Federal Surveyor Qualifications Standards

4009 - Federal Surveyor Qualifications Standards (Rev. 1, 05-21-04) (Also see §7201) In accordance with the “Personnel” clause of the State agreement, SA personnel must be under a merit system that meets Federal standards. Minimum standards specifically applicable to surveyors for Medicare and Medicaid Programs are as follows: 4009A - Persons Covered (Rev. 1, 05-21-04) The term “surveyor” means a person who investigates, evaluates, and/or makes official reports of situations and conditions in a health facility, and who determines the degree to which the facility meets specific criteria contained in regulations issued pursuant to titles XVIII and XIX of the Act. 4009B - Health Professional Qualifications (Rev. 96, Issued, 12-13-13, Effective: 12-13-13, Implementation: 12-13-13) To perform the surveyor functions requires an appropriate background in the health professions or health administration, in addition to basic investigative skills. Therefore, one element in the standard is that the surveyor be qualified in one of the following professions: • Hospital administrator; • Industrial hygienist; • Laboratory or medical technologist, bacteriologist, microbiologist, or chemist; • Medical record librarian; • Nurse; • Nursing home administrator; • Nutritionist; • Pharmacist; • Physical Therapist; • Physician; • Qualified Intellectual Disabilities Professional; • Sanitarian; • Social worker; or • Any other professional category used within State merit systems for health professional positions, provided the State has determined the position classification skill level to be commensurate with any of the above professions. This does not mean that the surveyor must belong to a professional organization or have prior work experience in the profession. It means that he/she must satisfy necessary requirements to be employed in one of these specialties by the State. 4009C - Education, Training, and Experience (Rev. 96, Issued, 12-13-13, Effective: 12-13-13, Implementation: 12-13-13) To assure that individuals have the necessary knowledge, skills, and abilities to carry out survey functions, the following prerequisites apply: • The amount of academic education required is that which is necessary to qualify in a profession listed in §4009B; • Newly hired surveyors must successfully complete an orientation program approved by CMS that includes the core elements of the CMS-developed orientation program. (See Exhibit 42.) The CMS provides this program for Federal surveyors and the States provide it for theirs; • The CMS and States assure that the health facility surveyors, laboratory surveyors, and Life Safety Code (LSC) surveyors have successfully completed, within the first 12 months of employment, the basic surveyor training course developed under CMS auspices, including all course prerequisites. LSC surveyors are required to complete a LSC basic course (there is self-paced training on a CD-ROM as a prerequisite). No individual may serve on a survey team until he or she fulfills this requirement, except as a trainee who is accompanied onsite by a surveyor, who has successfully completed the required training and testing program; • In States implementing the Quality Indicator Survey (QIS) process to determine if Medicare and Medicaid certified nursing homes meet the Federal participation requirements, additional training in QIS as described below at §4009F must be completed. • Before any State or Federal surveyor may serve on a survey team (except as a trainee) for an ICF/IID, ESRD facility, HHA, or Hospice survey, he/she must have successfully completed the relevant provider-specific Basic course and any course prerequisites; • Some State position classifications may require additional education, training, and experience as State minimums, as requirements for promotion, or entry at a higher scale of position classification; and • SAs must have a mechanism to identify and respond to the in-service training needs of the surveyors. 4009D - Evaluation (Rev. 1, 05-21-04) The surveyor must demonstrate ability to perform the essentials of the survey function, including knowledge of new or changing Federal regulations as obtained through continuing education sponsored by CMS or the State. All survey and certification staff must attend job-related training courses annually. 4009E - Implementation (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) Surveyors are considered qualified if: • They undergo the training prescribed in the second and third bullets and, if applicable, in the fourth bullet for QIS States in §4009C. Personnel are regarded as being in an associate or apprentice capacity until such time as they meet these training requirements; and • They either devoted 50 percent or more of their working time to Medicare and/or Medicaid survey activities or meet the professional qualifications for positions described in §4009B; • Associates and others who are not qualified surveyors may continue to participate as members of survey teams. However, teams must include one qualified surveyor who has responsibility for completing and signing the survey report and for the accuracy of the surveys conducted by associate or apprentice surveyors. 