Transcription
Skilled Nursing FacilityPolicy & ProcedureManualFEDERAL REGULATIONSNovember 2017
[FACILTIY NAME HERE]CLINICAL RISK PROGRAMS MANUALSThe Clinical Risk Programs Manuals were reviewed and approved by the Quality Assurance Committeeon .Nursing Home AdministratorDateDirector of NursingDateMedical DirectorDateAdditional Staff Member/TitleDateAdditional Staff Member/TitleDateAdditional Staff Member/TitleDate
RB HEALTHPARTNER'S POLICY INDEXI.PHASE 2 CROSSWALKS – COMPLIMENTS OF CMSII.DEFINITIONSa. F540 Definition of a Facility — SNF & NFIII.RESIDENT RIGHTSResident Rights General Policya. F550 Resident Rights/Exercise of Rightsb. F551 Rights Exercised by Representativec. F552 Right to be Informed/Make Treatment Decisionsd. F553 Right to Participate in Planning Caree. F554 Resident Self-Admin Meds-Clinically Appropriatef. Self-Administration of Medication Programg. F555 Right to Choose/Be Informed of Attending Physicianh. F557 Respect, Dignity/Right to have Personal Propertyi. F558 Reasonable Accommodations of Needs/Preferencesj. F559 Choose/Be Notified of Room/Roommate Changek. F560 Right to Refuse Certain Transfersl. F561 Self Determinationm. F562 Immediate Access to Residentn. F563 Visitationo. F564 Inform of Visitation Rights/Equal Visitation Privilegesp. F565 Resident/Family Group and Responseq. F566 Right to Perform Facility Services or Refuser. F567 Protection/Management of Personal Fundss. F568 Accounting and Records of Personal Fundst. F569 Notice and Conveyance of Personal Fundsu. F570 Surety Bond - Security of Personal Fundsv. F571 Limitations on Charges to Personal Fundsw. F572 Notice of Rights and Rulesx. F573 Right to Access/Purchase Copies of Recordsy. F574 Required Notices and Contact Informationz. F575 Required Postingsaa. F576 Right to Forms of Communication with Privacybb. F577 Right to Survey Results/Advocate Agency Infocc. F578 Request/Refuse/Discontinue Treatmentdd. Refusal of Experimental Researchee. Advance Directive Tracking Programff. Do Not Resuscitate Ordersgg. F579 Posting/Notice of Medicare/Medicaid on Admissionhh. F580 Notify of Changes (Injury/Decline/Room, Etc.)ii. Change in Condition Processjj. F582 Medicaid/Medicare Coverage/Liability Noticekk. F583 Personal Privacy/Confidentiality of Recordsll. F584 Safe/Clean/Comfortable/ Homelike Environmentmm. F585 Grievances
nn. Grievance Programoo. F586 Resident Contact with External EntitiesIV.FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATIONFreedom from Abuse, Neglect, and Exploitation General Policya. F600 Free from Abuse and NeglectF602 Free from Misappropriation/ExploitationF603 Free from Involuntary Seclusionb. F604 Right to be Free from Physical RestraintsF605 Right to be Free from Chemical RestraintsRestraint Reduction Programc. F606 Not Employ/Engage Staff with Adverse Actionsd. F607 Develop/Implement Abuse/Neglect, etc. Policiese. F608 Reporting of Reasonable Suspicion of a CrimeF609 Reporting of Alleged ViolationsF610 Investigate/Prevent/Correct Alleged Violationsf. Abuse, Neglect, Exploitation, Preventiong. Personal Property