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Facility
Self-Assessment
(Mock Survey)
Tool

LONG-TERM CARE SURVEY MANUAL
PREPARED BY MU NHA CONSULTANT
SECTION 5 - FACILITY SELF-ASSESSMENT (MOCK SURVEY TOOLS)
Facility Self-Assessment - Mock surveys are an opportunity to look at systems, procedures and processes of care and to identify potential survey-risk areas. Mock surveys should be performed on a scheduled basis and shared with nursing home staff. The most important part of the survey process is what you do after it is over with the results. F-tags are used in this section. Be advised that CMS makes revisions to the F-tags on a regular basis.

SECTION
Article: Mock Survey: An Important Component
Survey Preparation
Self-Assessment/Mock Survey
Guide to F-Tag Numbers
“F” Tag Deficiencies
Quality Indicator Report Results
Process-Survey Tasks
Meal Monitor Assignment and Times
Mock Survey Assignments
Survey Scope & Severity Grid
Resident Review Worksheet
General Observations of the Faculty
First Impressions Checklist
Surveyor Notes Worksheet
Administration Checklist
Contract Book Checklist
Personnel File Checklist
Environment
Physical Plant Rounds-Initial Tour
File Drill Grid
QA Review: Surveyor Notes Worksheet
Nursing
Resident Review Worksheet
Quality of Care
MDS Audit Tool
Investigative Protocol Hydration
Non-Sterile Dressing Change
Discharge Records Review
Chart Audit Tool
Med Pass Technique
CMS-677 Medication Pass Worksheet
Dietary
Dietary Observations
Monthly Meal Quality Review
Monthly Sanitation/Infection Control Review
Meal Audit Tool
Kitchen/Food Service Observation

Updated March 2013

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5.3
5.4-5.5
5.6-5.30
5.31
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5.35
5.36
5.37-5.38
5.39-5.42
5.43-5.44
5.45
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5.60
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5.65
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5.78-5.80
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5.86-5.87

LONG-TERM CARE SURVEY MANUAL
PREPARED BY MU NHA CONSULTANT
Social Services
Social Services Audit
Quality of Life Assessment Observation of
Non-Interviewable Resident
Quality of Life Assessment Resident Interview
Resident Interview
Quality of Life Assessment Family Interview
Quality of Life Assessment Group Interview
Resident Council Meeting Audit
Activities Chart Audit Tool

Updated March 2013

5.88
5.89
5.90
5.91
5.92-5.94
5.95-5.97
5.98-5.101
5.102-5.103
5.104

Mock Survey
An Important Component of Survey Preparation
Many long-term care providers strive to be ‘survey-ready’ all year round. But just like many of us schedule the big spring cleaning some time in advance of company arriving for their annual summer visit; some LTC providers opt to conduct a Mock Survey in anticipation of their annual licensure/certification visit. Mock Surveys can serve several purposes:




A Mock Survey can be an opportunity to take a fresh look at systems, procedures and processes of care, and identify potential survey-risk areas. And survey-risk can translate into litigation-risk. A Mock Survey also can reveal how staff will function under stressful circumstances.

Taking that fresh and objective look is essential in order to reap the maximum benefit from the Mock Survey process. LTC providers are discovering the hard way that the procedures, protocols and monitoring/QA systems that served them well enough in the past are no longer sufficient to avoid survey deficiencies. ‘But we’ve always done it this way; the surveyors never cited us on this in the past; we thought we were doing this correctly; we’ve always done well on our surveys before – how could this be happening?’ It is hard to stay current with new standards and the more stringent application of existing standards like F314 Pressure Ulcers, F315 Continence/Catheters, F323 Accidents, etc. It is hard to look at one’s own organization and see its shortcomings.

One way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. This ‘someone’ could be a consultant or an experienced and well informed professional from a neighboring LTC community. If, however, you elect to manage the process using your own personnel, incorporating the following approaches can facilitate objectivity: 





Assign department heads to ‘survey’ departments other than their own. In nursing, have charge nurses/unit managers, supervisors, etc., assigned to audit other units and/or aspects of care for which they are not usually responsible. It is often hard to see your own forest for the trees. Although obviously the internal ‘surveyors’ will know that a Mock Survey will be taking place at some point, it could be more beneficial if direct care staff and other workers were not informed. This maximizes the surprise and stress factor.

Even though the internal ‘surveyors’ know that the process is planned, the Mock Survey should be unannounced. The Administrator walks in one morning and proclaims it to be Mock Survey Day. This simulates ‘real life’ conditions...

The most important part of the Mock Survey process is what you do after it’s over. If you have about three months between the Mock Survey and the earliest likely date of the next survey, then I recommend the ‘Systems’ approach. The Systems approach includes a broader review and analysis of organizational policies, procedures, protocols and practices that may be contributing to Quality Indicator Report flags and/or to the ‘findings’ of the Mock Survey ‘survey team.’ If you have one month or less between the Mock Survey and the earliest likely date of the next survey, then I recommend you go into ‘Manage the Damage Mode.’ What are your high-risk areas, which residents have experienced negative outcomes, how can the risk be lessened and/or the negative outcome be explained and/or otherwise addressed? In either scenario, “Systems” or “Manage the Damage Mode” develop a Corrective Action Roadmap that assigns responsibility, targets timeframes and breaks down the plan into operational steps. Pre-survey preparation and risk management are the two most effective tools we have to weather today’s regulatory climate. Most LTC providers, if they haven’t endured it already themselves, know of a provider in their area- good reputation, well respected in their community, satisfactory survey history – that has been blown out of the water during their last survey. Wouldn’t you rather have a ‘friendly outsider’ or your own team discovers the dust-bunnies before the surveyors do?

Reprint from The Edge, April 29, 2009
The Edge is provided to members of the Kansas Association of Homes and Services for the Aging in partnership with Life Services Network, the Illinois AAHSA affiliate. Authored by Dorrie J. Seyfried, Vice President of Method Management, Risk Management & LTC Consultants based in St. Charles, Illinois.

5.2

Self-Assessment/Mock Survey
Today, more than ever, nursing facilities must be prepared to demonstrate compliance with federal regulations not only at survey time, but all year long. Survey teams can arrive at facilities as soon as nine months after the last annual survey. They can appear at any time to conduct complaint investigation surveys. And, these days, they are likely to begin surveys at nontraditional times and on weekends. These changes in the frequencies, times and types of surveys make it imperative that facilities be prepared at all times. Nevertheless, with rapidly increasing turnover rates for nursing staff and managers, facility staff might not be familiar with surveyors' procedures, care observations, interviews, and record reviews and could be unprepared to meet these challenges.

