CMS Manual System - Louisiana Department of Health and Hospitals

More documents

Recommendations

Info

An eligible resident received two doses of the pneumococcal vaccine, due to a failure to document the receipt of the first dose, but did not experience any untoward reactions; or The staff did not assess for medical contraindications prior to providing the vaccines, but there were no reactions to the vaccine. Severity Level 1: No Actual Harm with Potential for Minimal Harm The facility failed to document that information/education was provided to the resident prior to administering the immunizations. ________________________________________________________________________ F353 §483.30 Nursing Services The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Intent §483.30 To assure that sufficient qualified nursing staff are available on a daily basis to meet residents‘ needs for nursing care in a manner and in an environment which promotes each resident‘s physical, mental and psychosocial well-being, thus enhancing their quality of life. Procedures §483.30 §483.30(a) and (b) are to be reviewed during the standard survey whenever quality of care problems have been discovered (see Appendix P, Survey Protocol, Task 4, for further information and Task 5C for the investigative protocol to complete this review). In addition, fully review requirements of nursing services during an extended survey or when a waiver of RN and/or licensed nurse (RN/LPN) staffing has been requested or granted. Except as licensed nursing personnel are specifically required by the regulation (e.g., an RN for 8 consecutive hours a day, 7 days a week), the determination of sufficient staff will be made based on the staff‘s ability to provide needed care to residents that enable them to reach their highest practicable physical, mental and psychosocial well-being. The ability to meet the requirements of §§483.13, 483.15(a), 483.20, 483.25 and 483.65 determines sufficiency of nurse staffing. §483.30(a) Sufficient Staff §483.30(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (c) of this section, licensed nurses; and
(ii) other nursing personnel. §483.30(a)(2) Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. For Interpretive Guidelines and Probes on §483.30(a) see Tag F354 ____________________________________________________________________ F354 §483.30(b) Registered Nurse §483.30(b)(1) Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.30(b)(2) Except when waived under paragraph (c) or (d) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.30(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Interpretive Guidelines §483.30(a) and (b) At a minimum, ―staff‖ is defined as licensed nurses (RNs and/or LPNs/LVNs), and nurse aides. Nurse aides must meet the training and competency requirements described in §483.75(e). ―Full-time‖ is defined as working 35 or more hours a week. Except for licensed staff noted above, the determining factor in sufficiency of staff (including both numbers of staff and their qualifications) will be the ability of the facility to provide needed care for residents. A deficiency concerning staffing should ordinarily provide examples of care deficits caused by insufficient quantity and quality of staff. If, however, inadequate staff (either the number or category) presents a clear threat to residents reaching their highest practicable level of well-being, cite this as a deficiency. Provide specific documentation of the threat. The facility is required to designate an RN to serve as DON on a full time basis. This requirement can be met when RNs share the position. If RNs share the DON position, the total hours per week must equal 40. Facility staff must understand the shared responsibilities. The facility can only be waived from this requirement if it has a waiver under subsection (c) or (d). Probes: §483.30(a) and (b) Determine nurse staffing sufficiency for each unit: Is there adequate staff to meet direct care needs, assessments, planning, evaluation, supervision?
Page 1 and 2:
CMS Manual System Pub. 100-07 State