Theft and Loss Riskh. Photographs and Social Mediai. Sexual Abusej. Video Surveillance Closed-Circuit TVsV.ADMISSION, TRANSFER & DISHCARGEAdmission, Transfer and Discharge General Policya. F620 Admission Policyb. F621 Equal Practices Regardless of Payment Sourcec. F622 Transfer and Discharge Requirementsd. F623 Notice Requirements Before Transfer/DischargeF624 Preparation for Safe/Orderly Transfer/Dischargee. F625 Notice of Bed Hold Policy Before/Upon Transferf. Bed Hold Policyg. F626 Permitting Residents to Return to FacilityVI.RESIDENT ASSESSMENTSResident Assessment General Policya. F635 Admission Physician Orders for Immediate Careb. Resident Assessment Instrument (RAI)F636 Comprehensive Assessments & TimingF637 Comprehensive Assessment After Significant ChangeF638 Quarterly Assessment At Least Every 3 MonthsF639 Maintain 15 Months of Resident AssessmentsF640 Encoding/Transmitting Resident AssessmentF641 Accuracy of AssessmentsF642 Coordination/Certification of Assessmentc. F644 Coordination of PASARR and AssessmentsF645 PASARR Screening for MD & IDF646 MD/ID Significant Change Notification
VII.COMPREHENSIVE RESIDENT CENTERED CARE PLANSComprehensive Resident Centered Care Plans General Policya. F655 Baseline Care Planb. F656 Develop/Implement Comprehensive Care PlanF657 Care Plan Timing and RevisionF658 Services Provided Meet Professional StandardsF659 Qualified Personsc. F660 Discharge Planning Processd. Discharge Planning Proceduree. F661 Discharge SummaryVIII.QUALITY OF LIFEQuality of Life General Policya. F675 Quality of Lifeb. F676 Activities of Daily Living (ADLs)/Maintain AbilitiesF677 ADL Care Provided for Dependent ResidentsF678 Cardio-Pulmonary Resuscitation (CPR)c. F679 Activities Meet Interest/Needs of Each ResidentF680 Qualifications of Activity ProfessionalIX.QUALITY OF CAREQuality of Care General Policya. F684 Quality of Careb. F685 Treatment/Devices to Maintain Hearing/Visionc. F686 Treatment/Services to Prevent/Heal Pressure Ulcersd. Wound Prevention Programe. Wound Management Programf. Clean Dressing Change Procedureg. Skin Prep Application Procedureh. F687 Foot Carei. F688 Increase/Prevent Decrease in ROM/Mobilityj. Specialized Rehabilitative and Restorative Servicesk. Restorative Nursing Programl. Restorative Nursing Bed Mobility Programm. Mobilityn. F689 Free of Accident Hazards/Supervision/Deviceso. Reporting Accidents and Incidentsp. Medical Errors Occurrence Reportingq. Falling Star Programr. Missing Residents. Elopementt. F690 Bowel/Bladder Incontinence, Catheter, UTIu. Bowel and Bladder Programv. Indwelling Catheter Justification and Removalw. F691 Colostomy, Urostomy, or Ileostomy Carex. Assisted Nutrition and Hydrationy. F692 Nutrition/Hydration Status Maintenance
