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 ENFORCEMENT
Date:
01/17/2012
Document:
ยง 488.115 Care guidelines. (Part II of II)
SURVEY AREA EVALUATION FACTORS
*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- Unless there is documen-
tion & Treatment tation that the residents
medical condition should
F60-64 not be discussed with
SNF 405.1121(k)(2) him/her resident inter-
ICF 442.311(b) views/record reviews
should indicate that the
resident and physician
have discussed his/her
medical condition.*
If you cannot confirm
that this has occurred,
interview staff to get
further clarification.
Almost all residents who
are able to participate
to some extent in their
care planning do so.
You should find evidence
of this for the majority
of the residents (e.g.,
care planning interview,
nurses notes, social
worker progress notes).
Residents do have the
right to refuse medica-
tion or other treatment,
but you would expect that
the facility would dis-
cuss the implications of
this refusal with the
resident and possibly do
some "gentle
persuasion". *
However, except in an
emergency situation force
should never be used to
compel a resident to
accept medication or
treatment.
Deceit is also a viola-
tion of resident rights,
except in the case of
therapeutically indicated
placebos ordered by the
physician.
Any resident participa-
ting in research studies
should fully understand
the implication of the
study.
The facility is not in
compliance with the
resident rights
regulation if the
resident consents to
participate in a clinical
study without full know-
ledge of the study.
(Record review only as
other nonclinical studies
may not require informed
consent).
C. Transfer and To be in compliance with
Discharge transfer and discharge
F65-68 regulations the facility
SNF 405.1121(k)(4) must be able to confirm
ICF 442.311(c) that all discharges/
transfers were for medi-
cal or resident welfare
reasons, or non-payment.
Welfare reasons include
physical, emotional,
social issues.
Transfers and discharges
made solely for the con-
venience of the facility
are unacceptable.
(Relocation to accomodate
contagious or other dis-
orders requiring isola-
tion procedures are not
for the convenience of
the facility).
D. Exercising Compliance determinations
Rights will be made based pri-
F69 marily on resident/staff
SNF 405.1121(k)(5) interviews and the cor-
ICF 442.311(d) relation of interview
information with docu-
mentation in the Medical
record.
If residents ask, they
should be allowed to
speak to the surveyor
without facility person-
nel being present.
However, the resident has
the right to have a
third party of their
choosing present during
an interview.
E. Financial
Affairs
F72-78
SNF 405.1121(k)(6)
405.1121(m)
ICF 442.311(e)
442.320
Residents should have
reasonable access to
their funds (may not be
available at 2 A.M.) and
should have at least a
quarterly accounting of
their funds.
If questions arise they
should be resolved.
Personal possessions and
funds received from the
residents should be pro-
tected from theft and
other loss. If losses do
occur there should be:
1. a procedure which is
implemented to inves-
tigate the loss, and
2. a plan to prevent
recurrence.
Resident funds must not
be appropriated for fac-
ility furnishings, linen
direct care supplies, etc.
F. Freedom From There must be a physic-
Abuse and ian's order for all re-
Restraints straints, including
"safety devices" which
F79-83 are defined in some State
SNF 405.1121(k)(7) laws.
ICF 442.311(f)
Progress notes should
show evidence that me-
thods other than re-
straints were initially
used to protect the resi-
dent from injury, and
that restraints were
used only when other
methods were not adequate
If used in an "emergency"
the reason for use must
be documented and show
that:
a. Its use was necessary
to protect the resi-
dent from injury.
b. Its use was necessary
to protect others from
injury.
The resident must be ob-
served by a staff member
at least every 30 mins.
while restrained.
The restraints must be
released and the resident
exercised, toileted, etc.
at least every 2 hours.
The restraint must be
applied correctly.
If the use of restraints
increased during evening
and night hours review
progress notes, nurses
notes and staffing to
make a determination as
to whether the restraints
are justified or if they
are for staff
convenience.
Care plans should plan
not only for care while
the resident is restrain-
ed but should show effort
to find alternative
treatments to restraints,
or there should be
documentation in the
medical record that
no alternative is
appropriate.
An appropriate drug
regimen reviews should be
conducted on the
resident.
Your observations should
show interaction between
residents and staff
to be, except in unusual
situations, free from
tension and hostility.
Staff should step into
situation where one
resident may be abusing
another.
Resident should feel free
to voice complaints. If
no complaints are noted
in records or on record
review, why not?
Residents should seem
comfortable in relating
how they are treated?
G. Privacy Observations and inter-
views will give you in-
F84-89 formation to determine if
SNF 405.1121(k)(8) residents are respected
(9)(14) and treated as individ-
ICF 442.311(g) als.
Is privacy available --
e.g., access to a private
place to meet or make
phone calls, ability
to shut door when having
visitors, etc.
Medical records should
not be left where unauth-
orized personnel can read
them and there should be
identification codes
needed to access comput-
erized records.
Married residents should
be sharing rooms if they
desire to do so unless
there are appropriate
contradictions.
H. Work Services performed by a
resident should be part
F90 of the resident's plan of
SNF 405.1121(k)(10) care and should be done
ICF 442.311(h) only if the resident is
in full agreement.
Service rewards are spe-
cifically identified and
not obtained using the
residents own funds.
I. Freedom of All residents may have
Association and access to and maintain
Correspondence contact with the commun-
ity and members of that
F91-92 community have access to
SNF 405.1121(k)(11) them.
(12)
ICF 442.311(i) Subject to reasonable
scheduling restrictions,
residents may receive
visits from anyone they
wish. A particular vis-
itor may be restricted by
the facility for one of
the following reasons:
- The resident refuses to
see the visitor.
- The resident's physi-
cian documents specific
reasons why such a vis-
it would be harmful to
the resident's health.
- The visitor's behavior
is unreasonably disrup-
tive of the functioning
of the facility (rea-
sons are documented and
kept on file).
Decisions to restrict a
visitor are reviewed and
reevaluated each time the
resident's plan of care
and medical orders are
reviewed by the physician
and nursing staff or at
the resident's request.
Space is provided for
residents to receive vis-
itors in reasonable com-
fort and privacy.
Telephones, consistent
with ANSI standards
(45.1134(c)), are made
available and accessible
for residents to make and
receive calls with pri-
vacy. Residents who need
help are assisted in us-
ing the phone. The fact
that telephone communica-
tion is possible, as well
as any restrictions, is
made known to residents.
Arrangements are made to
provide assistance to
residents who require
help in reading or send-
ing mail.
J. Activities Compliance with this ele-
ment is determined by
F93 evidence that residents
SNF 405.1121(k)(12) are given the opportunity
ICF 442.311(j) to participate in avail-
able activities they
choose unless medically
contraindicated.
Residents must not be
forced to participate
against their wishes.
K. Personal Residents are permitted
Possessions to keep reasonable
amounts of personal
F94 clothing and possessions
SNF 405.1121(k)(13) for their use while in
ICF 442.311(k) the facility and such
personal property is kept
in a safe location which
is convenient to the
resident. The amount
that is reasonable will
be dependent on space
available in the
facility.
Patients are advised,
prior to or at admission,
of the kinds and amounts
of clothing and possess-
ions permitted for per-
sonal use, and whether
the facility will accept
responsibility for main-
taining these items
(e.g., cleaning and
laundry).
Any personal clothing or
possessions retained by
the facility for the
patient during his stay
is identified.
The facility is responsi-
ble for secure storage of
such items, and they are
returned to the patient
promptly upon request
or upon discharge from
the facility.
L. Delegation of The fact that a resident
Rights and has been judged incompe-
Responsibilities tent, is medically incap-
able of understanding, or
F95-97 exhibits a communication
SNF 405.1121(k) barrier, does not absolve
ICF 442.312 the facility from advis-
ing the resident of their
rights to the extent the
patient is able to under-
stand them. If the resi-
dent is incapable of
understanding their
rights, the facility ad-
vises the guardian or
sponsor and acquires a
statement indicating an
understanding of resi-
dent's rights.
The surveyor reviews
records of residents
selected for indepth re-
view who are classified
either incompetent, medi-
cally incapable of under-
standing their rights, or
have a communication
barrier to verify docu-
mented evidence (signed
acknowledgment) that the
guardian or other sponsor
has been advised of these
resident rights and
understand their role in
acting on behalf of the
resident.
