have access to all of the complaint details from the offsite prep screen when you click on the complaint indicator.

You will also see that the non-complaint resident – James Bond - who we marked as having a concern with personal funds is also listed but does not have the complaint indicator next to his name.

Now [Synora] will go over the changes made to the pathways.

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We have updated a number of facility task and CE pathways. Let’s first look at Sufficient Staffing.

We changed the second sentence in the probe that is asked of the nursing aide. It now says, “Has the facility management asked about staffing levels required to take care of current resident needs?”

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We’ll discuss one correction made to the dining pathway.

We clarified that one person should be assigned primary responsibility for the shared tasks like dining, infection control and sufficient staffing. Only the surveyor who is assigned primary responsibility is required to answer all CEs. All other surveyors will only answer the CEs of concern.

I also wanted to mention that for any facility task that has a resident box which includes dining, beneficiary notices, infection control, sufficient staffing, resident council, and the triggered tasks – if you review a resident for the task, you should include the resident’s name in the box by clicking on the Add Residents icon in the upper right hand corner of the screen. It will be important for you to add the residents to the box once the ROs begin to use the automated LTCSP comparative later this year since the system will only pull forward the resident names you added to the resident box.

One change that has been made to the Sample List that is given to the facility is that now anytime you use ALT+R in the notes field for any area within the system, that resident will be added to the Sample List. Let’s add a resident who isn’t in our sample to the notes field so I can show you the Sample List report later.

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Let’s cite one tag for this task.

I wanted to discuss one final area for this task. For any shared facility task or resident-specific investigation, if you are not seeing other surveyors documentation –remember to change the filter to All Surveyors at the bottom of the screen. Changing to All Surveyors will display everyone’s notes if data has been shared and their CE responses in a read-only format. You have to change back to Current Surveyor to document notes or answer CEs.

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I wanted to ensure everyone was aware of an issue with the kitchen screen display.

Please be aware that the probes on the screen may not be aligned appropriately with the CEs. If you are completing the kitchen task, we recommend you use the pathway.

Anytime you use the pathway button, if you wanted to keep the pathway static on the screen while you entered documentation in the notes field you just have to have the documents side-by-side.

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There was one change made to the Resident Assessment task regarding residents who are getting selected who have an MDS greater than 120 days from when the survey shell was exported. We are now excluding residents who have a death and admission assessment that occurred on same day.

The residents being selected are because the resident has not had an admission, quarterly, annual, or significant change assessment in the last 120 days. We know that the system is inappropriately selecting residents who had a discharge as their most recent assessment. That change has not been made yet. If you find that one of the residents was discharged and there weren’t any issues with any other residents related to this task, you can simply answer the CEs as Yes.

OR

If the only reason this task was triggered was because of an inappropriately selected resident, you may remove the task.

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Let’s discus the changes made to the Beneficiary Notices pathway.

Reference to the five denial letters was removed. The facility should only use the form referenced in the pathway.

There were also a few changes made to the table.

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Some of the information was rearranged on the Extended pathway.

We added a clarification statement to CE11 and CE12 that those two CEs should only be answered as Yes or No if there was a pending closure.

The payroll-based journal tag was removed.

Three new tags were added to cover the training requirements.

That’s it for the changes made to the facility task pathways. Now let’s move on to the changes made to the Closed Record Sample screen.

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If you add a complaint resident on the offsite prep screen for a closed record that resident will be displayed on this screen with a complaint indicator. The screen will still show the residents selected by the system since you have to ensure you have a sample of three residents for the closed record review areas. There are two residents on the closed record screen for hospitalization – one of which is the complaint resident. If you remember, we also had a complaint resident in our initial pool for hospitalization – so that would make our sample of three.

Now we will cover the changes made to the Investigations screen.

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Turn to Step 18 in the Procedure Guide.

The complaint indicator continues to pull forward on the Investigation screen next to the applicable care areas. When the TC’s adds a complaint care area directly to the investigation screen – this is where the assigned surveyor can access that investigation. As you can see, Jessica Fletcher’s Unnecessary Medication area is listed.

