Header:
CODE OF FEDERAL REGULATIONS
TITLE 42 -- PUBLIC HEALTH
CHAPTER IV -- CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER G -- STANDARDS AND CERTIFICATION
PART 488 -- SURVEY, CERTIFICATION, AND ENFORCEMEN
Date:
01/17/2012
Document:
ยง 488.115 Care guidelines. (Part I of II)
SURVEY AREA OBSERVATION INTERVIEWING
*2*Resident Rights
F53 Ask Resident:
SNF 405.1121(k)(1) - Did you receive a copy
ICF 442.311(a) of the Resident's Bill
of Rights? Was it ex-
F54 plained to you?
SNF 405.1121(h)(1)
ICF 442.311(a)(1)
A. Information *
F55 Where is information
SNF 405.1121(h)(1) concerning resident
ICF 442.311(a)(2) rights and responsi-
1. Rights and bilities available in - Were you told of any
Responsibili- the facility? responsibilities you
ties have in living here?
F56
SNF 405.1121(k)(1)
ICF 442.311(a)(3)
2. Rules of - Were you given a chance
Resident to ask questions?
Conduct
F57
SNF 405.1121(h)(2) - Did he/she receive a
ICF 442.311(a)(4) written copy of services
3. Resident provided by the facility
Acknow- and any additional costs
ledgement for these services?
* Information concerning incompetent residents is given in L. Delegation of Rights and Responsibilities.
INTENT
To assure that the resident maintains, in so far as possible, those personal rights that are a part of normal, adult life, and including the right to personal dignity.
SURVEY AREA RECORD REVIEW
*2*Resident Rights
F53 Looked for signed acknow-
SNF 405.1121(k)(1) ledgement of receipt of
ICF 442.311(a) resident rights informa-
tion. Residents unable
F54 to sign name may have
SNF 405.1121(h)(1) their "mark" witnessed.
ICF 442.311(a)(1)
Look for written statement
A. Information * of charges services.
F55 Social Work records may
SNF 405.1121(h)(1) idicate patient rights
ICF 442.311(a)(2) information discussed
1. Rights and with resident.
Responsibili-
ties
F56
SNF 405.1121(k)(1)
ICF 442.311(a)(3)
2. Rules of
Resident
Conduct
F57
SNF 405.1121(h)(2)
ICF 442.311(a)(4)
3. Resident
Acknow-
ledgement
* Information concerning incompetent residents is given in L. Delegation of Rights and Responsibilities.
INTENT
To assure that the resident maintains, in so far as possible, those personal rights that are a part of normal, adult life, and including the right to personal dignity.
SURVEY AREA EVALUATION FACTORS
*2*Resident Rights
F53 Because of the confusion
SNF 405.1121(k)(1) surrounding admission to
ICF 442.311(a) a new facility and the
large amount of informa-
F54 tion given to a resident
SNF 405.112(h)(1) or resident's family on
ICF 442.311(a)(1) admission, information
given at this time is
A. Information * often forgotten. There-
fore, surveyor should
F55 verify resident's recol-
SNF 405.1121(h)(1) lection with staff inter-
ICF 442.311(a)(2) views and record checks.
1. Rights and Written information on
Responsibili services and costs must
ties be given to the resident,
as well as copies of
F56 residents rights and
SNF 405.1121(k)(1) responsibilities. Copies
ICF 442.311(a)(3) of residents' rights
2. Rules of should also be available
Resident to patients and visitors,
Conduct e.g., in resident
lounges, lobbies, or
F57 other area where resi-
SNF 405.1121(h)(2) dents and visitors could
ICF 442.311(a)(4) easily see and read them.
3. Resident
Acknow
ledgement
* Information concerning incompetent residents is given in L. Delegation of Rights and Responsibilities.
INTENT
To assure that the resident maintains, in so far as possible, those personal rights that are a part of normal, adult life, and including the right to personal dignity.
SURVEY AREA CROSS REFERENCE
*2*Resident Rights
F53 Notification of
SNF 405.1121(k)(1) Change in Status
ICF 442.311(a) 405.1121(j)
442.307
F54
SNF 405.1121(h)(1) Patient Care
ICF 442.311(a)(1) Policies
405.1121(e)
A. Information *
442.308
F55 442.309
SNF 405.1121(h)(1) 442.310
ICF 442.311(a)(2) 442.305
1. Rights and
Responsibili- Medical Direction
ties 405.1122(a)
F56 Medical Records
SNF 405.1121(k)(1) 405.1132(b)(d)
ICF 442.311(a)(3) 442.310
2. Rules of
Resident
Conduct
F57
SNF 405.1121(h)(2)
ICF 442.311(a)(4)
3. Resident
Acknow-
ledgement
* Information concerning incompetent residents is given in L. Delegation of Rights and Responsibilities.
INTENT
To assure that the resident maintains, in so far as possible, those personal rights that are a part of normal, adult life, and including the right to personal dignity.
LONG TERM CARE SURVEY
SURVEY AREA OBSERVATION INTERVIEWING
*2*F58 Ask Resident:
SNF 405.1121(k)(2) - If there are changes in
ICF 442.311(a)(4) services or costs does
4. Resident someone explain these?
informed in
writing of Ask Administrative Staff:
changes in - How do residents learn
services and what is expected of
charges for them?
services. - How do they learn about
any changes in the
F59 facility's procedures
SNF 405.1121(k)(2) and/or costs?
ICF 442.311(a)(4)
5. Information
to resident
of services
not covered
by Medicare
or Medicaid
and not
covered in
the basic
rate.
B. Medical Condi- Ask Resident:
tion & Treatment - Has your doctor discuss-
ed your health with you,
F60-64 how is it, what's wrong,
SNF 405.1121(k)(2) and what you can expect
ICF 442.311(b) in the future?
- Have you had the oppor-
tunity to help plan
what you need and how
you are taken care of?
- Do you know that you
can refuse treatment
or medication?
- Have you ever refused
medication or treatment?
- What happened when you
did?
Ask Staff:
- Is the facility partici-
pating in any experi-
mental research?
If yes, ask what resi-
dents are involved.
Interview a sample of
these residents.
Ask Resident (or Guardian:
- Are you participating
in the study?
- Was this explained to
you well enough so that
you understand what the
study is about and any
risks that may be
involved?
C. Transfer and Look for residents that Ask Resident:
Discharge may be inappropriately - How well do you get
F65-68 placed physically - an along with your room-
SNF 405.1121(k)(4) alert resident rooming mate?
ICF 442.311(c) with a confused, noisy - Have you ever been
resident; very ill resi- moved from one room to
dent placed far from the another? If yes, why?
nurses station; residents - How were you involved
not compatible with each in the decision to move?
other, (e.g., different - How much time was there
life-styles, habits, between the time they
etc.). told you you were to be
moved, and when you were
moved?
- Have you asked for your
room to be changed?
Ask Direct Care and
Other Staff:
- What are some of the
reasons residents rooms
are changed?
- What are some of the
reasons for discharge
of residents or transfer
to a hospital or LTC
facility?
- How are residents in-
volved in the decision
to move?
- If a resident requests
a room change, how is
this handled?
- When a resident requests
a room change are the
following areas of con-
sideration presented and
discussed:
+ cost factors
+ resident welfare
+ resident's reason for
requesting the move
+ facility's assessment
of whether the move
would be beneficial or
not for the resident.
D. Exercising Do residents appear com- Ask Resident:
Rights fortable when speaking to - Do you belong to, or
F69 the surveyors as opposed have representation on
SNF 405.1121(k)(5) to being afraid that the resident council?
ICF 442.311(d) someone may see them or - Are you informed of
overhear their conversa- changes in the facility
tion? that will affect you?
- Are you given a chance
to express views on
these changes prior to
their implementation?
- Does the facility assist
in arranging for you to
vote either at the polls
or via absentee ballot?
- Are you assisted in
obtaining legal or
Social Services if
needed?
- Do you feel comfortable
in expressing yourself
freely or are you con-
cerned about retalia-
tion?
- Is staff/administration
responsive to com-
plaints? Do you know
who to complain to?
Ask Staff:
- What arrangements are
made for residents to
vote?
- How do you handle it if
someone needs a lawyer
or other service that
you don't provide?
E. Financial Ask Residents:
Affairs - Are you able to take
care of your own finan-
F72-78 cial affairs?
SNF 405.1121(k)(6) - Does the facility keep
405.1121(m) some money for you that
ICF 442.311(e) you can have when you
442.320 request it?
- When you ask for this
money, how quickly do
you get it?
- Do you know the amount
of money you have avail-
able at this time?
- If the facility pays
bills for you do they
periodically provide an
itemized listing of the
transactions they have
made?
- When did you receive the
last itemized statement?
- Are you comfortable that
your funds are taken
care of correctly?
- If you deposit money or
valuables with the fac-
ility, do you receive
a receipt for this
deposit?
- Are you or your family
able to review your
financial records when
you request to do so?
- Have you ever had money
or anything else stolen?
If so, what was done
about it?
- Does the home provide
safe-keeping for valu-
ables?
- Have they ever lost any-
thing of yours?
Ask Staff:
- What is the procedure
when residents lose per-
sonal belongings?
Valuables?
- How are resident person-
al funds handled?
- What is your procedure
when a resident asks to
get an accounting of
their funds?
* The special needs of
residents with Alz-
heimer's disease who
"lose" personal possess-
ions should be noted.
Individuals in stages 2
and 3 of Alzheimer's
disease sometimes be-
lieve their personal
possessions were stolen.
F. Freedom From - How many residents are Ask Resident:
Abuse and physically restrained? - Why are you wearing
Restraints this?
- What type or restraints - How often is this worn?
F79-83 are used? - Do you know what would
SNF 405.1121(k)(7) happen if it were re-
ICF 442.311(f) - Are they applied cor- moved?
rectly? - How often is it removed?
- What is done for you
- What is the apparent when the restraint is
physical/mental condi- removed?
tion of those residents - For nonrestrained resi-
restrained? dent --
+ Have you ever been re-
- Do you observe the re- strained?
lease of restraints + For what reason?
every 2 hours and the + What explanation was
provision of at least given for the
10 minutes exercise for restraint?
the resident? - Do you ever feel that
you receive medication
- Do staff respond to when you don't need it?
request for water,
assistance to bathroom,
etc., from a resident
who is restrained?
What is the interval
between request and
response?
- How often are Ask Staff:
restrained residents - What is the facility
observed by staff? policy regarding re:
restraints?
- Observe effect on resi- - What is considered an
dents. Do you see what "emergency" need for
may be signs of over- restraints?
medication? - What is the most common
reason for use of re-
- How often is this straints?
observed? - Do you try any alterna-
tive measures before
- Residents should be using restraints?
free from mental and - What information do you
physical abuse. give the physician to
help him make the decis-
- Observe interaction of ion to order restraints?
staff and residents for - What do you routinely do
any sign of harassment, for the resident when
humiliation or threats. you periodically release
the restraints?
- Do residents appear - Does use of restraints
comfortable with staff? increase on evenings or
nights when there are
- Look for numbers of fewer staff members?
residents with bruises - Have you had any acci-
or other injuries (skin dents or incidents in
of the elderly bruises the last year while
easily, so do not auto- residents were
matically assume abuse restrained?
or injury). - How do you define the
difference between a
- Observe resident to "safety device" and a
resident interactions "restraint"?
and staff response to - How do your policies
any physical or mental differ in regard to
abuse of one resident "safety devices" and
to another. restraints?
- Observe for evidence Ask Resident:
of resident neglect, - Do you feel safe in the
residents left in facility?
urine/feces without - Do you ever feel intim-
cleaning. idated, harassed, or
otherwise abused?
- How are confused resi-
dents treated?
- Is anyone ever hit or
treated roughly?
- Do you feel as if you
are treated with respect
/dignity?
- Is the staff/administra-
tion responsive to
complaints?
- Do you know who to com-
plain to?
G. Privacy - Observe interactions Ask Resident:
between staff and resi- - Do you feel that you are
F84-89 dents for indications treated as a worthwhile,
SNF 405.1121(k)(8) of respect, considera- adult individual? -
(9)(14) tion, dignity and - When you are being cared
ICF 442.311(g) individuality. for, are you comfor-
table?
- How do staff members - What is the degree of
enter a residents room privacy and respect you
or go behind a privacy receive?
curtain? - Do you feel comfortable
that if the door to your
- Are privacy curtains room is closed staff
used or doors shut will knock or otherwise
when personal care make their presence
needs and/or treatments known before entry?
are rendered? - Do you have a private
place to make telephone
- Are there areas for calls? -
residents to be alone - Can you see your record
or meet in private with if/when you ask?
visitors? - Has any information
about your condition
been given to someone
outside of the facility
without your permission?
- Are medical records For Married Residents:
kept in their assigned - When you husband/wife
spots not carelessly visits can you shut your
left for nonauthorized door and be assured of
persons to view? privacy?
- Can you ask that you not
- Are married residents be disturbed and have
sharing rooms? that request respected?
- Observe for negative Ask Staff:
attitudes toward aging- - What is done to assure
infantilization and that each resident main-
patronizing of resi- tains his/her dignity
dents. and individuality?
- How are medical records
- If residents undress in kept secure? Who has
public area, how does access?
staff handle this? - Do you have married
couples here?
- Listen to staff conver- - Do they share rooms?
sation in public places - If not, why?
(elevator, lobby). - What arrangements do you
Are resident issues make for spouses or
being discussed? significant others to
visit?
- Do you allow their door
to be closed?
- Can you adhere to a
request that they not
be disturbed?
- How are residents'
medical records and
conditions kept
confidential?
H. Work - Are residents doing any Ask Resident:
type of work such as - Are you ever asked to
F90 picking up dirty trays, help out in the facility
SNF 405.1121(k)(10) pushing laundry such as pick up dirty
ICF 442.311(h) hampers, etc.? trays or stamp mail?
- If yes, do you do this?
- What about clerical - Do you want to, or do
work? you feel it is expected
of you?
- Do you feel you can say
"no"?
Ask Staff:
- Are residents asked to
help with facility staff
if you are shorthanded?
- What is their reaction?
- What useful work is
available for residents
who want eed to be
usefully "employed"?
I. Freedom of - Are there areas in the Ask Residents:
Association and facility-e.g., small - Can you have visits from
Correspondence lounges, etc., where anyone?
residents can and do - Can you find a private
F91-92 meet privately? place to visit?
SNF 405.1121(k)(11) - Do you receive your mail
(12) - Is mail delivered unopened unless you
ICF 442.311(i) opened or unopened? request otherwise?
- Are there telephones you
- Are facility personnel have access to?
assisting residents, if - Does the staff or vol-
needed, in opening and/ unteers assist you in
or reading mail? reading or sending mail,
if needed?
- How timely is your mail
delivered?
- How do you receive
incoming calls?
Ask Staff:
- Where do residents go
when they want privacy?
- What telephones are
available to residents?
- What is the facility
visiting policy?
Do the available tele-
phones accomodate the
physically handicapped
(e.g., wheelchair bound,
hearing impaired, etc.).
J. Activities - What planned activities Ask Residents:
are occurring? - What do you like to do?
F93 - What did you do yester-
SNF 405.1121(k)(12) - What unplanned activi- day? (compare answers)
ICF 442.311(j) ties are occurring -- - Is participation in
individual, 2 or 3 activities optional?
persons or a larger - Are you encouraged to
group. participate?
- Is pressure exerted on
- If there is a facility you to attend specific
chapel, is it open? activities?
- Which ones? (Surveyors
- Are activities posted should be aware of spec-
at wheelchair level and ial encouragement --
kept up to date? "gentle persuasion",
- Are residents lined up which might be important
in front of a T.V. in for the depressed or
a common room for withdrawn resident.)
hours? - Are residents notified
of community activities?
- Are activities offered - Are arrangements made
during the evening and for transportation, etc.
on weekends. so that residents can
participate?
- Can residents go to re-
ligious services if they
wish?
- What opportunities are
you given to make
choices in your life
within the facility?
(eg. are all residents
"put to bed" at the same
time?).
Ask Staff:
- Are arrangements ever
made to take residents
to community activities?
- Do friends and relatives
ever take them to com-
munity activities?
- Do your residents attend
religious service of
their choice?
- How are residents kept
informed otified of
activities?
K. Personal - Are residents wearing Ask Residents:
Possessions their own clothing or - What clothing and per-
facility nightgowns, sonal belongings can
F94 robes, etc.? you have?
SNF 405.1121(k)(13) - Is there a place that
ICF 442.311(k) you can secure any val-
uables that you may not
want to keep in your
room?
- In resident rooms ob- Ask Staff:
serve for personal be- - What personal belongings
longings. may residents have?
- What do you do to secure
- Ask residents if you valuables and other per-
can look in the closet- sonal property?
is personal clothing - What provisions are made
in there? for the care of personal
clothing?
- Ask residents if be-
longings such as cloth-
ing are identified with
name tags or other
identifying methods?
- Is there enough space
to store clothing?
L. Delegation of Ask Administrative Staff:
Rights and - When do you have rela-
Responsibilities tives make decisions for
residents-i.e., how do
F95-97 you decide when the
SNF 405.1121(k) resident isn't capable
ICF 442.312 of making decisions him-
self?
- Have any legal steps
been taken?
Ask Resident and/or
Guardian:
- Do you feel that you are
given all pertinent in-
formation?
- What opportunities do
you have to make
decisions regarding
clothing, meals,
bathing schedules,
etc.?
- For guardian: are you
notified/informed in a
timely manner as
appropriate?
STAFF DEVELOPMENT Ask Residents
- Does staff know how to
F98 take care of you?
SNF 405.1121 - What things do they do
to help you accommodate
your (poor vision, un-
F99 steady walking, arth-
ICF 442.314 ritis, etc.)?
Ask Staff
F100 How do staff relate to - What, if any, training
1. Facility residents? have you had here to
staff are learn about unique pro-
knowledgeable Does the facility reflect blems and needs of the
about the adaptations for the aged?
problems and elderly, i.e., informa- - What training have you
needs of the tion given in large had during the last 12
aged, ill, print, floors covered months?
and disabled. with materials that allow - How have you learned
for ease of movement with about facility policies
walkers, wheel chairs, and procedures?
F101 etc.? - Does the facility ask
2. Facility your needs when they
staff prac- Is resident care given develop a training
tices proper using accepted profess- program?
techniques ional standards? - In what areas would you
in providing like to have training?
care to the Is privacy maintained
aged, ill during bathing treatment,
and diseased. toileting?