STAFF DEVELOPMENT Facility staff adjusts
care to needs/problems
F98 of resident.
SNF 405.1121
Staff is knowledgeable
concerning facility pol-
F99 icies and procedures.
ICF 442.314
Staff practices correct
techniques, i.e., infec-
F100 tion control rehabilita
1. Facility tion nursing techniques,
staff are etc.
knowledgeable
about the Staff interacts and
problems treats residents in a
needs of the kind, caring way.
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 knowledge-
able in cur-
rent practices,
use proper
techniques, and
interact with
residents in a
kind, caring
way.
Status Change - All injuries and
Notifications changes in condition
must be documented.
F103-104 The resident's physi-
SNF 405.1121(j) cian and family must
ICF 442.307 be notified of signi-
cant changes. This
F105 should be documented,
1. The facility but this notification
notifies the should be confirmed by
resident's the resident if
attending possible.
physician
and other
responsible
persons
in the event
of an acci-
dent involv-
ing the
resident, or
other
significant
change in
the resi-
dent's physi-
cal, mental,
or emotional
status, or
patient char-
ges, bill-
ings, and
related
administra-
tive
matters.
F106
2. Except in a - Except in an emergency,
medical emer- all transfers or dis-
gency, a charges are first dis-
resident is cussed with the resi-
not trans- dent or next of kin
ferred or
discharged, as evidenced by docu-
nor is treat- mentation in the medi-
ment altered cal record or confirmed
radically, by asking resident.
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 resi-
dent re-
ceives
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
conveni
-ence.
Physician's Examine medical records
Services of the residents selected
for indepth review to
F107 determine if date of
SNF 405.1123 orders, medical data and
other required informa-
A. Medical Findings tion is the date of
and Orders at admission or within 48
Time of hours of admission. The
Admission facility should receive
sufficient information
F108 and orders to provide
SNF 405.1123(a) continuity of care of
all residents.
F109
1. There is made
available to
the facility
prior to or
at the time
of ad-
mission,
resident
information
which
includes
current medi-
cal findings
diagnoses,
and orders
from a
physician for
immediate
care of the
resident.
F110
2. Information
about the
rehabilita-
tion po-
tential of
the resident
and a summary
of prior
treatments
are made
available to
the facility
at the time
of admission,
or within
48 hours
thereafter.
Resident Super- Medical records should
vision by Physician provide evidence that the
residents are under the
F111 supervision of a physi-
SNF 405.1123(b) cian by the coordination
of physician's orders and
F112 progress notes with the
ICF 442.346 resident's plan of care
and observations of resi-
B. Resident dents needs. There is
Supervision by evidence that the physi-
Physician cian reviews and revises
the plan of care as
F113 needed. There is evi-
1. Every resi- dence that physician
dent must be services are available
under the to the residents when the
supervision residents need such ser-
of a physi- vices. An alternate
cian schedule for physician
F114 visits may be established
2. A physician if the attending physi-
prescribes a cian determines that the
planned regi- resident need not be seen
men of care every 30 days. Justifi-
based on a cation for the decision
medical eval- is placed in the resi-
uation of dent's medical record and
each resi- is reviewed by the U.R.
dent's im- Committee and State med-
mediate and
long-term ical review team. Where
care needs. there is a change in the
resident's condition and
the physician has failed
to document his findings
or evaluation of the
condition, the physician
has failed to provide
evidence of his evalua-
tion of resident needs
and supervised care.
F115
3. A physician A physician is available
is available to respond within a
to provide reasonable time when a
care in resident needs medical
the absence attention.
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 Although medical evalua-
least once tion can be noted as a
every 30 days revision of the previous
for the first H&P
90 days after A statement such as "no
admission. change" when in conflict
with the status of the
resident on this admis-
sion to the facility,
does not constitute a
medical evaluation.
Exception: ICF
residents must be Verbal medication orders
seen every 60 days must be countersigned
unless otherwise with 48 hours.
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 - Surveyor verifies that
Services there are readily
available written pro-
F121 cedures for securing a
SNF 405.1123(c) physician in case of
emergency.
F122
Emergency services - Names and telephone
from a physician numbers are posted or
are available and on rolodex.
provided to each
resident who - An alternate physician
requires emergency is designated.
care
- There is provision for:
+ Notification of
INTENT: To assure attending physician/
that a physician emergency and other
has overall responsible person.
responsibility for + Arrangements for
the management and transportation.
supervision of the + Preparation of
residents care. reports.
+ There is evidence in
the medical records
that proper proce-
dures have been
carried out.
+ Residents with sudden
changes in condition
have been evaluated
by the physician.
Nursing Services
F123
SNF 405.1124
F124 Refer to information on
SNF 405.1124(c) observation. A pattern
F125 of evidence of poor per-
F126 sonal care indicates non-
ICF 442.1124(c) compliance unless the
A facility provides care plan specifically
nursing services deals with this and
sufficient to meet appropriate planning and
nursing needs of implementation is
all residents all occurring.
hours of each day. The regulations require
that individual prefer-
F127 Grooming and ences are taken into
Personal account when providing
Hygiene for grooming and personal
SNF 405.1124(c) hygiene and that resi-
dents are encouraged in
self-care activity. Do
your patient interviews
substantiate compliance
with the regulations?
Skin Condition Preventable pressure
F128-129 sores are not occurring.
SNF 405.1124(c) Ulcers present are
treated on a routine
basis according to P.O.C.
Is skin clean?
Is resident dry?
Is turning schedule
adhered to?
Are linens clean and
smooth?
Do personnel know pre-
ventive measures and
practice these?
Has a nutritional assess-
ment been done, and if
appropriate, recommen-
dations implemented?
Wounds/Wound Physician orders, your
Dressings observations, progress
F126 notes and POC should
SNF 405.1124(c) reflect the same infor-
mation.
Treatment provided over a
period of time with no
improvement and no re-
evaluation also would
represent non-compliance,
unless nursing/physician
progress notes address
the "no improvement"
problem.
Compliance is evidenced
by:
- treatment given accord-
ing to doctor's orders
and POC.
- use of appropriate
technique when caring
for wound/changing
dressing (e.g., follows
facility's written
procedures).
- periodic evaluation of
healing process and
revision of care plan
as needed.
Restraints - Is there a physician's
F130 order, including the
circumstances in which
they will be used, the
When residents re- length of use, and the
quire restraints type of restraint?
the application is - Is the restraint
ordered by the phy- applied properly?
sician, applied - Is it released at least
properly, and re- every two hours and the
leased at least resident provided with
every two hours. exercise and toilet
(See also informa- facilities if needed?
tion under Resident - Does the staff observe
rights-freedom from the resident frequently
abuse & restraints) while he/she is
restrained?
- Are chemical restraints
administered in accor-
dance with physician's
orders?
- Is the order for re-
straints renewed only
after a reassessment of
the patient?
Bowel and Bladder - Are all incontinent
F131 patients assessed for
SNF 405.1124(c) cause of incontinence
Each resident with and ability to be
incontinence is helped by a bowel/
provided with care bladder rehabilitative
necessary to en- training program or an
courage continence incontinence management
including frequent program?
toileting and - Are all appropriate
opportunities for residents involved in
rehabilitative bladder/bowel training
training. programs or, inconti-
nence management and
there is a schedule
that shows when the
program will be
started?
- Is there evidence of
follow through on all
shifts?
- For residents not on
bowel/bladder retrain-
ing programs the plan
of care should address
specific measures for
managing incontinence
with a view to preven-
tion of skin and other
problems and mainte-
nance of resident
dignity.
Catheter Care The facility should
F132 follow accepted profes-
SNF 405.1124(c) sional standards in their
catheter care.
Each resident with
a urinary catheter There should be medical
receives proper reasons for catheter in-
routine care in sertion - staff conven-
cluding periodic ience cannot be justi-
evaluation fication.
Direct care staff should
know signs and symtoms
of urinary tract
infections (U.T.I.s) and
these should be reported
and treated promptly.
* The Center for Disease
Control has developed
standards for catheter
care which may be used
but it is not a
requirement.
Injections - Is the medication
F133 administered according
SNF 1124(c) to the physicians
order?
- Is proper technique
used in preparation and
administration includ-
ing site rotation?