4009F - Quality Indicator Survey (QIS) Training Process (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) CMS is implementing the Quality Indicator Survey (QIS) which is a computer-assisted long term care survey process used by selected State Survey Agencies and CMS to determine if Medicare and Medicaid certified nursing homes meet the Federal requirements. The QIS is a federally-approved process for surveying nursing homes and it includes the use of computer technology that is not utilized in the traditional survey process. National implementation of the QIS is progressing State-by-State as resources are available to conduct training of State and Federal surveyors. Once a State is selected by CMS to implement the QIS, the time frame for achieving statewide QIS implementation can range from one to three years. The rate at which implementation occurs is dependent upon the number of surveyors needing QIS training and other issues as determined by the State. Therefore, until all nursing home surveyors in a selected State have received training in the QIS process, some nursing homes will continue to receive the traditional survey to determine compliance with Federal participation requirements. The standards outlined in this section apply to all State Survey Agencies (SAs) implementing the QIS and their respective CMS Regional Offices (ROs). Only CMS- approved QIS surveyor training course material will be used to train surveyors and trainers. The CMS-approved QIS training materials (with CMS logo) include the procedures, processes, and forms that are used to support the QIS process. CMS has approved the training entity to conduct the initial QIS training of selected State and CMS RO surveyors and the subsequent training of a State’s designated QIS trainers. Surveyors who successfully complete all QIS training components will be recognized as “Registered QIS Surveyors.” From the pool of initial Registered QIS Surveyors who have successfully completed at least six QIS surveys of record, individuals will be selected by the SA to receive additional training to become “CMS-Certified QIS Trainers.” (The approved CMS training entity certifies to CMS that these individuals have met the requirements to train surveyors on the QIS process.) The CMS-Certified QIS Trainers provide QIS training to the remaining nursing home surveyors in their State. 4009F.1 - Orientation and Training of Newly Employed Surveyors in a State Implementing the QIS (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) Each QIS State determines if a newly hired surveyor will be trained in the QIS process or the traditional survey process, and this determination will be based on the manner in which a QIS State is implementing the QIS. Implementation of the QIS process in a State does not replace or alter the requirements that a newly employed surveyor must be oriented to the nursing home survey process, successfully complete the Basic Long Term Care Health Facility Surveyor Training Course (BLTCC), and receive a passing score on the Surveyor Minimum Qualifications Test (SMQT). In a QIS State, if a newly hired surveyor is being oriented to the QIS process, the preceptor assigned to this surveyor is both SMQT qualified and a Registered QIS Surveyor. The preceptor performs the same responsibilities as a preceptor of a newly hired surveyor in a State using the traditional survey process. As part of the field experience in the State’s orientation to the QIS process of a newly hired surveyor and prior to attending the formal QIS classroom training, the newly hired surveyor in a QIS State should: • Receive training in basic computer skills (including data management using Folders, Import/Export functions and Microsoft Word); • Observe one or more QIS surveys to gain exposure to the QIS process; • Complete QIS survey tasks under the direct supervision of the preceptor to the extent that the preceptor is confident that the newly employed surveyor understands the QIS process; and • Attend the formal QIS training at the point in time that the State determines the newly employed surveyor is prepared to begin QIS training. The QIS training includes several required components described below. It is not a requirement that the newly hired surveyor be SMQT qualified prior to participating in QIS training components. Successful completion of all QIS training components will culminate in the student becoming a Registered QIS Surveyor. The designation as “Registered QIS Surveyor” indicates that the newly hired surveyor successfully completed the QIS training and is registered in the CMS Survey & Certification Learning Management System (LMS). The newly hired Registered QIS Surveyor continues to work as part of the team under an SMQT qualified and Registered QIS Surveyor preceptor. The newly hired surveyor who is a Registered QIS Surveyor meets the same requirements as a newly hired surveyor in a State that is not yet implementing the QIS process. Specifically, the newly hired surveyor must successfully complete the Basic Long Term Care Course (BLTCC) within the first year of employment and receive a passing score on the SMQT to independently (that is, without supervision of an SMQT qualified surveyor) survey nursing homes to determine compliance with the requirements of participation. In a QIS State that has fully implemented the QIS process or has otherwise determined that the newly hired surveyor would be oriented to the nursing home survey process via the QIS and not the traditional process, it is expected that newly employed surveyors would complete the requirements and become Registered QIS Surveyors before attending the BLTCC. 