To adequately prepare staff to succeed at survey time, and to ensure that the facility complies with regulations at all times, periodic self-assessments or mock surveys can be an important feature of a facility's quality assurance process. A mock survey can be performed by facility staff, by corporate advisors or by outside consultants. In whatever manner your facility chooses to provide these services, there are a few guidelines to bear in mind.

1. Enlist "fresh eyes" to see existing problems clearly. Be sure to include new employees, an "outsider" or other mock surveyors who are not overly familiar with the facility's staff and residents. If using facility staff, ask them to review areas outside their direct span of control.

2. Replicate "real" survey procedures as faithfully as possible. Use precise observation methods, select a sample of residents according to survey guidelines and interview the same staff that real surveyors are likely to interview.

The following pages include a variety of tools for you to use for your own self-assessment—use all or some of them. Remember, if you find any deficient practices be sure you bring it to your Quality Assurance Meetings, document your findings, and come up with a workable plan to correct the problem.

5.3

GUIDE TO “F” TAG
NUMBERS
483.10 RESIDENT RIGHTS
F-151Exercise of Rights
F-152Resident Competency
F-153Access to Records
F-154Informed of Health Status or Care
F-155Refusal of Treatment
F-156 Medicaid Services and Charges
F-157 Notification of Changes
F-158 Protection of Resident Funds
F-159 Personal Fund Management
F-160 Conveyance Upon Death
F-161 Assurance of Financial Security
F-162 Limitation on Charges to Personal Funds
F-163 Free Choice on Physician Informed re:
Care (refer to F-154)
Planning care (refer to F-280)
F-164 Privacy and Confidentiality
F-165 Voice Grievances
F-166 Resolution of Grievances
F-167 Examination of Survey Results
F-168 Agencies Acting as Advocates F169 Work
F-170 Mail
F-171 Access to Stationary
F-172 Access & Visitation Rights
F-173 Ombudsman Access to Records
F-174 Telephone
Personal Property (refer to F-252)
F-175 Married Couples
F-176 Self Administration of Drugs
F-177 Refused of Certain Transfers
483.12 ADMISSION, TRANSFER & DISCHARGE
F-201 Transfer & Discharge Requirements
F-202 Documentation of Transfer & Discharge
F-203Notice before transfer
F-204 Orient re Transfer & Discharge
F-205 Bed-hold Policy and Readmission
F-206 Return to the Facility
F-207 Equal Access to Quality Care
F-208 Admissions Policy
483.13 RESIDENT BEHAVIOR & FACILITY
PRACTICE
F-221 Restraints (physical)
F-222 Restraints (chemical)
F-223 Abuse
F-224 Treatment of Residents & their Property
F-225 Employ Individuals Guilty of Abuse
F-226 Policy & Procedure on Abuse

483.15 QUALITY OF LIFE
F-240 Quality of Life
F-241 Dignity
F-242 Self-determination/Participation
F-243 Participate in Resident/Family Groups
F-244 Resident/Family Recommendation
F-245 Participation in other Activities
F-246 Accommodations of Needs
F-247 Notification of Room Changes
F-248 Activities
F-249 Qualified Activity Professional
F-250 Social Services
F-251 Full Time Social Worker
Qualifications of Social Worker
F-252 Environment
F-253 Housekeeping & Maintenance
F-254 Linens Clean and in Good Condition
F-256 Lighting Levels
F-257 Comfortable Temperature
F-258 Comfortable Sound Levels
483.20 RESIDENT ASSESSMENT
F-271 Admission Orders
F-272 Comprehensive Assessments
F-273 Frequency of Assessments
F-274 Significant Change
F-275 Annual Assessments
F-276 Quarterly Review Assessments
(Refer to F-279)
F-278 Accuracy/Coordination, RN Cert.
F-279 Comprehensive Care Plans
F-280 Care Plan Development
F-281 Services Meets Professional Standards
F-282 Services by Qualified Persons
F-283 Discharge Summary
F-284 Post-Discharge Plan of Care
F-285 Preadmission Screening for MI
F-286 MDS Data Storage & Maintenance
F-287 Encoding & Transmitting
483.25 QUALITY OF CARE
F-309 Quality of Care
F-310 ADL Abilities
F-311 Appropriate Treatment & Services
F-312 Care for ADL Dependent Residents
F-313 Vision & Hearing
F-314 Pressure Sores
F-315 Urinary Incontinence
F-317 Range of Motion Diminished
F-318 Range of Motion Treatment & Services
F-319 Mental & Psychosocial Functioning
F-320 Adjustment Difficulty
F-321 Naso-gastric Tubes
F-322 Services to Prevent Aspiration

F-323 Accidents
F-325 Nutrition
F-327 Hydration

QUALITY OF CARE (Continued)
F-328 Special Needs
F-329 Unnecessary Drugs
F-332 Medication Errors 5% or Greater
F-333 Significant/Non-Significant Med.
Errors
F-334 Influenza & Pneumococcal
Immunizations
483.30 NURSING SERVICES
F-353 Nursing Services/Sufficient Staff
F-354 Registered Nurse Hours
F-355 SNF Waiver for Licensed Nurse
F-356 Posting Nursing Staff
483.35 DIETARY SERVICES
F-360 Dietary Services
F-361 Staffing
F-362 Sufficient Staff
F-363 Menus and Nutritional Adequacy
F-364 Food
F-365 Food Meets Individual Needs
F-366 Substitutes Offered
F-367 Therapeutic Diets
F-368 Frequency of Meals
F-369 Assistive Devices
F-371 Sanitary Conditions
F-372 Dispose of Garbage & Refuse
Properly
F-373 Paid Feeding Assistants
(Michigan does not have this
program)
483.40 PHYSICIAN SERVICES
F-385 Physician Services/Supervision
F-386 Physician Visits
F-387 Frequency of Physician Visits
F-388 Visits by Physician Exception
F-389 Physician Available for Emergency
Use
F-390 Dr. Delegation of Tasks Performed
in SNF/NF
483.45 SPECIALIZED
REHABILITATION SERVICES
F-406 Provision of Services
F-407 Qualifications
483.55 DENTAL
F-411 Skilled Nursing Facilities Dental
Services
F-412 Nursing Facilities Dental Services

5.4

483.60 PHARMACY
F-425 Pharmacy Services/Procedures
F-428 Drug Regimen Review
F-431 Control, Labeling & Storage of Drugs
483.65 INFECTION CONTROL
F-441 Infection Control