z. F693 Tube Feeding, Management/Restore Eating Skillsaa. Enteral Tube Feeding via Bolusbb. Enteral Tube Feeding via Pumpcc. Enteral Tube Feeding via Gravity Bagdd. Changing a Gastrostomy Tubeee. Gastrostomy/Jejunostomy Site Careff. Cleaning and Storing Reusable Syringegg. Enteral Feeding Medication Administrationhh. Placement and Residual Volume Check for Enteral Feeding Tubesii. F694 Parenteral/IV Fluidsjj. PICC Line Removal Procedurekk. F695 Respiratory/Tracheostomy Care and Suctioningll. F696 Prosthesesmm.F697 Pain Managementnn. Pain Management Programoo. F698 Dialysispp. F700 BedrailsX.PHYSICIAN SERVICESPhysician Services General Policya. F710 Resident's Care Supervised By a PhysicianF711 Physician Visits — Review Care/Notes/OrdersF712 Physician Visits – Frequency/Timeliness/Alternate NPPsF713 Physician for Emergency Care, Available 24 HoursF714 Physician Delegation of Tasks to NPPF715 Physician Delegation to Dietitian/TherapistXI.NURSING SERVICESNursing Services General Policya. F725 Sufficient Nursing StaffF726 Competent Nursing StaffF727 RN 8 Hrs./7 day/Wk. Full Time DONb. F728 Facility Hiring and Use of Nursec. F729 Nurse Aide Registry Verification, RetrainingF730 Nurse Aide Perform Review – 12Hr/Year In-serviced. F732 Posted Nurse Staffing InformationXII.BEHAVIOR HEALTH SERVICESBehavior Health Services General Policya. F740 Behavioral Health ServicesF741 Sufficient/Competent Staff-Behavior Health Needsb. F742 Treatment/Services for Mental/Psychosocial ConcernsF743 No Pattern of Behavioral Difficulties Unless UnavoidableF744 Treatment/Service for DementiaF745 Provision of Medically Related Social Servicesc. Behavior Management and Psychoactive Program
XIII.PHARMACY SERVICESPharmacy Services General Policya. F755 Pharmacy Services/Procedures/Pharmacist/RecordsF759 Free of Medication Error Rate of 5% or MoreF760 Residents Are Free of Significant Med ErrorsF761 Label/Store Drugs & Biologicalsb. F756 Drug Regimen Review, Report Irregular, Act Onc. F757 Drug Regimen is Free From Unnecessary DrugsF758 Free From Unnecessary Psychotropic Meds/PRN Used. Drug Regimen Review ProcessXIV.LABORATORY, RADIOLOGY, AND OTHER DIAGNOSTIC SERVICESLaboratory, Radiology, and Other Diagnostic Services General Policya. F770 Laboratory ServicesF771 Blood Bank and Transfusion ServicesF772 Lab Services Not Provided On-SiteF773 Lab Services Physician Order/Notify of ResultsF774 Assist with Transport Arrangements to Lab ServicesF775 Lab Reports In Record-Lab Name/AddressF776 Radiology/Other Diagnostic ServicesF777 Radiology/Diagnostic Services Ordered/Notify ResultsF778 Assist with Transport Arrangements to RadiologyF779 X-ray/Diagnostic Report In Record – Sign/DatedXV.DENTALDental General Policya. F790 Routine/Emergency Dental Services in Skilled Nursing FacilitiesF791 Routine/Emergency Dental Services Nursing FacilitiesXVI.FOOD AND NUTRITION SERVICESFood and Nutrition Services General Policya. Food and Nutrition ServicesF800 Provide Diet Meets Needs of Each ResidentF801 Qualified Dietary StaffF802 Sufficient Dietary Support PersonnelF808 Therapeutic Diet Prescribed by PhysicianF809 Frequency of Meals/Snacks at BedtimeF810 Assistive Devices – Eating Equipment/UtensilsF812 Food Procurement, Store/Prepare/Serve – SanitaryF813 Personal Food PolicyF814 Disposal Garbage & Refuse Properlyb. Menus and Nutritional AdequacyF803 Menus Meet Resident Needs/Prepare in Advance/Followedc. Food and DrinkF804 Nutritive Value/Appear Palatable/Prefer TempF805 Food In Form to Meet Individual NeedsF806 Resident Allergies, Preferences and Substitutes