4009F.2 - Training Process: Registered QIS Surveyor (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) The initial QIS training process in a newly selected State begins with the training of two core survey teams of four surveyors each. The initial QIS training is conducted by the CMS-approved training entity. The initial core group selected in a State Survey Agency (SA) implementing the QIS must: • Have a minimum of two years of recent long term care (LTC) survey experience; • Have received a passing score on the SMQT; • Possess strong leadership ability and/or prior experience as a trainer or teacher; and • Possess intermediate computer skills. Every SA or CMS RO surveyor must successfully complete prescribed training components to be considered a Registered QIS Surveyor whether the training is provided initially by the CMS-approved training entity or subsequently by a SA or RO CMS- Certified QIS Trainer. The training of surveyors in the QIS process includes all of the following components: • Web-based Lessons - Surveyors will initially complete a short series of Web- based learning modules prior to participation in the classroom training. The designated Web-based modules provide background information, a general overview of the QIS process, and an introduction to the QIS specific software. • Classroom Training - The classroom training uses the CMS-approved QIS surveyor training course manual, which incorporates various media presentations, lectures, exercises, computer tutorials, and discussions. Generally, each class will be comprised of 8 surveyor-students (2 teams of 4 surveyors each). In the case that a SA wishes to have more than 8 surveyors in one class at a time, consideration should be given to constructing teams of 4 surveyors each to assure there are a sufficient number of instructors to accompany each team on its mock survey and surveys of record. Class size will be determined by the State in consultation with the CMS training entity. If the State wishes to train additional survey teams initially, the State is expected to bear the expense and to make arrangements with the CMS training entity. During the initial round of QIS training of core surveyors in a State, the State will assure that at least one first-line supervisor/manager with responsibility for QIS surveys and an informational technology (IT) staff person receives training in the QIS training process. Additional training for the IT staff member is provided. The QIS utilizes the QIS Data Collection Tool (DCT) software. Therefore, it is essential that the State’s IT staff be available immediately either on site at the nursing home or by telephone to support the training activities conducted in the field. In addition, the CMS-Certified QIS Trainer must be able to assist students in resolving technical issues. • Mock Training Survey - Immediately upon completion of the QIS classroom training portion, surveyors will be organized into two survey teams (of about four surveyors each) and each team will participate in a mock, or simulated, survey in a nursing home using the QIS process. The mock training survey is a learning opportunity and not a survey of record. During the mock training survey, two trainers (the trainers may be CMS-Certified QIS Trainers or the CMS-approved training entity) are present and work with the survey teams to assure that the surveyors understand and implement the QIS process correctly. The trainers will identify problems, if any, in the surveyors’ adherence to the procedures and correct any problems identified. If there is a concern with the implementation of the QIS process by the surveyors, an additional mock survey would be conducted. A surveyor would not conduct surveys of record until instructor staffs are satisfied that the surveyor can independently conduct survey activities using the QIS. If necessary, additional classroom training or mock surveys would be conducted as a remediation activity before conducting surveys of record using the QIS process. The State Survey Agency bears the expense of any further remediation activities required beyond the first remediation visit provided in the CMS contract with the CMS training entity. • Surveys of Record with Compliance Assessments - Surveys of record will be conducted following the successful completion of the mock survey(s). During the first survey of record, two trainers (the trainers may be CMS-Certified QIS Trainers or the CMS-approved training entity) are present to assess the surveyors’ compliance with the QIS process and evaluate the extent to which surveyors are adhering to QIS procedures. The first compliance assessment will be conducted during each surveyor’s first survey of record. The second compliance assessment will be conducted usually during the second survey of record or, after one intervening survey (that is, during the third survey of record). There should be no more than one intervening survey of record between the first and second compliance assessment. Surveyors must pass two consecutive compliance assessments to become Registered QIS Surveyors. If a surveyor fails either of the two compliance assessments, additional compliance assessments will be conducted until there are two successful consecutive assessments. If additional compliance assessments are conducted by the CMS training entity, the State will bear the additional expense of this activity. The rate of a State’s QIS implementation and the availability of State resources may allow a State the ability to provide experienced and SMQT qualified surveyors an opportunity to observe an actual QIS survey before attending the required QIS training. 