Which best describes the use of QMs by the DNS and the QAA committee?

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Which best describes the use of QMs by the DNS and the QAA committee?
 

A. QMs are reviewed only when a substandard level deficiency has been cited.

 

B Regulations require the DNS to review QMs monthly and for the review to be documented in the QAA committee meeting minutes.

 

C QMs are used to evaluate staff performance and determine who is not following the facility’s policies and procedures.

 

D QMs are used to study performance and determine potential opportunities for improvement.

 

 
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Which of the following correctly identifies methods used in the Staffing Domain of the Five-Star Quality Rating System?

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Which of the following correctly identifies methods used in the Staffing Domain of the Five-Star Quality Rating System?

 

A The methodology is based upon acuity and staffing data submitted via the Payroll-Based Journal (PBJ) staffing system.

 

B Only registered nurses (RNs) and nursing home administrators are counted in the determination of the star rating for staffing.

 

C Acuity of residents is not included as part of the methodology. The star rating is solely based upon total number of staff for the quarter.

 

D MDS data is not used to help determine acuity levels in the nursing facility; only PBJ data is used to determine acuity.

 
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Happy Valley Nursing Center submitted 0.781 hours per resident day in the PBJ quarterly submission.

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Happy Valley Nursing Center submitted 0.781 hours per resident day in the PBJ quarterly submission. When the Staffing rating was calculated, the facility was adjusted downward to 0.667. What does this mean?

 

A The nursing facility did not have enough RNs on staff based on resident acuity and comparison to the national average for RN hours per resident day.

 

B The nursing facility had more than enough RNs on staff based on resident acuity and comparison to the national average for RN hours per resident day.

 

C The nursing facility was staffed at 66% of acceptable staffing based on resident acuity and comparison to the national average.

 

D The nursing facility was staffed at 78% of acceptable staffing based on federal minimum staffing laws.

 
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While reviewing their MDS 3.0 Facility Level Quality Measure Report, facility staff note that the facility observed percent for moderate/severe pain (short stay) has jumped from 16% to 27.6%

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While reviewing their MDS 3.0 Facility Level Quality Measure Report, facility staff note that the facility observed percent for moderate/severe pain (short stay) has jumped from 16% to 27.6% since the previous month’s printing. Which of the following is the most likely cause of this significant variance?

 

A The QM target assessment selection logic used

 

B The report period selected

 

C The QM look-back scan selection logic used

 

D The coding of the MDS

 
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The role and purpose of a PIP team is best described as:

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The role and purpose of a PIP team is best described as:

 

A A team of people with knowledge of the processes that are to be changed that work together to make the improvement

 

B A team of all QAA committee members

 

C A team that monitors an area of performance indefinitely

 

D A team convened to help manage the annual survey

 

 
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Which of the following does not describe the focus of QAPI?

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Which of the following does not describe the focus of QAPI?

 

A Preventive

 

B Reactive

 

C Process and systems

 

D Continuous improvement

 
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The quality assessment and assurance (QAA) committee is responsible for which of the following?

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The quality assessment and assurance (QAA) committee is responsible for which of the following?

A. Completing the plan of correction submitted to the state survey agency after a deficiency is cited

 

B Monitoring the performance outcomes of the care and services delivered to the residents of the facility

 

C Reviewing and analyzing cost reports at the required QAA/QAPI committee quarterly meeting

 

D Serving as the performance improvement project (PIP) team for all projects

 
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Which of the following describes when the Plan-Do-Study-Act (PDSA) cycle is used?

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Which of the following describes when the Plan-Do-Study-Act (PDSA) cycle is used?

 

A It is implemented once the QAA committee has determined that a PIP is a necessary priority, which requires a change in process(es).

 

B It is implemented to be the data-collection phase of a study.

 

C It is implemented as the primary tool for developing an action plan.

 

D It is implemented when surveyors cite a deficiency under the QAA/QAPI tag and an action is required to fix the problem area.

 

 
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Data collection tools might include all except which of the following?

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Data collection tools might include all except which of the following?

 

A A specific chart-audit form

 

B A log of how long it took for each call light to be answered on the evening shift during a one-week period

 

C A form using hash marks to indicate the number of times residents requested an alternative meal in two weeks’ time

 

D Purchased tools only, since facility staff are not trained to accurately develop data collection tools

 
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Which of the following describes the method that should be used to monitor a particular issue or process?

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Which of the following describes the method that should be used to monitor a particular issue or process?

 

A It should be standardized for all PIPs.

 

B It should be selected by each person who will be collecting the information.

 

C The determination should be based on the details of the particular project.

 

D It should be set by the administrator and director of nursing services (DNS).

 
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