483.10(c)(1)(4)(5) Resident Rights F (c)(1)(4)(5) (c)(7) Resident Rights F (c)(7)

Transcription

1 = Yes F540 Definitions F F550 Resident Rights/Exercise of Rights (a)(1)(2)(b)(1)(2) F151 F240 F (b)(1)(2) (a)(1)(2) (a)(1) F551 Rights Exercised by Representative (b)(3)-(7)(i)-(iii) F (b)(3)-(7) F552 Right to be Informed/Make Treatment Decisions F553 Right to Participate in Planning Care (c)(2)(3) F554 F555 F557 F558 F559 Resident Self-Admin Meds-Clinically Appropriate Right to Choose/Be Informed of Attending Physician Respect, Dignity/Right to have Personal Property Reasonable Accommodations of Needs/Preferences Choose/Be Notified of Room/Roommate Change (c)(1)(4)(5) F (c)(1)(4)(5) F154 F (c)(7) F (c)(7) (c)(2)(iii) (c)(2)(i)(ii)(iv)(v)(3)(i)-(iii) (d)(1)-(5) F (d)(1)(2)(4)(5) (e)(2) F (e)(2) (e)(3) F (e)(3) (e)(4)-(6) F175 F (e)(4)(5) (e)(6) F560 Right to Refuse Certain Transfers (e)(7)(i)-(iii)(8) F (e)(7)-(8) F561 Self Determination (f)(1)-(3)(8) F242 F (f)(1)-(3) (f)(8) F562 Immediate Access to Resident (f)(4)(i)(A)-(G) F (f)(4)(i) F563 Right to Receive/Deny Visitors (f)(4)(ii)-(v) F (f)(4)(ii)-(v) F564 Inform of Visitation Rights/Equal Visitation Priviledges F565 Resident/Family Group and Response (f)(5)(i)-(iv)(6)(7) F566 F567 F568 F569 Right to Perform Facility or Refuse Protection/Management of Personal Funds Accounting and Records of Personal Funds Notice and Conveyance of Personal Funds (f)(4)(vi)(A)-(D) F (f)(4)(vi)(A)-(D) F243 F (f)(5)(i)-(iii)(6)(7) (f)(5)(iv) (f)(9)(i)-(iv) F (f)(9) (f)(10)(i)(ii) F158 F (f)(10)(i) (f)(ii) (f)(10)(iii) F (f)(10(iii) (f)(10)(iv)(v) F (f)(iv) F570 Surety Bond Security of Personal Funds (f)(10)(vi) F (f)(10(vi) 1

2 F571 = Yes Limitations on Charges to Personal Funds (f)(11)(i)-(iii) F (f)(11)(i)-(iii) F572 Notice of Rights and Rules (g)(1)(16) F (g)(1)(16) F573 F574 Right to Access/Purchase Copies of Records Required Notices and Contact Information (g)(2)(i)(ii)(3) F (g)(2)(3) (g)(4)(i)-(vi) F (g)(4) F575 Required Postings (g)(5)(i)(ii) F (g)(5) F576 Right to Forms of Communication with Privacy (g)(6)-(9) F170 F171 F (g)(8)(i)(9)(i)-(iii) (g)(7)(ii)(iii) (g)(6)(7)(i) F577 F578 F579 F580 F582 F583 Right to Survey Results/Advocate Agency Info Request/Refuse/Discontinue Treatment;Formulate Adv Directives Posting/Notice of Medicare/Medicaid on Admission Notify of Changes (Injury/Decline/Room, Etc.) Medicaid/Medicare Coverage/Liability Notice Personal Privacy/Confidentiality of Records (g)(10)(11) F167 F (g)(10)(i)(11) (g)(10)(ii) (c)(6)(8)(g)(12)(i)-(v) F (c)(6)(8)(g)(12) (g)(13) F (g)(13) (g)(14)(i)-(iv) F (g)(14) (g)(17)(18)(i)-(v) F (g)(17)-(18) (h)(1)-(3)(i)(ii) F164 F (h)(1)(3)(i) (h)(3)(ii) F584 Safe/Clean/Comfortable/ Homelike Environment (i)(1)-(7) F252 F253 F254 F256 F257 F258 F (i)(1)(i)(ii) (i)(2) (i)(3) (i)(5) (i)(6) (i)(7) (i)(4) F585 Grievances (j)(1)-(4) F165 F (j)(1) (j)(2-4) F586 Resident Contact with External Entities (k) F (k) F600 Free from Abuse and Neglect (a)(1) F (a)(1) F602 Free from Misappropriation/Exploitation F223/ F

