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)

MANUAL INDEX

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

QIS Brochure
	CMS Quality Indicator Survey Demonstration Project

Manual Binder Covers
	Cover Page, Binder and Tab Labels, Index

Tab 1: Offsite Preparation
	CMS-20044 Offsite Preparation Worksheet
	New Admission Information Form

Tab 2: Entrance Conference Forms
	CMS-20045 - Entrance Conference - Facility Copy New 03/2013
	CMS-20046 - Entrance Conference - Team Copy New 03/2013

Tab 3: Stage Review Forms
	CMS-807 - Surveyor Notes
	CMS-20047 - Admission Record Review
	CMS-20048 - Census Record Review
	CMS-20049 - Family Interview
	CMS-20050 - Resident Interview and Observation New 03/2013
	CMS-20051 - Staff Interview

Tab 4: Mandatory Facility-Level Task Forms
	CMS-20052 - Demand Billing
	CMS-20053 - Dining
	CMS-20054 - Infection Control
	CMS-20055 - Kitchen New 03/2013
	CMS-20056 - Medication Admin New 03/2013
	CMS-20057 - Resident Council
	CMS-20058 - QAA
	CMS-20089 - Medication Storage

Tab 5: Tiggered Facility-Level Task Forms
	CMS-20059 - Abuse Prohibition
	CMS-20060 - Admit / Transfer / Discharge
	CMS-20061 - Environment
	CMS-20062 - Sufficient Nursing Staff
	CMS-20063 - Personal Funds New 03/2013

Tab 6: Stage II Review Forms
	Stage II Care Area Investigation Key
	*CE Pathway –*
	CMS-20065 - Activities
	CMS-20066 - ADL-ROM
	CMS-20067 - Behavioral / Emotional
	CMS-20068 - Bowel / Bladder / Catheter
	CMS-20069 - Communication / Sensory Problems
	CMS-20070 - Dental
	CMS-20071 - Dialysis
	CMS-20072 - General
	CMS-20073 - Hospice
	CMS-20074 - Hospital / Death
	CMS-20075 - Nutrition / Hydration / Tube-Feeding
	CMS-20076 - Pain Management
	CMS-20077 - Physical Restraints
	CMS-20078 - Pressure Ulcers
	CMS-20079 - Psychoactive Medications
	CMS-20080 - Rehabilitation and Community Discharge
	CMS-20081 - Ventilator - Dependent Residents
	CMS-20082 - Unnecessary Medication Review
	CMS-20090 - PASRR
	CMS-20091 - QIS Extended Survey
	CMS-20092 - Hydration
	CMS-20093 - Tube Feeding

Tab 7: QCLI Dictionary
	Quality of Care and Quality of Life Indicator (QCLI) Dictionary (126 Pages)