Federal Minimum Qualification Standards for LTC Facility

4009.1 - Federal Minimum Qualification Standards for LTC Facility Surveyors (Rev. 1, 05-21-04) Sections 1819(g)(2)(C)(ii), 1819(g)(2)(E)(iii), 1919(g)(2)(C)(ii), and 1919(g)(2)(E)(iii) of the Act require that individual members of long term care (LTC) survey teams meet minimum qualifications established by the Secretary and successfully complete a training and testing program in survey and certification techniques. In addition, LTC surveyors must successfully complete a training and testing program, which includes the Surveyor Minimum Qualifications Test (SMQT). 4009.1A - Purpose (Rev. 1, 05-21-04) The SMQT is part of the training and testing program and addresses the knowledge, skills, and abilities (KSAs) needed to conduct standard and extended surveys in LTC facilities. 4009.1B - Prerequisites (Rev. 1, 05-21-04) Prior to taking the SMQT, a LTC surveyor must complete the CMS Orientation Program, and the Basic Long Term Care Health Facility Surveyor Training Course. 4009.1C - Test Composition (Rev. 23, Issued: 01-19-07; Effective/Implementation Dates: 02-20-07) • The Surveyor Minimum Qualifications Test (SMQT) is a 1 day 4 hour automated test which focuses on the LTC facility, the survey process, related laws, regulations and guidelines, environmental quality, sanitation, resident assessment and care plans, facility records, medicine, nursing, rehabilitation, gerontology, disability, chronic disease, resident rights, quality of life, nutrition, pharmacy, infection control, scope, and severity. The test also focuses on skill in documenting, gathering, and integrating information. 4009.1D - Successful Performance (Rev. 23, Issued: 01-19-07; Effective/Implementation Dates: 02-20-07) Successful Completion An individual must successfully complete the SMQT in order to survey independently. A surveyor can serve as a member of a survey team with at least one surveyor who has successfully completed the required training, but cannot survey independently until the surveyor has successfully completed the SMQT. 4009.1E - Unsuccessful Performance (Rev. 23, Issued: 01-19-07; Effective/Implementation Dates: 02-20-07) 1. Unsuccessful Completion Individuals who do not successfully complete the SMQT must retake the examination until they are successful. Alternate procedures for meeting surveyor minimum qualifications in rare and extraordinary circumstances are specified in §4009.l.E.3. If a surveyor fails to successfully complete the SMQT, the State Survey Agency (or, if a federal surveyor, the RO) must develop an individual training plan (ITP) for the surveyor to correct deficiencies. The components of the ITP are specified in §4009.1.E.2. During this period, the surveyor may participate in surveys as a trainee, i.e., the surveyor must be accompanied onsite by a surveyor who has successfully completed the training and testing program. 2. Individual Training Plan (ITP) The ITP must have the following components: • Individual training objectives that address the area of deficiency identified by the training and testing program; • A plan to meet training objectives; • A schedule for meeting these objectives; and • Someone designated to monitor the progress of the individual toward meeting these objectives. Upon completing the ITP, the surveyor must retake the SMQT. 3. Rare and Extraordinary Circumstances If the SA considers an individual to be a highly qualified LTC surveyor and that individual does not successfully complete the SMQT after three attempts, the State Survey and Certification Director may petition the RO for an exception to the requirement of passing the SMQT for the individual. The State must include at least the following documentation in its request for an exception: • A rationale as to why this individual has not successfully completed the SMQT; • Attestation by the State Survey and Certification Director that the individual for whom the request is being made is a highly qualified LTC surveyor; and Evidence that the individual has full understanding of LTC requirements, guidelines, and survey procedures, and has applied them accurately, consistently, and effectively when conducting LTC surveys or accompanying the survey team. This evidence may consist of documentation of onsite evaluations of the surveyor’s performance by experienced surveyors, including supervisors.