MAPI LTCSP User Manual

Information in this procedures guide is subject to change without notice.

All brand or product names are trade names, service marks, trademarks, or registered trademarks of their respective companies or organizations.

Systems Environment

Application Development: Microsoft Visual C++ and C# 2008 (9.0), .NET 3.51 SP1, .NET 4.6.1 or later (ASE-Q only)

Desktop Database (ASE-Q only): SQL Anywhere 11

Oracle Database 19c Enterprise Edition Release 19.9.0.0.0

Oracle Client 12.2.0.1

Optional System Environments

MAPI Compliant E-mail client to support e-mail transfer of survey information

Note: This document can be viewed online or printed in a duplex (two-sided)

format. Blank pages have been automatically inserted as needed for correct pagination in the printed copy.

Introduction ................................................................................. 9

About this User’s Guide ..................................................................... 9

View and Navigate this Document Online.......................................... 10

View a Printed Copy of this Document.............................................. 11

Conventions ................................................................................. 11

LTCSP CBTs ..................................................................................... 11

Accessibility Features...................................................................... 12

In this Guide ................................................................................ 12

In the Application.......................................................................... 12

LTCSP Procedures...................................................... ................. 13

Import User Account File................................................................. 13

LTCSP Surveys................................................................................. 14

Create LTCSP Survey Shell in ACO................................................... 14

Transfer LTCSP Surveys to ASE-Q .................................................... 14

Open a Survey in LTCSP................................................................. 17

LTCSP Screen Navigation and Features ........................................... 19

Title toolbar ................................................................................. 19

Quick Access menu ....................................................................... 19

Function toolbar............................................................................ 20

Change Column Order ................................................................... 20

Drop-down Lists ........................................................................... 20

Hover.......................................................................................... 21

Expand/Collapse Sections .............................................................. 22

Resize Sections with Expander Bars................................................. 23

Update PDF Documents ................................................................... 24

LTCSP Notes.................................................................................... 25

Surveyor Notes............................................................................. 26

Surveyor Notes in Resident Manager........................................... 27

Interview, Observations, and Record Review Notes ............................ 28

Facility Task Notes......................................................................... 28

View Resident Initial Pool Notes ................................................. 28

View Surveyor Facility Task Notes............................................... 29

Medication Administration ......................................................... 30

Investigation Notes ....................................................................... 30

View Body Map and Drawings for any Surveyor ............................ 31

Notes History ............................................................................... 32

User’s Guide 1/29/21 3

Contents

Reports and Attachments ................................................................ 34

Generate Reports.......................................................................... 34

Use the “Immediate Jeopardy Template” ..................................... 36

Add Attachments .......................................................................... 37

Data Sharing ................................................................................... 40

Open the Data Sharing screen ........................................................ 40

Share Data by USB/File ................................................................. 42

Share Data Via Email..................................................................... 43

Share Data Across a Network ......................................................... 44

Data Sharing for RO/CO Users ........................................................ 45

RO/CO Data Share Using USB/File.............................................. 45

RO/CO Data Share Across a Network .......................................... 47

Team Meeting.................................................................................. 48

Offsite Preparation...................................................... .................... 49

Enter Offsite Prep Information ........................................................ 50

Active Complaint and FRI data ........................................................ 51

Complaints and FRIs Information during the Survey ..................... 53

Anonymous Complaints and FRIs ............................................... 56

Entrance Conference ....................................................................... 56

Resident Manager............................................................................ 58

Open the Resident Manager............................................................ 59

Resident Manager views................................................................. 59

Resident Manager Filter and Sort..................................................... 60

Filter by group......................................................................... 61

Sort residents.......................................................................... 61

Search Residents .......................................................................... 62

Initial Pool ...................................................................................... 63

Offsite Selected Residents .............................................................. 64

Include Resident in Initial Pool ........................................................ 65

Add/Update Residents .................................................................... 69

Add a New Admission .................................................................... 69

Update Resident Information .......................................................... 71

Assign Subgroup to Resident .......................................................... 72

Surveyor Assignments ..................................................................... 73

Assign Surveyor to Resident ........................................................... 74

Change Surveyor Assignments........................................................ 75

Unassign Surveyor ........................................................................ 76

Manage Your Workload .................................................................. 77

Initial Pool Resident Interviews, Observations, & Record Reviews.. 78

Open Interview and Observations.................................................... 78

Care Areas ................................................................................... 80

Navigate Care Areas................................................................. 81

Adding Care Areas on the Record Review screen .......................... 82

Probe Text ................................................................................... 83

Assign Interview Status and Subgroup to Resident ............................ 84

Conduct Resident Interview (RI) ..................................................... 85

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Contents

Conduct Resident Representative Interview (RRI) .............................. 85

Add an RRI after sample finalization ........................................... 86

Conduct Resident Observation (RO) ................................................. 87

Conduct a Limited Record Review (RR)............................................. 88

Determine Weight Loss/Gain........................................................... 89

Mark an MDS Discrepancy.............................................................. 90

Mark a Significant Concern............................................................. 91

Transfer Resident Data................................................................... 91

Completed Screens ....................................................................... 95

Finalize Sample ............................................................................... 96

Open the Finalize Sample screen..................................................... 96

Finalize Sample by Resident view ............................................... 99

Finalize Sample by Care Area view ............................................ 100

Finalize Sample Filter and Sort.................................................. 101

Adjust Facility Census ................................................................... 102

Start Sample Finalization .............................................................. 102

Reset Sample Finalization......................................................... 104

Modify Resident Care Areas ........................................................... 105

Add Residents to Sample .............................................................. 105

Remove Residents from Sample ..................................................... 106

Complete Sample Finalization ........................................................ 107

Balance the Survey Team’s Workload............................................ 108

Closed Record Review Sample....................................................... 110

Open the Closed Record Sample screen........................................... 110

Adjust the Closed Record Review Sample ........................................ 111

Finalize the Closed Record Review Sample....................................... 112

Facility Tasks......................................... ........................................ 112

Mandatory Facility Tasks ............................................................... 114

Triggered Facility Tasks ................................................................. 115

Open the Facility Tasks screen ....................................................... 116

Assign Facility Tasks ..................................................................... 117

Initiate a Facility Task ................................................................... 118

Remove Facility Tasks ................................................................... 119

Open a Facility Task...................................................................... 119

Add/Remove Residents to/from Facility Tasks................................... 123

Complete a Facility Task ................................................................ 124

Environment ............................................................................... 126

Infection Control.......................................................................... 128

Medication Administration ............................................................. 128

Determine Error Rate .............................................................. 129

Enter Med Admin Notes ........................................................... 131

Medication Storage and Labeling .................................................... 133

Resident Council .......................................................................... 134

Resident Investigations............................................... .................. 136

Open the Investigations screen...................................................... 136

Investigations Filter and Sort......................................................... 138

Assign Investigations.................................................................... 139

Add Investigations ....................................................................... 140

Remove Investigations.................................................................. 140

User’s Guide 1/29/21 5

Contents

Open an Investigation .................................................................. 141

Investigation screen layout............................................................ 142

Complete an Investigation............................................................. 146

Transfer Investigation Answers to Another Resident .......................... 149

Complete a Closed Record Review .................................................. 149

Initiate a Tag............................................................................... 150

Edit Potential Citation Documentation................. .......................... 152

Open Edit Potential Citation Doc ..................................................... 152

Potential Citations... ...................................................................... 154

Open Potential Citations................................................................ 154

Filter the Tag Tree ................................................................... 156

View Potential Citation Information............................................ 156

Declare Citations.......................................................................... 157

Cite a Tag .............................................................................. 158

Citing an SQC Tag ................................................................... 159

Don't Cite a Tag ...................................................................... 159

Modify the Sample List for the Facility.......... ................................. 161

Add Residents to List.................................................................... 161

Load Cites ........ ............................................................................. 162

Load Cites into Citation Manager .................................................... 162

Validation Issues.......................................................................... 163

Extended Survey for SQC Citation .................................................. 164

Generate Survey Documentation Reports in ACO....................... .... 165

LTCSP Comparative

Survey Procedures for ROs................................................. ...... 167

LTCSP Comparative Surveys......................... ................................. 167

Create the LTCSP Comparative Survey Shell in ARO .......................... 167

Transfer LTCSP Comparative Surveys to ASE-Q ................................ 171

Export the LTCSP Comparative and State Surveys ....................... 171

Import the LTCSP Comparative and State Surveys....................... 172

Open an LTCSP Comparative Survey in LTCSP .................................. 174

LTCSP for LTCSP Comparative Surveys.......................................... 174

Data Transferred from the State Survey .......................................... 174

Data not transferred from the SA survey ......................................... 175

Offsite Preparation........................................................................ 176

Resident Manager.......................................................................... 179

Interview, Observations, and Record Review ................................ 181

Team Meeting................................................................................ 182

Team Meeting Day 1..................................................................... 183

Day 1 Questions and Response Explanations............................... 183

Team Meeting Day 2 or Later......................................................... 185

Day 2 or Later Questions and Response Explanations ................... 185

6 1/29/21 LTCSP 11.9.5

Contents

Finalize Sample ............................................................................. 186

Facility Tasks......................................... ........................................ 190

Closed Record Sample ............................................................... .... 191

Investigations ............................................................................... 192

Potential Citations... ...................................................................... 193

Finishing the LTCSP Comparative .................................................. 19 3

Compare RO to SA Tags ................................................................ 194

Federal Monitoring Survey Documentation Report ............................. 196

Federal Monitoring Survey Documentation Report ........................ 197

Supporting Materials ................................................................ 203

Tips, Troubleshooting, Quick Reference ........................................ 203

Resident Manager Tips.................................................................. 203

Interview Status .......................................................................... 205

Interview and Observations Tips .................................................... 206

Sample Finalization Tips................................................................ 207

Facility Tasks Tips ........................................................................ 208

Non-mandatory Facility Task Triggers .............................................. 209

Resident Investigations Tips .......................................................... 210

Potential Citations Tips ................................................................. 211

Citation Determination Tips ........................................................... 212

MDS Indicators ............................................................................ 212

Care Area to RI/RO/RR Mapping..................................................... 214

Record Review Rules .................................................................... 222

Care Area to Investigative Area Mapping......................................... 223

Data Sharing Checklists................................................................. 226

Checklist for Using USB Drive ........................................................ 226

Checklist for Using Wired Network.................................................. 227

Checklist for Using Wireless Network .............................................. 228

Keyboard Shortcuts....................................................................... 229

Ease of Access Keyboard Shortcuts................................................. 229

Additional Ease of Access/Navigation Keyboard Shortcuts .................. 229

Quick Access Menu Shortcuts ........................................................ 230

Notes Menu Bar ........................................................................... 230

Surveyor Notes and Note Fields Shortcuts ....................................... 232

General keyboard shortcuts........................................................... 234

Dialog Box Keyboard Shortcuts ...................................................... 236

User’s Guide 1/29/21 7

Contents

8 1/29/21 LTCSP 11.9.5

The Long-Term Care Survey Process (LTCSP) application supports the survey process for long-term care facilities. The application lets you enter information electronically as you work through the survey process. For those acting as team coordinator (TC) for a given survey, the application provides extra functionality.

The software also includes the ability for RO teams to conduct LTCSP Comparative surveys. By linking the state survey to the LTCSP Comparative survey in ARO, the system will display information from the SA survey in the LTCSP Comparative survey for the RO team members to use during their survey. See

“LTCSP Comparative Survey Procedures for ROs” for details.

About this User’s Guide

The LTCSP User’s Guide gives you the information you need to:

Introduction

• Create and access a survey

• Use the LTCSP application to conduct the survey

• Manage citations

• Create and conduct an LTCSP Comparative survey

Note: This guide assumes that you are familiar with basic Windows operations

and that you have attended training offered by your agency.

This guide consists of this introduction and the following two chapters:

1 Procedures

Provides task-based procedures for using the LTCSP application.

2 Supporting Materials

Contains supplemental information and reference items.

Note: For detailed information about the LTCSP process, refer to the Long Term Care Survey Process (LTCSP) Procedure Guide (Navigation menu |

Resources | Procedures Guide).

User’s Guide 1/29/21 9

Introduction

View and Navigate this Document Online

You must have Adobe Reader installed to view this document online. You can download the latest version from

On any page, you can click the Increase (+) or Decrease (-) button in the toolbar

to adjust the page magnification to your comfort level. Use the bookmarks in the left pane of Adobe Reader to locate and go (click the bookmark) to relevant information in this User’s Guide.

https://get.adobe.com/reader/.

Figure 1: Bookmarks

You can also click the Contents bookmark and then click links in the table of contents to go to relevant topics.

TIP: For best viewing quality in Adobe Reader, go to Edit | Preferences | Page

Display (path may vary somewhat depending on version). Select the

applicable Smooth Text option.

If you need more information, links to relevant additional material in this document are included. Click a link to directly access the related information.

In the Procedures chapter, there are three types of links (cross-references) to

onal material. They are grouped at the end of a procedure or descriptive

additi section in the format shown below.

More ...

“View and Navigate this Document Online” on page 10 “Resident Manager” on page 58

➥ Click the first link to go to the indicated procedure.

➥ Click the second link to go to descriptive information about the indicated

topic.

