CMS Manual System - Louisiana Department of Health and Hospitals

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Medication Issues and Concerns levofloxacin moxifloxacin ofloxacin Anticoagulants prolonged QTc intervals or who are receiving antiarrhythmic agents in class Ia (e.g., procainamide), class Ic (e.g., flecainide) or class III (e.g., amiodarone) Adverse Consequences warfarin Monitoring Anticonvulsants All anticonvulsants, e.g., carbamazepine gabapentin lamotrigine levetiracetam oxcarbazepine phenobarbital phenytoin May cause prolonged QTc interval May increase risk of hypo- or hyperglycemia in individuals age 65 or older, and in individuals with diabetes mellitus, renal insufficiency (CrCl < 60 ml/min), or those receiving other glucose-altering medications May increase risk of acute tendonitis Use must be monitored by Prothrombin Time (PT)/International Normalization Ratio (INR), with frequency determined by clinical circumstances, duration of use, and stability of monitoring results Adverse Consequences Multiple medication interactions exist (See 42 CFR 483.60(c) F428 for Table of Common Medication- Medication Interactions in Long Term Care), which may: o Significantly increase PT/INR results to levels associated with life-threatening bleeding, or o Decrease PT/INR results to ineffective levels, or o Increase or decrease the serum concentration of the interacting medication Indications In addition to seizures, may also be used to treat other disorders, such as bipolar disorder, schizoaffective disorder, chronic neuropathic pain, and for prophylaxis of migraine headaches Need for indefinite continuation should be based on confirmation of the condition (for example, distinguish epilepsy from isolated seizure due to
Medication Issues and Concerns primidone valproic acid medical cause or distinguish migraine from other causes of headaches) and its potential causes (medications, electrolyte imbalance, hypocalcemia, etc.) Duration If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Monitoring Serum medication concentration monitoring is not required or available for all anticonvulsants. Only the following anticonvulsants should be monitored with periodic serum concentrations: phenytoin, phenobarbital, primidone, divalproex sodium (as valproic acid), and carbamazepine Serum medication concentrations may help identify toxicity, but significant signs and symptoms of toxicity can occur even at normal or low serum concentrations. When anticonvulsants are used for conditions other than seizure disorders (e.g., as mood stabilizers), the same concerns exist regarding the need for monitoring for effectiveness and side effects; but evaluation of symptoms––not serum concentrations––should be used to adjust doses. High or toxic serum concentrations should, however, be evaluated and considered for dosage adjustments Symptom control for seizures or behavior can occur with subtherapeutic serum medication concentrations Adverse Consequences May cause liver dysfunction, blood dyscrasias, and serious skin rashes requiring discontinuation of treatment May cause nausea/vomiting, dizziness, ataxia, somnolence/lethargy, incoordination, blurred or double vision, restlessness, toxic encephalopathy, anorexia, headaches. These effects can increase the risk for falls
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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
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• Impact of pain on quality of li
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National Center for Complementary a
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3 National Center for Complementary
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The objective of this protocol is t
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How effective the interventions hav
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Nurse Interview. Interview a nurse
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Communicated with the health care p
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qualified persons with input from t
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of pain. First, the team must rule
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The resident experienced daily or l
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Extensive Assistance - While reside
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Procedures: §483.25(a)(1)(ii) Dete
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Identify if resident triggers CAAs
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USE OF SPEECH, LANGUAGE, OR OTHER F
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___________________________________
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Probes: §483.25(b) Identify if res
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―Debridement‖- Debridement is t
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OVERVIEW A pressure ulcer can occur
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procedures, during prolonged ambula
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Assessment of a resident‘s skin c
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Both urine and feces contain substa
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use of lifting devices for repositi
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in accord with resident‘s overall
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Whether pain, if present, is being
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Some clinicians utilize validated i
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generally impairs wound healing, se
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15 Fuhrer M., Garber S., Rintola D.