483.70 PHYSICAL ENVIRONMENT
F-454Physical Environment
F-455Emergency Power
Space & Equipment (Refer to F246) F-456 Patient Care Equipment is Safe Resident Rooms (Refer to F-252)
F-457Bedroom Accommodations
F-458Square Footage/Room
F-459Direct Access to Exit
F-460Full Visual Privacy
F-461Room with Window/Floor at Grade
F-462Toilet Facilities
F-463Resident Call System
F-464Dining & Resident Activities
F-465Other Environmental Conditions
F-466Available Water Supply
F-467Outside Ventilation
F-468 handrails
F-469Pest Control Program
483.75 ADMINISTRATION
F-490 Administration
F-491 licensure
F-492 Federal, State, & Local
Laws
F-493Governing Body
F-494 Required Training
NA F-495 Competency
F-496Registry Verification/Retraining
F-497Regular In-Service Education
F-498Proficiency of Nurse Aides
F-499Staff Qualifications
F-500Use of Outside Resources
F-501Medical Doctor
F-502Laboratory Services
F-503Laboratory Requirements
F-504 Physician Ordered Lab
Services F-505 Promptly Notify Dr.
of Findings
F-506 Transportation To/From
F-507Lab Reports in Resident File
F-508Radiology & Diagnostic Services
Meets Resident Needs
F-509Radiology & Diagnostic Requirements
F-510MD Ordered Radiology Services
F-511 Promptly Notify Dr. of Findings
F-512 Transportation To/From
F-513 X-ray Reports in Resident File
F-514Clinical Records
F-515Retention of Clinical Records
F-516Safeguard Clinical Records
F-517Disaster & Emergency
F-518Training for Emergency
F-519 Transfer Agreement
F-520 Quality Assessment &
Assurance
F-522 Disclosure of Ownership

5.5

“F” TAG DEFICIENCIES
Facility Name:
ID
PREFIX
TAG

Dates of Quality Review:
SUMMARY STATEMENT OF FINDINGS

Reviewer:
FINDINGS

PLAN OF CORRECTION

DATE OF
COMPLETION

RESIDENT RIGHTS
F-151

F-152

F-153

F-154

Exercise of Rights.
1. The resident has the right to exercise his or her rights
as a resident of the facility and as a citizen or resident
of the United States.
2. The resident has the right to be free of interference,
coercion, discrimination, and reprisal from the facility
in exercising his or her rights.
Resident Competency.
1. In the case of a resident adjudged incompetent under
the laws of a State by a court of competent jurisdiction,
the rights of the resident are exercised by the person
appointed under State law to act on the resident’s
behalf.
2. In the case of a resident who has not been adjudged
incompetent by the State court, any legal-surrogate
designated in accordance with State law may exercise
the resident’s rights to the extent provided by State
law.
Access to Records. The resident or his or her legal
representative has the right:
1. Upon an oral or written request, to access all records
pertaining to himself or herself including current
clinical records within 24 hours (excluding weekends
and holidays); and
2. After receipt of his or her records for inspection, to
purchase at a cost not to exceed the community
standard, photocopies of the records or any portions of
them upon request and 2 working days advance notice
to the facility.
Informed of Health Status or Care.
1. The resident has the right to be fully informed in a
language that he or she can understands, of his or her
total health status, including but not limited to, his or
her medical condition.
2. The resident has the right to be fully informed in
advance about care and treatment and of any changes
in that care or treatment that may affect the resident’s
well-being.

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5.6

F-155

F-156

F-157

F-158

F-159

F-160

F-161

F-162

Refusal of Treatment. The resident has the right to
refuse treatment, to refuse to participate in experimental
research, and to formulate an advance directive.
Medicaid Services and Charges. The facility must
inform the resident both orally and in writing in a
language that the resident understands, of his or her
rights and all rules and regulations governing resident
conduct and responsibilities during the stay in the
facility. The facility must also provide the resident with
the notice (if any) of the State. Such notification must
be made prior to or upon admission and during the
resident’s stay. Receipt of such information, and any
amendments to it, must be acknowledged in writing.
Notification of Changes. A facility must immediately
inform the resident; consult with the resident’s
physician; and if known, notify the resident’s legal
representative or an interested family member when
there is:
1. An accident involving the resident which results in
injury and has the potential for requiring physician
intervention;
2. A significant change in the resident’s physical,
mental, or psychosocial status (i.e., a deterioration in
health, mental, or psychosocial status in either lifethreatening conditions or clinical complications). Protection of Resident Funds. The resident has the
right to manage his or her financial affairs, and the
facility may not require residents to deposit their
personal funds with the facility.
Personal Fund Management. Upon written
authorization of a resident, the facility must hold,
safeguard, manage, and account for the personal funds
of the resident deposited with the facility.
Conveyance Upon Death. Upon the death of a resident
with a personal fund deposited with the facility, the
facility must convey within 30 days the resident’s
funds and a final accounting of those funds, to the
individual or probate jurisdiction administering the
resident’s estate.
Assurance of Financial Security. The facility must
purchase a surety bond, or otherwise provide assurance
satisfactory to the Secretary, to assure the security of all personal funds of resident deposited with the facility.
Limitation on Charges to Personal Funds.
1. The facility may not impose a charge against the

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5.7

F-163

F-164

F-165

F-166

F-167

F-168

F-169
F-170

F-171

F-172

personal funds of a resident for any item(s) or services
for which payment is made under Medicaid or
Medicare (except for applicable deductible and
coinsurance amounts).
2. The facility may charge to resident’s funds, any
item(s) or services requested by a resident, if the
facility informs the resident there will be a charge and
if payment is not made by Medicaid or Medicare.
Free Choice/Physician. The resident has the right to
choose a personal attending physician regarding:
Care (refer to F-154)
Planning Care (refer to F-280).
Privacy and Confidentiality. The resident has the right
to personal privacy and confidentiality of his or her
personal and clinical records.
Voice Grievances. The resident has the right to voice
grievances without discrimination or reprisal. Such
grievances include those with respect to treatment
which has been furnished as well as that which has not
been furnished.
Resolution of Grievances. The resident has the right to
prompt efforts by the facility to resolve grievances the
resident may have, including those with respect to the
behavior of other residents.
Examination of Survey Results. The facility must make
the results of the most recent survey (Federal or State)
available for examination in a place readily accessible
to residents and must post a notice of their availability.
Agencies Acting as Advocates. The resident has the
right to receive information from agencies acting as
client advocates, and be afforded the opportunity to
contact these agencies.
Work. The resident has the right to refuse to perform
services for the facility.
Mail. The resident has the right to privacy in written
communications, including the right to send and
promptly receive mail that is unopened.
Access to Stationary. The resident has the right to have
access to stationery, postage, and writing implements at
the resident’s own expense.
Access & Visitation Rights. The facility must provide
reasonable access to any resident by an entity or
individual that provides health, social, legal, or other
services to the resident, subject to the resident’s right to

