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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

F847

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

094

F847

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

095

F847

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

096

F847

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

097

F847

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

098

F847

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

099

F848

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

100

F848

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

101

F848

BINDING ARBITRATION AGREEMENTS

 
 
 
 
 
 
 
 
 
 
 
 

102

F849

HOSPICE - AGREEMENT

 
 
 
 
 
 
 
 
 
 
 
 

103

F849

HOSPICE - TRANSFER TO ANOTHER FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

104

F849

HOSPICE - PROFESSIONAL STANDARDS

 
 
 
 
 
 
 
 
 
 
 
 

105

F849

HOSPICE - WRITTEN AGREEMENT - SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

106

F849

HOSPICE - SERVICES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

107

F849

HOSPICE - HOSPICE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

108

F849

HOSPICE - SERVICES BY THE FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

109

F849

HOSPICE - COMMUNICATION PROCESS

 
 
 
 
 
 
 
 
 
 
 
 

110

F849

HOSPICE - SIGNIFICANT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

111

F849

HOSPICE - CLINICAL COMPLICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

112

F849

HOSPICE - NEED TO TRANSFER

 
 
 
 
 
 
 
 
 
 
 
 

113

F849

HOSPICE - RESIDENT'S DEATH

 
 
 
 
 
 
 
 
 
 
 
 

114

F849

HOSPICE - LEVEL OF SERVICES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

115

F849

HOSPICE - FACILITY - 24 HOUR ROOM AND BOARD

 
 
 
 
 
 
 
 
 
 
 
 

116

F849

HOSPICE - MEDICAL DIRECTION AND MANAGEMENT

 
 
 
 
 
 
 
 
 
 
 
 

117

F849

HOSPICE - PRESCRIBED THERAPIES

 
 
 
 
 
 
 
 
 
 
 
 

118

F849

HOSPICE - REPORT ALL ALLEGED VIOLATIONS

 
 
 
 
 
 
 
 
 
 
 
 

119

F849

HOSPICE - BEREAVEMENT SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

120

F849

HOSPICE - INTERDISCIPLINARY TEAM MEMBER

 
 
 
 
 
 
 
 
 
 
 
 

121

F849

HOSPICE - CARE PLANNING PROCESS

 
 
 
 
 
 
 
 
 
 
 
 

122

F849

HOSPICE - COMMUNICATION - OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

123

F849

HOSPICE - COMMUNICATION - PRACTITIONERS

 
 
 
 
 
 
 
 
 
 
 
 

124

F849

HOSPICE - MOST RECENT PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

125

F849

HOSPICE - ELECTION FORM

 
 
 
 
 
 
 
 
 
 
 
 

126

F849

HOSPICE - PHYSICIAN CERTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

127

F849

HOSPICE - PERSONNEL

 
 
 
 
 
 
 
 
 
 
 
 

128

F849

HOSPICE - 24 HOUR ON CALL SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

129

F849

HOSPICE - MEDICATION INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 

130

F849

HOSPICE - PHYSICIAN ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

131

F849

HOSPICE - ORIENTATION

 
 
 
 
 
 
 
 
 
 
 
 

132

F849

HOSPICE - ATTAIN OR MAINTAIN

 
 
 
 
 
 
 
 
 
 
 
 

133

F850

SOCIAL SERVICES 120 BEDS

 
 
 
 
 
 
 
 
 
 
 
 

134

F850

SOCIAL WORKER QUALIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

135

F850

SOCIAL WORKER EXPERIENCE

 
 
 
 
 
 
 
 
 
 
 
 

136

F851

MANDATORY STAFFING SUBMISSION

 
 
 
 
 
 
 
 
 
 
 
 

137

F851

MANDATORY SUBMISSION - DIRECT CARE STAFF

 
 
 
 
 
 
 
 
 
 
 
 

138

F851

MANDATORY SUBMISSION - CATEGORY

 
 
 
 
 
 
 
 
 
 
 
 

139

F851

MANDATORY SUBMISSION - RESIDENT CENSUS

 
 