10 1/29/21 LTCSP 11.9.5

View a Printed Copy of this Document

While it is designed to be used easily online, you can print this document if you prefer. If you print this document, use the table of contents to locate the information you need. Links (cross-references) to additional material in this document include page numbers; simply go to the indicated page.

Conventions

This guide uses the following conventions:

Bold In procedures: names of screens, screen sections, buttons, menu

options, keys you press.

ASE-Q Generic reference to ASPEN Survey Explorer-Quality.

web Generic reference to the World Wide Web.

More … 

Introduces a list of “see also” cross-references.

LTC S P C BTs

Note: Notes give you important information that may affect how you use a

function.

TIP: Tips give you useful hints, suggestions, or alternative approaches.

LTCSP CBTs

Interactive Computer-based Training (CBT) modules covering a number of LTCSP application features and procedures are available on the Quality, Safety, Education Portal, (QSEP). Follow your SA’s practice for accessing the site.

User’s Guide 1/29/21 11

Introduction

Accessibility Features

This LTCSP User’s Guide and the application user interface include

508-compliant accessibility features, which are detailed below.

In this Guide

This User’s Guide incorporates the following 508-compliant accessibility features:

• Alternate text (alt text), which screen

graphics.

• All graphics have captions.

• Information is not conveyed by means of color alone.

• Tables are not used for formatting, so all text is accessible to screen

readers.

• The last chapter lists keyboard

• Reading order is optimized, so content is read correctly by screen readers.

In the Application

• The LTCSP application adopts the tablet or laptop accessibility settings you

set in ASE-Q. The Accessibility menu option on the System menu in ASE-Q lets you specify field color preferences and enable/disable save point notification, i.e., audible confirmation upon saving.

readers can read, is defined for all

shortcuts for easy reference.

Figure 2: Accessibility option and Accessibility Configuration window

12 1/29/21 LTCSP 11.9.5

LTCSP Procedures

Import User Account File

To use the Long-Term Care Survey Process (LTCSP) application, you need an ID with Assessment access. You will need to import your user account file the first time you open ASE-Q.

To import your user account:

1 Locate the ASE-Q shortcut on your desktop and double-click. 2 Click OK on the alert that you are accessing a U.S. Government Information

System.

3 I

f you receive an ASPEN Explorer notice that the date format needs to be

updated, click Yes to proceed.

the ASE-Q Login window, enter your User Name and Password.

4 In 5 Click Log In.

Figure 3: ASE-Q Login window

If this is your first time opening ASE-Q, your user account information is not recognized by the Sybase database and a message indicates that ASPEN cannot validate the login.

To validate the login:

1 Select Load a User Account File. 2 Navigate to and select the file ASEUserTx.zip. 3 Click Op

en to import the user information.

4 Click Apply to complete the transfer and open ASE-Q.

User’s Guide 1/29/21 13

LTCSP Procedures

LTCSP Surveys

The scheduling supervisor or team coordinator (TC) first sets up an LTCSP survey shell in ACO, then exports it to team members. This ensures that all team members are working with the same survey when they begin. Later, survey data from all team members is combined.

Note: The term Team Leader appears in the application. This represents the

same roles/responsibilities as Team Coordinator.

Create LTCSP Survey Shell in ACO

A new survey can be set up in ACO at any time, even before the survey visit. It is associated with the applicable certification kit for the facility.

To create a survey shell:

1 In ACO, open or create a certification kit for the facility. 2 In the Survey List section of the Certification & Surveys tab, click New

to open the Create Survey window.

3 Enter basic survey information. 4 Assign team members and designate the team leader.

More ...

For detailed information on creating certification kits and surveys including combined

surveys (certification and complaint), refer to the ACO Procedures Guide, which is posted on

the QTSO website at

https://qtso.cms.gov/software/aspen/reference-manuals.

Transfer LTCSP Surveys to ASE-Q

From ACO, the scheduling supervisor or team coordinator can export one or more LTCSP surveys with the associated provider and intake information in an encrypted format to a transfer location. This can be a shared wired or wireless network location, or USB flash drive. Surveyors then import the contents of the export transfer file into ASE-Q.

Note: The survey shell should be exported from ACO as close to the survey

start data as possible and no more than 5 business days before the survey start date.

To export an LTCSP survey shell from ACO:

1 In ACO, locate and select the survey in the Tree or List view. 2 Drag it to the Export button in the toolbar.

14 1/29/21 LTCSP 11.9.5

LTC S P Surveys

3 In the Export window, indicate your Export To location according to your

SA practices.

• Aspen Transfer Location–Select the applicable location.

• Other Zip File Location–Enter the path to the transfer file or navigate to it using the binoculars.

4 Click OK in the Export window. 5 In the Survey Export window, select the survey(s) you want to send to the

transfer destination.

6 Click Continue with Export.

If there are differences between source and destination content, one or more Merge windows may appear.

7 Resolve any source/destination differences and continue the transfer. 8 Address sample calculation issues.

• Survey already exported

If this is the initial export of the survey, the LTCSP sample is automatically calculated. If the survey has already been exported, however, a message appears with the date and time of the previous export, as well as the user who exported the survey.

➥ Indicate whether you want to recalculate the LTCSP sample.

•Select Yes to recalculate the sample and continue with the

export.

•Select No to continue the export without recalculating the

sample.

•Select Cancel to abort the export.

Note: Only recalculate the sample if the prior export was more than 5

days before the survey start date. If survey team members all export the survey from ACO, only the team coordinator should recalculate the sample to avoid data conflicts.

• Survey being exported by another user

If another user is exporting the survey, a message notifies you that the LTCSP sample calculations are currently being performed by other users, and asks if you would like to wait and retry the transfer.

➥ Indicate whether you want to retry the transfer.

•Select Yes to retry the LTCSP transfer after the other user’s

transfer is complete.

•Select No to skip the LTCSP transfer.

•Select Cancel to abort the transfer.

User’s Guide 1/29/21 15

LTCSP Procedures

9 In the LTC Survey Process Transfer window, click OK. 10 In the Finalize Transfer window, select Apply to complete the export

process, or Cancel to reverse the transfer.

When the export is complete, surveyors can import the survey(s) with the associated provider and intake information into ASE-Q.

To import an LTCSP survey into ASE-Q:

1 On the ASE-Q toolbar, click Import. 2 In the Import Type section, select Surveys. 3 Select the appropriate Import From option to indicate the location of the

transfer file:

• ASPEN Transfer Location–Select the applicable location.

• Other Zip File Location–Enter the path to the transfer file or navigate to

• Locate ASE Database–Use option for wired or wireless ASE-Q to ASE-Q

it.

network transfers. Enter database name or IP address.

4 In the Select Survey(s) to Import window, select the surveys you want

to import and click Continue with Import.

A log of changes made during the import is displayed.

5 Click OK in the LTCSP Survey Process Information window. 6 In the LTC Survey Process Transfer window, click OK. 7 Click Apply to finalize the transfer.

16 1/29/21 LTCSP 11.9.5

LTC S P Surveys

Import an existing survey

If you import an existing survey into ASE-Q, you have two options: to

mport only survey and complaint data or to import all data. Importing all

i data runs the risk of overwriting all your survey data. You will receive the following message during the survey transfer.

Figure 4: LTC Survey Process Transfer window

More ...

For detailed information on transferring surveys from ACO to ASE-Q, refer to the ACO Procedures Guide and ASE-Q Procedures Guide, which are posted at

https://qtso.cms.gov/software/aspen/reference-manuals.

Open a Survey in LTCSP

You open a survey in LTCSP through ASE-Q either directly in Tree view or through the Citation Manager. You must be on the survey team and have Assessment access.

To open LTCSP from Tree view:

1 Open ASE-Q. 2 In Tree view, locate the LTCSP survey. 3 Right-click the survey and select LTCSP.

The LTCSP application is opened for the

Note: The LTCSP option is enabled only for LTCSP surveys. Currently that

is the initial health survey for a certification or recertification, or a Federal Monitoring Survey (FMS) for a federal nursing home.

selected survey.

User’s Guide 1/29/21 17

LTCSP Procedures

To open LTCSP from Citation Manager:

1 Open ASE-Q. 2 In Tree view, locate the LTCSP survey. 3 Right

-click the survey and select Citation Manager.

4 Click the LTC Survey button to open the survey.

Figure 5: LTC button in Citation Manager

The LTCSP application opens for the survey.

Note: The LTC Survey button only appears if the survey is defined as an

LTCSP survey. Currently that is the initial survey for a certification or recertification for a federal nursing home.

18 1/29/21 LTCSP 11.9.5

LTCSP Screen Navigation and Features

All screens have the same basic layout making it easy to move from one task to the next.

Title toolbar

The Title bar always includes the screen title and Navigation menu. Some screens include a Back button and navigation icons.

Figure 6: Title toolbar

Quick Access menu

This set of general function icons is located on the right side of every screen.

Figure 7: Quick Access menu

User’s Guide 1/29/21 19

LTCSP Procedures

Function toolbar

This toolbar includes function icons specific to the screen/task.

Figure 8: Residents screen–Function toolbar example

Change Column Order

You can rearrange column headings to any order you want in the Residents list; Offsite Prep, Finalize Sample, Investigations, and Workload screens; and any area of a screen that has a list with headings.

To move a column:

➥ Click the title of the column and drag it to the desired location in the header.

Drop-down Lists

Drop-down lists appear throughout the application where you need to select one or more items from a list. For example, the following screen within Investigations has two drop-down lists.

Figure 9: Resident drop-down list

20 1/29/21 LTCSP 11.9.5

Figure 10: Investigations drop-down list

LTCSP Screen Navigation and Features

To close a drop-down list:

➥ Click outside the list or press Escape.

Hover

When you hover the cursor (i.e., move it over object on screen), the application will determine the cursor type/shape to display (hand, i-beam, etc.) based on the context. If you hover the cursor over a button or icon, a description of the command it represents displays.

Figure 11: Example of Hover help

User’s Guide 1/29/21 21

LTCSP Procedures

Expand/Collapse Sections

On facility task and investigation screens, you can expand and collapse Use, Instructions, Probes/Critical Elements, MDS indicators, etc. as needed to more easily accomplish your work.

To expand/collapse a section:

➥ Click the arrow in front of the section label. Click again to collapse/expand.

Figure 12: Use and Instructions sections collapsed, Observations section expanded

22 1/29/21 LTCSP 11.9.5

Resize Sections with Expander Bars

In the Entrance Conference, facility task, and investigation screens, use Expander bars to control screen space by adjusting section size.

To resize a section:

➥ Hover over the Expander bar until you see a double-headed arrow, then

click and drag the bar up or down to resize the area. For example, it may be helpful to expand the Notes section so you can see more of the text you entered.

LTCSP Screen Navigation and Features

Figure 13: Expander bar activated

-or-

Hover over the Expand icon in the center of the bar until you see a hand cursor, then click to expand the area beneath the bar to full screen. Click the icon again to return the area to its previous size.

Figure 14: Expander bar–Expand icon

User’s Guide 1/29/21 23

LTCSP Procedures

Update PDF Documents

LTCSP includes PDFs for facility task and investigation pathways along with procedure guides and report templates. On occasion these PDFs need to be updated, and you can update them from LTCSP. Your state agency will be notified when updates have been made to these documents. You need to be connected to the internet to update documents.

To update PDF documents:

1 Verify you are connected to the internet. 2 Open a survey in LTCSP (it doesn’t matter which survey, once updated all

PDFs will be available for any survey).

3 Th

Figure 15: System menu expanded to show Update Documents option

4 Click OK when

e Navigation menu should be open, if not, click the menu icon to open.

Expand the System section, and select Update Documents.

A popup reminds you to close all open PDF documents—if open, a document cannot be updated.

Click OK.

the updates are complete.

TIP: If you get a message saying that a PDF was open and the update

stops, close the PDF and rerun Update Documents.

24 1/29/21 LTCSP 11.9.5

LTCSP Notes

The LTCSP application provides multiple places to add notes. The main notepad, Surveyor Notes, is available from the Quick Access menu and can be used to record general notes. Specific notes fields are available in some screens and are associated with the screen’s functionality. For example, when conducting a facility task, you can take notes for the task you are working on.

If you copy and paste from another application (e.g., a web page) the formatti in LTCSP. Copying and pasting text from an LTCSP notes field to another LTCSP notes field will keep any formatting.

TIP: If you want to keep the formatting from another document, attach the

Features common to a number of notes fields include:

• Al

ng will be removed and only the text will copy. You can format the text

document using the Attachments feature (see

page 37).

t + R or Insert Resident ID button to insert resident number.

LTC S P Notes

“Add Attachments” on

Figure 16: Insert Resident ID button

In a screen used to gather information for a specific resident, the resident ID is inserted. In notes fields where no specific resident is referenced, you select a specific resident from the full resident list to insert their ID.

Note: Inserting a resident ID using the keystroke or icon automatically adds

the resident to the “Sample List Provided to the Facility” report.

• Alt + T or Insert Timestamp button to insert current date/time.

Figure 17: Insert Timestamp button

The system automatically inserts a date/time stamp into some notes fields when you click in the field the first time. For subsequent notes, use the shortcut (Alt + T) or button to insert the date/time stamp.

User’s Guide 1/29/21 25

LTCSP Procedures

• Standard word processing features.