Page 3 and 4:
State Operations Manual Appendix PP
Page 5 and 6:
§483.25(n) Influenza and Pneumococ
Page 7 and 8:
(including eligibility, coverage, c
Page 9 and 10:
___________________________________
Page 11 and 12:
Procedures §483.10(a)(3) and (4) D
Page 13 and 14:
―Advance directive‖ means a wri
Page 15 and 16:
§483.10(b)(5) -- The facility must
Page 17 and 18:
Provide written information concern
Page 19 and 20:
___________________________________
Page 21 and 22:
§483.10(c)(3) Deposit of Funds (i)
Page 23 and 24:
Were limits placed on amounts that
Page 25 and 26:
___________________________________
Page 27 and 28:
(B) Dietary services as required at
Page 29 and 30:
medical service that is recognized
Page 31 and 32:
satisfactorily resolved by discussi
Page 33 and 34:
(i) Transfer to another health care
Page 35 and 36:
Interpretive Guidelines §483.10(g)
Page 37 and 38:
(ii) Any representative of the Stat
Page 39 and 40:
___________________________________
Page 41 and 42:
efore the resident may exercise tha
Page 43 and 44:
§483.12(a) Transfer, and Discharge
Page 45 and 46:
§483.10(o), Tag F177, addresses th
Page 47 and 48:
Look for changes in source of payme
Page 49 and 50:
How to notify the ombudsman (name,
Page 51 and 52:
___________________________________
Page 53 and 54:
Interpretive Guidelines §483.12(d)
Page 55 and 56:
Interpretive Guidelines §483.12(d)
Page 57 and 58:
―Convenience‖ is defined as any
Page 59 and 60:
order reflecting the presence of a
Page 61 and 62:
consistently implemented. Determine
Page 63 and 64:
monitored separation from other Res
Page 65 and 66:
to prevent occurrences, monitoring
Page 67 and 68:
injurious behaviors, residents with
Page 69 and 70:
A certified nurse aide found guilty
Page 71 and 72:
o Day-to-day use of plastic cutlery
Page 73 and 74:
for the resident‘s safety. For ex
Page 75 and 76:
If a facility changes its policy to
Page 77 and 78:
___________________________________
Page 79 and 80:
Staff should strive to reasonably a
Page 81 and 82:
egarding medical information. The f
Page 83 and 84:
The report stated that, ―Resident
Page 85 and 86:
If not contraindicated, modifying t
Page 87 and 88:
o Visual interaction and to compens
Page 89 and 90:
For residents from diverse ethnic o
Page 91 and 92:
Encouraging volunteer-type work tha
Page 93 and 94:
12 Christenson, M.A. (1996). Enviro
Page 95 and 96:
selected this activity. The Nationa
Page 97 and 98:
Interview the social services staff
Page 99 and 100:
Identifies how the facility will pr
Page 101 and 102:
o Determine if the facility has acc
Page 103 and 104:
(ii) Has 2 years of experience in a
Page 105 and 106:
Once the team has completed its inv
Page 107 and 108:
___________________________________
Page 109 and 110:
transportation services that are no
Page 111 and 112:
F252 (Rev. 66, Issued: 10-01-10, Ef
Page 113 and 114:
Although this Tag can be used for i
Page 115 and 116:
___________________________________
Page 117 and 118:
___________________________________
Page 119 and 120:
Intent §483.20 To provide the faci
Page 121 and 122:
(vii) Psychosocial well-being ―Ps
Page 123 and 124:
___________________________________
Page 125 and 126:
Resident‘s decision making change
Page 127 and 128:
___________________________________
Page 129 and 130:
(i) Admission assessment. (ii) Annu
Page 131 and 132:
Completing an assessment that is no
Page 133 and 134:
Interpretive Guidelines §483.20(h)
Page 135 and 136:
Submitting correction(s) to informa
Page 137 and 138:
If the resident has refused treatme
Page 139 and 140:
. Do the dietitian and speech thera
Page 141 and 142:
Are physicians‘ orders carried ou
Page 143 and 144:
What types of pre-discharge prepara
Page 145 and 146:
If the resident‘s PAS report indi
Page 147 and 148:
Briefly review the assessment, care
Page 149 and 150:
and knowledge of the resident, shou
Page 151 and 152:
Determine whether the facility had
Page 153 and 154:
NOTE: Guidance regarding pressure u
Page 155 and 156:
The resident has the right to refus
Page 157 and 158:
others being hypersensitivity, idio
Page 159 and 160:
