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Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850

Center for Medicaid and State Operations/Survey and Certification Group

                                                                             Admin Info: 08-40
DATE:          August 22, 2008

TO:            State Survey Agency Directors

FROM:          Director
               Survey and Certification Group

SUBJECT:       FY 2009 Survey and Certification Mission & Priority Document (MPD) -
               Training Program Addendum

                                   Memorandum Summary

     This portion of the MPD provides State Agencies (SAs) with the program requirements,
      mandatory trainings, and budget guidelines to be used for the FY2009 survey and
      certification TRAINING budget process.

     Please develop budgets by workload based on this segment of the FY2009 MPD and the
      Surveyor Employment and Training (SET) Report completed recently by the State
      Training Coordinators (STCs).

This memorandum provides the training portion of the FY2009 MPD, as incorporated by
reference in the main body of the MPD issued on August 8, 2008 (Admin Info: 08-37).

CMS will continue to provide a program of instruction for surveyors, supervisors, State Resident
Assessment Instrument Coordinators and other State Agency staff members. In addition to
traditional classroom training, the Survey and Certification Group will provide satellite
broadcasts, computer and web-based training applications, videos, train-the-trainer modules,
audio conferencing, and other instructional products, which will expand opportunities for
training to occur and be replicated consistently at local levels. The pilot of the Virtual
Classroom (VC) was completed in FY2008, and is now a regular part of the curriculum. VC
distance learning tools will be used for the Basic Life Safety Code (BLSC) training and
Rehabilitation training. The BLSC will also be offered as a traditional classroom experience.
FY2009 will also debut the pilot of several additional VC courses, all of which will be
asynchronous (available 24/7). Courses in development during FY 2009 include Emergency
Medical Treatment and Labor Act (EMTALA), Critical Access Hospital (CAH), Ambulatory
Surgical Center (ASC) and Psychiatric Residential Treatment Facilities (PRTF). These courses
may not debut until early FY 2010.
Page 2 – State Survey Agency Directors

These efforts will increase the reach of training in terms of numbers and types of participants and
the consistency of training across the surveyor and certification specialist populations.

This memorandum addresses specific areas of training necessary to prepare a complete budget
for FY2009.

Once again, I wish to express my deep appreciation for the work of the State Training
Coordinators who labor constantly to ensure that the nation’s surveyors have the knowledge and
skill sets essential to their effectiveness.

Concerning your help: Over the last several years we have asked for STC and other SA expert
assistance with a variety of tasks to include their direct involvement in training workgroups.
These groups help us build training tools that will improve access to training and help assure
consistent survey. We ask that you reserve funds sufficient to attend two Baltimore-based events
for this purpose. We will coordinate these requests through each SA Director.

Training is often a target for budget-cutting and retrenchment in times of scarce resources. We
reject that approach as unwise in the long run. Medicare and Medicaid beneficiaries deserve the
protection of fully informed and capable surveyors. Through the MPD, and this addendum, we
are therefore committed to supporting the training program of surveyors as a high priority. We
continue to expand the Centers for Medicare & Medicaid Services’ (CMS) training courses and
formats, and look forward to another year of dialogue with you regarding methods by which
training may be improved.

                                             Thomas E. Hamilton

cc: Regional Office Survey and Certification Management

Attachment – Training Supplement to 09 MPD

FY 2009 Survey and Certification Mission Letter

           Training Program

                 August 22, 2008

                       FY 2009 Survey and Certification Mission Letter
                                    Training Program

Key points of the Training Program for FY2009 include:

   The Surveyor Employment and Training (SET) report was again revised in FY2008 and has
    moved to annual projections of training needs, versus twice per year. SAs express new
    training topics and staff training needs via this document. Accurate needs assessment
    projections via this report are essential to making accurate budget projections and the sizing
    and positioning of classes as close as possible to student population centers.

   The Learning Management System (LMS) was moved to the Web in FY2006 allowing easier
    access and making new capabilities available to STCs and students. Extensive training was
    offered to assist with the transition. FY2009 will bring the One-Stop access to classes and
    additional expansion of Student Center to more classes. STCs should have already received
    information concerning this expansion and should know how to budget for its impact.

   Still more distance learning options are under development and may require SA staff to assist
    with content input. Expect periodic announcements during the Fiscal Year requesting SA
    staff help as instructors and as Subject Matter Experts (SMEs) to help us develop new
    training content. We ask that you reserve funds sufficient to attend two Baltimore-based
    events for this purpose.

   Quality Indicator Survey (QIS) for LTC surveyors and Surveyor Technical Assistant for
    Reporting (STAR) for ESRD surveyors. Tablet-Computer-based survey administrative tools
    will continue in various stages in FY2009. Training associated with QIS and STAR was
    more widely available in FY2008 and will be further expanded as needed to provide training
    on their use. Significant SA-led training commitments will be required. Those SAs
    implementing the QIS should contact the Central Office (CO) Training Coordinator when
    these persons who will be trained in QIS attend a Basic Long Term Care Course (BLTCC) as
    students. A special one-to-four QIS track is offered to QIS SAs that send students to the

   The Master QIS Trainer Program. CMS is developing a master trainer program to permit
    QIS States to train their own additional trainers. Each QIS State that already has CMS-
    Certified QIS trainers will be requested to identify one of their trainers to participate in a
    national master QIS trainer program that will be held in Baltimore in FY2009. Once the
    selected trainer has successfully completed the master QIS trainer program they will be
    permitted to train and certify additional QIS trainers. The master QIS trainer will be required
    to participate in an annual training program provided by CMS. The QIS States will need to
    budget for travel to Baltimore in FY2009 for one CMS-Certified QIS trainer in each QIS
    State to participate in the “Master QIS Trainer Program.” This Baltimore training will be
    added to the Training Schedule as soon as plans are finalized.

   Website-based Survey and Certification Letters and other forms of guidance will be available
    on the CMS Web site and should be used as the basis for updates to training content by STCs.