 
 
 
 
 
 
 
 
 
 

140

F851

MANDATORY SUBMISSION - TURNOVER AND TENURE

 
 
 
 
 
 
 
 
 
 
 
 

141

F851

MANDATORY SUBMISSION - AGENCY

 
 
 
 
 
 
 
 
 
 
 
 

142

F851

MANDATORY SUBMISSION - DATA FORMAT

 
 
 
 
 
 
 
 
 
 
 
 

143

F851

MANDATORY STAFFING - SCHEDULE

 
 
 
 
 
 
 
 
 
 
 
 
483.75 Quality Assurance and Performance Improvement

144

F865

QUALITY ASSURANCE - EVIDENCE OF PROGRAM

 
 
 
 
 
 
 
 
 
 
 
 

145

F865

QUALITY ASSURANCE - CORRECTIVE ACTIONS

 
 
 
 
 
 
 
 
 
 
 
 

146

F865

QUALITY ASSURANCE - WRITTEN PLAN

 
 
 
 
 
 
 
 
 
 
 
 

147

F865

QUALITY ASSURANCE - ANNUAL WRITTEN PLAN

 
 
 
 
 
 
 
 
 
 
 
 

148

F865

QUALITY ASSURANCE - ONGOING QAPI PROGRAM

 
 
 
 
 
 
 
 
 
 
 
 

149

F865

QUALITY ASSURANCE - CARE AND MANAGEMENT PRACTICES

 
 
 
 
 
 
 
 
 
 
 
 

150

F865

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

 
 
 
 
 
 
 
 
 
 
 
 

151

F865

QUALITY ASSURANCE - BEST AVAILABLE EVIDENCE

 
 
 
 
 
 
 
 
 
 
 
 

152

F865

QUALITY ASSURANCE - SERVICES FACILITY PROVIDES

 
 
 
 
 
 
 
 
 
 
 
 

153

F865

QUALITY ASSURANCE - GOVERNANCE

 
 
 
 
 
 
 
 
 
 
 
 

154

F865

QUALITY ASSURANCE - TRANSITION IN LEADERSHIP

 
 
 
 
 
 
 
 
 
 
 
 

155

F865

QUALITY ASSURANCE - RESOURCES

 
 
 
 
 
 
 
 
 
 
 
 

156

F865

QUALITY ASSURANCE - EQUIPMENT

 
 
 
 
 
 
 
 
 
 
 
 

157

F865

QUALITY ASSURANCE - STAFF TIME

 
 
 
 
 
 
 
 
 
 
 
 

158

F865

QUALITY ASSURANCE - TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

159

F865

QUALITY ASSURANCE - RESIDENT INPUT

 
 
 
 
 
 
 
 
 
 
 
 

160

F865

QUALITY ASSURANCE - IDENTIFY PROBLEMS

 
 
 
 
 
 
 
 
 
 
 
 

161

F865

QUALITY ASSURANCE - STAFF INPUT

 
 
 
 
 
 
 
 
 
 
 
 

162

F865

QUALITY ASSURANCE - CORRECTIVE ACTIONS

 
 
 
 
 
 
 
 
 
 
 
 

163

F865

QUALITY ASSURANCE - EXPECTATIONS

 
 
 
 
 
 
 
 
 
 
 
 

164

F865

QUALITY ASSURANCE - DISCLOSURE NOT REQUIRED

 
 
 
 
 
 
 
 
 
 
 
 

165

F865

QUALITY ASSURANCE - SANCTIONS

 
 
 
 
 
 
 
 
 
 
 
 

166

F866

QUALITY ASSURANCE - POLICY AND PROCEDURES

 
 
 
 
 
 
 
 
 
 
 
 

167

F866

QUALITY ASSURANCE - FEEDBACK FROM OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

168

F866

QUALITY ASSURANCE - USE OF INFORMATION FROM OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

169

F866

QUALITY ASSURANCE - INFORMATION FROM DEPARTMENTS

 
 
 
 
 
 