- Does the nurse adminis-
tering the medication
know the expected
action of the drug?
- If infection control
reports show infections
at injection sites.
- Is the resident's
response to the medi-
cation noted in the
progress notes?
Parenteral Fluids - Is the parenteral fluid
F133 administered according
SNF 405.1124(c) to the physician's
order and in accordance
with accepted nursing
practice?
- Are infiltrations noted
in a timely manner
before a large amount
of fluid infiltrates?
- Is the facility pro-
cedure for care of the
IV site and tubing
changes followed for
all patients unless
contraindicated?
- Does documentation
reflect what the
patient received, any
problems, and his/her
response to the
parenteral fluid?
- Have any adverse
effects been caused by
administration of IV
fluid?
- If yes, were these
preventable?
Colostomy/Ileostomy Compliance would be
F133 indicated if residents
SNF 405.1124(c) are physically and emo-
tionally comfortable with
the ostomy with minimal
or no skin problems.
If residents are not com-
fortable with the ostomy,
are having skin or other
problems, the facility
should be responding to
these and correcting
them as reasonable. Care
plans should indicate
specific goals in rela-
tion to problems and
specific interventions
for reaching these goals.
When available an en
terostomal therapy nurse
should be involved in
developing the care plan
for residents with
urinary and intestinal
stomas.
Respiratory Therapy Only qualified (trained)
F133 personnel should adminis-
SNF 405.1124(c) ter/assist with respira-
tory therapy. Therapy
must be provided as
ordered.
The effectiveness of the
therapy must be periodi-
cally evaluated and
therapy revised as
appropriate.
Effective infection con-
trol measures must be
practiced. Needed
safety precaution for the
use of oxygen must be
practiced.
Equipment should be avai-
lable and in working
order.
Tracheostomy Care Stoma and surrounding
F133 skin should be in good
SNF 405.1124(c) condition and if not,
there should be treat-
ment directed to re-
solving this problem.
All staff caring for the
tracheostomy must be
trained and emergency
procedures must be known.
All needed equipment must
be available and in
working order. Resident
must at all times have
readily available a means
of communicating with
the staff in an
emergency.
Suctioning - All equipment must be
F133 available and in work-
SNF 405.1124(c) ing order.
- All staff caring for
the resident must know
what to do in an
emergency.
- Current professionally
accepted standards of
care must be main-
tained.
Tube Feedings - Has the feeding been
F133 ordered by a physician?
SNF 405.1124(c) - Is tube feeding nutri-
tionally adequate?
- Have attempts been made
to discontinue tube
feeding if indicated?
- Is skin free from
irritation; mouth care
is given several times
daily? (More frequent
mouth care in the case
of continuous feeding.)
- Have changes in resi
dent condition been
noted and addressed
(weight loss, consti-
pation, diarrhea, skin
condition)?
- Have observed problems
been coordinated with
other departments and
resolved?
- Is feeding being moni-
tored to ensure that
feeding is occurring at
the ordered/appropriate
rate?
- Varied supplements as
preferences allow?
Nursing Services All nursing personnel
F137 must function within
SNF (405.1124) their State Nursing
ICF (442.338) Practice Act.
B. Twenty-four Levels of staffing meet
hour nursing. at least minimum require-
ments.
F137 Nursing care needs must
1. Assigned be identified by the
duties con- facility & documentation,
sistent with resident and staff inter-
their educa- views should determine
tion and if these needs are met.
experience/ All nursing staff should
based on the have education or
characteris- training to prepare them
tics of the for the care they
resident perform.
load.
F138
2. Weekly time
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 person-
nel qualified
to provide
the care &
that sufficient
numbers &
classifica-
tions of
personnel are
available.
Patient Care - Are all resident's
Management needs/problems identi-
fied?
F167 - Is the plan developed
SNF 405.1124(d) to meet these needs?
- Does the plan demon-
strate an interdisci-
F168 plinary approach, and
ICF 442.341 include:
+ Goals stated in mea
F169 surable/observable
A. Each resi- terms?
dent's needs + Approaches (staff
are addressed action) to meet the
in a written resident action
plan of care goals?
which demon- + Responsible disci-
strates that plines/staff
the plans of responsible for ap-
all services proaches to assist
are integrat- resident in achieving
ed, consonant goal/goals?
with the phy- + Is plan being re-
sician's plan assessed and changed
of medical as needed to reflect
care, and is current status?
implemented + Does plan of care
shortly after accurately reflect
admission. information gained
from observation,
interview and record
F170 review?
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 Are patient needs identi-
Activities of Daily fied? Verify that the
Living plan of care addresses
F171-176 resident needs and is
SNF 405.1124(e) implemented as scheduled
and that all appropriate
ICF 442.342 information is
442.343(a)(c) documented.
If goals are not reached,
has a reevaluation been
performed and goals
revised?
Does restorative nursing
assist the resident to
acquire a higher level
of independence?
Is sufficient time
allowed to resident for
learning to increase
his/her level of inde-
pendence?
Are assistive devices
used regularly as per
INTENT plan and are they in
To assist the good repair?
resident to Is there an assessment,
attain or and if appropriate, a
maintain his/ plan for each ADL that
her maximum the resident needs to
level of gain independece in?
independence Maintenance goals should
and function? be noted as appropriate.
Positioning Plan of care should be
F175 complete (addressing
SNF 405.1124(e) resident positioning
needs) and plan is imple-
mented on a daily basis.
Care givers are know-
ledgeable re plan content
Residents are turned as
Intent scheduled.
In good body alignment
To assure that with proper assistive
the resident is devices & equipment.
positioned at Contractures are pre-
all times to vented and/or treated.
promote maximum Plan is reviewed, reeval-
therapeutic uated and revised at
benefit and least quarterly, but must
comfort, as be done as often as
well as patient condition dic-
safety. tates.
Ask aide assigned to
demonstrate the hand
holds he/she uses for
ROM. If aide doesn't
know, ROM is probably
not being done. Do it
"at bath time" is not
sufficient.
Nursing Services
G. Administration If the combined total
of Drugs of significant & non-
F183-184 significant errors is
SNF 405.1124(g) 5% or above, a deficiency
ICF 442.337 is present.
F186 Any significant error is
1. The patient cause for a deficiency.
is identified
prior to ad- See Appendix N for
ministration details.
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 See Appendix N for
Physician Drug details
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 or-
dered by the
physician.
DIETETIC SERVICES * Were physician diet
(Condition of orders followed?
Participation) * Did nursing plan for
feeding and assistance
F193 at mealtime?
SNF (405.1125) * Is there rehabilitative
use of assistive de-
A. Menus and vices, if appropriate?
Nutritional * Is modification of
Adequacy consistency of meals
made if resident has a
problem or change in
F194 condition?
SNF (405.1125(b)) * Are between meal and
bedtime snacks pro-
vided as needed?
F194 * Is socialization at
ICF 442.332(a)(1) meals provided?
* Has dietitian provided
counseling of resident
F196 and family as needed
Menus are planned (related to diet)?
and followed to * Usual body weight is
meet the nutri- maintained/supported?
tional needs of * Is there evidence that
each resident in the plan is being
accordance with carried out (e.g., doc-
physicians' orders umentation in the resi-
and, to the extent dent's chart, observa-
medically possible, tion by the surveyor,
based on the recom- and resident/staff
mended dietary al- interviews)? If the
lowances of the resident refuses meals
Food and Nutrition or does not respond to
Board of the intervention, the notes
National Research in the chart should
Council, National indicate efforts to
Academy of intervene or provide
Sciences. counseling.
Is there evidence that
the resident's progress
is regularly observed
(e.g., awareness of
Intent food and fluid intake
Ensures that such as acceptance of
each resident foods, food consumed,
receives and resident's
food in the appetite)?
amount, kind, * Is fluid intake for
and consis- resident encouraged,
tency to Foley catheter, problem
support op- feeders monitored?
timal nutri- * Is there general evi-
tional dence as to whether
status. poor resident condi-
tions are due to poor
care or whether the
facility has taken
appropriate measures
to prevent or resolve
problems.
* Is there indication of
progress toward desired
outcomes? If not, is
the evidence of re-
evaluation available
within specified time
frames?
* When the antropometric
and clinical data
do not correlate with
dietary data, (food
intake, dietary sup-
plements) the surveyor
should take note that
the problem may not be
nutritional.
