Feb 6, 2021 — will be listed next to the Care Areas label in the drop-down menu. The o Dining Observation (assign all surveyors who are assigned to a
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 1 I. OFFSITE PREP .. .. .. .. . 3 Step 1: Create survey shell in ASPEN Central Office (ACO) .. .. . 3 LTCSP Application HELP .. .. .. . 3 Step 2: Export shell from ACO .. .. .. . 3 Step 3: Import shell into ASPEN Survey Explorer (ASE – Q) .. .. .. 4 Step 4: Add team members in ASE – Q (if team composition changes) .. . 5 Step 5: Access the survey .. .. .. .. 5 Step 6: TC completes offsite prep screen .. .. .. 6 Step 7: TC makes facility unit assignments .. .. 8 Step 8: TC makes mandatory facility task assignments .. .. .. 8 Step 9: TC prints documents .. .. .. .. 9 Step 10: TC shares offsite prep data with team members .. .. . 9 DATA SHARING METHODS .. .. .. 10 Using the File method .. .. .. . 10 Using Secured Wireless method or using Wired method with a switch: .. .. 11 Using Secured Wired method using a cable to connect two machines: .. 11 Step 11: Team reviews offsite information .. .. . 12 II. FACILITY ENTRANCE .. .. .. .. 13 Step 12: Enter the facility and go to your assigned area .. .. . 13 III. INITIAL POOL PROCESS .. .. .. 14 Step 13: Briefly screen all residents in your assigned area and observe, interv iew, and complete a limited record review for initial pool residents .. .. . 14 Overview: .. .. .. .. 14 Initial Pool Workload: .. .. .. . 14 Screening: .. .. .. .. 15 Initial Pool Residents: .. .. .. .. 18 Organizational Options for Screening and Initial Pool Residents: .. . 19 Process Steps for Initial Pool Residents: .. .. .. 23 Additional Initial Pool Process Information: .. .. .. 30 Step 14: Share data at the end of each day and team composition changes .. 32 Step 15: End of Day 1 team meeting .. .. .. 33 IV. SAMPLE SELECTION .. .. .. . 35
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 2 Step 16: Share Completed Initial Pool Data and TC Confirms Initial Pool Data is Completed . 35 Step 17: Select the Sample .. .. .. 35 V. INV ESTIGATION .. .. .. .. . 40 Step 18: Conduct investigations for sampled residents .. .. .. 40 VI. ONGOING AND OTHER SURVEY ACTIVITIES .. .. 45 Step 19: Complete closed record reviews .. .. .. 45 Step 20: Complete facility task assignments .. .. .. 45 Dining .. .. .. .. 46 Infection Control .. .. .. 47 SNF Beneficiary Protection Notification Review .. .. .. 47 Kitchen .. .. .. .. . 48 Med Admin .. .. .. 48 Med Storage .. .. .. . 49 Resident Council Meeting .. .. .. . 49 Suff icient and Competent Nurse Staffing .. .. 50 Personal Funds .. .. .. 50 Environment .. .. .. . 50 Resident Assessment .. .. .. .. 51 Extended S urvey .. .. .. 51 Step 21: End of the day meeting .. .. .. 51 Step 22: Complete QAA/QAPI .. .. .. . 52 VII. POTENTIAL CITATIONS .. .. .. .. 52 Step 23: Share Completed Investigation Data, Confirm Investigation Data is Complete, and Team Deficiency determination .. .. .. .. 52 Step 24: Exit Con ference with Facility .. .. .. . 54 Step 25: Load Cites .. .. .. .. . 55 Step 26: Save and Delete Completed Survey .. .. . 56 Attachment A: Sample Size, Recommended Team Size, Initial Pool Size, and Complaint/FRI Size 57 Note on Survey Team Size .. .. .. 58 Attachment B: Policy for Including Complaints and Facility Reported Incidents with Standard Survey .. .. .. .. .. 59 Enforcement Considerations .. .. .. .. 59
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 3 Step 1: Create s urvey shell in ASPEN Central Office ( ACO ) Create a survey shell in ACO according to your state practice. Add team members in ACO and designat e the team coordinator. o . o Right click on the Event ID . o Select Team Roster from the list . It is recommended to add the team in ACO. o Select Update . o Check the box for each team member that will participate in the survey. Ensu r e each person has a check next to his or her name . Select OK . o Highlight the surveyor that is Team Coordinator (TC). Select Leader. The TC will have a diamond in front of their name . o Select D one . Link any complaints and Facility Reported Inciden ts (FRIs) to the survey according to your state practice. LTCSP Application HELP Contact the designated state technical lead according to your state procedures for any hardware or software difficulties. OR you are having technical issues, make a print s creen of the message or technical concern. While still on the screen, press the Function [Fn] key and the Print Screen [Prnt Scrn] key. Open a new Word document and paste the print screen [Ctrl+V]. Describe in the Word document the actions being completed just before the error message or technical concern. Send the document to your state technical lead. If the designated state technical lead is not available and the technical difficulty stops the survey process, contact the QTSO Help Desk (1/888/477 – 7876). Inform the Help Desk responder that the contact is about a LTCSP and immediate assistance is required because the team cannot continue with the survey until the issue is resolved . o To send Se r ver Log Files to the QTSO Help Desk , i n the navigator menu go t o System , click on Email Server Log , use the drop – down next to Log File to select the date(s) of the concern, and click Save. If you have internet access, you will be directed to email the Log Files to the QTSO Help Desk. If you do not have internet access, save the Log Files to email at a later time. Step 2: Export shell from ACO In ACO, export the shell according to your stat e practice (e.g., flash drive or via Direct Connect) as close to the survey start date as possible but no more than 5