3 = Yes F603 Free from Involuntary Seclusion (a)(1) F (a)(1) F604 Right to be Free from Physical Restraints (e)(1) (a)(2) F221 F (e )(1), (a)(2) (e )(1), (a)(2) F605 Right to be Free from Chemical Restraints (e)(1) (a)(2) F (e )(1), (a)(2) F606 Not Employ/Engage Staff with Adverse Actions (a)(3)(4) F (a)(3)(4) F607 Develop/Implement Abuse/Neglect, etc. Policies (b)(1)-(4) (b)(4) - Phase 3 F (b)(1)-(4) F608 Reporting of Reasonable Suspicion of a Crime (b)(5)(i)-(iii) F609 Reporting of Alleged Violations (c)(1)(4) F (c)(1)(4) F610 Investigate/Prevent/Correct Alleged Violation (c)(2)-(4) F (c)(2)-(4) F620 Admissions Policy (a)(1)-(7) F621 Equal Practices Regardless of Payment Source (b)(1)-(3)(c)(9) F622 Transfer Requirements (c)(1)(i)(ii)(2)(i)-(iii) F623 F624 F625 F626 F635 Notice Requirements Before Transfer/Discharge Preparation for Safe/Orderly Transfer/Discharge Notice of Bed Hold Policy Before/Upon Transfer Permitting Residents to Return to Facility Admission Physician Orders for Immediate Care (c)(3)-(6)(8) (c)(7) (d)(1)(2) (e)(1)(2) F208 F207 F201 F202 F203 F204 F205 F (a)(1)-(7) (b)(1)-(3)(c)(9) (c)(1)(i)(ii) (c)(2)(i)-(iii) (c)(3)-(6)(8) (c)(7) (d)(1)(i)-(iv)(2) (e)(1)(2) (a) Resident Assessments F (a) 3

4 = Yes F636 Comprehensive Assessments & Timing (b)(1)(2)(i)(iii) Resident Assessments F272 F273 F (b)(1) (b)(2)(i) (b)(2)(iii) F637 F638 F639 F640 Comprehensive Assmt After Significant Change Quarterly Assessment At Least Every 3 Months Maintain 15 Months of Resident Assessments Encoding/Transmitting Resident Assessment (b)(2)(ii) Resident Assessments F (b)(2)(ii) (c) Resident Assessments F (c ) (d) Resident Assessments F279 F (d) (d) (f)(1)-(4) Resident Assessments F (f)(1)-(4) F641 Accuracy of Assessments (g) Resident Assessments F (g) F642 F644 Coordination/Certification of Assessment Coordination of PASARR and Assessments (h)-(j) Resident Assessments F (h)-(j) (e)(1)(2) Resident Assessments F (e) F645 PASARR Screening for MD & ID (k)(1)-(3) Resident Assessments F (k)(1)-(3) F646 MD/ID Significant Change Notification (k)(4) Resident Assessments F (k)(4) F655 Baseline Care Plan (a)(1)-(3) F656 Develop/Implement Comprehensive Care Plan (b)(1) F (b)(1) F657 Care Plan Timing and Revision (b)(2)(i)-(iii) F (b)(2)(i)-(iii) F658 Provided Meet Professional Standards (b)(3)(i) F (b)(3)(i) F659 Qualified Persons (b)(3)(ii)(iii) (b)(iii) - Phase 3 F (b)(3)(ii) F660 Discharge Planning Process (c)(1)(i)-(ix) F (c)(1)(i)-(ix) 4