4009F.3 - Training Process: CMS-Certified QIS Trainer (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) Trainer-candidates will be selected from the two core survey teams initially trained in QIS by the CMS- approved training entity. The CMS-Certified QIS Trainers function as a training team of two persons and provide QIS training to the State’s remaining nursing home surveyors. CMS expects that each State will have a minimum of two training teams composed of two CMS-Certified QIS Trainers on each team. If a State wishes to have more than the initial 4 trainers, the State bears the expense of training the additional two person teams as QIS trainers for the State. In the event that a trainer-candidate fails any component of the training, the costs associated with remediation training for QIS trainer-candidates are the responsibility of the SA. Those selected to become CMS-Certified QIS Trainers must: • Be Registered QIS Surveyors; • Have participated in at least six QIS surveys of record; and • Developed sufficient mastery of the QIS process to serve as an instructor/trainer. To become a CMS-Certified QIS Trainer, the selected Registered QIS Surveyors must successfully complete the following training components, under the tutelage of the CMS training entity: • Train-the-Trainer Workshop - Trainer-candidates will participate in a 4-day train- the-trainer workshop, which will be held in a classroom setting by the State. Led by the CMS-approved training entity, this workshop will provide trainer- candidates specialized background information and knowledge of the QIS, including in-depth training on the QIS Data Collection Tool (DCT), classroom and onsite facilitation techniques, optimal use of the QIS process, protocols for assessing onsite compliance with the QIS process, and preparation for questions frequently asked by surveyors. • Instruct One Class of Surveyor-Students - Generally, four trainer-candidates will provide classroom training to a class of approximately eight surveyor-students with CMS training entity staff observer(s) participating at the classroom session. The class size may vary; however, the number of surveyors trained in the QIS process is dependent on the trainers’ ability to perform all of the training steps in a timely manner. The training components include classroom instruction, mock survey, two successful compliance assessments, and remediation training, if necessary. The QIS classroom training session will be conducted as follows: • Presentations and instruction are rotated to provide the CMS training entity staff multiple opportunities for observation and evaluation of the trainer- candidates’ delivery of the QIS training to surveyor-students. • Each trainer-candidate’s performance during the classroom training will be evaluated on knowledge of the QIS, QIS computer skills, ability to articulate QIS concepts to the group, and ability to answer questions from the class. • The surveyor-students will evaluate the trainer-candidates and these evaluations will be considered in addition to the CMS training entity’s evaluation of each trainer-candidate. • Each of the four components of performance will be rated on a Pass/Fail basis. If a trainer-candidate fails any one of the four topic areas, he/she fails the classroom training component of the trainer certification process. • Evaluations of Surveyor-Students During Mock Surveys – Each mock survey will include two trainer-candidates and four surveyor-students (generally), accompanied by the CMS training entity staff. Each trainer candidate will be evaluated by the CMS training entity on QIS knowledge, QIS computer skills, ability to answer individual questions, and organizational skills. Evaluations will be rated on a Pass/Fail basis; and failure of any of the four components will result in failure on the mock survey training component of the trainer certification process. • Oversight of First Survey of Record with Compliance Assessment – The first survey of record will be comprised of two trainer-candidates, usually four surveyor-students, and one or two CMS training entity staff. Each trainer- candidate will be evaluated by the CMS training entity based on individual QIS knowledge, QIS computer skills, and the ability to apply the CMS- approved compliance assessment and use of forms to conduct the first compliance assessment of surveyor-students. Evaluations of the trainer- candidates will be rated on a Pass/Fail basis, and failure on any of the three components will result in failure on the survey of record component of the trainer certification