Mock Survey Worksheet

Facility Name: Date of Last Annual Survey: Facility Concerns: Facility Reviewer(s):

Resident Council Interviews: Comments:

Yes

No

THE FOLLOWING REPORT HAS BEEN GENERATED AS PART OF THE FACILITIES QUALITY ASSESSMENT AND ASSURANCE PROCESS AND CONSTITUTES CONFIDENTIAL QUALITY ASSURANCE COMMITTEE RECORDS. Ref. 42 CFR 4438.75 (0). FTag 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 Cited In 2004 S/S Un Met Scope / Severity

Area
483.10 Resident Rights Exercise Rights of the Individual Exercise Rights on Behalf of the Resident Notice of rights and services Informed in a language that is understood Refuse Treatments / Formulate Adv. Directives Written Info: Non Charges/Charges/Etc Informed of charges impacting the resident Protection of Personal Funds Management of Personal Funds Conveyance upon death within 30 days Assurance of Financial Security Limitations / Charges from Personal Funds Free Choice Privacy / Confidentiality Grievances w/o discrimination /reprisal Prompt resolution of grievances Examine survey results Receive / Contact agencies as Resident Advocates Right to Work Right to receive unopened mail Access to stationary/etc at res. own expense

Met

Comments

Area

FTag 172 173 174 252 175 176 177 201 202 203 204 205 206 207 208 221 222 223 224 225 226 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 271 272

Cited In 2004

Met

Un Met

Scope / Severity

Comments

Access and visitation rights State reps can examine res. records w/permission Telephone Personal Property Married Couples / sharing rooms Self administration of medications Refusal of certain transfers 483.12 ADMIT/TRANS/DISCH RIGHTS Transfer and Discharge Requirements Documentation Notice before transfer and discharge Orientation for transfer and discharge Notice of bed hold policy and readmission Permitting resident to return to facility Equal access to quality care Admission policy requirements 483.13 Resident Behavior and Facility Physical Restraints Chemical Restraints Right to be free from Abuse Staff Treatment of Residents Not employ Individuals with criminal history Facility policies regarding abuse 483.15 QUALITY OF LIFE Dignity Self Determination / Participation Participation in Resident and Family Groups Right to organize and participate in groups Participation in other activities Accommodation of Needs Receive notice of room or roommate change Activities Activity Director Qualifications Social Services Social Worker Qualifications Personal Belongings Maintain a Sanitary/Orderly/Comfortable Environ Clean Linens in good condition Private Closet for each resident Adequate comfortable lighting levels in all areas Comfortable and safe temps 71-81 degrees F Comfortable noise levels 483.20 Resident Assessment Admission Orders Comprehensive Assessments

Area

FTag 273 274 275 276 278 279 280 281 282 283 284 285 287 309 310

Cited In 2004

Met

Un Met

Scope / Severity

Comments

Assessment must be completed within 14 days Promptly after a significant change Not les than once every 12 months Reassess the resident every 90 days Accuracy of Assessments Comprehensive Care Plans Comp. care plan is developed 7 days after RAI Services must meet professional standards Services are to be provided by qualified staff Must have recapitulation of stay Discharge Sum Post Discharge Plan Preadmission screening for MR/MI Automated Data Processing requirement for MDS 483.25 QUALITY OF CARE Maintain highest practicable level of functioning ADL ability doesnt diminish w/o good cause Bathing Dressing Grooming Transfer Ambulation Toilet Eat Communication Treatments given consistent with identified needs Dependent resident receives needed assistance Vision and Hearing Pressure Sores Indwelling catheters Urinary Incontinence Reduction in ROM is not experienced w/o cause Resident with limited ROM receives services Mental and psychosocial services Psychosocial adjustment Naso gastric tubes are medically necessary Complications R/T enteral feedings are avoided Accidents environment is free of hazards Adequate supervision to prevent accidents Nutrition maintain acceptable parameters Receives a therapeutic diet Hydration Special Needs

