Quality Indicator Survey (QIS) Resource Manual

Prepared by:
Division of Health Care Policy and Research
University of Colorado Health Sciences Center
~ in conjunction with ~
Centers for Medicare & Medicaid Services (CMS)


Note: All documents are either in Acrobat Reader Adobe Logo or Microsoft Word Word Logo format. The format of the document is indicated by the appropriate icon.

QIS Brochure
Adobe Logo CMS Quality Indicator Survey Demonstration Project
Manual Binder Covers
Adobe Logo Cover Page, Binder and Tab Labels, Index
Tab 1:  Offsite Preparation
Word Logo CMS-20044 Offsite Preparation Worksheet
Word Logo New Admission Information Form
Tab 2:  Entrance Conference Forms
Adobe Logo CMS-20045 - Entrance Conference - Facility Copy
Adobe Logo CMS-20046 - Entrance Conference - Team Copy
Tab 3:  Stage Review Forms
Word Logo CMS-807 - Surveyor Notes
Adobe Logo CMS-20047 - Admission Record Review
Adobe Logo CMS-20048 - Census Record Review
Adobe Logo CMS-20049 - Family Interview
Adobe Logo CMS-20050 - Resident Interview and Observation New 11/2013
Adobe Logo CMS-20051 - Staff Interview
Tab 4:  Mandatory Facility-Level Task Forms
Adobe Logo CMS-20052 - Demand Billing New 11/2013
Word Logo CMS-20053 - Dining
Word Logo CMS-20054 - Infection Control
Adobe Logo CMS-20055 - Kitchen
Adobe Logo CMS-20056 - Medication Admin New 11/2013
Word Logo CMS-20057 - Resident Council
Word Logo CMS-20058 - QAA
Word Logo CMS-20089 - Medication Storage
Tab 5:  Tiggered Facility-Level Task Forms
Word Logo CMS-20059 - Abuse Prohibition
Word Logo CMS-20060 - Admit / Transfer / Discharge
Word Logo CMS-20061 - Environment
Word Logo CMS-20062 - Sufficient Nursing Staff
Adobe Logo CMS-20063 - Personal Funds
Tab 6:  Stage II Review Forms
Word Logo Stage II Care Area Investigation Key
  CE Pathway –
Word Logo CMS-20065 - Activities
Word Logo CMS-20066 - ADL-ROM
Adobe Logo CMS-20067 - Behavioral / Emotional New 11/2013
Word Logo CMS-20068 - Bowel / Bladder / Catheter
Word Logo CMS-20069 - Communication / Sensory Problems
Word Logo CMS-20070 - Dental
Word Logo CMS-20071 - Dialysis
Word Logo CMS-20072 - General
Word Logo CMS-20073 - Hospice
Word Logo CMS-20074 - Hospital / Death
Word Logo CMS-20075 - Nutrition / Hydration / Tube-Feeding
Word Logo CMS-20076 - Pain Management
Word Logo CMS-20077 - Physical Restraints
Adobe Logo CMS-20078 - Pressure Ulcers New 11/2013
Word Logo CMS-20079 - Psychoactive Medications
Word Logo CMS-20080 - Rehabilitation and Community Discharge
Word Logo CMS-20081 - Ventilator - Dependent Residents
Adobe Logo CMS-20082 - Unnecessary Medication Review New 11/2013
Word Logo CMS-20090 - PASRR
Word Logo CMS-20091 - QIS Extended Survey
Word Logo CMS-20092 - Hydration
Word Logo CMS-20093 - Tube Feeding
Tab 7:  QCLI Dictionary
Adobe Logo Quality of Care and Quality of Life Indicator (QCLI) Dictionary (126 Pages)

| KDADS Disclaimer | Kansas Open Records | KDADS Privacy Statement |
Page Last Updated: February 4, 2014