The California Department of Health Services (CDHS), Licensing and Certification (L&C) Program is participating in a Centers for Medicare & Medicaid Services (CMS) Quality Indicator Survey (QIS) Demonstration Project. This automated survey system is designed as a staged process for use by L&C surveyors to systematically and objectively review all regulatory areas and focus on the selected areas for further review.

The QIS provides a structure for initial review of a larger sample of residents based on the MDS, observations, interviews, and medical record reviews. Utilizing onsite automation, survey findings from the first stage are combined to provide rates on a comprehensive set of Quality Care Indicators (QCIs) covering all residents and facility-level federal regulations for skilled nursing homes.

There are two district offices participating in the QIS Demonstration Project: San Diego District Office South and East Bay District Office. As a result, your facility may be selected as a site to participate in the automated survey system. The QIS survey conducted will be the survey of record; however, most of the facilities surveyed will continue to be surveyed using the traditional survey process.

If your facility is selected to participate in the QIS survey system there will be some aspects of the survey that are different and involve your cooperation and assistance. The on-site survey will require:

Two separate lists: Census List and Admission List:
 
1. Census List:

An alpha list of all residents CURRENTLY “In The Facility” including BEDHOLDS, which must be Indicated as “Bed holds”, either by ***or highlighting or writing “Bed hold” by the Resident Name, with Birth Date, Admission Date and Current Room Number/Unit.

2. Admission List:

List of Residents Admitted within the LAST 30 days, INCLUDE ONLY: Residents Currently Residing in the Facility. For example, if the survey starts on August 14th, the Team needs an Alpha List of ALL RESIDENTS CURRENTLY RESIDING IN THE FACILITY, that were ADMITTED from July 14th through and including August 14th, with Birth Date, Admission Date, Room Number/Unit Number.

Upon entering the facility, the L&C Team Coordinator will give the facility Administrator or Director of Nursing (DON) the “New Admission Information Form” which contains headings of the above required information: Name, Birth Date, Admission Date, Room Number, Unit Number (for Residents admitted within the last 30 days that are currently in the facility.) We are requesting that you provide this information with the first 30 minutes of the L&C team’s arrival.

The team must have both of these lists (Census and Admissions) as soon as possible after entering the facility, preferably BEFORE the Entrance Conference is conducted. The lists must be accurate, so that the team can reconcile the lists with the QI data sheets, before they can proceed with their interviews, observations and survey tasks.

Our recent survey experience indicates that the admission list seems to be the list that the facilities have the hardest time providing to the survey team. The Admissions List should be an alpha list with ONLY the residents currently in the facility that were admitted within the last 30 days.

We appreciate your cooperation and assistance in producing these lists as soon as possible after the survey team enters the facility. Although, QIS System is currently a demonstration project, CMS has announced that they expect the rest of the States to use the QIS System as the survey of record for all surveys in the near future. Rollout of the system and training is expected to commence in Fiscal Year 2007-08. San Diego and East Bay District Offices will be using the QIS System for all surveys by the end of next fiscal year. 

If you have any questions, please contact Donna Loza, District Manager for San Diego South, at (956) 278-3700, or Ardene Nakagawa, District Manager for East Bay, at (510) 620-3900.

Sincerely,

Original Signed by Anna Ramirez

Anna Ramirez, Chief
Field Support Branch Coastal Area