B. Therapeutic
Diets
F197
SNF 405.1125(c)
F198
ICF 442.332(b)(1)
(2)
F199
1. Therapeutic
diets are
prescribed by
the attending
physician. On Pureed diets:
* Ordered by physician
F182 * Prepared fresh daily
2. Therapeutic * Same calories and/or
menus are food groups as if
planned in served whole.
writing, pre-
pared, and Pureed foods are coordin-
served as ated with general/regular
ordered with menu.
supervision
from the di- On Tube Feeding:
etician and * Has the feeding been
advice from ordered by physician?
the attending * Is tube feeding nutri-
physician tionally adequate?
whenever * Have attempts been made
necessary. to progress tube feed-
ing if indicated?
* Have changes in resi-
dent condition been
noted and addressed.
weight loss, consti-
pation, diarrhea, skin
condition)?
* Have observed problems
been coordinated with
other departments and
resolved?
* Is feeding being moni-
tored to ensure that
feeding is occurring at
the ordered/appropriate
rate?
* Varied nourishmnts as
preferences allow?
On Diabetic Diets and
Other Therapeutic Diets
* Ordered by Physician
* Varied, nutritionally
adequate
* Individualized to suit
resident
* Re-evaluation indicates
diet meets objectives.
If not appropriate,
documentation is
provided
* Laboratory results
support diagnosis
* Between meals nourish-
ment provided as needed
and recorded in meas-
urable amounts.
F198
Therapeutic diets
prescribed by the
attending physician
F199
Therapeutic menus A system is in place to
are planned in provide the type and
writing, prepared amount of nutritional
and served as support needed by the re-
ordered with super- sidents who have developed
vision from the decubitus ulcers.
dietician and
advice from the Food and supplementation
physician whenever are provided in a method
necessary. to ensure intake of
nutrients needed by
residents with decubitus
ulcers.
Nutritional intervention
is assessed and reassessed
to ensure appropriate in-
tervention for acceptable
health care outcome.
On Renal Diets
F198
Therapeutic diets - Ordered by physician
prescribed by the
attending physi- - Written menu nutri-
cian tionally complete in
so far as medically
F199 possible, including
calories
Therapeutic menus
are planned in - Individualized to suit
writing, prepared resident
and served as
ordered with - Laboratory testing as
supervision from needed
the dietician and
advice from the - Coordination with
physician whenever dialysis unit to
necessary. determine effective-
ness of diet
C. Preparation The facility has kitchen
and dietetic service
F204 areas adequate to meet
SNF 405.1125(e) the food service needs.
These areas are properly
ventilated, arranged,
F205 and equipped for sanitary
refrigeration, storage,
1. Food is pre- and preparation of food.
pared by me- Equipment and storage
thods that areas are clean, well
conserve its maintained, within pro-
nutritive per temperatures ranges,
value and and safe
flavor.
F206 Proper temperatures:
2. Meals are (Fahrenheit)
palatable,
served at Frozen food storage --
proper tem- 0 or below
peratures.
They are cut, Cold food storage --
ground, chop- 40-45 degrees
ped, pureed
or in a form Hot food holding equip-
which meets ment -- 140 degrees
individual minimum
resident
needs.
F207 Dishwasher wash cycle --
150-160 degrees
3. If a resident
refuses food Dishwasher rinse cycle --
served, ap- 160-180 degrees or a
propriate color change in thermo-
substitutes paper; or adherence to
of similar manufacturers
nutritive recommendations
value are
offered.
Dietary personnel are
clean and free of infec-
tious disease. They
INTENT practice acceptable tech-
niques and procedures to
To provide foods keep foods at proper
that are safe and temperatures and pro-
nutritious tected against contamin-
ation.
SNF 495.1125(e)
Is dietary information
pertinent to dietary
modification?
Has resident been
assessed for eating pro-
gram to maintain
independence?
The food substitute is
of similar nutritive
value as the refused
item (e.g., milk refused,
alternate of calcium rich
food should
be provided.
D. Frequency Three meals or their
equivalent are served
F208 daily with not more than
SNF 405.1124(d) a 14-hour span between
the evening meal and
breakfast.
F209
ICF 442.331(a) The nourishment service
is more difficult to
evaluate: must find
F210 evidence that patients
1. At least are offered nourishments
three meals on a planned basis and
are served documented.
daily at reg-
ular hours
with not
more than a
14-hour span
between a
substantial
evening meal
and break-
fast.
F211
2. To the extent
medically
possible,
bedtime
nourishments
are offered
to all
residents
E. Staffing - From an assessment of
the total dietetic ser-
vice operation:
F212
+ The dietetic supervisor
SNF 405.1125(a) is capable of the over-
all management and sup-
ervision of the
F213 dietetic service.
+ There are dietetic
1. Food service personnel on duty over
personnel are a 12-hour period who
on duty daily demonstrate ability to
over a period perform tasks ade-
of 12 or more quately.
hours. + Dietetic personnel re-
ceive appropriate or-
ientation and training
consistent with their
duties and responsi-
Intent bilities. There is
evidence that the
Persons are dietetic staff are
providing ser- knowledgeable about
vices commensur- food service policies
ate with their and procedures and ap-
level of ply these accepted pro-
training; and at fessionals practices in
the level of their daily work.
sophistication + Services provided are
needed by the consistent with the
residents. size, scope and fac-
ilities available.
SPECIALIZED - Are rehabilitation
REHABILITATIVE services integrated with
SERVICES restorative nursing?
F214 - Do therapists part-
SNF 405.1126 icipate in development
F215 of resident plan of
SNF 405.1126(b) care?
- Do observations and in-
F216 terview indicate that
ICF 442.343 services are provided in
conjunction with 24 hour
nursing, and in accord-
A. PLAN OF CARE ance with the overall
ICF442.343(e)(1)(2) plan of care regarding
restorative nursing and
F217 specialized rehabilita-
Rehabilitative tion services?
services are pro-
vided under a
written plan of
care, initiated
by the attending
physician and de-
veloped in con-
sultation with
appropriate ther-
apist(s) and the
nursing service.
B. THERAPY
F218
ICF442.343(a)(c)(d)
Therapy is pro-
vided according
to orders of the
attending physi-
can in accordance
with accepted
professional
practices by
qualified
therapists or
qualified
assistants.
C. QIOGRESS
ICF 442.343(f)
F219
1. A report of
the resi-
dent's pro-
gress is com-
municated to
the attending
physician
within 2
weeks of
the initia-
tion of spe-
cialized
rehabili-
tative
services.
EXCEPTION:
ICF resident's
progress must be
reviewed
regularly.
F220
2. The resi-
dent's pro-
gress is
thereafter
reviewed reg-
ularly and
the plan of
rehabilitat-
ive care is
reevaluated
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 Reviews were performed in
Services the facility. There was
evidence of a review per-
F221 formed on every resident
SNF 405.1127 whose record was reviewed
indepth. In records re-
F222 viewed, the average pre-
A. Supervision scription utilization was
not substantially over 6.1
F223 If it is, review for
ICF 442.336(a)(b) appropriateness. Apparent
irregularities were ident-
F224 ified and reported.
SNF 405.1127(a) * Refer to SOM Appendix N
The pharmacist in 174 for further in-
reviews the drug formation on drug reg-
regimen of each imen review.
resident at least
monthly & reports
any irregularities
to the medical
director and
administrator.
A registered nurse
may be utilized to
perform this mon-
thly review for
ICF residents.
Also the attending
or staff physician
must review medi-
cation quarterly.
B. Labeling of
Drugs and Bio-
logicals
F225
SNF 405.1127(c)
F226
ICF 442.333
F227
The labeling of
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 There must be signed phy-
Radiological sician orders for all lab/
Services radiology services
performed.
F228
SNF 405.1128 Record results of all
testing in the medical
record.
F229
SNF 405.1128 (a) There is documentation in
nursing or physician
A. Provision of notes to indicate the re-
Services sults of lab tests were
promptly communicated to
F230 the physician.
1. All services When lab tests are per-
are provided formed the resident should
only on the be informed of significant
orders of a findings and the possible
physician. therapeutic alternatives.
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 The residents social and
emotional needs are ident-
F233 ified. The plan of care
SNF 405.1130 addresses those needs.
