CMS Manual System - Louisiana Department of Health and Hospitals

42 CFR §483.20(k)(2)(iii), F280, Comprehensive Care Plan Revision
Determine whether staff reassessed the effectiveness of the interventions
and review and revised the plan of care (with input from the resident or
representative, to the extent possible), if necessary, to meet the needs of
the resident.
42 CFR §483.25(l), F329, Unnecessary Drugs
Determine if the facility has reviewed with the prescriber the rationale for
placing the resident on an antibiotic to which the organism seems to be
resistant or when the resident remains on antibiotic therapy without
adequate monitoring or appropriate indications, or for an excessive
duration.
42 CFR §483.25(l)(2)(n), F334, Influenza and Pneumococcal Immunizations
Determine if the facility has systems in place to immunize residents
against influenza and pneumococcal infections.
42 CFR §483.35(i)(2), F371, Sanitary Conditions
Determine if the facility has implemented processes to prevent infection
transmission via food handling, storing and delivery systems.
42 CFR 483.75(f) (F498) Proficiency of Nurse Aides
Determine whether the nurse aides demonstrate the knowledge and skills
regarding use of accepted infection control principles, e.g., hand hygiene,
transmission barriers, signs and symptoms of infection to report to the
nurse, etc.
V. DEFICIENCY CATEGORIZATION (PART IV, APPENDIX P)
Once the team has completed its investigation, analyzed the data, reviewed the
regulatory requirements, and determined that noncompliance exists, the team must
determine the severity of each deficiency, based on the resultant effect or potential
for harm to the resident.
The key elements for severity determination for Tag F441 are as follows:
1. Presence of harm/negative outcome(s) or potential for negative outcomes due
to a failure of care and services. Actual or potential harm/negative outcomes for
F441 may include but are not limited to facility failure to: