CMS Manual System - Louisiana Department of Health and Hospitals

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An inability to order radiological and diagnostic services in a timely manner, including delays in transporting the resident for these services? Delays in interpreting the results of x-rays and other tests? Lack of prompt notification, in writing, of test results to the attending physician, contributing to delays in changing care plans or the course of treatment? ______________________________________________________________________ F509 §483.75(k)(1)(i) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in §482.26 of this subchapter. §483.75(k)(1)(ii) If the facility does not provide it’s own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare. ______________________________________________________________________ F510 §483.75(k)(2) The Facility must--- (i) Provide or obtain radiology and other diagnostic services only when ordered by the attending physician; ______________________________________________________________________ F511 §483.75(k)(2)(ii) Promptly notify the attending physician of the findings; ______________________________________________________________________ F512 §483.75(k)(2)(iii) Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance; and ______________________________________________________________________ F513 §483.75(k)(2)(iv) File in the resident’s clinical record signed and dated reports of x-ray and other diagnostic services.
______________________________________________________________________ F514 §483.75(l) Clinical Records (1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are-- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized. Intent §483.75(l)(1) To assure that the facility maintains accurate, complete and organized clinical information about each resident that is readily accessible for resident care. Interpretive Guidelines §483.75(l)(1) A complete clinical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. Documentation should provide a picture of the resident‘s progress, including response to treatment, change in condition, and changes in treatment. The facility determines how frequently documentation of an individual‘s progress takes place apart from the annual comprehensive assessment, periodic reassessments when a significant change in status occurs, and quarterly monitoring assessments. Good practice indicates that for functional and behavioral objectives, the clinical record should document change toward achieving care plan goals. Thus, while there is no ―right‖ frequency or format for ―reporting‖ progress, there is a unique reporting schedule to chart each resident‘s progress in maintaining or improving functional abilities and mental and psychosocial status. Be more concerned with whether the staff has sufficient progress information to work with the resident and less with how often that information is gathered. In cases in which facilities have created the option for an individual‘s record to be maintained by computer, rather than hard copy, electronic signatures are acceptable. In cases when such attestation is done on computer records, safeguards to prevent unauthorized access, and reconstruction of information must be in place. The following guideline is an example of how such a system may be set up:
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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
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This requirement has several aspect
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Determine whether the noncompliance
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§483.65 Infection Control The faci
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―Contact precautions‖ are measu
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Critical aspects of the infection p
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Conducting data analysis to help de
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observations of staff practices and
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Complications from invasive diagnos
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Airborne transmission can occur by
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After removing gloves or aprons; an
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Depending on the situation, options
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tears or holes be replaced. It is r
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ENDNOTES 68 Siegel, J.D., Rhinehart
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Guidelines for environmental infect
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INVESTIGATIVE PROTOCOL FOR INFECTIO
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Multiple use items (e.g., shower ch
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Interview the Designated Infection
Page 576 and 577: Utilize infection precautions to mi
Page 578 and 579: Properly implement transmission bas
Page 580 and 581: influenza in residents on another,
Page 582 and 583: §483.70(a)(6)(ii) The dispensers a
Page 584 and 585: Additional guidance is available in
Page 586 and 587: §483.70(d)(1)(i) Accommodate no mo
Page 588 and 589: Procedures: §483.70(d)(1)(iv) Ther
Page 590 and 591: Interpretive Guidelines: §483.70(d
Page 592 and 593: centralized nursing station, this c
Page 594 and 595: Are spaces adaptable for all intend
Page 596 and 597: defined as substandard quality of c
Page 598 and 599: (ii) Responsible for the management
Page 600 and 601: Probes: §483.75(e)(2 - 4) During a
Page 602 and 603: 1919(e)(2)(A) of the Act the facili
Page 604 and 605: Interpretive Guidelines: §483.75(f
Page 606 and 607: The medical director helps the faci
Page 608 and 609: MEDICAL DIRECTION The facility is r
Page 610 and 611: The medical director is responsible
Page 612 and 613: REFERENCES 1 Pattee JJ, Otteson OJ.
Page 614 and 615: support with ventilators, intraveno
Page 616 and 617: The medical director provides input
Page 618 and 619: V. DEFICIENCY CATEGORIZATION (Part
Page 620 and 621: NOTE: If immediate jeopardy has bee
Page 622 and 623: Intent: §483.75(j)(1) The intent o
Page 624 and 625: Probes: §483.75(j)(1)(i) - (iv) Ar
Page 628 and 629: There is a written policy, at the h
Page 630 and 631: If there is a problem with confiden
Page 632 and 633: (i) Residents will be transferred f
Page 634 and 635: Preventing deviation from care proc
Page 636 and 637: Meetings of the QAA committee must
Page 638 and 639: INVESTIGATIVE PROTOCOL QUALITY ASSE
Page 640 and 641: The assigned surveyor should interv
Page 642 and 643: 2. Degree of harm (actual or potent
Page 644 and 645: The facility‘s QAA committee meet
Page 646 and 647: R04SOM 11/12/2004 Guidance to Surve
Page 648 and 649: e. Special Care Fl19____ Receiving
Page 650 and 651: Form CMS-672 (10/10) ReSIDent CenSu
Page 652 and 653: Form CMS-672 (10/10) ReSIDent CenSu
Page 654 and 655: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 656 and 657: 22. Psychoactive Medications: If th
Page 658 and 659: 16. Weight Change/Nutrition/Swallow
Page 660 and 661: RESIDENT REVIEW WORKSHEET (continue
Page 662: RESIDENT REVIEW WORKSHEET (continue
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