d.e.f.XVII.XVIII.XIX.XX.F807 Drinks Available to Meet Needs/Preferences/HydrationF811 Feeding Assistant – Training/Supervision/ResidentUse and Storage of Food Brought in by Family or VisitorsWeight ManagementSPECIALIZED REHAB SERVICESSpecialized Rehab Services General Policya. F825 Provide/Obtain Specialized Rehab ServicesF826 Rehab Services — Physician Order/Qualified PersonADMINISTRATIONAdministration General Policya. F835 AdministrationF836 License/Comply With Federal/State/Local Law/Professional StandardsF837 Governing Bodyb. F838 Facility Assessmentc. F839 Staff QualificationsF840 Use of Outside Resourcesd. F841 Responsibilities of Medical Directore. F842 Resident Records – Identifiable Informationf. Record Retentiong. F843 Transfer Agreementh. F844 Disclosure of Ownership Requirementsi. F845 Facility Closure – AdministratorF846 Facility Closurej. F849 Hospice Servicesk. F850 Qualifications of Social Worker 120 Bedsl. F851 Payroll Based JournalQUALITY ASSURANCE AND PERFORMANCE IMPROVEMENTQuality Assurance and Performance Improvementa. F865 QAPI Program/Plan, Disclosure/Good Faith AttemptF867 QAPI/QAA Improvement Activitiesb. F868 QAA CommitteeINFECTION CONTROLInfection Control General Policya. F880 Infection Prevention and Controlb. F881 Infection Control - Antibiotic Stewardship Programc. F883 Influenza and Pneumococcal Immunizations Residentsd. Influenza and Pneumococcal Immunizations for Staffe. Infection Control - Standard and Transmission-based Precautionsf. Infection Control - Cleaning and Disinfection/Non-critical care and shared equipmentg. Infection Control - Central Venous Catheter/Central Line Access and Maintenanceh. Infection Control - Clean Dressing Changei. Infection Control - Food Handlingj. Infection Control - Hand Hygiene
k.l.m.n.o.p.Infection Control - Indwelling Catheter CareInfection Control - Indwelling Urinary Catheter UseInfection Control - Linen ManagementInfection Control - Medication AdministrationInfection Control - Point of Care Devices and Injection SafetyInfection Control - Tuberculosis (TB) Screening ProgramXXI.PHYSICAL ENVIRONMENTPhysical Environment General Policya. F906 Emergency Electrical Power System (Blank)b. F907 Space and EquipmentF908 Essential Equipment, Safe Operating Conditionc. F909 Resident Bedd. Resident RoomsF910 Bedrooms Accommodate No More Than 4 ResidentsF912 Bedrooms Measure at least 80 square foot/residentF913 Bedrooms Have Direct Access to Exit CorridorF914 Bedrooms Assure Full Visual PrivacyF915 Bedrooms Window/Floor, Bed/Furniture/ClosetF916 Bedrooms Floor Above GradeF917 Bedrooms Bed/Furniture/ClosetF918 Bedrooms Equipped/Near Lavatory/Toilete. F919 Resident Call System — Rooms/Toilet/BathF920 Requirements for Dining and Activity RoomsF921 Safe/Functional/Sanitary/Comfortable EnvironmentF922 Procedures to Ensure Water AvailabilityF923 VentilationF924 Corridors Have Firmly Secured HandrailsF925 Maintains Effective Pest Control ProgramF926 Smoking Policiesf. Resident Smoking PolicyXXII.TRAINING REQUIREMENTSTraining Requirements General Policya. F943 Abuse, Neglect, and Exploitation Trainingb. F947 Required In-Service Training for Nurse Aidesc. F948 Training for Feeding Assistantsd. Staff Education Plan