 
 
 
 
 
 

170

F866

QUALITY ASSURANCE - METHODOLOGY AND DEVELOPMENT

 
 
 
 
 
 
 
 
 
 
 
 

171

F866

QUALITY ASSURANCE - ADVERSE EVENT MONITORING

 
 
 
 
 
 
 
 
 
 
 
 

172

F867

QUALITY ASSURANCE - PERFORMANCE IMPROVEMENT PROJECT

 
 
 
 
 
 
 
 
 
 
 
 

173

F867

QUALITY ASSURANCE - POLICY - CORRECTIVE ACTIONS

 
 
 
 
 
 
 
 
 
 
 
 

174

F867

QUALITY ASSURANCE - POLICY - SYSTEMATIC APPROACH

 
 
 
 
 
 
 
 
 
 
 
 

175

F867

QUALITY ASSURANCE - MONITOR EFFECTIVENESS

 
 
 
 
 
 
 
 
 
 
 
 

176

F867

QUALITY ASSURANCE - PRIORITIES - HIGH-RISK

 
 
 
 
 
 
 
 
 
 
 
 

177

F867

QUALITY ASSURANCE - MEDICAL ERRORS AND ADVERSE EVENTS

 
 
 
 
 
 
 
 
 
 
 
 

178

F867

QUALITY ASSURANCE - PERFORMANCE IMPROVEMENT PROJECT

 
 
 
 
 
 
 
 
 
 
 
 

179

F867

QUALITY ASSURANCE - STAFF KNOWLEDGE

 
 
 
 
 
 
 
 
 
 
 
 

180

F867

QUALITY ASSURANCE - PLANS OF ACTION

 
 
 
 
 
 
 
 
 
 
 
 

181

F867

QUALITY ASSURANCE - REVIEWS AND ANALYZES

 
 
 
 
 
 
 
 
 
 
 
 

182

F868

QUALITY ASSURANCE - DIRECTOR OF NURSING

 
 
 
 
 
 
 
 
 
 
 
 

183

F868

QUALITY ASSURANCE - MEDICAL DIRECTOR OR DESIGNEE

 
 
 
 
 
 
 
 
 
 
 
 

184

F868

QUALITY ASSURANCE - THREE ADDITIONAL MEMBERS

 
 
 
 
 
 
 
 
 
 
 
 

185

F868

QUALITY ASSURANCE - QUARTERLY MEETING

 
 
 
 
 
 
 
 
 
 
 
 

186

F868

QUALITY ASSURANCE - INFECTION PREVENTIONIST

 
 
 
 
 
 
 
 
 
 
 
 
483.80 Infection Control

187

F880

INFECTION PREVENTION AND CONTROL PROGRAM

 
 
 
 
 
 
 
 
 
 
 
 

188

F880

INFECTION PREVENTION AND CONTROL PROGRAM - TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

189

F880

INFECTION PREVENTION AND CONTROL PROGRAM - TB SCREENING

 
 
 
 
 
 
 
 
 
 
 
 

190

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

191

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SURVEILLANCE - REAL TIME

 
 
 
 
 
 
 
 
 
 
 
 

192

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SURVEILLANCE POLICY

 
 
 
 
 
 
 
 
 
 
 
 

193

F880

INFECTION PREVENTION AND CONTROL PROGRAM - REPORTING POLICY

 
 
 
 
 
 
 
 
 
 
 
 

194

F880

INFECTION PREVENTION AND CONTROL PROGRAM - REPORTING OUTBREAK

 
 
 
 
 
 
 
 
 
 
 
 

195

F880

INFECTION PREVENTION AND CONTROL PROGRAM - TRANSMISSION BASED PRECAUTIONS - POLICY

 
 
 
 
 
 
 
 
 
 
 
 

196

F880

INFECTION PREVENTION AND CONTROL PROGRAM - BARRELS OUT DURING MEALS

 
 
 
 
 
 
 
 
 
 
 
 

197

F880

INFECTION PREVENTION AND CONTROL PROGRAM - ISOLATION POLICY

 
 