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5.8

F-173

F-174

F-175

F-176

F-177

deny or withdraw consent at any time.
Ombudsman Access to Records. The facility must
allow representatives of the State Ombudsman to
examine a resident’s clinical records with the
permission of the resident or the resident’s legal
representative, and consistent with State law.
Telephone. The resident has the right to have
reasonable access to the use of a telephone where calls
can be made without being overheard.
Personal Property (refer to F-252)
Married Couples. The resident has the right to share a
room with his or her spouse when married residents
live in the same facility and both spouses consent to the
arrangement.
Self Administration of Drugs. The resident has the
right to self-administer drugs if the interdisciplinary
team has determined that this practice is safe.
Refused of Certain Transfers. The resident has the
right to refuse a transfer to another room within the
facility if it does not affect the resident’s eligibility or entitlement to Medicare or Medicaid benefits.

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ADMISSION, TRANSFER AND DISCHARGE
F-201

Transfer & Discharge Requirements. The facility must
permit each resident to remain in the facility and not
transfer or discharge the resident from the facility
unless:
1. The transfer or discharge is necessary for the
resident’s welfare;
2. The transfer or discharge is appropriate because the
resident’s health has improved;
3. The safety of individuals in the facility is
endangered;
4. The resident (or Medicare or Medicaid) has failed to
pay for a stay at the facility.
5. The facility ceases to operate.

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F-202

Documentation of Transfer & Discharge. The
resident’s clinical record must be documented when the
facility transfers or discharges a resident

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5.9

F-203

Notice Before Transfer. Before a facility transfers or
discharges a resident, the facility must notify the
resident and a family member or legal representative of
the resident, of the transfer or discharge and the
reasons for the move, in writing and in a language and
manner they understand.

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F-204

Orient Regarding Transfer & Discharge. The facility
must provide sufficient preparation and orientation to
residents to ensure safe and orderly transfer or
discharge from the facility.

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F-205

Bed-Hold Policy and Readmission. The facility must
provide written information that specifies the duration
of the bed-hold policy, to the resident and a family
member or legal representative, before transfer of a
resident to a hospital or allowing a resident to go on
therapeutic leave.

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F-206

Return to the Facility. The facility must establish and
follow a written policy under which a resident whose
hospitalization or therapeutic leave exceeds the bedhold period is readmitted to the facility.

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F-207

Equal Access to Quality Care. The facility must
establish and maintain identical policies and practices
regarding transfer, discharge, and the provision of
services for all individuals regardless of source of
payment.

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F-208

Admissions Policy. The facility must not require
residents or potential resident to waive their rights to
Medicare or Medicaid, nor require oral or written
assurance that residents or potential residents are not
eligible for, or will not apply for, Medicare or
Medicaid benefits.

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RESIDENT BEHAVIOR & FACILITY PRACTICE
F-221

Restraints (physical). The resident has the right to be
free from any physical restraints imposed for purposes
of discipline or convenience and not required to treat
the resident’s medical symptoms.

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F-222

Restraints (chemical). The resident has the right to be
free from any chemical restraints imposed for purposes
of discipline or convenience and not required to treat
the resident’s medical symptoms.

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5.10

F-223

Abuse. The resident has the right to be free from
verbal, sexual, physical, and mental abuse, corporal
punishment, and involuntary seclusion.

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F-224

Treatment of Residents & Their Property. The facility
must identify residents whose personal histories render
them at risk for abusing other residents, and
development of intervention strategies to prevent
occurrences, monitoring for changes that would trigger
abusive behavior, and reassessment of the interventions
on a regular basis.

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F-225

Employ Individuals Guilty of Abuse. The facility must
not employ individuals who have been found guilty of
abusing, neglecting or mistreating residents by a court
of law.

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F-226

Policy & Procedure on Abuse. The facility must
develop and implement policies and procedures that
include screening and training employees, protection of
residents and for the prevention, identification,
investigation, and reporting of abuse, neglect,
mistreatment and misappropriation of property.

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F-240

Quality of Life. The facility must care for its residents
in a manner and in an environment that promotes
maintenance or enhancement of each resident’s quality
of life.

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F-241

Dignity. The facility must promote care for residents in
a manner and in an environment that maintains or
enhances each resident’s dignity and respect in full
recognition of his or her individuality.

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F-242

Self-Determination/Participation. The resident has the
right to:
1. Choose activities, schedules, and health care
consistent with his/her interests, assessments and plans
of care;
2. Interact with members of the community both inside
and outside the facility;
3. Make choices about aspects of his/her life in the
facility that are significant to the resident.

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F-243

Participate in Resident/Family Groups. The resident
has the right to organize and participate in resident
groups and/or meet with the families of other residents.

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QUALITY OF LIFE

5.11

F-244

Resident/Family Recommendation. The facility must
listen to the views and act upon the grievances and
recommendations of resident and families concerning
proposed policy and operational decisions affecting
resident care and life in the facility.

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F-245

Participation in Other Activities. The resident has the
right to participate in social, religious, and community
activities that do not interfere with the rights of other
residents in the facility.

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F-246

Accommodations of Needs. The resident has the right
to reside and receive services in the facility with
reasonable accommodations of individual needs and
preferences, except when the health or safety of the
individual or other residents would be endangered.

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F-247

Notification of Room Changes. A resident has the
right to receive notice before the resident’s room or
roommate in the facility is changed.

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F248

Activities. The facility must provide for an ongoing
program of activities designed to meet, in accordance
with the comprehensive assessment, the interests and
the physical, mental, and psychosocial well-being of
each resident.

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F-249

Qualified Activity Professional. The activities program
must be directed by a qualified therapeutic recreation
specialist or an activities professional who is licensed,
registered or certified, if applicable, in the State where
practicing.

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F-250

Social Services. The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident.

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F-251

Full Time Social Worker. A facility with more than
120 beds will employ a qualified social worker on a
full time basis.
Qualifications of Social Worker: a bachelor’s degree in
social work or in a human services field, and one year
of supervised social work experience working directly
with individuals.

