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Management Practices

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483.70 Administration

001

F835

ADMINISTRATION - WELL BEING OF EACH RESIDENT

 
 
 
 
 
 
 
 
 
 
 
 

002

F836

LICENSURE - FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

003

F836

COMPLIANCE FEDERAL, STATE, & LOCAL LAWS & PROFESSIONAL STANDARDS

 
 
 
 
 
 
 
 
 
 
 
 

004

F836

RELATIONSHIP TO OTHER HHS REGULATIONS

 
 
 
 
 
 
 
 
 
 
 
 

005

F837

GOVERNING BODY

 
 
 
 
 
 
 
 
 
 
 
 

006

F837

ADMINISTRATOR LICENSE

 
 
 
 
 
 
 
 
 
 
 
 

007

F837

ADMINISTRATOR APPOINTMENT LETTER

 
 
 
 
 
 
 
 
 
 
 
 

008

F837

GOVERNING BODY - REPORT AND ACCOUNTABLE

 
 
 
 
 
 
 
 
 
 
 
 

009

F837

QAPI PROGRAM - GOVERNING BODY

 
 
 
 
 
 
 
 
 
 
 
 

010

F838

FACILITY-WIDE ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

011

F838

FACILITY-WIDE ASSESSMENT - UPDATES

 
 
 
 
 
 
 
 
 
 
 
 

012

F838

FACILITY-WIDE ASSESSMENT - RESIDENT POPULATION

 
 
 
 
 
 
 
 
 
 
 
 

013

F838

FACILITY-WIDE ASSESSMENT - CARE REQUIRED

 
 
 
 
 
 
 
 
 
 
 
 

014

F838

FACILITY-WIDE ASSESSMENT - STAFF COMPETENCY

 
 
 
 
 
 
 
 
 
 
 
 

015

F838

FACILITY ASSESSMENT - PHYSICAL PLANT

 
 
 
 
 
 
 
 
 
 
 
 

016

F838

FACILITY-WIDE ASSESSMENT - ETHNIC - CULTURAL - RELIGIOUS FACTORS

 
 
 
 
 
 
 
 
 
 
 
 

017

F838

FACILITY-WIDE ASSESSMENT - BUILDINGS - PHYSICAL STRUCTURES

 
 
 
 
 
 
 
 
 
 
 
 

018

F838

FACILITY-WIDE ASSESSMENT - MEDICAL AND NON-MEDICAL EQUIPMENT

 
 
 
 
 
 
 
 
 
 
 
 

019

F838

FACILITY-WIDE ASSESSMENT - THERAPIES

 
 
 
 
 
 
 
 
 
 
 
 

020

F838

FACILITY-WIDE ASSESSMENT - ALL PERSONNEL

 
 
 
 
 
 
 
 
 
 
 
 

021

F838

FACILITY-WIDE ASSESSMENT - CONTRACTS

 
 
 
 
 
 
 
 
 
 
 
 

022

F838

FACILITY-WIDE ASSESSMENT - HEALTH INFORMATION TECHNOLOGY RESOURCES

 
 
 
 
 
 
 
 
 
 
 
 

023

F838

FACILITY-WIDE ASSESSMENT - FACILITY AND COMMUNITY BASED RISK ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

024

F839

CONSULTANTS

 
 
 
 
 
 
 
 
 
 
 
 

025

F839

COMPETENCY EVALUATION

 
 
 
 
 
 
 
 
 
 
 
 

026

F839

PROFESSIONAL LICENSURE

 
 
 
 
 
 
 
 
 
 
 
 

027

F840

PSYCHOLOGIST CONTRACT

 
 
 
 
 
 
 
 
 
 
 
 

028

F840

HOSPICE CONTRACT

 
 
 
 
 
 
 
 
 
 
 
 

029

F840

PSYCHIATRIST CONTRACT

 
 
 
 
 
 
 
 
 
 
 
 

030

F840

DIETITIAN SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

031

F840

PODIATRY SERVICES CONTRACT

 
 
 
 
 
 
 
 
 
 
 
 

032

F840

OUTSIDE RESOURCES - PROFESSIONAL STANDARDS

 
 
 
 
 
 
 
 
 
 
 
 

033

F840

DENTIST TIMELINESS

 
 
 
 
 
 
 
 
 
 
 
 

034

F840

PSYCHOLOGIST CONTRACT

 
 
 
 
 
 
 
 
 
 
 
 

035

F840

PSYCHIATRIST CONTRACT

 
 
 
 
 
 
 
 
 
 
 
 

036

F840

OUTSIDE SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

037

F841

MEDICAL DIRECTOR

 
 
 
 
 
 