 
 
 
 
 
 
 
 
 
 

198

F880

INFECTION PREVENTION AND CONTROL - ISOLATION ROOM

 
 
 
 
 
 
 
 
 
 
 
 

199

F880

INFECTION PREVENTION AND CONTROL PROGRAM - DEDICATED EQUIPMENT

 
 
 
 
 
 
 
 
 
 
 
 

200

F880

INFECTION PREVENTION AND CONTROL - COHORTING RESIDENTS

 
 
 
 
 
 
 
 
 
 
 
 

201

F880

INFECTION PREVENTION AND CONTROL - PROHIBIT EMPLOYEES

 
 
 
 
 
 
 
 
 
 
 
 

202

F880

INFECTION PREVENTION AND CONTROL PROGRAM - EMPLOYEE ILLNESS

 
 
 
 
 
 
 
 
 
 
 
 

203

F880

INFECTION PREVENTION AND CONTROL PROGRAM - HAND WASHING POLICY

 
 
 
 
 
 
 
 
 
 
 
 

204

F880

INFECTION PREVENTION AND CONTROL PROGRAM - HAND WASHING

 
 
 
 
 
 
 
 
 
 
 
 

205

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SOILED LINEN - GLOVES

 
 
 
 
 
 
 
 
 
 
 
 

206

F880

INFECTION PREVENTION AND CONTROL PROGRAM - RECORDS OF INCIDENTS

 
 
 
 
 
 
 
 
 
 
 
 

207

F880

INFECTION PREVENTION AND CONTROL PROGRAM - ACTIVE RECORDS OF INCIDENTS

 
 
 
 
 
 
 
 
 
 
 
 

208

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SOILED LINEN - TIGHT FITTING LIDS

 
 
 
 
 
 
 
 
 
 
 
 

209

F880

INFECTION PREVENTION AND CONTROL PROGRAM - CLEAN & SOILED LINEN - CLEARLY LABELED

 
 
 
 
 
 
 
 
 
 
 
 

210

F880

INFECTION PREVENTION AND CONTROL PROGRAM - LINENS

 
 
 
 
 
 
 
 
 
 
 
 

211

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SOILED LINEN - VENTILATION

 
 
 
 
 
 
 
 
 
 
 
 

212

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SOILED LINEN - NOT OVERFLOWING

 
 
 
 
 
 
 
 
 
 
 
 

213

F880

INFECTION PREVENTION AND CONTROL PROGRAM - SOILED LINEN - GLOVES

 
 
 
 
 
 
 
 
 
 
 
 

214

F880

INFECTION PREVENTION AND CONTROL PROGRAM - CLEAN & SOILED LINEN - SEPARATION

 
 
 
 
 
 
 
 
 
 
 
 

215

F880

INFECTION PREVENTION AND CONTROL PROGRAM - CLEAN LINEN - STORAGE

 
 
 
 
 
 
 
 
 
 
 
 

216

F880

INFECTION PREVENTION AND CONTROL PROGRAM - ANNUAL REVIEW

 
 
 
 
 
 
 
 
 
 
 
 

217

F881

INFECTION PREVENTION AND CONTROL PROGRAM - ANTIBIOTIC STEWARDSHIP

 
 
 
 
 
 
 
 
 
 
 
 

218

F881

INFECTION PREVENTION AND CONTROL PROGRAM - ANTIBIOTIC MONITORING

 
 
 
 
 
 
 
 
 
 
 
 

219

F882

INFECTION PREVENTION AND CONTROL PROGRAM - INFECTION PREVENTIONIST

 
 
 
 
 
 
 
 
 
 
 
 

220

F882

INFECTION PREVENTION AND CONTROL - INFECTION PREVENTIONIST

 
 
 
 
 
 
 
 
 
 
 
 

221

F882

INFECTION PREVENTION AND CONTROL - INFECTION PREVENTIONIST

 
 
 
 
 
 
 
 
 
 
 
 