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 4 business days before the survey start date so the export ed shell has the most up – to – date Minimum Data Set (MDS ) data . o During the transfer, if there are no residents included in the shell you will receive a warning indicating there is no available MDS assessment data. It is recommended if possible (e.g., address submission concerns with the facility) and reschedule the survey once the issue has been resolved . I t is critical to have MDS data for the survey , if at all possible . If there is a lack of MDS data during the public health emergency (PHE) because of the blanket waivers, then it is acceptable to move forward with the survey. If you decide to continue with the survey, the team will not have offsite – selected residents , MDS indicators , or closed record residents . T he initial pool and sample will be comprised of just onsite – selected residents. o If the survey shell has already been exported, you will see a warning. You should only overwrite the data if the survey start date has significantly changed (e.g., the survey was postponed or delayed) or if you originally pulled the shell more than 5 working days before the survey start date. Otherwise, you will always answer No to the warning to avoid overwriting the data (e.g., when the SA attaches additiona l complaints after the survey has begun). Step 3: Import shell into ASPEN Survey Explorer ( ASE – Q ) In ASE – Q (also referred to as ASE) , import the shell according to your state practice (e.g., flash drive or via Direct Connect) . o C lick on the Import button . o Insert the USB drive (if using) . o Select Other Zip File Location . o Click on the binoculars . o Locate the shell . o Switch to All Files if you renamed the shell – The default file type is ASPEN Export (ASPENTx.zip) . o C lick the drop – down and select All Files (*.*) . o Double click on the survey shell . o Click OK . o Select Continue with Import in the Survey Import dialog box . o During the transfer (both import and export) , a pop – up will appear display ing the number of residents included in the shell (i.e., Residents Exported) . This number will be used to identify the maximum number of complaints/FRIs that may be included in the initial pool (Step 6 below) since the number is indicative of the facility census size. If the number of residents is reasonable, click OK . NOTE: Ensure the re is an adequate number of resident s included in the shell as com pared to the facility bed size. If there are very few residents and the PHE
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 5 has ended or the 1135 blanket waivers for MDS has been rescinded ( https://www.cms.gov/files/document/summary – covid – 19 – emergency – declaration – waivers.pdf ) , again the S A may need to resolve the issue with your MDS/RAI Coordinator and the facility , if appropriate, which means the survey may need to be delayed depending on the specific circumstances . o Click Apply . o I f the re are C omplaints or FRIs that will be investigated with the survey, they will appear under the event ID with a C OMP or FRI indication . Step 4: Add team members in ASE – Q (if team composition changes) Best practice is always to add team members in ACO, but you can add them in ASE – Q when necessary (e.g., team members were changed after the shell was exported or added later in the survey process). In ASE – Q, click on the appropriate alphabetical grouping o Click on the plus sign next to the facility name Right click on the Event ID Right click on Team Roster . Click on Update Team . Click on the Update button. Place a checkmark next to e , when all survey team members are selected, click OK . o If you are adding more than one surveyor to the team, ensure each team member adds the names in the same order. Adding team members in ASE – Q in different orders could lead to du plicate resident IDs. o To confirm there are no issues, every team member should go to the data sharing screen in the LTCSP system and confirm the system ID (last column in the table) is the same for each team member on all computers . If not, in the System ID column for the applicable surveyor, double click on the inconsistent number and manually update the system ID number , so they match. Highlight the name of the TC (Team Coordinator) , click Leader (a blue diamond will Done . Important: The system will protect the data and not allow a team member to be removed if they have contributed any data to the survey. The only exception is if the team has not entered the facility yet. In that case, the TC should unassign facility tasks from the surveyor and then remove the surveyor from the team. Step 5 : Access the survey There are two ways to access the LTCSP survey: o Right click on the Event ID and select LTCSP from the drop down menu. o Rig ht click on the Event ID , select Citation Manager , and click the LTCSP Survey button .