 
 
 
 
 
 

038

F841

MEDICAL DIRECTOR - COORDINATE CARE

 
 
 
 
 
 
 
 
 
 
 
 

039

F841

MEDICAL DIRECTOR - CARE POLICIES

 
 
 
 
 
 
 
 
 
 
 
 

040

F842

MEDICAL RECORDS - DOCUMENTATION -COMPLETE

 
 
 
 
 
 
 
 
 
 
 
 

041

F842

MEDICAL RECORDS - CHANGE OF CONDITION

 
 
 
 
 
 
 
 
 
 
 
 

042

F842

MEDICAL RECORDS - ACCURATELY DOCUMENTED

 
 
 
 
 
 
 
 
 
 
 
 

043

F842

MEDICAL RECORDS - CHART ACCESSIBILITY

 
 
 
 
 
 
 
 
 
 
 
 

044

F842

MEDICAL RECORDS - ORGANIZED

 
 
 
 
 
 
 
 
 
 
 
 

045

F842

MEDICAL RECORDS - ORGANIZATION OF MEDICAL RECORDS

 
 
 
 
 
 
 
 
 
 
 
 

046

F842

CONFIDENTIALITY

 
 
 
 
 
 
 
 
 
 
 
 

047

F842

RECORD RELEASE POLICY & PROCEDURE

 
 
 
 
 
 
 
 
 
 
 
 

048

F842

RECORD RELEASE WHEN REQUIRED BY LAW

 
 
 
 
 
 
 
 
 
 
 
 

049

F842

RELEVANT HEALTH INFORMATION RELEASE

 
 
 
 
 
 
 
 
 
 
 
 

050

F842

RELEASE OF RECORDS UPON TRANSFER

 
 
 
 
 
 
 
 
 
 
 
 

051

F842

PRIVACY - TRANSFER TO ANOTHER INSTITUTION

 
 
 
 
 
 
 
 
 
 
 
 

052

F842

PRIVACY - PAYMENT

 
 
 
 
 
 
 
 
 
 
 
 

053

F842

PRIVACY - HEALTH CARE OPERATIONS

 
 
 
 
 
 
 
 
 
 
 
 

054

F842

RELEASE OF RECORDS - PUBLIC HEALTH ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

055

F842

RELEASE OF ACTIVITIES - REPORT OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE

 
 
 
 
 
 
 
 
 
 
 
 

056

F842

RELEASE OF RECORDS - HEALTH OVERSIGHT ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

057

F842

RELEASE OF RECORDS - JUDICIAL AND ADMINISTRATIVE PROCEEDINGS

 
 
 
 
 
 
 
 
 
 
 
 

058

F842

RELEASE OF RECORDS - LAW ENFORCEMENT PURPOSES

 
 
 
 
 
 
 
 
 
 
 
 

059

F842

RELEASE OF RECORDS - ORGAN DONATION PURPOSES

 
 
 
 
 
 
 
 
 
 
 
 

060

F842

RELEASE OF RECORDS - RESEARCH PURPOSES

 
 
 
 
 
 
 
 
 
 
 
 

061

F842

RELEASE OF RECORDS - CORONERS - MEDICAL EXAMINERS - FUNERAL DIRECTOR

 
 
 
 
 
 
 
 
 
 
 
 

062

F842

RELEASE OF RECORDS - AVERT SERIOUS THREAT TO HEALTH AND SAFETY

 
 
 
 
 
 
 
 
 
 
 
 

063

F842

MEDICAL RECORD CONFIDENTIALITY

 
 
 
 
 
 
 
 
 
 
 
 

064

F842

MEDICAL RECORD CONFIDENTIALITY

 
 
 
 
 
 
 
 
 
 
 
 

065

F842

SAFEGUARDING OF MEDICAL RECORDS

 
 
 
 
 
 
 
 
 
 
 
 

066

F842

MEDICAL RECORDS RETENTION

 
 
 
 
 
 
 
 
 
 
 
 

067

F842

MEDICAL RECORDS RETENTION - 5 YEARS

 
 
 
 
 
 
 
 
 
 
 
 

068

F842

MEDICAL RECORDS RETENTION - MINOR

 
 
 
 
 
 
 
 
 
 
 
 

069

F842

MEDICAL RECORDS- SUFFICIENT INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 

070

F842

MEDICAL RECORDS - RESIDENT ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

071

F842

MEDICAL RECORDS - PLAN OF CARE - SERVICES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

072

F842

MEDICAL RECORDS - PRE-ADMISSION SCREENING

 
 
 
 
 
 
 
 
 
 
 
 

073

F842

MEDICAL RECORDS - PROGRESS NOTES

 
 
