CMS Manual System - Louisiana Department of Health and Hospitals

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centralized nursing station, this communication may be through audible or visual signals and may include ―wireless systems.‖ In those cases in which a facility has moved to decentralized nurse/care team work areas, the intent may be met through other electronic systems that provide direct communication from the resident to the caregivers. Interpretive Guidelines: §483.70(f) This requirement is met only if all portions of the system are functioning (e.g., system is not turned off at the nurses‘ station, the volume too low to be heard, the light above a room or rooms is not working), and calls are being answered. For wireless systems, compliance is met only if staff who answer resident calls, have functioning devices in their possession, and are answering resident calls. Probes: §483.70(f) Is there a functioning communication system from rooms, toilets, and bathing facilities in which resident calls are received and answered by staff? ______________________________________________________________________ F464 §483.70(g) Dining and Resident Activities The facility must provide one or more rooms designated for resident dining and activities. These rooms must-- §483.70(g)(1) Be well lighted; Interpretive Guidelines: §483.70(g)(1) ―Well lighted‖ is defined as levels of illumination that are suitable to tasks performed by a resident. Probes: §483.70(g)(1) Are there adequate and comfortable lighting levels? Are illumination levels appropriate to tasks with little glare? Does lighting support maintenance of independent functioning and task performance?
§483.70(g)(2) Be well ventilated, with nonsmoking areas identified; Interpretive Guidelines: §483.70(g)(2) ―Well ventilated‖ is defined as good air circulation, avoidance of drafts at floor level, and adequate smoke exhaust removal. ―Nonsmoking areas identified‖ is defined as signs posted in accordance with State law regulating indoor smoking policy and facility policy. Probes: §483.70(g)(2) How well is the space ventilated? Is there good air movement? Are temperature, humidity, and odor levels all acceptable? Are non-smoking areas identified? §483.70(g)(3) Be adequately furnished; and Interpretive Guidelines: §483.70(g)(3) An ―adequately furnished‖ dining area accommodates different residents‘ physical and social needs. An adequately furnished organized activities area accommodates the specific activities offered by the facility. Probes: §483.70(g)(3) How adequate are furnishings? Are furnishings structurally sound and functional (e.g., chairs of varying sizes to meet varying needs of residents, wheelchairs can fit under the dining room table)? §483.70(g)(4) Have sufficient space to accommodate all activities. Interpretive Guidelines: §483.70(g)(4) ―Sufficient space to accommodate all activities‖ means that the space available is adaptable to a variety of uses and residents‘ needs. Probes: §483.70(g)(4) How sufficient is space in dining, health services, recreation and program areas to accommodate all activities?
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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
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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
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 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
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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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CMS Manual System - Louisiana Department of Health and Hospitals

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