222

F882

INFECTION PREVENTION AND CONTROL - INFECTION PREVENTIONIST

 
 
 
 
 
 
 
 
 
 
 
 

223

F882

INFECTION PREVENTION AND CONTROL PROGRAM - QAA

 
 
 
 
 
 
 
 
 
 
 
 

224

F883

FLU VACCINE - EDUCATION

 
 
 
 
 
 
 
 
 
 
 
 

225

F883

FLU VACCINE - TIME OF YEAR OFFERED

 
 
 
 
 
 
 
 
 
 
 
 

226

F883

FLU VACCINE - REFUSAL

 
 
 
 
 
 
 
 
 
 
 
 

227

F883

FLU VACCINE - EDUCATION - MEDICAL RECORD

 
 
 
 
 
 
 
 
 
 
 
 

228

F883

FLU VACCINE - RECEIVED AND REFUSAL - MEDICAL RECORD

 
 
 
 
 
 
 
 
 
 
 
 

229

F883

PNEUMONIA VACCINE - EDUCATION

 
 
 
 
 
 
 
 
 
 
 
 

230

F883

PNEUMONIA VACCINE - OFFERED

 
 
 
 
 
 
 
 
 
 
 
 

231

F883

PNEUMONIA VACCINE - REFUSAL

 
 
 
 
 
 
 
 
 
 
 
 

232

F883

PNEUMONIA VACCINE - EDUCATION - MEDICAL RECORD

 
 
 
 
 
 
 
 
 
 
 
 

233

F883

PNEUMONIA VACCINE - EXCEPTION - MEDICAL RECORD

 
 
 
 
 
 
 
 
 
 
 
 

234

F883

PNEUMONIA VACCINE - RECEIVED AND REFUSAL - MEDICAL RECORD

 
 
 
 
 
 
 
 
 
 
 
 
483.85 Compliance and Ethics Program

330

F895

COMPLIANCE AND ETHICS PROGRAM - PREVENTION AND DETECTION

 
 
 
 
 
 
 
 
 
 
 
 

331

F895

COMPLIANCE AND ETHICS PROGRAM - REQUIREMENTS

 
 
 
 
 
 
 
 
 
 
 
 

332

F895

COMPLIANCE AND ETHICS PROGRAM - IN OPERATION

 
 
 
 
 
 
 
 
 
 
 
 

333

F895

COMPLIANCE AND ETHICS PROGRAM - CRIMINAL - CIVIL - ADMINISTRATIVE VIOLATIONS

 
 
 
 
 
 
 
 
 
 
 
 

334

F895

COMPLIANCE AND ETHICS PROGRAM - PROGRAM CONTACT

 
 
 
 
 
 
 
 
 
 
 
 

335

F895

COMPLIANCE AND ETHICS PROGRAM - DISCIPLINARY STANDARDS

 
 
 
 
 
 
 
 
 
 
 
 

336

F895

COMPLIANCE AND ETHICS PROGRAM - HIGH LEVEL PERSONNEL

 
 
 
 
 
 
 
 
 
 
 
 

337

F895

COMPLIANCE AND ETHICS PROGRAM - RESOURCES

 
 
 
 
 
 
 
 
 
 
 
 

338

F895

COMPLIANCE AND ETHICS PROGRAM - DELEGATION OF AUTHORITY

 
 
 
 
 
 
 
 
 
 
 
 

339

F895

COMPLIANCE AND ETHICS PROGRAM - FACILITY COMMUNICATION

 
 
 
 
 
 
 
 
 
 
 
 

340

F895

COMPLIANCE AND ETHICS PROGRAM - FACILITY COMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

341

F895

COMPLIANCE AND ETHICS PROGRAM - FAILURE TO REPORT

 
 
 
 
 
 
 
 
 
 
 
 

342

F895

COMPLIANCE AND ETHICS PROGRAM - VIOLATION DETECTED

 
 
 
 
 
 
 
 
 
 
 
 

343

F895

COMPLIANCE AND ETHICS PROGRAM - ANNUAL TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