Basic editing functions are available in all notes fields.

Note: Highlighted text does not show in combined notes fields such as

Resident IP Notes in facility tasks or when showing answers for all surveyors in either facility tasks or investigations. Highlighting also does not show on reports.

• Record notes using stylus or keyboard entry.

•Click Back button to exit notes field when finished.

• All information in notes fields and throughout the application is automatically saved every two minutes.

More ...

“Notes Menu Bar” on page 230 “Surveyor Notes and Note Fields Shortcuts” on page 232

Surveyor Notes

Allows each surveyor to enter notes throughout the survey. You cannot view other surveyor’s notes in LTCSP, but you can view all surveyor notes (after data share) in the “Surveyor Notes” report. You can also review your notes History.

To open Surveyor Notes:

1 In the Quick Access menu on any screen, click the Surveyor Notes icon,

or press Alt + N.

Figure 18: Surveyor Notepad

2 Click the Minimize button to keep notepad available from the taskbar.

-or-

Click the X in the upper right to close.

26 1/29/21 LTCSP 11.9.5

LTC S P Notes

Surveyor Notes in Resident Manager

When in the Resident Manager List or Card view screens, you can pin Surveyor Notes to the bottom of the screen. These are the only screens where this option is available. Once you have pinned the notes, LTCSP remembers this setting for both the List and Card View screens until you unpin or close Surveyor Notes.

To pin Surveyor Notes:

➥ From the Quick Access menu, click the Surveyor Notes icon, or press

Alt + N to open the Surveyor Notes window.

➥ Click the Pin icon in the Surveyor Notes title bar. The Surveyor Notes

appear at the bottom of the screen.

TIP: Use the Expander bar to resize the notes box.

To unpin Surveyor Notes:

➥ Click the Unpin icon in the Surveyor Notes title bar. The Surveyor Notes

window opens and no longer appears on the bottom of the screen.

To close Surveyor Notes:

➥ In either the Surveyor Notes window or the pinned notes box, click the

blue X to close Surveyor Notes.

Figure 19: Surveyor Notes pinned and unpinned in Resident Manager

More ...

“Notes Menu Bar” on page 230 “Facility Tasks” on page 112 “Reports and Attachments” on page 34

User’s Guide 1/29/21 27

LTCSP Procedures

Interview, Observations, and Record Review Notes

Notes entered for care areas in the initial pool Interview and Observations, Observations, and Record Review screens carry forward with the resident and care area. The date/time stamp is automatically inserted when you click in the

field the first time. For subsequent notes, press Alt + T or use the Insert Timestamp button to insert the date/time stamp.

Figure 20: Care area notes field

Facility Task Notes

Notes fields are available for every task and include standard notes features. These notes carry forward with the facility task. Care area notes taken during the interview, observation, or record review for a resident listed in a facility task can be viewed in the Resident Initial Pool Notes field or by clicking the resident name in the facility task resident list.

View Resident Initial Pool Notes

For any surveyor who took notes for a resident added to a facility task, those notes are viewable in the notes area for the facility task.

To view initial pool notes for residents in a facility task:

➥ On the specific facility task screen, select Resident Initial Pool Notes for

the notes field.

You can copy any notes from here and paste into any other notes field. If you want to include the initial pool notes in the CMS-2567, ensure you copy and paste the applicable information into the Facility Task Notes since that is the only information that pulls forward to the Potential Citation screen.

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LTC S P Notes

Figure 21: Resident Initial Pool Notes in a facility task

View Surveyor Facility Task Notes

Show Answers for Select All Surveyors to see notes entered for that task

by any surveyor (read-only) after data is shared, or select Current Surveyor

(default) to show only notes entered by you. You must set the filter to Current Surveyor to enter documentation or answer any CEs.

Figure 22: Facility task Notes field

User’s Guide 1/29/21 29

LTCSP Procedures

Medication Administration

You can view other surveyors’ notes (after data share) in the Med Admin notes screen—both handwritten and in the text editor.

To review other surveyor Med Admin notes:

1 From the Medication Administration facility task, open the Med Admin

screen (click the icon in the upper right).

2 Fr

only.

Note: You will see the selected surveyor notes in whatever view you have

open. For example, if you only have the handwritten panel open, you will not see any notes in the text editor.

om the Staff ID drop-down select a surveyor. Their notes appear as read

Figure 23: View other surveyors’ Med Admin notes

Investigation Notes

Two Notes fields are provided on investigation screens:

• Investigation Notes

Notes specific to the investigative area for the current resident. Investigation Notes apply only to the current investigative area. Initial pool notes for the investigative area appear under the Investigation Notes.

• Resident Notes

General information about the resident available to any investigation the resident is associated with. Resident Notes carry over to all investigative areas for the resident.

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LTC S P Notes

Use the radio buttons to toggle between Investigation Notes and Resident Notes.

Select Show Answers for All Surveyors to

show notes entered by any surveyor

(read-only) after data is shared, or select Show Answers for Current Surveyor

to show only notes entered by you. You must set the filter to Current Surveyor to enter documentation or answer any CEs.

Figure 24: Investigation Notes field

View Body Map and Drawings for any Surveyor

You can view other surveyors’ drawings (after data share) in the investigation notes screens—body maps for pressure ulcers and abuse; drawn/handwritten notes in other investigations, and the dining and kitchen facility tasks.

To review another surveyor’s drawings:

1 From the investigation, open the Draw or Body Map screen (click the icon in

the upper right).

om the Staff ID drop-down, select a surveyor. Their drawings appear as

2 Fr

read only.

Figure 25: View other surveyors’ investigation drawings

User’s Guide 1/29/21 31

LTCSP Procedures

Notes History

The History feature in Surveyor Notes, Facility Task Notes, and Investigation Notes allows you to view the notes you have previously taken in your current survey. If you deleted, lost, or edited any text that you may want to include, you can find the information by selecting the time stamp before the text was changed or removed. The system saves your notes every two minutes or when you close the Surveyor Notepad or leave the facility task or investigation screen ensuring that you will never lose more than two minutes of work. If no change is made to the notes within two minutes, that time stamp will not appear in the list.

The history is saved locally and does not get transferred when you data share.

system automatically deletes the notes history after 90 days.

The

To view Document History:

1 From the Surveyor Notes window or the notes field in a facility task or

investigation, click the History button on the notes toolbar to open the Document History window.

Figure 26: Example of a Notes History button in the toolbar

2 Select a note by the time stamp in the left-hand pane. The notes for that

time appear on the right. Use the scroll bar to review the entire note, if necessary.

You can copy and paste all or any portion of the notes into your notes, any other note

s field, or any text editor.

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LTC S P Notes

3 Click the X in the upper right hand corner to close the Docum ent History

window.

Figure 27: Surveyor Notes Document History window

Note: The Show History option is not available when the Surveyor Notepad is

pinned to the list or card view screens. Unpin the notes to access the history function.

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LTCSP Procedures

Reports and Attachments

A number of LTCSP reports and forms are available to view and print as needed during the survey process. You can add supporting and supplemental material as attachments.

Generate Reports

The Reports option provides access to a variety of reports. Click the Reports icon (or press Alt + P) from any screen to generate, view, and print reports.

Figure 28: Reports icon

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Reports and Attachments

The Reports window is context sensitive. Depending on the screen you are on when you click the Reports icon, different reports appear in the top section (Reports associated with the current view). The bottom section lists all other LTCSP reports.

Figure 29: Reports window opened from Finalize Sample

To generate a report:

1 On the Quick Access menu. click the Reports icon.

-or-

Press Alt + P.

2 In the Reports window, select one or more reports.

Report(s) related to the screen you are on,

appear in the top of the window.

3 Click the Run Reports button at the bottom of the window.

A PDF of each report is generated.

4 Click the X

in the upper right of the PDF window to close it.

5 Click Done to close the Reports window.

User’s Guide 1/29/21 35

LTCSP Procedures

Use the “Immediate Jeopardy Template”

If you need to conduct an IJ investigation, the “Immediate Jeopardy Template” is available from Reports. You can fill in the writable PDF form on your tablet.

To use the “Immediate Jeopardy Template”:

1 From the Quick Access menu. click the Reports icon.

Press Alt + P.

2 Scroll to the Immediate Jeopardy Template listing and click the icon to

open.

-or-

Figure 30: Immediate Jeopardy Template listed in Reports

3 Enter information into the template. Once you have entered some text,

from the File menu, select Save As (or Shift + Ctrl + S) to save the PDF

and automatically attach it to your LTCSP survey.

➥ The Save in recent folder dialog opens. Select the default directory (if

you change the directory, the system will not be able to attach this document).

➥ Click Save in the Save As dialog and Yes to overwrite the file. The

system automatically names the form with the event ID and the

surveyor ID (eventID-surveyorID-IJ_Template.pdf).

➥ Close the document and click Attach in the File Open in Another

Program dialog. The system automatically attaches the document and

lists it on the Attachments screen. Enter a description for the IJ

Template on the Attachments list.

TIP: If you close the “Immediate Jeopardy Template” and want to make

changes, use the Edit button on the Attachments screen (see below). When you use File | Save As again, the system attaches the

updated version of the document to the survey with a new date/time stamp.

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Reports and Attachments

4 If you want to add a new “Immediate Jeopardy Template” once you have

already created and saved one (e.g., if you have more than one FTag cited at IJ and you only list one FTag on each template), open a new template

from Reports. Answer Yes to create a new document or No if you want to

edit an already existing template.

If you click Yes As (or Shift + Ctrl + S) as before to save and attach a new copy of the template. The system automatically assigns the Immediate Jeopardy

category. To help keep multiple copies of the “Immediate Jeopardy

Template” straight, enter a description on the Attachments screen for each

(see below).

Add Attachments

During a survey, you may want to attach forms and other documentation that support the investigation. Files attached in LTCSP are included in the data sharing process, and also appear in ASE-Q Tree view and Citation Manager | Attachments.

to create a new template, from the File menu, select Save

Figure 31: Attachments screen

The Attachments icon on the Quick Access menu opens the Attachments

screen where you to attach files to the survey; it is available from all screens.

Attachments uploaded from LTCSP are limited to 4 MB in size. Anything larger must be

uploaded from ASE-Q.

The same file types can be attached in LTCSP as in ASE-Q:

• Microsoft Word documents

Microsoft Excel spreadsheets

•

User’s Guide 1/29/21 37

LTCSP Procedures

•PDF documents

• Images: jpg, png etc.

You can either copy and paste or drag and drop an attachment.

To copy and paste a screenshot:

1 In the Quick Access menu, click the Attachments icon (paper clip).

Press Alt + A.

•Press Ctrl + Alt + Print Screen or use the Windows Snip tool to grab

2 On the Attachments screen, click the Paste from Clipboard button at the

bottom of the screen to add.

You will get an error message if the file is larger than 4 MB.

3 Click in the text box to the right of the file name and enter a brief

description.

-or-

a screenshot.

4 Click View to see the screenshot.

To copy and paste a file:

1 Open the Attachments screen. 2 Copy the file from Windows Explorer. 3 Repeat steps 3-5 above.

To drag and drop an attachment:

1 Open the Attachments screen. 2 Drag a file from your desktop to the Attachments screen. 3 Repeat steps 4 and 5 above.

To confirm an attachment is in ASE-Q:

1 Open ASE-Q.

From the Tree view:

•In Tree view, locate the applicable LTC survey.

•Expand the Attachments node and verify that the attachment is listed.

-or-

From Citation Manager:

• Right-click the survey and select Citation Manager.

•Click the Attach button.

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Reports and Attachments

To edit an attachment:

1 On the Attachments screen, click the Edit button for the attachment. The

attachment opens in the default program for the file type (excluding scanned or read-only documents).

2 Update the document. From the File menu, select Save As. You must use

the Save As option and not just Save to have the updated version of your document attached to the survey.

➥ The Save in recent folder dialog opens. Select the default directory (if

you change the directory, the system will not be able to attach this document).

➥ Click Save in the Save As dialog and Yes to overwrite the file.

3 Close the document and click Attach in the File Open in Another

Program dialog. The system automatically attaches the document and lists

it on the Attachments screen.

The document changes are saved in LTCSP and the date/time stamp updates to the time you made the changes.

TIP: You must use Save As to have your updates automatically saved to

your document already attached to your LTCSP survey. If you just save a document, the system won’t update the attached document and you will have to attach the updated version to LTCSP.

To view an attachment:

1 On the Attachments screen, click the View button for the attachment. The

attachment opens in the default program for the file type.

2 Review the information. If you make any changes that you wish to include,

you cannot automatically attach the file since it is in Read-only mode. Follow the above directions to attach the updated document to your LTCSP survey.

To filter attachments:

1 On the Attachments screen, click the Filter by Category drop-down

menu and select the Immediate Jeopardy category (this is currently the

only available category).

The screen lists only those attachments assigned the Immediate

Jeopardy category.

2 To to show all the attached documents again, click the Filter by Category

drop-down menu and select the blank line.

User’s Guide 1/29/21 39

LTCSP Procedures

To delete an attachment:

1 On the Attachments screen, click the Delete button for the document.

The filename and description appear with a strike through, but you can still view the document.

2 To restore the attachment while it is still visible in the list, click the

Undelete button for the document.

3 To permanently delete attached file(s) marked with a strike through, click

Delete Marked Attachments at the bottom of the screen.