The plan of care is being
F234 followed, reviewed and
SNF 405.1130(a) revised as necessary. The
family's needs and con-
F235 cerns are addressed if
ICF 442.344(d) applicable. There is
referral to appropriate
A. Plan agencies if necessary.
Sufficient space is pro-
F236 vided for private meetings
The medically re- and discussions.
lated social and While it is not a program
emotional needs of requirement a social work-
the residents are er or other staff may
identified. contribute to the resi-
dent's care plans by in-
B. Provision of dicating personal
Services strengths that can be used
to build upon.
F237
1. Services are
provided to
meet the so-
cial and emo-
tional needs
by the
facility or
by referral
to an appro-
priate social
agency.
F238
2. If financial
assistance is
indicated,
arrangements
are made
promptly for
referral to
an appropri-
ate agency.
- There is documentation
of collaboration between
nursing and social work
for meeting emotional
needs.
Activities
Are each resident's
F239 personal interests known?
SNF 405.1131 If not, what actions are
being taken to identify
F240 them? Residents in
SNF 405.1131(b) facility 60 days should
not be without some
F241 identified interests.
ICF 442.345
Are each resident's needs
identified? If not, what
F242 actions are being taken
1. An ongoing to identify them?
program of
meaningful Have medical contraindi-
activities is cations been identified
provided in the care plans?
based on
identified Needs and contraindica-
needs and tions of residents in the
facility more than 30
days should be known and/
or have a plan of action.
interests of Does each resident's
each resi- activities promote his
dent. It is physical, social and
designed to mental well-being?
promote op-
portunities
for engaging
in normal
pursuits,
including
religious
activities
of their
choice, if
any.
F243
2. Unless con-
traindicated
by the atten-
ding physi-
cian, all
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 Are equipment and sup-
4. Equipment is plies to meet residents
maintained in interests available and
good working maintained in good work-
order. ing order?
F246 Are residents evaluated
5. Supplies and periodically with
equipment for emphasis on participation
activities of levels and desire for
interest are new activities?
available.
Are plans readjusted if
INTENT they do not reach
desired outcomes?
Each resident has
individual and/or Residents in the facility
group activities more than 60 days should
to meet activi- have at least two activi-
ties needs ties per week of interest
through his to them personally.
interests daily.
Resident may refuse to
participate in activity.
However if the activities
are part of a diagnostic
or therapeutic program,
the resident is responsi-
ble for assisting in the
selection of mutually
acceptable alternative
activities.
MEDICAL RECORDS All information required
is present in the record.
F247
SNF 405.1132 Does the record document
all observable resident
needs/problems?
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
caregivers to
make decisions
on care
needed.
TRANSFER AGREEMENT All pertinent resident
information must be
F265 documented on the medical
SNF 405.1133 record at the time of
transfer.
F266 The resident was not
SNF 405.1133(a) injured in any way by a
delay in the transfer
process.
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 Medication preparation
SNF 405.1134(d) and storage areas provide
adequate space and light
to prepare medication
F272 and to store medication
1. Unit properly and needed supplies.
equipped for
preparation Light is available when
and storage and where the medication
of drugs and cart is in use.
biologicals. A medication refrigerator
is available and does not
contain patient or
F273 employee snacks. Juice,
2. Utility and etc., used in administer-
storage rooms ing medication is
are adequate allowed.
size.
Clean and dirty areas
must be separated, pre-
F274 ferably in separate
3. The unit is rooms.
equipped to
register Storage space must be
resident available for bulky items
calls with a and supplies so that they
functioning can be stored without
communica- blocking corridors and
tions system exits.
from resident
areas includ- Medications are protected
ing rooms and from unauthorized use.
toilets and
bathing Call bells must be in
facility. working order and must be
present in all resident
bedrooms, toilets and
bathing areas.
Audible signals, if in
the system, must be in
working order and turned
on.
B. Dining and Regulations clearly set
activities area out conditions for
compliance. Refer to
F275 the regulations.
SNF 405.1134(g)
F276
ICF 442.329
F277
1. The facility
provides one
or more
clean, order-
ly, and
appropriately
furnished
rooms of ade-
quate size,
designed for
resident
dining and
resident
activities.
F278
2. Dining and
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 Refer to the regulations.
F281
ICF 442.325
F282
1. Single rooms
have at least
100 sq. ft.
F283
2. Multiple res-
ident rooms
have no more
that 4 resi-
dents and at
least 80 sq.
feet per
resident.
F284
3. Each room is
equipped with
or conven-
iently
located near
toilet and
bathing
facilities.
F285
4. There is a
capability of
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 Privacy is maintained for
facilities residents in toilet and
bathing areas.
F292
ICF 442.326 Toilet and bathing areas
F293 are clean. Water is
1. Facilities removed from floors im-
are clean, mediately upon completion
sanitary and of bathing.
free of
odors. Hot water is within
the acceptable tempera-
F294 ture range.
2. Facilities
have safe and Soap, toilet paper and
comfortable towels are available in
hot water the bathrooms.
temperatures.
Grab bars are present
and securely fastened to
F295 the wall.
3. Facilities
maintain Ventilation and lighting
privacy. systems are correctly
functioning.
Plumbing and other fix-
tures are in good
F296 condition.
4. Facilities
have grab
bars and
other safe
guards
against
slipping.
F297
5. Facilities
have fixtures
in good
condition.
F298
6. The resident
call system
functions in
toliet and
bath facili-
ties.
E. Social Service Refer to regulations.
Area
F299
SNF 405.1130(b)
ICF 442.344
F300
1. Ensures
privacy for
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
F303
SNF 405.1126(a)
F304
ICF 442.328(a)
F305
1. Space is ade-
quate for
proper use
of equipment
by all resi-
dents receiv-
ing treatment
G. Facilities for Rooms meeting the regu-
Special care latory requirements are
available in the
F307 facility.
SNF 405.1134(f)
There is a procedure that
is implemented when an
F308 isolation is needed, but
ICF 442.328(b) it is already occupied.
Isolation signs are
visable and clearly con-
vey their intended
message.
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 - Floors and furniture
Areas should appear clean --
free of gross contami-
F311 nation.
SNF 405.1134(j) - Residents should have
lighting bright enough
to safely negotiate
F312 corridors, lounges,
ICF 442.324 etc., and in reading
area, be bright enough
to read. But the
F313 brightness should be
1. All common free of glare. Remem-
resident ber, the elderly need
areas are a higher level of
clean, sani- lighting as their
tary and sight diminishes.
free of - Except for times when
odors. a louder level of sound
is necessary for com-
munication, sounds
F314 should be unobtrusive
2. Provision is and "comfortable".
made for - Room temperature com-
adequate and fort levels vary
comfortable widely, and in general
lighting the elderly will re-
levels in all quire a higher temper-
areas. ature for comfort than
younger people. Use
information from resi-
F315 dent interviews and
3. There is your observations to
limitation of determine if the tem-
sounds at perature is "comfor-
comfort table" for most
levels. residents.
- All corridors in
F316 resident-used areas are
4. A comfortable equipped with handrails
room temper- on each side. These
ature is rails securely fastened
maintained. provide the residents
with a firm support.
- Supervisory staff are
F317 able to tell you how
5. There is ade- they will obtain water
quate venti- for drinking, cleaning/
lation thru bathing of residents,
windows or and other essential
mechanical functions if their
measures or a normal water supply is
combination interrupted.
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
Building and
Equipment
F320
SNF 405.1134(i)
F321
1. The interior
and exterior
of the build-
ing are clean
and orderly.
F322
2. All essential
mechanical
and electri-
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
F326
SNF 405.1134(h)
F327
1. Kitchen and
dietetic ser-
vice areas
are adequate
to insure
proper,
timely ser-
vice for all
patients.
F328
2. Kitchen areas
are properly
ventilated,
arranged, and
equipped for
storage and
preparation
of food as
well as for
dish and
utensil
cleaning, and
refuse stor-
age and
removal.
Indicator K
applies to ICF
K. Dieteary Staff
Hygiene
F329
SNF 405.1125(f)
F330
1. Dietetic ser-
vice person-
nel practice
hygenic food
handling
techniques.