PLACE TAB FOR PHASE 2 CROSSWALKS HERE
PHASE 2 TAG CROSSWALKS – COMPLIMENTS OF CMSNewTag #SQCTag?X YesF540Tag TitleCFRDefinitions483.5Resident Rights/Exerciseof Rights483.10(a)(1)(2)(b)(1)(2)F551Rights Exercised byRepresentativeF573Regulatory GroupingsTags / SubpartsImplementedin Phase 3OldTag #Regulation Text that wasMoved toNew TagF150483.5483.10 i)(iii)483.10 ResidentRightsF152483.10(b)(3)-(7)Right to Access/PurchaseCopies of Records483.10(g)(2)(i)(ii)(3)483.10 ResidentRightsF153483.10(g)(2)(3)F552Right to beInformed/MakeTreatment Decisions483.10(c)(1)(4)(5)483.10 ResidentRightsF154483.10(c)(1)(4)(5)F553Right to Participate inPlanning Care483.10(c)(2)(3)483.10 (g)(12)(i)-(v)483.10 3)483.24 Quality /Discontinue Treatment;Formulate )F572Notice of Rights and Rules483.10(g)(1)(16)483.10 ResidentRightsF156483.10(g)(1)(16)F574Required Notices andContact Information483.10(g)(4)(i)-(vi)483.10 ResidentRightsF156483.10(g)(4)F575Required Postings483.10(g)(5)(i)(ii)483.10 ResidentRightsF156483.10(g)(5)483.10(g)(13)483.10 )-(v)483.10 i)-(iv)483.10 /Notice ofMedicare/Medicaid onAdmissionMedicaid/MedicareCoverage/Liability NoticeNotify of nagementof Personal Funds483.10(f)(10)(i)(ii)483.10 anagementof Personal Funds483.10(f)(10)(i)(ii)483.10 0Accounting and Recordsof Personal FundsNotice and Conveyance ofPersonal FundsSurety Bond - Security ofPersonal f)(10)(vi)483.10 ResidentRights483.10 ResidentRights483.10 ResidentRights
Limitations on Charges toPersonal FundsRight to Choose/BeInformed of AttendingPhysicianPersonalPrivacy/Confidentiality ofRecords483.10(f)(11)(i)-(iii)483.10 1)-(5)483.10 )(3)(i)(ii)483.10 ResidentRightsF164483.10(h)(1)(3)(i)F842Resident Records Identifiable Information483.20(f)(5)483.70(i)(1)-(5)483.20 i)(2)F585Grievances483.10(j)(1)-(4)483.10 (j)(1)-(4)483.10 83.10 )(11)483.10 ResidentRightsF168483.10(g)(10)(ii)483.10(k)483.10 .10 10 (g)(6)-(9)483.10 )(i)(A)(G)483.10 (v)483.10 (vi)(A)(D)483.10 (1)(3)(i)(ii)483.10 483.10 6)483.10 0 (8)483.10 t to SurveyResults/Advocate AgencyInfoRight to SurveyResults/Advocate AgencyInfoResident Contact withExternal EntitiesF577F577F586Right to Perform FacilityServices or RefuseRight to Forms ofCommunication withPrivacyRight to Forms ofCommunication withPrivacyImmediate Access F560XRight to Receive/DenyVisitorsInform of VisitationRights/Equal y ofRecordsRight to Forms ofCommunication withPrivacyChoose/Be Notified ofRoom/Roommate ChangeResident Self-AdminMeds-ClinicallyAppropriateRight to Refuse CertainTransfers