   All Basic trainings are mandatory for surveyors new or cross training to those disciplines of
    survey. Every effort will be made to offer Basic trainings at least twice per year to
    accommodate the acquisition of new surveyors and their training needs. However, there are
    still some courses that are only offered once per year and STCs should be prepared to get
    students there. Later we will provide additional options for Basic trainings to make these
    trainings more available regardless of the point in time in the Fiscal Year.

   The core training offerings, as well as satellites and other forms of Distance Learning and
    training are described here. Certain of these trainings are mandatory. STCs will be provided
    separate notice of whether it is mandatory that surveyors attend particular core training,
    satellites, video trainings and Web Based Training (WBT). Please check the Training
    Schedule for this information.

Magnet Area Training & Virtual Classroom: FY2009 activities will include the continued
piloting of several new experimental and distance learning efforts that integrate training by
provider type, and offer students access to training at times convenient to them. We refer to
these efforts as Magnet Area Training (MAT) and the Virtual Classroom (VC).

       We will offer two forms of the BLSC. The VC version will continue in FY2009. It has
        proved to be both cost effective and training-effective (students retain knowledge better).
        We will also continue to offer a non-VC BLSC, or traditional classroom version. Two
        VC BLSCs will be offered, together with one traditional BLSC classroom course. The
        pilot of the VC-based Rehab training was in beta testing in FY2008 and will pilot in FY

       MAT programs are designed to bring training closer to SAs in terms of both geography
        and the time of year that student surveyors complete SA pre-Basic training. MAT pilots
        will continue in FY2009. MAT training completed its pilot in Florida, for the Basic
        Home Health Agency (HHA) training, and in California, for the Basic Long Term Care
        Course (BLTCC). The MATs have been and will continue to be carefully monitored for
        consistency of CMS message and compared against student performance in traditional
        classroom versions of these trainings. Pre- and Post-testing are used to measure
        continuing accuracy of training and the level of knowledge retention by students. The
        LMS contains information concerning which training requires pre and post-training tests.
        We are considering an additional MAT pilot in FY2009. An announcement on this item
        should be made shortly.

MAT and VC are the result of the efforts of several workgroups, STCs, Regional Training
Administrators (RTAs) and many others to create training platforms that expedite fully
integrated curricula. We extend our thanks to the members of those workgroups for their
many contributions, and express our appreciation to the SA staff in Florida and California
who have worked so diligently to make the MAT concept a reality.

Readers are directed to the main body of the MPD to identify training needs proposed by
program and policy changes. These training needs are reflected at a high level in the program of
training proposed for FY2009 and further described below.

State Responsibilities for Training and the Role of the State Training Coordinator (STC).
States are responsible for assuring that their survey and certification staff members are trained in
all regulatory and program requirements, and that surveyors and State RAI Coordinators have the
necessary skills to perform their roles.

In addition, each State is responsible for identifying training needs and providing continuing
education for its staff and that all LMS functions are completed timely and accurately. It is
mandatory that each State identify an STC and a backup person who will be the overall leads for
survey and certification training. CMS will supply LMS training and help-desk support to assure
that LMS functions are completed timely and accurately.

The STC is responsible for:

      SET Reports: This activity requires collaboration among internal and external partners to
       determine training needs for individuals, groups, program areas, or across the SAs. SET
       Report data collections are mandatory and will occur once per year.

      Training: This activity includes developing and revising SA-directed training programs
       to meet SA needs identified through assessments; providing program information;
       validating and implementing training using formal training packages issued by CMS
       (such as the Preceptor Manual released in May 2006) or other materials developed
       locally; assuring quality of instructional delivery; recommending policies and procedures
       for inclusion in standardized curricula; ensuring provision and implementation of
       orientation programs; and serving as a resource for educational materials.

       STCs are accountable to assure that each student coming to a Basic training has
       completed the following mandatory prerequisite activities and trainings:

       1. Principles of Documentation (POD) Web Based Training (WBT).
       2. Basic Health Facility Surveyor WBT.
       3. Two to three surveys as observer, under supervision of a mentor or the STC. One of
          these may be a complaint survey and one or more must be a team survey in the
          designated survey discipline, e.g., a LTC Standard Survey.
       4. Approximately three to six months on the job as surveyors.
       5. The Preceptor Manual is not mandatory, but STCs are strongly urged to use it to
          assure consistent initial orientation of surveyors. See also Exhibit 42 of the SOM.

       It is vital that students arrive prepared to learn and able to keep up with their classmates.
       We recognize, however, that sometimes SAs obtain hiring authority at the last moment,
       for a person with key skills needed for survey within that SA. No matter the preparation,
       we expect that persons receiving training will regularly be using such training as a part of
       their jobs following training.

       Waiver of these prerequisites: STCs are required to apply to the CMS CO Director of
       Training for waivers concerning those students who have not completed preparation
       (prerequisites) or who will not be using these skills following training.

       1. STC contacts RTA by email to request waiver of one or more prerequisites listed above.
       2. STC submits information, documentation (e.g., vetting information) and other
          justification to the RTA.
       3. RTA submits the request for waiver by email to CMS CO Director, Training Staff.
       4. CMS CO Director of Training makes the decision and advises the STC and RTA by email.

       An additional note: The new training for QIS represents a substantial investment. Such
       trained surveyors also need to continue to conduct QIS surveys in order to retain the
       necessary knowledge and skills. We therefore request that those trained in the QIS
       method for LTC surveys should be used almost exclusively to complete QIS supported

Quality assurance and quality improvement: This activity includes assessing, evaluating and
reporting on the effectiveness of the State's training at both the level of the individual staff
member and on an aggregate basis.

      Facilitation/coordination: This activity includes serving as liaison with regional and CO
       training contacts; providing logistical support for traditional training methods (e.g.,
       classroom instruction, videos, etc.) plus distance learning and other technology-based
       training forums; participating in training budget development and allocation of training
       resources; and planning for and supporting the VC and MAT when these programs are
       released to your SA. In FY2009, the CO Training Staff will be developing training for
       STCs and RTAs who would like to use Virtual Classroom resources at their locations. If
       interested, please watch for further announcements during late FY2008 and 2009.