The attachment(s) disappear from the list.

Data Sharing

The LTCSP application includes functionality to facilitate data sharing between Team Coordinators (TCs) and team members as they prepare for and conduct a survey. LTCSP has one data sharing screen that provides all methods of data transfer—no difference for RO users. You can share encrypted data using a:

• File stored on a USB drive or anywhere on a shared system

• Secured wireless network

• Secured wired network

Each team member’s data is first shared with the team coordinator, then the TC shares the data with all team members to ensure that updates are correctly recorded and the TC and all team members are working with the same survey information. Data sharing is always performed between team members and the team coordinator. Team members cannot share data with other team members directly.

Open the Data Sharing screen

The Survey Team Data Sharing screen looks the same for team members and the team coordinator, but the options and instructions are different depending on your role.

40 1/29/21 LTCSP 11.9.5

Data Sharing

To open the Survey Team Data Sharing screen:

➥ Click the Data Transfer icon in the Quick Access menu, or press Alt + D.

Figure 32: Survey Team Data Sharing screen

The blue diamond next to the name in the team roster section at the top

indicates the team coordinator. If you need to reassign the TC role to a different survey team member, you can select the desired team member and then select

the Assign Leader button. The blue diamond indicator then appears next to

the newly assigned TC.

ast Update Date column displays the last date and time data was

The L

shared. When sharing data using a file (USB), this is the date and time of the most recent data send/receive action for the associated surveyor. When sharing data using a network (wired/wireless), the date and time indicate the most recent transfer for both the team member and team coordinator.

The Se

rver column lists IDs of servers using an LTCSP database that are

connected to your secured network. You can select the Reload Server List

button to refresh the list to see any connected team members.

The Machine ID (IP) column

allows you to enter another team member's computer IP address if necessary, when data sharing using a wireless network. The computer assigns each machine a unique IP address when it is connected to a wired/wireless network, so every survey team member should verify their IP address before data sharing.

User’s Guide 1/29/21 41

LTCSP Procedures

The System ID column lists the resident ID number assigned to each of the

surveyors. This number is used to identify the resident ID range assigned to each team member. This assures that if surveyors add residents, they’ll have unique resident IDs.

Reorder the columns by clicking the column title and dragging to desired place.

Share Data by USB/File

To share LTCSP data by file, the file is first sent to a transfer file on a flash drive (USB), or a drive on a shared system. Then the data is received by pulling it from the transfer file to the destination computer where data is updated accordingly. Regional and Central Office (RO/CO) users must adhere to additional security requirements when sharing data using a USB/File.

To send data to a flash drive for sharing:

1 Open the Survey Team Data Sharing screen. 2 Insert the flash drive into your computer. 3 On the Survey Team Data Sharing screen, select the team member(s) for

data sharing if you are the team coordinator (The TC may select multiple team members to share data with). If you are a team member, you must select the team coordinator.

Team coordinators can share data with all team members, but team members can only share data with the TC.

4 In the Share Data Using A File section, select Send Data. 5 In the Select the Drive/Folder you want to transfer to window, select

the USB as your transfer location.

The default transfer filename is <EventID>-<Surveyor ID>, e.g., 2EN911-50250.

6 Select Open to initiate the data send.

A Transfer Progress window appears (often very briefly). When the data send is complete, a notification lets you know if it was successful or not. If the transfer failed, this window lets you know what didn't transfer, and why.

7 If the data send was successful, select OK.

To receive shared data from a flash drive:

1 If necessary, open the Survey Team Data Sharing screen on your (the

receiving TC’s/member’s) computer.

2 Insert the flash drive with the sent data into your computer. 3 In the Share Data Using a File section, select Receive Data to pull the

data into your machine.

Since you're receiving from a flash drive, it is not necessary to select names in the team roster section.

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Data Sharing

4 In the Select the Drive/Folder you want to transfer from window,

select the location and file to receive (<EventID>-<Surveyor ID>, e.g., 2EN911-50250).

5 Select Open to initiate the data transfer to your computer.

A Transfer Progress window appears (often very briefly). When the transfer is complete, a notification lets you know if the data receive was successful or not. If the data share failed, this window lets you know what didn't transfer, and why.

6 If the data share was successful, select OK. 7 Select Open to initiate the data transfer to your machine.

The Transfer Progress window appears. For the team coordinator, conflicts (if any) are listed during the transfer process for resolution.

8 When the transfer concludes successfully, select OK in the confirmation

message.

The survey on your machine now contains the updated information that the TC sent.

More ...

“Open the Data Sharing screen” on page 40 “RO/CO Data Share Using USB/File” on page 45 “Data Sharing Checklists” on page 226

Share Data Via Email

From LTCSP, you can email a survey with associated LTCSP data to one or more recipients, by creating a data share file containing the survey as an attachment to the email.

To share data via email:

1 Save the survey file to data share to a file location on your computer. 2 Open your email, and attach that file to an email message to the desired

team coordinator/team member (TC/TM).

3 The receiving TC/TM saves the attached data share file on their computer. 4 On the Survey Team Data Sharing screen, select Receive Data.

If you are the TC, you must select the TM you are receiving the data share

file from, and then select Receive Data.

5 In the Select the Drive/Folder you want to transfer from window,

select the location and file to receive (<EventID>-<Surveyor ID>, e.g., 2EN911-50250).

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LTCSP Procedures

6 Select Open to initiate the data transfer to your computer.

The Transfer Progress window appears. For the team coordinator, conflicts (if any) are listed during the transfer process for resolution.

7 When the transfer concludes successfully, select OK in the confirmation

message.

The survey on your machine now contains the updated information that the TC/TM sent.

Share Data Across a Network

Survey team members can share encrypted LTCSP data across a network with a secured wired or wireless connection. A wired connection exists when multiple computers are physically connected to each other, or to a secured router with a cable. A wireless connection exists when multiple computers access the same secured wireless router.

Only the team coordinator can initiate data sharing across a network, whether wired or wireless. The procedure is the same for both. Data is copied across the network from specified team member(s) to the TC’s computer, then the updated data is copied from the TC’s computer back across the network to the team member(s).

Note: A TC can initiate data sharing using a network at any time during the

survey.

To share data across a network:

1 If necessary, connect any computers from/to which you want to transfer

data.

That could mean connecting to the team's secure server with a cable or wirelessly, or in the case of a direct connection, plugging a cable into the team member computer(s) and team coordinator's computer.

2 Open the Survey Team Data Sharing screen. 3 Select the checkbox to the left of the surveyor(s) you want to share data

with.

4 For each selected team member, select the applicable Server (computer).

TIP: You may need to select Reload Server List to make sure the list of

server IDs is current. The search and update may take several minutes. If the Reload Server List function does not find a team member's server ID when data sharing over a wireless network, you can enter the team member’s computer IP in the IP column to complete the transfer.

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Data Sharing

5 Select Share Data Now to initiate the data transfer.

When the data share begins, the Transfer Progress window appears.

Message(s) appear if there is an issue with starting the transfer, e.g., you selected a server ID but not the checkbox for a surveyor.

Notification(s) appear when data conflicts prevent synchronization, e.g., a resident is assigned to two surveyors. The LTCSP application uses pre-defined rules to resolve most data conflicts, but if a notification appears, you (the TC) must resolve the conflict.

6 When the transfer and synchronization concludes successfully, select OK in

the confirmation message.

This confirmation indicates that the survey data was first copied from the selected team member(s), then to the team member(s). That is, the survey

data was copied from the team member(s) to your computer and then the updated survey data was sent back to the team member(s).

More ...

“Open the Data Sharing screen” on page 40

“Data Sharing Checklists” on page 226

Data Sharing for RO/CO Users

Regional Office, Central Office, and CMS contract (RO/CO) users must adhere to additional security requirements when sharing data, both when using a USB/file, or wired/wireless methods. When a survey team consists of state and RO/CO users, special measures must be taken.

• The survey team must use the state configuration.

• Some states may provide an RO user with a pre-configured state computer

for the survey. In these instances, the state configuration is used, and there are no special considerations.

The following instructions are for RO/CO users if the state survey team is data sharing using a USB drive/file or a wired/wireless connection.

RO/CO Data Share Using USB/File

Although LTCSP automatically encrypts the data when it is shared, RO/CO users are required to encrypt any USB/flash drive in order to send and receive files on it. For survey teams with both state and RO/CO users, data sharing using a USB drive may not work due to incompatible encryption methods, and testing whether it works may end up encrypting a flash drive and making it unusable. In that case, it may be necessary to share files via email.

To send data to a flash drive for sharing:

1 Open the Survey Team Data Sharing screen. 2 Insert the flash drive (USB) into your computer.

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LTCSP Procedures

3 When you insert a USB stick into an RO/CO user’s machine, the CMS Check

Point Encryption application automatically asks to encrypt the USB stick if it is not already CMS encrypted.

Note: If the USB has embedded default encryption, it must be formatted in

FAT32 format (Standard format for removable devices). CMS Check Point encryption automatically creates dual partition storage on the stick: Drive E: Business related (Encrypted by CMS), and drive D: Non Business (no encryption).

4 Enter and confirm a password for the USB stick encryption, then select

Continue.

Both sender and recipient must use the same password.

5 On the Survey Team Data Sharing screen, select team member(s) for

data sharing if you are the team coordinator. If you are a team member, you must select the team coordinator.

Team coordinators can share data with all team members, but team members can only share data with the TC.

6 In the Send Data Using A File section, select Send Data. 7 In the Select the Drive/Folder you want to transfer to window, select

the USB as your transfer location. i.e., Business Data - Encrypted (E).

The default transfer filename is <EventID>-<Surveyor ID>, e.g., 2EN911-50250.

Note: For Non Business storage, any files coming out from the CMS laptop

cannot be saved to a D: non-Business storage location (with no encryption).

8 Select Open to initiate the data transfer.

A Transfer Progress window appears (often very briefly). When the transfer is complete, a notification lets you know if the data share was successful or not. If the data share failed, this window lets you know what didn't transfer, and why.

9 If the data share was successful, select OK.

To receive shared data from a flash drive:

1 If necessary, open the Survey Team Data Sharing screen on your (the

receiving TC’s/member’s) computer.

2 Insert the flash drive with the sent data into your computer and enter the

encryption password if asked.

Both sender and recipient must use the same password.

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Data Sharing

3 In the Share Data Using A File section, select Receive Data to pull the data

into your machine.

Since you're receiving data from a flash drive, you don't have to select names in the team roster section.

4 In the Select the Drive/Folder you want to transfer from window,

select the file to receive from the E drive or Business Data - Encrypted (E)

location, and select Open.

A Transfer Progress window appears (often very briefly). When the data share is complete, a notification lets you know if the data share was successful or not. If the data share failed, this window lets you know what didn't transfer, and why.

5 If the data share was successful, select OK.

RO/CO Data Share Across a Network

RO/CO computers are already configured to share data across a secured wired or wireless network. However, you are required to disconnect from the CMS Cisco Connect VPN before you can begin sharing your LTCSP data.

After you have disconnected from the CMS Cisco Connect VPN, the process for sharing data using a network is the same as the state method.

To disconnect from CMS VPN:

1 Launch the Cisco AnyConnect Secure Mobility Client application from

the desktop or system tray, or you can search for it in the Start menu.

2 On the Cisco AnyConnect Secure Mobility Client window, select

Disconnect.

Note: Internet access and CMS email will be disconnected.

To reconnect CMS VPN:

1 Connect to a secured network location or internet access point. 2 Launch the Cisco AnyConnect Secure Mobility Client application from

the desktop or system tray, or you can search for it in the Start menu.

3 On the Cisco AnyConnect Secure Mobility Client window, select

Connect.

4 Enter your PIV card PIN.

After connecting successfully, you can minimize or close the Cisco AnyConnect Secured Mobility Client window.

More ...

“Share Data Across a Network” on page 44

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LTCSP Procedures

Team Meeting

The Team Meeting screen is available only to the team coordinator. The survey team meets as needed throughout the survey. The Team Meeting screen provides information to facilitate team discussion. Some information is entered by the TC, and some information is automatically updated each time the TC opens the screen. After data sharing with the team, all team members’ data is included on this screen.

Day 1 questions deal mainly with the initial pool each surveyor included in the initial pool. Day 1 also lists remaining work that each surveyor needs to complete for their initial pool. Day 2 questions focus more on concerns and survey workload such as how much work each surveyor has left. These questions help the team gauge the status of the survey and make decisions for the next steps.

such as how many residents

To enter and review Team Meeting information:

1 From the Navigation menu, select Team Meeting.

The Team Meeting screen opens to Day 1.

Figure 33: Team Meeting screen—Day 1

2 Review and enter Day 1 team meeting information and notes about any

issues.

The system indicates if no information is available for system-generated entries

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Offsite Preparation

3 To enter and view Day 2 or later team meeting information, select Day 2 or

Later.

Figure 34: Team Meeting screen—Day 2 or Later

4 To print Team Meeting information as a report, click the Reports icon in the

Quick Access menu, select Team Meeting Notes, and click the Run Reports button at the bottom of the dialog box.

Offsite Preparation

Before going out on a survey, the TC must do some preparation. The Offsite Preparation screen in LTSCP provides a place where the system automatically enters some information and the TC enters other information. This information helps guide the survey team while on the survey.