F622Transfer and i)F622Transfer and i)F623Notice 6)(8)F624Preparation otice of Bed Hold PolicyBefore/Upon Transfer483.15(d)(1)(2)F626Permitting Residents toReturnto Facility483.15(e)(1)(2)F621Equal PracticesRegardless of PaymentSource483.15(b)(1)(3)(c)(9)F620Admissions Policy483.15(a)(1)-(7)F604XRight to be Free fromPhysical Restraints483.10(e)(1)483.12(a)(2)F604XRight to be Free fromPhysical Restraints483.10(e)(1)483.12(a)(2)F605XRight to be Free fromChemical Restraints483.10(e)(1)483.12(a)(2)F600XFree from Abuse andNeglect483.12(a)(1)483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.15Admission,Transfer, andDischarge483.10 ResidentRights483.12 Freedomfrom Abuse,Neglect, andExploitation483.10 ResidentRights483.12 Freedomfrom Abuse,Neglect, andExploitation483.10 ResidentRights483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, 3.10(e )(1),483.12(a)(2)F222483.10(e )(1),483.12(a)(2)F222483.10(e )(1),483.12(a)(2)F223483.12(a)(1)
F602XFree fromMisappropriation/ExploitationF603XFree from InvoluntarySeclusion483.12(a)(1)F602XFree fromMisappropriation/Exploitation483.12F606XNot Employ/Engage Staffwith Adverse Actions483.12(a)(3)(4)F609XReporting of revent/Correct Alleged eglect, etc.Policies483.12(b)(1)-(4)Abuse, Neglect, andExploitation Training483.95(c)(1)-(3)F607F943483.12483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, andExploitation483.12 Freedomfrom Abuse,Neglect, c)(2)-(4)F226483.12(b)(1)-(4)483.95 TrainingRequirementsF226483.95(c)(1)-(3)(b)(4) - Phase 3Will not be inASPEN untilPhase 3F550XResident Rights/Exerciseof Rights483.10(a)(1)(2)(b)(1)(2)483.10 ResidentRightsF240483.10(a)(1)(2)F550XResident Rights/Exerciseof Rights483.10(a)(1)(2)(b)(1)(2)483.10 ResidentRightsF241483.10(a)(1)F561XSelf Determination483.10(f)(1)-(3)(8)483.10 mily Groupand Response483.10(f)(5)(i)(iv)(6)(7)483.10 esident/Family Groupand Response483.10(f)(5)(i)(iv)(6)(7)483.10 ResidentRightsF244483.10(f)(5)(iv)F561XSelf Determination483.10(f)(1)-(3)(8)483.10 modations ofNeeds/Preferences483.10(e)(3)483.10 ResidentRightsF246483.10(e)(3)F559XChoose/Be Notified ofRoom/Roommate Change483.10(e)(4)-(6)483.10 ResidentRightsF247483.10(e)(6)
F679XActivities MeetInterest/Needsof Each Resident483.24(c)(1)483.24 Quality ofLifeF248483.24(c)(1)F680XQualifications of 24 Quality ofLifeF249483.24(c)(2)(i)(ii)(A)(D)F745XProvision of MedicallyRelatedSocial Services483.40(d)483.40Behavioral HealthServicesF250483.40(d)F850XQualifications of SocialWorker 120 p)(1)(2)Respect, Dignity/Right tohave Personal Property483.10(e)(2)483.10 Comfortable/Homelike Environment483.10(i)(1)-(7)483.10 an/Comfortable/Homelike Environment483.10(i)(1)-(7)483.10 ortable/Homelike Environment483.10(i)(1)-(7)483.10 ortable/Homelike Environment483.10(i)(1)-(7)483.10 ortable/Homelike Environment483.10(i)(1)-(7)483.10 ortable/Homelike Environment483.10(i)(1)-(7)483.10 ResidentRightsF258483.10(i)(7)483.20(a)483.20 (iii)483.20 (i)(iii)483.20 (ii)483.20 )(2)(i)(iii)483.20 83.20 ResidentAssessmentsF276483.20(c )483.20(g)483.20 0 0 36F638F641F642F639Admission PhysicianOrders forImmediate CareComprehensiveAssessments &TimingComprehensiveAssessments &TimingComprehensive AssmtAfterSignificant ChangeComprehensiveAssessments &TimingQuarterly Assessment AtLeastEvery 3 MonthsAccuracy of AssessmentsCoordination/Certification ofAssessmentMaintain 15 Months ofResidentAssessments
