Documente Academic
Documente Profesional
Documente Cultură
Date: ________________
FACILITY RECORDS
____200 Maintain good business records; accessible ____201 Maintain up-to-date admission/discharge log ____202 Maintain log of all temporary/respite residents ____203 Record of major incidences w/in last 2 yrs. ____204 Documentation of radon testing if required ____205 Maintain liability insurance coverage at all times ____206 Admission package w/ required components ____207 Copy of all Alzheimers advertisements maintained ____208 Grievance procedure for receipt/respond to residents ____209 Proof of having annual fire inspection ____210 Maintains fire safety reports for the last 2 years ____211 Proof of satisfactory sanitation inspection by CHD ____212 Maintains all sanitation inspection reports for last 2 yrs ____213 Surveys, inspections, complaint reports for 5 years ____214 Survey, inspections, etc. available to residents/public ____215 Last inspection report posted in prominent place ____216 Required records available to Agency, ACPD, LTCOC ____217 Facility maintains up-to-date adverse incident reports ____218 Submitted preliminary adverse incident report w/in 1 day ____219 Submitted full adverse incident report w/in 15 days ____220 Liability claims against ALF reported to agency monthly ____221 Assessment of the facilitys risk management program ____222 Facility records should include elopement P&P ____223 Conducts at least 2 elopement drills per year ____224 Documents elopement drills; drills conducted per policies RESIDENT RECORDS STANDARDS ____300 Maintained on premises ____301 Available to resident, et al, for inspection ____302 Contain specific demographic information on resident ____303 Contain a copy of medical examination ____304 Medical record have orders for medications/services, etc. ____305 Signed resident statement refusing therapeutic diet ____306 Weight record initiated at admission ____307 Residents receive assist w/ ADLs, weight record 6 mos. ____308 Written consent reg. non-lic. personnel admin. meds. ____309 Signed, dated contract between facility & resident Contract shall contain 310 326: ____310 Services and accommodations ____311 Daily, weekly, monthly rates or charges ____312 List of available services & fees not in rate ____313 Provision for 30 days written notice of rate increase ____314 Rights, duties, obligations of resident ____315 Purpose of any advanced payment/deposit; refund policy ____316 Conditions when claims will be made against refund ____317 No more than 30 days notice of termination ____318 Written bed hold policy ____319 Religious organization & which one affiliated ____320 Written termination agreement if inappropriate resident ____321 Refund policy ____322 Written notification of claim; 14 days to respond ____323 Refund shall occur w/in 45 days vacated unit ____324 Notice of termination waived in death, medical reasons ____325 Advance payments returned 10 days discont. operation ____326 Refund/funds/property at death to rep. or via probate ____327 Alternate Care Cert./OSS Form CF-ES 1006, 3/98 ____328 Doc. surrogate, guardian, power of attorney in file ____329 Documentation of resident being a hospice patient
____023 Freestanding ALF not advertise/imply any part a N.H. ____024 Include affiliation w/ religious org. & which one ____025 Non-CCRC facilities include license # in advertising ____026 New residents not admitted during moratorium ____027 Moratorium posted & visible to public ____028 Unlawful to knowingly refer to unlicensed facility ____029 No medical or other record is altered or falsified ____030 Revocation, suspension, denial notice posted FISCAL STANDARDS ____100 Facility administered on sound financial basis ____101 Unlawful to w/hold evidence of financial instability ____102 Adverse court action/financial viability report in 7 days ____103 Access to records to determine financial stability ____104 Written records reflect assets, liabilities, income, expen. ____105 Resident funds or property held as trust funds ____106 Separate account for each resident, no co-mingling ____107 Advanced payments kept separate from facility funds ____108 Resident permits facility safekeeping $500/200 ____109 Complete/accurate record of funds/personal effects ____110 