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5.12

F-252

Environment. The facility must provide a safe, clean,
comfortable and homelike environment, allowing the
resident to use his or her personal belongings,
including some furnishings and appropriate clothing, as
space permits, unless to do so would infringe upon the
rights or health and safety of other residents.

/

/

F-253

Housekeeping and Maintenance. The facility must
provide housekeeping and maintenance services
necessary to maintain a sanitary, orderly, and
comfortable interior.

/

/

F-254

Linens Clean and in Good Condition. The facility
must provide clean bed and bath linens that are in good
condition.

/

/

F-256

Lighting Levels. The facility must provide adequate
and comfortable lighting levels in all areas.

/

/

F-257

Comfortable Temperature. The facility must provide
comfortable and safe temperature levels maintaining a
temperature range of 71-81°F.

/

/

F-258

Comfortable Sound Levels. The facility must provide
for the maintenance of comfortable sound levels.

/

/

RESIDENT ASSESSMENT
F-271

Admission Orders. At the time each resident is
admitted, the facility must have physician orders for
the resident’s immediate care.

/

/

F-272

Comprehensive Assessments. The facility must
conduct initially and periodically a comprehensive,
accurate, standardized reproducible assessment of each
resident’s functional capacity.

/

/

F-273

Frequency of Assessments. The facility must conduct a
comprehensive assessment of a resident within 14
calendar days after admission, excluding readmissions
in which there is no significant change in the resident’s
physical or mental condition.

/

/

F-274

Significant Change. The facility should determine if
there has been a significant change (major decline or
improvement) in a resident’s status which requires
intervention, interdisciplinary review or revision of the
care plan.

/

/

5.13

F-275

Annual Assessments. The facility shall conduct a
resident assessment not less than once every 12
months.

/

/

F-276

Quarterly Review Assessments. The facility must
assess a resident not less frequently than once every 3
months.
(refer to F-279)

/

/

F-278

Accuracy/Coordination, RN Cert.
1. The facility must ensure that each resident receive an
assessment that accurately reflects the resident’s status. 2. A registered nurse must conduct or coordinate each
assessment with the appropriate participation of health
professionals.

/

/

F-279

Comprehensive Care Plans. The facility must develop
a comprehensive care plan for each resident that
includes measurable objectives and timetables to meet
a resident’s medical, nursing and mental and
psychosocial needs that are identified.

/

/

F-280

Care Plan Development. The resident has the right to
participate in planning his/her care and treatment or
changes in his/her care and treatment, unless adjudged
incompetent or otherwise found to be incapacitated
under the laws of the State.

/

/

F-281

Services Meet Professional Standards. The facility
must assure that services being provided meet
professional standards of quality and are provided by
appropriate qualified persons.

/

/

F-282

Services by Qualified Persons. The services provided
or arranged by the facility must be provided by
qualified persons in accordance with each resident’s
written plan of care.

/

/

F-283

Discharge Summary. The facility must have a
discharge summary that includes a recapitulation of the
resident’s stay, a final summary of the resident’s status at the time of discharge to ensure appropriate planning
and communication of necessary information to the
continuing care provider.

/

/

F-284

Post-Discharge Plan of Care. The facility will develop
a post-discharge plan of care, with the participation of
the resident and his/her family, which will assist the
resident in adjusting to his/her new living environment.

/

/

5.14

F-285

Pre-Admission Screening for Mental Illness. The
facility must coordinate assessments with the preadmission screening and resident review program to ensure that individuals with mental illness and mental
retardation receive the care and services they need in
the most appropriate setting.

/

/

F-286

MDS Data Storage & Maintenance. A facility must
maintain all resident assessments completed within the
previous 15 months in the resident’s active record.

/

/

F-287

Encoding & Transmitting. Within 7 days after a facility
completes a resident’s assessment, the facility must
encode and be capable of transmitting the appropriate
information for each resident in the facility, in the
specified format to the appropriate agency.

/

/

QUALITY OF CARE
F-309

Quality of Care. Each resident must receive and the
facility must provide the necessary care and services to
attain or maintain the highest practicable physical,
mental, and psychosocial well-being, in accordance
with the comprehensive assessment and plan of care.

/

/

F-310

ADL Abilities. The facility must ensure that a
resident’s abilities in activities of daily living do not
diminish unless circumstances of the individual’s
clinical condition demonstrate that diminution was
unavoidable. This includes the resident’s ability to:
1. Bathe, dress, groom;
2. Transfer and ambulate;
3. Toilet;
4. Eat; and
5. Use speech, language, or other functional
systems.

/

/

F-311

Appropriate Treatment & Services. The facility must
ensure that a resident is given appropriate treatment
and services to maintain or improve his or her ADL
abilities listed in F-310.

/

/

F-312

Care for ADL Dependent Residents. The facility must
ensure that a resident who is unable to carry out ADL
receives the necessary services to maintain good
nutrition, grooming, and personal and oral hygiene.

/

/

5.15

F-313

Vision & Hearing. The facility must ensure that
residents receive proper treatment and assistive devices
to maintain vision and hearing abilities by making
appointments and arranging transportation to the
offices of the appropriate professionals.

/

/

F-314

Pressure Sores. The facility must ensure that
1. A resident who enters the facility without pressure
sores does not develop pressure sores unless the
individual’s clinical condition demonstrates that they
were unavoidable.
2. A resident having pressure sores receives necessary
treatment and services to promote healing, prevent
infection and prevent new sores from developing.

/

/

F-315

Urinary Incontinence. The facility must ensure that a
resident who enters the facility without an indwelling
catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was
necessary and a resident that is incontinent of bladder
receives appropriate treatment and services to prevent
UTI’s and to restore as much bladder function as much
as possible.

/

/

F-317

Range of Motion Diminished. The facility must ensure
that a resident who enters the facility without a limited
range of motion does not experience reduction in range
of motion unless the resident’s clinical condition
demonstrates that a reduction in range of motion is
unavoidable.

/

/

F-318

Range of Motion Treatment and Services. The facility
must ensure that a resident with a limited range of
motion receives appropriate treatment and services to
increase range of motion and/or to prevent further
decrease in range of motion.

/

/

F-319

Mental & Psychosocial Functioning. The facility must
ensure that a resident who displays mental or
psychosocial adjustment difficulty receives appropriate
treatment and services to correct the assessed problem
and/or assist him/her in reaching and maintaining the
highest level of mental and psychosocial functioning.