F656Develop/ImplementComprehensive Care Plan483.21(b)(1)F553Right to Participate inPlanning Care483.10(c)(2)(3)F657Care Plan Timing andRevision483.21(b)(2)(i)-(iii)F658Services Provided MeetProfessional tCentered CarePlans483.10 ResidentRights483.21ComprehensiveResidentCentered CarePlans483.21ComprehensiveResidentCentered CarePlans483.21ComprehensiveResidentCentered CarePlans483.21ComprehensiveResidentCentered CarePlans483.21ComprehensiveResidentCentered CarePlans483.21ComprehensiveResidentCentered CarePlans(b)(iii) - Phase 3Will not be inASPEN untilPhase ified Persons483.21(b)(3)(ii)(iii)F661Discharge Summary483.21(c)(2)(i)-(iv)F660Discharge PlanningProcess483.21(c)(1)(i)-(ix)F661Discharge Summary483.21(c)(2)(i)-(iv)F644Coordination of PASARRandAssessments483.20(e)(1)(2)483.20 ResidentAssessmentsF285483.20(e)F645PASARR Screening for MD& ID483.20(k)(1)-(3)483.20 ResidentAssessmentsF285483.20(k)(1)-(3)F646MD/ID Significant ChangeNotification483.20(k)(4)483.20 ResidentAssessmentsF285483.20(k)(4)483.20(d)483.20 3.20 4 Quality ofLifeF309483.24Maintain 15 Months AssessmentF639F640F675XQuality of Life
F684XQuality of Care483.25483.25 Quality ofCareF309483.25F697XPain Management483.25(k)483.25 Quality ofCareF309483.25(k)F698XDialysis483.25(l)483.25 Quality ofCareF309483.25(l)F744XTreatment /Service forDementia483.40(b)(3)483.40Behavioral (1)(5)(i)-(iii)483.24 Quality )(1)(b)(1)(5)(i)-(iii)483.24 Quality ofLifeF311483.24(a)(1)F677X483.24(a)(2)483.24 Quality ofLifeF312483.24(a)(2)F685X483.25(a)(1)(2)483.25 Quality 483.25 Quality 483.25 Quality .25 Quality ofCareF317483.25(c)(1)F688X483.25(c)(1)-(3)483.25 Quality es of Daily Living(ADLs)/Maintain AbilitiesActivities of Daily Living(ADLs)/Maintain AbilitiesADL Care Provided forDependent ResidentsTreatment/Devices toMaintainHearing/VisionTreatment/Svcs nce,Catheter, UTIIncrease/PreventDecrease inROM/MobilityIncrease/PreventDecrease inROM/MobilityTreatment/Svc forMental/PsychosocialConcernsNo Pattern of BehavioralDifficulties UnlessUnavoidableTube FeedingManagement/RestoreEating SkillsFree of ioral HealthServices483.40Behavioral HealthServices483.25(g)(4)(5)483.25 Quality ofCareF322483.25(g)(4)(5)483.25(d)(1)(2)483.25 Quality ofCareF323483.25(d)(1)(2)483.25(n)(1)-(4)483.25 Quality ofCareF323483.25(n)(1)-(3)483.25(g)(1)-(3)483.25 Quality ofCareF325483.25(g)(1)(3)483.25(g)(1)-(3)483.25 Quality ofCareF327483.25(g)(2)
F687XFoot Care483.25(b)(2)(i)(ii)483.25 Quality ofCareF328483.25(b)(2)(i)(ii)F691XColostomy, Urostomy, orIleostomy Care483.25(f)483.25 Quality ofCareF328483.25(f)F694XParenteral/IV Fluids483.25(h)483.25 Quality ofCareF328483.25(h)F695XRespiratory/Tracheostomy careand Suctioning483.25(i)483.25 Quality ofCareF328483.25(i)F696XProstheses483.25(j)483.25 Quality ofCareF328483.25(j)F757X483.45(d)(1)-(6)483.45 1)(5)483.45 (1)483.45 83.45 2)483.80 InfectionControlF334483.80(d)(1)(2)Drug Regimen is FreeFromUnnecessary DrugsFree from UnnecPsychotropic Meds/PRNUseFree of Medication ErrorRatesof 5% or MoreResidents Are Free ofSignificantMed ErrorsInfluenza andPneumococcalImmunizationsF725Sufficient