Count of QIS potential citations. This None Determine whether a district office or team has a considerably lower/higher average count of QIS potential is the total number of potential citations over time compared with the state and national average. citations determined onsite by the If concerns are identified, examine the QIS process steps associated with Stage 2 investigations and compliance survey team during the analysis and decisions. Ensure surveyors: decision-making meeting. Follow the guidance on the facility task and CE pathway when conducting the investigation. Conduct a comprehensive and thorough investigation. Report calculation: Discuss pertinent findings with the team to assess the potential for noncompliance and determine the An average of all QIS potential need for additional investigation. citations across the set of surveys Make accurate compliance decisions. being reviewed. Outlier rules Low outlier- 2 or less than the national average. High outlier- 4 or more than the national average 28. Number of Actual CMS-2567 Citations Count of Citations on the CMS-2567. None Determine whether a district office or team has a considerably lower/higher average count of CMS-2567 citations over time compared with the state and national average. Report calculation: Determine whether surveyors add or delete deficiencies after the team has made compliance decisions during The average count of actual the analysis and decision-making meeting. (See DAR-SA item #27) citations across the set of Determine whether supervisors/reviewers add or delete deficiencies during the internal QA review process. surveys Determine whether the CMS-2567 indicates numerous changes made to the QIS potential citations. Outlier rules If there are numerous differences between the QIS potential citations identified during the survey and the final Low outlier- CMS-2567, determine the underlying reasons for the differences (e.g., is the deletion due to an inadequate 2 or less than the national average. investigation or insufficient documentation, are supervisors adding F-tags that the team should have identified, High outlier- is training warranted)? 4 or more than the national average 29. Number of Tags with No Citation Decision
Count of QIS potential citations. This is the total number of potential citations determined onsite by the survey team during the analysis and decision-making meeting. Report calculation: An average of all QIS potential citations across the set of surveys being reviewed. Outlier rules Low outlier- 2 or less than the national average. High outlier- 4 or more than the national average None Determine whether a district office or team has a considerably lower/higher average count of QIS potential citations over time compared with the state and national average. If concerns are identified, examine the QIS process steps associated with Stage 2 investigations and compliance decisions. Ensure surveyors: Follow the guidance on the facility task and CE pathway when conducting the investigation. Conduct a comprehensive and thorough investigation. Discuss pertinent findings with the team to assess the potential for noncompliance and determine the need for additional investigation. Make accurate compliance decisions. 28. Number of Actual CMS-2567 Citations Count of Citations on the CMS-2567. Report calculation: The average count of actual citations across the set of surveys Outlier rules Low outlier- 2 or less than the national average. High outlier- 4 or more than the national average None Determine whether a district office or team has a considerably lower/higher average count of CMS-2567 citations over time compared with the state and national average. Determine whether surveyors add or delete deficiencies after the team has made compliance decisions during the analysis and decision-making meeting. (See DAR-SA item #27) Determine whether supervisors/reviewers add or delete deficiencies during the internal QA review process. Determine whether the CMS-2567 indicates numerous changes made to the QIS potential citations. If there are numerous differences between the QIS potential citations identified during the survey and the final CMS-2567, determine the underlying reasons for the differences (e.g., is the deletion due to an inadequate investigation or insufficient documentation, are supervisors adding F-tags that the team should have identified, is training warranted)? 29. Number of Tags with No Citation Decision
DAR-SA%20Item-by-Item-Instruction%20Guide.docx