/

/

5.16

F-320

Adjustment Difficulty. The facility must ensure that a
resident whose assessment did not reveal a mental or
psychosocial adjustment difficulty does not display a
pattern of decreased social interaction and/or increased
withdrawn, angry, or depressive behaviors, unless the
resident’s clinical condition demonstrates that such a
pattern is unavoidable.

/

/

F-321

Naso-Gastric Tubes. The facility must ensure that a
resident who has been able to eat enough alone or with
assistance is not fed by naso-gastric tube unless the
resident’s clinical condition demonstrates that the use
of a naso-gastric tube was unavoidable.

/

/

F-322

Services to Present Aspiration. The facility must
ensure that a resident who is fed by an N/G or G/T
receives the appropriate treatment and services to
prevent aspiration pneumonia, diarrhea, vomiting,
dehydration, metabolic abnormalities, and nasalpharyngeal ulcers and to restore, if possible, normal eating skills.

/

/

F-323

Accidents. The facility must ensure that the resident’s
environment remains as free of accident hazards as is
possible, and each resident receives adequate
supervision and assistance devices to prevent accidents.

/

/

F-325

Nutrition. The facility must ensure that:
1. A resident maintains acceptable parameters of
nutritional status, such as body weight and protein
levels, unless the resident’s clinical condition
demonstrates that this is not possible.
2. A resident receives a therapeutic diet when there is a
nutritional problem.

/

/

F-327

Hydration. The facility must provide each resident
with sufficient fluid intake to maintain proper
hydration and health.

/

/

5.17

F-328

Special Needs. The facility must ensure that residents
receive proper treatment and care for the following
special services:
1. Injections;
2. Parental and enteral fluids;
3. Colostomy, ureterostomy or ileostomy care;
4. Tracheostomy care;
5. Tracheal suctioning;
6. Respiratory care;
7. Foot care; and
8. Prostheses.

/

/

F-329

Unnecessary Drugs. Each resident’s drug regime must
be free from unnecessary drugs. Residents who use
antipsychotic drugs receive gradual dose reductions,
and behavioral interventions, unless clinically
contraindicated, in an effort to discontinue these drugs.

/

/

F-332

Medication Errors 5% or Greater. The facility must
ensure that it is free of medication error rates of five
percent or greater.

/

/

F-333

Significant/Non-Significant Med. Errors. The facility
must ensure that residents are free of any significant
medication errors.

/

/

F-334

Influenza & Pneumococcal Immunizations. The
facility must develop policies and procedures that
ensure the following:
1. Before offering the immunization, each resident or
the resident’s legal representative receives education
regarding the benefits and potential side effects of the
immunization;
2. Each resident is offered an immunization, unless the
immunization is medically contraindicated or the
resident has already been immunized;
3. The resident or the resident’s legal representative has the opportunity to refuse immunization;
4. The resident’s medical record includes
documentation that indicates, at the minimum, the
following:
a. that the resident or resident’s legal representative
was provided education regarding the benefits and
potential side effects of the immunization; and
b. that the resident either received the immunization
or did not receive the immunization due to medical
contraindications or refusal.

/

/

5.18

NURSING SERVICES
F-353

Nursing Services/Sufficient Staff. The facility must
have sufficient nursing staff to provide nursing and
related services to attain or maintain the highest
practicable physical, mental and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care.

/

/

F-354

Registered Nurse Hours.
1. The facility must use the services of a registered
nurse (except when waived) for at least 8 consecutive
hours a day, 7 days a week;
2. The facility must designate a registered nurse
(except when waived) to serve as the director of
nursing on a full time basis;
3. The director of nursing may serve as a charge nurse
only when the facility has an average daily occupancy
of 60 or fewer residents.

/

/

F-355

SNF Waiver for Licensed Nurse. The State may waive
certain requirements with respect to the facility if:
1. The facility demonstrates that despite diligent
efforts, the facility has been unable to recruit
appropriate personnel;
2. The State determines a waiver will not endanger the
health or safety of individuals staying in the facility;
3. The State finds, for any periods in which licensed
nursing services are not available, a registered nurse or
a physician is obligated to respond immediately to
telephone calls from the facility;
4. A waiver granted under the conditions listed in
paragraph (c) of this section is subject to annual State
review;
5. In granting or renewing a waiver, a facility may be
required by the State to use other qualified, licensed
personnel;
6. The State agency granting a waiver of such
requirements provides notice of the waiver to the State
long term care ombudsman, and the protection and
advocacy system in the State for the mentally ill and

/

/

mentally retarded; and
7. The nursing facility that is granted such a waiver by
a State notifies residents of the facility (or, where
appropriate, the guardians or legal representatives of
such residents) and members of their immediate
families of the waiver.

5.19

F-356

Posting Nursing Staff.
1. Data requirements: The facility must post the
following information on a daily basis:
a. Facility name;
b. Current date;
c. Total number and actual hours worked by the
following categories of licensed and unlicensed
nursing staff directly responsible for resident care per
shift:
- Registered nurses,
- Licensed practical nurses or licensed vocational
nurses.
- Certified nurse aides,
d. Resident census;
2. Posting requirements:
a. Facility must post the nurse staffing date specified
in paragraph (e)(1) of this section on a daily basis at
the beginning of each shift.
b. data must be posted as follows:
- Clear and readable format,
- In a prominent place readily accessible to
residents and visitors.
3. Public access to posted nurse staffing data.
4. Facility data retention requirements.

/

/

DIETARY SERVICES
F-360

Dietary Services. The facility must provide each
resident with a nourishing, palatable, well-balanced
diet that meets the daily nutritional and special dietary
needs of each resident.

/

/

F-361

Staffing. The facility must employ a qualified dietitian
either full-time, part-time, or on a consultant basis.

/

/

F-362

Sufficient Staff. The facility must employ sufficient
support personnel competent to carry out the functions
of the dietary service.

/

/

F-363

Menus and Nutritional Adequacy.
1. Meet the nutritional needs of resident in accordance
with the recommended dietary allowances of the Food
and Nutritional Board of the National Research
Council, National Academy of Sciences;
2. Be prepared in advance; and
3. Be followed.

/

/

5.20

F-364

Food. Each resident receives and the facility provides:
1. Food prepared by methods that conserve nutritive
value, flavor and appearance;
2. Food that is palatable, attractive, and at the proper
temperature.

/

/

F-365

Food Meets Individual Needs. Each resident receives
and the facility provides food prepared in a form
designed to meet individual needs.

/

/

F-366

Substitutes Offered. Each resident receives and the
facility provides substitutes offered of similar nutritive
value to residents who refuse food served.

