Lists all care areas and facility tasks None Identify the care areas and tasks that were triggered and not cited (0%) for the report (Totals) and state. that can be triggered. Identify whether the report and state have a low or high citation rate for triggered care areas and tasks Identifies triggered care areas and compared to the national average. tasks (T), cited care areas and tasks When evaluating the citation rate, also consider the number of the care area or task triggered. A citation (C), and surveyor-initiated care areas rate of 0% when the care area only triggered once may not have as much significance for this item as a care and tasks (S). Survey totals for area that triggered on all ten surveys but was only cited once for a 10% rate. Triggered, Triggered and Cited, and Triggered and Not Cited are given at Determine trends or patterns regarding whether a particular care area or task continues to have a low/high the end of each survey column. citation rate when triggered. Looking across the report, the Totals If is a low citation rate for a triggered care area or task, examine the QIS process steps that are associated column shows the number of times with citations. Ensure surveyors: each care area was triggered and Follow the guidance on the facility task and CE pathway when conducting the investigation. cited, the number of times each care Conduct a comprehensive and thorough investigation. area triggered, and the percentage of Discuss pertinent findings with the team to assess the potential for noncompliance and determine the need for additional investigation. times each care area was triggered Make accurate compliance decisions. and cited. Outlier Low Outlier- If the national average is <26%, then the low outlier is ½ or less than the national average. If the national average is and ≥26% <61%, then the low outlier is 15 or more points less the national average. If the national average is then ≥61%, the low outlier is 20 or more points less than the national average. High outlier-
Lists all care areas and facility tasks that can be triggered. Identifies triggered care areas and tasks (T), cited care areas and tasks (C), and surveyor-initiated care areas and tasks (S). Survey totals for Triggered, Triggered and Cited, and Triggered and Not Cited are given at the end of each survey column. Looking across the report, the Totals column shows the number of times each care area was triggered and cited, the number of times each care area triggered, and the percentage of times each care area was triggered and cited. Outlier Low Outlier- If the national average is <26%, then the low outlier is ½ or less than the national average. If the national average is ≥26% and <61%, then the low outlier is 15 or more points less the national average. If the national average is ≥61%, then the low outlier is 20 or more points less than the national average. High outlier- None Identify the care areas and tasks that were triggered and not cited (0%) for the report (Totals) and state. Identify whether the report and state have a low or high citation rate for triggered care areas and tasks compared to the national average. When evaluating the citation rate, also consider the number of the care area or task triggered. A citation rate of 0% when the care area only triggered once may not have as much significance for this item as a care area that triggered on all ten surveys but was only cited once for a 10% rate. Determine trends or patterns regarding whether a particular care area or task continues to have a low/high citation rate when triggered. If is a low citation rate for a triggered care area or task, examine the QIS process steps that are associated with citations. 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.
DAR-SA%20Item-by-Item-Instruction%20Guide.docx