Indicator L
applies to ICF
L. Dietary Sanitary
Conditions
F331
SNF 405.1125(g)
F332
1. Food is
stored,
refrigerated,
prepared,
distributed,
and served
under sani-
tary condi-
tions.
F333
2. Waste is
disposed of
properly.
L. Emergency Power
F334 As per regulations and
SNF 405.1134(b) covered by the Life
Safety Code surveyor
F335
1. An emergency
source of
electrical
power neces-
sary to pro-
tect the
health and
safety of
residents is
available.
F336
2. Emergency
power is ade-
quate at
least for
lighting in
all means of
egress;
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 Compliance will be based
F338 mainly on your observa-
SNF 405.1135 tions.
Deficiencies will be
A. Infection cited if you see:
Control - breaks in aseptic or
F339 isolation technique
SNF 405.1135(b) - clutter or unclean
conditions that would
cause unsafe conditions
F340 - inadequate supplies of
Aseptic and linen to provide proper
isolation tech- care and comfort for
niques are residents
followed by all - inadequate techniques
personnel. for handling clean and
dirty linen
- evidence of insect or
B. Sanitation rodent infestation
F341 - use flash light to
SNF 405.1135(c) check for roaches in
closets, cabinets.
F342
The facility
maintains a
safe, clean,
and orderly
interior.
C. Linen
F343
SNF 405.1135(d)
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
F347
SNF 405.1135(e)
F348
ICF 442.315(c)
F349
The facility is
maintained free
from insects and
rodents.
DISASTER A disaster plan is avail-
PREPAREDNESS able and facility staff
know their roles.
F350
SNF 405.1136
F351
SNF 405.1136(a)
F352
ICF 442.313
Indicators A and
B apply to ICFs.
A. Disaster Plan
F353
1. Facility
staff are
aware of
plans, pro-
cedures to be
followed for
fire, explo-
sion or other
disaster.
F354
2. Facility
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
promptly and
correctly
carries out
a specific
role in case
of a dis-
aster.
INTENT
To ensure a
clean, safe
environment
for residents.
LONG TERM CARE SURVEY
SURVEY AREA CROSS REFERENCE
*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- Patient Care
tion & Treatment Management
405.1124(d)
F60-64 442.319
SNF 405.1121(k)(2) 442.341
ICF 442.311(b)
C. Transfer and Status Change
Discharge Notification
F65-68 405.1121(j)
SNF 405.1121(k)(4)
ICF 442.311(c) Medical Records
405.1132(c)(e)
442.318(c)(4)
Transfer Agreement
405.1133(a)(2)
442.307(b)(1)(2)
D. Exercising Social Services
Rights 405.1130
F69 442.344
SNF 405.1121(k)(5)
ICF 442.311(d)
E. Financial Social Services
Affairs 405.1130(a)
F72-78
SNF 405.1121(k)(6)
405.1121(m)
ICF 442.311(e)
442.320
F. Freedom From Nursing Services
Abuse and 405.1124(c)(5)
Restraints
Rehab Nursing
F79-83 405.1124(e)
SNF 405.1121(k)(7)
ICF 442.311(f) Patient Care
Management
405.1124(d)
G. Privacy
F84-89
SNF 405.1121(k)(8)
(9)(14)
ICF 442.311(g)
Medical Records
405.1132(b)
442.318(d)
H. Work 405.1124(d)
442.341
F90
SNF 405.1121(k)(10)
ICF 442.311(h)
I. Freedom of Resident Rights
Association and 405.1121(k)(8)
Correspondence 442.311(g)
F91-92
SNF 405.1121(k)(11)
(12)
ICF 442.311(i)
J. Activities Patient Activities
405.1131(b)
F93 442.345(a)(c)
SNF 405.1121(k)(12)
ICF 442.311(j)
K. Personal
Possessions
F94
SNF 405.1121(k)(13)
ICF 442.311(k)
L. Delegation of Resident Rights
Rights and 405.1121(k)(1)
Responsibilities 442.311(a)
F95-97
SNF 405.1121(k)
ICF 442.312
STAFF DEVELOPMENT Residents Rights
SNF 405.1121(k)
F98 ICF 442.311
SNF 405.1121
Infection Control
405.1135(a)(b)(c)
F99 (d)(e)
ICF 442.314 442.327(b)
Physical Environ-
F100 ment
1. Facility 405.1134(a)
staff are 442.315(b)(c)
knowledgeable 442.326(a)(c)
about the
problems and Nursing Services
needs of the 405.1124(a)(c)(e)
aged, ill, 442.338(a)(2)
and disabled.
Social Services
405.1130(a)
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 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 proper tech-
niques, and inter-
act with residents
in a kind, caring
way.
Status Change Resident Super-
Notifications vision by Physician
405.1123(b)(3)
F103-104
SNF 405.1121(j) Emergency Services
ICF 442.307 405.1123(c)
F105
1. The facility
notifies the
resident's at-
tending phy-
sician and
other respons-
ible persons
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
medical emer-
gency, a resi-
dent is not
transferred or
discharged,
nor is treat-
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
Services
F107
SNF 405.1123
A. Medical Findings
and Orders at
Time of
Admission
F108
SNF 405.1123(a)
F109
1. There is made
available to
the facility
prior to or at
the time of
admission,
resident
information
which includes
current medi-
cal findings
diagnoses, and
orders from a
physician for
immediate care
of the resi-
dent.
F110
2. Information
about the
rehabilitation
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-
vision by Physician
F111
SNF 405.1123(b)
F112
ICF 442.346
B. Resident
Supervision by
Physician
F113
1. Every resi-
dent must be
under the
supervision
of a physician
F114
2. physician
prescribes a
planned regi-
men of care
based on a
medical eval-
uation of each
resident's
immediate and
long-term care
needs.
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 Status Change
Services Notification
405.1121(j)
F121
*2 *SNF 405.1123(c)
F122
Emergency services
from a physician
are available and
provided to each
resident who
requires emergency
care
INTENT: To assure
that a physician
has overall
responsibility for
the management and
supervision of the
residents care.
Nursing Services
F123
SNF 405.1124
F124 Resident Rights
SNF 405.1124(c) 405.1121(k)(8)(13)
F125 442.311 (g)(k)
F126
ICF 442.1124(c) Social Services
A facility provides 405.1130(a)
nursing services 442.344
sufficient to meet
nursing needs of Activities
all residents all 405.1131
hours of each day. 442.345(a)(c)
Patient Care
F127 Grooming and Management
Personal 405.1124(d)
Hygiene 442.341
SNF 405.1124(c)
Training
405.1121(h)
442.314
Ski n Condition Dietetic Services
F128-129 405.1125(i)(c)(e)
SNF 405.1124(c) 442.332(a)(1)(b)(1)
Activities
405.1131( b)
442.345(a)
Patient Care
Management
405.1124(d)
442.341
Training
405.1121(h)
442.314
Rehabilitative
Nursing
405.1124(e)
442.342
Supervision of
Patient Nutrition
405.1124(f)
442.332(b)(2)
Resident Super-
vision by Physician
405.1123(b)
Wounds/Wound Physician Services
Dressings 405.1123
F126 442.346
SNF 405.1124(c)
Infection Control
405.1135(b)
Pt. Care Management
405.1124
442.341
Dietetic Services
405.1125(b)(c)(e)
442.332(a)(1)(b)(1)
M edical Records
405.1132
442.318
Restraints Patient Rights
F130 405.1121(k)(1)(7)
442.311(f)(2)
When residents re-
quire restraints
the application is
ordered by the phy-
sician, applied
properly, and re-
leased at least
every two hours.
(See also informa-
tion under Resident
rights-freedom from
abuse & restraints)
Bowel and Bladder Nursing Services
F131 405.1124(e)
SNF 405.1124(c)
Each resident with Dietetic Services
incontinence is 405.1125(c)
provided with care
necessary to en-
courage continence
including frequent
toileting and
opportunities for
rehabilitative
training.