Are housekeeping staff
F102 courteous and responsive
3. Facility to resident needs?
staff prac-
tice proper
technique for
prevention
and control
of infection,
fire pre-
vention
and safety,
accident pre-
vention, con-
fidentiality
of resident
information,
and preserva-
tion of resi-
dent dignity
including
pro-
tection of
privacy and
personal and
property
rights.
INTENT
To assure that
facility
provides
ongoing
training
to staff
so that
they will
be know-
ledgeable
in cur-
rent practices,
use pro-
per tech-
niques,
and inter-
act with
residents
in a
kind,
caring
way.
Status Change Note residents condition: Ask Resident:
Notifications - Clean - Have you been injured
- Well groomed since you have been in
F103-104 - Well adjusted the facility?
SNF 405.1121(j) - Casts - If you are injured or
ICF 442.307 - Bruises become ill, is your
- Decubitus Ulcer physician called?
F105 - Multiple sites of edema - Are your relatives noti-
1. The facility - Aberrant behavior, fied?
notifies the e.g., abusive, disrup- - Do you know who is noti-
resident's
at- tive, not reasonable, fied if administrative
tending phy- etc. changes such as changes
sician and in charges, billings,
other
respons- etc. occur?
ible persons
in the event Ask Staff:
of an
accident - Who do you notify if a
involving the resident is injured or
resident, or has a change in condi-
other
signifi- tion?
cant
change in - When would they be noti-
the
resident's fied? Does the facility
physical,
men- have a policy regarding
tal, or emo- how soon a relative or
tional
status, responsible party would
or patient be notified?
charges,
bill- - Do you notify them of
ings, and actual changes in resi-
related
admin- dent condition and also
istrative if resident's condition
matters. is getting progressively
worse?
F106
2. Except in a Ask Resident:
medical emer- - Have you ever been or
gency,
a resi- do you know if others
dent is not have been transferred
transferred
or or discharged without
discharged, discussing it with you
nor is treat- first?
ment altered
radically,
without con-
sultation
with
the resident
or, if the
resident is
incompetent,
without prior
notification
of next
of kin
or sponsor.
INTENT
To assure that:
- the resident
receives proper
treatment in the
event of an acci-
dent or change of
condition.
- resident and/or
next of kin or
responsible party
is aware in
advance of any
changes.
- resident is not
discharged to
gain a higher
source payment
for that bed or
facility
convenience.
Physician's Ask Staff:
Services - Interview nursing staff
to determine if they
F107 receive transfer infor-
SNF 405.1123 mation and admission
orders on day of
A. Medical Findings admission.
and Orders at - Ask Administrator and
Time of Director of Nursing to
Admission explain procedure if a
resident arrives with-
F108 out sufficient medical
SNF 405.1123(a) information and/or
orders.
F109
1. There is made
available to
the facility
prior to
or at
the time of
admission,
resident
information
which
include s
current medi-
cal findings
diagnoses,
and
orders from a
physician for
immediate
care
of the resi-
dent.
F110
2. Information
about the
rehab-
ilitation
potential of
the resident
and a summary
of prior
treat-
ments are
made
available to
the
facility at
the time of
admission, or
within
48 hours
thereafter.
Resident Super- Observe resident for any Ask Resident:
vision by Physician problem/conditions that - How often physician
should be addressed by visits.
F111 physician, e.g., edema, - If physician has dis-
SNF 405.1123(b) loss of appetite, weight cussed plan of care and
loss, etc. medical treatment.
F112 - If resident feels treat-
ICF 442.346 ment and/or plan of care
meets his/her needs.
B. Resident - What kinds of questions
Supervision by do you ask the physician
Physician about your health
problems? (Cite
F113 examples).
1. Every resi-
dent must be Ask Licensed Nursing Staff
under the - How often physician
supervision visits and is it often
of a
physician enough to meet resi-
dent's need?
F114 - Does physician partici-
2. A physician pate in evaluation and
prescribes a reevaluation of resi-
planned regi- dent's plan of care?
men of care - Does plan of care meet
based on a resident's needs?
medical eval- - Is physician available
uation
of each in an emergency?
resident's - Is physician available
immediate and to disucss residents
long-term
care treatment and care?
needs.
Ask Administrator
- Facility's policy
regarding a physician
to provide care in the
absence of the resi-
dent's own physician.
- Facility's policy on
physician visits.
F115
3. A physician
is available
to provide
care in
the absence
of any
resident's
attending
physician.
F116
4. Medical
evaluation is
done within
48 hours of
admission
unless done
within 5 days
prior to
admissions.
NOT ICFs.
F117
5. Each SNF
resident is
seen by their
attending
physician at
least once
every 30 days
for the first
90 days after
admission.
Exception: ICF
residents must be
seen every 60 days
unless otherwise
justified and
documented by the
attending physi-
cian.
F118
6. Each resi-
dent's total
program of
care includ-
ing medica-
tions and
treatments is
reviewed dur-
ing a visit
by the
attending
physician at
least once
every 30 days
for the first
90 days and
revised as
necessary.
Exception: Only
medications must
be reviewed quart-
erly for ICF resi-
dents.
F119
7. Progress
notes are
written and
signed by the
physician at
the time of
each visit,
and all
orders are
signed by the
physician.
F120
8. Alternate
physician
visit sched-
ules that
exceed a 30-
day schedule
adopted after
the 90th day
following ad-
mission are
justified by
the attending
physician in
the medical
record.
These visits
cannot exceed
60 days or
apply to pa-
tients who
require
specialized
rehabilita-
tion
schedul es.
Exception ICF resi-
dents must be seen
every 60 days un-
less justified
otherwise document-
ed by the attending
physician.
C. Emergency Ask Staff:
Services - Are you aware of physi-
cian reporting proce-
F121 dures and medical
SNF 405.1123(c) protocols to be followed
during a fire
F122 emergency?
Emergency services - Do you know where names
from a physician and telephone numbers
are available and are of physicians to be
provided to each called in case of emer-
resident who gency?
requires emergency
care
INTENT: To assure
that a physician
has overall
responsibility for
the managment and
supervision of the
residents care.
Nursing Services
F123
SNF 405.1124
F124 Basic care provided to
SNF 405.1124(c) residents:
F125 Ask Resident:
F126 Surveyors should observe
ICF 442.1124(c) the basic care provided - If the resident's
A facility provides by staff to the resi- clothing is inappropr-
nursing services dents. Listed below are ate, ask:
sufficient to meet suggested areas of atten- + Did you choose your
nursing needs of tion which may provide clothing today?
all residents all evidence of the quality + Is this what you want
hours of each day. of personal care: to wear?
- Eyes/Ears/Mouth + Do you have other
Presence/absence of: clothing available?
F127 Grooming and + Secretions forming - If the resident is not
Personal around eyelids, clean, poorly groomed,
Hygiene redness or irrita- or inappropriately
SNF 405.1124(c) tion of eyes. groomed, ask the resi-
+ Eyeglasses worn when dent:
appropriate are + Have you had any help
clean, in good in caring for yourself
repair and fit today (e.g., washing
properly. your face, brushing
+ Backs of ears scaly, your teeth, etc.)?
obvious wax build-up, + How often do you have
discharge, odor. a bath/shower?
+ Hearing aid worn when + How often is your hair
appropriate, is in washed?
good repair and + How often do you
working. brush your teeth/
+ Dried food particles clean your dentures?
or drool, etc. + Were there extenuating
around mouth. cicumstances (e.g.,
+ Dentures worn when resident is partici-
appropriate and in pating in dressing
good repair. retraining program)?
+ Oral hygiene. - Special consideration
- Odors might be given to the
presence/absence of: demented patient who
+ Body odors frequently "borrows"
- Hair/Scalp clothes and for whom
+ Clean and free of removal may elicit
rashes catastrophic reaction-
+ Hair combed whether clothing
- Nails are clean and "matches" may not be
appropriate length the most important issue
- Clothing is appropri- in the care of these
ate, clean, and in patients.
good repair.
+ Extremities elevated Ask Direct Care Staff:
as necessary while - How do you choose what
in chair or wheel- clothing each of your
chair. residents wear each day?
+ Appropriate tech- - Do you have a specific
niques to prevent schedule for washing
infection. residents' hair?
+ Use of whirlpool as - How did you learn to
a treatment modality bathe resident?
as available and - How did you learn to
appropriate. wash residents hair?
- With resident's permis- - How did you learn to
sion check: shave residents?
+ heels, feet and toes - How do you handle situ-
+ lateral hip ations when residents
+ scapular area want to wear dirty
+ sacrum clothes, or mismatched
+ buttocks clothes?
+ bony prominences in - How much care do you
contact with braces let the residents do
+ condition of stump on their own?
(especially diabetic
amputees with elastic
bandage or sock
removed).
Skin Condition Observe with residents' Ask Resident:
F128-129 permission: - Are your feet usually
SNF 405.1124(c) - General condition of swollen?
skin - Do you know what causes
+ Redness the swelling?
+ Blanching - What do you do to alle-
+ Soft/dry/rough etc. viate it?
+ Rashes/irritation - Is this discoloration
+ Bruises normal for you?
+ Scabs - How did this wound/
+ Free of above bruise develop?
- Measures taken to pre- - Are the treatments done
vent skin breakdown. about the same time
- Pressure sores every day?
- Pressure sores Rx - What staff person has
- Factors contributing looked at your skin
to prevention of recently?
pressure sores
+ Overall cleanliness
and maintenance of
dry and aerated skin
(uncompromised by
urine/feces/perspira-
tion)
+ Padding for pressure
points and bony
prominences including
padding on bed/chair
+ Proper gentle massage
to bony areas several
times a day.
+ Regular assistance Ask Direct Care Staff:
for resident to turn - What can you tell me
or shift weight (bed- about Mr./Mrs.
rails, footboards, swollen feet/wounds/
trapeze). bruises/etc.?
+ Bed linens, clothing, - What do you do for them?
underpads smooth and
free from wrinkles. Ask Charge Nurse:
+ Elastic bandages or - How did get
hose are smooth and cuts, bruises, etc.?
wrinkle free. - What is being done to
+ Elastic bandages prevent further occur-
wrapped smooth with ance?
appropriate overlap. - What treatment is he/she
+ Dietary utritional receiving?
support for skin
integrity. (See
Guidelines for
Dietary/Nutrition
+ Prevention of
shearing force when
resident's position
altered by staff.
+ Turning and reposi-
tioning as needed.
- Care and Treatment:
+ Turning and reposi-
tioning every two
hours or as needed
(e.g., alternative
approach that is
justified by the
facility.)
+ Positioning of the
ulcer site or protec-
tion of affected
areas.
+ Use of effective
pressure relief
devices.
Wounds/Wound - Condition of dressing - Ask Resident:
Dressings i.e., clean, firmly - How often is the dress-
F126 secured unless contra- ing changed?
SNF 405.1124(c) indicated. - By whom is the dressing
- Observe, if possible, changed?
and with resident's - Does it seem dressing
permission, a dressing changes are frequent
change enough?
+ Pre-dressing - Are there any odors from
Removal the dressing?
Equipment and - Is the dressing change
supplies organized always done in a similar
Hands washed way?
Residents provided - If not, what are the
with privacy differences?
- Dressing - Do you feel confident
Is: that the wound is being
+ Old dressing ob- well cared for?
served for drainage? - Is the area/wound
+ Wound examined healing?
+ Appropriate technique - What caused the ulcer,
used wound, etc.? Is it
+ Proper disposal of healing? Does the staff
old dressing? keep you informed of its
+ Post dressing status?
+ Does staff member
wash hands? Ask Staff:
+ Return resident to - Specific treatment and
comfortable position schedule for each
or previous activity? resident?
Restraints Direct to evidence of: Use of restraints may be
F130 precipitated by an "emer-
- Proper application gency" situation in which
- Proper use there is a threat to the
When residents re- - Maintenance of good resident's health or safe-
quire restraints body alignment ty, or a threat to the
the application is - Resident observation, health and safety of
ordered by the phy- release and exercise others due to the resi-
sician, applied dent's behavior.
properly, and re- Observe frequently Restrained residents may
leased at least throughout your visit to not be coherent or
every two hours. validate care. Specific rational enough to re-
(See also informa- observations should in- spond to questions and
tion under Resident clude the following caution in interviewing
rights-freedom from items: therefore, must be exer-
abuse & restraints) - Type of restraint: cised. However, observa-
belts, wrist or ankle tion of a resident in a
cuffs, blanket geri-chair with table in
restraints, vests, bed place or a resident in a
nets, locked, etc., wheelchair (with vest
(When locked restraints restraint) for several
are used can you hours would warrant
readily find the key appropriate questions as
and/or scissors?) to when the staff last
as well as geriatric assisted him or her to
chair or geri-table/ move about or whether the
tray in place for resident would like to get
prolonged periods. out of the chair. Staff
- Protective devices interviews focus on the
and/or safety devices reason why the resident is
that are used as re- restrained.
straints must be eval-
uated as restraints. Ask Direct Care Staff and
- Appropriate applica- Charge Nurse:
tion: skin protected - When, why, and how to
from injury (restraint release and apply re-
neither too loose nor straints?
too tight to prevent - Why is the resident
rubbing and blistering restrained?
or impeded circulation) - Was the resident given
- Body alignment and sup- an option of restraint?
port: use of pillows, - When were you taught
footboards, and wheel- the use of restraints?
chair footrests to By whom?
maintain appropriate - If chemically restrained
posture, circulation, (excessively sedated)
and to prevent skin + Why is this done?
injury or breakdown. + Whether alternate
- Periodic release and means of restraint
exercise: exercise may have been attempted,
include ambulation, for how long this will
range of motion, continue, etc. This
massage, or other op- should elucidate from
portunities for motion staff whether the
(at least 10 minutes chemical restraint is
every 2 hours during necessary, or whether
day and evening hours). it is done for staff
- Chemical restraints: convience by control-
residents appear ling resident behavior
drowsy throughout the - Do you ask the resident
day (may indicate for permission before
tranquilizers or other using restraints?
drgus are being used - How does the restrained
to limit or control resident summon
behavior for staff assistance?
convenience). - What is the usual time-
frame for assistance to
reach the restrained
resident?
Ask Resident:
+ Why are you restrained?
+ What would happen if the
restraint were removed?
+ When do you use bed
rails?
+ What purpose do they
serve?
+ How do you gain
assistance?
Bowel and Bladder - There should be a Both the resident and
F131 chart/record in the direct care staff should
SNF 405.1124(c) resident's room on be interviewed and should
Each resident with which the program is exhibit a good under-
incontinence is documented accurately. standing of the importance
provided with care - If the room is located of maintaining a regular
necessary to en- a distance from the schedule of elimination.
courage continence toileting room or for If neither are aware of
including frequent residents with problems the intake and toileting
toileting and ambulating, a commode schedule, then determine
opportunities for may be present in the whether they are appropri-
rehabilitative room. ately panning the resident
training. - Verify that a call or carrying out a retrain-
light is available to ing program.
the resident if non- - Verify that the resident
ambulatory or re- is aware that he/she is
strained. on a retraining program
- Are fluids available at and knows the content
bedside? of the program.
- Is there roughage on
meal tray? Ask Resident:
- Diet is appropriate Suggested questions are:
to enhance elimination? - How do you deal with
constipation/diarrhea?
- Are you involved in a
special bowel/bladder
training program?
- If so, how does your
program work?
- Any problems with it?
- Any successes to date?
- What does the staff do
for you in this matter?
- Are they consistent and
timely?
- How long do you have to
wait to be taken to the
toilet?
- When a resident puts Ask Nurses Aides and
on his/her call bell Charge Nurse:
for toileting assis- + Will you describe this
tance, how long is it resident's bowel/
before assistance is bladder (B/B) training
given/ program?
- Observe pre-meal + How long has it been
toileting. in effect?
- Privacy provided. + When will you evaluate
- Schedule for toileting the results?
should allow for resi- + If this program is not
dent's normal sleep successful
pattern, to avoid - What assessment was done
disrupted sleep. to determine B/B status
- For residents not on
B/B retraining programs
what is the facility
program for managing
incontinence?
Catheter Care The indwelling catheter Ask Resident:
F132 should promote a contin- - What is the tubing/
SNF 405.1124(c) uous flow of urine unless cathetor for?
ordered otherwise. The - Why do you have one?
Each resident with surveyor should also - Does it cause any dis-
a urinary catheter observe for the comfort?
receives proper following: - If it does, what is done
routine care in- - Ample supplies for about it?
cluding periodic catheter insertion and - How do you feel about
evaluation care. having the catheter?
- Proper positioning of - Is any special care
the tubing and drainage given in relation to
bag. the catheter?
- Cleaniness of the
tubing and drainage Ask Nursing Aide and
bag. Charge Nurse:
- Color and consistency - How do you routinely
of urine in bag. position and secure
- Availability and accur- catheters and drainage
acy of documentation bags?
on the I&O sheet if - How often is each part
ordered or policy. of the system changed?
- Proper equipment for - What are the indications
ambulation - leg bag if for insertion of the
resident is ambulating. catheter?
(if ordered) - What is the facility's
- Availability of fluids. procedure for routine
- When indicated moni- catheter care?
tor intake to ensure - How do you observe
adequate intake and for U.T.I.'s in resi-
output or conformance dents with indwelling
with physician orders. catheters?
- How many observed - What is the facility's
residents are on procedure for the
catheter care? cleansing and storage
of reusable catheter
equipment and drainage
receptacles?
- How do you care for
catheter tubing?
Injections - Observe for preparation Ask Nurse:
F133 of injection - i.e - What is your plan for
SNF 1124(c) maintenence of steri- alternating injection
lity; correct dilution, sites? Show me.
handwashing, before - What is the medication
preparation, etc. for and what are poten-
- Observe injection site tial adverse reactions?
for: - Is there nonspecific
+ Redness pain at the injection
+ Discoloration site or shooting pains
+ Swelling down a limb?
+ Lesions - Is there skin irrita-
- Observe for proper tions or lumps under
technique when injec- the skin?
tion is given - If adverse reaction
+ correct site occur, how soon are they
+ correct needle size reported?
+ correct volume of - Could this be given by
drug any other route?
+ sterility maintained
- Resident is observed Ask Resident:
for any adverse reac- Suggested questions are:
tion 1. What kind of medicine
- What is the disposal do you receive by
method for used needles injection/shot? Why
or syringes? do you need that
medicine?