5 = Yes F661 Discharge Summary (c)(2)(i)-(iv) F283 F (c)(2)(i)-(iii) (c)(2)(iv) F675 Quality of Life Quality of Life F F676 F677 F678 F679 F680 Activities of Daily Living (ADLs)/ Maintain Abilities ADL Care Provided for Dependent Residents Cardio Pulmonary Resuscitation (CPR) Activities Meet Interest/Needs of Each Resident Qualifications of Activity Professional (a)(1)(b)(1)-(5)(i)-(iii) Quality of Life F310 F (a)(b)(1)-(5)(i)-(iii) (a)(1) (a)(2) Quality of Life F (a)(2) (a)(3) Quality of Life F (a)(3) (c)(1) Quality of Life F (c)(1) (c)(2)(i)(ii)(A)-(D) Quality of Life F (c)(2)(i)(ii)(A)-(D) F684 Quality of Care Quality of Care F F685 Treatment/Devices to Maintain Hearing/Vision (a)(1)(2) Quality of Care F (a)(1)-(2) F686 Treatment/Svcs to Prevent/Heal Pressure Ulcers (b)(1)(i)(ii) Quality of Care F (b)(1)(i)(ii) F687 Foot Care (b)(2)(i)(ii) Quality of Care F (b)(2)(i)(ii) F688 F689 F690 F691 F692 Increase/Prevent Decrease in ROM/Mobility Free of Accident Hazards/Supervision/Devices Bowel/Bladder Incontinence, Catheter, UTI Colostomy, Urostomy, or Ileostomy Care Nutrition/Hydration Status Maintenance (c)(1)-(3) Quality of Care F317 F (c)(1) (c)(2)(3) (d)(1)(2) Quality of Care F (d)(1)(2) (e)(1)-(3) Quality of Care F (e)(1)-(3) (f) Quality of Care F (f) (g)(1)-(3) Quality of Care F325 F (g)(1)(3) (g)(2) F693 Tube Feeding Management/Restore Eating Skills (g)(4)(5) Quality of Care F (g)(4)(5) F694 Parenteral/IV Fluids (h) Quality of Care F (h) F695 Respiratory/Tracheostomy care and Suctioning (i) Quality of Care F (i) F696 Prostheses (j) Quality of Care F (j) 5

6 = Yes F697 Pain Management (k) Quality of Care F (k) F698 Dialysis (l) Quality of Care F (l) F699 Trauma Informed Care (m) Quality of Care F700 Bedrails (n)(1)-(4) Quality of Care F710 F711 F712 F713 F714 F715 Resident's Care Supervised by a Physician Physician Visits Review Care/Notes/Order Physician Visits Frequency/Timeliness/Alternate NPPs Physician for Emergency Care, Available 24 Hours Physician Delegation of Tasks to NPP Physician Delegation to Dietitian/Therapist F323 F (n)(1)-(3) (n)(4) (a)(1)(2) Physician F (a)(1)(2) (b)(1)-(3) Physician F (b)(1)-(3) (c)(1)-(4) Physician F387 F (c)(1)(2) (c)(3)(4) (d) Physician F (d) (e)(1)(4)(f) Physician F (e)(1)(4)(f) (e)(2)(3) Physician F (e)(2(3) F725 Sufficient Nursing Staff (a)(1)(2) Nursing F (a)(1)(2) F726 Competent Nursing Staff (a)(3)(4)(c) Nursing F353 F (a)(3)(4) (c) F727 RN 8 Hrs/7 days/wk, Full Time DON (b)(1)-(3) Nursing F (b)(1)-(3) F728 F729 F730 F731 F732 Facility Hiring and Use of Nurse Aide Nurse Aide Registry Verification, Retraining Nurse Aide Perform Review 12 Hr/Year In service Waiver Licensed Nurses 24 Hr/Day and RN Coverage Posted Nurse Staffing Information F740 Behavioral Health F741 Sufficient/Competent Staff-Behav Health Needs (d)(1)-(3) Nursing F494 F (d)(1)(2) (d)(3) (d)(4)-(6) Nursing F (d)(4)-(6) (d)(7) Nursing F (d)(7) (e)(1)-(7)(f)(1)(2) Nursing F (e)(1)-(7)(f)(1)(2) (g)(1)-(4) Nursing F (g)(1)-(4) (a)(1)(2) Behavioral Health Behavioral Health 6

7 F742 F743 = Yes Treatment/Svc for Mental/Psychosocial Concerns No Pattern of Behavioral Difficulties UnlessUnavoidable (b)(1) (b)(2) F744 Treatment /Service for Dementia (b)(3) F745 F755 F756 F757 F758 F759 F760 F761 Provision of Medically Related Social Pharmacy Svcs/Procedures/Pharmacist /Records Drug Regimen Review, Report Irregular, Act On Drug Regimen is Free From Unnecessary Drugs Free from Unnec Psychotropic Meds/PRN Use Free of Medication Error Rates of 5% or More Residents Are Free of Significant Med Errors Label/Store Drugs & Biologicals (d) (a)(b)(1)-(3) Behavioral Health Behavioral Health Behavioral Health Behavioral Health Pharmacy F319 F320 F309 F250 F425 F (b)(1) (b)(2) (b)(3) (d) (a)(b)(1) (b)(2)(3) (c)(1)(2)(4)(5) Pharmacy F (c)(1)(2)(4)(5) (d)(1)-(6) Pharmacy F (d) (c)(3)(e)(1)-(5) Pharmacy F329 F (e)(1)-(5) (c)(3) (f)(1) Pharmacy F (f)(1) (f)(2) Pharmacy F (f)(2) (g)(h)(1)(2) Pharmacy F (g)-(h) F770 Laboratory (a)(1)(i) and Other Diagnostic F502 F (a)(1) (a)(i) F771 Blood Blank and Transfusion (a)(1)(ii) and Other Diagnostic F502 F (a)(1) (a)(ii) F772 Lab Not Provided On Site (a)(1)(iv) and Other Diagnostic F (a)(iv) F773 Lab Svs Physician Order/Notify of Results (a)(2)(i)(ii) and Other Diagnostic F504 F (a)(2)(i) (a)(2)(ii) F774 Assist with Transport Arrangements to Lab Svcs (a)(2)(iii) and Other Diagnostic F (a)(2)(iii) F775 Lab Reports in Record Lab Name/Address (a)(2)(iv) and Other Diagnostic F (a)(2)(iv) 7

