CMS Manual System - Louisiana Department of Health and Hospitals

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2 Gardner, S.E. & Frantz, R.A. (2003). Wound Bioburden. In Baranoski, S. & Ayello, E.A. (Eds.), Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott, Williams, & Wilkins. 3 Ayello, E.A. & Cuddigan, J.E. (2004). Debridement: Controlling the Necrotic/Cellular Burden. Advances in Skin and Wound Care, 17(2), 66-75. 4 Bergstrom N., Bennett, M.A., Carlson, C.E., et al. (1994). Treatment of Pressure Ulcers in Adults (Publication 95-0652). Clinical Practice Guideline, 15, Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. 5 Thompson, P.D. & Smith, D.J. (1994). What is Infection? American Journal of Surgery, 167, 7-11. 6 Ayello, E.A., Baranoski, S., Kerstein, M.D., & Cuddigan, J. (2003). Wound Debridement. In Baranoski. S. & Ayello, E.A. (Eds.) Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins 7 Bergstrom, N., et al. (1994). Clinical Practice Guideline, 15. 8 Ayello & Cuddigan. (2004). Advances in Skin and Wound Care, 66-75. 9 Sherman, R.A. (1998). Maggot Debridement in Modern Medicine. Infections in Medicine, 15(9), 651-656. 10 Piper, B. (2000). Mechanical Forces: Pressure, Shear, and Friction. In Bryant, R.A. (Ed.) Acute and Chronic Wounds. Nursing Management (2 nd ed., pp. 221-264). St.Louis, MO: Mosby. 11 Kosiak, M. (1961). Etiology of Decubitus Ulcers. Archives of Physical Medicine and Rehabilitation, 42, 19-29. 12 Frequently Asked Questions: Pressure Ulcer Staging and Assessment, Question 202 (2000, July 28). Retrieved July 1, 2004 from http://www.npuap.org/archive/stagingdefinition.htm. 13 Lyder, C., Yu C., Emerling, J., Empleo-Frazier, O., Mangat, R., Stevenson, D. & McKay, J. (1999). Evaluating the Predictive Validity of the Braden Scale for Pressure Ulcer Risk in Blacks and Latino/Hispanic Elders. Applied Nursing Research, 12, 60-68. 14 Lyder, C. (2003). Pressure Ulcer Prevention and Management. Journal of the American Medical Association, 289, 223-226.
15 Fuhrer M., Garber S., Rintola D., Clearman R., Hart K. (1993). Pressure Ulcers in Community-resident persons with spinal cord injury: Prevalence and Risk Factors. Archives of Physical Medicine Rehabilitation, 74, 1172-1177. 16 Cuddigan, Ayello, Sussman, & Baranoski S. (Eds.). (2001). NPUAP Monograph, 153. 17 Ayello, E.A., Braden, B. (May-June 2002). How and Why to do Pressure Ulcer Risk Assessment. Advances in Skin and Wound Care, 15(3), 125-32. 18 Bergstrom, N. & Braden, B.A. (1992). A Prospective Study of Pressure Sore Risk Among Institutionalized Elderly. Journal of the American Geriatric Society, 40(8), 747-758. 19 Gosnell S.J. (1973). An Assessment Tool to Identify Pressure Sores. Nursing Research, 22(1), 55-59. 20 Bergstrom, N., Braden, B., Kemp, M., Champagne, M., Ruby, E. (1998). Predicting Pressure Ulcer Risk: A Multistate Study of the PredictiveValidity of the Braden Scale. Nursing Research, 47(5), 261-269. 21 Bergstrom N. & Braden, B.A. (1992). Journal of the American Geriatric Society, 747- 758. 22 Braden, B. (2001). Risk Assessment in Pressure Ulcer Prevention. In Krasner, D.L., Rodeheaver, G.T., Sibbeald, R.G. (Eds.) Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (3 rd ed., pp. 641-651). Wayne, PA: HMP Communications Pub. 23 Ayello, E.A., Baranoski, S., Lyder, C.H., Cuddigan, J. (2003). Pressure Ulcers. In Baranoski S. & Ayello, E.A. (Eds.) Wound Care Essentials: Practice Principles (pp. 245). Philadelphia, PA: Lippincott Williams & Wilkins. 24 Cuddigan, J., Ayello, E.A., Sussman, C., & Baranoski, S. (Eds.). (2001). NPUAP Monograph, 27 & 168. 25 Ferguson, R., O‘Connor, P., Crabtree, B., Batchelor A., Mitchell J., Coppola, D. (1993). Serum Albumin and Pre-albumin as Predictors of Hospitalized Elderly Nursing Home Patients. Journal of the American Geriatric Society, 41, 545-549. 26 Covinsky, K.E., Covinsky, K.H., Palmer, R.M., & Sehgal, A.R. (2002). Serum Albumin Concentration and Clinical Assessments of Nutritional Status in Hospitalized Older People: Different Sides of Different Coins? Journal of the American Geriatric Society, 50, 631-637. 27 Maklebust, J. & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention and
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CMS Manual System Pub. 100-07 State
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State Operations Manual Appendix PP
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§483.25(n) Influenza and Pneumococ
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(including eligibility, coverage, c
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___________________________________
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Procedures §483.10(a)(3) and (4) D
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―Advance directive‖ means a wri
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§483.10(b)(5) -- The facility must
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Provide written information concern
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___________________________________
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§483.10(c)(3) Deposit of Funds (i)
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Were limits placed on amounts that
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___________________________________
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(B) Dietary services as required at
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medical service that is recognized
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satisfactorily resolved by discussi
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(i) Transfer to another health care
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Interpretive Guidelines §483.10(g)
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(ii) Any representative of the Stat
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___________________________________
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efore the resident may exercise tha
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§483.12(a) Transfer, and Discharge
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§483.10(o), Tag F177, addresses th
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Look for changes in source of payme
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How to notify the ombudsman (name,
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___________________________________
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Interpretive Guidelines §483.12(d)
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Interpretive Guidelines §483.12(d)
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―Convenience‖ is defined as any
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order reflecting the presence of a
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consistently implemented. Determine
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monitored separation from other Res
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to prevent occurrences, monitoring
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injurious behaviors, residents with
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A certified nurse aide found guilty
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o Day-to-day use of plastic cutlery
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for the resident‘s safety. For ex
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If a facility changes its policy to
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___________________________________
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Staff should strive to reasonably a
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egarding medical information. The f