2. Do you have pain or
numbness at or around
your injection site?
3. Who gives the
injection?
4. Do you receive your
injection according to
a schedule?
Parenteral Fluids The surveyor should Ask Resident:
F133 observe that parenteral - Why do you have this
SNF 405.1124(c) fluids are administered tube in your (arm)(leg)?
with safe, aseptic tech- - Is it comfortable?
nique providing fluids as - Is there a way it would
ordered by the physician. be more comfortable?
Safety and comfort - How long has it been in?
measures are to be taken - How much longer will it
insuring maximum protec- stay in?
tion and optimum hydra-
tion of the resident. Ask Appropriate Staff:
- Why the resident is
The surveyor should note receiving I.V. therapy?
the following items: - What the drip rate is
- Labeling of the (the amount of fluid to
solution bottle/bag. be received per hour).
- Rate of infusion/cc/ml - How often the dressing
per hour. is changed.
- Date and time started - How often the tubing is
-- additives, if any. changed.
- Any signs of swelling - What are possible side
or redness at site. effects?
- Site dressing is clean, - How often is the site
dry and dated. changed?
- Accurate I&O of paren- - How often is the infu-
tal and P.O. fluids sion checked for drip
- If splint (armboard) rate and the remaining
is used, it is applied volume to be adminis-
to prevent movement tered?
but not impede circu-
lation. Ask Nursing Aide
- Positioning of I.V. - What are your respons-
tubing. ibilities when caring
- Comfort of restraint for a resident receiving
used to allow for IV fluids?
maximum resident free- - What training have you
dom while preventing had?
movement of I.V. site.
Colostomy/Ileostomy The surveyor should Ask Resident:
F133 ascertain that the - Why was the ostomy per-
SNF 405.1124(c) facility is providing formed?
appropriate nursing care - How do you feel about
to those residents who the ostomy?
have had bowel surgery - Does it ever cause you
resulting in a colostomy problems (e.i., pain,
or ileostomy. It is skin problems, odors
recommended that the accidents)? If so, what
surveyor, with the resi-
dents permission, observe does staff do about it?
care being given to de- - What does the staff
termine that proper tech- generally do with or for
niques are being used. the ostomy? Are they
The following steps consistent and timely?
should be taken to assure - Has staff talked to you
that proper ostomy care about doing some of the
is being provided. care for this? If so,
what was the outcome?
- The ostomy dressing If not, is this some-
should be changed or thing you'd be inter-
the bag emptied and ested in learning more
thoroughly cleaned about?
promptly after each
bowel evacuation or Ask Staff:
more frequently, if - If nurses aid:
drainage continues. + How did you learn to
- The peristomal skin take care of colos-
should be cleansed and tomies?
dried, and appropriate + What do you do if the
measures taken to pre- skin around the colos-
vent excoriation and tomy becomes red or
infection. sore?
- The resident's privacy + Do you ever teach
should be considered the residents to care
while providing care. for their own colos-
- The resident should be tomies?
provided with informa- - If nurse (RN or LPN)
tion and instruction in + What is the procedure
self-care at the if the resident be-
appropriate level of comes constipated?
understanding.
- The resident should be Ask Other Nursing Staff:
observed for signs of - Is there a facility
withdrawal, disgust procedure for ostomy
anxiety, or other emo- care?
tional responses which - Do you have skin
may be related to his/ problems with your
her acceptance of the ostomy residents?
colostomy/ileostomy. - What do you do when
- The surveyor should skin becomes excoreated?
observe the staff - What teaching do you
giving ostomy care to do with the residents?
verify that proper - What in general is the
technique is used. response to this
teaching?
Respiratory Therapy - Aerosol Compressor or While interviewing the
F133 IPPB (Intermittent resident, observe for
SNF 405.1124(c) Positive Pressure sounds of congestion.
Breathing Machine) Note color of lips and
The surveyor must nail beds.
determine that the
facility is providing Ask Resident:
respiratory therapy as - Do you ever feel short
ordered by the physi- of breath?
cian. Observation for - If yes, what is done
this indicator should when this occurs?
focus on the necessary - Is the therapy helping
equipment as well as on you to feel better?
the resident. In order - Are there any problems
to determine that the with it?
necessary equipment is - If so, how does the
available, the surveyor staff respond?
must look for the - Is the therapy con-
following: sistently performed -
+ Aerosol compressor or both concerning time
IPPB Machine. Check and method of providing
that the machine is it.
clean and operable.
+ Tubing - If tubing
is not attached to
the machine, ask to Ask Staff:
see it. Check that - What is the reason the
it is stored dry and resident is getting this
with consideration therapy?
for cleanliness. - What are the expected
+ Nebulizer Cup - results?
should be attached to - Can you demonstrate how
tubing. It is filled you use the equipment?
with either the pre- - How often is the equip-
scribed medicine or ment cleaned?
distilled water only - What are the infection
if about to be used. control procedures in
It should not be regard to use of res-
stored wet. If it is piratory equipment?
not attached to the - What training was given
tubing, ask to see you in the use of this
it. The mouthpiece equipment?
is connected to the - Where is the emergency
nebulizer cup. oxygen supply?
The surveyor should also
check that all involved
equipment is clean.
- Oxygen Therapy
The surveyor must
establish that the
facility is meeting
the oxygen needs of
the resident. When
the facility does not
have wall units, check
that:
+ There are enough
cylinders for oxygen
delivery.
+ There should be
flow meters and reg-
ulators for tanks
in use.
+ A wrench should be
attached or stored
close by.
+ If using large
cylinders (size G or
H), look for a
carrier since these
tanks cannot be
transported without
it.
+ The cylinder at the
resident's bedside
should either be on
the carrier, sitting
on a metal skirt, or
otherwise secured.
+ There should be other
necessary equipment
available such as
humidifiers, nebul-
izers, masks, nasal
cannulas, T-pieces,
etc., all should be
dry and clean when
stored.
+ Check to see that non
bed-bound residents
are not limited to
their own chair/room
when using oxygen
(portable units
will prevent social
isolation.
+ Water reservoir is
appropriately filled
per manufacturers
instructions.
+ Check to make certain
the tank is not
empty and that any
tank is labeled as
such.
+ Check for good oral
hygiene of resident.
+ The room should be
posted with a "No
Smoking" sign.
- Residents on respira- Residents on Respirators
tors: Ask Staff (all levels):
+ Are alarm systems - What training have you
turned on? had in caring for
+ Is sufficient Oxygen residents on respira-
supply available? tors?
+ Is the ventilator - Can you show me how the
accessible to an alarm system works?
emergency outlet? - What is your procedure
+ Is the resident in for pulmonary care?
a location that - What is your procedure
allows for frequent for changing tubing and
observation by staff? the water reservoir?
+ How does the resident - What happens if the
communicate with power goes off?
staff?
+ What level of staff
(aide, LPN, RN)
caring for the resi-
dent?
+ Is such equipment
at bedside?
+ Is there reserve
back-up equipment?
+ What is the condition
of the residents skin
around intubation
tube/tracheostomy.
+ Does the care given
use appropriate
technique in caring
of the patient?
Tracheostomy Care Satisfactory tracheo- Resident interviews must
F133 stomy care is a pro- be guided by the resi-
SNF 405.1124(c) cedure which promotes dent's communication
a clean, unobstructed ability.
air passageway and main-
tains the skin integrity Ask Resident:
surrounding the tracheo- - How long will you have
stomy site. it?
The surveyor should - What care can you do
determine whether: for yourself?
- Adequate supplies are - What do you need help
available for the care with?
of the tracheostomy - Who helps you?
such as tracheostomy - Is someone always avail-
kits, hydrogen per- able to suction him/her
oxide, normal saline when needed?
or sterile water, - Is the suction equipment
suction machine, always available in
catheter, sterile working order?
gloves, and clean - Is the dressing kept
dressings. clean and comfortable?
- The resident is - Is the tube kept clean
breathing without and changed as needed?
difficulty and is - How often are the tubes
comfortable. and dressings changed?
- The dressing is clean, - Does he/she feel confi-
dry, and intact; the dent in the personnel
cannula is clean, in caring for his trach-
the proper position, - What is communicating
and secured. with staff and other
- The skin surrounding residents like?
trach is clean and dry - Are staff patient and
with no redness or do they allow you enough
inflammation. time to express your
- The resident has ade- needs/thoughts/
quate oral hygiene. feelings?
- An extra tube, the same [- May I observe your
size as the one in tracheostomy care?]
Ask Staff:
- Why does resident have
place, is available at tracheostomy?
bedside. - What training were you
- Does resident have an given to enable you to
adequate method of care for tracheostomies?
communicating with the - What is the procedure
staff? for tracheostomy care?
- Does staff allow enough - How often is the tube
time for residents to changed?
communicate? - What do you do if the
tube comes out?
- May I watch you do a
dressing change?
- If not convenient, de-
scribe what you do.
[- How do you communicate
with a tracheostomized
resident?]
Suctioning Suctioning is necessary Ask Resident:
F133 for any resident who is - How are you feeling now
SNF 405.1124(c) unable to cough up after the suctioning?
secretions that are ob- Does the suctioning seem
structing his airway. to help?
Suctioning may occur via - Has staff explained to
the oral or nasal route, you the need for suc-
or stoma route with tioning? Why do you
sterile technique. need to be suctioned?
Attempts should be made How often?
to observe a resident - Who performs the
being suctioned should suctioning (i.e., nurses
such an opportunity or nurses aides)? Do
arise. If so, observe you feel safe with the
that a clean/aseptic staff performing the
technique is observed suctioning?
throughout and that the - Does everyone do it
resident tolerated the about the same way?
procedure. There should
not be bloody aspirant, Ask Staff:
cyanosis, or broncho- - When and where did you
spasm. Check that equip- learn to suction?
ment is in good working - Tell me what procedure
order, frequency of pro- you use when you suction
cedure, etc. a resident.
- Do you always have
Resident observations enough suction machines
which indicate need for and catheters?
intervention include: - How frequently is
- Secretions are draining suction tubing changed?
from a resident's - What provisions do you
mouth or trach and the have for suctioning if
resident is unable to the electricity is lost?
cough or clear himself. - Where are your emergency
- There are audible electrical outlets?
crackles or wheezes - What is your procedure
and/or diminished for disposing of the
breath sounds. secretions from
- The resident is suctioning?
dyspneic. - How often does Mrs./Mr.
- Restlessness or agita- need to be suctioned?
tion may also be an - May I observe you when
indication that suc- you suction Mrs./Mr.?
tioning is needed.
Upon completion of
suctioning above symp-
toms should, in most
cases, be relieved.
The surveyor should
observe that the re-
sident is positioned
to facilitate breath-
ing (usually at a 45
degree angle). Check
to see that the facil-
ity has an ample supply
of suction machines
and suction catheters
to meet the needs of
residents requiring
them and that they are
clean and properly
stored.
Tube Feedings - Staff use proper tech- If the resident is able
F133 nique in administering to be interviewed, sug-
SNF 405.1124(c) feedings and medica- gested questions may be:
tions. Check to see
that staff checks for Do you feel comfortable/
location of tube before safe with all the staff
feeding and that tubing who perform the feeding?
is irrigated before and If not, what happens?
after addition of medi-
cation. Are you losing or gaining
- The tube is clean and weight? What is your
formula flows freely. goal?
- The equipment is clean
and protected. If Ask Staff:
dressings are ordered, - Please describe how
they are in place, you would carry out a
clean, and dry. resident's tube
- The nasal tube is feeding.
securely but comfort-
ably secured on the
face with skin main-
tained intact and with-
out irritation.
- The skin around the
gastrostomy is kept
clean and free from
irritation or infec-
tion. It should be
checked carefully for
leakage of gastric
contents.
- A resident who has a
N/G tube for a pro-
longed period of time
should be observed for
possible complications,
such as nasal erosion,
sinusitis, esophagitis,
gastric ulceration, and
pulmonary infection.
- Resident is fed slowly
with head elevated to
45 degrees during feeding
and at least 1 hour
post-feeding.
- Supplies for mouth care
are in evidence, ob-
serve if possible for
technique; mouth shows
evidence of good care
(i.e., moist, clean.)
Nursing Services Are personnel performing Ask Resident:
F137 duties that are allowed - Do residents generally
SNF (405.1124) under the State Nurse feel that people taking
ICF (442.338) Practice Act? care of them know what
B. Twenty-four they are doing?
hour nursing. Do you observe care being - If no, explain.
rendered in an appro- - Are your treatments
F137 priate, competent manner? done in a consistent
1. Assigned manner?
duties con- Does the time schedule - If no, explain.
sistent with posted indicate that at - Do you feel that there
their educa- least the minimum re- are enough people here
tion and quired personnel are to take care of you?
experience/ scheduled and actually - If no, explain.
based on the on duty? - How long do you usually
characteris- wait for help when you
tics of the What is the usual put your call light on?
resident response time before a - Is there anything that
load. call bell is answered? doesn't get done as
often as it should?
F138 In SNF's is an RN on
2. Weekly time duty during the day? Ask Staff:
schedules are - Do you feel qualified
maintained. Are licensed staff and to do all the work you
aide staff functioning are assigned to do?
F139 in appropriate roles? - If no, explain.
3. There is a - Do you feel you have
sufficient Where are staff spending enough training to keep
number of their time? up with the care the
nursing staff residents require?
available to Check for staff who are - If no, what else do
meet the actually on duty. you need?
total needs
of all resi-
dents.
F140
4. There is a
registered
nurse on the
day tour of
duty 7 days
a week (for
SNF only).
Intent
That all resi-
dents are cared
for by
personnel
qualified
to pro-
vide the care &
that sufficient
numbers
& class-
ifications of
personnel are
available.
Patient Care Observe resident level of Ask Resident:
Management physical, mental, emo- - Are you aware that you
tional and social func- have a plan of care?
F167 tioning. Note problems, - Did you participate in
SNF 405.1124(d) potential problems, developing a plan of
needs, using observation/ care?
interview/record review - Do you/your family know
F168 work sheet. what the plan is and
ICF 442.341 details? (e.g., diet,
ambulation, dressing,
etc.)
F169 - Do you attend and par-
A. Each resi- ticipate in plan of
dent's needs care meetings?
are addressed - Who else attends the
in a written plan of care meetings?
plan of care - When did you last attend
which demon- the meeting for your
strates that plan of care?
the plans of - Does the staff assist
all services you in achieving the
are integrat- goals on the plan of
ed, consonant care? If not, who does
with the phy- or why not?
sician's plan - Do you have all neces-
of medical sary assistive devices
care, and is and equipment?
implemented - Is there anything that
shortly after is not part of your plan
admission. of care that you think
should be included?
- What happens if you
F170 question any treatment
or procedure? Can you
B. Each profes- give an example?
sional ser-
vice identi-
fies needs,
Ask Staff:
goals, plans, - What is your input into
and evaluates resident's plan of care?
the effec- - What aspect of the
tiveness of resident plan of care
interventions are you carrying out?
plus insti- - What is this particular
tutes changes resident's plan of care?
in the plan - How do you assist the
of care in a resident in carrying out
timely man- the plan of care?
ner. - Who attends the care
planning meeting?
INTENT - Is the plan of care
useful to you in caring
The intent
is to for the resident?
assure that the - Is there anything the
facility
identi- resident needs that is
fies the resi- not addressed in the
dent's (with plan of care?
residents/
family - How often is it
input if appli- reassessed?
cable) needs
through the
coordinated
efforts of all
disciplines.
Restorative Nursing A. Observe residents in Ask Resident:
Activities of Daily need of assistance. - What assistance do you
Living 1. Is needed assist- need with bathing and/or
F171-176 ance provided? dressing? Who helps
SNF 405.1124(e) 2. Is resident pro- you?
vided assistance - Does the staff plan
ICF 442.342 and instruction, with you your dressing/
442.343(a)(c) as appropriate, in bathing schedule?
all ADL's to in- - Do the nursing and
crease his/her activities staff coor-
level of indepen- dinate your schedule so
dence? that you have the
3. Does staff opportunity to partici-
minimize pain/dis- pate in favorite
comfort while activities?
assisting resi- - Are you able to dress/
dent? bathe at times con-
4. Is resident taught venient for you?
transfer tech- - Are you bathed con-
niques? sistently? (i.e., on
5. Is resident the day(s) scheduled
assisted to toilet does the bath get
in timely manner? performed?)
INTENT 6. Resident personal - Where are you bathed?
equipment avail- (bed, shower, tub?)
To assist
the re- able & within - Are there adequate
sident to
attain reach? clothes available for
or maintain
his/ you to wear?
her maximum
level Glasses - Do they come back from
of independence Hearing aids laundry in appropriate
and function? Dentures condition?
[Artificial larynx] - How do you get in and
out of bed?
- If staff assists you,
do they seem to be able
to do their job
appropriately? Do you
always feel safe when
being helped?
Prosthetic devices - Are staff members en-
(eg. braces, artifi- couraging you to do
cial extremities). things for yourself?
Adaptive equipment - Do you have any problems
(e.g., built-up getting to the bathroom
spoon, reachers). on time?
Orthotic devices (eg. - Do you have any problems
splints, AFO's). with leakage when you
Restraints (eg. vest, sneeze, laugh or at any
waist, wrist, ankle, other particular time?
mitts, nets, geri- - How does the staff help
chairs). you with these problems?
Grooming items (eg. - Are they aware of the
comb, brush, shaver). problems?
Oral hygiene (eg. - Do you bowels move reg-
toothbrush, tooth- ularly?
paste, mouthwash, - If not, what do you/
denture cup). staff do about this?
Self-feeding devices. Are you able to feed
Assistive devices for yourself?
special sensory loss - Are you able to get to
needs (eg. communica- the dining room by your-
tion boards, large self? If not, why? In
print books, magni- that case, what does
fiers, writing tab- staff do about this?
lets, picture cards, - How long have you been
talking books). up today?
- Do you usually lie down
Training/re-training for a rest?
Prosthetic management - If you need help getting
Stroke adapted ADL's into or out of bed, is
Self-injections of staff available to help
medications you when you need it?
Bowel/Bladder - Where do you spend most
Self-feeding of your time - in your
Self grooming chair, wheelchair or in
Ambulation bed?
Colostomy/Ileostomy Care Does anyone move your
Respiratory Care arms or legs or help you
(oxygen inhalation) with exercises?
Speech - Have your sleeping hab-
Mobility its changed since you
Upper extremity dressing came to the nursing
Lower extremity dressing home? If yes, in what
way?