      Learning Management System (LMS) operation: This activity encompasses all aspects
       of the operation of the LMS. In addition to the above traditional duties, the STC will
       have an ongoing role in the operation of the mandatory LMS as outlined later in this
       document. It is mandatory that STCs assure entries to the LMS contain accurate data
       concerning student profile information and training completions. Examples of data entry
       include: new Tag information, changes in CMS policy expressed by satellites, videos,
       and special teleconferences, etc. STCs are expected to learn Student Center operations
       and apply LMS tools. Training in Student Center began in May 2007 and will continue
       into 2009. Record-keeping is facilitated by use of the LMS, but it is mandatory that the
       STC assure that such records are kept for as long as required. Records prior to 2002
       (when the LMS was launched) will usually be paper records. Regardless of the form,
       CMS uses a ten-year guideline on records retention for those records (paper or electronic)
       that might be important in a provider suit. Training records and transcripts fall into that

      Virtual Classroom (VC): This activity, when fully implemented, will require that each
       STC and backup, as well as SA instructors who will use the VC, attend training in the use
       of VC software and related, provider-specific VC-based training tools. This is
       mandatory training for pilot SAs and those others for whom the VC is implemented
       in your SA. Other than VC training for STCs and SA instructors, SAs should expect
       minimal, if any, impact on SA budgets.
       SAs who participate in VC training like that of the BLSC VC will be required to support
       the following:

              Protected time for students to complete their VC training and meet timelines
               expressed in the Training Plan and by instructors. From our test results and from
               the descriptions supplied by both students and Training Coordinators in pilot
               States, we have found a correlation between poor performance on the BLSC final
               examination and interruptions in student’s attention to the training. We need your
               help to be sure that students’ time is protected.
              Offer at least one Subject Matter Expert (SME) to function as a local VC facilitator
               in that subject area, and to work with CO-designated on-line instructors.
              Sufficient computer capability to permit students to access high-speed internet
               when interacting with VC and WBT designated for this medium. IT requirements
               are listed in the main MPD document.
              Assist with coordination of VC-software training for students, VC facilitators and
               mentors to permit them to be comfortable in using VC tools. CO will train the SA
               VC facilitators and expect them to facilitate student orientation to the VC
               software. Additional software training support will be provided as needed.
              Have an information technology person available to assist during pilots and, later,
               when problems arise. These persons must be knowledgeable of VC processes.
               [Although CO will provide help-desk functions, there may still be a need for one-
               on-one coaching for students and VC facilitators]. CO will provide VC training
               for the IT person and for the STC, as appropriate to the application of VC in their
              Assure that there is sufficient travel budget to support student travel to
               abbreviated classroom training that may be required as a part of a VC Training
               Plan. This will largely be within-State travel, but may also include elements that
               take students to the Regional Office (RO) for final presentations and Case Study
               critiques by experienced staffs. [Of course, the regular schedule of traditional
               classroom training will be continuing and will also require travel budget support
               for student surveyors and managers]. Currently there are no VC trainings that
               require travel, but we anticipate that this may be needed in the future to assure
               that students are fully prepared for their new duties.

Each State must ensure that its STC has CD-ROM (or CD/DVD), Internet, and E-mail capability
at their desktop. This will ensure that STCs and students have access to the LMS and VC to
determine the most current training programs, information, and schedules to guide student and
SME VC work. IT requirements have been gradually increased over the last several years.
Requirements for computers are provided in the main body of the 09 MPD (Admin Info: 08-37).

The CO Training Staff, in collaboration with both CO and RO program experts, will be
developing new, and enhancing current, training tools. For example, a new course for
Certification Specialists or Operations Specialists (title depends on SA preferences) began
development in 2005 and began roll out in August 2008.

States should plan to send their STCs to regional, consortium level, and national meetings and
conferences convened to participate in pilot programs such as the VC and MAT, and resolve
coordination issues and learn about their roles and responsibilities in the national training
program. Such meetings will also serve as a forum for sharing training packages and initiatives
developed at the local and Federal level. Please plan on participation in up to two workgroups
for the STC and one or more subject matter experts. Additional travel requirements will be
specified for future MAT and VC States. Teleconferences will be used where possible to reduce
travel expense. These important actions help to assure consistency across the country. When
offered, it is mandatory that the STC and backup attend the Training Coordinators’

Cross-training procedures: In the event that an STC is guiding an experienced surveyor
through a cross-training process, the STC will consult with the CMS RTA concerning special
procedures for attesting that individuals may bypass certain designated pre-requisite trainings as
designated by CO. The RTA will obtain CO approval for those advanced staff members. These
special procedures (called “vetting form”) have been in use since mid-FY 2005 and will continue
in future years.

The remaining sections of this letter address specific areas of attention for FY2009.

These include:
    Greater detail on LMS changes;
    Training procedures for new surveyors and experienced surveyors;
    Multi-media training;
    RAI/OASIS training;
    Satellites and videos;
    Web Based Training (WBT);
    Survey & Certification Letters and training requirements;
    Coordination of training efforts among RO, SA, and CO;
    Importance of collaboration on SET report data collections to make the training schedule
       as predictable as possible; and
    Completion of periodic electronic surveys that assist in obtaining focused data and
       information to enhance and clarify training offerings.

Learning Management System (LMS)
In FY2002, CO implemented a nationwide, university-style training administration data
management system designed to capture and manage student and course information. States
must provide the minimum hardware and software systems capabilities to support both the VC
and the current version of the LMS, including any necessary hardware maintenance.

Minimum IT requirements apply equally to either Laptop or Desktop hardware used by the STC
and backup, as well as for VC participants. Those SAs that are in the QIS and STAR pilots
should look to the LTC CO program lead and to the ESRD program lead to be sure that there are
no conflicts in hardware requirements. The specification list contained in the main MPD
document is consistent with QIS and STAR IT requirements. All should make reference to the
hardware and software requirements outlined there.

All such IT equipment should be assigned or readily available to the STC and backup. It will
require periodic accessing and data entry by the STC, but it does not constitute an entirely new
workload or labor intensive maintenance requirements for SA staff.

LMS took the place of some manual data collection and reporting processes. And, new Web-
enabled processes will continue and strengthen these advances in labor productivity for STCs.