For example, to help ensure that a survey team TC assigns areas of the facility to each survey team member. For this purpose, the TC uses the facility f l o or plan on file (for a recert, not an initial certification) and divides the facility among the team to ensure every area is covered. The

surveyors screen all the residents in their assigned area.

If the survey is a combined complaint survey, complaint data is pulled from

S and appears in the LTCSP Offsite Preparation screen. The TC should

ACT review the complaints and make assignments as applicable once the survey has been imported.

Note: For specific instructions on attaching complaints to an LTCSP survey, refer to the LTCSP Complaints Guide posted at

https://qtso.cms.gov/software/ltcsp/reference-manuals, then expand the

LTCSP Reference Materials section.

covers the entire facility, the

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LTCSP Procedures

Enter Offsite Prep Information

Only the team coordinator can make changes to information on the Offsite Preparation screen in LTCSP; however, all team members can view the information.

To enter offsite prep info:

1 From the Navigation menu, select Offsite Prep.

Some information has already been provided.

Figure 35: Offsite Preparation screen

2 In the Review Prior to Visit section, enter patterns of repeat deficiencies,

results from the last Standard survey, complaint/FRI history, and active complaint/FRI information (e.g., specific allegations).

3 If a combined complaint surv

ey, review and make assignments in the Active

Complaints and FRIs section.

4 Answ

50 1/29/21 LTCSP 11.9.5

er the abuse question below the Active Complaints section.

5 As applicable, add federal waivers/variances, active enforcement cases, and

Ombudsman information.

6 Scroll to the bottom of the screen to the Team unit assignments section

and enter team assignments.

7 Open the Facility Tasks screen to assign mandatory facility tasks. 8 From Reports (see “Generate Reports” on page 34), print the Facility Matrix

with instructions, the Entrance Conference Instructions, and the Beneficiary Notice worksheet.

9 Share offsite prep data with the team.

Active Complaint and FRI data

When you have a combined complaint survey, the active complaint and FRI information is pulled from ACTS when you export the survey from ACO and appears on the Offsite Preparation screen. The TC can use this information to add complaints/FRIs to the survey

Offsite Preparation

For each complaint or FRI the TC can:

• Review intake information

• Select complaints/FRIs to be included with the survey based on each facility’s census information; you can add more to the survey later by initiating an investigation)

• Match complaint/FRI residents to MDS residents or add a resident not in the MDS resident list

• Match anonymous complaints/FRIs to the Facility

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LTCSP Procedures

• Add applicable initial pool care areas, investigations, or facility tasks

• Assign selected complaints/FRIs to surveyors

Figure 36: Active Complaint and FRI section of the Offsite Preparation screen

After reviewing the complaints and FRIs, the TC determines which should be added to the initial pool. Those complaints and FRIs added need to be assigned appropriate LTCSP areas and then assigned to a surveyor. All this can be done from the Offsite Prep screen.

To add a complaint/FRI resident to the initial pool:

1 On the Offsite Preparation screen, click the Expand/Collapse arrow to

view the Complaint/FRI information.

ick the Intake number or the Allegation name to view the notes (usually

2 Cl

one of the two has been filled out). Click Close to close the notes box.

3 Identi

fy the complaint resident and select from the LTCSP Resident

Roster.

•In the LTCSP Resident Roster, scroll to match the reported Complaint

esident to the MDS name and select.

• If the resident is not in the list, click the Add New Resident icon to add

the resident to the survey and then use the roster to add the new resident to the complaint or FRI.

• If no resident has been identified, select Facility, Facility from the list.

The system then adds this to all anonymous complaints and FRIs.

52 1/29/21 LTCSP 11.9.5

Offsite Preparation

4 Based on the allegations, select the appropriate LTCSP area(s) for the

complaint or FRI resident. These links become active when you assign the LTC SP Res i d ent.

• Add Initial Pool Care Area: Associates the complaint resident with a

care area on the Interview/Observation/Record Review screens. A Complaint link appears next to the assigned care area.

• Directly Add New Investigation: Use the Initiate One or More

Investigations dialog to select investigative area and assign a surveyor.

• Link or Add Facility Task: Select one or more tasks to add to the

survey for the complaint.

• Add a Closed Record Review: Select the Reason and provide a

description.

LTCSP areas added are listed on the screen.

5 When you decide to add a complaint resident (or Facility) to the initial pool:

Note: You can add an investigation to any complaint/FRI resident without

adding them to the initial pool.

• Select the checkbox in the In Pool column—this also activates the

surveyor drop-down list and updates the Initial Pool status to Yes in Resident Manager.

•In the Initial Pool Surveyor column, select a surveyor—this

assignment also appears in Resident Manager.

Note: the maximum number of complaint and FRI residents is based on the

facility census information. For detailed instructions on complaints, refer to the

Long Term Care Survey Process (LTCSP) Procedure Guide (In LTCSP:

Navigation menu | Resources | Procedures Guide).

Complaints and FRIs Information during the Survey

The Complaint or Facility Reported Incident subgroups are added to the selected residents. A Complaint link appears on any relevant screens—click to

bring up a list of Complaints/FRIs with intakes relevant to that area. Use the expand/collapse arrows to view the same information that is on the Offsite Prep screen.

User’s Guide 1/29/21 53

LTCSP Procedures

Initial Pool Care Areas: A Complaint link appears on the Interview,

Observations, and Record Review screens beneath the MDS indicators and next to any Care Areas linked to a complaint/FRI for that resident. Anonymous complaints/FRIs links appear for every resident.

Figure 37: Interview and Observations screen with Complaint information

Facility Tasks: COMP appears on main screen and a Complaint link

appears next to the Pathway link in the Function toolbar. For any resident added to a facility task, a Complaint link appears next to their name in the resident list.

Figure 38: Complaint notation and links in facility task screens

54 1/29/21 LTCSP 11.9.5

Offsite Preparation

Investigations: C o m p is noted in the Inv. Reason column a n d a Complaint

link appears next to the investigation title.

Figure 39: Complaint notation and links in investigations screens

Sample Screens: Sample by Resident and Sample by Care Area indicate

Complaint Care Areas. Closed Record Review indicates complaint residents.

Figure 40: Complaint notation and links on sample and Closed Record Review screens

User’s Guide 1/29/21 55

LTCSP Procedures

Potential Citations: When a tag that came from a complaint is cited, the A-Complaint Investigation citation category is automatically selected.

Note: For specific instructions on adding complaints to an LTCSP survey already

in progress, refer to the LTCSP Complaints Guide posted at

https://qtso.cms.gov/software/ltcsp/reference-manuals, then expand the

LTCSP Reference Materials section.

Anonymous Complaints and FRIs

Since no one resident can be linked to an anonymous complaint or FRI, a Complaint link appears on relevant screens. If a complaint or FRI has been linked to an Initial Pool Care Area, Complaint links appear for every resident on the Interview, Observations, and Record Review screens.

More ...

“Assign Facility Tasks” on page 117 “Generate Reports” on page 34 “Data Sharing” on page 40

Entrance Conference

Upon entering the facility, the team gives a copy of the Entrance Conference form to the facility for them to complete. The Entrance Conference screen provides a place to enter notes and to check off items on the form as they are completed.

Multiple documents of various formats can be attached and are transferred as part of the data sharing process. The information helps guide the survey team while on the survey.

Note: Only the team coordinator can enter notes for the entrance conference;

however, all surveyors can view the information after data share.

56 1/29/21 LTCSP 11.9.5

Entrance Conference

To enter data on the Entrance Conference screen:

1 From the Navigation menu, select Entrance Conference.

Figure 41: Entrance Conference screen

2 Review the screen:

• Entrance Conference Date and Time—automatically rec

ords when the entrance conference screen is opened for the first time (at the top of the screen), but if this is not the actual start time you can reset the time and

date. Click Set to update the current Date and Time.

• Entrance Conference form checklist—the TC can check off items as the

facility provides information.

•Notes—area for TC to enter entrance conference notes.

• Expander bar—adjusts the size of the form and notes areas.

3 Enter notes about

User’s Guide 1/29/21 57

the entrance conference at the bottom of the screen.

LTCSP Procedures

To print the Entrance Conference Instructions for the facility:

1 Click the Reports icon in the Quick Access menu, or press Alt + P. 2 On the Reports screen, select the box for Entrance Conference

Instructions, which is listed in the first section of the Reports window when

you are on the Entrance Conference screen.

3 Click the Run Reports button to generate a PDF of the report. 4 Print the PDF. 5 Click X to close the PDF window and Done to close the Reports screen.

More ...

“LTCSP Notes” on page 25 Procedure: “Adjust Facility Census” on page 102

Resident Manager

The residents listed in the Resident Manager screens are generated by the system based on Minimum Data Set (MDS) data. When the survey shell is exported from ACO/ARO into ASE-Q, the MDS data is used to:

• Identify all residents still in the facility with an assessment within the last 180 days.

• Calculate MDS indicators for each resident, and then determine facility rates for each indicator.

• Flag residents as offsite selected based on:

- Number of assessments/residents included with the exported survey

shell

- Residents with the highest number of indicators that reflect the facility

rates.

A resident qualifies for the offsite selected group only if they've had an assessment in the last 120 days.

The Resident Manager screens in LTCSP are used by the survey team to:

• Add newly admitted residents who did not have MDS data from the last 120 days and therefore are not listed in Resident Manager.

• Identify residents for the initial pool process.

• Identify the appropriate subgroup(s).

• Update a resident's information such as room number.

• Provide access to Interviews, Observations, and Record Review screens for any resident included in the initial pool.

• Provide status of resident interview process to help manage work.

• Search for a resident by name or room number.

58 1/29/21 LTCSP 11.9.5

Open the Resident Manager

The Resident Manager is opened from the Navigation menu. There are two

different views, List and Card. Surveyors can choose the view they prefer and can switch between the views.

To open the Resident Manager:

1 From the Navigation menu, select Resident Manager.

This opens the Residents screen in List view.

o switch between views, click the Card View or List View icon at the

2 T

upper right of the screen.

Resident Manager views

There are two different views that can be used to manage residents:

•List view

Resident Manager

The default Residents list view displays residents alphabetically by last name. Use the Sort function to change the sort as desired and Filter to see specific residents.

Figure 42: Navigation features in Residents screen–List view

User’s Guide 1/29/21 59

LTCSP Procedures

• Card view

Individual cards display resident information. The screen title displays Incomplete Residents and changes to Residents when all are completed.

Figure 43: Residents–Card view

Most functionality is available in both views; however, some functions are easier to perform in one view versus the other. Surveyors can use their preferred view or switch between views depending on the task they are performing.

Resident Manager Filter and Sort

The Filter and Sort functions let you display only the residents you need to see. You can filter residents in both List and Card views by group, and sort residents in List view by category.

Figure 44: Filter and Sort options

60 1/29/21 LTCSP 11.9.5

Resident Manager

Filter by group

The Filter by group drop-down menu, located on the left side of the function bar, allows you to view the following groups of residents:

• All Residents: All residents from MDS data plus any added by surveyors

• My Residents: All residents assigned to you

• All Current Sample Residents: All system-selected residents included as

sample candidates:

- Offsite selected residents with at least one area marked for Further

Investigation (FI)

- Any initial pool resident with FI marked for abuse

- Any initial pool resident the surveyor marked Harm or IJ

• Offsite Selected: All residents preselected by system from MDS data

• New Admissions: All residents noted by surveyors as being admitted

within the last 30 days

• FRI: Residents associated with an official facility reported incident that the

survey team is investigating with the survey

• Vulnerable: Residents marked as vulnerable by surveyors

• Complaint: Residents associated with an official complaint made to the

state that the survey team is investigating with the survey

• Identified Concern: Residents who are not in any of the above subgroups.

but are noted by surveyors as having a specific concern

To filter residents by group:

1 In either List view or Card view, click the arrow in the Filter by group box

to see the list of filter choices.

2 Select the desired group.

The screen refreshes to display only those residents belonging to that group.

More ...

“Resident Manager Tips” on page 203

Sort residents

The Sort residents drop-down menu, located to the right of the Filter by group menu in List view, allows you to sort the residents according to the following categories:

• Name: Lists residents alphabetically by last name.

• Room: Lists residents by room number in ascending order. Residents

without a room number are listed alphabetically by last name at the top of the list.

User’s Guide 1/29/21 61

LTCSP Procedures

• Surveyor: Lists residents assigned to surveyors by surveyor number.

Residents not assigned to a surveyor are listed alphabetically by last name at the bottom of the list.

• Offsite Selected: Lists residents preselected by the system at the top of

the list.

• New Admissions: Lists residents with the subgroup New Admissions at the

top of the list.

• FRI: Lists residents with the subgroup FRI at the top of the list.

• Vulnerable: Lists residents with the subgroup Vulnerable at the top of the

list.

• Complaint: Lists residents with the subgroup Complaint at the top of the

list.

• Identified Concern: Lists residents marked with the subgroup Identified

Concern at the top of the list.

Although the Sort residents menu is not available in Card view, the sort option selected in List view is applied to Card view.

TIP: You can apply a sort to any group you filter by, not only the full resident

list.

To sort residents by category:

1 In List view, click the arrow in the Sort residents box to see the list of

categories.