Observe at mealtime - Are you able to get help
whether staff encourages/ during the night if
guides residents in self- needed?
feeding or feeds the + What kind of help is
residents. needed?
+ Is staff response
timely?
- Do you feel there are
adequate care supplies
at this facility?
- If not, can you give me
an example of why you
feel this way?
- Is your family involved
in assisting you or if
learning to help you?
- Do you feel there is ad-
equate staff at this
facility?
- If not, can you give me
an example of why you
feel this way?
- Does staff assist and/or
encourage activities
(e.g., R.O.M., ambula-
tion ADL, communication
programs, feeding)?
- How often does staff
assist in activities?
- Is there anything resi-
dent would like to do
for himself/herself that
staff is doing?
- Is resident comfortable
(e.g. free from pain)?
- Is your cane/walker/
crutches comfortable for
you to use?
- Did anyone measure you
so you have the right
size cane/walker/crutch-
es?
- Did anyone show you the
correct way to use your
cane/walker/crutches?
- If the facility arrang-
ed so that you can get
around easily?
Ask Activities Staff
Do you provide information
to nursing staff about
time and place of activi-
ties, plus names of resi-
dents who are to attend or
those who might be inter-
ested in attending?
Chair-bound Resident
Ask Resident:
- Does he/she know why he/
she is in a chair?
- Is resident assisted to
use bathroom?
- Is resident comfortable?
- Does he/she see thera-
pist? (O.T., Speech,
P.T.) and how often?
- Does resident go to a
therapy area or does
therapist come to resi-
dent?
- Is able to reach items
needed?
Ask Nurses Aide
- Who give you information
about the time and place
of activities and which
residents are to attend?
How are you given this
information?
- How do you encourage a
resident to do the most
for themself?
Wheelchair Resident
Ask Resident:
- Does he/she know why he/
she needs a wheelchair?
- Is resident trained and/
or encouraged in inde-
pendent W/C ambulation
and activity?
- Does resident know how
to lock and unlock
wheelchair?
Ask Staff:
- How is a resident set up
for independent W/C
ambulation?
- Nurse Aide - has resi-
dent received instruc-
tion in transfer tech-
niques?
For Bed Bound Resident
In addition to appropriate
interview questions above:
Ask Resident:
- How do you spend your
day?
- Can you do some things
for yourself?
- Does the staff give you
a chance to learn self-
care skills?
Ask Nurse:
- If the resident had
access to a recliner
chair, would he/she be
able to be out of bed?
- Is the time out of bed
coordinated with the
activity schedule and
necessary care?
Ask Nurses Aide:
- Does this resident do
any self-care? Why not?
- If no, has anyone tried
to teach him/her to do
some care?
Positioning Observe residents in bed, Ask Resident:
F175 chairs, restrained, or in - How often are you
SNF 405.1124(e) "protective devices" for turned/repositioned by
- body alignment the staff?
- positioning - Is that often enough?
- contractures (when did - Are you comfortable now?
they occur and what is Do you have any pain or
being done)? discomfort? Where?
Intent - ROM program (observe - How long have you had
extent & technique of joint stiffness (con-
To assure that provider) tractures)?
the resident is - Assistive devices - What kinds of exercise
positioned at (overhead pulleys, do you do every day, in-
all times to
promote maximum slings, splints, etc.) cluding range of motion
therapeu- - Turning/repositioning (ROM)? How long does
tic benefit and schedule and adherence the exercise last and
comfort, as to the schedule. how frequently do you
well as safety. - Devices to maintain exercise each week?
positioning, i.e., - Do you wear special
sandbags, extra devices? How often?
pillows, etc. - Consistently?
- Are they always applied
Specific Observations and removed appropri-
for the Bed Resident ately and promptly?
(as appropriate to How Often?
condition). - By whom?
Positioning/body align-
ment Bed Rest Resident
Resting splints & correct Ask Resident:
application - Why do you have to
Foot positioning boards stay in bed?
Trapeze - How often does staff
Hand rolls get you OOB?
Elbow/leg splints & - Do they know how to get
correct application you up?
Restraints - Who sets you up and/or
Siderails (padded) assists you in bedside
Special mattresses ADL's?
- Does staff, therapist
check positioning,
supportive devices?
Blankets/pillows - When?
Clean, smooth linen - Does staff answer call
Clean, appropriate bed bells promptly? How
wear soon?
Turning schedules - Is resident able to
ROM schedule reach items (e.g., water
O.O.B. (as tolerated) call bell, urinal,
Water available emesis basin, tissues)?
All adaptive devices are - How much confidence do
clean and in good you have when the nurses
repair. are helping you
All assistive supportive transfer, or turn and
devices are clean and so on?
in good repair. - Does resident go to
therapy area or does
Specific Observation for therapist come to
the OOB Resident in Chair resident?
(geri-chair, lounge chair
in room, as appropriate Bed Rest Resident
to condition) Ask Staff:
Arrangement of room fac- - How often is position
ilitates residents op- changed?
timal independence (e.g., - What activity is done at
independent eating, the time (e.g., R.O.M.,
grooming, T.V., radio, toileting, OOB,
water). grooming?
Positioning/body align- - What can resident do
ment. independently?
Blankets/lap robe, pil- - Is equipment available?
lows, foot stool. - Who maintains and cleans
Hand rolls, splints. the equipment?
Clean, dry attire. - What is the schedule
Pressure relief device. for this?
Restraints, with release - What training have you
& activity schedule. had to learn to position
Call bell available. patients correctly?
Specific Observation for - Was there any part of
the Wheel Chair Resident your orientation when
(as appropriate to you first came to work
condition, including here that addressed
deliberate alterations positioning?
made to equipment for - Do you have any periodic
specific reasons.) reviews/updates on
- Proper fit positioning?
- Good working condition
- Appropriate arm rest, Chair Bound Resident
footrest, leg support, Ask Staff:
lap tray - How often is resident
- Proper positioning repositioned/taken out
- Pressure relief aids, of chair?
(e.g., gel flotation - What is the activity at
pads, egg crate time of repositioning
mattress, sheepskin) and/or release of the
- Set up for independent restraint?
W/C ambulation - What can resident do
- Functional adapted independently?
toilet area
- Transfer techniques Ambulatory Resident
Observe how staff wheel Ask Staff:
the resident (e.g., do Is resident encouraged to
they inform before independently ambulate to
starting movement)? and from activities and
Are patients moved dining room (with or
wheeling forward and without personal assist-
facing elevator doors? ance)?
Observe staff for: - Does resident do as much
- verbal cues as he/she can
- physical support independently?
- body mechanics - What does resident do?
- How do you know that
Specific Observation for resident is maximally
the Ambulatory Resident independent?
(as appropriate to - If it is not working
condition) independently, how do
- Gait (steady/unsteady)
- Appropriate devices for
ambulation (e.g., cane, you deal with it?
crutches, hemi-sling - Is there something
- Posture resident would like to
- Appropriate staff do that he/she is not
assistance in allowed to do (e.g.,
ambulation shave self, apply make-
- Grab bars (halls, bath/ up, style own hair)?
shower area) - What training have you
- Functionally adapted had in learning to
toilet area position residents and
do range of motion?
- What opportunity do you
have for ongoing
training?
- Who does the actual
training?
Check question placement
under Interviewing. May
be more appropriate for
resident's rights section.
Observe wheeling technique
used by staff.
Nursing Services Ask Resident
G. Administration Observe a drug pass with - Do you always receive
of Drugs at least 20 residents your medication on time?
F183-184 receiving medication. - If not, what is the
SNF 405.1124(g) See SOM Appendix N. problem?
ICF 442.337 Transmittal No. 174 for - Do you receive the
details of the Surveyor correct medication?
F186 Methodology for Detecting - What does it look like?
1. The patient Medication Errors. - Who explained your
is identified medications to you?
prior to ad- - Observe medication - What reactions do you
ministration administration tech- have?
of a drug. niques (e.g., hand- - What happens if you have
a question or refuse to
take your medication?
- Who gives you your
medication?
- Do your medications
change in appearance?
washing, pouring of - Do the nurses stay with
F187 dosage, position of you when you take your
2. Drugs and resident). medication?
biologicals - Do any of the medi-
are admin- cations bother you?
istered as
soon after Ask Staff:
doses are - Do you generally have
prepared. available the medi-
cations you need?
F188 - Are there any problems
b. Administered in administering
by same per- medications?
son who pre-
pared the Note drug doses refused by
doses for ad- resident and how handled
ministration by staff.
except under
single unit
dose packet
distribution
system.
Exception:
ICF residents
may self ad-
minister
medications
with their
physician's
permission.
H. Conformance with Combine with observation
Physician Drug of drug pass.
Orders
F189
F190
F191
SNF 405.1124(h)
ICF 442.334(a)
Drugs are admin-
istered in ac-
ordance with
written orders
of the attending
physician.
Intent
All residents
receive medica-
tions as
ordered by
the physician.
DIETETIC SERVICES * Specific Observations Ask dietary manager to
(Condition of which might be indica- explain the procedure for
Participation) tive of possible nutri- making substitutions and
tion problems: recording the changes.
F193 - Is menu usually
SNF (405.1125) Clinical followed?
- underweight/
A. Menus and overweight
Nutritional - dehydration Ask Resident:
Adequacy - edema
- cracked lips 1. How are your meals?
- pallor 2. Are there foods you
F194 - dull or dry hair are not allowed to
SNF (405.1125(b)) - swollen or red have?
tongue 3. Are you on a special
- bleeding gums diet?
F194 - decubitus ulcers 4. Do you receive foods
ICF 442.332(a)(1) - infections that are not appro-
priate for your diet?
* Physiologic factors If so, what do you and
F196 which may affect the staff do about
Menus are planned intake: that?
and followed to - Swallowing diffi- 5. What time do you re-
meet the nutri- culties ceive breakfast, lunch
tional needs of - Vomiting and supper? Do you
each resident in - Food intolerance always receive a meal
accordance with - Poor dentition at mealtime? If not,
physicians' orders - Sore mouth why? What happens
and, to the extent - Constipation then?
medically possible, - Diarrhea 6. Do you like the taste
based on the recom- - Inability to feed of the food?
mended dietary al- slef 7. Is the temperature
lowances of the - Decreased visual and appropriate (i.e.,
Food and Nutrition olfactory acuity milk chilled, coffee
Board of the - Unable to communicate hot, etc.)?
National Research - Loss of appetite 8. Do you get enough to
Council, National eat? What do you do
Academy of * Psychological/Social if you're still
Sciences. hungry after a meal?
- Confusion
- Excessive food likes 9. Do you receive nourish-
and dislikes ment in the evening? Do
- Refusal to eat you have a choice about
* Selected biochemical what you want to eat?
Intent changes which might
Ensures that indication changes in 10. Do you receive medi-
each resident
receives nutritional status: cines during meals?
food in the - Visceral protein If yes, do you know
amount, kind,
and consis- status what it is or what it
tency to * serum albumin is for?
support optimal
nutritional * transferrin
status. * BUN
* Serum electrolytes
11. Do you get food from
During mealtime ob- outside of facility
serve the resident that you buy or family
for: brings? How often?
- adherence to food What kind of food?
preferences
- adequate space for 12. How often does anyone
eating from the kitchen come
- self-feeding skills to ascertain your feel-
- proper position for ings and opinions on
eating the food service, your
- ability to eat foods portion size, etc.?
served
- use of adaptive 13. Where do you eat (e.g.,
feeding devices dining room, your room,
- amount of food etc.)? Is this your
actually eaten choice? Do you have a
- protection of choice of where you
resident's clothes eat?
- amount of time
resident is allowed 14. How often have you
to chew and swallow seen a therapist for
- Assistance provided your swallowing diffi-
as needed to and from culties?" "How has
dining area the therapist
- All beverages are instructed you/staff/
covered] family on methods to
improve your swallow-
ing?
Ask Dietician
- Describe the meal
planning input you
receive from
residents.
Assistance being provided
in case of choking,
incontinence, falling,
or other emergencies.
Nursing Staff supervision
of dining areas including
residents' rooms during
meal times.
Observe serving portions
sizes on all menu items:
MILK GROUP
- 1 pint daily
Source of: Protein
Calcium
Phosphorus
B Complex
MEAT GROUP
- 5 lean meat equivalents
(1 meat equivalent = 1
oz meat, poultry, fish,
cheese & eggs; also
dried peas, beans, and
nuts).
Source of: Protein
Iron
Vitamin B12
VEGETABLE AND FRUIT GROUP
- 5 servings or more
(1/2 cup = 1 serving)
Source of: Vitamin A, C,
B6, Folacin,
Fiber
BREAD-CEREAL-POTATO-
LEGUME-PASTA GROUP
- 7 servings
(1 serving = 1 slice
bread; 1/2 cup other;
3/4 cup flake-type
cereal).
FATS AND SWEETS
(to increase caloric
intake)
IODIZED SALT
(unless contraindicated)
Adequate fiber in diet
B. Therapeutic System for the provision Ask Staff:
Diets of diets:
* Number, type of thera-
F197 * Dietetic service Kardex peutic diets?
SNF 405.1125(c) or file * Time of nourishment
* Therapeutic menus activity, who's respon-
* Nourishment preparation sible?
F198 and service * Nourishment provided for
ICF 442.332(b)(1) * Adequacy of nourishment day of survey?
(2) * Individual menus or
diet cards The surveyor should inter-
view staff regarding their
F199 SPECIAL FEEDINGS: knowledge of the feeding
1. Therapeutic The surveyor should also schedule and training in
diets are attempt to observe that: administering tube
prescribed
by the feedings. Some residents
attending * Staff use proper tech- having difficulty in
physician. nique in administering speaking or swallowing
feedings and medica- with the tube in place
tions. Check to see (i.e., poor toleration).
F182 that staff checks for The surveyor should in-
2. Therapeutic location of tube before quire if mouth feeding was
menus are feeding and that tubing attempted.
planned in is irrigated before and
writing, pre- after addition of medi- Ask Resident:
pared, and cation.
served as If the resident is able
ordered with * Unused milk-based tube to be interviewed, sug-
supervision feeding should be gested questions may be:
from
the dietician discarded in a timely
and advice manner 1. How long have you been
from
the attending fed by this tube?
physician
whenever
necessary. 2. When was the last time
you tried to eat by
mouth? What happened?
3. How often do you
receive the feeding?
Is this consistent?
4. Does the staff help you
in feeding? Do you feel
comfortable/safe with
all the staff who per-
form the feeding? If
not, what happens?
5. Are you losing or gain-
ing weight? What is
your goal?
6. How often is the tube
changed? Who does this?
Do you feel comfortable/
safe with all staff who
perform this procedure?
Interview staff regarding
knowledge of diabetic
diets.
* What nourishment does
the diabetic patient
receive?
* If diabetic patient
refuses the meal, what
is done to supplement
the meal?
If resident is able to be
interviewed, suggested
questions:
1. How long have you been
on your diabetic diet?
2. Do your know some of
foods you must avoid?
What are they?
Observe tray/meal 3. Do you receive a
service: nourishment between
F198 * Low sodium diets are meals or before going
platable (taste) go bed?
Therapeutic diets * Sugar sources on
prescribed by the diabetic diet trays
attending physician * Salt sources on sodium
restricted diet trays.
F199 FOR THE RESIDENT WITH
DECUBITUS ULCERS
Therapeutic menus Functioning system to Ask Staff:
are planned in provide the needed 1. Regarding knowledge of
writing, prepared nutrients: dietary needs.
and served as - Resident's general 2. What do you do when
ordered with super- appearance this resident refuses
vision from the - Meal service milk, meats, bread,
dietician and + Food acceptance etc.?
advice from the + Adherence to food 3. What nourishments are
physician whenever preferences provided to this res-
necessary. - Food supplement ident? How often?
+ Type to support 4. What happens when a
+ Method of service weight loss is noticed
+ Assistance provided with this resident?
+ Timely provision as
ordered Ask Resident:
- Portion sizes 1. Has anyone talked with
- Conforms to physicians you about the import-
orders ance of eating your
meals?
2. Do you get foods that
you don't eat on your
tray?
3. When do you feel
hungry?
4. Do you get between meal
nourishments?
RENAL REVIEW Interview Staff regarding
F198 knowledge of renal diets:
Therapeutic diets System in place for the
prescribed by the the correct provision of 1. What foods should be
attending physi- renal diets. restricted when a
cian patient has kidney
- Individualized menu problems?
F199 - Dietary Staff
2. What nourishments are
Therapeutic menus Utilize menu when given to these
are planned in serving diets. patients?
writing, prepared
and served as 3. Are fluids restricted?
ordered with
supervision from Ask Resident:
the dietician and
advice from the 1. Are you on a special
physician whenever diet?
necessary.
2. What foods must you
avoid?
3. Do you feel hungry?
4. Do you eat everything
at mealtimes?
5. Are the foods the
kitchen sends you the
correct ones for your
diet?
6. Has the dietitian ex-
plained your diet to
you?
C. Preparation Observe:
* Feeding assistance is
F204 provided or not provid-
SNF 405.1125(e) ed by staff
* Length of time resi-
dents sit and wait for
F205 meal service
* Food is served soon
1. Food is after cooking or re-
prepared by
methods that frigerated
conserve its * Trays are free of
nutritive spillage of foods or
value
and flavor. liquids
* Foods are appropriately
covered and kept at a
F206 proper temperature
2. Meals are * Cooking and service
palatable,
served at utensils are clean,
proper sanitary and greaseless
temperatures.
They are * Refrigerated foods must
cut, ground, be covered
chopped, * Leftover and pre-cooked
pureed
or in a form foods must be dated
which meets and labeled
individual * All cooked food stored
resi-
dent needs. above raw meats in
refrigerator
* Temperature gauge on
F207 or in refrigerator to
record temperature
3. If a resident * Shelving to allow air
refuses food circulation
served, * Food not stored in re-
appropriate
substitutes frigerator must be
of similar stored off the floor
nutritive (This is applicable to
value
are offered. food stored in walk-in
refrigerator and
freezer.)
- No rust on shelves
- No dripping or spillage
on shelves and floors
INTENT - Degree to which diet
modification is comm-
To provide foods ensurate with residents
that are safe and tolerance and
nutritious capability
- Residents for meal
SNF 495.1125(e) satisfaction
- Observe appearance of
food color, texture,
aroma, and flavor
- Less than 75% of meal
is consumed
- Type of substitutions
provided
D. Frequency * Menus as under A on Interview various resi-
page 63 dents about the nourish-
F208 * Who serves nourishments ment service:
SNF 405.1124(d) * Nourishment list and
schedule * Are nourishments offered
routinely?
