CMS Manual System - Louisiana Department of Health and Hospitals

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The outcome for the resident, the decrease or elimination of the behavior, either validates the activity intervention or suggests the need for a new approach. ENDNOTES 1 Miller, M. E., Peckham, C. W., & Peckham, A. B. (1998). Activities keep me going and going (pp. 217-224). Lebanon, OH: Otterbein Homes. 2 Alzheimer‘s Association (n.d.). Activity based Alzheimer care: Building a therapeutic program. Training presentation made 1998. 3 Thomas, W.H. (2003). Evolution of Eden. In A. S. Weiner & J. L. Ronch (Eds.), Culture change in long-term care (pp. 146-157). New York: Haworth Press. 4 Bowman, C. S. (2005). Living Life to the Fullest: A match made in OBRA ‘87. Milwaukee, WI: Action Pact, Inc. 5 Glantz, C.G., & Richman, N. (2001). Leisure activities. In Occupational therapy: Practice skills for physical dysfunction. St Louis: Mosby. 6 Glantz, C.G., & Richman, N. (1996). Evaluation and intervention for leisure activities, ROTE: Role of Occupational Therapy for the Elderly (2 nd ed., p. 728). Bethesda, MD.: American Occupational Therapy Association. 7 Glantz, C.G., & Richman, N. (1998). Creative methods, materials and models for training trainers in alzheimer‘s education (pp. 156-159). Riverwoods, IL: Glantz/Richman Rehabilitation Associates. 8 Hellen, C. (1992). Alzheimer‘s disease: Activity-focused care (pp. 128-130). Boston, MA: Andover. 9 American Occupatinal Therapy Association. (2002). Occupational therapy practice framework: domain & process. American Journal of Occupational Therapy, 56(6), 616-617. Bethesda, MD: American Occupational Therapy Association. 10 Henderson, A., Cermak, S., Costner, W., Murray, E., Trombly, C., & Tickle-Gegnen, L. (1991). The issue is: Occupational science is multidimensional. American Journal of Occupational Therapy, 45, 370-372, Bethesda, MD: American Occupational Therapy Association. 11 Pedretti, L.W. (1996). Occupational performance: A model for practice in physical dysfunction. In L.W. Pedretti (Ed.), Occupational therapy: Practice skills for physical dysfunction (4 th ed., pp. 3-11). St. Louis: Mosby-Year Book
12 Christenson, M.A. (1996). Environmental design, modification, and adaptation, ROTE: Role of occupational therapy for the elderly (2 nd ed., pp. 380-408). Bethesda, MD: American Occupational Therapy Association. 13 Coppard, B.M., Higgins, T., & Harvey, K.D. (2004). Working with elders who have orthopedic conditions. In S. Byers-Connon, H.L. Lohman, and R.L. Padilla (Eds.), Occupational therapy with elders: Strategies for the COTA (2 nd ed., p. 293). St. Louis, MO: Elservier Mosby. 14 Glantz, C.G., & Richman, N. (1992). Activity programming for the resident with mental illness (pp. 53-76). Riverwoods, IL: Glantz/Richman Rehabilitation Associates. 15 Day, K., & Calkins, M.P. (2002). Design and dementia. In R. B. Bechtel & A. Churchman (Eds.), Handbook of environmental psychology (pp. 374-393). New York: Wiley. 16 Barrick, A.L., Rader, J., Hoeffer, B., & Sloane, P. (2002). Bathing without a battle: Personal care of individuals with dementia (p. 4). New York: Springer.