Catheter Care Infection Control
F132 405.1135(b)
SNF 405.1124(c)
Each resident with
a urinary catheter
receives proper
routine care in-
cluding periodic
evaluation
Injections
F133
SNF 1124(c)
Staff Development
405.1121(h)
442.314
Infection Control
405.1135(b)
Parenteral Fluids Resident Care
F133 Policies
SNF 405.1124(c) 405.1121(1)
Infection Control
405.1135(b)
Patient Care
Management
405.1124(d)
442.341
Colostom y/Ileostomy Patient Care
F133 Management
SNF 405.1124(c) 405.1124(d)
Social Services
405.1130(a)
442.334(a)(b)
Respiratory Therapy Staff Development
F133 405.1121 (h)
SNF 405.1124(c) 442.314
Infection Control
405.1135(b)
Patient Care
Management
405.1124(d)
442.341
Physica l Environment
405.1134 (i)
Medical Records
405.1132
442.318
Tracheostomy Care Infection Control
F133 405.1135(b)
SNF 405.1124(c)
Training
405.1121(h)
442.314
Pa tient Care
Management
405.1124(d)
Physicians Services
405.1123(b)
Social Services
405.1130(a)
Suctioning Infection Control
F133 405.1135(b)
SNF 405.1124(c)
Patient Care
Management
405.1124(d)
Tube Feedings Nursing Services
F133 405.1124(d)(f)
SNF 405.1124(c) 442.338(a)(2)
Meal Service
442.331(c)
Dietetic Services
405.1125(c)
Nursing Services Patient Rights
F137 405.1121(k)(g)
SNF (405.1124)
ICF (442.338) Patient Care
B. Twenty-four Policies
hour nursing. 405.1121(1)
F137 Medical Records
1. Assigned 405.1132(c)
duties con- 442.318(a)(c)
sistent with
their educa- Patient Care
tion and Management
experience/ 405.1124(d)
based on the 442.341
characteris-
tics of the Staff Development
resident 405.1121(h)
load. 442.314
F138
2. Weekly time
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 Physician Services
Management 405.1123
442.346
F167
SNF 405.1124(d) Medical Records
405.1132
442.318
F168
ICF 442.341 Resident Rights
405.1121(k)
442.311
F169
A. Each resi- 24 Hour Nursing
dent's needs Service
are addressed 405.1124
in a written 442.338
plan of care
which demon- Specialized Reha-
strates that bilitation Services
the plans of 405.1126
all services 442.343
are integrat-
ed, consonant Training
with the phy- 405.1121(h)
sician's plan 442.314
of medical
care, and is Resident Rooms
implemented 405.1134(e)
shortly after
admission. 442.325
442.326
F170 Infection Control
405.1135
B. Each profes- 442.328
sional ser- 442.324
vice identi-
fies needs,
Social Services
goals, plans, 405.1130
and evaluates 405.1130(a)
the effec- 442.344(d)
tiveness of
interventions Activities
plus insti- 405.1131
tutes changes 442.345
in the plan
of care in a Dietetic Services
timely man- 442.1135
ner. 442.332
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 Physicians Services
Activities of Daily 405.1124(a)(b)
Living
F171-176 Nursing Services
SNF 405.1124(e) 405.1124(a)(b)(c)
442.342
ICF 442.342
442.343(a)(c) Dietetic Services
405.1125(a)
442.331(c)
Activities
405.1131(a)(b)
442.345(a)(b)
Specialized Rehab.
Services
405.1126
442.343(e)(1)(2)
INTENT
To assist the re-
sident to attain
or maintain his/
her maximum level
of independence
and function?
Positioning Rehabilitative
F175 Services
* 2*SNF 405.1124(e) 405.1126(h)
442.343(c)(2)
MD Orders
Activities
Resident Rights
Nursing-Staffing
Intent Inservice
Social Service
To assure that Dietary
the resident is
positioned at
all times to
promote maximum
therapeutic
benefit and
comfort, as
well as safety.
Nursing Services
G. Administration Physician Services
of Drugs 405.1124(b)(7)
F183-184
SNF 405.1124(g) Pharmaceutical
ICF 442.337 Services Super-
vision
F186 405.1127(a)
1. The patient 442.336(a)(b)
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 Physician Services
Physician Drug 405.1123(b)(7)
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 Physician Services
(Condition of
Participation) 405.1123
442.346
F193
SNF (405.1125) Medical Records
A. Menus and 405.1132
Nutritional 442.318
Adequacy
Nursing Services
F194 405.1124(e)(f)
SNF (405.1125(b))
Specialized
Rehabilitative
F194 Services
ICF 442.332(a)(1)
405.1126
F196 Patient Care
Menus are planned Management
and followed to 405.1124(d)
meet the nutri-
tional needs of
each resident in
accordance with
physicians' orders
and, to the extent
medically possible,
based on the recom-
mended dietary al-
lowances of the
Food and Nutrition
Board of the
National Research
Council, National
Academy of
Sciences.
Intent
Ensures that
each resident
receives food
in the amount,
kind, and
consistency to
support optimal Nursing Services
nutritional
status. -405.1124(f)
B. Therapeutic Nursing Services
Diets 405.1124
405.1124(c)
F197 (d.) Patient care
SNF 405.1125(c) plan
(f.) Supervision of
F198 patient
ICF 442.332(b)(1) nutrition
(2)
F199
1. Therapeutic
diets are
prescribed
by the
attending
physician.
F182
2. Therapeutic
m enus are
planned in
writing, pre-
pared, and
served as
ordered with
supervision
from the
dietician
and advice
from the
attending
physician
whenever
necessary.
F 198
Therapeutic diets
prescribed by the
attending physician
F199
Therapeutic menus Nursing Service
are planned in 405.1124
writing, prepared (d) Patient Care
and served as Plan
ordered with super- (f) Supervision of
vision from the Patient
dietician and Nutrition
advice from the
physician whenever
necessary.
Nursing Service
F198
Therapeutic diets 405.1124
prescribed by the
attending physi- (d) Patient Care
cian Plan
(f) Supervision of
F199 Patient
Nutrition
Therapeutic menus
are planned in
writing, prepared
and served as
ordered with
supervision from
the dietician and
advice from the
physician whenever
necessary.
C. Preparation
F204
SNF 405.1125(e)
F205
1. Food is
prepared by
methods that
conserve its
nutritive
value and
flavor.
F206
2. Meals are
palatable,
served at
proper
temperatures.
They are
cut, ground,
chopped,
pureed or in
a form which
meets
individual
resident
needs.
F207
3. If a resident
refuses food
served,
appropriate
substitutes
of similar
nutritive
value are
offered.
INTENT
To provide foods
that are safe and
nutritious
SNF 495.1125(e)
D. Frequency
F208
SNF 405.1124(d)
F209
ICF 442.331(a)
F210
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 break-
fast.
F211
2. To the extent
medically
possible,
bedtime
nourishments
are offered
to all
residents
E. Staffing
F212
SNF 405.1125(a)
F213
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 Nursing Services
REHABILITATIVE 405.1124
SERVICES 442.338
F214 442.319
SNF 405.1126 442.341
F215
SNF 405.1126(b) Physician Services
405.1123
F216 442.346
ICF 442.343
Medical Records
405.1132
A. PLAN OF CARE 442.318
ICF442.343(e)(1)(2)
Activities Program
F217
Rehabilitative 405.1131
services are pro- 442.345
vided under a
written plan of Resident Rights
care, initiated
by the attending 405.1121(k)
physician and de- 442.311
veloped in con-
sultation with Training
appropriate ther-
apist(s) and the 405.1121(h)
nursing service. 442.311
B. THERAPY Infection Control
F218
ICF442.343(a)(c)(d) 405.1135
442.315
Therapy is pro- 442.327
vided according 442.328
to orders of the
attending physi-
can in accordance
with accepted
Physical
Environment
professional
practices by 405.1134
qualified 442.324
therapists or 442.325
qualified 442.326
assistants. 442.328
C. QIOGRESS 442.329
442.330
ICF 442.343(f) Dietetic Services
405.1125(e)
F219 442.329
1. A report of 442.331(c)
the resi-
dent's pro-
gress is com-
municated to
the attending
physician
within 2
weeks of
the initia-
tion of
specialized
rehabilita-
tive
services.
EXCEPTION:
ICF resident's
progress must be
reviewed
regularly.
F220
2. The resi-
dent's pro-
gress is
thereafter
reviewed
regularly
and the plan
of rehabil-
itative care
is reevaluat-
ed as neces-
sary, But at
least every
30 days by
the physi-
cian 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 Physicians Services
Services 405.1123(b)
442.346
F221
SNF 405.1127 Nursing Services
405.1124
F222 442.338
A. Supervision
F223
ICF 442.336(a)(b)
F224
SNF 405.1127(a)
The pharmacist
reviews the drug
regimen of each
resident at least
monthly & reports
any irregularities
to the medical
director and
administrator.