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 6 If you receive a warning message that the system is unable to connect to the server, click on the LTCSP button again to access the LTCSP survey. Step 6 : TC completes offsite prep screen C lick on Survey Preparation | Offsite Prep in the navigation menu. Review the CASPER 3 report for pattern of repeat deficiencies . Document your findings in the C ASPER 3 report notes field. Document the r esults of the last Standard survey . Review c omplaint s (COMP) and Facility Reported Incidents (FRI) since the last Standard survey to gain a general understanding of repeated issues or concerns that have been reported. If you are investigat ing c omplaints or FRIs with the survey, identify the maximum number of complaints/FRIs that may be included in the initial pool and sample based on the facility census siz e (i.e., the number displayed on the pop – up when the survey shell was im ported in Step 3) . This information is shown in Attachment A to the LTCSP PG ( The Sample Size Grid, Recommended Team Size, Initial Pool Size , and Complaint/FRI Size ). If you are including on a survey more than the designated maximum number of complaint/FRI residents for the facility census size , any residents over the maximum are considered additional complaint/FRIs; do not include these additional complaint/FRI residents in the initial pool or sample . Y ou will only investigate the allegations for these additional (i.e., more than the designated maximum number ) residents . T he a ctive /outstanding c omplaint s/FRI s that were linked from the ASPEN Complaints/Incidents Tracking System ( ACTS ) will be listed on the Offsite Preparation screen in the table . The following information is linked to each complaint/FRI: Intake ID with a link to notes entered in ACTS , Type (COMP or FRI), Complaint Resident Name from ACTS , and an indicator if the complaint resident is also an o ffsite selected resident. Expand the in take ID ( using the down arrow) to review the a llegations with a link to notes entered in ACTS . State – only complaints will be identified as such. o Review the intake ID notes and allegation notes to identify the concern. o Unknown/anonymous complaints are when the resident is unknown. T he system will default the LTCSP Resident column to the general facility placeholder titled Facility, Facility . Select Facility, Facility if the complaint resident is listed as anonymous. If a resident is identified but was not added in ACTS, add the resident in ACTS , export the shell, but do not over write the data . o For any complaint resident identified , l ink the c omplaint r esident name to the name listed in the LTCSP system by using the drop – down box under LTCSP Resident – Room.
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 8 have been reported since the last recertification survey during offsite prep. We b elieve this information is very important but understand that reviewing complaint and FRI information may be difficult, and that States have different ways of documenting these events. Therefore, we encourage States and survey teams to understand this info rmation prior to entering a facility; however, it is not required. Note any f acility Federal variances/waivers . Note a ctive enforcement cases that should not be investigated (e.g., pending complaints already investigated that have a civil money penalty ) . Contact the Ombudsman in accordance with State policy. Notify the ombudsman of the proposed day of entrance into the facility and if applicable, obtain any information/concer ns. Ascertain whether the ombudsman will be available if residents wish her/him to be present during the Resident Council Interview. Enter the Review CDC, state/local public health information, if available , to be aware of the COVID – 19 status of the facility including the COVID – 19 county positivity rate . Step 7 : TC makes facility unit assignments O n the o ffsite p rep screen , a ssign all units equally across the team members using plan . o o If the facility rehab unit is large , c onsider assign ing two surveyors to cover it . o Consider the location of offsite selected residents and complaint or FRI residents. o Where practical, one surveyor should be assigned to COVID – 19 positive residents only. Additionally, a different surveyor should be assigned to the COVID – 19 suspected residents, or those residents under ob servation. Once t he surveyor that is assigned to the COVID – 19 unit enters the unit, the surveyor should stay on that unit for the remainder of the day while completing the investigation and tasks specific to that unit . o Keep surveyors on one unit/floor as m uch as possible. Be mindful of the number screens all residents in their assigned area and includes about eight residents (may be adjusted depending on team size) in the initial pool. o Assign units according to surveyor specialty , when applicable (e.g., assign a social worker to the dementia care unit). o To attach a copy of the floor plan with assignments in the software, c lick on the paperclip icon on the far – right side and follow the instructions on the screen. Step 8 : TC makes mandatory facility task assignments Assign mandatory facility tasks by selecting Investigation | F acility Tasks from the N avigat i o n menu :
