REFERENCE INFO - SURVEY PREPARATION

The report fragment above is very similar to the Facility Quality Indicator Profile report that surveyors use for offsite survey preparation and provide to the administrator when they arrive. The survey team uses it to identify potential concerns. QIs are calculated using the data facilities send to their states from MDS (quarterly, annual, and significant change) assessments.

In the draft State Operations Manual, dated May 5, 1999, surveyors are instructed to use the report to select concerns based on the following:

• Any sentinel health event QI that is flagged. A “sentinel health event” is a QI that represents a significant occurrence that should be investigated, even if it applies to only one or a few residents. Sentinel events are Prevalence of Fecal Impaction, Prevalence of Dehydration, and Prevalence of Pressure Ulcers (for residents at low risk).

• Any QI in which the facility is at or above the 75th percentile rank.