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of Localized Chronic Wound Infectio
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Previously unidentified open areas;
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complications including reassessmen
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If not, the development of the pres
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o Determine if the care plan was pe
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Examples of possible avoidable nega
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(Rev. 66, Issued: 10-01-10, Effecti
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later stages of dementia, diabetes,
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the resident‘s concerns and offer
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Functional and cognitive capabiliti
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toileting and response to specific
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cognitive deficit—provided that t
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the epidermis (comparable to a deep
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adequate. Based on the resident‘s
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Follow-Up of UTIs rectal temperatur
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9 Maki, D.G. & Tambyah, P.A. (2001)
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Whether the resident is on a schedu
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catheter/continence services. Reque
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Defines the catheter, tubing and ba
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If the attending physician is unava
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Assess, prevent (to the extent poss
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perform relevant activities of dail
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Requires immediate correction, as t
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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
Page 317 and 318: 11 Chouinard, J. (2000). Dysphagia
Page 319 and 320: Objectives Use INVESTIGATIVE PROTOC
Page 321 and 322: Nutrition interventions, such as sn
Page 323 and 324: Whether the facility identified res
Page 325 and 326: Review of Facility Practices Relate
Page 327 and 328: 42 CFR §483.20(b)(1), Tag F272, Co
Page 329 and 330: DEFICIENCY CATEGORIZATION (Part IV,
Page 331 and 332: If immediate jeopardy has been rule
Page 333 and 334: Intent §483.25(j) The intent of th
Page 335 and 336: Is proper administration technique
Page 337 and 338: §483.25(k)(5) Standard: Tracheal S
Page 339 and 340: (v) In the presence of adverse cons
Page 341 and 342: physical actions such as: pacing, c
Page 343 and 344: o Support decisions about modifying
Page 345 and 346: individual with dementia, to improv
Page 347 and 348: Medication management is based in t
Page 349 and 350: Whether the signs, symptoms, or rel
Page 351 and 352: o Pain; o Chronic psychiatric illne
Page 353 and 354: Common Conditions/ Symptoms Example
Page 355 and 356: Identifying the essential informati
Page 357 and 358: necessarily indicate a need for dos
Page 359 and 360: Sometimes, the decision about wheth
Page 361 and 362: The continued use is in accordance
Page 363 and 364: J., & Bates, D.W. (2005). Incidence
Page 365 and 366: (NSAIDs) Medication Issues and Conc
Page 367: Antibiotics Medication Issues and C
Page 371 and 372: Medication Issues and Concerns Mono
Page 373 and 374: chlorpropamide glyburide Antifungal
Page 375 and 376: Medication Issues and Concerns MAO
Page 377 and 378: Medication Issues and Concerns days
Page 379 and 380: Medication Issues and Concerns Medi
Page 381 and 382: uspirone Medication Issues and Conc
Page 383 and 384: Medication Issues and Concerns amio
Page 385 and 386: Medication Issues and Concerns Angi
Page 387 and 388: Nitrates, e.g., Medication Issues a
Page 389 and 390: Medication Issues and Concerns Anti
Page 391 and 392: Medication Issues and Concerns esom
Page 393 and 394: Medication Issues and Concerns laxa
Page 395 and 396: Medication Issues and Concerns Resp
Page 397 and 398: Medication Issues and Concerns hygi
Page 399 and 400: Medication Issues and Concerns All
Page 401 and 402: iperiden trihexyphenidyl olanzapine
Page 403 and 404: NOTE: This review is not intended t
Page 405 and 406: If during the review, you identify
Page 407 and 408: How he/she approaches the MRR proce
Page 409 and 410: o Failure to monitor a medication c
Page 411 and 412: 42 CFR 483.20(b), F272, Comprehensi
Page 413 and 414: Complications (such as diarrhea wit
Page 415 and 416: NOTE: If Severity Level 3 (actual h
Page 417 and 418: ―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
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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
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Preventing deviation from care proc
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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
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R04SOM 11/12/2004 Guidance to Surve
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e. Special Care Fl19____ Receiving
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Form CMS-672 (10/10) ReSIDent CenSu
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Form CMS-672 (10/10) ReSIDent CenSu
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DEPARTMENT OF HEALTH AND HUMAN SERV
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22. Psychoactive Medications: If th
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16. Weight Change/Nutrition/Swallow
Page 660 and 661:
RESIDENT REVIEW WORKSHEET (continue
Page 662:
RESIDENT REVIEW WORKSHEET (continue
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