Examples of clinical resources avai
Page 161 and 162:
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 and 214:
generally impairs wound healing, se
Page 215 and 216:
15 Fuhrer M., Garber S., Rintola D.
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
Page 265 and 266:
Identify if resident triggers CAAs
Page 267 and 268:
Probes: §483.25(f)(1) For sampled
Page 269 and 270:
___________________________________
Page 271 and 272:
Using universal precautions and cle
Page 273 and 274:
Monitor the effectiveness of the
Page 275 and 276:
Directs resources to address safety
Page 277 and 278:
Monitoring is the process of evalua
Page 279 and 280:
those (e.g., disease, environment)
Page 281 and 282:
Addressing the factors for the fall
Page 283 and 284:
155°F 148°F 140°F 133°F 127°F
Page 285 and 286:
NOTE: The Safe Medical Devices Act
Page 287 and 288:
ENDNOTES 1 Centers for Medicare & M
Page 289 and 290:
Use To evaluate whether the facilit
Page 291 and 292:
2. Interview The adequacy of the su
Page 293 and 294:
Changes in condition such as the ab
Page 295 and 296:
Noncompliance for F323 After comple
Page 297 and 298:
Once the survey team has completed
Page 299 and 300:
Unsafe wandering and/or elopement t
Page 301 and 302:
Severity Level 1 Considerations: No
Page 303 and 304:
―Qualified dietitian‖ refers to
Page 305 and 306:
Current standards of practice recom
Page 307 and 308:
dry mouth, and diseases of the orop
Page 309 and 310:
Based on analysis of relevant infor
Page 311 and 312:
For many residents (including overw
Page 313 and 314:
In deciding whether and how to inte
Page 315 and 316:
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 and 368:
Antibiotics Medication Issues and C
Page 369 and 370:
Medication Issues and Concerns prim
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
Page 419 and 420: Medication Errors Due to Failure to
Page 421 and 422: Medications Administered with Enter
Page 423 and 424: if the facility uses the ―recap
Page 425 and 426: technique requires a comparison of
Page 427 and 428: eaction to the vaccine than would h
Page 429 and 430: o Persons who are 50 years of age o
Page 431 and 432: Sampling: To determine if education
Page 433 and 434: Processes to address issues that ar
Page 435 and 436: The facility failed to document tha
Page 437: Requires immediate correction as th
Page 441 and 442: (3) The State finds that, for any p
Page 443 and 444: (A) Has only patients whose physici
Page 445 and 446: For SNFs and SNF/NFs which may be w
Page 447 and 448: Assessing special nutritional needs
Page 449 and 450: Probes: §483.35(c)(1) Are resident
Page 451 and 452: ___________________________________
Page 453 and 454: Interpretive Guidelines: §483.35(f
Page 455 and 456: ―Food Preparation‖ refers to th
Page 457 and 458: for growth of harmful pathogens. Ba
Page 459 and 460: Source of Primary Agents of Primary
Page 461 and 462: Food Receiving and Storage When foo
Page 463 and 464: specified below will either kill da
Page 465 and 466: may consist of a combination of foo
Page 467 and 468: at the manifold, which is the area
Page 469 and 470: INVESTIGATIVE PROTOCOL SANITARY CON
Page 471 and 472: 2. Interview Observe that foods are
Page 473 and 474: cooling, and ensure that PHF/TCS fo
Page 475 and 476: 2. Degree of harm (actual or potent
Page 477 and 478: Severity Level 1 Considerations: No
Page 479 and 480: Intent: §483.35(h) The intent of t
Page 481 and 482: Whether they are assisting assigned
Page 483 and 484: and drink. If concerns are identifi
Page 485 and 486: Compliance with 42 CFR 483.35(h), F
Page 487 and 488: eligibility to eat and drink with a
Page 489 and 490:
Examples of the facility‘s non-co
Page 491 and 492:
delegating and supervising follow-u
Page 493 and 494:
Probes: §483.40(b) Do services ord
Page 495 and 496:
For what reasons are residents sent
Page 497 and 498:
(2) Obtain the required services fr
Page 499 and 500:
Probes: §483.45(a)(1)(2) 1. For ph
Page 501 and 502:
a care plan must be developed, foll
Page 503 and 504:
Are residents missing teeth and may
Page 505 and 506:
Definitions are provided to clarify
