CMS Manual System - Louisiana Department of Health and Hospitals

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Clothing, uniforms, laboratory coats, or isolation gowns used as PPE may become contaminated with potential pathogens after care of a resident colonized or infected with an infectious agent, (e.g., MRSA, VRE, and Clostridium difficile). Indirect contact may occur through toilets and bedpans. Examples of illnesses spread via a fecal-oral route include salmonella, shigella, and pathogenic strains of E. coli, norovirus, and symptomatic Clostridium difficile. Reducing and/or preventing infections through indirect contact requires the decontamination (i.e., cleaning, sanitizing, or disinfecting an object to render it safe for handling) of resident equipment, medical devices, and the environment. Alternatively, the facility may also consider using single-use disposable devices. The choice of decontamination method depends on the risk of infection to the resident coming into contact with equipment or medical devices. The CDC has adopted the Spaulding classification system that identifies three risk levels associated with medical and surgical instruments: critical, semi-critical and noncritical. 87 This includes: Critical items (e.g., needles, intravenous catheters, indwelling urinary catheters) are defined as those items which normally enter sterile tissue, or the vascular system, or through which blood flows. The equipment must be sterile when used, based on one of several accepted sterilization procedures; 87 Semi-critical items (e.g., thermometers, podiatry equipment, electric razors) are defined as those objects that touch mucous membranes or skin that is not intact. Such items require meticulous cleaning followed by high-level disinfection treatment using an FDA- approved chemo sterilizer agent, or they may be sterilized; and . Non-critical items (e.g., stethoscopes, blood pressure cuffs, over-bed tables) are defined as those that come into contact with intact skin or do not contact the resident. They require low level disinfection by cleaning periodically and after visible soiling, with an EPA disinfectant detergent or germicide that is approved for health care settings. Single-use disposable equipment is an alternative to sterilizing reusable medical instruments. Devices labeled by the manufacturer for single use are never to be reused, even if they are reprocessed. Prevention and Control of Transmission of Infection Infectious organisms (e.g., bacteria, viruses, or parasites) may be transmitted by direct contact (e.g., skin to skin) or indirect contact (e.g., via air, water, inanimate objects). Healthcare personnel and resident care equipment often move from resident to resident and therefore may serve as a vehicle for transferring infectious organisms. Another potential challenge is that the transmission of infectious organisms within the facility may be facilitated by inadequate hand hygiene facilities, rinsing bed pans in inappropriate places (e.g., resident‘s sink), or inappropriate placement of colonized or infected residents (e.g., sharing a bathroom with a non- infected resident).
Airborne transmission can occur by inhaling pathogenic droplet nuclei (e.g., M Tuberculosis). Contaminated environmental surfaces are also potential reservoirs for infections. Infections caused by bacteria and viruses are especially common. Clostridium difficile can live on inanimate surfaces for up to 5 months 88 while the hepatitis B virus can last up to a week 89 and the influenza virus can survive on fomites (e.g., any inanimate object or substance capable of carrying infectious organisms and transferring them from one individual to another) for up to 8 hours. 90 The appropriate disposal of waste helps minimize the potential transmission of infections. It is important for the facility to monitor safe handling of blood and body fluids and the disposal of contaminated waste. General Approaches to Prevention and Control A facility‘s infection control practices are important to preventing the transmission of infections. Infection control precautions used by the facility include two primary tiers: ―Standard Precautions‖ and ―Transmission-Based Precautions.‖ Standard Precautions Standard precautions are based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are intended to be applied to the care of all persons in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of standard precautions constitutes the primary strategy for preventing healthcare-associated transmission of infectious agents among residents and healthcare personnel. Appropriate infection control measures should be used in each resident interaction. Standard precautions include but are not limited to hand hygiene, safe injection practices, the proper use of PPE (e.g., gloves, gowns, and masks), resident placement, and care of the environment, textiles, and laundry. Also, equipment or items in the resident environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents, (e.g., wear gloves for handling soiled equipment, and properly clean and disinfect or sterilize reusable equipment before use on another resident). 91 In addition to proper hand hygiene, it is important for staff to use appropriate protective equipment as a barrier to exposure to any body fluids (whether known to be infected or not). For example, in situations identified as appropriate, gloves and other equipment such as gowns and masks are to be used as necessary to control the spread of infections. Standard precautions are also intended to protect residents by ensuring that healthcare personnel do not carry infectious agents to residents on their hands or via equipment used during resident care. Disposal of waste is also handled as though all body fluids are infectious. Potentially contaminated articles are stored and disposed of in appropriate containers (e.g., sharps containers, biohazard bags, etc.), and the environment is cleaned using germicidal agents to reduce the risk of transmission of infection. Hand Hygiene
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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
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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
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
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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: Complications from invasive diagnos
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
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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
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RESIDENT REVIEW WORKSHEET (continue
Page 662:
RESIDENT REVIEW WORKSHEET (continue
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