1. Desk Audit Report Training Training on Desk Audit Reports (DARs) for RO and SA

2. Purpose and Goal Provide an overview of the Desk Audit Reports for the State Agencies (DAR-SA) Provide an overview of the State-Specific DAR for the Regional Office (DAR-RO) Overview of the differences and similarities Overview of how each item on the reports could be used for training and education Quality Indicator Survey 2

3. Overview Desk Audit Reports DAR-SA 10 Surveys Survey and Surveyor-Level info State completes analysis Training State-Specific DAR- RO Aggregate over quarter QI call FOQIS

4. Item 1 Number of Residents Quality Indicator Survey 4

5. Item 1 – Follow Up Census Sample Incomplete –Pay attention to completion checks –Verify during team meetings –If not complete, surveyor finishes work Admission Sample Incomplete –Assign in facility residents –Cross off names as they are completed Quality Indicator Survey 5

6. Item 2 (DAR-SA) Item 2_19 (DAR-RO) Quality Indicator Survey 6

7. Item 2 – SA Follow Up Understand the intent of the question Ask the questions accurately Do not ask leading questions Do not repeat the question to elicit positive response Ask all questions Answers the questions correctly Conduct appropriate observations Conduct appropriate record reviews Quality Indicator Survey 7

8. Item 2 – RO Follow-Up QI Call –Discuss all outliers –Determine SA follow up FOQIS –Include low outliers for any area triggered by resident interview and observation Quality Indicator Survey 8

9. Item 3 Count of QCLIs Exceeded the Threshold Quality Indicator Survey 9

10. Desk Audit Report Training Quality Indicator Survey 10

11. Item 5 Distribution of Negative Response Between Data Sources Quality Indicator Survey 11

12. Items 3, 4 and 5 – Follow Up Understand the intent of the question Ask the questions accurately Do not ask leading questions Do not repeat the question to elicit positive response Ask all questions Answers the questions correctly Conduct appropriate observations Conduct appropriate record reviews Quality Indicator Survey 12

13. Item 5 – RO Follow-Up QI Call –Discuss all outliers –Determine SA follow up FOQIS –Include low outliers for resident interview and observation Quality Indicator Survey 13

14. Item 6 Census Sample Interview Rate Quality Indicator Survey 14

15. Item 6 – Follow Up Screen all residents Effectively manage time Prioritize interviews over record review Interviewing short stay residents Quality Indicator Survey 15

16. Item 7.1 Census Sample Refusal Rate Quality Indicator Survey 16

17. Item 7.1 – Follow Up Building rapport with the resident Quality Indicator Survey 17

18. Item 7.2 Census Sample Unavailable Rates Quality Indicator Survey 18

19. Item 7.2 – Follow Up Effectively manage time Prioritizing resident interviews Makes sufficient attempts Quality Indicator Survey 19

20. Item 8 Relevant Findings for "Negative" Responses Quality Indicator Survey 20

21. Item 8 – Follow Up Probing appropriately Document relevant finding during interview Adequate computer skills Quality Indicator Survey 21

22. Item 11 Number of Investigated Non- Mandatory Facility Tasks Quality Indicator Survey 22

23. Item 11 – Follow Up Understand the intent of the question Ask the questions accurately Do not ask leading questions Do not try to elicit positive response Ask all questions Answer questions correctly Conduct adequate observations Quality Indicator Survey 23

24. Item 12 Facility Task Citations Quality Indicator Survey 24

25. Item 12 – SA Follow Up Conduct thorough investigations Begin investigation in Stage 1 if needed Use Facility Task pathway Discuss findings during team meetings Make accurate compliance decisions Quality Indicator Survey 25

26. Item 12 – RO Follow-Up QI Call –Discuss all outliers –Determine SA follow up FOQIS –Include low outliers for resident interview and observation Quality Indicator Survey 26

27. Item 15 Number of Triggered Care Areas and Non- Mandatory Tasks Quality Indicator Survey 27

28. Item 15 – Follow Up Stage 1 is completed appropriately Quality Indicator Survey 28

29. Item 16 Surveyor Initiated, New Care Areas and Non-Mandatory Tasks Quality Indicator Survey 29

30. Item 16 – Follow Up Identify patterns and if initiated areas are cited Stage 1 appropriate Investigation and compliance decisions appropriate Quality Indicator Survey 30