process. In summary, as described above, the training approach developed for QIS requires surveyors in each State to first master the QIS process and become Registered QIS Surveyors. The trainer-candidates must have conducted QIS surveys of record and achieved proficiency with the QIS. The trainer-candidates must have completed an intensive train-the-trainer workshop. Through these processes, the States’ trainer- candidates have developed a unique body of knowledge and achieved a level of expertise that they will pass on to surveyor-students in the classroom and in the other training components. Many QIS surveyor-students participating in the training process are seasoned SMQT- qualified surveyors, supervisors, or RO staff, all with proven proficiency in the traditional survey process. However, in the QIS classroom training, mock survey, and survey of record with compliance assessment, the QIS surveyor-students are the learners. To optimize the learning experience, it is essential that the surveyor-students be open- minded about the QIS process and respect the leadership and expertise of the CMS- Certified QIS Trainers and QIS trainer-candidates. The training process includes the requirement that the QIS trainer-candidates conduct evaluations of the surveyor-students’ use of the QIS process. These evaluations are not intended to critique the surveyor- students skills but rather to ensure the consistent and accurate implementation of the QIS process as approved by CMS. The CMS-Certified QIS Trainer status awarded to each individual who has successfully completed the QIS trainer program remains in effect as long as the individual is actively involved in the QIS process. To be considered actively involved, the CMS-Certified QIS Trainer is expected to conduct a minimum of two SA QIS trainings of all components (classroom, mock, compliance assessments) per year or participate as a survey team member in at least one QIS survey per quarter. A trainer’s name will be removed from the LMS as a “CMS-Certified QIS Trainer” if the individual is not actively involved. 4009F.4 - Documentation of Successful Completion of Training (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) The CMS Survey and Certification Learning Management System (LMS) tracks the successful completion of training as a “Registered QIS Surveyors” and the successful completion of training as a “CMS-Certified QIS Trainers.” Completion of the QIS training requirements for surveyors and trainers must be timely documented in the LMS so that surveyors can conduct QIS surveys. 4009F.5 - CMS Regional Office Staff Participation in QIS Training (Rev. 39, Issued: 12-19-08, Effective: 12-19-08, Implementation: 12-19-08) The number of States implementing the QIS in each particular CMS Regional Office (RO) will determine the number of RO surveyors to receive QIS training. At least two RO SMQT-qualified long term care surveyors are expected to participate as students in a State’s QIS training; however, the two RO surveyors need not participate at the same QIS training session. The selected RO surveyor(s) will travel to the State within their region that is conducting the QIS training. The CMS training entity is present during the first cycle of QIS training conducted by the State's trainer-candidates and this may be an opportune time for RO surveyor participation. The RO surveyors nominated to complete QIS training to become Registered QIS Surveyors should have: • Have a minimum of 2 years of recent long term care survey experience; • Have received a passing score on the SMQT; • Possess strong leadership ability and/or prior experience as a trainer or teacher; and • Possess intermediate computer skills. The RO surveyors are students and participate in all components of the QIS training process including classroom, mock survey, compliance assessments, and six surveys of record (conducted consecutively if possible, to maximize learning and minimize disruption). The two compliance assessments of the RO surveyors will be conducted by the State’s QIS trainer-candidates. It is expected that the two RO surveyors will each be embedded with a different State survey team (one RO surveyor per State QIS team). By being embedded, the RO surveyor will participate as a member of the team, receiving survey assignments and carrying out the same survey functions as other members of the team. The RO surveyor who is learning the QIS process will also need to become proficient performing some of the team coordinator functions such as, using the primary laptop. The RO surveyors will receive the same QIS training as SA surveyors to become Registered QIS Surveyors. In the future, the RO’s Registered QIS Surveyors must complete the same QIS training process as the States’ Registered QIS Surveyors to become CMS-Certified QIS Trainers. A CMS consortium may decide to develop a blended training team consisting of two RO Registered QIS Surveyors from different ROs within the consortium to receive training to be CMS-Certified QIS Trainers. As the CMS training entity instructs initial core teams of surveyors, supervisors, and IT staff in new States, a CMS RO informational technology (IT) expert should participate with the State’s IT experts in receiving the specialized QIS IT training.