311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328

Area

FTag

Cited In 2004

Met

Un Met

Scope / Severity

Comments

Injections Parenteral / Enteral Fluids Colostomy / Ureterostomy / Ileostomy Care Tracheostomy care Tracheal suctioning Foot care Prostheses Unnecessary Drugs Antipsychotic Medications clinically indicated Residents have dose reductions if appropriate Less than 5% med error rate Residents are free of significant med errors 483.30 Nursing Services Sufficient Staffing RN coverage 8 hours a day 7 days a week RN requirements waiver 483.35 Dietary Services Provide meals that meet the requirements Dietary Staffing RD FSD etc Sufficient staffing Menus and nutritional adequacy Prepared properly and is palatable/attractive/temp Prepared in a form designed to meet individual needs Substitutes are offered Therapeutic diets ordered by physician Frequency of meals 3 meals a day at regular times No more than 14 hours between dinner and bkft 16 hours if nourishing HS snack is provided HS snacks are offered Assistive devices Procure foods from approved sources Store prepare distribute and serve Sanitary Cond. Dispose of garbage and refuse properly 483.40 Physician Services MD must approve in writing recommendation for resident to be admitted MD must review orders, write and sign notes and sign and date orders Frequency of MD visits at least once every 30 days for the first 90 days and at least every 60 days thereafter; visit is considered late if more than 10 days after the date required

329 330 331 332 333 353 354 355 360 361 362 363 364 365 366 367 368

369 370 371 372 385 386 387

Area

FTag 388 389 390 406 407 411 412 425 426 427 428 429 430 431 432 441 442 443 444 445 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 490 491 492 493 494 495 496 497 498 499

Cited In 2004

Met

Un Met

Scope / Severity

Comments

Must be made by MD or NP / PA as allowed Availability of Physician emergency care Physician delegation of tasks in SNFs 483.45 Specialized Rehab Services Provide the required services PT/OT/SLP Provided under the written order of the MD by qualified staff 483.55 Dental Services Facility must provide services as required in SNF NF must provide dental services as needed 483.60 Pharmacy Services Procedures for Rx Management Consultant Services Rx Regime Review every month Report Irregularities to MD and DNS Reports must be acted upon Rx must be labeled correctly Temp control/correct storage/stores narcotics correctly 483.65 Infection Control Investigates/controls/prevents infection Prevents the spread of infection Assures employee well-being Monitors hand washing Monitors linen handling 483.70 Physical Environment Emergency power / generator Space equipment No more than 4 in a bedroom 80 sq ft for multi 100 for private Direct access to corridor Provides full visual privacy At least 1 window to outside Toilet facilities Resident call system 1 or more Dining/Activity rooms Environment Safe clean functional comfortable Emergency water supply if normal is lost Outside venting Firm handrails on each side Effective Pest control 483.75 Administration Licensure Compliance w/state fed and local laws Governing Body Nurse Assist training NAR Competency NAR Registry Verification Reg Inservice Training Proficiency of NA Competency Staff Qualifications

Area

FTag 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516

Cited In 2004

Met

Un Met

Scope / Severity

Comments

Use of outside resources Medical Director Lab Services Lab meets requirements / transfusions Provided only when ordered by MD Report results timely to MD Assist resident to off site lab appointments Results are filed in chart noted when done Radiology Have agreement with services providers Provide only when ordered by MD Report findings to MD immediately Assist resident to off site radiology appointments Results are filed in chart noted when done Clinical Records Complete Accurate Accessible Retained for time period identified by law Safe Guarded - theft/loss/destruction Sufficient data to identify resident Record of resident assessment Plan of care is based on data assessments Fire/Disaster/Emergency Plans Staff trained in Emergency policy and procedure Carry out unannounced drills Transfer agreements Quality Assessment and Assurance Committee DNS/MD/+ 3 other team members QA meets at least quarterly Reviews/Implements/Plans/Corrects Disclosure of Ownership

517 518 519 520 521 522

RESIDENT ROSTER INFORMATION

Roster (HCFA 802) Current and Correct? Bedfast # Tube Feeding # Dialysis # Pressure Ulcers: Acquired # Foley Cath # N/G# Hospice # Total Ulcers # (%) Stage 2 3 4 GT# IV # Yes No

Total Residents with Pressure Ulcers: Isolation # Physical Restraints # Psychoactive Meds # Significant Weight Loss # Types: (%) (Types:)

Antipsychotic Meds # (%)

Falls with Significant Injury Past 30 Days? #