F209 * At what time are they
ICF 442.331(a) offered?
* By whom?
* What kind of nourish-
F210 ments are offered?
1. At least
three meals
are served
daily at
regular hours
with not more
than a 14-
hour span
between a
substantial
evening
meal and
breakfast.
F211
2. To the extent
medically
possible,
bedtime
nourishments
are offered
to all
residents
E. Staffing - Food service personnel - Interview personnel to
are on duty for all de- verify that they are
fined dietary responsi- aware of their respons-
F212 bilities: ibilities and job
- Supervision descriptions
SNF 405.1125 (a) - Food Preparation
- Dishwashing
- Cleaning
F213
- Duty Schedules
1. Food service
personnel are
on duty daily
over a period
of 12 or more
hours.
Intent
Persons are
providing ser-
vices commensur-
ate with their
level of
training; and at
the level of
sophistication
needed by the
residents.
SPECIALIZED OBSERVE RESIDENTS ASK RESIDENT:
REHABILITATIVE As per "Restorative Nurs- (or ask staff, if resident
SERVICES ing Activities of Daily has severe communication
F214 Living" problem):
SNF 405.1126 - Are you receiving any
F215 SNF 405.1124(e)2(b) kind of therapy? P.T.?
SNF 405.1126(b) O.P.? Speech?
ALSO: - What kinds of ther-
F216 OBSERVE RESIDENTS IN apist(s) are working with
ICF 442.343 THERAPY AREAS: you on your swallowing
- Is privacy provided problem?
during treatment, as - What kinds of therapists
A. PLAN OF CARE applicable (e.g., cub- have instructed you on
ICF442.343(e)(1)(2) icle curtains, room how to improve your
dividers, one to one swallowing?
F217 area)? - How do the methods to
Rehabilitative - Is there appropriate, improve swallowing help
services are pro- courteous resident/ you?
vided under a staff interaction? - How often do you see the
written plan of - Are therapy areas appro therapist?
care, initiated -priate to treatment - What happens if the ther-
by the attending given (e.g., small, apist is absent for sch-
physician and de- quiet area for speech/ eduled treatments?
veloped in con- language/ hearing - Where do you receive
sultation with test and sessions, your therapy?
appropriate ther- large for P.T., exer- - How long have you been
apist(s) and the cise and therapy receiving therapy?
nursing service. groups, O.T. perceptual - Do other staff members
testing/splinting, assist with therapy? Who
B. THERAPY A.D.L. adaptations and in what way?
F218 area, as applicable)? - Are you in a comfortable
ICF442.343(a)(c)(d) - Is equipment clean and environment (room temp-
in good working cond- erature, privacy, etc.)?
Therapy is pro- ition? Is it operating - Do you have input into
vided according as per manufacturer developing or revising
to orders of the instructions (e.g., your therapy treatments?
attending physi- hydrocollator temp., - What things did you do
cian in parafin, whirlpool, immediately before enter-
accordance
with accepted etc.)? ing this facility, that
you are unable to do
now?
ASK THERAPY STAFF:
- How many days/hours per
week do you provide
therapy?
- Do you participate in the
development of the res-
ident's overall plan of
care? In what way?
- Do you utilize P.T.
- Are assistive devices "aides" In what way (if
being provided as interviewing the regist-
professional needed? ered physical therapist)?
practices by - Do assistive devices - How do you assure carry-
qualified
therapists or fit well, function and over of therapeutics in
qualified are used properly your absence?
assistants. (e.g., wheelchairs, - How often do you provide
crutches, braces, glas- inservice to staff?
C. QIOGRESS ses, hearing aids, What topics are covered?
canes, artificial limbs - Do you have opportunities
assistive eating to attend inservices?
ICF 442.343(f) devices)? - How do you communicate
- Is staff responsive to patient progress/regres-
resident expressions of sion, etc. with phys-
F219 discomfort? ician, nursing personnel,
1. A report of - How are the prescribed family, other
the
resident's treatments and training disciplines?
pro-
gress is com- meeting the needs of - How many residents cur-
municated to the resident? rently are receiving
the attending - Are parallel bars P.T., O.T., Speech-
physician sturdy and well sec- language pathology and
with-
in 2 weeks of ured to floor? Are audiology therapy
the systems designed for (SLP/AT).
initiation of
specialized weight lifting sturdy - Do you utilize the ser-
rehabili- and well secured; if vices of a certified
tative
services attached to wall with occupational/therapy
rigging and hand grips assistant (if interview-
in good conditions? ing the registered occu-
EXCEPTION: - Are nonverbal residents pational therapist)?
provided with means of If so, in what way?
ICF resident's communication (e.g., - Is space available for
progress must be writing tablets and the conduction of your
reviewed utensils, picture therapy?
regularly. cards)? - Is equipment readily
- Are visually impaired available to meet res-
residents provided with ident needs?
- Is there a coordinated
interdisciplinary
magnifiers and large approach toward rehabi-
print books? litation of the geriatric
resident evident in your
- Is equipment such as facility? In what way
whirlpool cleaned do you see this?
between patients?
F220
2. The
resident's
progress is
thereafter
reviewed
regular-
ly and the
plan of
rehabilitat-
ive care
is re-
evaluated as
necessary,
But at
least every
30 days
by the
physician and
therapist.
EXCEPTION
ICF resident's
plan must be re-
vised as necessary
INTENT
Therapy services
are provided that
will assist the
resident to attain
his/her optimal
level of function.
Pharmaceutical - Observe residents for Ask Resident:
Services excess sedation or - Are you aware of the med-
adverse effects: ications you are taking --
F221 + drooling use, frequency, contrain-
SNF 405.1127 + shuffling gait dictions?
+ involuntary movements - Has your physician dis-
F222 of limbs, tongue, fac- cussed the medications
A. Supervision ial muscles you are taking, with you?
+ loss of affect - How many medications are
F223 + drowsiness you taking?
ICF 442.336(a)(b) + postural abnormalities - How do you feel the med-
+ pill rolling movement cation helps you?
F224 - Observe for depression - How do medications bother
SNF 405.1127(a) aggitation you? (e.g., make you feel
The pharmacist nauseated or dizzy)
reviews the drug - Have you told anyone
regimen of each about this?
resident at least
monthly & reports Ask Staff:
any irregularities - How often does the pharm-
to the medical acist review the
director and resident's medications?
administrator. - To whom does he report
any irregularities?
- When the pharmacist re-
A registered nurse ports irregularities,
may be utilized to what is done about it?
perform this mon- - To whom do you report
thly review for any problems about
ICF residents. medication?
Also the attending - Do you feel the residents
or staff physician are receiving the proper
must review medi- medications, amount and
cation quarterly. kind?
- Is the pharmacist avail-
able to you for consult-
ation?
- Where does the pharmacist
perform his drug regimen
review?
B. Labeling of Observe labels of medicat-
Drugs and Bio- ions for residents observ-
logicals ed on drug pass tour for:
- name of drug
F225 - dosage form
SNF 405.1127(c) - strength of drug
- quantity of drug
F226 - expiration date
ICF 442.333 - presence of a control
number
F227 - appropriate accessory or
The labeling of cautionary statement
drugs and biologi-
cals is based on
currently accepted
professional prin-
ciples and includ-
es the appropriate
accessory and
cautionary inst-
ructions as well
as an expiration
date when
applicable.
INTENT
To assure that re-
sidents receive
medications as
ordered and that
they are monitored
for possible side
effects.
Laboratory and Observe symptoms of Ask Nursing/Rehabilitative
Radiological targeted residents, e.g., Staff:
Services drainage, odors, jaundice, -What do you do when you
fevers, edema, etc. think a resident needs
F228 laboratory work done -
SNF 405.1128 blood work, cultures,
etc.?
- How long does it take to
F229 get lab results back?
SNF 405.1128 (a) - What do you do with the
results when they do come
A. Provision of back?
Services - Do you have any problems
with your laboratory
F230 services?
- How are lab specimens
1. All services stored?
are provided
only on - Do you have any instruct-
the orders of ion from the lab regard-
a physician. ing collection and stor-
age of specimens?
F231
2. The attending
physician is
notified
promptly
of findings.
F232
3. Signed and
dated reports of a
clinical labora-
tory, x-ray and
other diagnostic
services are
filled with the
patient's medical
record.
INTENT
To assure that lab
tests are
performed
as ordered and
findings are
reported to phy-
sicians are made
aware of symptoms
that may require
lab tests.
Social Services Observe resident for: - How long have you been in
- level of alertness the facility?
F233 - behavior exhibited (dis- - Can you explain to me
SNF 405.1130 oriented, confused, un- why you are here?
cooperative, disruptive, - Have you had any problem
F234 aggressive, anxious, adjusting to the facility
SNF 405.1130(a) withdrawn, isolated, i.e., loss of independ-
lonely). ence?
F235 - personal appearance - Have you had any other
ICF 442.344(d) - apparent disabilities problems?
- apparent vision and/or - Has staff been helpful,
A. Plan hearing problems they e.g., financial?
exhibit as you talk to - Do you have any family or
F236 them any other visitors?
The medically re- - interaction to staff, - Do they have any problems
lated social and other residents, family, with which this facility
emotional needs of visitors has not been helpful?
the residents are - participation in group - If exhibiting disruptive
identified. activities depressed, agitated, an-
- independence in xious, etc. behavior- I
B. Provision of activities, decision noticed that you are up-
Services making set (quiet, nervous, un-
- Therapeutic staff inter- happy) today, Can you
vention: constructive tell me what has bothered
reaction to resident's you?
behavior - Does staff respond to
F237 - resident's participation your suggestions about
1. Services are on policy making bodies your own care?
provided to and committees of facil- - Did you participate in
meet the ity, e.g., resident planning what care you
social
and emotional councils. will get and who will
needs by the give it to you?
facility or - Do you make use of the
by referral
to an dining, activity, commun-
appropriate ity room, and/or outdoor
social area?
agency.
- Can you tell me about
your life here? What do
you do in a usual day?
F238 - Are things like getting
2. If financial up, bathing, dressing,
assistance is eating, done at the same
indicated, time for everyone?
arrangements - If you could change some
are made things about living here,
promptly
for refer- what would you change?
ral to an
appropriate Ask Social Worker/Nurse
agency. - When the social worker is
readily available, delete
"ask the nurse".
- How often is the resident
seen by a social
worker?"
- Who is responsible for
identifying the
resident's:
+ social and emotional
needs
+ family and home
situation
+ problems and needs
+ financial needs
- How are needs identified
and reported?
- Does resident participate
in the development of
his/her care plan?
- Ask nursing how often the
social worker sees
resident.
- Does the social worker
discuss residents needs/
problems with nursing
staff if there is a need
for nursing to be
involved?
- How is physician notified
and involved in plan of
care?
- Ask social service staff
their role, function, and
what services they
provide.
- Ask staff what referral
services are available.
- If services are being
provided by outside re-
source, are resources
documented work service?
- Ask social service staff
about their background
and education.
- If there is a consultant
ask staff:
+ How often does the per-
son come?
+ How long do they stay?
+ What does the person do
while in the facility?
+ What assistance, con-
sultation is being pro-
vided?
+ Ask social service
staff if adequate space
is provided for them by
the facility to conduct
private interviews and
meetings.
Activities
General level of - How does he/she spend
F239 activities throughout the the day?
SNF 405.1131 facility, as well as in - Of the activities
specifically designated resident has during the
F240 areas. week, what does he/she
SNF 405.1131(b) enjoy most/least?
How many residents are - If has none, why?
F241 lying on their beds or - Has staff asked about
ICF 442.345 sitting in chairs staring his/her interests?
at the walls during Suggested specific
waking hours? activities or people to
F242 get acquainted with in
1. An ongoing What is the level of response to interests?
program of residents interest in - What organized activi-
meaningful activities they are ties has he/she partici-
activities doing? pated in this past week?
provided - How does resident find
based on Are residents positioned out about upcoming
identified correctly for activity? programs or happenings?
needs and
interests of Are needed personal - Does resident get out
each resi- equipment (e.g., splints, of facility to activi-
dent. It is glasses) and adaptations ties?
designed to for limitations and - Does resident have prob-
promote op- safety (e.g., cardholder, lems getting to activi-
portunities goggles, footrests) used ties? If so, does the
for engaging in activities? staff assist?
in normal - Does the staff encourage
pursuits, residents to go to
including activities?
religious - Does resident partici-
activities pate in Resident
of their Council?
choice, if - Does resident have free
any. choice of activities?
- What kind of activities
F243 do bedfast residents
2. Unless con- engage in?
traindicated Ask Resident:
by the atten- - Hove you ever had diffi-
ding physi- culty in having private
cian, all visits? Give examples.
residents
are encour-
aged to part-
icipate in
activities.
F244
3. The activi-
ties promote
the physical,
social and
mental well
being of the
residents.
F245 Is lighting adequate Ask Nursing/Activity Staff
4. Equipment is throughout the facility - Do they know the inter-
maintained in for activities in which ests of residents under
good working residents are engaged? their care? TV programs
order. they like? Activities
Do men and women have they want to participate
F246 activities of interest in today/this week?
5. Supplies and to them? - Do they know the per-
equipment for sonal equipment needed
activities of Do residents communicate (e.g., glasses, hearing
interest are with each other in aids, reacher)?
available. activities? - Do they know the adap-
tive equipment used by
INTENT Are methods of communi- residents for specific
cating upcoming activi- activities (e.g., talk-
Each resident has ties appropriate to the ing books, built up
individual and/or resident populations? tools)?
group activities - Do they talk to resi-
to meet activi- Specific observation for dents to identify new
ties needs physically impaired/alert interests and report
through his residents: these and "dislikes" to
interests daily. Activities adapted to activities personnel?
meet specific needs of How?
the resident. - What is staff's involve-
ment with individual and
Alert residents have group activities of
activities of interest residents in their care?
and at their cognitive - How do they determine
functional level. interests of residents
who have difficulty
Specific observations for communicating?
confused/disoriented, - What activities does
emotionally disturbed and resident participate
mentally retarded resi- in regularly? Which
dents: activities does he/she
There are current calen- enjoy most/least?
dars, clocks and patients
and patients names or - If he/she does not par-
symbols visible to all ticipate, why?
the residents. - Which activities appear
to relax/calm the resi-
Staff consistently use dent? Excite him/her?
techniques such as - How does staff manage
reality orientation, maladaptive behavior
empathy, and/or valida- (e.g., abusive, disrup-
tion therapy as per each tive, combative)?
individual's needs. - Is direct care staff
involved in resident
Resident has familiar activities? How?
items if available in When (weekends, even-
room (e.g., family pic- ings)?
tures, artwork, afghan, - Does resident have
chair from home). one-to-one
assistance in activi-
Residents in restraints ties?
have activities of - How many residents have
interest geared to their few
abilities when restrained activities a day of
(e.g., table-top activ- interest to them as
ity, music, radio, read- individuals?
ing and writing material; - Why do these residents
when out of restraints have so little interest?
(e.g., walks, exercise, - What is your plan to
group, toileting). find more activities of
interest to them that
Small group and one-on- will meet their needs?
one involvement with - What types of residents
staff reinforcing appro- seem not to be inter-
priate responses. ested in activities?
- How many (who) residents
Staff reaction to resi- have only passive
dent behavior during activities?
activities (e.g., crying,
whining, demanding, non-
verbal, agression,
loudness). - How do you adapt activi-
ties for needs of resi-
Specific observation for dents who are:
comatose or terminally - confused/disoriented
ill resident: - emotionally disturbed
- mentally retarded
- Appropriate items for - physically impaired
sensory enrichment but alert
in room (e.g., TV, - terminally ill?
radio, adequate light-
ing)
- Resident placed in
supportive living - Are community volunteers
environment (e.g., utilized in the activi-
around people, in hall, ties program? In what
activities room, sun- way?
shine, fresh air), when - Are the residents
appropriate to the encouraged to offer
resident needs and suggestions for new
consistent with the activities? If so, what
resident's choice. activities have been
instituted as a result?
Specific observation of
environment for conduct-
ing activity program:
- How they manage mala-
- Adequate lighting. daptive behavior (e.g.,
- Functional area is abusive, disruptive,
appropriate for activi- combative)?
ties of interest (e.g., - How do they help
religious services, depressed residents
arts and crafts, cook- (e.g., tearful, emotion-
ing, reading, TV watch- ally labile)?
ing, card playing,
parties, discussion
groups, gardening).
- Multi-purpose room use
and timing of activi-
ties does not conflict.
- Outdoor activity area.
- Functional furniture,
indoors and outdoors.
- Evidence of free choice
activities:
- newspapers
- magazines
- record player
- radios
- games
- TV's
- reading
- sewing
- personal visits
- church services
- Activities, equipment
and supplies are appro-
priate and sufficient
to meet interest of
residents.
- Activities equipment
and supplies sufficient
for conducting activi-
ties.
- Activities equipment
clean, safe, and in
working order.
- Residents rooms contain
independent project
materials, as appro-
priate.
- Residents have access
to the total activity
environment (e.g.,
lobby, sunroom, day-
room, porch, dining
room).
MEDICAL RECORDS
F247
SNF 405.1132
Content
F248
SNF 405.1132(c)
F249
ICF 442.318(a)(c)
F250
1. The medical
record con-
tains suffic-
ient infor-
mation to
identify the
resident
clearly to
justify diag-
noses and
treatment and
to document
results
accurately.
F251
2. The medical
record con-
tains the
following
information.
a. Identifica-
tion informa-
tion.
F252
b. Admission
data includ-
ing past
medical soc-
ial history.
F253
c. Transfer
form, dis-
charge sum-
mary from any
transferring
facility.
F254
d. Report of
resident's
attending
physician.
F255
e. Report of
physical
examinations.
F256
f. Reports of
physicians'
periodic
evaluations
and progress
notes.
F257
g. Diagnostic
reports and
therapeutic
orders.
F258
h. Reports of
treatments.
F259
i. Medications
administered.
F260
j. An overall
plan of care
setting forth
goals to be
accomplished
through each
service's de-
signed activ-
ities, thera-
pies and
treatments.
F261
k. Assessments
and goals of
each ser-
vice's plan
of care.
F262
l. Treatments
and services
rendered.
F263
m. Progress
notes.