Page 507 and 508:
The National Coordinating Council f
Page 509 and 510:
Establish procedures that address m
Page 511 and 512:
How the receipt of medications from
Page 513 and 514:
Documentation of actual disposition
Page 515 and 516:
the pharmaceutical services. Fourth
Page 517 and 518:
The facility‘s failure to involve
Page 519 and 520:
The facility in collaboration with
Page 521 and 522:
(2) The pharmacist must report any
Page 523 and 524:
errors, or other irregularities, an
Page 525 and 526:
NOTE: The surveyor‘s review of me
Page 527 and 528:
o Seizure activity; o Spontaneous o
Page 529 and 530:
Common Medication-Medication Intera
Page 531 and 532:
The identification of any irregular
Page 533 and 534:
aspects of pharmaceutical services.
Page 535 and 536:
The pharmacist‘s MRR failed to id
Page 537 and 538:
(3) Determines that drug records ar
Page 539 and 540:
During a medication pass, medicatio
Page 541 and 542:
This requirement has several aspect
Page 543 and 544:
Determine whether the noncompliance
Page 545 and 546:
§483.65 Infection Control The faci
Page 547 and 548:
―Contact precautions‖ are measu
Page 549 and 550:
Critical aspects of the infection p
Page 551 and 552:
Conducting data analysis to help de
Page 553 and 554:
observations of staff practices and
Page 555 and 556:
Complications from invasive diagnos
Page 557 and 558:
Airborne transmission can occur by
Page 559 and 560:
After removing gloves or aprons; an
Page 561 and 562:
Depending on the situation, options
Page 563 and 564:
tears or holes be replaced. It is r
Page 565 and 566:
ENDNOTES 68 Siegel, J.D., Rhinehart
Page 567 and 568:
Guidelines for environmental infect
Page 570 and 571:
INVESTIGATIVE PROTOCOL FOR INFECTIO
Page 572 and 573:
Multiple use items (e.g., shower ch
Page 574 and 575:
Interview the Designated Infection
Page 576 and 577:
Utilize infection precautions to mi
Page 578 and 579:
Properly implement transmission bas
Page 580 and 581:
influenza in residents on another,
Page 582 and 583:
§483.70(a)(6)(ii) The dispensers a
Page 584 and 585:
Additional guidance is available in
Page 586 and 587:
§483.70(d)(1)(i) Accommodate no mo
Page 588 and 589:
Procedures: §483.70(d)(1)(iv) Ther
Page 590 and 591:
Interpretive Guidelines: §483.70(d
Page 592 and 593:
centralized nursing station, this c
Page 594 and 595:
Are spaces adaptable for all intend
Page 596 and 597:
defined as substandard quality of c
Page 598 and 599:
(ii) Responsible for the management
Page 600 and 601:
Probes: §483.75(e)(2 - 4) During a
Page 602 and 603:
1919(e)(2)(A) of the Act the facili
Page 604 and 605:
Interpretive Guidelines: §483.75(f
Page 606 and 607:
The medical director helps the faci
Page 608 and 609:
MEDICAL DIRECTION The facility is r
Page 610 and 611:
The medical director is responsible
Page 612 and 613:
REFERENCES 1 Pattee JJ, Otteson OJ.
Page 614 and 615:
support with ventilators, intraveno
Page 616 and 617:
The medical director provides input
Page 618 and 619:
V. DEFICIENCY CATEGORIZATION (Part
Page 620 and 621:
NOTE: If immediate jeopardy has bee
Page 622 and 623:
Intent: §483.75(j)(1) The intent o
Page 624 and 625:
Probes: §483.75(j)(1)(i) - (iv) Ar
Page 626 and 627:
An inability to order radiological
Page 628 and 629:
There is a written policy, at the h
Page 630 and 631:
If there is a problem with confiden
Page 632 and 633:
(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
Page 638 and 639:
INVESTIGATIVE PROTOCOL QUALITY ASSE
Page 640 and 641:
The assigned surveyor should interv
Page 642 and 643:
2. Degree of harm (actual or potent
Page 644 and 645:
The facility‘s QAA committee meet
Page 646 and 647:
R04SOM 11/12/2004 Guidance to Surve
Page 648 and 649:
e. Special Care Fl19____ Receiving
Page 650 and 651:
Form CMS-672 (10/10) ReSIDent CenSu
Page 652 and 653:
Form CMS-672 (10/10) ReSIDent CenSu
Page 654 and 655:
DEPARTMENT OF HEALTH AND HUMAN SERV
Page 656 and 657:
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
show all

CMS Manual System - Louisiana Department of Health and Hospitals

Create successful ePaper yourself

Delete template?

Save as template?