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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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___________________________________
Page 41 and 42: efore the resident may exercise tha
Page 43 and 44: §483.12(a) Transfer, and Discharge
Page 45 and 46: §483.10(o), Tag F177, addresses th
Page 47 and 48: Look for changes in source of payme
Page 49 and 50: How to notify the ombudsman (name,
Page 51 and 52: ___________________________________
Page 53 and 54: Interpretive Guidelines §483.12(d)
Page 55 and 56: Interpretive Guidelines §483.12(d)
Page 57 and 58: ―Convenience‖ is defined as any
Page 59 and 60: order reflecting the presence of a
Page 61 and 62: consistently implemented. Determine
Page 63 and 64: monitored separation from other Res
Page 65 and 66: to prevent occurrences, monitoring
Page 67 and 68: injurious behaviors, residents with
Page 69 and 70: A certified nurse aide found guilty
Page 71 and 72: o Day-to-day use of plastic cutlery
Page 73 and 74: for the resident‘s safety. For ex
Page 75 and 76: If a facility changes its policy to
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Page 79 and 80: Staff should strive to reasonably a
Page 81 and 82: egarding medical information. The f
Page 83 and 84: The report stated that, ―Resident
Page 85 and 86: If not contraindicated, modifying t
Page 87 and 88: o Visual interaction and to compens
Page 89 and 90: For residents from diverse ethnic o
Page 91: Encouraging volunteer-type work tha
Page 95 and 96: selected this activity. The Nationa
Page 97 and 98: Interview the social services staff
Page 99 and 100: Identifies how the facility will pr
Page 101 and 102: o Determine if the facility has acc
Page 103 and 104: (ii) Has 2 years of experience in a
Page 105 and 106: Once the team has completed its inv
Page 107 and 108: ___________________________________
Page 109 and 110: transportation services that are no
Page 111 and 112: F252 (Rev. 66, Issued: 10-01-10, Ef
Page 113 and 114: Although this Tag can be used for i
Page 115 and 116: ___________________________________
Page 117 and 118: ___________________________________
Page 119 and 120: Intent §483.20 To provide the faci
Page 121 and 122: (vii) Psychosocial well-being ―Ps
Page 123 and 124: ___________________________________
Page 125 and 126: Resident‘s decision making change
Page 127 and 128: ___________________________________
Page 129 and 130: (i) Admission assessment. (ii) Annu
Page 131 and 132: Completing an assessment that is no
Page 133 and 134: Interpretive Guidelines §483.20(h)
Page 135 and 136: Submitting correction(s) to informa
Page 137 and 138: If the resident has refused treatme
Page 139 and 140: . Do the dietitian and speech thera
Page 141 and 142: 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
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Utilize infection precautions to mi
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Properly implement transmission bas
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influenza in residents on another,
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§483.70(a)(6)(ii) The dispensers a
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Additional guidance is available in
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§483.70(d)(1)(i) Accommodate no mo
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Procedures: §483.70(d)(1)(iv) Ther
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Interpretive Guidelines: §483.70(d
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centralized nursing station, this c
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Are spaces adaptable for all intend
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defined as substandard quality of c
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(ii) Responsible for the management
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Probes: §483.75(e)(2 - 4) During a
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1919(e)(2)(A) of the Act the facili
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Interpretive Guidelines: §483.75(f
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The medical director helps the faci
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MEDICAL DIRECTION The facility is r
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The medical director is responsible
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REFERENCES 1 Pattee JJ, Otteson OJ.
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support with ventilators, intraveno
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The medical director provides input
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V. DEFICIENCY CATEGORIZATION (Part
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NOTE: If immediate jeopardy has bee
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Intent: §483.75(j)(1) The intent o
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Probes: §483.75(j)(1)(i) - (iv) Ar
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An inability to order radiological
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There is a written policy, at the h
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If there is a problem with confiden
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(i) Residents will be transferred f
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Preventing deviation from care proc
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Meetings of the QAA committee must
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INVESTIGATIVE PROTOCOL QUALITY ASSE
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The assigned surveyor should interv
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2. Degree of harm (actual or potent
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The facility‘s QAA committee meet
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R04SOM 11/12/2004 Guidance to Surve
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e. Special Care Fl19____ Receiving
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Form CMS-672 (10/10) ReSIDent CenSu
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Form CMS-672 (10/10) ReSIDent CenSu
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DEPARTMENT OF HEALTH AND HUMAN SERV
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22. Psychoactive Medications: If th
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16. Weight Change/Nutrition/Swallow
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RESIDENT REVIEW WORKSHEET (continue
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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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