8 = Yes F776 Radiology/Other Diagnostic (b)(1)(i)(ii) and Other Diagnostic F508 F (b)(1) (b)(i)(ii) F777 Radiology/Diag. Svcs Ordered/Notify Results (b)(2)(i)(ii) and Other Diagnostic F510 F (b(2)(i) (b)(2)(ii) F778 Assist with Transport Arrangements to Radiology (b)(2)(iii) and Other Diagnostic F (b)(2)(iii) F779 Ray/Diagnostic Report in Record Sign/Dated (b)(2)(iv) and Other Diagnostic F (b)(2)(iv) F790 F791 F800 Routine/Emergency Dental in SNFs Routine/Emergency Dental in NFs Provided Diet Meets Needs of Each Resident (a)(1)-(5) Dental F (a)(1)-(5) (b)(1)-(5) Dental F (b)(1)-(5) F801 Qualified Dietary Staff (a)(1)(2) F802 F803 F804 F805 F806 F807 F808 F809 F810 F811 F812 Sufficient Dietary Support Personnel Menus Meet Res Needs/Prep in Advance/Followed Nutritive Value/Appear, Palatable/Prefer Temp Food in Form to Meet Individual Needs Resident Allergies, Preferences and Substitutes Drinks Avail to Meet Needs/ Preferences/ Hydration Therapeutic Diet Prescribed by Physician Frequency of Meals/Snacks at Bedtime Assistive Devices Eating Equipment/Utensils Feeding Asst Training/Supervision/Resident Food Procurement, Store/Prepare/Serve Sanitary (a)(3)(b) (c)(1)-(7) (d)(1)(2) (d)(3) (d)(4)(5) (d)(6) (e)(1)(2) (f)(1)-(3) (g) (h)(1)-(3) (i)(1)(2) F F361 F (a)(1)(2) (a)(3)(b) F (c )(1)-(7) F364 F365 F366 F366 F367 F368 F369 F373 F (d)(1(2) (d)(3) (d)(4)(5) (d)(6) (e)(1)(2) (f)(1)-(3) (g) (h)(1)-(3) (i)(1)(2) 8

9 = Yes F813 Personal Food Policy (i)(3) F814 F825 F826 Dispose Garbage & Refuse Properly Provide/Obtain Specialized Rehab Rehab Physician Order/Qualified Person (i)(4) (a)(1)(2) (b) Specialized Rehabilitative Specialized Rehabilitative F371 F372 F406 F (i)(3) (i)(4) (a)(1)(2) (b) F835 Administration Administration F F836 License/Comply w/fed/state/local Law/Prof Std (a)-(c) Administration F491 F (a) (b)(c) F837 Governing Body (d)(1)-(3) Administration (d)(3) - Phase 3 F (d)(1)-(3) F838 Facility Assessment (e)(1)-(3) Administration F839 Staff Qualifications (f)(1)(2) Administration F (f)(1)(2) F840 Use of Outside Resources (g)(1)(2) Administration F (g)(1)(2)(i)(ii) F841 F842 Responsibilities of Medical Director Resident Records - Identifiable Information (h)(1)(2) Administration F (h)(1)(2) (f)(5) (i)(1)-(5) Resident Assessments Administration F164 F514 F515 F (i)(2) (i)1)(5) (i)(4)(i)-(iii) (f)(5); (i)(3) F843 Transfer Agreement (j)(1)(2) Administration F (j)(1)(2) F844 Disclosure of Ownership Requirements (k)(1)-(3) Administration F (k)(1)-(3) F845 Facility closure Administrator (l)(1)-(3) Administration F (l)(1)-(3) F846 Facility closure (m) Administration F (m) F849 Hospice (o)(1)-(4) Administration F (o)(1)-(4) F850 Qualifications of Social Worker >120 Beds (p)(1)(2) Administration F (p)(1)(2) F851 Payroll Based Journal (q)(1)-(5) Administration F (q)(1)-(5) 9