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Let’s select our complaint resident Durrette.

If a care area is related to a complaint, you will again see the complaint indicator next to the care area name which will include the complaint details that were on the offsite prep screen.

If a complaint is called into the state and added to the survey during the investigative process and the team is going to include the complaint with the survey, we recommend the assigned surveyor just initiate the resident and the areas associated with the complaint. At this late stage in the survey, we do not recommend the team re-import the shell to reflect the new complaint.

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I just wanted to ensure everyone understand the two ways to document your investigation:

You may use the Investigation Notes field to document any information specific to the care area being investigated (e.g., observations, interviews, specific record review such as relevant MDS information, care plan, or physician orders). Any notes entered during the initial pool process will be displayed in the investigation notes.

You may use the Resident Notes field to document any general information about the resident that you would like to have access to for all care areas (e.g., diagnoses, BIMS, general MDS information regarding cognition and ADL status, and general care plan information.

Either documentation option is acceptable. Resident Notes may be a more efficient option to document your information during your investigation since your documentation is one continuous notes field; however, you may spend more time editing your documentation for the CMS-2567. Using Investigation Notes will have the reverse pros and cons as Resident Notes.

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Let’s add Resident Notes for Durrette. All we will type is “Added Resident Notes.”

Let’s cite a couple of tags for Accidents and one tag for Hospitalization.

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Another change made for this release was the inclusion of a general facility placeholder to initiate care areas or tags. Two potential reasons you may need to use this general facility placeholder is if there are complaints or concerns not associated with a resident or you wanted to cite a tag that wasn’t mapped to a facility task. Now when you click on the Add New Investigation button, the first name listed is Facility, Facility.

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There were two CE pathway changes.

The first change was to the death pathway. We added Advance Directives and F678 (CPR) to the list of other areas to consider at the bottom of the pathway.

The second change was to the positioning, mobility, and ROM pathway. We added an NA option to CE2 which you can now mark if there were no positioning concerns for the resident.

That concludes the changes made to the Investigation screen.

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Let’s discuss another new feature included in this release. You now have the ability, if you have time, to edit your investigative documentation for any CE marked No prior to the potential citation meeting. There is a new option in the navigator menu called “Edit Potential Docs.” This is where you will edit your investigation notes.

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The left pane will display the CEs you marked as No and the applicable area. We have marked a CE as No for three areas: Dining, and accidents and hospitalization for Durrette. To see your documentation, you have to click on a resident or facility task to enable the right screen.

Your Investigation Notes will display at the top of the right screen as read-only. You will see the CE marked as No and the associated reg or IG which you can click on if you need the information.

The Investigation Notes will also copy to the editable section at the bottom of the screen as read-only until you begin editing. To begin editing your documentation, you will select the Edit Citation Doc button. We won’t edit our documentation for Dining.

Let’s go to Durrette and accidents. For a resident, you can see that both the Investigation Notes and Resident Notes pull forward. You can also see the top of the screen shows we marked CE1 and CE2 as No. Let’s edit our investigation notes for accidents.

Once you begin to edit your citation documentation, a clipboard is displayed next to

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the Investigation on the left side of the screen.

You can collapse the CEs and Tags, Resident Notes, and Investigation Notes as needed to have more of the editable notes field visible.

If you edit your documentation, only your edited notes are displayed on the Potential Citations screen.

If you do not have time to edit your investigative notes prior to the potential citation meeting, your resident notes and investigation notes will continue to display on the Potential Citation screen.

If you receive additional information after you begin editing your documentation, add the new information to the applicable facility task or resident investigation screen so your investigation notes are accurate and complete. The changes will be displayed on the Edit screen at the top of the screen. The changes will not automatically be included in the edited version of the documentation if you have already begun editing. In this case, you can copy and paste the new text added on the investigation screen into your edited text. Let me show you how this works.