F264
n. All symptoms
and other
indications
of illness
or injury
including
date, time
and action
taken regard-
ing each
problem.
INTENT
Brings together
all resident
information.
Reflects the care
being given
to the
residents and
helps all care
givers to make
decisions on care
needed.
TRANSFER AGREEMENT Ask Staff:
- What is the routine
F265 information you provide
SNF 405.1133 to a new facility when
you transfer a resident?
- Who provides this?
F266
SNF 405.1133(a)
F267
ICF 442.316
F268
A. Whenever the
physician de-
termines that
a transfer
is medically
appropriate
between a
hospital or a
facility
providing
more special-
ized care and
the nursing
facility,
admission to
the new
facility
shall be
effected in
a timely
manner.
F269
B. Information
necessary for
providing
care and
treatment to
transferred
individuals
is provided.
PHYSICAL
ENVIRONMENT
F270
SNF 405.1134
F271
A. Nursing Unit
SNF 405.1134(d)
F272
1. Unit properly There is adequate light
equipped for to prepare medications. Ask Nursing Staff:
preparation - What do you use the med-
and storage There is sufficient space ication room (area) for?
of drugs and to prepare medications - Where is the handwashing
biologicals. for administration in sink?
a safe and effective - Do you have enough, con-
manner. venient storage area for
F273 I.V. fluids and medica-
2. Utility and There is sufficient space tions needing refrigera-
storage rooms for storage of medica- tion.
are adequate tions. - Where are the keys for
size. the medication room and
Unit dose carts are unit dose carts?
protected from tampering - Do you feel you have
F274 and theft. adequate storage space
3. The unit is for supplies and equip-
equipped to Medications are stored ment?
register in a locked area. - If no, what problems
resident Refrigeration facilities does that cause?
calls with a are available for medi- - Does the resident call
functioning cations. system function
communica- properly?
tions system There is sufficient
from resident storage space for I.V. Ask Residents:
areas includ- fluids. - Do the call bells in
ing rooms and your room and in the
toilets and Handwashing facilities toilets and bathing
bathing are readily accessible areas always work?
facility. either in the medication
preparation area or adja-
cent to it.
Audible call system is - If no:
on and working. Long - How often is it that
cords are available for they do not work?
chair bound patients. - How long does it take
to get them fixed?
B. Dining and Area is clean and well
activities area maintained. Ask Residents:
- Is there enough room
F275 There is sufficient between tables to allow
SNF 405.1134(g) space between tables to you to feel safe in
F276 allow for safe passage of getting to your table?
ICF 442.329 wheelchairs and residents - Can you sit comfortably
with walkers, canes and in your wheelchair at
other assistive devices. the table?
F277 - How is the lighting
1. The facility Table height or design and ventilation level
provides one allows residents in for you?
or more wheelchairs to sit a - Are sitting preferences
clean, order- normal distance from the permitted?
ly, and table. - Do you go to the dining
appropriately room for meals?
furnished Lighting and ventilation
rooms of ade- in the dining/activity
quate size, areas is provided accord-
designed for ing to recommended
resident standards.
dining and
resident A multi-purpose room
activities. should not be used for
storage of items such as
beds, mattresses, boxes,
etc.
F278 Are dining areas utilized
2. Dining and at meal service?
activity
rooms are
well lighted
and venti-
lated.
F279
3. Any multi-
purpose room
used for
dining and
resident
activities
has suffic-
ient space
to accommo-
date all
activities
and prevent
their inter-
ference with
each other.
F280
SNF 405.1134(e)
Indicators C&D
apply to SNFs
C. Resident Rooms Observe rooms and furn- Ask Residents:
ishings for maintenance, - Is your room kept clean?
F281 cleanliness and safety. Who cleans it? When, and
ICF 442.325 how often?
Look for dust/dirt on - Is your bed, chair, and
lights, high surfaces, other furniture and fix-
F282 under heating units, and tures kept in good
1. Single rooms in corners. Use a repair?
have at least flashlight. - Do you feel you have
100 sq. ft. enough privacy?
Are beds, lights, plumb- - What personal belongings
ing all in working order? are you allowed to have?
F283 - Is the lighting in your
2. Multiple res- Observe for all regula- room sufficient for you?
ident rooms tory requirements as - Is your chair comfor-
have no more noted to the left. table?
that 4 resi- - When do you permit staff
dents and at Are privacy curtains to clean you room?
least 80 sq. present, and appropriate - When do you ask staff
feet per to maintain resident not to clean you room?
resident. privacy?
Test several call lights.
F284
3. Each room is Are call lights within
equipped with reach, including emer-
or conven- gency lights in toilets
iently and bathing areas?
located near
toilet and Are toilet and bathing
bathing facilities appropriate
facilities. in number, size, and
design to meet resident
needs?
What personal belongings
do residents have in
their rooms? Is there
F285 sufficient storage and
4. There is a security for their
capability of belongings?
maintaining
privacy in
each.
F286
5. There is ad-
equate stor-
age space
for each
resident.
F287
6. There is a
comfortable
and func-
tioning bed
and chair,
plus a func-
tional cabi-
net and
light.
F288
7. The resident
call system
functions in
resident
rooms.
F289
8. Each room is
designed and
equipped for
adequate
nursing care
and the com-
fort and
privacy of
residents.
F290
9. Each room is
at or above
grade level.
F291
10. Each room
has direct
access to a
corridor and
outside
exposure.
Exception: Not
required for ICF
residents.
D. Toilet and bath Are there adequate num- Ask Residents:
facilities bers of toilets, baths, - When was your last bath?
and showers for the res- The one before?
F292 idents that are access- - What safety precautions
ICF 442.326 ible to, and functional are used for getting in
F293 for all residents? and out of the bathtub?
1. Facilities - What equipment is needed
are clean, Are these conveniently to get in and out of the
sanitary and located in or near resi- tub, and how do you
free of dent rooms? feel about it?
odors. - How do you get your
Check for water on floors wheelchair into the
F294 of bath and shower rooms. toilet or bathroom?
2. Facilities
have safe and Is privacy provided? - When, if ever, do you
comfortable refuse to be bathed?
hot water Are facilities clean,
temperatures. sanitary and free of
unpleasant odors?
F295 Are bathrooms equipped
3. Facilities with soap, toilet tissue,
maintain towels, etc.? Hot water
privacy. is between 110-120
degrees or the acceptable
State level. Hot water
temperature control must
be maintained. Single
F296 use, disposable towels
4. Facilities should be available for
have grab handwashing purposes.
bars and
other safe Note also condition of
guards grab bars, plumbing and
against fixtures.
slipping.
Bath areas are not used
for storage.
F297
5. Facilities
have fixtures
in good
condition.
F298
6. The resident
call system
functions in
toliet and
bath facili-
ties.
E. Social Service Does the social worker Ask Resident:
Area have a locked file - Does the social worker
available? see you in a private
F299 room or in your own
SNF 405.1130(b) Where are social service room?
ICF 442.344 interviews and clerical - If in your own room, do
functions performed? you feel that you have
F300 enough privacy?
1. Ensures Are rooms in areas easily
privacy for accessible to residents?
social ser-
vice inter-
viewing.
F301
2. Adequate
space for
clerical and
interviewing
functions
is provided.
F302
3. Facilities
are easily
accessible
to residents
and staff.
F. Therapy areas Therapy areas are access- Ask Resident:
ible to all residents - Do you feel that the
F303 needing the facilities. equipment you use is
SNF 405.1126(a) safe?
Space allows for safe - Do you have enough room
maneuvering of residents for your treatment?
F304 and equipment and staff.
ICF 442.328(a) Ask Therapy Staff:
All residents are able - Is your equipment
to be observed and adequately maintained?
F305 supervised during - Do you have enough room
1. Space is ade- therapy. to safely and adequately
quate for provide treatment?
proper use Equipment has labels
of equipment (stickers, etc.) to indi-
by all resi- cate proper maintenance.
dents receiv-
ing treatment All equipment fastened
to floor and walls is
secure.
G. Facilities for Are therapy areas proper- Ask Supervisory personnel:
Special care ly ventilated to effec- - What room(s) do you use
tively reduce heat, for isolation?
F307 moisture and odors? - What is your procedure
SNF 405.1134(f) if the room is already
Are private rooms avail- occupied when you need
able that meet regulatory it for isolation?
F308 criteria. - Will you show me the
ICF 442.328(b) signs you use to iden-
If a resident is infected tify the isolation room?
and in isolation, are
precautionary signs
posted, and are they
legible and understand-
able?
F309
1. Single rooms
with private
toilet and
handwashing
facilities
are available
for isolating
residents.
F310
2. Precautionary
signs are
used to iden-
tify these
rooms when
in use.
H. Common Resident Use senses - sight, hear- Ask Residents:
Areas ing, olfactory when - Do you think that the
surveying common areas as lounges and corridors
F311 lounges, lobby, corri- are usually clean?
SNF 405.1134(j) dors. - Do they have any un-
Note levels of lighting pleasant odors?
for both reading and non- - Is the lighting level
F312 reading areas. Is it comfortable for you to
ICF 442.324 bright enough but without read? Is it adequate
glare? for you to feel safe
Are areas clean and with- walking?
F313 out offensive odors? - Do you have any diffi-
1. All common Do background sound culty with the noise
resident levels allow for ease of level?
areas are communication and comfort - Is the temperature
clean, sani- for residents/visitors? usually comfortable for
tary and Do residents seem comfor- you?
free of table with the room tem- - Do you feel there is
odors. perature - note the use adequate ventilation?
of several layers of - Are there handrails in
clothing, many residents all of the corridors?
F314 fanning themselves, etc. - Are they securely fast-
2. Provision is Are handrails on each ened to the wall?
made for side of the corridor and
adequate and are they secure? Ask Supervisory Staff:
comfortable Are smoking o smoking - If there is a water main
lighting areas designated? break or other inter-
levels in all ruption in the water
areas. supply, how do you ob-
tain water for essential
areas and duties?
F315
3. There is
limitation of
sounds at
comfort
levels.
F316
4. A comfortable
room temper-
ature is
maintained.
F317
5. There is ade-
quate venti-
lation thru
windows or
mechanical
measures or a
combination
of both.
F318
6. Corridors are
equipped with
firmly
secured hand-
rails on each
side.
F319
7. Staff are
aware of pro-
cedures to
ensure water
to all essen-
tial areas in
the event of
loss of nor-
mal supply.
I. Maintenance of - Ceiling and floor tile Ask Staff:
Building and in good condition - How many housekeeping
Equipment - Paint in good repair staff are available?
F320 - No holes in walls - How late are house-
SNF 405.1134(i) - Look for rat and other keepers on duty during
rodent trails outside the week?
and inside - How is weekend coverage
F321 - Preventive maintenance different?
1. The interior program for all equip-
and exterior ment is followed Ask Resident:
of the build- - Wheelchairs not stored
ing are clean in hallways, bathrooms, - What if any problems
and orderly. etc. have you had with
- Window screens are in special equipment you
good repair need to use?
F322 - Check overbed tables,
2. All essential wheelchairs, etc., for
mechanical cleanliness and opera-
and electri- tion
cal equipment
is maintained
in safe oper-
ating condi-
tion.
F323
3. Sufficient
storage space
is available
and used for
equipment
to ensure
that the fac-
ility is
orderly and
safe.
F324
4. Resident care
equipment is
clean and
maintained in
safe opera-
ting condi-
tion.
Indicator J
applies to ICFs.
J. Dietetic
Service Area Observe for Ask Staff:
F326 - needed space to carry - What have you been
SNF 405.1134(h) out routine operations trained to do?
- maintenance of working - What type of dishwasher
surfaces equipment, machine do you have?
F327 utensils, and serving How does it operate?
1. Kitchen and dishes
dietetic ser- - operable dish washer
vice areas machine.
are adequate - 3-sink method of pot/
to insure dish washing properly
proper, carried out/or written
timely ser- procedure posted
vice for all - operable and clean
patients. exhaust fan
- stored dishes and pots
are free of baked-on
F328 food particles and
2. Kitchen areas chipped/cracked sur-
are properly faces
ventilated, - food stored off floor
arranged, and - protective covers for
equipped for fluorescent lights
storage and - handwashing sink read-
preparation ily accessible
of food as
well as for
dish and
utensil
cleaning, and
refuse stor-
age and
removal.
Indicator K
applies to ICF
K. Dietary Staff Observe the following: Ask Staff:
Hygiene - cleanliness of hands, - What happens when you
fingernails, hair, report to work with a
F329 clothing cold, a cut or sore on
SNF 405.1125(f) - use of hair restraint your hand?
- whether employees wash - Where is handwashing
hands with soap and sink for dietary staff?
F330 water after using the - Do you use disposable
1. Dietetic ser- toilet, smoking, blow- plastic hand covers?
vice person- ing their nose, touch- If so, when?
nel practice ing raw meat, poultry - Where are your serving
hygenic food or eggs utensils located?
handling - employees using hands - What are temperatures
techniques. to mix food when uten- for the refrigerators
tils could be used and freezers? Who is
Indicator L - employees using the responsible for checking
applies to ICF same spoon more than temperatures?
L. Dietary Sanitary once for tasting food - Do you have thermometers
Conditions while preparing, cook- to check water and food
F331 ing, or serving. temperatures? (ask them
SNF 405.1125(g) to demonstrate how they
Verify that: take temperatures)
- hot foods are 140
F332 degrees or above
1. Food is - cold foods are 45
stored, degrees or lower
refrigerated, ("note: food held for
prepared, more than 2-3 hours
distributed, between 60 and 125
and served degrees may not be
under sani- safe to eat)
tary condi- - cooked meats held
tions. longer than 72 hours
are used, discarded or
put in the freezer
F333
2. Waste is
disposed of
properly.
- check that the refrig-
erators are equipped
with an accurate ther-
mometer
- food does not have an
"off" or bad odor
- cracked eggs are dis-
carded
- foods are dated and
then stored as to their
preparation date.
Observe that waste is in
covered containers,
bagged and tied for dis-
posal, and that dumpsters
are covered.
L. Emergency Power
F334 Is an emergency generator
SNF 405.1134(b) available?
Test generator under full
F335 load conditions.
1. An emergency
source of Check items of emergency
electrical power:
power neces- - lighting
sary to pro- - fire detection
tect the - alarms
health and - extinguishing systems
safety of - life support systems
residents is
available. Transfer time from normal
power to emergency power
to occur within 10
F336 seconds.
2. Emergency
power is ade- Check for gounded exten-
quate at sion cords at nurses
least for stations.
lighting in
all means of Where are emergency out-
egress; lets?
equipment to
maintain fire
detection,
alarm, and
extinguishing
systems; and
life support
systems.
F337
3. Emergency
power is pro-
vided by an
emergency
generator
located on
the premises
where life
support sys-
tems are
used.
Infection Control - Observation of dressing Ask Staff:
F338 technique to identify - What type of dressing
SNF 405.1135 if infection control changes are you per-
principles are being forming?
adhered to: - How often are dressings
A. Infection - sterile technique changed?
Control - sterile/clean field - Why is resident on iso-
F339 - disposal of dressing lation/precautions?
SNF 405.1135(b) - handwashing - Do laundry/housekeeping
- use of gloves personnel/aides know
procedures?
F340 - Observation of isola-
Aseptic and tion precautions: Ask Resident:
isolation tech- - signs - Do you know why you have
niques are - linen, double bagged dressings?
followed by all - soiled linen, double - Do you know why you are
personnel. bagged on isolation/precau-
- gowns/masks tions?
- gloves - Do you have clean linen
B. Sanitation - handwashing when you need it?
F341 - disposable dishes
SNF 405.1135(c) - information for
visitors
F342 - Procedures followed by:
The facility - Laundry
maintains a - Housekeeping
safe, clean,
and orderly How is dirty linen trans-
interior. ported to laundry or
holding area?
C. Linen Do aides wash hands after
F343 cleaning dirty linen?
SNF 405.1135(d)
How do aides handle
clean/dirty linen while
changing beds?
F344
ICF 442.327
F345
1. The facility
has available
at all times
a quantity of
linen essen-
tial for pro-
per care and
comfort of
residents.
F346
2. Linens are
handled:
stored, pro-
cessed, and
transported
in such a
manner as to
prevent the
spread of
infection.
D. Pest Control Look for evidence of Ask Staff:
F347 insect or rodent presence - Have you seen insects
SNF 405.1135(e) (mouse or rat droppings, (roaches, ants, flies,
roaches, ants, flies etc.)?
F348 around trash) - Have you seen rodents
ICF 442.315(c) - Screen doors closed and/or droppings?
- Windows that can be - What foods are residents
opened have screens permitted to keep in
F349 that are in good repair their rooms?
The facility is
maintained free
from insects and
rodents.
DISASTER - Disaster plan is Ask Residents:
PREPAREDNESS located at each nursing - Do you know what to do
station. in case of fire?
F350 - Evacuation plans posted - How often do you re-
SNF 405.1136 in each smoke compart- hearse it?
ment.
F351 Ask Staff:
SNF 405.1136(a) - What are your responsi-
bilities at a fire
F352 drill?
ICF 442.313 - What is the facilities
disaster plan? (Specify
types, [(e.g., fire,
Indicators A and flood, etc.)]
B apply to ICFs. - How you undergone
disaster training?
A. Disaster Plan - Have you participated in
a fire disaster drill?
F353 When?
1. Facility - How frequently are
staff are drills held?
aware of - Have you been trained/
plans, pro- instructed in the use
cedures to be of fire equipment, fire
followed for containment methods?
fire, explo- - Have you been trained in
sion or other transfer or casualties
disaster. and routes?
- How would staff meet
emotional needs of resi-
F354 dents during/following
2. Facility a "disaster", e.g., fire
staff are
knowledgeable
about evacu-
ation routes.
F355
3. Facility
staff are
aware of
their speci-
fic responsi-
bilities in
regard to
evaluation
and protec-
tion of re-
sidents.
F356
4. Facility
staff are
aware of
methods of
containing
fire.
B. Drills
F357
SNF 405.1136(b)
F358
1. All employees
are trained
as part of
their employ-
ment orienta-
tion in all
aspects of
preparedness
for any
disaster.
F359
2. Facility
staff parti-
cipate in
ongoing
training and
drills in all
procedures so
that each
employee
promtly and
correctly
carries out
a specific
role in case
of a
disaster.
INTENT
To ensure
a clean,
safe environment
for residents.
