CMS Manual System - Louisiana Department of Health and Hospitals

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Additional guidance is available in the National Fire Protection Association‘s Life Safety Code 99 and 101 (NFPA 99 and NFPA 101), 12-5.1.3 which is surveyed in Tags K105 and K106 of the Life Safety code survey. §483.70(b)(2) When life support systems are used, the facility must provide emergency electrical power with an emergency generator ( as defined in NFPA 99, Health Care Facilities) that is located on the premises Interpretive Guidelines: §483.70(b)(2) ―Life support systems‖ is defined as one or more Electro-mechanical device(s) necessary to sustain life, without which the resident will have a likelihood of dying (e.g., ventilators suction machines if necessary to maintain an open airway). The determination of whether a piece of equipment is life support is a medical determination dependent upon the condition of the individual residents of the facility e.g. suction machine maybe required ―life support equipment‖ in a facility, depending on the needs of its residents). Procedures: §483.70(b)(2) If life support systems are used determine if there is a working emergency generator at the facility, A generator is not required if a facility does not use life support systems. Check that the emergency generator starts and transfers power under load conditions within 10 seconds after interruption of normal power. Where residents are on life support equipment, do not test transfer switches by shutting off the power unless there is an uninterruptible power supply available. Probes: §483.70(b)(2) Is there a working generator if the facility is using life support systems? §483.70(c) Space and Equipment The facility must-- (1) Provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident’s plan of care; and Intent: §483.70 (c)(1) The intent of this regulation is to ensure that dining, health services, recreation, activities and programs areas are large enough to comfortably accommodate the needs of the residents who usually occupy this space.
Dining, health services, recreation, and program areas should be large enough to comfortably accommodate the persons who usually occupy that space, including the wheelchairs, walkers, and other ambulating aids used by the many residents who require more than standard movement spaces. ―Sufficient space‖ means the resident can access the area, it is not functionally off-limits, and the resident‘s functioning is not restricted once access to the space is gained. Program areas where resident groups engage in activities focused on manipulative skills and hand-eye coordination should have sufficient space for storage of their supplies and ―works in progress.‖ Program areas where residents receive physical therapy should have sufficient space and equipment to meet the needs of the resident‘s therapy requirement. Recreation/activities area means any area where residents can participate in those activities identified in their plan of care. Procedures: §483.70(c)(1) In the use of space, consider if available space allows residents to pursue activities and receive health services and programs as identified in their care plan. ______________________________________________________________________ F456 §483.70(c)(2) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Probes: §483.70(c)(2) Is essential equipment (e.g., boiler room equipment, nursing unit/medication room refrigerators, kitchen refrigerator/freezer and laundry equipment) in safe operating condition? Is equipment maintained according to manufacturers recommendations. ______________________________________________________________________ §483.70(d) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. ______________________________________________________________________ F457 §483.70(d)(1) Bedrooms must--
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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
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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
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 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
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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
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RESIDENT REVIEW WORKSHEET (continue
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CMS Manual System - Louisiana Department of Health and Hospitals

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