 
 
 
 
 
 
 
 
 
 

074

F842

MEDICAL RECORDS - DIAGNOSTICS

 
 
 
 
 
 
 
 
 
 
 
 

075

F842

RELEASE OF RECORDS

 
 
 
 
 
 
 
 
 
 
 
 

076

F842

POLICY & PROCEDURE - RECORD RELEASE

 
 
 
 
 
 
 
 
 
 
 
 

077

F842

POLICY & PROCEDURE - RECORD RELEASE

 
 
 
 
 
 
 
 
 
 
 
 

078

F843

TRANSFER AGREEMENT - TIMELY ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

079

F843

TRANSFER AGREEMENT - LEAST RESTRICTIVE

 
 
 
 
 
 
 
 
 
 
 
 

080

F843

TRANSFER AGREEMENT - CLOSEST ACUTE FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

081

F844

DISCLOSURE OF OWNERSHIP - FAMILY

 
 
 
 
 
 
 
 
 
 
 
 

082

F844

DISCLOSURE OF OWNERSHIP - CONTROL INTEREST

 
 
 
 
 
 
 
 
 
 
 
 

083

F844

DISCLOSURE OF OWNERSHIP - OFFICERS - DIRECTORS

 
 
 
 
 
 
 
 
 
 
 
 

084

F844

DISCLOSURE REQUIREMENTS - CHANGE IN CORPORATION - MANAGEMENT

 
 
 
 
 
 
 
 
 
 
 
 

085

F844

NOTIFICATION OF CHANGES - ADMINISTRATOR - DIRECTOR OF NURSING

 
 
 
 
 
 
 
 
 
 
 
 

086

F844

DISCLOSURE OF OWNERSHIP - OTHER PERSON

 
 
 
 
 
 
 
 
 
 
 
 

087

F845

FACILITY CLOSURE - WRITTEN NOTICE

 
 
 
 
 
 
 
 
 
 
 
 

088

F845

FACILITY CLOSURE - 60 DAYS

 
 
 
 
 
 
 
 
 
 
 
 

089

F845

FACILITY CLOSURE - TERMINATION

 
 
 
 
 
 
 
 
 
 
 
 

090

F845

FACILITY CLOSURE - NO NEW ADMITS

 
 
 
 
 
 
 
 
 
 
 
 

091

F845

FACILITY CLOSURE - RELOCATION

 
 
 
 
 
 
 
 
 
 
 
 

092

F846

FACILITY CLOSURE - POLICIES AND PROCEDURES

 
 
 
 
 
 
 
 
 
 
 
 

093

F849

HOSPICE - AGREEMENT

 
 
 
 
 
 
 
 
 
 
 
 

094

F849

HOSPICE - TRANSFER TO ANOTHER FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

095

F849

HOSPICE - PROFESSIONAL STANDARDS

 
 
 
 
 
 
 
 
 
 
 
 

096

F849

HOSPICE - WRITTEN AGREEMENT - SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

097

F849

HOSPICE - SERVICES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

098

F849

HOSPICE - HOSPICE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

099

F849

HOSPICE - SERVICES BY THE FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

100

F849

HOSPICE - COMMUNICATION PROCESS

 
 
 
 
 
 
 
 
 
 
 
 

101

F849

HOSPICE - SIGNIFICANT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

102

F849

HOSPICE - CLINICAL COMPLICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

103

F849

HOSPICE - NEED TO TRANSFER

 
 
 
 
 
 
 
 
 
 
 
 

104

F849

HOSPICE - RESIDENT'S DEATH

 
 
 
 
 
 
 
 
 
 
 
 

105

F849

HOSPICE - LEVEL OF SERVICES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

106

F849

HOSPICE - FACILITY - 24 HOUR ROOM AND BOARD

 
 
 
 
 
 
 
 
 
 
 
 

107

F849

HOSPICE - MEDICAL DIRECTION AND MANAGEMENT

 
 
 
 
 
 
 
 
 
 
 
 

108

F849

HOSPICE - PRESCRIBED THERAPIES

 
 
 
 
 
 
 
 
 
 
 
 

109

F849

HOSPICE - REPORT ALL ALLEGED VIOLATIONS

 
 
 
 
 
 
 
 
 
 
 
 

110

F849

HOSPICE - BEREAVEMENT SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

111

F849

HOSPICE - INTERDISCIPLINARY TEAM MEMBER

 
 
 
 
 
 
 
 
 
 
 
 

112

F849

HOSPICE - CARE PLANNING PROCESS

 
 
 
 
 
 
 
 
 
 
 
 