A registered nurse
may be utilized to
perform this mon-
thly review for
ICF residents.
Also the attending
or staff physician
must review medi-
cation quarterly.
B. Labeling of
Drugs and Bio-
logicals
F225
SNF 405.1127(c)
F226
ICF 442.333
F227
The labeling of
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 Nursing Services
Radiological 405.1124(a)(b)(c)
Services 442.343
F228 Physician Services
SNF 405.1128 405.1123(b)
F229
SNF 405.1128 (a)
A. Provision of
Services
F230
1. All services
are provided
only on the
orders of a
physician.
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 perform-
ed as ordered and
findings are
reported to phy-
sicians are made
aware of symptoms
that may require
lab tests.
Social Services Nursing Services
SNF 405.1124
F233 ICF 442.338
SNF 405.1130
Activities
F234 SNF 405.1131
SNF 405.1130(a) ICF 442.345(a)(c)
(d)
F235
ICF 442.344(d) Physicians Services
SNF 405.1123(b)
A. Plan ICF 442.346
F236 Patient Care
The medically re- Management
lated social and SNF 1124(d)
emotional needs of ICF 442.346
the residents are
identified. Physical
Environment
B. Provision of SNF 405.1130(b)
Services ICF 442.344(c)
F237
1. Services are
provided to
meet the
social and
emotional
needs by the
facility or
by referral
to an
appropriate
social
agency.
F238
2. If financial
assistance is
indicated,
arrangements
are made
promptly for
referral to
an appropri-
ate agency.
Patient Care
Management
405.1124(d)
Activities
Nursing Services
F239 405.1124
SNF 405.1131 442.319
F240 Social Services
SNF 405.1131(b) 405.1130
442.344
F241
ICF 442.345 Special Rehabili-
tative Services
405.1126
F242 442.363
1. An ongoing
program of Physician Services
meaningful 405.1123
activities is 442.329
provided
based on
identified
needs and
interests of Physical
each resi- Environment
dent. It is 405.1134
designed to 442.329
promote op-
portunities Infection Control
for engaging 405.1135
in normal 442.328
pursuits,
including Resident Rights
religious 405.1121(k)
activities 405.311
of their
choice, if
any. Medical Records
405.1132
F243 405.318
2. Unless con-
traindicated Patient Care
by the atten- Management
ding physi- 405.1124(d)
cian, all 442.341
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
4. Equipment is
maintained in
good working
order.
F246
5. Supplies and
equipment for
activities of
interest are
available.
INTENT
Each resident has
individual and/or
group activities
to meet activi-
ties needs
through his
interests daily.
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
1. 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
caregivers to
make decisions
on care needed.
TRANSFER AGREEMENT Patient Rights
404.1121(k)
F265 442.311
SNF 405.1133
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 Nursing Service
SNF 405.1134(d) 405.1124(g)
442.337
F272 Infection Control
1. Unit properly 405.1135
equipped for
preparation Governing Body
and storage 442.325
of drugs and
biologicals. Resident Rooms
405.1134(e)
442.325
F273
2. Utility and
storage rooms
are adequate
size.
F274
3. The unit is
equipped to
register
resident
calls with a
functioning
communica-
tions system
from resident
areas includ-
ing rooms and
toilets and
bathing
facility.
B. Dining and Dietetic Services
activities area 405.1125
442.331
F275
SNF 405.1134(g) Patient Activities
F276 405.1131
ICF 442.329 442.345
F277
1. The facility
provides one
or more
clean, order-
ly, and
appropriately
furnished
rooms of ade-
quate size,
designed for
resident
dining and
resident
activities.
F278
2. Dining and
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 Resident Rights
405.1121(k)(1)(5)
F281 (9)(13)
ICF 442.325 442.311(a)(d)(2)
(g)(1)(2)
F282 (6)(k)
1. Single rooms Physical Environ-
have at least ment
100 sq. ft. 405.1134(d)(e)
442.326
F283
2. Multiple res-
ident rooms
have no more
that 4 resi-
dents and at
least 80 sq.
feet per
resident.
F284
3. Each room is
equipped with
or conven-
iently
located near
toilet and
bathing
facilities.
F285
4. There is a
capability of
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
facilities
F292
ICF 442.326
F293
1. Facilities
are clean,
sanitary and
free of
odors.
F294
2. Facilities
have safe and
comfortable
hot water
temperatures.
F295
3. Facilities
maintain
privacy.
F296
4. Facilities
have grab
bars and
other safe
guards
against
slipping.
F297
5. Facilities
have fixtures
in good
condition.
F298
6. The resident
call system
functions in
toliet and
bath facili-
ties.
E. Social Service
Area
F299
SNF 405.1130(b)
ICF 442.344
F300
1. Ensures
privacy for
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
F303
SNF 405.1126(a)
F304
ICF 442.328(a)
F305
1. Space is ade-
quate for
proper use
of equipment
by all resi-
dents receiv-
ing treatment
G. Facilities for Resident Rights
Special care 405.1121(k)(4)
442.311(c)(2)
F307
SNF 405.1134(f) Infection Control
405.1135(b)
F308
ICF 442.328(b)
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 Infection Control
Areas 405.1135(c)
F311
SNF 405.1134(j)
F312
ICF 442.324
F313
1. All common
resident
areas are
clean, sani-
tary and
free of
odors.
F314
2. Provision is
made for
adequate and
comfortable
lighting
levels in all
areas.
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 Disaster Prepared-
7. Staff are ness
aware of pro- 405.1136
cedures to 442.313
ensure water
to all essen-
tial areas in
the event of
loss of nor-
mal supply.
I. Maintenance of Physical Environ-
Building and ment
Equipment 405.1134(d)
F320
SNF 405.1134(i)
F321
1. The interior
and exterior
of the build-
ing are clean
and orderly.
F322
2. All essential
mechanical
and electri-
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 Dietetic Services
Service Area 405.1125(g)
F326 442.331(b)
SNF 405.1134(h)
F327
1. Kitchen and
dietetic ser-
vice areas
are adequate
to insure
proper,
timely ser-
vice for all
patients.
F328
2. Kitchen areas
are properly
ventilated,
arranged, and
equipped for
storage and
preparation
of food as
well as for
dish and
utensil
cleaning, and
refuse stor-
age and
removal.
Indicator K
applies to ICF
K. Dieteary Staff Dietetic Services
Hygiene 405.1125(e)(f)(g)
F329
SNF 405.1125(f)
F330
1. Dietetic ser-
vice person-
nel practice
hygenic food
handling
techniques.
Indicator L
applies to ICF
L. Dietary Sanitary
Conditions
F331
SNF 405.1125(g)
F332
1. Food is
stored,
refrigerated,
prepared,
distributed,
and served
under sani-
tary condi-
tions.
F333
2. Waste is
disposed of
properly.
L. Emergency Power
F334
SNF 405.1134(b)
F335
1. An emergency
source of
electrical
power neces-
sary to pro-
tect the
health and
safety of
residents is
available.
F336
2. Emergency
power is ade-
quate at
least for
lighting in
all means of
egress;
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 Nursing Services
F338 405.1124
SNF 405.1135 442.338
A. Infection
Control
F339
SNF 405.1135(b)
F340
Aseptic and
isolation tech-
niques are
followed by all
personnel.
B. Sanitation
F341
SNF 405.1135(c)
F342
The facility
maintains a
safe, clean,
and orderly
interior.
C. Linen
F343
SNF 405.1135(d)
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
F347
SNF 405.1135(e)
F348
ICF 442.315(c)
F349
The facility is
maintained free
from insects and
rodents.
DISASTER Physical Environ-
PREPAREDNESS ment
405.1134(a)(b)
F350 4 42.321
SNF 405.1136
F351
SNF 405.1136(a)
F352
ICF 442.313
Indicators A and
B apply to ICFs.
A. Disaster Plan
F353
1. Facility
staff are
aware of
plans, pro-
cedures to be
followed for
fire, explo-
sion or other
disaster.
F354
2. Facility
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.
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