10 = Yes F865 QAPI Program/Plan, Disclosure/Good Faith Attmpt (a)(b)(f)(h)(i) Quality Assurance and Performance Improvement (a)(1)(3)(4)(b)(f) - Phase 3 F (a)(2)(h)(i) F866 QAPI/QAA Data Collection and Monitoring (c)(1)-(4) Quality Assurance and Performance Improvement F (c)(1)-(4) F867 QAPI/QAA Improvement Activities (d)(1)(2)(e)(1)-(3)(g)(2) Quality Assurance and Performance Improvement (d)(1)(2)(i)-(iii)(e)(1)- (3)(g)(2)(iii) will not be in ASPEN F (g)(2)(ii) F868 QAA Committee (g)(1)(i)-(iv)(2)(i) Quality Assurance and Performance Improvement (g)(1)(iv) - Phase 3 F (g)(1)(i)-(iii)(2)(i) F880 Infection Prevention & Control (a)(1)(2)(4)(e)(f) Infection Control F (a)(1)(2)(4) F881 Antibiotic Stewardship Program (a)(3) Infection Control F882 F883 Infection Preventionist Qualifications/Role Influenza and Pneumococcal Immunizations (b)(1)-(4)(c) F895 Compliance and Ethics Program (a)-(e) Infection Control (d)(1)(2) Infection Control F (d)(1)(2) Compliance and Ethics Program (d)(1)(2) F906 RESERVED F907 Space and Equipment (d)(1) Physical Environment F (d)(1) F908 Essential Equipment, Safe Operating Condition (d)(2) Physical Environment F (d)(2) F909 Resident Bed (d)(3) Physical Environment F (d)(3) F910 Resident Room (e) Physical Environment F (e) F911 Bedroom Number of Residents (e)(1))(i) Physical Environment F (e)(1))(i) F912 Bedrooms Measure at Least 80 Square Ft/Resident (e)(1)(ii) Physical Environment F (e)(1)(ii) 10

11 F913 F914 = Yes Bedrooms Have Direct Access to Exit Corridor Bedrooms Assure Full Visual Privacy F915 Resident Room Window (a)(7)(e)(1)(vi) Physical Environment F916 F917 F918 Resident Room Floor Above Grade Resident Room Bed/Furniture/Closet Bedrooms Equipped/Near Lavatory/Toilet (e)(1)(iii) Physical Environment F (e)(1)(iii) (e)(1)(iv)(v) Physical Environment F (e)(1)(iv)(v) F454 F (a)(7) (e)(1)(vi) (e)(1)(vii) Physical Environment F (e)(1)(vii) (i)(4) (e)(2)(3) Physical Environment F (i)(4) (e)(2)(3) (f) Physical Environment F (f) F919 Resident Call System (g)(1)(2) Physical Environment F920 F921 Requirements for Dining and Activity Rooms Safe/Functional/Sanitary/ Comfortable Environment (g)(1)- Phase 3 F (g)(1)(2) (h)(1)-(4) Physical Environment F (h)(1)-(4) (i) Physical Environment F (i) F922 Procedures to Ensure Water Availability (i)(1) Physical Environment F (i)(1) F923 Ventilation (i)(2) Physical Environment F (i)(2) F924 Corridors Have Firmly Secured Handrails (i)(3) Physical Environment F (i)(3) F925 Maintains Effective Pest Control Program (i)(4) Physical Environment F (i)(4) F926 Smoking Policies (i)(5) Physical Environment F940 Training Requirements General Training Requirements F941 Communication Training (a) Training Requirements F942 Resident s Rights Training (b) Training Requirements F943 Abuse, Training (c)(1)-(3) Training Requirements F (c)(1)-(3) 11

12 = Yes F944 QAPI Training (d) Training Requirements F945 Infection Control Training (e) Training Requirements F946 Compliance and Ethics Training (f)(1)(2) Training Requirements F947 Required In Service Training for Nurse Aides (g)(1)-(4) Training Requirements F (g)(1)-(4) F948 Training for Feeding Assistants (h) Training Requirements F (h) F949 Behavioral Health Training (i) Training Requirements 12