2 Select the desired category.

The screen refreshes to display residents in the specified order.

More ...

“Resident Manager Tips” on page 203

Search Residents

The Search field lets you locate residents by name or room number in List and

Card views. A history of searches is kept so you can conveniently repeat searches.

Note: Partial name or number searches do not work.

62 1/29/21 LTCSP 11.9.5

Initial Pool

Figure 45: Search field in Card view

To search for a resident:

1 In the Search box, type full first name, last name, or room number and

press Enter or click the magnifying glass.

o repeat a search, click the down arrowhead and select the desired search

2 T

text.

3 Click the x in

Note: Until you select X, the screen will only show the search results.

More ...

“Resident Manager Tips” on page 203

Initial Pool

There are many ways to organize the initial pool. One option is the team coordinator assigns area(s) of the facility to each surveyor. Surveyors visit room to room to screen all residents in their assigned area(s) in order to identify residents for their initial pool. The goal of each surveyor is to conduct an interview, observation, and limited record review with the residents in their initial pool. It is from the initial pool (for all surveyors) that the survey team pulls residents into the sample.

Surveyors set the Initial Pool (IP) Status to Y pool. Only residents with an Initial Pool status of Yes appear on the Finalize Sample screen. Offsite residents automatically have an IP status of Yes and must be included unless they have been discharged.

Up to five complaint and FRI residents, when coordinator on the offsite prep screen, are automatically included in the initial pool and sample for the team and will have an IP status of Yes.

the Search box to clear the search results.

es to add a resident to the initial

designated by the team

Surveyors can include any other resident in their initial pool by setting the IP status to

Yes on the Resident Manager screens, the Interview, Observations,

and Record Review screens and in the Add/Update resident dialogs.

User’s Guide 1/29/21 63

LTCSP Procedures

During the screening process, surveyors can use all the IP statuses to help organize their residents. LTCSP assigns the IP status Unknown to all non-offsite residents. You can change this to Maybe during screening to identify possible residents for your initial pool. Select No to remove a resident from the initial pool (offsite residents require a discharge reason).

Only an IP indicator of Yes activates the interview, observation and record review screens. The RI, RO, and RR screens remain read-only for any other IP indicator status (U, N, or M).

More ...

For detailed instructions on performing the initial pool process, refer to the Long Term Care Survey Process (LTCSP) Procedure Guide (In LTCSP: Navigation menu | Resources

| Procedures Guide).

Offsite Selected Residents

When you export the survey shell from ACO/ARO, the system identifies the residents in the facility and performs MDS indicator calculations. This

information is included with the survey shell imported into ASE-Q. From these

calculations, some residents are pre-selected to be included in the initial pool during the survey and automatically have an IP status of Yes. They are referred to as offsite selected residents and must be included in the initial pool unless they no longer reside at the facility.

The number of offsite selected residents depends on the number of residents included with the survey shell and the required sample size needed for investigation. The offsite selected residents comprise 70% of the sample and your team will fill in the remaining 30%. For example, if the facility MDS data shows 100 residents currently at the facility, the Target Sample Size will be 20. Of those 20, 14 will be pre-selected by the system and added to the sample if concerns are identified.

Once onsite, surveyors do not need to consider maintaining a 70/30 split between offsite and onsite selected residents. The focus is on identifying residents for the initial pool and sample based on concerns.

Note: Since each surveyor needs to cover a certain area of the facility, some

surveyors may have a higher number of offsite selected residents in their initial pool than others.

64 1/29/21 LTCSP 11.9.5

Include Resident in Initial Pool

Surveyors can manage their residents using the Initial Pool (IP) status available in the Resident Manager, Interview, Observations, and Record Review screens. Only those with an IP status of Yes will be included in the initial pool and only these residents appear in the Finalize Sample list.

Cli ck a n I P st at u s i con to o pe n th e I P st atu s d i al og w hi c h p rov id e s b a si c re si d en t

nformation and their MDS indicators.

Offsite selected residents have IP status values of:

Initial Pool

• Yes—default;

• No—removes from initial pool; requires a reason

For the remaining residents you can set an IP status of:

• Unkno

• Maybe—mark residents during initial screening as possibilities for IP or that

the resident is unavailable, for example, the resident isn't in the room

• Yes—re

• No—removes from initial pool; removes surveyor assignment

The system will change the IP status of complaint residents added to the initial

pool in Offsite Prep to Yes.

Surveyors can set the IP status on the following:

• Resident Manager List and Card view screens

• Interview & Observations screen

• Observations screen

• Record Review screen

• Add/Update Resident dialog

wn—default

quired to proceed with interview/observation and sampling

required to proceed with interview/observation and sampling

➥ Click the icon on a screen to open the IP selection dialog for that resident.

From the Resident Manager List View:

Figure 46: IP Status icon on Resident Manager List View

User’s Guide 1/29/21 65

LTCSP Procedures

From the Resident Manager Card View:

From Interview, Observations, or Record Review screens:

Figure 47: IP Status icon on Resident Manager Card View

Figure 48: IP Status icon in Interview, Observations, or Record Review screens

66 1/29/21 LTCSP 11.9.5

From the Add/Update Resident dialog:

Initial Pool

Figure 49: IP Status selection in the Add/Update Resident dialog

Note: Only residents with an IP of Yes appear on the Finalize Sample screen

regardless if any Further Investigations were marked during the interview process.

User’s Guide 1/29/21 67

LTCSP Procedures

To include a resident in your initial pool:

1 Open the Resident Manager List View or Card View screens, or open the

Interview, Observations, or Record Review screen for the resident.

2 Click the Initial Pool icon to open the selection box:

➥ For an Offsite resident, Yes is default; select No and provide a reason.

Figure 50: IP Status selection dialog for an offsite resident

➥ For a non-offsite resident Unknown is default; select Maybe, Yes, or

No.

Figure 51: IP Status selection dialog for an offsite resident

TIP: The button with an * and bolded text indicates the current IP status.

For example, if the status is Yes it appears on the button as *Yes.

3 Select applicable subgroups.

More ...

“Open the Resident Manager” on page 59 “Add a New Admission” on page 69 “Assign Surveyor to Resident” on page 74 “Assign Subgroup to Resident” on page 72

68 1/29/21 LTCSP 11.9.5

Add/Update Residents

You can add a newly admitted resident or update information for a current resident. If you duplicate a resident, you can delete the added resident as long as no data has been added to that resident.

Add a New Admission

When surveyors begin the initial pool process, the facility should provide them with a list of new admissions in their area. A new admission should be added to the resident list only if the surveyor includes the newly admitted resident in

the initial pool (based on the screening) and the resident isn't already included

in the resident list. The system automatically assigns a unique ID to each new admission added to the resident list. The process is the same in both List and Card views.

To add a new admission:

1 Open the Resident Manager.

Add/Update Residents

2 Click the Add N

dialog.

ew Resident icon to open the Add/Update Resident

Figure 52: Add/Update Resident window

3 Enter resident information including Name, Room #, Admission Date.

When you add a new admission, the system automatically assigns you as the surveyor.

User’s Guide 1/29/21 69

LTCSP Procedures

4 The system automatically assigns the subgroup New Admissions to the

resident to ensure high risk medications, diagnoses, and hospice are listed in the Record Review. Select any other subgroup(s), if applicable, in the Subgroup drop-down list.

When you add a new admission, the system assigns a unique ID for that resident (in parentheses after the name). To avoid any conflict, each surveyor is assigned a block of 50 numbers to use for the unique IDs.

5 Click Save.

To delete an added resident:

1 Open the Add/Update Resident dialog for the duplicate resident (you can

only delete residents added by the team not those on the MDS resident list).

From the List view, select the resident’s name and click the Update Selected Resident icon.

From the Card view, select the resident’s name.

-or-

2 Click the Delete Resident button at the bottom of the dialog box.

If the resident has data associated to their ID or is found associated with a task you will receive a warning and the resident will not be deleted. Remove or transfer the data to the correct resident to delete.

70 1/29/21 LTCSP 11.9.5

Add/Update Residents

Add/Update Resident dialog—Delete Resident

More ...

“Open the Resident Manager” on page 59 “Assign Subgroup to Resident” on page 72

Update Resident Information

Basic resident information such as room number or name can be changed by surveyors. These changes do not affect the MDS data and are only used to help surveyors in the field.

To update resident information:

1 Open the Resident Manager.

List view, select the checkbox for the resident, then click the Update

2 In

Resident icon.

-or-

In Card view, click the resident name on the card.

the Add/Update Resident window, update resident information (e.g.,

3 In

First Name, Room #, IP status) as needed.

4 Click Save.

More ...

“Open the Resident Manager” on page 59

User’s Guide 1/29/21 71

LTCSP Procedures

Assign Subgroup to Resident

If you decide to include a resident in the initial pool who is not offsite selected, or want to assign an additional subgroup to an offsite selected resident, you can assign one or more of the following subgroups to indicate why you chose to include the resident.

All applicable subgroups should be identifi

ed for each initial pool resident.

•All

•New Admissions

• Facility Reported Incidents

• Vulnerable Residents

• Complaint Residents (official complaints from ACTS)

If none of these reasons apply, but you feel the re

sident should be included in the initial pool, select Identified Concern and enter a description of the concern. Once Identified Concern is selected, all other subgroup options are grayed out. If any other subgroup(s) are selected, Identified Concern is grayed out; you must deselect any other subgroups in order to activate Identified Concern.

Subgroup(s) can also be assigned on

the Resident Interview/Observation screen. For example, if you determine from observation that a resident is very dependent on the facility staff, you may want to mark that resident as vulnerable.

To add a subgroup to a resident:

1 Open the Resident Manager. 2 In List view, click the down arrow in the Subgroup field for the resident.

Figure 53: Subgroup options

72 1/29/21 LTCSP 11.9.5

3 Select the applicable option.

If you select Identified Concern, all other options gray out and you are required to enter a rationale for the concern.

TIP: Subgroup can also be assigned in the Add/Update Resident window, and

Interview and Observations (RI) or Observations (RO) screens, all of which can be opened from List or Card view.

More ...

“Open the Resident Manager” on page 59 “Resident Manager Tips” on page 203

Surveyor Assignments

Team coordinators can assign survey team members to residents at any time, even before arriving at the facility (e.g., active complaints or offsite selected residents). Later, team member assignments may need to be changed and team members can make their own assignments.

Surveyor Assignments

More ...

“Balance the Survey Team’s Workload” on page 108

User’s Guide 1/29/21 73

LTCSP Procedures

Assign Surveyor to Resident

Surveyor assignments can be made in the Surveyor field in the Residents list or in the Add/Update Resident dialog for a selected resident.

Note: Team coordinators can assign any survey team member; team members

can assign only themselves.

To assign a surveyor to a resident in List view:

1 Open the Resident Manager.

List view, select the checkbox to the left of the resident.

2 In 3 From the Surveyor drop-down list, select the surveyor you want to assign

to the resident.

Figure 54: Surveyor drop-down list

TIP: In List view only, to assign a surveyor to multiple residents at once, select

the checkbox for all applicable residents, then select the surveyor name for one of the selected residents and the surveyor name will be applied to all selected residents.

To assign a surveyor to a resident via Add/Update Resident:

1 In List view, select the checkbox for the resident, then click the Update

Selected Resident icon.

-or-

In Card view, select the resident name on the card.

74 1/29/21 LTCSP 11.9.5

Surveyor Assignments

2 In the Add/Update Resident dialog, select the surveyor you want to

assign from the Surveyor drop-down list.

Figure 55: Assign surveyor to resident via Add/Update Resident

3 Click Save.

More ...

“Open the Resident Manager” on page 59

Change Surveyor Assignments

Use this function to change surveyor assignments for the initial pool. In Resident Manager anyone can change surveyor assignments—only one surveyor can be assigned to a resident during the initial pool interviews, observations, and record review. Once the sample is finalized, adjust surveyor assignments on the Investigations screen.

To change an existing surveyor assignment:

1 Open the Resident Manager. 2 In List view or the Add/Update Resident window, select the new

surveyor you want to assign to the resident from the Surveyor drop-down

list.

User’s Guide 1/29/21 75

LTCSP Procedures

3 Click Yes in the reassignment confirmation message.

Note: Once the survey has been started, each surveyor will have to assign a

different resident to themselves—data share will not assign a resident to another surveyor, so each surveyor maintains their own resident list after starting the surveyor.

More ...

“Open the Resident Manager” on page 59 “Assign Investigations” on page 139

Unassign Surveyor

All team members can unassign or reassign any survey team member; it is a good idea to communicate these changes to help with data conflicts during data sharing.

To unassign a surveyor:

1 Open the Resident Manager. 2 In List or Card view, open the Add/Update Resident window and select

the blank option in the Surveyor drop-down.

-or-

In Card view, drag and drop the resident’s card to the Unassign icon.

-or-

In List view, in the row for the resident open the Surveyor drop-down and

select the blank line.

-or-

Change the IP status to No or Unknown (non-offsite only) for the resident.

When you unassign a surveyor from an offsite selected resident, the LTCSP application requires a reason be specified: Expired, Hospitalized, Discharged to community, or Assign to another surveyor. Any offsite selected resident marked as Discharged is automatically added as a Closed Record Review candidate.

Note: When you unassign a non-offsite resident, the system automatically changes the IP status to No.