/

/

F-367

Therapeutic Diets. Therapeutic diets must be
prescribed by the attending physician.

/

/

F-368

Frequency of Meals.
1. Each resident receives and the facility provides at
least three meals daily, at regular times comparable to
normal mealtimes in the community.
2. There must be no more than 14 hours between a
substantial evening meal and breakfast the following
day, except as provided in (4) below.
3. The facility must offer snacks at bedtime daily.
4. When a nourishing snack is provided at bedtime, up
to 16 hours may elapse between a substantial evening
meal and breakfast the following day if a resident
group agrees to this meal span, and a nourishing snack
is served.

/

/

F-369

Assistive Devices. The facility must provide special
eating equipment and utensils for residents who need
them.

/

/

F-371

Sanitary Conditions. The facility must store, prepare,
distribute, and serve food under sanitary conditions.

/

/

F-372

Dispose of Garbage & Refuse Properly. The facility
must dispose of garbage and refuse properly.

/

/

5.21

F-373

Paid Feeding Assistants. (Michigan does not have this
program)
1. A facility may use a paid feeding assistant if the
assistant has successfully completed a State-approved
training course.
2. The feeding assistant must work under the
supervision of a registered nurse.
3. A facility must ensure the feeding assistant feeds
only residents who have no complicated feeding
problems.

/

/

PHYSICIAN SERVICES
F-385

Physician Services/Supervision. A physician must
personally approve in writing a recommendation that
an individual be admitted to a facility. Each resident
must remain under the care of a physician.

/

/

F-386

Physician Visits. The physician must:
1. Review the resident’s total program of care,
including medications and treatments at each visit.
2. Write, sign, and date progress notes at each visit.
3. Sign and date all orders with the exception of
influenza and pneumococcal polysaccharide vaccines,
which may be administered per physician-approved
facility policy after an assessment for
contraindications.

/

/

F-387

Frequency of Physician Visits.
1. The residents must be seen by a physician at least
once very 30 days for the first 90 days after admission,
and at least once every 60 thereafter.
2. A physician visit is considered timely if it occurs not
later than 10 days after the date the visit was required.

/

/

F-388

Visits by Physician Exception.
1. All required physician visits must be made by the
physician personally.
2. At the option of the physician, required visits in
SNFs, after the initial visit, may alternate between
personal visits by the physician and visits by a
physician assistant, nurse practitioner or clinical nurse
specialist.

/

/

F-389

Physician Available for Emergency Use. The facility
must provide or arrange for the provision of physician
services 24 hours a day, in case of emergency.

/

/

5.22

F-390

Doctor Delegation of Tasks Performed in SNF/NF.
1. A physician may delegate tasks to a physician
assistant, nurse practitioner, or clinical nurse specialist. 2. A physician may not delegate a task when the
regulations specify that the physician must perform it
personally or when the delegation is prohibited under
State law or by the facility’s own policies.

/

/

F-406

Provision of Services. The facility must provide or
obtain the required services from an outside source if
specialized rehab services, such as but not limited to,
PT, ST, OT or mental health rehab for mental illness or
mental retardation are required in the resident’s
comprehensive care plan.

/

/

F-407

Qualifications. Specialized rehabilitative services must
be provided under the written order of a physician by
qualified personnel.

/

/

SPECIALIZED REHABILITATION SERVICES

DENTAL
F-411

Skilled Nursing Facilities Dental Services. The facility
must provide or obtain from an outside resource,
routine and emergency dental services to meet the
needs of each resident.

/

/

F-412

Nursing Facilities Dental Services. The facility must:
1. Provide or obtain from an outside resource the
following dental services to meet the needs of each
resident:
a. Routine dental services
b. Emergency dental services
2. If necessary, assist the resident with making
appointments and/or arranging transportation.
3. Must promptly refer residents with lost or damaged
dentures to a dentist.

/

/

5.23

PHARMACY
F-425

Pharmacy Services/Procedures.
The facility must provide
1. Routine and emergency drugs and biologicals to its
residents, or obtain them under an agreement.
2. Permit unlicensed personnel to administer drugs if
State law permits, but only under the general
supervision of a licensed nurse.
3. Provide pharmaceutical services (including
procedures that assure the accurate acquiring,
receiving, dispensing and administering of all drugs
and biologicals) to meet the needs of each resident.
4. Must employ or obtain the services of a licensed
pharmacist who provides consultation on all aspects of
the provision of pharmacy services in the facility.

/

/

F-428

Drug Regimen Review.
1. The drug regimen must be reviewed at least once a
month by a licensed pharmacist.
2. The pharmacist must report any irregularities to the
attending physician, and the director of nursing and
these reports must be acted upon.

/

/

F-431

Control, Labeling and Storage of Drugs. The facility
must:
1. Employ or obtain services of a licensed pharmacist
who establishes a system of records in order to
maintain and reconcile the disposition of all controlled
drugs.
2. Drugs and biologicals used in the facility must be
labeled in accordance with currently accepted
professional principles, include the appropriate
accessory and cautionary instructions and expiration
date when applicable, and be stored in accordance with
State and Federal laws.

/

/

/

/

INFECTION CONTROL
F-441

Infection Control.
The facility must establish and maintain an infection
control program designed to provide a safe, sanitary,
and comfortable environment and to help prevent the
development and transmission of disease and infection.

5.24

PHYSICAL ENVIRONMENT
F-454

Physical Environment. The facility must be designed,
constructed, equipped, and maintained to protect the
health and safety of residents, personnel and the public.

/

/

F-455

Emergency Power, Space & Equipment. The facility
must have:
1. An emergency electrical power system adequate for
lighting, maintaining the fire, alarm, extinguishing
systems and life support systems.
2. Provide sufficient space and equipment to enable
staff to provide residents with needed services as
required and identified in each resident’s plan of care.
(refer to F-246)

/

/

F-456

Patient Care Equipment is Safe/Resident Rooms. The
facility must maintain all essential mechanical,
electrical, and patient care equipment in safe operating
condition. (refer to F-252)

/

/

F-457

Bedroom Accommodations. Resident rooms must be
designed and equipped for adequate nursing care,
comfort and privacy of residents.

/

/

F-458

Square Footage/Room. Rooms must measure at least
80 square feet per resident in multiple resident
bedrooms, and at least 100 square feet in single
resident rooms.

/

/

F-459

Direct Access to Exit. Resident rooms must have
direct access to an exit corridor.

/

/

F-460

Full Visual Privacy. Bedrooms must be designed or
equipped to assure full visual privacy for each resident.