344

F895

COMPLIANCE AND ETHICS PROGRAM - COMPLIANCE OFFICER

 
 
 
 
 
 
 
 
 
 
 
 

345

F895

COMPLIANCE AND ETHICS PROGRAM - COMPLIANCE OFFICER - REPORT

 
 
 
 
 
 
 
 
 
 
 
 

346

F895

COMPLIANCE AND ETHICS PROGRAM - COMPLIANCE LIAISONS

 
 
 
 
 
 
 
 
 
 
 
 

347

F895

COMPLIANCE AND ETHICS PROGRAM - ANNUAL REVIEW

 
 
 
 
 
 
 
 
 
 
 
 
483.90 Physical Environment

348

F906

EMERGENCY ELECTRICAL POWER - ADEQUATE

 
 
 
 
 
 
 
 
 
 
 
 

349

F906

EMERGENCY ELECTRICAL POWER - ENTRANCES AND EXITS

 
 
 
 
 
 
 
 
 
 
 
 

350

F906

EMERGENCY ELECTRICAL POWER - LIFE SUPPORT

 
 
 
 
 
 
 
 
 
 
 
 

351

F907

SPACE AND EQUIPMENT

 
 
 
 
 
 
 
 
 
 
 
 

352

F908

ESSENTIAL EQUIPMENT OPERATION

 
 
 
 
 
 
 
 
 
 
 
 

353

F909

ENTRAPMENT - BED FRAMES - MATTRESSES - BED RAILS

 
 
 
 
 
 
 
 
 
 
 
 

354

F909

COMPATIBLE - BED FRAMES - MATTRESSES - BED RAILS

 
 
 
 
 
 
 
 
 
 
 
 

355

F910

RESIDENT ROOMS - DESIGNED AND EQUIPPED

 
 
 
 
 
 
 
 
 
 
 
 

356

F911

BEDS PER ROOM

 
 
 
 
 
 
 
 
 
 
 
 

357

F912

RESIDENT ROOM SIZE

 
 
 
 
 
 
 
 
 
 
 
 

358

F913

ACCESS TO EXIT CORRIDOR

 
 
 
 
 
 
 
 
 
 
 
 

359

F915

SLEEPING AREAS - WINDOW OR DOOR

 
 
 
 
 
 
 
 
 
 
 
 

360

F914

VISUAL PRIVACY

 
 
 
 
 
 
 
 
 
 
 
 

361

F914

PRIVACY CURTAINS

 
 
 
 
 
 
 
 
 
 
 
 

362

F915

RESIDENT ROOMS - WINDOW

 
 
 
 
 
 
 
 
 
 
 
 

363

F916

RESIDENT ROOMS - AT OR ABOVE GROUND LEVEL

 
 
 
 
 
 
 
 
 
 
 
 

364

F917

FUNCTIONAL FURNITURE

 
 
 
 
 
 
 
 
 
 
 
 

365

F917

CLOSET SPACE

 
 
 
 
 
 
 
 
 
 
 
 

366

F917

MATTRESS

 
 
 
 
 
 
 
 
 
 
 
 

367

F917

BEDDING

 
 
 
 
 
 
 
 
 
 
 
 

368

F917

BED/MATTRESS SIZE

 
 
 
 
 
 
 
 
 
 
 
 

369

F917

RESIDENT ROOMS - SPECIAL

 
 
 
 
 
 
 
 
 
 
 
 

370

F917

RESIDENT ROOMS - NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

371

F917

RESIDENT ROOMS - COMFORT

 
 
 
 
 
 
 
 
 
 
 
 

372

F918

TOILET AND BATHING FACILITIES

 
 
 
 
 
 
 
 
 
 
 
 

373

F919

RESIDENT ROOM CALL SYSTEM - DIRECT

 
 
 
 
 
 
 
 
 
 
 
 

374

F919

BATHROOM CALL SYSTEM - DIRECT

 
 
 
 
 
 
 
 
 
 
 
 

375

F920

DINING - ACTIVITY AREA - LIGHTING

 
 