The STC will be responsible for operating the LMS at the SA in support of national survey and
certification training programs. LMS-Fundamentals classes (Basic training for LMS users)
lasting 3 days will be offered three times in FY2009. It is mandatory that new State Training
Coordinators and back-ups hired after July 31, 2002 attend an LMS Fundamentals class
prior to being issued a user id that permits using the LMS.

Web-based LMS training is adjunctive and does not replace the LMS-Fundamentals class.

STCs who do not have access to the equipment and software specified in the 09 MPD, or who do
not attend LMS training, will not be able to enter and manage their student requirements using
the LMS. Access to mandatory CMS training will be more difficult and more labor intensive.

Training for New Surveyors:
All new surveyors must successfully complete the Orientation Program for Newly Employed
Health Facility Surveyor as outlined in Exhibit 42 of the State Operations Manual. The
Orientation Program and certain, selected, prerequisite distance learning trainings are mandatory
before attendance at a Basic Course (except for those qualified under the “vetting form”
procedures described earlier). States should also use the lesson plans included in the Preceptor
Manual to prepare their new surveyors, particularly new LTC surveyors. VC capability will
further enhance the package of training support for both new and advanced surveyors (available
to the STC when fully implemented).

It is mandatory that all new surveyors attend a Basic Course in their surveyor discipline (e.g., the
Basic LTC Course, Basic Hospital course, Basic ESRD, etc.), and should do so as close as
possible to six months after being hired. Documentation of the completion of required
Orientation Program and mandatory prerequisite distance learning materials are required for
acceptance into the BLTCC and other Basic Courses. STCs are accountable to check that
prerequisites are completed.

Any State with unusual or extraordinary needs for Basic training for their staff due to increased
hiring authority, changes in organizational structure within the State agency, etc. should alert
their ROs to the need as soon as it is identified.

The RO will work with CO to confirm and accommodate the need, or to authorize individual
exceptions to the processes described above.

Emergency Basic Training Procedure: When a Basic Course is not scheduled and a State
needs immediate relief to carry out its program responsibilities, a State may provide a modified
Basic Course for surveyors at the discretion of the RO. The modified Basic Course is available
for all courses, except Basic Long Term Care (LTC), Basic End Stage Renal Disease (ESRD),
Basic Home Health Agency (HHA), Hospital Organ Transplant Training, and Basic Intermediate
Care Facility for Mentally Retarded (ICF/MR), using training materials and other implementing
guidance provided by CO. However, any new surveyor trained in this manner must also attend
the next CO-sanctioned Basic Course when the next one becomes available.

Surveyors who have successfully completed the Orientation Program and the Basic Course
must also attend other specified training as required by CMS in this letter and in periodic
SCG Director’s Letters.

Attendance during the entire length of the course (as shown in the agenda located on the LMS) is
required in order for the student to receive credit and/or certificate of completion.

If an emergency or unusual circumstance arises that causes the student to miss a section of the
course, the student will be required to complete the incomplete section in order to receive credit
for attendance. However, it is sometimes not possible to make up incomplete work, in which
case a certificate of training cannot be issued. These special circumstances, at the discretion of
the on-site Training Coordinator, may require approval of the individual’s supervisor, STC, RTA
and the Director of the Training Staff at CO.

Training for Experienced Surveyors, Supervisors, and Certification Staff
During FY2009, CMS will provide training programs directed at experienced surveyors,
supervisors, and support staffs. In past years this has primarily taken the form of satellites,
videos, and special teleconferences.

As each program is announced, the target audience, participation, and completion requirements
will be identified. In some instances, the passing of a test located in the LMS will be required to
demonstrate mastery of the materials. A “C” code for “completion” will be entered into student
transcripts upon completion of the final examination.

Many programs or select program components will be available locally or regionally via satellite
broadcast, computer, web-based training, video, or VC. More and more CMS training will be
moving to distance learning methods. Some training programs may require classroom or face-to-
face training in addition to distance learning components.

For States that are joining the QIS training program: Training will start with a small team
receiving classroom and on the job training (OJT), followed by time to gain experience
performing QIS surveys. During the second offering of training, members of the first group will
watch and assist CO contractor staff with the training and help mentor the students on OJT.
Once a sufficient number of State instructors are ready, the training with be handed off to the
State. Other arrangements will be tailored for States with a very small number of surveyors.

No experienced surveyor, enforcement official, or their supervisors should attend a Basic
training that they previously completed within the past 6 years, unless (a) the governing
regulation has been completely revised and reissued by CMS in final form; or (b) approval has
been obtained from the CMS Director of Surveyor Training. To do so takes a seat away from
another person needing the Basic training. Every effort will be made to offer advanced topics
and policy/procedure updates for supervisors, managers, and senior surveyors to maintain their
skills. Once the VC has moved into full operation, special “advanced surveyor” training tools
will be mounted in this medium.

For training programs with mandatory completion requirements: STCs will be expected to
validate records identifying each person successfully trained, including the date that training was
completed by that person. This information will be input to the LMS by the STC. The STC is
accountable for the accuracy of transcript information.
CO will periodically issue and update lists of mandatory satellite, CD-ROM, video, or other
distance learning media together with viewing dates and/or other instructions on accessing such
information. Non-mandatory but strongly recommended distance learning media lists will be
updated and identified to STCs. STCs are expected to validate student attendance at distance
learning activities by keeping sign-in sheets, and authenticating transcripts in the LMS and in
reports to their RTA. Most of the updated CMS policies and procedures will be made available
to experienced staffs via distance learning methods.

Multimedia Training and Requirements--General
In FY2009, CMS will continue to use various multimedia vehicles to disseminate training,
including satellite broadcasts, CD-ROM, DVD, training packages and Internet web-based
courses. These technologies provide expedient communication and real-time training to SA
staff. SAs should check their technology to be certain that these resources are available to
students and STCs.

Training of State & RO RAI Coordinators—Specific
In FY2009, it is mandatory that State RAI coordinators participate in all CMS RAI Training
programs. A change in the RAI process related to the MDS Version 3.0 (MDS 3.0) will require
re-training of the RAI process including the MDS and the RAI User’s Manual.