More ...

“Open the Resident Manager” on page 59 “Closed Record Review Sample” on page 110

76 1/29/21 LTCSP 11.9.5

Manage Your Workload

You can manage your workload by either:

• Assigning yourself the offsite selected residents in your assigned area of the

facility, then adding other residents who should be in the initial pool as determined through screening.

Surveyor Assignments

Figure 56: Manage workload by only assigning offsite residents

-or-

• Assigning yourself all residents in your assigned area of the facility, then

unassigning residents who should not be in the initial pool as determined

through screening.

Figure 57: Manage workload by only assigning all residents

More ...

“Assign Surveyor to Resident” on page 74 “Unassign Surveyor” on page 76

User’s Guide 1/29/21 77

LTCSP Procedures

Initial Pool Resident Interviews, Observations, & Record Reviews

After identifying residents for the initial pool, you are ready to interview, observe, and perform a limited record review for those residents. You may find issues related to care areas that will be investigated later in the LTCSP process.

For the residents in your initial pool, the Interview and Observations screen is used to:

• Conduct resident interviews (RI)

• Conduct resident representative interviews for non-interviewable residents

(RRI)

• Make observations of residents (RO)

• Perform a limited record review of residents (RR)

During the initial pool process you will:

• Conduct the Interview, Observations, and Record Reviews for all care areas

(CAs) and indicate the areas where you determine a need for further investigation (FI) (it is best practice to respond to all areas to know they have been addressed)

• Indicate if there are any MDS discrepancies

• Indicate if any issues found are at the Harm or IJ level

More ...

“Interview and Observations Tips” on page 206

Open Interview and Observations

Access the Interview and Observations (RI) screen from the Resident Manager in either List or Card view.

To open the Interview and Observations screen:

1 In List or Card view, locate the resident. 2 In List view, double-click the resident’s name.

-or-

In Card view, click the RI icon on the resident’s card.

78 1/29/21 LTCSP 11.9.5

Initial Pool Resident Interviews, Observations, & Record Reviews

The Interview and Observations screen opens. The layout is the same, whether opened from List or Card view.

Figure 58: Interview and Observations screen

The interview CAs are organized first by quality of life and resident rights, followed by quality of care. Resident information displays on the upper left, process information in the middle, and MDS indicators on the right. A weight calculator is available to determine weight gain/loss.

Note: Interview and Observations appear together on this screen since

surveyors often conduct an observation while interviewing a resident. The Observations (RO) screen shows only observation CAs.

More ...

“Interview and Observations Tips” on page 206

User’s Guide 1/29/21 79

LTCSP Procedures

Care Areas

The screen lists all care areas (aka initial pool or interview areas) specific to the screen (Interview and Observations, Observations, or Record Review).

TIP: To jum p to a s p ecif ic ca r e are a (CA ) , click the tab on the right of the screen

When conducting a resident interview, you must cover every care area (initial pool/interview area), whether or not the area is an MDS indicator for a resident. You will ask questions guided by the probes provided in the application, or your own questions, as long as you adequately address the area with the resident. You will then select the appropriate response option:

•No Issues/NA

Select if you have determined that there are either no issues (NI) for the CA or the CA does not apply to the resident (e.g., catheter questions only apply to residents needing a catheter).

to open the Care Area pullout menu and select the desired CA.

Dialysis, smoking, hospice, ventilator, and transmission-based precautions CAs have a separate NA option.

• Further Investigation

Select if something heard or observed requires further investigation (FI). You should document the concern in the Notes field for the CA.

When you select a response, the CA is marked with a green checkmark (no concern) or an orange exclamation point (further investigation required) to indicate completion, both on the screen and pullout menu.

It is best practice to respond to all areas to know they have been addressed. You may only mark those CAs that require further investigation with two exceptions (see below).

Function toolbar for the system to recognize that you have completed the resident Interview, Observations, and Record Review (you must mark all three screens).

You do not have to mark No Issues/NA with two exceptions:

1 For the required areas of hospice, dialysis, ventilator, smoking,

transmission-based precaution, you must mark No Issues if the area applies to the resident and there are no concerns to ensure at least one resident is sampled for the area, and

2 For the medication-related record review areas of insulin,

antipsychotic, anticoagulant, high risk medications, diagnoses, and hospice, you must document whether the resident is currently receiving the medication or has one of the conditions listed to ensure the Unnecessary Medication selection is based on accurate and current information.

However, you must check the Complete option in the

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Initial Pool Resident Interviews, Observations, & Record Reviews

Note: On the combined Interview and Observation screen, the completion

indicator (checkmark or orange exclamation) shows only when NI or FI is marked for the Resident Interview portion of the care area. If you only mark NI or FI for the Resident Observation portion, no completion indicator shows for the Interview and Observation care area or on the pullout menu. The completion indicator does show on the Observation screen and pullout menu for that care area. If the RO portion is marked FI, and the RI portion is marked NI, the orange exclamation shows on both screens.



However, if the care area is a Resident Observation only (no interview portion), the completion indicator shows for the care area on both the Interview and Observation and the Observation screens.

When all CAs for the interview, observation, and record review are complete (i.e., marked either NI or FI), a green checkmark appears over the corresponding icon.

• In Card view, a green checkmark appears on the RI/RO/RR icon to indicate

completion, and an orange exclamation point appears next to the resident’s name if at least one CA was marked FI.



• In List view, a green checkmark appears next to the resident’s name when

all three screens (RI, RO, RR) are complete, and a blue circle in the Investigate column indicates at least one CA is marked for Further Investigation.

TIP: To free up screen space as you go along, select Collapse Completed

Care Areas at the bottom of the screen (RI, RO, RR).

Navigate Care Areas

You should conduct the interview in the order that the care areas appear on the screen—starting with quality of life questions and moving on to quality of care questions. If, however, you do need to go to a specific care area use the Care Area pullout menu. You can also alphabetize the list of care areas on the menu to make it easier to find a specific care area.

To use the Care Area pullout menu:

➥ Click the tab to open the Care Area pullout menu. Initially the view is the

same order as the care areas appear on the screen (quality of life to quality of care).

• Click a care area name to jump to that care area on the screen.

TIP: The menu uses abbreviations for the care area names, hover over a

menu name to see the full care area name.

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LTCSP Procedures

➥ Click the Alphabetize Care Area button to sort the care areas listed on the

menu alphabetically.

•Click the Alphabetize Care Area button again to return the sort order

Note: Whichever sort order you set the Care Area menu to remains the sort

order in LTCSP until you change the order again.

Figure 59: Care Area pullout menu Alphabetize Care Area menu button

to the default.

Adding Care Areas on the Record Review screen

If you find issues during limited record reviews that are not covered by the system-selected care areas, you can add any other care area to the Record Review screen. Rather than selecting the Other Concerns care area, you can select a more specific care area that will then trigger the appropriate investigation.

To add a care area to the Record Review screen:

1 On the Record Review screen, click to open the Additional Care Areas

list.

2 Sele

ct one or more care areas you would like to add; click out of the

drop-down list or press Escape to close.

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Initial Pool Resident Interviews, Observations, & Record Reviews

The added care areas appear on the screen and in the pullout menu.

Figure 60: Select an additional care area

TIP: You can remove a care area that you added as long as you remove your

answers (NI or FI) from the care area. Remove the selection from the Additional Care Areas list and the CA will be removed.

More ...

“Interview and Observations Tips” on page 206 “LTCSP Notes” on page 25

Probe Text

LTCSP provides a list of questions specifically tailored for each care area. These questions are called probe text. They serve as suggestions or guidance that surveyors can reference for assistance when conducting interviews, observations, and record review.

TIP: Select/deselect Show probe text at the bottom of the screen (RI) to

show/hide suggested questions.

More ...

“Interview and Observations Tips” on page 206

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LTCSP Procedures

Assign Interview Status and Subgroup to Resident

After selecting residents to include in the initial pool, you determine and set the interview status and subgroup for each resident on the Interview and Observations screen.

Resident Interview (RI) or Observation (RO) ma

y or may not be applicable and required depending on the assigned interview status. If RI or RO is not required, a green checkmark is placed on the corresponding icon (indicating completion) as soon as a triggering interview status is selected. For example, neither interview or observation is possible or required if a resident is out of the facility, so both RI and RO are marked as complete.

Record Review (RR) is required for all initial pool residents regardless of interview status. Different CAs will be listed on the RR screen depending on interview status and subgroup. For example, additional areas are listed for new admissions.

To set resident interview status and subgroup:

1 Open the Interview and Observations screen. Verify th a t the IP status is

Yes. If not, set to Yes to continue.

2 In the

resident information section at the top of the screen, select the

appropriate Interview Status and Subgroup for the resident.

Figure 61: Interview Status options

Figure 62: Subgroup options

More ...

“Open Interview and Observations” on page 78 “Interview Status” on page 205

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Initial Pool Resident Interviews, Observations, & Record Reviews

Conduct Resident Interview (RI)

Offsite selected residents should always be interviewed unless they are Out of Facility, refused, unavailable for interview, or non-interviewable. If they cannot be interviewed, a limited record review must be completed. If the offsite resident is discharged from the facility, they are listed in the closed record sample as a closed record candidate.

To record results of a resident interview/observation:

1 Open the Interview and Observations screen. Verify th a t the IP status is

Yes. If not, set to Yes to continue.

2 For Interview Status, select Interviewable. 3 Based on the interview/observation, select No Issues/NA or Further

Investigation for all CAs and enter notes as appropriate.

When you select an option, the CA is marked with a green checkmark (no concern) or an orange exclamation point (further investigation required), both on the screen and pullout menu.

Some CAs are observation-only. When you complete an observation-only CA on the Interview and Observations screen, the green checkmark appears even if you mark Further Investigation for the observation. The orange exclamation appears only on the Observations screen.

When all Resident Interview CAs are complete for a resident, a green checkmark appears over the RI icon to indicate the interview process is complete.

More ...

“Open Interview and Observations” on page 78 “Interview and Observations Tips” on page 206 “LTCSP Notes” on page 25

Conduct Resident Representative Interview (RRI)

Not every resident is capable of being interviewed. The survey team should try to conduct three resident representative interviews for non-interviewable residents per survey. If a representative is not available, the surveyor still conducts the observations and limited record review for the resident.

To record results of a resident representative interview:

1 Open the Interview and Observations screen. Verify th a t the IP status is

Yes. If not, click the IP status icon and set to Yes to continue.

2 For Interview Status, select Non-Interviewable.

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3 Select the Representative Interview checkbox. An RRI Contact

Information field appears. Enter representative contact information for easy reference.

The RRI option is enabled only when Interview Status i

s Non-Interviewable. When selected, the probes change and some additional probes specific to the representative interview are available.

4 Based on the

interview, select No Issues/NA or Further Investigation

and enter any notes for all care areas.

When you select an option, the CA is mark

ed with a green checkmark (no concern) or an orange exclamation point (further investigation required), both on the screen and pullout menu.

Some CAs are observation-on

ly. When you complete an observation-only CA on the Interview and Observations screen, the green checkmark appears even if you mark Further Investigation for the observation. The orange exclamation appears only on the Observations screen.

When all Resident Representative Intervi

ew CAs are complete for a resident, a green checkmark appears over the RI icon to indicate the interview process is complete.

Add an RRI after sample finalization

Before sample finalization you may not have an opportunity to conduct a resident representative interview. If an RRI/family interview is completed during the investigative process, complete the RRI interview on the Resident Manager screen.

If the resident was already included in the ini

tial pool, go to the RI screen to complete the RRI interview. If the resident was not part of the IP, you can add them to the initial pool and conduct interview.

To conduct a resident representative interview after sample finalization:

1 Open the Interview and Observations screen for the resident. 2 Click the Add to Initial Pool for Representative Interview button.

Figure 63: Add to Initial Pool for Representative Interview button

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Initial Pool Resident Interviews, Observations, & Record Reviews

3 Click Yes in the Confirm Status Change dialog to add the resident to the

initial pool. The system automatically:

• Changes the IP status to Yes

• Changes the Interview Status to Non-Interviewable

•Selects Representative Interview and activates RRI Contact field

• Activates questions for the representative interview

• Adds resident to the Finalize Sample screen, even though the sample has been finalized

• Adds resident to all Initial Pool reports

Figure 64: Screen updated after adding a representative interview

4 Conduct the interview.

If you determine that a CA needs further investigation, you will need to initiate the investigation on the Investigations screen or add the resident to the appropriate facility task.

More ...

“Open Interview and Observations” on page 78 “LTCSP Notes” on page 25

Conduct Resident Observation (RO)

The resident interview screen (Interview and Observations) includes the Resident Observation section since it is often possible to conduct an observation while interviewing a resident. If you complete observation-only care areas on the Interview and Observations screen, the Complete and Further Investigation indicators appear only on the Observations screen. You can, of course, complete observation-only CAs directly on the Observations screen, the likely option for residents you observe but do not interview.

To record resident observation results:

1 Open the Interview and Observations screen. Verify th a t the IP status is

Yes. If not, set to Yes to continue.

2 Sel

User’s Guide 1/29/21 87

ect the RO icon to open the Observations screen.

LTCSP Procedures

3 Based on your observations, select No Issues/NA or Further

Investigation and enter any notes for all CAs.