113

F849

HOSPICE - COMMUNICATION - OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

114

F849

HOSPICE - COMMUNICATION - PRACTITIONERS

 
 
 
 
 
 
 
 
 
 
 
 

115

F849

HOSPICE - MOST RECENT PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

116

F849

HOSPICE - ELECTION FORM

 
 
 
 
 
 
 
 
 
 
 
 

117

F849

HOSPICE - PHYSICIAN CERTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

118

F849

HOSPICE - PERSONNEL

 
 
 
 
 
 
 
 
 
 
 
 

119

F849

HOSPICE - 24 HOUR ON CALL SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

120

F849

HOSPICE - MEDICATION INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 

121

F849

HOSPICE - PHYSICIAN ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

122

F849

HOSPICE - ORIENTATION

 
 
 
 
 
 
 
 
 
 
 
 

123

F849

HOSPICE - ATTAIN OR MAINTAIN

 
 
 
 
 
 
 
 
 
 
 
 

124

F850

SOCIAL SERVICES 120 BEDS

 
 
 
 
 
 
 
 
 
 
 
 

125

F850

SOCIAL WORKER QUALIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

126

F850

SOCIAL WORKER EXPERIENCE

 
 
 
 
 
 
 
 
 
 
 
 

127

F851

MANDATORY STAFFING SUBMISSION

 
 
 
 
 
 
 
 
 
 
 
 

128

F851

MANDATORY SUBMISSION - DIRECT CARE STAFF

 
 
 
 
 
 
 
 
 
 
 
 

129

F851

MANDATORY SUBMISSION - CATEGORY

 
 
 
 
 
 
 
 
 
 
 
 

130

F851

MANDATORY SUBMISSION - RESIDENT CENSUS

 
 
 
 
 
 
 
 
 
 
 
 

131

F851

MANDATORY SUBMISSION - TURNOVER AND TENURE

 
 
 
 
 
 
 
 
 
 
 
 

132

F851

MANDATORY SUBMISSION - AGENCY

 
 
 
 
 
 
 
 
 
 
 
 

133

F851

MANDATORY SUBMISSION - DATA FORMAT

 
 
 
 
 
 
 
 
 
 
 
 

134

F851

MANDATORY STAFFING - SCHEDULE

 
 
 
 
 
 
 
 
 
 
 
 
483.75 Quality Assurance and Performance Improvement

135

F865

QUALITY ASSURANCE - EVIDENCE OF PROGRAM

 
 
 
 
 
 
 
 
 
 
 
 

136

F865

QUALITY ASSURANCE - CORRECTIVE ACTIONS

 
 
 
 
 
 
 
 
 
 
 
 

137

F865

QUALITY ASSURANCE - WRITTEN PLAN

 
 
 
 
 
 
 
 
 
 
 
 

138

F865

QUALITY ASSURANCE - ANNUAL WRITTEN PLAN

 
 
 
 
 
 
 
 
 
 
 
 

139

F865

QUALITY ASSURANCE - ONGOING QAPI PROGRAM

 
 
 
 
 
 
 
 
 
 
 
 

140

F865

QUALITY ASSURANCE - CARE AND MANAGEMENT PRACTICES

 
 
 
 
 
 
 
 
 
 
 
 

141

F865

QUALITY ASSURANCE - CLINICAL CARE - QUALITY OF LIFE - RESIDENT CHOICE

 
 
 
 
 
 
 
 
 
 
 
 

142

F865

QUALITY ASSURANCE - BEST AVAILABLE EVIDENCE

 
 
 
 
 
 
 
 
 
 
 
 

143

F865

QUALITY ASSURANCE - SERVICES FACILITY PROVIDES

 
 
 
 
 
 
 
 
 
 
 
 

144

F865

QUALITY ASSURANCE - GOVERNANCE

 
 
 
 
 
 
 
 
 
 
 
 

145

F865

QUALITY ASSURANCE - TRANSITION IN LEADERSHIP

 
 
 
 
 
 
 
 
 
 
 
 

146

F865

QUALITY ASSURANCE - RESOURCES

 
 
 
 
 
 
 
 
 
 
 
 

147

F865

QUALITY ASSURANCE - EQUIPMENT

 
 
 
 
 
 
 
 
 
 
 
 

148

F865

QUALITY ASSURANCE - STAFF TIME

 
 
 
 
 
 
 
 
 
 
 
 

149

F865

QUALITY ASSURANCE - TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

150

F865

QUALITY ASSURANCE - RESIDENT INPUT

 
 
 
 
 
 
 
 
 
 
 
 

151

F865

QUALITY ASSURANCE - IDENTIFY PROBLEMS

 
 
 
 