Satellite Broadcasts/Webcasts
SAs that have neither a CMS downlink nor access to and control of their own satellite systems
should continue to make arrangements to send staff to universities, community colleges, and
other nearby downlink sites to receive CMS satellite broadcasts. In FY2009, CMS will continue
to record and send out CD or DVD copies of its satellite broadcasts after each broadcast or to
offer these trainings through an archived video available as WBT. States should plan to
participate in the live satellite broadcasts whenever possible so that their staff members can
participate in the interactive portions of the programs. CMS will no longer supply video tapes of

CMS will produce and broadcast up to 12 satellite and video programs in FY2009. Videos from
the satellites are retained for up to one year following transmission; longer if the material
continues to correctly express CMS policy. More than 90 satellites and videos are contained in
the Central Office library. These are available by internet streaming on a 24/7 basis.

If an SA does not have CD and DVD capabilities, they should plan to invest in these
technologies as the VC will require their availability for students.

CMS will continue to seek partnerships with other telecommunication and training entities in
order to combine resources and expand opportunities for survey and certification staff to
participate in a broad spectrum of training activities. As other training opportunities from non-
CMS sources are identified, information will be shared. It is expected that most of these
opportunities will be provided via satellite or video at minimal or no cost to participants at the
local level.

Again in FY2009, satellite broadcasts viewing will be mandatory for certain identified target
audiences, and the training must be completed and documented in the LMS within required
timeframes. Mandatory target audiences will be specified in the advance announcement.
All CMS satellite broadcasts will be offered live via satellite and on the Web via live or archived
Webcast. This means that viewers will be able to watch the program live via downlink or on the
Web on the date of the broadcast, or they can watch an archived version of the live broadcast on
the web one day after the date it was aired. The programs will be available for accessing via the
web 24 hours a day, 7 days a week, and they can be viewed on any computer equipped with
system requirements identified in the 09 MPD. Some of these training media will be available
on the VC as well.

As noted earlier, States must provide their staffs with access to computer equipment and
software that meets or exceeds these requirements.

In addition, States must ensure that their computer systems firewalls would not prevent
staff from viewing these programs or participating in VC training events.

States may also use video as a means for training the targeted audience.

Web-Based Training (WBT)
In FY2004, CMS implemented standalone web-based training modules to support Basic Health
Facility Surveyor training (i.e., Principles of Documentation, How to be an Effective Witness,
Legal Aspects of Surveying, etc.) and other program initiatives. These training programs will
not be tied to satellite broadcasts. For programs that support Basic training, it is mandatory that
each new surveyor be required to complete these pre-Basic training modules prior to attending a
Basic training course. In order to access WBT, States must provide staff with access to
computers that meet minimum system requirements. Gradually these pre-requisites and
additional, more specialized pre-requisites will be created and provided via an integrated, “single
portal” to the training resources provided by CO (probably available in late FY2008).

Training Equipment and Technology
States should continue to purchase, update, and maintain equipment as needed for their
training/learning centers and processes. The extent and nature of purchasing should be based on
a review of past equipment purchases funded by the survey and certification program, an
assessment of current use, and estimates of future use. We anticipate an accelerated expansion in
the use of technology for both training and survey in FYs 2008 – 2010. SAs should plan

Survey and Certification Policy Letters
In addition to formal training programs, States are expected to share program guidance,
instructions, and updates with every staff member with a need for the information. This includes
distribution of or access to Survey and Certification Policy Letters issued by CMS CO to State
Survey Agency Directors. These Policy Letters are available on the CMS Web site.

Each Policy Letter contains a section on Training, which identifies the audience for the
information, as well as the Effective Date.

It is mandatory that States carefully review the information included in these sections of the
Policy Letters and take appropriate action to ensure distribution and implementation of the
STCs should always receive copies of Policy Letters for use in developing in-service training
programs and revising existing training.

The Policy Letters are numbered and posted on the CMS Web site as they are issued. (SA
Directors may also want to have STCs make distributions of these Policy Letters to appropriate
external stakeholders and trade organizations.)

Coordination of Training Efforts
For FY2009, States may be asked to fund travel and per diem for instructors and State training
coordinators who will be involved in teaching CMS-sponsored courses, planning or revising
training, or participating in other activities for the national surveyor training program.

States should reserve funds sufficient to attend two Baltimore-based events for this purpose.

CMS CO will make the request for State assistance and use of this funding through the RO and
SA Director.

The SET Report & the Training Schedule

Once each year a schedule is drafted that guides the delivery of training. The Training Schedule
is predominantly based on SET report statistics to determine the number of seats and classes, as
well as their location. To maximize efficiency that schedule will be adhered to as strictly as
possible using the guidance below:

Please develop your schedule of training needs using the requirements of your current surveyor
and certification staffs – please do not include those persons whom you may hire over the next
FY. There will be periodic needs assessment surveys to obtain information that will permit up-
to-date projection of budget requirements. Needs are determined using the SET Report
described earlier.

Changes to the schedule will only be made due to (1) lack of enough students to make the
training cost efficient; (2) per direction of the Director, Survey and Certification Group to
respond to new regulations or guidance; (3) overflow of scheduled course or hotel capacity.

If you wish to provide a separate listing of training requirements for projected staffing gains
(new people), by specialty and course title, please provide that list in a separate letter or email to
your RTA, who will consolidate these requests and supply them to CO, Director of Training.

In the remaining pages of this document you will find a description of the FY2009, tentative
SCG Training Curriculum.


         8-BASIC LONG TERM CARE (distributed around the country)
         5-ESRD Basic (new survey protocol). We are scheduling up to five trainings.
         1-BASIC HOSPITAL (Baltimore)
         2-BASIC ICF/MR, active treatment (San Diego, Baltimore)
         2-BASIC HOME HEALTH (Orlando [MAT], San Diego WI) (3.5 days)
         2-BASIC HOSPICE (Baltimore)


 1 - END STAGE RENAL DISEASE (ESRD), Update (4 days) (San Diego)

  ESRD SA & RO SURVEYORS. (Denver, Baltimore). Participating States only. We are
  scheduling up to five trainings. There may be fewer.