31. Item 17.1 Count of Unique Surveyor Initiated F-tags Quality Indicator Survey 31

32. Item 17.2: Number of Surveyor- Initiated F-Tags not Cited Quality Indicator Survey 32

33. Item 17.3 Number of Surveyor-Initiated F-Tags Associated with Care Area/Task by Surveyor Quality Indicator Survey 33

34. Item 17 – Follow Up Initiating care area when applicable Cited correct tag Answer Stage 1 questions appropriately Initiate tag when investigating care area or task Quality Indicator Survey 34

35. Item 18 Survey Citation Rates for Triggered Care Areas and Tasks Quality Indicator Survey 35

36. Item 18 – Follow Up Use pathways Conduct thorough investigation Discuss findings during meetings Make accurate compliance decisions Provide documentation to support decision Quality Indicator Survey 36

37. Item 19 Citation Rate for Triggered Areas Quality Indicator Survey 37

38. Item 19 – Follow Up Use pathways Conduct thorough investigation Discuss findings during meetings Make accurate compliance decisions Provide documentation to support decision Quality Indicator Survey 38

39. Item 20 Care Area, Facility Tasks, and F-tags Removed Quality Indicator Survey 39

40. Item 20 – Follow Up Identify removal trends Appropriate rationale for removal Quality Indicator Survey 40

41. Item 21 Rate of CE Responses of No Quality Indicator Survey 41

42. Item 21 – Follow Up Use pathways Conduct thorough investigation Discuss findings during meetings Make accurate compliance decisions Provide documentation to support decision Quality Indicator Survey 42

43. Item 22 Rate of CE Responses of “NA” Quality Indicator Survey 43

44. Item 22 – Follow Up Marked NA appropriately Followed NA guidance in pathway Only marked CE when investigation complete Quality Indicator Survey 44

45. Item 23 (QCLI Denominators) 24 (670 time) Quality Indicator Survey 45

46. Item 25 – Stage 2 Assignments Quality Indicator Survey 46

47. Item 26 – Citations by Surveyor Quality Indicator Survey 47

48. Item 27 and Number of QIS Potential and 2567 Citations Quality Indicator Survey 48

49. Item 27 – Follow Up Use pathways Conduct thorough investigation Discuss findings during meetings Make accurate compliance decisions Provide documentation to support decision Quality Indicator Survey 49

50. Item 30 Potential Findings Not Cited Quality Indicator Survey 50

51. Item 30 – Follow Up Use pathways Conduct thorough investigation Discuss findings during meetings Make accurate compliance decisions Provide documentation to support decision Quality Indicator Survey 51

52. Item 31 Frequency of F-tags Cited Quality Indicator Survey 52

53. Item 31 – Follow Up Use pathways Conduct thorough investigation Discuss findings during meetings Make accurate compliance decisions Provide documentation to support decision Quality Indicator Survey 53

54. Item 32.1 and 32.2 Quality Indicator Survey 54

55. Item 32 – Follow Up Expansion leads to higher scope Expansion leads to deficient practice Quality Indicator Survey 55

56. Item 33 Scope and Severity Quality Indicator Survey 56

57. Item 33 – Follow Up High isolated – identifying patterns appropriately High rate of Level 1 – follow key elements of severity determinations Use psychosocial outcome severity grid Quality Indicator Survey 57

58. Desk Audit Report Training Questions? QIS Help Desk (303) 724-7484 CU Web Page http://www.ucdenver.edu/academics/colleges/medi calschool/departments/medicine/hcpr/qis/Pages/def ault.aspx http://www.ucdenver.edu/academics/colleges/medi calschool/departments/medicine/hcpr/qis/Pages/def ault.aspx CMS FOQIS Materials https://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/SurveyCertificationGenInfo/QIS- Comparative-FOQIS.html https://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/SurveyCertificationGenInfo/QIS- Comparative-FOQIS.html Quality Indicator Survey 58