SURVEY AREA RECORD REVIEW
*2*F58
SNF 405.1121(k)(2)
ICF 442.311(a)(4)
4. Resident
informed in
writing of
changes in
services and
charges for
services.
F59
SNF 405.1121(k)(2)
ICF 442.311(a)(4)
5. Information
to resident
of services
not covered
by Medicare
or Medicaid
and not
covered in
the basic
rate.
B. Medical Condi- If the resident has not
tion & Treatment been informed of his/her
medical condition,
F60-64 physician notes should
SNF 405.1121(k)(2) document that the resident
ICF 442.311(b) was not informed because
it was medically contra-
indicated.
Do care plans or other
documentation reflect
resident participation in
care planning?
If resident states he/she
has refused treatment or
medication does documen-
tation indicate adherence
to/violation of resident
rights.
Review records of resi-
dents identified as par-
ticipating in a clinical
research study. Are
informed consent forms
signed? Do these signed
forms list all known
risks for the resident?
All needed informed con-
sent statements are
present and properly
signed.
C. Transfer and Nursing, physician, and/or
Discharge social service progress
F65-68 notes should indicate rea-
SNF 405.1121(k)(4) son for transfer and dis-
ICF 442.311(c) cussion with resident
and/or family/guardian.
If staff interviews give
you cause to feel that
transfers and discharges
may be in violation of
these regulations, review
a sample of closed records
for transfer information
on how it was handled.
If residents are trans-
ferred between facilities
with common ownership and
similar levels of care,
transfers must be reviewed
to determine reasons for
transfer. Efforts to
maintain the census is
not an acceptable reason
for transfer.
Do discharge records
review:
- reason for discharge,
medical non-payment or
need for different
level of care?
D. Exercising Review resident council
Rights documentation, as
F69 available, to determine
SNF 405.1121(k)(5) level of activity.
ICF 442.311(d)
Review social work or
progress notes for legal
referrals.
Is there documentation in
progress notes or else-
where, of resident com-
plaints and disposition of
complaints?
E. Financial
Affairs
F72-78
SNF 405.1121(k)(6)
405.1121(m)
ICF 442.311(e)
442.320
A copy of the statement
should be in the residents
financial record and given
to the resident at least
quarterly.
Receipts, account logs
showing deposits/with-
drawals, authorization/
reasons for withdrawals,
and interest earned should
be reviewed. If resident
indicates there may be a
problem, an in-depth in-
terview should be
conducted.
Resident records indicate
separate financial records
from facility records.
F. Freedom From Look for a physician's or-
Abuse and der for the restraint.
Restraints
Review nurses', physicians'
F79-83 progress notes re: reason
SNF 405.1121(k)(7) for restraints and resi-
ICF 442.311(f) dent reaction to them.
Also any alternative me-
thods tried.
What time of day are re-
straints most often ap-
plied?
Review schedule of releas-
ing restraints.
Care plans:
- When restraint is to be
used.
- For how long.
- What are plans for al-
ternative measures.
- Is the resident period-
ically re-evaluated?
If appropriate are the
Social Service or activi-
ties departments involved
in providing different
directions for resident
attention?
Who authorizes the use of
restraints in an emer-
gency?
Do progress notes indicate
that a professional staff
member authorized the use
of "emergency" restraints?
There should be documenta-
tion that the use of
"emergency" restraint has
been promptly reported to
the residents physician.
Review incident and acci-
dent reports to identify
any problematic trends.
Does the drug regimen
review indicate appropri-
ate use of psychoactive
drugs?
Are there resident com-
plaints documented?
What is the resolution of
these complaints?
G. Privacy Review progress notes for
indications that staff see
F84-89 resident as an individual-
SNF 405.1121(k)(8) i.e., resident eats break-
(9)(14) fast in bed because he/she
ICF 442.311(g) enjoys it.
Signed consent for release
of information.
Do maintenance of and con-
tent of medical records
indicate that confidenti-
ality is practiced?
H. Work If residents are perform-
ing services for the fa-
F90 cility, is that included
SNF 405.1121(k)(10) in their care plan. with
ICF 442.311(h) specific therapeutic goals
defined?
If appropriate does the
family concur?
Are results documented in
progress notes?
What service (activities,
nursing, etc.) is respons-
ible for planning reeval-
uating and adjusting work
activity?
Look for physician's
orders for approval or
disapproval of work activ-
ity or restrictions on
this activity. Look for
evidence that the resident
is given opportunities to
refuse to do the work.
The resident, however, is
not restricted from doing
the amount and type of
work they desire unless
it is in conflict with
the plan of care.
I. Freedom of Physician orders and care
Association and plans for indications of
Correspondence restrictions on visitors
and/or receiving and send-
F91-92 ing mail.
SNF 405.1121(k)(11)
(12)
ICF 442.311(i)
J. Activities Care plans or other docu-
mentation should indicate
F93 resident preferences for
SNF 405.1121(k)(12) both facility and non-
ICF 442.311(j) facility planned activi-
ties.
Progress notes of
responses to activities.
K. Personal Admission notes on person-
Possessions al property inventory
(e.g., the record should
F94 indicate a list of any
SNF 405.1121(k)(13) personal property secured
ICF 442.311(k) by the facility).
The record should indicate
how personal clothing will
be laundered.
L. Delegation of Review physician progress
Rights and notes -- incapability must
Responsibilities be documented.
F95-97 Is there clear documenta-
SNF 405.1121(k) tion as to whom rights
ICF 442.312 and responsibilities have
been assigned?
Are pertinent consents/
documents signed by
appointed guardian?
STAFF DEVELOPMENT Care plans reflect staff's
knowledge of the problems
F98 and needs of the residents
SNF 405.1121 and special adaptations
that are needed.
F99 Progress notes indicate
ICF 442.314 that the special needs
are considered in imple-
menting planned care.
F100
1. Facility
staff are
knowledgeable
about the
problems and
needs of the
aged, ill,
and disabled.
F101
2. Facility
staff prac-
tices proper
techniques
in providing
care to the
aged, ill
and diseased.
F102
3. Facility
staff prac-
tice proper
technique for
prevention
and control
of infection,
fire pre-
vention
and safety,
accident pre-
vention, con-
fidentiality
of resident
information,
and preserva-
tion of resi-
dent dignity
including
protection of
privacy and
personal and
property
rights.
INTENT
To assure that
facility provides
ongoing training
to staff so that
they will be know-
ledgeable in cur-
rent practices,
use proper tech-
niques, and inter-
act with residents
in a kind, caring
way.
Status Change - Progress note should
Notifications document injury/change
in condition plus
F103-104 notification of physi-
SNF 405.1121(j) cian and appropriate
ICF 442.307 family member/guardian.
F105 - Changes in charges
1. The facility should be documented.
notifies the Ask facility where this
resident's at- is located.
tending phy-
sician and - Review accident and
other respons- incident reports for
ible persons indepth sample.
in the event
of an accident
involving the
resident, or
other signifi-
cant change in
the resident's
physical, men-
tal, or emo-
tional status,
or patient
charges, bill-
ings, and
related admin-
istrative
matters.
F106
2. Except in a - Nursing, physician and
medical emer- social work progress
gency, a resi- notes should be reviewed
dent is not for evidence of discus-
transferred or sion of transfer/dis-
discharged, charge with resident or
nor is treat- other designated person.
ment altered
radically,
without con-
sultation with
the resident
or, if the
resident is
incompetent,
without prior
notification
of next of kin
or sponsor.
INTENT
To assure that:
- the resident
receives proper
treatment in the
event of an acci-
dent or change of
condition.
- resident and/or
next of kin or
responsible party
is aware in
advance of any
changes.
- resident is not
discharged to
gain a higher
source payment
for that bed or
facility
convenience.
Physician's Review records of resi-
Services dents selected for indepth
review to ascertain that:
F107
SNF 405.1123 - There is a referral form
from the transferring
A. Medical Findings facility that was re-
and Orders at ceived in advance of
Time of admission or on date of
Admission admission that includes
current medical find-
F108 ings, diagnosis and
SNF 405.1123(a) orders from a physician
for the immediate care
F109 of the residents.
1. There is made - If the medical orders
available to were not obtained from
the facility the residents attending
prior to or at physician, there are
the time of temporary orders from
admission, the emergency care
resident physician.
information - Information on the re-
which includes habilitation potential
current medi- (prognosis) of the resi-
cal findings dent and a summary of
diagnoses, and the course of treatment
orders from a followed in the trans-
physician for ferring facility were
immediate care transmitted within 48
of the resi- hours of admission.
dent. - The summary of treatment
should include discharge
F110 summaries from therapies
2. Information or special services when
about the appropriate.
rehabilitation - For residents admitted
potential of directly from the
community, the attending
the resident physician provided cur-
and a summary rent medical findings,
of prior treat- diagnosis, prognosis,
ments are made and orders.
available to - The order should cover:
the facility at + Medications and treat-
the time of ments
admission, or + Diet
within 48 hours + Therapies (P.T., O.T.,
thereafter. Speech)
+ Activities (bedrest,
ambulatory, able to
participate with any
specific limitations
on activity).
Resident Super- Review medical records of
vision by Physician selected for indepth
review for:
F111
SNF 405.1123(b) - A current plan of care
that is based upon
F112 physician's orders and
ICF 442.346 resident needs.
- Evidence that the plan
B. Resident is reviewed and revised
Supervision by as needed.
Physician - Evidence through physi-
cian's progress notes,
F113 nurses notes, physi-
1. Every resi- cian's orders, that the
dent must be physician participates
under the in the resident's over-
supervision all plan of care.
of a physician - Evidence that rehabili-
tation potential is
F114 addressed.
2. A physician - Long range plans include
prescribes a an estimate of the
planned regi- length of time for
men of care skilled nursing care and
based on a a discharge plan.
medical eval- - Physician's orders for
uation of each medications and treat-
resident's ments on admission and
immediate and during stay.
long-term care - A medical evaluation
needs. completed within 48
hours of admission
unless done within 5
days prior to admission
that includes attention
to needs such as diet,
vision, hearing, speech
level of activity, emo-
tional adjustment.
- Evidence in care plans
F115 and treatment records
3. A physician that physician's orders
is available are being implemented.
to provide - Discrepancies in medi-
care in cation record, diet
the absence order, intake and output
of any records.
resident's - Evidence that an alter-
attending nate physician provided
physician. care if applicable.
- Progress notes by physi-
F116 cian at least every 30
4. Medical days for first 90 days
evaluation is (ICF - at least every 60
done within days).
48 hours of - Review of medications
admission and treatments every 30
unless done days or 60 days if an
within 5 days alternate schedule of
prior to visits has been
admissions. approved.
NOT ICFs. - Documentation of physi-
cian observations,
F117 actions and plans for
5. Each SNF treatment.
resident is - Justification for alter-
seen by their nate schedule of visits.
attending
physician at A few closed records
least once should be reviewed to
every 30 days determine if residents
for the first were appropriately dis-
90 days after charged by an order writ-
admission. ten by the attending
physician. Also review
discharge plans to assure
that they were adequate
and implemented.
Exception: ICF Verbal medication orders
residents must be are countersigned by a
seen every 60 days physician.
unless otherwise
justified and Physician is reviewing
documented by the all medication orders
attending physi- every quarter.
cian.
F118
6. Each resi-
dent's total
program of
care includ-
ing medica-
tions and
treatments is
reviewed dur-
ing a visit
by the
attending
physician at
least once
every 30 days
for the first
90 days and
revised as
necessary.
Exception: Only
medications must
be reviewed quart-
erly for ICF resi-
dents.
F119
7. Progress
notes are
written and
signed by the
physician at
the time of
each visit,
and all
orders are
signed by the
physician.
F120
8. Alternate
physician
visit sched-
ules that
exceed a 30-
day schedule
adopted after
the 90th day
following ad-
mission are
justified by
the attending
physician in
the medical
record.
These visits
cannot exceed
60 days or
apply to pa-
tients who
require
specialized
rehabilita-
tion
schedul es.
Exception ICF resi-
dents must be seen
every 60 days un-
less justified
otherwise document-
ed by the attending
physician.
C. Emergency - If records document an
Services accident or a medical
emergency, was the pa-
F121 tient seen by a physi-
SNF 405.1123(c) cian or was the physi-
cian notified promptly
F122 of the emergency?
Emergency services
from a physician - Review physician's
are available and orders to see if speci-
provided to each fic medications or
resident who treatments were ordered
requires emergency to treat emergency
care situation if applicable.
- Review physicians pro-
gress notes to see if
INTENT: To assure emergency situation was
that a physician addressed.
has overall
responsibility for
the management and
supervision of the
residents care.
Nursing Services
F123
SNF 405.1124
F124 Nursing notes, flow sheets
SNF 405.1124(c) or bathing records should
F125 indicate that the care
F126 plan for grooming and
ICF 442.1124(c) personal hygiene is being
A facility provides followed. For example:
nursing services - Bathing schedules are
sufficient to meet being followed (includ-
nursing needs of ing the use of any soaps
all residents all or special lotions).
hours of each day. - Assistance instruction
and/or supervision is
being provided as
F127 Grooming and identified for each
Personal activity.
Hygiene
SNF 405.1124(c) Nursing documentation
should also indicate resi-
dent response or any
changes in the resident's
behavior, reaction to an
activity, or the ability
to carry out grooming and
personal hygiene activi-
ties. Look for indica-
tions of progress toward
a goal or further deter-
ioration of resident
functioning.
Skin Condition Look at nursing notes and
F128-129 P.O.C. for evidence of:
SNF 405.1124(c) - Planned preventive
measures
- Treatments/Intervention
including nutrition
- Routine assessment/
evaluation of skin
condition
- Documentation of speci-
fic skin problems with
location number,
severity, measurements
as appropriate, and
cause
- Progress or lack of
progress in healing
- Assessment/Reevaluation
of interventions with
alterations in plan
- Appropriate nutritional
plan
- Methods to control edema
of lower extremities
Wounds/Wound - Physician orders for
Dressings wound care
F126 - Progress notes detailing
SNF 405.1124(c) condition of wound -
i.e., size, drainage,
surrounding tissue, odor
- Treatment provided
- Progress/change
- Plan of Care (POC)
+ The plan of care
should address:
- Area in need of
treatment, treatment
to be performed,
frequency, and
responsible staff.
- All necessary solu-
tions, ointments,
irrigations, types
of dressings, and
materials.
- Any necessary pre-
cautions, drains,
if present, sutures
and tubing.
- Specific goals of
treatment as well
as any problems or
limitations imposed
as a result of
treatment.
Restraints - Physician orders for
F130 restraint: reason,
length of time, type
- Progress notes
When residents re- - Describe the resident's
quire restraints status/behavior which
the application is prompted the use of the
ordered by the phy- restraint.
sician, applied - If a chemical restraint,
properly, and re- the order should indi-
leased at least cate a specific time
every two hours. period for its use as
(See also informa- well as a stop date.
tion under Resident - Plan of Care should
rights-freedom from + Identify other methods
abuse & restraints) or therapies that are
being used in conjunc-
tion with restraints.
+ What alternatives to
restraints have been
considered.
+ Identify staff respon-
sible for observing
the resident (every 30
minutes), and
releasing and exercis-
ing the resident
(every 2 hours for at
least 10 minutes).
Time intervals should
be identified.
+ Indicate involvement
and input of other
disciplines necessary
to overcome the
problem.
+ Indicate a specific
period of time for
using the restraint.
- Indication of assessment
of factors which pre-
cipitate residents be-
havior which has war-
rented restraints and
plans to intervene early
enough to prevent
occurrence.
- Type, duration and
frequency of exercise
should be documented.
- An assessment of why
restraints are continued
should be documented.
Bowel and Bladder - Physician orders if req-
F131 uired by facility
SNF 405.1124(c) policy
Each resident with - Nursing notes for
incontinence is + Assessment
provided with care + Documentation of tech-
necessary to en- niques and progress,
courage continence reevaluation
including frequent - Plan of care
toileting and The plan of care should
opportunities for clearly address:
rehabilitative + Goals that resident
training. will aim for.
+ Methods to accomplish
the goals.
+ Schedule for fluid
intake.
+ Schedule for
toileting.
+ Responsible staff
+ Any limitations the
resident may encounter
as a result of either
incontinence or the
training program.
- Progress notes/physician
orders for cause of
incontinence.
- Laboratory tests of
kidney function when
available
- Treatment for diarrhea/
constipation
- Residents preference for
treatment of constipa-
tion.
- Recently admitted and
newly incontinent resi-
dents should be thor-
oughly assessed for at
at least 7 days for the
cause of incontinence
and when appropriate an
intensive bowel and
bladder B/B training
program should be in-
stituted.
- A trial B/B training
program is suggested
for all residents with
incontinance problems.
- I & O
Catheter Care The surveyor should verify
F132 that there is a physicians
SNF 405.1124(c) order for an indwelling
catheter, including the
Each resident with type and frequency of
a urinary catheter catheter care. If irriga-
receives proper tion is ordered, the order
routine care in- should include type of
cluding periodic solution and frequency of
evaluation irrigation. The record
should also indicate the
color, consistency, and
amount of urinary
drainage.
- Assessment should
address:
+ Need for an indwelling
catheter.
+ Resultant problems or
limitations.
- Plan of Care should
address:
+ Type of catheter and
type and frequency of
care.
+ For irrigation, the
rationale, the type
of solution, amount,
and frequency of
irrigation.
+ Frequency of symptoms
which would precipi-
tate catheter change.
+ Time frames of cath-
eter change and
responsible staff.
+ Appropriate increase
in oral fluid intake.
- Intervention
The record must reflect:
+ When and by whom the
catheter was inserted
and for what reason.
+ Any special care
provided
+ New problems or
changes
+ Only appropriately
trained staff should
deliver catheter care
+ Only licensed staff
should insert
indwelling catheter.
+ The specific type and
size of equipment used
should be noted.
+ Signs and symptoms of
urinary tract infec-
tions (UTI) should be
acted upon and docu-
mented as to follow-
up.
- Evaluation/Reevaluation
The record should
reflect that the
resident:
+ Is assessed for UTI.
+ Has no abdominal
distention.
- Notes should also in-
clude:
+ The color and odor of
urine and the develop-
ment of any problems
after insertion of
indwelling catheter.
+ Verify that catheter
is patent.
Injections - Physician order sheet
F133 - Nursing notes for:
SNF 1124(c) + Resident response to
medication if appro-
priate
+ Any problems noted at
injection site
+ Any other adverse
reactions
+ Site of injection
- Plan of care
+ Rotation of injection
site
+ Care for any special
problems related to
the injection.