Statements of residents funds provided in file ____111 Monthly written statement of any transactions ____112 Funds, property, advances held in Fla. bank institution ____113 W/in 30 days advise resident where money held ____114 If CHOW all deposits/funds transferred to new owner ____115 Transferor provides resident statement amt., where held ____116 Transferee gives resident written statement about funds ____117 Personal funds may be used by resident for anything ____118 Separate charges only w/ resident consent ____119 Fac. rep. payee/attorney-in-fact, get surety bond ____120 RP bond equals twice avg. mo. Income/SSI/OSS/SSDI ____121 Power/attorney equals twice avg. incom/prop./SS/OSS ____122 Owner, admin., employee can not act as guardian ____123 Refunds, funds, property returned upon resident death
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____905 Report evacuation to local EM/agency w/in 6 hrs ____906 Not reoccupy till cleared by local EM ____907 Relocate residents of structurally damaged facility ____908 Facility knows location of all relocated residents ____909 Contact person 24 hrs, 7 days till facility reoccupied ____910 Assist with re-location; resident needs/preferences ____911 Provide emerg. shelter over lic. capacity IF conditions met PHYSICAL PLANT STANDARDS - FACILITY TOUR ____1000 Comply w/ building codes new or renovations ____1001 Promotes residential non-medical environment; safe ____1002 Structurally sound, interior & exterior ____1003 Peeling paint, torn carpet, etc. must be replaced ____1004 Windows, doors, appliances, etc. in good working order ____1005 Furniture/furnishings clean, functional, good repair ____1006 Obtain sanitation inspection every 365 days ____1007 Required radon testing completed ____1008 Bldgs under 1 license on contiguous property ____1009 Increase/decrease in capacity takes prior approval ____1010 Change in space to resident use need prior approval ____1011 Outside temp 65F or below, 72 inside during wake hours ____1012 Outside temp 65F or below, 68 inside during sleep hours ____1013 Individually controlled thermostats controlled by individ. ____1014 Awake hrs, mechanical cooling, 85F in, 89 or below out
____1015 90 degrees out, indoor no more than 81F degrees ____1016 No resident in any area exceeding 90 degrees Fahrenheit ____1017 Resident have option to choose own roommate ____1018 Single bedroom 80 sq. feet usable floor space ____1019 Multi-occupancy bedroom, 60 sq.ft. usable floor space ____1020 Newly liced./renov. after 4/16/00, max of 2 to a bedroom ____1021 Licensed before 10/17/99, max of 4 to bedroom ____1022 Bdrms open to corridor, outside, common area ____1023 Resident has option of using own stuff as space permits ____1024 Bedroom furnishings-storage, table, light, clean bed ____1025 Separate reading, social, leisure room ____1026 35 sq. ft. living and dining space per resident ____1027 Dining room accommodates communal dining ____1028 Adult day care services an additional 35 sq.ft. per client ____1029 Day care residents may not use residents bedrooms ____1030 Separate sleeping space for live-in staff ____1031 Master or duplicate key to residents bedrooms ____1032 1 toilet & sink/ 6 residents; 1 tub/shower per 8 residents ____1033 Portable bedside commodes have privacy ____1034 Bathroom has door, single toilet has a lock from inside ____1035 Master or duplicate key to residents bathrooms ____1036 Non-slip/skid safety surface in showers & bathtubs ____1037 Grab bars on all showers & bathtubs ____1038 Grab bars next to commode after 4/16/00 new/renovated ____1039 Bathroom access not thru another residents bedroom ____1040 Linens/personal laundry clean, no tears, stains, odors, etc. ____1041 Secured areas have egress or perimeter control devices ____1042 Residents in secure area able to move freely throughout ____1043 Resid. able to enter/exit w/out superv. have keys/codes ____1044 Staff trained in level 1 w/ Alzheimers in secure area STAFF RECORDS STANDARDS ____1100 Personnel record contains copy of original employ appl. ____1101 Verification of freedom from communicable disease ____1102 New staff 30 days to statement freedom communicable ____1103 Freedom from TB documented annually; false positive
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