 2 - FSES/HC (3 DAYS) (Albany, Philadelphia )

 1 – FSES/BC (3 DAYS) (Dallas)

 1 – NFPA 99 (3 DAYS) (Atlanta)


* NOTE: Basic trainings are mandatory for each discipline. With the exception of ESRD classes, all
students must have completed mandatory pre-requisites as outlined on page 5 of this MPD addendum.
Those attending Basic trainings must attend all sessions to receive their certificate of completion. The on-
site Training Coordinator, in consultation with the pertinent SA, RO, and CO will determine whether the
student has attended a sufficient amount of the classroom training, excepting severe mitigating
circumstances. Students may be sent home if they arrive late without the specific direction of their
supervisor and coordination with the RO. Again, consistent with current policy, STCs are required to
document in the LMS that prerequisites have been completed. Such documentation is required before a
student may be registered for Basic trainings.

 1 - STATE SURVEY AGENCY DIRECTORS, Annual Leadership Summit (3.5 DAYS)

 6 - ASPEN 101/102 TECHNICAL TRAINING – (2 DAYS) (Denver/Longmont, CO)

 2 – TRANSPLANT HOSPITAL – (3 DAYS) (Sacramento, Baltimore)

 1 – EMTALA (45 hours) (Virtual Classroom Pilot)

 1 – HOSPITAL UPDATE for SA and RO survey managers – (4 DAYS) (Baltimore)

 1 – 2009 OASIS Coordinator’s Conference – (4 days) (Baltimore)

 1 – RAI/MDS COORDINATORS’ CONFERENCE – (5 days) (Baltimore)


                          BASED ON DEMAND

                      (DATES TO BE ANNOUNCED)


Number of Seats: 200 for ESRD Basic Technical; 100 total seats ESRD Advanced Technical;
100 total seats for Basic HHA;150 Basic Hospital; 100 total seats for Basic ICF/MR; 700 total
seats for Basic LTC; 150 total seats for Basic LSC; 60 total seats for Basic LSC – VC; 200 total
seats for Basic Hospice.

Program Focus: Generally, Basic Health Facility Surveyor Training Courses are a five-day
didactic and interactive training experience designed to teach new State and Federal surveyors
how to correctly apply and interpret Federal regulations in a consistent and time efficient
manner. These courses are designed and especially addressed to student needs for core
surveying skills. Training content is based on outcomes from actual surveys.

Target Audience: All newly employed health facility surveyors who have completed the State
Orientation Program for Newly Employed Surveyors and whose primary job responsibility is to
survey health care facilities. Basic training in each survey discipline is mandatory for those who
will conduct surveys in each of these areas. Basic students should be sent for training after
completing approximately six months of SA orientation training, The Principles of
Documentation WBT, Basic Health Facility Surveyor WBT, and the Preceptor Manual.

    ESRD BASIC (new protocol) TRAINING (5 DAYS) (5 OFFERINGS): This course
     qualifies new and experienced surveyors to survey ESRD facilities

     Program Focus: This 5-day course provides basic information on the process and tasks of
     the new ESRD survey protocol. The course provides information about the primary
     technical areas of the survey: water treatment, infection control, reuse of dialyzers, and the
     dialysis process. All areas of the survey are covered in this course including use of data in
     the survey process, observations and interviews, clinical record review, and documentation
     of deficiencies. The course is conducted in 3 different venues and includes learning
     demonstrations of dialysis equipment. The course is limited to 40 participants

     Target Audience: ESRD Basic Technical Surveyor Training (new survey protocol): The
     ESRD Basic Technical Surveyor Training course qualifies new and experienced surveyors
     to survey ESRD facilities. The Basic Technical Surveyor Training (new survey protocol)
     course is a mandated course for all ESRD surveyors who want to become qualified to
     survey ESRD facilities. In FY2008, new ESRD regulations were published, and all ESRD
     surveyors need to attend this course describing the new ESRD survey protocol based upon
     the new ESRD regulations.


    Program Focus: The Basic Home Health Agency Surveyor Training Course is a three and
    ½ - day didactic and interactive training experience designed to teach new State and
    Federal surveyors how to correctly apply and interpret Federal regulations in a consistent
    and time efficient manner. The training focuses on provider Conditions of Participation,
    OASIS, and the survey process. This course is designed and especially addresses core
    skills. The training content is based on outcomes from actual surveys. A new survey
    protocol will be introduced in FY2009 and all HHA surveyors should plan to attend.

    Target Audience: Newly hired surveyors and existing surveyors who will be conducting
    Home Health Agency surveys


    Program Focus: The basic Hospice Surveyor Training Course is a three-day didactic and
    interactive training experience designed to teach new State and Federal surveyors how to
    correctly apply and interpret Federal regulations in a consistent and time efficient manner.
    The training focuses on new Hospice Conditions of Participation that will be effective
    December 2, 2008 and the survey process. This course is designed and especially addresses
    core skills. The training content is based on the new regulation and will include material
    that has been developed for inclusion in the SOM.

    Target Audience: Newly hired surveyors who will be conducting Hospice surveys.


    Program Focus: Provides basic information about the hospital CoPs, survey process, and
    interpretive guidelines. SPECIAL NOTE: Basic Hospital is now a prerequisite to entry to
    Critical Access Hospital (CAH) training and to Psychiatric Hospital Basic training.

    Target Audience: Brand new hospital surveyors or those who have not yet taken a Basic
    Hospital training course should attend. Surveyors who have attended a Basic Hospital may
    not take this course.


    Program Focus: Presenting the CMS interpretation for every W tag as well as teaching
    the eight tasks for the ICF/MR survey process. After all the tags are discussed, an
    interactive exercise is done on the fourth day which gives the audience members an
    abbreviated opportunity to apply and use the W tags.