 
 
 
 
 
 
 
 

152

F865

QUALITY ASSURANCE - STAFF INPUT

 
 
 
 
 
 
 
 
 
 
 
 

153

F865

QUALITY ASSURANCE - CORRECTIVE ACTIONS

 
 
 
 
 
 
 
 
 
 
 
 

154

F865

QUALITY ASSURANCE - EXPECTATIONS

 
 
 
 
 
 
 
 
 
 
 
 

155

F865

QUALITY ASSURANCE - DISCLOSURE NOT REQUIRED

 
 
 
 
 
 
 
 
 
 
 
 

156

F865

QUALITY ASSURANCE - SANCTIONS

 
 
 
 
 
 
 
 
 
 
 
 

157

F866

QUALITY ASSURANCE - POLICY AND PROCEDURES

 
 
 
 
 
 
 
 
 
 
 
 

158

F866

QUALITY ASSURANCE - FEEDBACK FROM OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

159

F866

QUALITY ASSURANCE - USE OF INFORMATION FROM OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

160

F866

QUALITY ASSURANCE - INFORMATION FROM DEPARTMENTS

 
 
 
 
 
 
 
 
 
 
 
 

161

F866

QUALITY ASSURANCE - METHODOLOGY AND DEVELOPMENT

 
 
 
 
 
 
 
 
 
 
 
 

162

F866

QUALITY ASSURANCE - ADVERSE EVENT MONITORING

 
 
 
 
 
 
 
 
 
 
 
 

163

F867

QUALITY ASSURANCE - PERFORMANCE IMPROVEMENT PROJECT

 
 
 
 
 
 
 
 
 
 
 
 

164

F867

QUALITY ASSURANCE - POLICY - CORRECTIVE ACTIONS

 
 
 
 
 
 
 
 
 
 
 
 

165

F867

QUALITY ASSURANCE - POLICY - SYSTEMATIC APPROACH

 
 
 
 
 
 
 
 
 
 
 
 

166

F867

QUALITY ASSURANCE - MONITOR EFFECTIVENESS

 
 
 
 
 
 
 
 
 
 
 
 

167

F867

QUALITY ASSURANCE - PRIORITIES - HIGH-RISK

 
 
 
 
 
 
 
 
 
 
 
 

168

F867

QUALITY ASSURANCE - MEDICAL ERRORS AND ADVERSE EVENTS

 
 
 
 
 
 
 
 
 
 
 
 

169

F867

QUALITY ASSURANCE - PERFORMANCE IMPROVEMENT PROJECT

 
 
 
 
 
 
 
 
 
 
 
 

170

F867

QUALITY ASSURANCE - STAFF KNOWLEDGE

 
 
 
 
 
 
 
 
 
 
 
 

171

F867

QUALITY ASSURANCE - PLANS OF ACTION

 
 
 
 
 
 
 
 
 
 
 
 

172

F867

QUALITY ASSURANCE - REVIEWS AND ANALYZES

 
 
 
 
 
 
 
 
 
 
 
 

173

F868

QUALITY ASSURANCE - DIRECTOR OF NURSING

 
 
 
 
 
 
 
 
 
 
 
 

174

F868

QUALITY ASSURANCE - MEDICAL DIRECTOR OR DESIGNEE

 
 
 
 
 
 
 
 
 
 
 
 

175

F868

QUALITY ASSURANCE - THREE ADDITIONAL MEMBERS

 
 
 
 
 
 
 
 
 
 
 
 

176

F868

QUALITY ASSURANCE - QUARTERLY MEETING

 
 
 
 
 
 
 
 
 
 
 
 

177

F868

QUALITY ASSURANCE - INFECTION PREVENTIONIST

 
 
 
 
 
 
 
 
 
 
 
 
483.80 Infection Control

178

F880

INFECTION PREVENTION AND CONTROL PROGRAM

 
 
 
 
 
 
 
 
 
 
 
 

179

F880

INFECTION PREVENTION AND CONTROL PROGRAM - TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

180

F880

INFECTION PREVENTION AND CONTROL PROGRAM - TB SCREENING

 
 
 
 
 
 
 
 
 
 
 
 

181

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

182

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SURVEILLANCE - REAL TIME

 
 
 
 
 
 
 
 
 
 
 
 

183

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SURVEILLANCE POLICY

 
 
 
 
 
 
 
 
 
 
 
 

184

F880

INFECTION PREVENTION AND CONTROL PROGRAM - REPORTING POLICY

 
 
 
 
 
 
 
 
 
 
 
 

185

F880

INFECTION PREVENTION AND CONTROL PROGRAM - REPORTING OUTBREAK