We will only edit the text for accidents so you can see what documentation gets pulled forward to potential citations. For Hospitalization, we only added notes under the Resident Notes option.

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Turn to Step 20 in the Procedure Guide.

The sample list given to the facility will now automatically include the initial pool residents, sample residents, closed record and unnecessary medication residents, and any resident included in a resident box on a facility task screen or added to any notes field using the ALT+R option.

You can also add a resident to the Sample List report by selecting the resident on the new Add Residents to List screen in the navigator menu. Atom Ant is already checked since we added that resident using the ALT+R in the notes field for dining. Any other resident we select will be listed on the report. Let’s add Yogi Bear. Now let’s look at the sample list report. As you can see Atom Ant and Yogi Bear are listed as well as a number of other residents covering the areas I just mentioned.

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Turn to Step 24 in the Procedure Guide.

Once everyone has completed their investigations for residents and tasks, we want to ensure the TC is confirming all investigative work is completed after receiving everyone’s data.

The TC should review the Investigation screen, filtered to All Investigations. There should be a green checkmark next to every care area. For our training, you can see that we haven’t completed any resident-specific investigations. On a survey of record, confirming all investigations have been completed is important since it is easy to forget about the closed records and unnecessary medication reviews that weren’t assigned to a surveyor on the sample screen.

The TC should also check the facility task screen and ensure a green checkmark is next to every task. If there is incomplete work, the surveyor should complete the work, and then share the data with the TC.

We’ve received a number of questions regarding how to update the closed record and unnecessary medication selections on the Investigation screen. If you need to remove a closed record selection just click on the X in the far right Remove column.

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Then you can add a different closed record resident, if needed, by using the Add New Investigation option.

If you realize a resident selected for the unnecessary medication review is discharged, you can use the same Removal X and the system will replace the resident with the next most appropriate resident. You will receive a warning message ensuring work hasn’t begun for the resident being removed.

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Once investigations are completed and everyone shares their data with the TC, the TC should also verify the combined med error rate is consistent with the response for CE1 which is the med error rate CE. If the error rate is less than 5% but a surveyor marked CE1 as No, do not cite the tag during the potential citation meeting. If the error rate is 5% or greater but CE1 is not marked as No, update the response for CE1 prior to the potential citation meeting.

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Turn to Step 25 in the Procedure Guide.

We are now ready to move on to discuss the changes made to the Potential Citation screen.

Let’s look at F684. As you can see, the unedited resident notes pulled forward. Once I select cite you can see that the complaint citation category was already checked. The system will automatically check that category if the tag is related to the complaint area added on the offsite prep screen. You will have to select the recert category.

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You will also notice the SQC indicator has been removed. It used to be listed next to every tag that fell under the SQC umbrella – it did not mean the tag had been cited at SQC. We thought that was confusing folks so it has been removed. Now if you cite a tag at SQC you will receive a warning that SQC has been cited and the Extended Survey should be completed.

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Now let’s move to F689. The edited text is displayed.

The other change made to the potential citation screen is what happens when you move a tag. To move a tag to a different citation, you will still select the Don’t Cite Option because we are going to move the tag, and we’ll select F700 as the new tag which we are already citing. Once you do that, you will now see the move on this screen. You can now tell F689 has been moved under F700. F700 will be marked as cited – you will just have to select the scope and severity and the citation category.

When we select F812 you can see our un-edited investigation notes pulled forward. We won’t cite this tag.

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We have received a number of questions regarding how to determine the universe. The universe is the number of residents investigated for each care area as noted on the Sample Finalization screen – by Care Area option. As an example, we are citing one resident for falls. The universe for the tag would be 1 of 2 sampled residents.

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We are now on Step 27 in the Procedure Guide. Let’s close the LTCSP tool and go to Citation Manager.

If you cite SQC and aren’t able to complete the extended survey, you can now load citations in ASE-Q so the team can begin finalizing their citations. You should not upload the completed shell into ACO until the extended survey has been completed.

Now [Kellie] is going to finish the training by discussing additional changes made to the LTCSP forms and reports.