    Target Audience: State ICF/MR surveyors


     Program Focus: This course provides nursing home surveyors with training on the survey
     process. The training content is based on the code of Federal regulations under 483 and the
     interpretive guidelines found in the State Operations Manual. CMS requires every
     surveyor to successfully complete this training as a part of the new surveyor orientation.
     This course is offered eight times per year to allow all surveyors the opportunity to attend
     but it may be offered more frequently in smaller class sizes if SET report projections show
     that this approach would be more efficient. (This course does not teach how to pass the
     SMQT; it provides skills in how to conduct survey).

     Target Audience: New surveyors from all States and Regions that will be conducting
     LTC surveys.


Please note that these courses are to be taken in sequence, starting with the self-paced training
presented via CD-ROM which is required before attending the Basic LSC class. This class was
revised in 2001 and designed for a small audience that will work on exercises in teams using the
information obtained via the self-paced training. Attendance is mandatory for persons who will
survey in these areas.


     Traditional Classroom version

     Program Focus: The purpose of this training is to provide new surveyors with a
     comprehensive understanding of the 2000 edition of the Life Safety Code. This training
     will teach new surveyors how to apply, interpret, and document the principles of the 2000
     Medicare/Medicaid healthcare facilities.

     Target Audience: New Life Safety Code State Surveyors


     Virtual Classroom version

     Program Focus: The purpose of this training is to provide new surveyors with a
     comprehensive understanding of the 2000 edition of the Life Safety Code. This training
     will teach new surveyors how to apply, interpret, and document the principles of the 2000
     Medicare/Medicaid healthcare facilities.

     Target Audience: New Life Safety Code State Surveyors


    Program Focus: The FSES\HC course is designed to instruct participants on how to
    effectively use the appropriate survey instrument to evaluate the level of safety from fire in
    new and existing health care facilities.

    Target Audience: It is mandatory that Surveyors complete the Basic Life Safety Code
    Training (LSC) as a pre-requisite before FSES/HC, and these surveyors should have
    responsibilities in connection with determining a facility's compliance with LSC

    (3 DAYS) (1 OFFERING)

    Program Focus: The FSES\BC training course is designed to train surveyors how to rate
    residents in small ICFs/MR and the buildings used as residences for mentally and
    physically disabled individuals.

    Target Audience: It is mandatory that Surveyors have previously completed the Basic
    LSC and FSES/HC training courses before attending FSES/BC. They must have
    responsibility for surveying small ICFs/MR in connection with LSC requirements.

    (2 DAYS) (1 OFFERING)

    Program Focus: The purpose of this training is to provide surveyors who have had the
    Basic Life Safety Code Course more thorough training on the NFPA 1999 Standard. The
    LSC references multiple standards. The NFPA 1999 includes requirements for essential
    electrical systems (including generators), medical gas storage and piping systems,
    laboratories, and fire protection requirements for hyperbaric facilities. The standard is
    highly complex and difficult to train survey procedures. The standard is critical to patient
    safety. It is not always covered in sufficient detail in the Basic Life Safety Code courses.

    Target Audience: SA LSC surveyors who will be dealing with medical facility gases and
    related systems (see above).


     Number of Participants/Seats: 80 seats providing training for RO DD Specialists and
     SA Surveyors using an experience/scenario based training methodology.

     Program Focus: This program is geared to assisting Regional Office DD Specialists and
     SA surveyors to identify program policies, guidelines and protocols required to
     consistently implement the ICF/MR regulations; to analyze current issues in the field that
     may be impacting the delivery of services to individuals living in ICF/MR. Topics are
     decided from the contract data and issues that arise while Regions, Central Office and
     States use the 1988 ICF/MR Regulations. Concepts and systems will be discussed rather
     than each individual tag/COP.

     Target Audience: This training is for experienced State Surveyors and the RO DD
     specialists. It offers the only opportunity for the Regional ICF/MR staff, CO ICF/MR
     staff, and State Survey staff to work together during an interactive training session.

(1 OFFERING, virtual classroom pilot )

     Program Focus: The purpose of this training will be to familiarize surveyors with both
     the history of the PRTF program and the procedures for surveying a PRTF. The training
     will include: the survey protocol and procedures, the interpretive guidance, principles of
     documentation, as well as report writing and documentation techniques.

     Target Audience: State Agency and Regional Office PRTF surveyors.


     Program Focus: This 4-day course provides surveyors with updated technological and
     clinical information related to nephrology. This course is held in conjunction with a large
     national nephrology meeting. Two key components of this meeting are surveyors’ access
     to sessions of the national meeting and the availability of the national meeting’s Exhibit
     Hall. Surveyors use the Exhibit Hall as a laboratory in which they can talk with
     exhibitors and collect information about new technologies and equipment; clinical
     advances in dialysis and transplantation, including data, standards, and studies;
     educational initiatives; and medications and their uses.

     Target Audience: All RO and State Agency ESRD surveyors who are ESRD survey
     specialists should attend this course at least every other year. However, with the many
     new technical releases in 2008 and anticipated for 2009, every effort should be made to
     attend this training.


     Program Focus: STAR (Surveyor Technical Assistant for Renal) is new software
     designed for use on a Tablet PC that guides a surveyor through the ESRD survey process.
     This 4-day course teaches the ESRD surveyor how to use the STAR software as a single
     surveyor or as a leader or member of a team; how to use tablet technology; and how to
     integrate STAR into ASPEN.

     Target Audience: This program is intended and is mandatory for all ESRD surveyors
     who are a part of the pilot program and who will be surveying ESRD facilities following
     training. ESRD surveyors will be unable to complete survey documentation without
     attending this training.


     Program Focus: In addition to providing a thorough understanding of the regulations
     and Interpretive Guidance for organ transplant programs, this course provides a
     comprehensive understanding of the clinical and psychosocial and interagency
     implications within the transplant arena. Training strategies will include presentations by
     transplant surgeons, transplant patients, transplant coordinators, transplant advocates and
     use of scenarios to reinforce understanding of regulatory instructions.

     Target Audience: Surveyors who have completed the Basic Hospital Training, are
     actively involved in the survey of general, acute hospitals, and will be assigned the
     responsibility for survey of organ transplant programs within their State or region.


     Program Focus: The training will focus primarily on new trends in hospital surveys, the
     hospital survey process, updated requirements, provider-based determinations, PPS-
     exclusions, certification & enforcement, and hospital accreditation.