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The report stated that, ―Resident
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If not contraindicated, modifying t
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o Visual interaction and to compens
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For residents from diverse ethnic o
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Encouraging volunteer-type work tha
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12 Christenson, M.A. (1996). Enviro
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selected this activity. The Nationa
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Interview the social services staff
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Identifies how the facility will pr
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o Determine if the facility has acc
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(ii) Has 2 years of experience in a
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Once the team has completed its inv
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___________________________________
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transportation services that are no
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F252 (Rev. 66, Issued: 10-01-10, Ef
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Although this Tag can be used for i
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___________________________________
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___________________________________
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Intent §483.20 To provide the faci
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(vii) Psychosocial well-being ―Ps
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___________________________________
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Resident‘s decision making change
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___________________________________
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(i) Admission assessment. (ii) Annu
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Completing an assessment that is no
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Interpretive Guidelines §483.20(h)
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Submitting correction(s) to informa
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If the resident has refused treatme
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. Do the dietitian and speech thera
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Are physicians‘ orders carried ou
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What types of pre-discharge prepara
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If the resident‘s PAS report indi
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Briefly review the assessment, care
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and knowledge of the resident, shou
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Determine whether the facility had
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NOTE: Guidance regarding pressure u
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The resident has the right to refus
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others being hypersensitivity, idio
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Examples of clinical resources avai
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indicators which may represent pain
Page 163 and 164: • Impact of pain on quality of li
Page 165 and 166: National Center for Complementary a
Page 167 and 168: 3 National Center for Complementary
Page 169 and 170: The objective of this protocol is t
Page 171 and 172: How effective the interventions hav
Page 173 and 174: Nurse Interview. Interview a nurse
Page 175 and 176: Communicated with the health care p
Page 177 and 178: qualified persons with input from t
Page 179 and 180: of pain. First, the team must rule
Page 181 and 182: The resident experienced daily or l
Page 183 and 184: Extensive Assistance - While reside
Page 185 and 186: Procedures: §483.25(a)(1)(ii) Dete
Page 187 and 188: Identify if resident triggers CAAs
Page 189 and 190: USE OF SPEECH, LANGUAGE, OR OTHER F
Page 191 and 192: ___________________________________
Page 193 and 194: Probes: §483.25(b) Identify if res
Page 195 and 196: ―Debridement‖- Debridement is t
Page 197 and 198: OVERVIEW A pressure ulcer can occur
Page 199 and 200: procedures, during prolonged ambula
Page 201 and 202: Assessment of a resident‘s skin c
Page 203 and 204: Both urine and feces contain substa
Page 205 and 206: use of lifting devices for repositi
Page 207 and 208: in accord with resident‘s overall
Page 209 and 210: Whether pain, if present, is being
Page 211 and 212: Some clinicians utilize validated i
Page 213: generally impairs wound healing, se
Page 217 and 218: of Localized Chronic Wound Infectio
Page 219 and 220: Previously unidentified open areas;
Page 221 and 222: complications including reassessmen
Page 223 and 224: If not, the development of the pres
Page 225 and 226: o Determine if the care plan was pe
Page 227 and 228: Examples of possible avoidable nega
Page 229 and 230: (Rev. 66, Issued: 10-01-10, Effecti
Page 231 and 232: later stages of dementia, diabetes,
Page 233 and 234: the resident‘s concerns and offer
Page 235 and 236: Functional and cognitive capabiliti
Page 237 and 238: toileting and response to specific
Page 239 and 240: cognitive deficit—provided that t
Page 241 and 242: the epidermis (comparable to a deep
Page 243 and 244: adequate. Based on the resident‘s
Page 245 and 246: Follow-Up of UTIs rectal temperatur
Page 247 and 248: 9 Maki, D.G. & Tambyah, P.A. (2001)
Page 249 and 250: Whether the resident is on a schedu
Page 251 and 252: catheter/continence services. Reque
Page 253 and 254: Defines the catheter, tubing and ba
Page 255 and 256: If the attending physician is unava
Page 257 and 258: Assess, prevent (to the extent poss
Page 259 and 260: perform relevant activities of dail
Page 261 and 262: Requires immediate correction, as t
Page 263 and 264: The failures of the facility to pro
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Identify if resident triggers CAAs
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Probes: §483.25(f)(1) For sampled
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___________________________________
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Using universal precautions and cle
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Monitor the effectiveness of the
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Directs resources to address safety
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Monitoring is the process of evalua
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those (e.g., disease, environment)
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Addressing the factors for the fall
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155°F 148°F 140°F 133°F 127°F
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NOTE: The Safe Medical Devices Act
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ENDNOTES 1 Centers for Medicare & M
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Use To evaluate whether the facilit
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2. Interview The adequacy of the su
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Changes in condition such as the ab
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Noncompliance for F323 After comple
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Once the survey team has completed
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Unsafe wandering and/or elopement t
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Severity Level 1 Considerations: No