- Infection Control:
reports for any infec-
tions connected with
injections.
Parenteral Fluids - Physician's order for
F133 parental therapy
SNF 405.1124(c) specifying type of
fluid, rate of infusion/
hour, and additives, if
any, is available and
current.
- Twenty-four hour I&O
record.
- Nursing documentation
indicates physician's
orders are being
followed.
- Any adverse reactions
are noted in the medical
record.
- Record indicates:
+ Infusion started by
whom; cite time, rate
of flow
+ Note is made of obser-
vation of pain or
swelling at infusion
site.
+ The need or reason for
parenteral fluids.
+ Response to the
therapy.
+ Problems and limita-
tions encountered by
the resident as a re-
sult of receiving
parenteral fluids.
- Plan of Care *
The plan of care should
include
+ Type, rate of infusion
/hour, and additives
(if ordered),
specified goals for cor-
rection, time frames,
and responsible staff.
- Documentation must in-
clude time administered
and by whom, the amount
of fluid infused, and
any other special care
administered as a
result of IV therapy
(i.e., mouth care,
assistance with ADLs,
etc.).
- The record must reflect:
+ Conditions of site and
any infiltrations,
phlebitis, necrosis,
etc. noted, along with
measures taken to
correct these.
+ The resident's
response to therapy
+ Changes in laboratory
studies
* Plan of care would not
be modified for a one-
time IV infusion.
Colostomy/Ileostomy The surveyor should deter-
F133 mine that:
SNF 405.1124(c)
- Colostomy irrigations,
if ordered, are docu-
mented as performed by
the resident or appro-
priately trained staff.
- In the case of sigmoid
colostomy regular
patterns of bowel
elimination are
documented as estab-
lished through manage-
ment of diet, fluid in-
take, exercise, and the
use of prescribed laxa-
tives, suppositories,
and/or irrigations.
- Ostomy care is docu-
mented in the resident's
record along with a
description of the
excreta.
- Problems in irregu-
larity, skin breakdown,
or other observable con-
cerns are documented and
reported to the physi-
cian.
- Documentation indicates
that nursing measures
are taken to assist the
resident who is experi-
encing problems in
understanding and/or
accepting the presence
of the ostomy.
- Documentation of nursing
measures to maintain
skin integrity.
- Assessment
The assessment should
indicate:
+ Needs, problems, and
limitations as a re-
sult of an ostomy.
+ Specific degree of
self-care performed
or assistance needed.
+ Special skin care
needs.
+ Special dietary
needs.
+ Emotional support.
+ Medications and treat-
ments if needed.
- Plan of Care
The plan of care should
clearly address:
+ Specific goals to
overcome or improve
the problem(s) iden-
tified.
+ Methods to accomplish
the goal (training,
assistance, super-
vision, treatments,
emotional support).
+ Services necessary and
who will perform the
services.
+ Time frame for accom-
plishing goals.
Respiratory Therapy The surveyor should
F133 determine that:
SNF 405.1124(c)
- Respiratory/oxygen
therapy is performed or
administered by appro-
priately trained staff.
- There is a physician's
order for therapy, and
it is specific as to
rate of delivery, etc.
- If the physician's order
is for prn therapy, it
should specify for what
symptoms.
- Any information gained
from resident or staff
is verified in the
record.
- Assessment
+ The assessment should
address both the need
or reason for therapy
and any problems or
limitations which
result from the need
for therapy.
- Plan of Care
The surveyor should
note:
+ The kind, amount,
frequency, and/or
duration of therapy
based on the physi-
cian's order.
+ Specific goals to
overcome to improve
any identified
problems and/or
limitations.
+ Specific methods to
accomplish the goals
(observation, super-
vision, training,
etc.).
+ Who is responsible to
perform therapy or
assist in accomplish-
ment of goal.
- Intervention -
The record should dis-
play evidence that:
+ The plan of care is
functional
+ The therapy was admin-
administered in
accordance with phy-
sician's order for the
specified reason(s) by
an appropriately
trained staff member
+ Change in condition is
tion is documented and
acted upon promptly.
- Evaluation/Reevaluation
The record should
reflect:
+ The resident's
response to therapy.
+ If response was
undesirable, evidence
of further interven-
tion.
+ Any progress, deter-
ioration, or develop-
ment of new problems.
+ Based on the above
information, possible
modification of goals.
Tracheostomy Care - The surveyor should
F133 determine that trache-
SNF 405.1124(c) ostomy care is done as
scheduled and as needed
following the proper
procedure.
- Any special solutions
that are needed should
be addressed in the
physician's orders.
- Assessment - The record
should reflect that the
need for tracheostomy
care was assessed in
terms of:
+ Frequency
+ Skin integrity sur-
rounding the trache-
ostomy, noting red-
ness, inflammation,
and/or excoriations.
- Plan of Care should
include:
+ Specific times of
trach care and the
responsible, appro-
priate trained person
performing this task.
+ Specific problems
relating to skin and
breathing as well as
the goals set to over-
come these problems
listing the appropri-
ate personnel respon-
sible.
+ Time frames for
resolving problems
listed in goals.
+ Plan for periodic
assessment of appro-
priateness of resi-
dents own self care
re: teaching or
nursing assuming more
responsibility as
appropriate.
- Intervention - The sur-
veyor should look for
documentation of:
+ Trach care and oral
hygiene administra-
tion, including re-
sponsible personnel,
time and date, and
effects.
+ Any problems or
changes noted in resi-
dent condition (e.g.,
redness, swelling,
tracheal obstruction).
+ Emotional response to
tracheostomy.
- Evaluation/Reevaluation
+ Resident is or is not
benefiting from trach
care and skin care.
+ If problems are noted,
the progress notes and
plans for care should
indicate changes in
treatment.
+ Resident's emotional
response to care of
the tracheostomy
should be evaluated,
since this may require
additional care
planning.
Suctioning - Assessment - The record
F133 should reflect that:
SNF 405.1124(c) + The resident is fre-
quently observed for
suctioning needs.
+ Any limitations a re-
sident has as a result
of his suctioning
needs should be
specifically noted.
+ Any problems resulting
must be specified.
- Plan of Care should in-
clude:
+ Awareness of the
resident's suctioning
needs, goals,
approaches, and re-
sponsible staff
needed to improve the
problem or at least
to maintain the resi-
dent at his present
status without further
deterioration.
The plan must clearly
indicate specific
approaches towards:
- Prevention of skin
problems around the
trach if one exists.
- Correction of any
existing skin pro-
blems.
- Provision of good
oral hygiene in-
cluding a rigid
schedule for mouth
care, schedules, or
procedures for main-
taining clean equip-
ment at bedside, as
well as disposal of
used (dirty) equip-
ment.
- Route of suctioning
(i.e., oral asal/
trach).
- Intervention - The
record should indi-
cate clearly that:
+ The plan of care
is being imple-
mented. Docu-
mentation should
reflect:
+ The number of
times the resi-
dent required
suctioning, for
what specific
reason, and by
whom the resi-
dent was
suctioned.
+ Any special
treatment the
resident re-
ceived in con-
junction with
suctioning
(i.e., oral
hygiene, skin
care, etc.).
- Evaluation/Reevaluation
The record should
reflect:
+ How well the resident
tolerates suctioning
procedures.
+ Any bloody aspirant,
cardiac arrhythmia,
cyanosis, or broncho-
spasm.
+ Further interventions
utilized to overcome
or improve these.
+ The amount of sputum
as well as its color
and consistency.
+ Any progress or lack
of progress, deterior-
ation, and/or the de-
velopment of new
problems.
+ The evaluation should
determine whether
goals are being reach-
ed or if new goals
must be addressed.
Tube Feedings Tube Feeding Review:
F133
SNF 405.1124(c) - Plan of care
- Must document tube
placement and formula
potency prior to each
feeding.
- In the case of contin-
uous feeding, tube
placement must be
documented at least
every 4 hours.
- Naso gastric tube must
be secured in a manner
that avoids creating
pressure on the nose
and nasopharynx.
- Identify frequency, amt.
of feeding based on the
physician's order and
time span over which
each feeding is accom-
plished.
- Medication and treatment
records.
- Fluid intake records.
- Number of calories as
well as amount of addi-
tional water.
- Documentation present
regarding removal and
reinsertion of tubes.
- Record should indicate
measures taken to pre-
vent diarrhea and con-
stipation and to treat
if they have developed.
Nursing Services - Review progress notes
F137 to determine who is
SNF (405.1124) giving care.
ICF (442.338) - Review care plan to
B. Twenty-four determine who the
hour nursing. facility has assigned
to care responsibility
F137 to.
1. Assigned - Check staffing sheets
duties con- for minimal require-
sistent with ments and time and
their educa- attendance for actual
tion and staffing.
experience/ - Review charts main-
based on the tained for ADL medica-
characteris- tions, I & O,
tics of the restraints, etc., to
resident assure that sufficient
load. staff are available for
carrying out responsi-
F138 bilities as specified
2. Weekly time in patient care plans.
schedules are
maintained.
F139
3. There is a
sufficient
number of
nursing staff
available to
meet the
total needs
of all resi-
dents.
F140
4. There is a
registered
nurse on the
day tour of
duty 7 days
a week (for
SNF only).
Intent
That all resi-
dents are cared
for by personnel
qualified to pro-
vide the care &
that sufficient
numbers & class-
ifications of
personnel are
available.
Patient Care Review:
Management - Plan of care
F167 The content of the plan
SNF 405.1124(d) of care is of primary
importance rather than
the format. Separate
F168 care plans are not re-
ICF 442.341 quired for each disci-
pline, but may be
accepted if there is
F169 evidence that the vari-
A. Each resi- ous disciplines coordin-
dent's needs ate their planning.
are addressed - Nursing assessment/re-
in a written assessment and notes.
plan of care - Physician orders.
which demon- - Physician notes.
strates that - Assessments/evaluations
the plans of and progress notes from
all services all professional disci-
are integrat- plines as appropriate.
ed, consonant - Medication and treatment
with the phy- records as applicable.
sician's plan - Lab reports, as applic-
of medical able.
care, and is
implemented
shortly after
admission.
F170
B. Each profes-
sional ser-
vice identi-
fies needs,
goals, plans,
and evaluates
the effec-
tiveness of
interventions
plus insti-
tutes changes
in the plan
of care in a
timely man-
ner.
INTENT
The intent is to
assure that the
facility identi-
fies the resi-
dent's (with
residents/family
input if appli-
cable) needs
through the
coordinated
efforts of all
disciplines.
Restorative Nursing Review:
Activities of Daily - Plan of care
Living + Reflects assessment,
F171-176 goals, methods to
SNF 405.1124(e) reach goals, service
providers, evaluation,
ICF 442.342 and achievement.
442.343(a)(c) + Addresses restorative
nursing assessment,
program initiation,
implementation and
evaluation of the pro-
gress over a reason-
able time period.
Professional judge-
ment determines the
assessment of appropr-
iate time frames.
+ Identifies planning
for potential dis-
charge for all
residents to determine
a disposition on home
INTENT care or an alternate
level of care.
To assist the re- - Nursing Notes
sident to attain + Demonstrate evidence
or maintain his/ of assessment, inter-
her maximum level vention, response to
of independence treatments/teaching
and function? and their progress
toward independence,
a maintenance level
or a deterioration.
+ Provide evidence of
interdisciplinary
conferences.
Positioning - MD orders for non-nsq
F175 interventions/treat-
SNF 405.1124(e) ments.
- Plan of care should in-
clude at a minimum:
+ Restorative goals
88+ specific joints to be
exercised
Intent + devices to be used in
positioning
To assure that + frequency of treatment
the resident is or repositioning
positioned at all + resident teaching in-
times to promote formation
maximum therapeu- + resident teaching
tic benefit and information
comfort, as well + services responsible
as safety. for carrying out the
procedures
+ time frames for
reaching goals
- Nursing progress notes
indicate:
+ Plan has been imple-
mented
+ Progress toward goals
+ Response to informa-
tion from reevaluation
- Look for actual turning/
repositioning schedule
Nursing Services
G. Administration Review the medication
of Drugs administration record.
F183-184 (as appropriate)
SNF 405.1124(g)
ICF 442.337 See S.O.M. Appendix N,
Transmittal No. 174 for
F186 details of the record
1. The patient review.
is identified
prior to ad-
ministration
of a drug.
F187
2. Drugs and
biologicals
are admin-
istered as
soon after
doses are
prepared.
F188
b. Administered
by same per-
son who pre-
pared the
doses for ad-
ministration
except under
single unit
dose packet
distribution
system.
Exception:
ICF residents
may self ad-
minister
medications
with their
physician's
permission.
H. Conformance with - Review the latest recap
Physician Drug of the physicians orders
Orders
F189 - Review the medication
F190 administration record
F191 (as appropriate)
SNF 405.1124(h)
ICF 442.334(a) - See S.O.M. Appendix N,
Drugs are admin- Transmittal No. 174 for
istered in ac- details of the record
ordance with review.
written orders
of the attending
physician.
Intent
All residents
receive medica-
tions as ordered
by the physician.
DIETETIC SERVICES Review Nutrition
(Condition of assessment for the
Participation) following documentation:
* Usual/ideal body weight/
F193 height
SNF (405.1125) * Dietary allergies/
sensitivities, ability
A. Menus and to chew and swallow
Nutritional regular foods without
Adequacy difficulty.
* Full or partial dentures
* Mental and emotional
F194 condition
SNF (405.1125(b)) * Physical appearance,
skin condition
* Appetite and food pre-
F194 ference.
ICF 442.332(a)(1) * Vitamin and mineral
supplements.
* Food and fluid intake
F196 in measurable terms and
Menus are planned frequency of meals.
and followed to * Degree of assistance
meet the nutri- needed in eating,
tional needs of related mobility,
each resident in vision, or other identi-
accordance with fied problems.
physicians' orders * Medications (e.g.,
and, to the extent diuretics, insulin,
medically possible, antibiotics, etc.)
based on the recom- * Related laboratory
mended dietary al- findings (e.g., fasting
lowances of the blood sugar, cholester-
Food and Nutrition ol, sodium, potassium,
Board of the hemoglobin, BUN, serum
National Research albumin, transferring or
Council, National creatinine-height index
Academy of if available).
Sciences.
* Food/drug interactions
* Mental/emotional assess-
ment as it relates to
resident's food habits.
Intent Review:
Ensures that each * Plan of Care
resident receives * Nursing Notes
food in the amount,
kind, and consis- Review:
tency to support
optimal nutritional * Physicians orders
status. * Progress notes
* Notes from other profes-
sional disciplines as
appropriate.
Nutritional status depends
not only on adequacy of
menu planning but also
whether the resident eats
the food and how the body
uses it. While the sur-
veyor is not responsible
for individual nutritional
assessments of residents,
when specific information
is needed during the
survey to make a com-
pliance decision, the
surveyor will utilize the
following minimum assess-
ment guideline:
Menu Evaluation
* Adequate in energy and
nutrients
- Protein
- Calories
- Vitamin C
- Calcium
Selected evaluation of
residents for in depth
review:
A check list can be used
to evaluate daily menus
for basic foods:
(use standard serving
protions)
Daily food plan should
include:
MILK GROUP
1 pt milk
MEAT GROUP
5 equivalents: * 1 equiv-
alent equals 1 oz. of
meat (edible portion)
weighed after cooking
(this includes eggs,
dried peas, beans, nuts,
and all meat, fish and
poultry).
VEGETABLE AND FRUIT GROUP
5 services or more,
including a dark green or
deep yellow vegetable for
vitamin A value every
other day and a citrus
fruit or other fruit rich
in Vitamin C daily.
BREAD-CEREAL-POTATO-
LEGUME-PASTA GROUP
7 servings
FATS AND SWEETS
(Without this group the
diet contains 1,415
Kcal)
Diets should be adapted
from facility's currently
approved diet manual.
Menus are dated and con-
tain minimum portion
sizes.
Are substitutions noted on
the file copy?
Are substitutions made
within the same food group
i.e., meat for another
source of protein in the
meat group, or vegetable
of similar nutritional
value?
a. Documentation of deci-
sion to withdraw or
begin artificial feeding
and hydration.
Check menus for variety
Are they specific (i.e.,
states kinds of fruit,
juice, vegetable)?
DIETARY SERVICES
SELECTED NUTRITIONAL
REQUIREMENT RECORD REVIEW
N.B. The basal energy ex-
penditure (BEE) and ca-
lorie requirement using
Harris-Benedic formula
recognizes the variation
in energy needs for in-
dividuals.
1. Anthropometry-Weight
/Height
NOTE: The following
sample formulas and
guidelines are not the
only acceptable guides
available. The surveyor
should ask to use the
assessment guidelines
used by the facility
before using the ones
provided here.
* Important indicator
of nutritional out-
comes.
* Disease state can have
adverse effect on
desired body weight.
2. Weight for Height
Calculation
Females:
Allow 100 lbs. for
first 5 ft. of height
plus 5 lbs. for each
additional inch
Males:
Allow 106 lbs. for
first 5 ft. of height
plus 6 lbs. for each
additional inch
Estimating Caloric Needs
1. FORMULA: Harris-
Benedict Equation
Men: 66 + (13.7 X
Wt. in Kg)
+ (5 X Ht. in cm)
- (6.8 X Age) = BEE
Women: 65.5 + 9.6 X
Wt. in Kg.)
+ (1.7 X Ht. in cm)
- (4.7 X Age) = BEE
Parenteral Anabolic:
1.75 X BEE
Oral Anabolic: 1.5 X BEE
(Kcals)
Oral Maintenance:
1.20 X BEE
(Kcals)
Metric Conversions
(Approx)
pounds (lb.) X 0.45 =
kilograms (Kg)
inches (in.) X 2.5 =
centimeters (cm)
Estimating Protein Needs
1. Allow 0.8 gram protein
per kilogram of ideal
body weight.
2. Increase to 1.2 - 1.5
gm/kg for patients
with depleted protein
stores (decubitus,
draining wounds,
fractures, etc.).
Fluid Requirement
Based on actual body
weight:
Over 55 years with no
major cardiac or renal
diseases:
(NOTE: 2.2 lbs. equals 1
kg of body weight)
Example: 120 lbs/2.2 lbs.
= 54.5 kg (55
kgs)
55 kg X 30 cc -
1,650 cc/day
Note: Isotonic Standard
Tube Feeding =
Approximately 80%
water.
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