     Target Audience: Experienced SA hospital survey managers (minimum 3-5 years
     hospital survey experience), RO staff who review hospital surveys and/or process
     hospital certifications, SA or RO attorneys.

EMTALA SURVEYOR TRAINING (1 OFFERING - pilot virtual classroom training-in-

     The EMTALA Surveyor Training course qualifies experienced hospital surveyors to
     conduct an investigation of an alleged violation of the Emergency Medical Treatment and
     Labor Act. The offer of training in 2009 will be the piloting and testing of the use of
     Virtual Classroom facilities for this training. It will be available as needed in FY2010.

     Program Focus: This virtual classroom course equips surveyors with the knowledge
     and skills required to assess compliance by hospitals having dedicated emergency
     departments with EMTALA requirements. Upon completion of the course participants
     will have the ability to investigate complaints alleging an EMTALA violation. They will
     be able to identify violations when conducting an EMTALA survey, based on an in-depth
     understanding of the EMTALA regulations as well as survey procedure. It is anticipated
     that the pilot version will require 45 hours to complete over a 7-week period and will
     include some monitoring for purposes of assessing the course design. The final version is
     anticipated to be available in FY 2010 and will be self-paced; student completion will be
     based upon successful mastery of the course content as measured by a post-test.

     Target Audience: The EMTALA Training Course is attended by experienced hospital
     surveyors who have not conducted EMTALA surveys. Surveyors with experience in
     conducting EMTALA surveys will also be allowed to attend, if space permits. All
     attendees are expected to have completed a hospital basic training course prior to
     attending the EMTALA course.


     Program Focus: This course provides instruction on use of the new LMS software
     which is mandatory for STCs and their backups before they can register students for
     CMS training classes. In FY2009 this training will cover specific new procedures for the
     upgraded software and Student Center. See earlier note for more detail on software

     Target Audience: State and Regional training coordinators and their backups.
     Attendance is mandatory for these persons.


     Program Focus: The conference will provide information on current
     initiatives/issues associated with the certification program.

     Target audience: State Survey Agency Director and one key subordinate, RO Staff
     (ARA and one key subordinate). Attendance is mandatory for these persons.

ASPEN 101/102 TECHNICAL TRAINING (6 OFFERINGS, 20 per class) (Longmont, CO)

     Program Focus: Basic technical training for SAs and ROs on using ASPEN-ACO,
     ASE, ARO, ACTS, AST and AEM

     Target Audience: RO and SA staff persons who need training on ASPEN products.


     Number of Seats: 200 (2 per State and 2 per RO, plus additional CO,
     Fiscal Intermediary and AO staff)

     Program Focus: OASIS data is a key component supporting quality measures, payment
     and the survey process. It is targeted to be the basis for Pay-for-Reporting and Pay-for-
     Performance. It is integral to the survey process for home health providers and accurate
     information is required to provide reliable results. This course focuses on data accuracy
     and how OASIS forms the basis for assuring quality of care. Turnover at the State and
     provider level puts accuracy at risk. A thorough understanding of CMS policy and
     regulatory information is needed. Mandatory training is required for State OASIS
     Education Coordinators; optional training is recommended for Regional Office staff
     responsible for OASIS. Course will be offered to CO staff, RHHI, national provider
     organizations and AO staff. Provides basic OASIS training and update for all OECs to
     include policy issues, OBQI/OBQM, and public reporting of Quality measures. Provides
     training on Conditions of Participation related to OASIS.

     Target Audience: OECs, State agency staffs, RO and CO staff, AOs, Fiscal
     Intermediary and other interested stakeholders. Attendance is mandatory for


     Number of Participants: 124

     Program Focus: This conference will provide State and Regional RAI/MDS
     Automation Coordinators with information needed to successfully manage provider and
     surveyor inquiries and issues related to the RAI process and the MDS 3.0, including
     augmentation of the training efforts of CO.

     Target Audience: This training is mandatory for SA and RO RAI coordinators. Others
     may be accommodated if space is available and the sponsoring organization will pay
     travel expenses for the individual.


     Number of Participants: 20

     Program Focus: This program is intended to develop the capacity for QIS States to train
     and certify additional trainers beyond those trained by the CMS contractor during initial
     implementation in the State. Training of master trainers will be limited to one per QIS
     State. The Master QIS Trainer will have the ability and authority to train QIS trainers in
     his or her own State and will be responsible for communicating updates regarding the
     QIS process and training protocols to their State’s CMS–Certified QIS Trainers.
     Limiting the number of trainers selected to be master trainers is intended to control the
     process by which an SA is permitted to train and certify additional QIS trainers. The
     purpose of limiting the number of master trainers to one person per State is intended to
     create greater consistency and quality of training.

     Target Audience: The person selected by the SA to participate in the CMS QIS Master
     Trainer Program must be a CMS-Certified Trainer meeting the requirements outlined in
     S&C- 08-14. The CMS-Certified QIS Trainer must, at a minimum, be actively involved
     as explained in S&C-08-14. (To be considered actively involved, the CMS-Certified QIS
     Trainer is expected to conduct a minimum of two SA QIS trainings of all components
     (classroom, mock, compliance assessments) per year or participate as a survey team
     member in at least one QIS survey per quarter. Nevertheless, assuring that the CMS-
     Certified QIS Trainer who is selected as the State’s QIS Master Trainer conducts as many
     QIS trainings as possible (ideally 6 full QIS trainings) helps assure greater consistency,
     competency, and success.


    Tentative topics for Satellites during FY2009 include:
    (up to12 new offerings – illustrations shown below) A full list of satellites and videos is
    available from Leslie Boyd in CO. This list indicates which of these training tools is still
    mandatory. STCs should check the list periodically to be sure that they are aware of new
    items or the reduction in priority (i.e., mandatory to non-mandatory).

       RAI Process/MDS 3.0 part I
       RAI Process/MDS 3.0 part II
       RAI Process/MDS 3.0 part III
       Investigative Techniques
       Listening: It's Not Just Hearing the Words
       Dealing with Turbulence in Organizations



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