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There were a few changes made to the facility matrix. We added new abbreviations that the facility can use for the pressure ulcer and tube feeding areas.

For falls, we clarified that the facility should identify any resident who has fallen in the facility in the last 90 days. If the resident hasn’t been in the facility for 90 days it’ll be since their admission.

For dehydration, we removed the examples. The focus should be on anyone who has actual hydration concerns.

We removed three variances from the Entrance Conference worksheet since they no longer apply. We removed the variance for below ground level, no window to the outside, and no direct access to an exit corridor.

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Let me cover the changes made to three reports included within the LTCSP system.

Initial Pool Report will list:

• Any resident who was assigned to a surveyor but didn’t have a subgroup.

• Triggered facility tasks and resident names.

• Any discharged offsite selected resident and the discharge location.

Surveyor Workload Report will list:

• Facility task info such as resident names reviewed.

• The initial pool area such as edema, skin conditions, falls, or smoking instead of the investigation area like general or accidents.

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Investigation Report will list:

• Documentation if the surveyor marked FI for Other Concerns on the RI/RO/RR screens.

The description for the indicators have been updated on the MDS Indicator Facility Rate Report.

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This release also includes the ability to review and print all of the survey documentation in ACO. There are many different sort and filter options available depending on what type of documentation you need to access.

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The LTCSP Procedure Guide has undergone extensive revisions so we continue to advise everyone refer to the Procedure Guide during the survey. To wrap up, I want to summarize the major changes made to the Procedure Guide.

We have added a table of contents and now you can easily navigate around the Procedure Guide using a bookmark feature.

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We added how to create a team in ACO to Step 1 since the team is encouraged to add the team in ACO.

We’ve also included instructions for how to handle technical issues. We’ve provided the QTSO Help Desk number for immediate concerns and instructions for creating screen shots with a description of the technical issue.

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For Step 5, we have included the other way you can use to access the LTCSP survey which is to right click on the Event ID in ASE-Q and select LTCSP from the drop down menu.

If you get a warning when you try to access the survey that says the system is unable to connect to the server, if you just click on the LTCSP button again, you will be able to access the survey.

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Step 6 now includes all of the new complaint and FRI features included during offsite prep. Assigning the complaints and FRIs was removed from Step 7 since they are now assigned during offsite prep.

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Step 10 now explains that during the survey, the team should only be sharing data within the LTCSP survey. Surveyors should not export and import the survey shell in ASE-Q unless the team composition has changed and a new surveyor has been added to the team.

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For Step 11, we’ve added a recommendation for the team to bring a power strip with surge protector for use onsite as needed. You should not use an extension cord with the surge protector.

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We’ve added instructions to Step 12 for how the time works on the Entrance Conference screen. The first time you click on the Entrance Conference screen, the date and time will populate at the top of the screen. If you click on the Set button the time will reflect the current date and time which cannot be changed.

There is also a reminder that if you are assigned to the kitchen task, it is recommended to use the pathway instead of the probes on the screen since they may not be paired correctly with the CEs.

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There were a number of changes made to Step 13. The initial pool workload description was moved to the beginning of this section. The initial pool workload outlines the number of initial pool residents per surveyor which may change depending on whether the team size is greater or fewer than the number of surveyors that is recommended.

We have also teased out screening of residents and added a lot of description regarding how the screening should be conducted which we discussed earlier.

We added instructions for how to handle complaints called in during the initial pool.

While we made other changes throughout this step, I’m only going to mention a few other major changes. When you are reviewing residents in your assigned area and you do not see the resident’s name in the system ensure you search for the resident to avoid duplicating the resident’s name. If you accidently duplicate a resident’s name you cannot remove the name you added. In that case, you should use the system populated name since that name may have MDS indicator information.

I want to ensure we are all on the same page when to use the Identified Concern subgroup for an initial pool resident. The identified concern subgroup should only be

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used for a resident who isn’t vulnerable, newly admitted, complaint, FRI or offsite selected. You should not use the identified concern subgroup if a resident in the initial pool has expressed a concern. Those concerns will be noted with an FI for the applicable area.