Nursing Staff483.35(a)(1)(2)483.35 NursingServicesF353483.35(a)(1)(2)F726Competent Nursing Staff483.35(a)(3)(4)(c)483.35 NursingServicesF353483.35(a)(3)(4)F727RN 8 Hrs/7 days/Wk, FullTime DON483.35(b)(1)-(3)483.35 nsed Nurses24Hr/Day and RN Coverage483.35(e)(1)(7)(f)(1)(2)483.35 ted Nurse StaffingInformation483.35(g)(1)-(4)483.35 NursingServicesF356483.35(g)(1)-(4)F800Provided Diet MeetsNeeds ofEach Resident483.60483.60 Food andNutrition ServicesF360483.60F801Qualified Dietary Staff483.60(a)(1)(2)483.60 Food andNutrition ServicesF361483.60(a)(1)(2)F802Sufficient Dietary SupportPersonnel483.60(a)(3)(b)483.60 Food andNutrition ServicesF362483.60(a)(3)(b)F803Menus Meet ResNeeds/Prep inAdvance/Followed483.60(c)(1)-(7)483.60 Food andNutrition ServicesF363483.60(c )(1)-(7)F804Nutritive Value/Appear,Palatable/Prefer Temp483.60(d)(1)(2)483.60 Food andNutrition ServicesF364483.60(d)(1(2)
F805F806F807F808F809Food in Form to MeetIndividualNeedsResident Allergies,Preferencesand SubstitutesDrinks Avail to MeetNeeds/Preferences/ HydrationTherapeutic DietPrescribed byPhysicianFrequency ofMeals/Snacks atBedtime483.60(d)(3)483.60 Food andNutrition ServicesF365483.60(d)(3)483.60(d)(4)(5)483.60 Food andNutrition ServicesF366483.60(d)(4)(5)483.60(d)(6)483.60 Food andNutrition ServicesF366483.60(d)(6)483.60(e)(1)(2)483.60 Food andNutrition ServicesF367483.60(e)(1)(2)483.60(f)(1)-(3)483.60 Food andNutrition ServicesF368483.60(f)(1)-(3)F810Assistive Devices - EatingEquipment/Utensils483.60(g)483.60 Food andNutrition ServicesF369483.60(g)F812Food Procurement,Store/Prepare/Serve Sanitary483.60(i)(1)(2)483.60 Food andNutrition ServicesF371483.60(i)(1)(2)F813Personal Food Policy483.60(i)(3)483.60 Food andNutrition ServicesF371483.60(i)(3)483.60(i)(4)483.60 Food andNutrition ServicesF372483.60(i)(4)483.60(h)(1)-(3)483.60 Food andNutrition ServicesF373483.60(h)(1)-(3)F814F811Dispose Garbage &RefuseProperlyFeeding Asst Training/Supervision/ResidentF948Training for FeedingAssistants483.95(h)483.95 TrainingRequirementsF373483.95(h)F710Resident's CareSupervised by aPhysician483.30(a)(1)(2)483.30 PhysicianServicesF385483.30(a)(1)(2)F711Physician Visits- ReviewCare/Notes/Order483.30(b)(1)-(3)483.30 (4)483.30 4)483.30 0 3.30 )(3)483.30 4F715Physician VisitsFrequency/Timeliness/AlternateNPPsPhysician VisitsFrequency/Timeliness/AlternateNPPsPhysician for EmergencyCare,Available 24 HoursPhysician Delegation ofTasks toNPPPhysician Delegation toDietitian/Therapist
F825Provide/ObtainSpecializedRehab Services483.65(a)(1)(2)F826Rehab Services- PhysicianOrder/Qualified Person483.65(b)F790Routine/EmergencyDentalServices in vices in cist/RecordsDrug Regimen Review,ReportIrregular, Act OnFree from UnnecPsychotropic F407483.65(b)483.55 483.55 (3)483.45 PharmacyServicesF4
XI. NURSING SERVICES Nursing Services General Policy a. F725 Sufficient Nursing Staff F726 Competent Nursing Staff F727 RN 8 Hrs./7 day/Wk. Full Time DON b. F728 Facility Hiring and Use of Nurse c. F729 Nurse Aide Registry Verification, Retraining F730 Nurse Aide Perform Review – 12Hr/Year