When you select a result, the CA is marked with a green checkmark or an orange exclamation point to indicate completion, both on the screen and pullout menu.

When all Resident Observation CAs are complete, a green checkmark appears over the RO icon.

More ...

“Open Interview and Observations” on page 78 “Interview and Observations Tips” on page 206 “LTCSP Notes” on page 25

Conduct a Limited Record Review (RR)

The system selects certain care areas for the limited record review based on assigned MDS indicators for each resident.

A limited record review must be conducted for all initial pool residents including those who refuse, are non-interviewable, or are out of the facility. Different CAs appear for each resident based on MDS data, interview status, and subgroup.

Since no MDS data exists for new admissions, the limited record review lists all available CAs. The record review is used to identify MDS indicators, for example:

•Hospice

• High risk medications

•Diagnoses

You can add additional care areas to the Record Review, if necessary (see

“Adding Care Areas on the Record Review screen”).

Complete a limited record review:

1 Open the Interview and Observations screen. Verify th a t the IP status is

Yes. If not, set to Yes to continue.

2 Click the RR icon to open the Record Review screen.

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Initial Pool Resident Interviews, Observations, & Record Reviews

3 Based on the record review, select No Issues/NA or Further

Investigation and enter any notes for all CAs.

When you select a result, the CA is marked with a green checkmark or an orange exclamation point to indicate completion, both on the screen and Care Area pullout menu.

When all Record Review CAs are complete, a green checkmark appears over the RR icon.

More ...

“Open Interview and Observations” on page 78 “Adding Care Areas on the Record Review screen” on page 82 “Interview and Observations Tips” on page 206 “LTCSP Notes” on page 25

Determine Weight Loss/Gain

The weight calculator, available in the RI, RO, RR as well as the Nutrition investigation screens, provides a way to calculate weight loss/gain for a resident. Once calculated, you can paste a statement into a notes field with the weights, the date each weight was taken and the percent difference in weight measurements. Once you enter both dates, the system will determine the gain or loss based on the earliest date entered whether it is first or second.

The system keeps the data in the weight calculator only for that resident—once you switch to a different screen (e.g., the Resident Manager card or list view) the data no longer appears in the weight calculator.

To calculate weight loss/gain for a resident:

1 Click the Weight Calculator button. 2 Enter the first weight and associated date. 3 Enter the second weight and associated date.

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LTCSP Procedures

To paste the weight loss/gain statement into a notes field:

1 Click the X to close the calculator. 2 Click in the notes field where you want the statement. 3 Click the Paste Weight Calcul

Figure 65: Weight calculator (top) and example of message inserted

Mark an MDS Discrepancy

If you discover an MDS discrepancy during interview/observation/record review, mark it for the care area. For example, if Cath (Catheter) is included in a resident’s MDS indicator list, but you discover during the interview that the resident never had a catheter, you need to mark this as an MDS discrepancy. The Resident Assessment facility task is triggered when an MDS discrepancy is identified.

ation icon, or press Alt + W.

To mark an MDS discrepancy:

1 On the applicable screen (RI, RO, or RR), click the tab on the right to open

the Care Area pullout menu, if desired.

elect the applicable care area.

2 S 3 Click the MDS Discrepancy checkbox.

This checkbox is available only for CAs that are mapped to an MDS indicator.

More ...

“Interview and Observations Tips” on page 206

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Mark a Significant Concern

If issues are found indicating a potential Harm or IJ (Immediate Jeopardy) situation, you can indicate this. The resident is automatically flagged for further investigation and included in the current sample.

To mark a significant concern:

➥ On an RI, RO, or RR screen, select a reason for Include in s ample due to:

Harm or IJ.

In Card view, an orange exclamation point appears next to the resident’s name. In List view, there is a blue circle in the Investigate column for the resident.

Note: The Include in Sample due to reason also appears in the Sample Reason column on the Finalize Sample screen.

Transfer Resident Data

Surveyors on occasion may accidentally record interview/observations/record review data under the wrong resident name.

All care area answers and notes transfer from the original (wrong) resident to the receiving (correct) resident. If a subgroup was assigned to the resident, you will have to manually update that for the correct resident. You can transfer answers for all screens or any combination of the resident interview, resident observation, or record review screens, including resident representative interview.

The notes transfer for care areas and appear on all screens—for example, if you transfer only the Resident Interview screen, the care area notes for those care areas that appear on the Observations or Record Review screens appear for all screens as they normally do when you enter notes for a care area that appears on more than one screen.

LTCSP provides an interview transfer option to move all the data to the correct

resident if that resident

• has an IP indicator set to Yes

• is not assigned to a different surveyor

• has no data entered on any screen

If you are transferring only one (or two) screens, you can transfer data to the

correct resident’s screen, if that resident

• has an IP indicator set to Yes

• is not assigned to a different surveyor

• has no responses entered on the screen being transferred

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LTCSP Procedures

• has no MDS Discrepancies selected on any screen

• has no care area notes in shared care area notes fields (see table below)

For the screens that you are not transferring you can have care area notes for care areas specific to that screen and not a shared care area—you still must not have any care area notes in the other care areas on any screen for the transfer to work. The following table lists the care areas where you can have data if not transferring to that screen.

OK to have a note in care area…

If NOT

transferring data

to this screen

Notification of Change

Language/Communication

Mood/Behavior

Restraints

Accident Hazards

Call Light in Reach, Call system Functioning

Edema

Psych Med Side Effects

Psych/Opioid Med Side Effects

AC Med Side Effects

Oxygen

Positioning

Ventilator/Tracheostomy

Change of Condition

RRI

Antipsychotic with Alzheimer's or Dementia

PASSAR

High Risk Meds

Advance Directives

Diagnoses

Insulin

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To transfer interview data to another resident:

1 Open the Resident Manager. 2 Verify that the receiving resident has no information entered and the IP

status is set to Yes.

3 In Card or List view, locate the resident with the data you want to transfer. 4 In Card view, click the resident’s name.

-or-

In List view, select the box next to the resident’s name and click the Update Resident icon.

5 In the Add/Update Resident dialog, click the Transfer RI/RRI, RO, or

RR Info to Another Resident button at the bottom.

6 In the To list, select the receiving resident. 7 In the Types list, select All or RI, RO, RR, or any combination of these to

transfer.

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Note: If you only transfer resident interview/resident representative

interview answers and not the resident observation answers, the completed

indicators appear on the RI/RRI screen for the correct resident only, even if

the care area included the answer for the observation section.

Figure 66: Select resident and info to transfer

8 Click the Transfer button.

TIP: When you set the IP Status to Yes, the system automatically assigns

you as surveyor, but you can change the surveyor assignment in the Add/Update Resident dialog.

9 Click OK, then Save. 10 Verify that the information transferred correctly. Select an Interview Status

to complete any remaining care areas on any screen.

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Completion checkmarks or Further Investigation exclamations and all notes transfer along with the answers. Notes for RI/RRI and RO combined care areas appear for both residents if you only transfer one of the screens (e.g., transfer answers for RI, not RO, that include notes for the Nutrition CA, notes stay in the original resident’s notes field as well as appear in the receiving resident’s notes).

TIP: If you used the resident unique ID in any of your notes, this number does

not change, so you will need to update your notes to the ID of the resident you transferred the answers to.

More ...

“Open the Resident Manager” on page 59

Completed Screens

As you choose NI or FI for a care area, the system marks these CAs complete. When all CAs for a screen (Interview and Observations, Observations, or Record Review) are completed, the system automatically marks the screen as complete with a green checkmark over the RI, RO, or RR icon in the upper right part of the screen or on the Resident card.

Initial Pool Resident Interviews, Observations, & Record Reviews

When you have completed all three screens for a resident, the system marks

the resident as complete. In List view a green checkmark displays beside the resident name. In Card view, the resident’s card is automatically moved to the Complete folder.

You always want to complete a full interview with a resident, but if for some reason you cannot complete an interview/observation/record review for a resident, you can manually mark any or all of them as complete. You might use this option, for example, to manually mark RI as complete for a resident you cannot complete an interview with.

To manually mark a screen as complete:

1 Go to the applicable screen: RI, RO, or RR. 2 Select the Complete checkbox (at the top in the Function toolbar).

A green checkmark is placed on the applicable icon.

To view residents marked as complete:

➥ In the List view, look for the green checkmark to the left of a resident’s

name.

➥ In the Card view, click the Complete folder.

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Finalize Sample

The sample selection process occurs after the initial pool process is completed and data is shared with all team members. During the sample selection process, the TC will:

• Update the facility census number if necessary.

• Determine the number of residents required to complete the sample.

• Decide if any offsite selected residents should be replaced in the sample.

• Record the selected sample residents in the LTCSP application, and verify

any areas of concern.

All the data gathered from the initial pool process (interviews, observations, and record review) is available and provides the survey team with information to help choose residents to include in the sample for investigation.

TIP: If you start sample finalization on the Finalize Sample screen too soon,

press Alt + U to reactivate the Start Sample Finalization button. This only

works for Start Sample Finalization; once the sample is finalized, it cannot be reset.

Residents are selected for investigation, either by the system or the survey team, through:

•Sample finalization

• Closed record review

There is a separate process for selecting residents with closed records for

the sample.

More ...

“Closed Record Review Sample” on page 110

“Reset Sample Finalization” on page 104

Open the Finalize Sample screen

There are two different views of the Finalize Sample screen, by Resident and by Care Area. Surveyors can choose the view they prefer and switch between views.

Note: Do not start sample finalization until data has been shared with all team

members.

Only the team coordinator can actually select the sample. All surveyors have read-only access to the information to help with the team discussion and decision making. Both views are read-only until the finalize sample process is initialized.

96 1/29/21 LTCSP 11.9.5

To open the Finalize Sample screen:

1 From the Navigation menu, select Finalize Sample.

Figure 67: Finalize Sample option

Finalize Sample

Resident view appears by default.

Figure 68: Finalize Sample screen–default Resident view

2 To switch between views, click the by Resident or by Care Area icon in

the upper right corner of the screen.

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3 To display care areas and MDS information in either Resident or Care Area

view, click the arrow to the left of the resident’s name to expand/collapse

the resident record.

Care areas and MDS information can be viewed at any time, but CAs cannot

be modified until

you initiate sample finalization.

4 In eithe

r view, click a CA for a resident to display any notes that were

recorded during the interview and observation of initial pool residents.

Figure 69: Finalize Sample–Care Area notes

More ...

“Sample Finalization Tips” on page 207

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Finalize Sample

Finalize Sample by Resident view

By default, current sample residents are listed according to the value in the

Sort residents field. The Finalize Sample by Resident view displays basic

resident information, the number of care areas marked as Further Investigate for each resident, and also provides the ability to select which residents to include in the sample.

Figure 70: Finalize Sample with resident expanded to show care areas and MDS indicators

More ...

“Sample Finalization Tips” on page 207

User’s Guide 1/29/21 99

LTCSP Procedures

Finalize Sample by Care Area view

Care areas are listed by default in descending order according to the number

of residents marked for Further Investigation for each area. In Sample shows

how many of these residents are included in the sample. Care Area view may help in ensuring care area representation in the sample.

Figure 71: Finalize Sample by Care Area with resident expanded

More ...

“Sample Finalization Tips” on page 207

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MAPI LTCSP User Manual

Specifications and Main Features

Frequently Asked Questions

User Manual

Contents

About this User’s Guide

Introduction

View and Navigate this Document Online

View a Printed Copy of this Document

Conventions

LTC S P C BTs

Accessibility Features

In this Guide

In the Application

LTCSP Procedures

Import User Account File

LTCSP Surveys

Create LTCSP Survey Shell in ACO

Transfer LTCSP Surveys to ASE-Q

Open a Survey in LTCSP

LTCSP Screen Navigation and Features

Title toolbar

Quick Access menu

Function toolbar

Change Column Order

Drop-down Lists

Hover

Expand/Collapse Sections

Resize Sections with Expander Bars

Update PDF Documents

LTCSP Notes

Surveyor Notes

Surveyor Notes in Resident Manager

Interview, Observations, and Record Review Notes

Facility Task Notes

View Resident Initial Pool Notes

View Surveyor Facility Task Notes

Medication Administration

Investigation Notes

View Body Map and Drawings for any Surveyor

Notes History

Reports and Attachments

Generate Reports

Use the “Immediate Jeopardy Template”

Add Attachments

Data Sharing

Open the Data Sharing screen

Share Data by USB/File

Share Data Via Email

Share Data Across a Network

Data Sharing for RO/CO Users

RO/CO Data Share Using USB/File

RO/CO Data Share Across a Network

Team Meeting

Offsite Preparation

Enter Offsite Prep Information

Active Complaint and FRI data

Complaints and FRIs Information during the Survey

Anonymous Complaints and FRIs

Entrance Conference

Resident Manager

Open the Resident Manager

Resident Manager views

Resident Manager Filter and Sort

Filter by group

Sort residents

Search Residents

Initial Pool

Offsite Selected Residents

Include Resident in Initial Pool

Add/Update Residents

Add a New Admission

Update Resident Information

Assign Subgroup to Resident

Surveyor Assignments

Assign Surveyor to Resident

Change Surveyor Assignments

Unassign Surveyor

Manage Your Workload

Initial Pool Resident Interviews, Observations, & Record Reviews