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―Qualified dietitian‖ refers to
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Current standards of practice recom
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dry mouth, and diseases of the orop
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Based on analysis of relevant infor
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For many residents (including overw
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In deciding whether and how to inte
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End-of-Life Resident choices and cl
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11 Chouinard, J. (2000). Dysphagia
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Objectives Use INVESTIGATIVE PROTOC
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Nutrition interventions, such as sn
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Whether the facility identified res
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Review of Facility Practices Relate
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42 CFR §483.20(b)(1), Tag F272, Co
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DEFICIENCY CATEGORIZATION (Part IV,
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If immediate jeopardy has been rule
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Intent §483.25(j) The intent of th
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Is proper administration technique
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§483.25(k)(5) Standard: Tracheal S
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(v) In the presence of adverse cons
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physical actions such as: pacing, c
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o Support decisions about modifying
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individual with dementia, to improv
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Medication management is based in t
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Whether the signs, symptoms, or rel
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o Pain; o Chronic psychiatric illne
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Common Conditions/ Symptoms Example
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Identifying the essential informati
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necessarily indicate a need for dos
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Sometimes, the decision about wheth
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The continued use is in accordance
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J., & Bates, D.W. (2005). Incidence
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(NSAIDs) Medication Issues and Conc
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Antibiotics Medication Issues and C
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Medication Issues and Concerns prim
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Medication Issues and Concerns Mono
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chlorpropamide glyburide Antifungal
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Medication Issues and Concerns MAO
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Medication Issues and Concerns days
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Medication Issues and Concerns Medi
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uspirone Medication Issues and Conc
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Medication Issues and Concerns amio
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Medication Issues and Concerns Angi
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Nitrates, e.g., Medication Issues a
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Medication Issues and Concerns Anti
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Medication Issues and Concerns esom
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Medication Issues and Concerns laxa
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Medication Issues and Concerns Resp
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Medication Issues and Concerns hygi
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Medication Issues and Concerns All
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iperiden trihexyphenidyl olanzapine
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NOTE: This review is not intended t
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If during the review, you identify
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How he/she approaches the MRR proce
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o Failure to monitor a medication c
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42 CFR 483.20(b), F272, Comprehensi
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Complications (such as diarrhea wit
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NOTE: If Severity Level 3 (actual h
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―Resident Condition‖ -- The res
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Medication Errors Due to Failure to
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Medications Administered with Enter
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if the facility uses the ―recap
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technique requires a comparison of
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eaction to the vaccine than would h
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o Persons who are 50 years of age o
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Sampling: To determine if education
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Processes to address issues that ar
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The facility failed to document tha
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Requires immediate correction as th
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(ii) other nursing personnel. §483
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(3) The State finds that, for any p
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(A) Has only patients whose physici
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For SNFs and SNF/NFs which may be w
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Assessing special nutritional needs
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Probes: §483.35(c)(1) Are resident
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___________________________________
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Interpretive Guidelines: §483.35(f
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―Food Preparation‖ refers to th
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for growth of harmful pathogens. Ba
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Source of Primary Agents of Primary
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Food Receiving and Storage When foo
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specified below will either kill da
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may consist of a combination of foo
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at the manifold, which is the area
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INVESTIGATIVE PROTOCOL SANITARY CON
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2. Interview Observe that foods are
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cooling, and ensure that PHF/TCS fo
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2. Degree of harm (actual or potent
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Severity Level 1 Considerations: No