 
 
 
 
 
 
 
 
 
 

376

F920

DINING - ACTIVITY - VENTILATION

 
 
 
 
 
 
 
 
 
 
 
 

377

F920

DINING - ACTIVITY AREA - TEMPERATURE AND ODOR

 
 
 
 
 
 
 
 
 
 
 
 

378

F920

DINING - FURNISHINGS

 
 
 
 
 
 
 
 
 
 
 
 

379

F920

DINING - ACTIVITY AREA - FURNISHING

 
 
 
 
 
 
 
 
 
 
 
 

380

F920

SUFFICIENT ACTIVITY SPACE

 
 
 
 
 
 
 
 
 
 
 
 

381

F920

SPACE ACCOMMODATION - ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

382

F921

OTHER ENVIRONMENTAL CONDITIONS

 
 
 
 
 
 
 
 
 
 
 
 

383

F922

EMERGENCY WATER

 
 
 
 
 
 
 
 
 
 
 
 

384

F923

AIR MOVEMENT

 
 
 
 
 
 
 
 
 
 
 
 

385

F923

TEMPERATURE, HUMIDITY, ODOR

 
 
 
 
 
 
 
 
 
 
 
 

386

F923

VENTILATION EFFICIENCY

 
 
 
 
 
 
 
 
 
 
 
 

387

F924

HANDRAILS - SECURE

 
 
 
 
 
 
 
 
 
 
 
 

388

F925

PEST CONTROL PROGRAM - FREE OF PESTS

 
 
 
 
 
 
 
 
 
 
 
 

389

F925

PEST CONTROL PROGRAM - MAINTAIN

 
 
 
 
 
 
 
 
 
 
 
 

390

F926

SMOKING - POLICY

 
 
 
 
 
 
 
 
 
 
 
 

391

F926

SMOKING - OXYGEN USE

 
 
 
 
 
 
 
 
 
 
 
 
483.95 Training Requirements

392

F940

TRAINING REQUIREMENTS

 
 
 
 
 
 
 
 
 
 
 
 

393

F941

TRAINING REQUIREMENTS - COMMUNICATION

 
 
 
 
 
 
 
 
 
 
 
 

394

F942

TRAINING REQUIREMENTS - RESIDENT RIGHTS

 
 
 
 
 
 
 
 
 
 
 
 

395

F943

RESIDENT BEHAVIOR AND TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

396

F943

ABUSE TRAINING

 
 
 
 
 
 
 
 
 
 
 
 

397

F943

ABUSE REPORTING PROCEDURES

 
 
 
 
 
 
 
 
 
 
 
 

398

F943

DEMENTIA MANAGEMENT

 
 
 
 
 
 
 
 
 
 
 
 

399

F944

TRAINING REQUIREMENTS - QUALITY ASSURANCE

 
 
 
 
 
 
 
 
 
 
 
 

400

F945

TRAINING REQUIREMENTS - INFECTION CONTROL

 
 
 
 
 
 
 
 
 
 
 
 

401

F946

TRAINING REQUIREMENTS - COMPLIANCE AND ETHICS

 
 
 
 
 
 
 
 
 
 
 
 

402

F946

TRAINING REQUIREMENTS - ANNUAL COMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

403

F947

NURSE AIDES - IN-SERVICES - 12 HOURS

 
 
 
 
 
 
 
 
 
 
 
 

404

F947

NURSE AIDES - IN-SERVICES - DEMENTIA - ABUSE

 
 
 
 
 
 
 
 
 
 
 
 

405

F947

NURSE AIDES - PERFORMANCE REVIEW - IN-SERVICE

 
 
 
 
 
 
 
 
 
 
 
 

406

F947

NURSE AIDES - IN-SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

407

F948

PAID FEEDING ASSISTANTS - WORK IN FACILITY - STATE APPROVED COURSE

 
 
 
 
 
 
 
 
 
 
 
 

408

F949

TRAINING REQUIREMENTS - BEHAVIORAL HEALTH