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 9 o Beneficiary Protection Notification Review o Dining Observation ( assign all surveyors who are assigned to a dining area or room trays but communicate that one surveyor has primary responsibility ) o Infection Control ( assign all surveyors but communicate that one surveyor has primary responsibility ) o Kitchen o Medication Admin istration o Med ication Storage o QA A/ QAPI o Resident Council Meeting o Sufficient and Competent Nurse Staffing ( assign all surveyors but communicate that one surveyor has primary responsibility) Note: To enter data on a facility task screen , a surveyor must be assigned to that task. For those tasks where all team members need to enter data, assign to ALL (only the TC can assign to All) . During the survey , if a surveyor is not assigned to a facility task and identifies a concern related to a specific task , the surveyor can add their name to that task. Step 9 : TC prints documents Print the following documents ( click the Reports icon the clipboard without a pencil – on the right side of the screen or press Alt+P ) . If you are not printing the reports from the LTCSP system, e nsure you are using the most recent version of the reports . o Facility Matrix with instructions (1 copy of instructions, multiple copies of the blank matrix ) o Entrance Conference worksheet ( 1 cop y ) o Beneficiary Notices worksheet (3 copies) i n the Reports window Step 10 : TC s hare s offsite prep data with team members The TC should share the completed offsite prep data with team members using the Data Sharing screen . The Data Sharin g Methods instructions below should be used for all data sharing throughout the survey. Data Sharing is always performed between the TC and team members. Team members cannot share data between themselves. To access the Data Sharing screen click on the flash drive icon on the right tool bar menu or use ALT + D .
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 10 DATA SHARING METHODS Using the File method IMPORTANT: TC should always receive data from all team members before sending the consolidated data back to the team if the team members have updated information . If team members share data with the TC, make additional changes in their system, and then receive data from the TC without sharing their newly added information, any newly added information may be lost. Some data sharing steps only require the TC sending out data (e.g., offsite prep or investigation assignments) , so the sharing of data from team members can be skipped. For example, the TC s hares offsite preparation data to team members without needing to receive any data from team members. File used for data sharing can be written to a USB device, to a central location accessible by all surveyors , or to another location where it can be sent by secured email . The file browser will default to the USB device if one is entered and the desktop if no USB device is found . In order to send or receive data , team members need to be o n the Survey Team Data Sharing screen. o To send data to TC, all team members should: o Insert a flash drive. o Click Send Data . o A file browser will open and default to the flash drive folde r with the correct file name entered. o Click Open . o Message will confirm that data was successfully sent. o To receive team member data, the Team Coordinator should: o Insert the flash drive containing one or more files from the team members. o Place a checkmark o Select Receive Data . o The flash drive folder should automatically appear. If not, browse to the flash drive. o The title of the browser window will contain the name of the survey team member it is currently processing. o Ensure the correct flash drive is entered and the correct file for that surveyor is selected. File name will default to the correct name for the team member currently being processed. o Click Open . o Message will confirm that data was successfully received. o To send consolidated data to team members the Team Coordinator should: o Insert a flash drive. o o Click Send Data .
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Long Term Care Survey Process (LTCSP) Procedure Guide Effective February 6 , 20 21 2/6/21 Page 11 o The flash drive folder should automatically appear. If not, browse to the flash dr ive. o Click Open . o Message will confirm that data was successfully sent. o To receive consolidated data from the TC , all Team Members should: o Insert the flash drive containing TC file. o Click Receive data . o The flash drive folder should automatically appear. If not, browse to the flash drive . o o Click Open . o Message will confirm that data was successfully received. Using Secured Wireless method or using Wired method with a switch: If using other w ireless network(s) during the survey (e.g. , a facility provided network) ensure that all team members have disconnected from those networks prior to sharing data. Disconnect from your VPN as well. All team members must be connected to the same secured wir eless or wired router your state is using for data sharing. To ensure that all team members receive data from all the other team members, it is recommended that all team members share data thr ough the TC at the same time . This may not be possible w hen a t eam member has to leave the survey but is recommended at all other times. The Team Coordinator should : o Ensure everyone is connected to the same secured wireless connection or plugged into the same wired switch. o o Ensure the team members have a server defined: o Use the pull – o The Reload Server List button can be used to refresh the pull – down list o OR have entered t he Machine Address (IP). o Enter the IP address exactly as it is written on the team member s machine. o Click Share Data Now . o The TC will receive a message noting each team member that successful ly sen t data to the TC and each team member that successfully received data back from the TC. Using Secured Wired method using a cable to connect two machines: If using other wireless network(s) during the survey (e.g., a facility provided network) ensure that all team members have disconnected from those networks prior to sharing data.
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