We clarified how to share workload during the initial pool. If two surveyors share an initial pool resident just realize the warning message the TC gets when the completed initial pool data is shared is related to the assignment of the resident. The message is asking, “Who should be assigned to the resident” – typically the assignment will stay with the initial surveyor. When residents are shared, all initial pool notes will merge and any FI response will override a response of No Issue.

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We moved the team composition change instructions from the data sharing step to Step 14 which covers data sharing at the end of each day and team composition changes.

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We’ve added a reminder to Step 16 that the TC should confirm the initial pool data is complete.

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For Step 17, we moved updating the facility census number to before starting the sample meeting. We’ve updated the sample selection instructions to include the new complaint/FRI features, how to remove a discharged unnecessary med resident, and how to refresh the screen before the sample is finalized.

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Step 18 was updated to reflect the new complaint/FRI changes made to the investigation screen and the instructions for how to handle a complaint called in during the investigation portion of the survey. We also added instructions for the new feature to edit your investigative documentation prior to the potential citation meeting.

We also explained that if you try to add a care area or tag but it isn’t listed on the initiation screen that means the area already exists on the Investigation screen and cannot be initiated again.

We stressed that if you share a resident or task in order to see the other surveyor’s documentation you have to change the filter on the screen to All Surveyors.

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For the facility task step 20, we added instructions that using ALT+R will include the resident on the sample list report for the facility – this applies to any notes field in the system, not just facility tasks.

For dining, we explained why residents may appear in the resident box - if they had an MDS indicator of weight loss or dehydration or they had further investigate marked for nutrition, hydration or food quality. Clicking on the resident’s name will show the relevant interview notes.

We added clarification that any initial pool resident who had FI marked for staffing, will be displayed in the resident box on the sufficient staffing screen once the sample is finalized.

We added instructions for the applicable facility tasks explaining how to add a resident to the resident box.

For environment, we clarified that it is up to the state whether the surveyors review emergency preparedness and oxygen. We also added Extended to the triggered task section.

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We’ve updated Step 23 so it now provides instructions for the team to share their completed investigation data with the TC and the TC is reminded to confirm all resident and facility task investigations have been completed.

Step 23 was also updated so it now provides the instructions required to complete the potential citation meeting, including the new features regarding SQC and moving tags.

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We’ve included instructions for how to add residents to the sample list report for the facility in Step 24. We also clarified that you shouldn’t discuss tags unless the administrator requests that you give the tag number which is outlined in the S&C memo included in Step 24.

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For Step 25, we’ve ensured the steps are correct for how to load cites and how to handle the situation if errors are identified. We also provided instructions for how to handle the extended survey if SQC is cited and the team has to return to complete the extended.

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Step 26 now provides instructions for how to delete the completed survey once it is imported back to ACO.

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Attachment A was updated and now includes the approximate total number of initial pool residents for the team based on the recommended team size.

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If you are onsite and are having technical issues that your state cannot resolve, you should contact the QTSO Help Desk. The number is on the slide and is on the splash screen when you first log in to ASE-Q. If you need immediate assistance make sure you tell them you are onsite. If you identify technical issues with the software onsite, it is important that you report the issues to QTSO Help Desk so the issue can be addressed. It is helpful if you can take screen shots with a detailed explanation of the issue.

If you have survey process questions contact the SA trainer or RO Ambassador. You should continue to send any survey process questions to the CMS nursing home survey development email.

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Finally, the roll-out date is the weekend of 5/6; however, the auto update will be available the evening of 5/4.

You should download a new version of the LTCSP Survey Resource folder which has all updated forms, pathways and the mapping document and is posted on CMS’s website which is included on the slide.

The recording of this training is on ISTW and will be available after April 23rd. There will be Q&A sessions for Regions and States – the information will be forthcoming to ROAs and Branch Managers.

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