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Intent: §483.35(h) The intent of t
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Whether they are assisting assigned
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and drink. If concerns are identifi
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Compliance with 42 CFR 483.35(h), F
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eligibility to eat and drink with a
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Examples of the facility‘s non-co
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delegating and supervising follow-u
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Probes: §483.40(b) Do services ord
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For what reasons are residents sent
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(2) Obtain the required services fr
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Probes: §483.45(a)(1)(2) 1. For ph
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a care plan must be developed, foll
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Are residents missing teeth and may
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Definitions are provided to clarify
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The National Coordinating Council f
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Establish procedures that address m
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How the receipt of medications from
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Documentation of actual disposition
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the pharmaceutical services. Fourth
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The facility‘s failure to involve
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The facility in collaboration with
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(2) The pharmacist must report any
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errors, or other irregularities, an
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NOTE: The surveyor‘s review of me
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o Seizure activity; o Spontaneous o
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Common Medication-Medication Intera
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The identification of any irregular
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aspects of pharmaceutical services.
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The pharmacist‘s MRR failed to id
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(3) Determines that drug records ar
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During a medication pass, medicatio
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This requirement has several aspect
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Determine whether the noncompliance
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§483.65 Infection Control The faci
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―Contact precautions‖ are measu
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Critical aspects of the infection p
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Conducting data analysis to help de
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observations of staff practices and
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Complications from invasive diagnos
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Airborne transmission can occur by
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After removing gloves or aprons; an
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Depending on the situation, options
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tears or holes be replaced. It is r
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ENDNOTES 68 Siegel, J.D., Rhinehart
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Guidelines for environmental infect
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INVESTIGATIVE PROTOCOL FOR INFECTIO
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Multiple use items (e.g., shower ch
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Interview the Designated Infection
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Utilize infection precautions to mi
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Properly implement transmission bas
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influenza in residents on another,
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§483.70(a)(6)(ii) The dispensers a
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Additional guidance is available in
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§483.70(d)(1)(i) Accommodate no mo
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Procedures: §483.70(d)(1)(iv) Ther
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Interpretive Guidelines: §483.70(d
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centralized nursing station, this c
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Are spaces adaptable for all intend
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defined as substandard quality of c
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(ii) Responsible for the management
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Probes: §483.75(e)(2 - 4) During a
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1919(e)(2)(A) of the Act the facili
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Interpretive Guidelines: §483.75(f
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The medical director helps the faci
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MEDICAL DIRECTION The facility is r
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The medical director is responsible
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REFERENCES 1 Pattee JJ, Otteson OJ.
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support with ventilators, intraveno
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The medical director provides input
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V. DEFICIENCY CATEGORIZATION (Part
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NOTE: If immediate jeopardy has bee
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Intent: §483.75(j)(1) The intent o
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Probes: §483.75(j)(1)(i) - (iv) Ar
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An inability to order radiological
Page 628 and 629:
There is a written policy, at the h
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If there is a problem with confiden
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(i) Residents will be transferred f
Page 634 and 635:
Preventing deviation from care proc
Page 636 and 637:
Meetings of the QAA committee must
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INVESTIGATIVE PROTOCOL QUALITY ASSE
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The assigned surveyor should interv
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2. Degree of harm (actual or potent
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The facility‘s QAA committee meet
Page 646 and 647:
R04SOM 11/12/2004 Guidance to Surve
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e. Special Care Fl19____ Receiving
Page 650 and 651:
Form CMS-672 (10/10) ReSIDent CenSu
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Form CMS-672 (10/10) ReSIDent CenSu
Page 654 and 655:
DEPARTMENT OF HEALTH AND HUMAN SERV
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22. Psychoactive Medications: If th
Page 658 and 659:
16. Weight Change/Nutrition/Swallow
Page 660 and 661:
RESIDENT REVIEW WORKSHEET (continue
Page 662:
RESIDENT REVIEW WORKSHEET (continue
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