/

/

F-461

Room with Window/Floor at Grade Level. Resident
rooms must have at least one window to the outside
and have a floor at or above grade level.

/

/

F-462

Toilet Facilities. Each resident room must be equipped
with or located near toilet facilities.

/

/

F-463

Resident Call System. The nurses’ station must be
equipped to receive resident calls through a
communication system from resident rooms and toilet
and bathing facilities.

/

/

5.25

F-464

Dining & Resident Activities. The facility must
provide one or more rooms designated for resident
dining and activities that are well lighted, well
ventilated, adequately furnished and have sufficient
space to accommodate all activities.

/

/

F-465

Other Environmental Conditions. The facility must
provide a safe, functional, sanitary, and comfortable
environment for residents, staff and the public.

/

/

F-466

Available Water Supply. The facility must establish
procedures to ensure that water is available to essential
areas when there is a loss of normal water supply.

/

/

F-467

Outside Ventilation. The facility must ensure there is
adequate outside ventilation by means of windows,
mechanical ventilation, or a combination of the two.

/

/

F-468

Handrails. The facility must ensure corridors are
equipped with firmly secured handrails on each side.

/

/

F-469

Pest Control Program. The facility must maintain an
effective pest control program so that the facility is free
of pests and rodents.

/

/

ADMINISTRATION
F-490

Administration. The facility must be administered in a
manner that enables it to use its resources effectively
and efficiently to attain or maintain the highest
practicable physical, mental, and psychosocial wellbeing of each resident.

/

/

F-491

Licensure. The facility must be licensed under
applicable State and local law.

/

/

F-492

Federal, State & Local Laws. The facility must operate
and provide services in compliance with all applicable
Federal, State, and local laws, regulations, and codes,
and with accepted professional standards and principles
that apply to professionals providing services in such a
facility.

/

/

F-493

Governing Body. The facility must have a governing
body that is legally responsible for establishing and
implementing policies regarding the management and
operation of the facility; and appointing the
administrator who is licensed by the State (where
required) and responsible for the management of the
facility.

/

/

5.26

F-494

Required Training NA. The facility must not use any
individual working in a facility as a nurse aide for more
than 4 months, on a full-time basis, unless that
individual has completed a training and competency
evaluation program or is deemed competent.

/

/

F-495

Competency. The facility must not use any individual
who has worked less than 4 months as a nurse aide in
that facility unless the individual:
1. Is a full-time employee in a State-approved training
and competency evaluation program;
2. Has demonstrated competence through satisfactory
participation in a State-approved nurse aide training
and competency evaluation program or competency
evaluation program; or
3. Has been deemed competent.

/

/

F-496

Registry Verification/Retraining.
1. The facility must receive registry verification that
the individual has met competency evaluation
requirements before allowing an individual to serve as
a nurse aide.
2. If 24 months have passed since an individual’s most
recent completion of a training and competency
evaluation program and paid nursing or nursing-related
services, the individual must complete a new training
and competency evaluation program.

/

/

F-497

Regular In-Service Education. The facility must
complete a performance review on every nurse aide at
least once every 12 months and provide regular inservice education based on the outcome of these reviews.

/

/

F-498

Nurse Aide Proficiency. The facility must ensure that
nurse aides are able to demonstrate competency in
skills and techniques necessary to care for residents’
needs, as identified through resident assessments and
described in the plan of care.

/

/

F-499

Staff Qualifications. The facility must employ on a
full-time, part time or consultant basis , professionals
who are licensed, certified, or registered in accordance
with applicable State laws, and necessary to carry out
all requirements.

/

/

5.27

F-500

Use of Outside Resources. The facility must provide
services to residents by a person or agency outside the
facility if the facility does not employ a qualified
professional person to furnish a specific service.

/

/

F-501

Medical Doctor. The facility must designate a
physician to serve as medical director.

/

/

F-502

Laboratory Services. The facility must provide or
obtain lab services to meet the needs of its residents.
The facility is responsible for quality and timeliness of
the lab services.

/

/

F-503

Laboratory Requirements. If the facility provides its
own laboratory services, the services must meet the
applicable requirements for laboratories.

/

/

F-504

Physician Ordered Lab Services. The facility must
provide or obtain laboratory services only when
ordered by the attending physician.

/

/

F-505

Promptly Notify Doctor of Findings. The facility must
promptly notify the attending physician of the findings.

/

/

F-506

Transportation To/From. The facility must assist the
resident in making transportation arrangements to and
from the source of service, if needed.

/

/

F-507

Lab Reports in Resident File. The facility will file in
the resident’s clinical record, laboratory reports that are dated and contain the name and address of the testing
laboratory.

/

/

F-508

Radiology & Diagnostic Services Meets Resident
Needs. The facility must provide or obtain radiology
and other diagnostic services to meet the needs of its
residents. The facility is responsible for the quality and
timeliness of the services.

/

/

F-509

Radiology & Diagnostic Requirements. If the facility
provides its own diagnostic services, the services must
meet the applicable conditions of participation for
hospitals.

/

/

F-510

MD Ordered Radiology Services. The facility must
provide or obtain radiology and other diagnostic
services only when ordered by the attending physician.

/

/

F-511

Promptly Notify Doctor of Findings. The facility must
promptly notify the attending physician of the findings.

/

/

5.28

F-512

Transportation To/From. The facility must assist the
resident in making transportation arrangements to and
from the source of service, if needed.

/

/

F-513

X-Ray Reports in Resident File. The facility will file
in the resident’s clinical record, signed and dated
reports of x-rays and other diagnostic services.

/

/

F-514

Clinical Records. The facility must maintain clinical
records on each resident in accordance with accepted
professional standards and practices that are:
1. Complete;
2. Accurately documented;
3. Readily accessible; and
4. Systematically organized.

/

/

F-515

Retention of Clinical Records. The facility must retain
clinical records for:
1. The period of time required by State law; or
2. Five years from the date of discharge when there is
no requirement in State law; or
3. For a minor, three years after a resident reaches legal
age under State law.

/

/

F-516

Safeguard Clinical Records. The facility must
safeguard clinical record information against loss,
destruction, or unauthorized use.

/

/

F-517

Disaster & Emergency. The facility must have detailed
written plans and procedures to meet all potential
emergencies and disasters, such as fire, severe weather,
and missing residents.

/

/

F-518

Training for Emergency. The facility must train all
employees in emergency procedures when they begin
to work in the facility and periodically review the
procedures with existing staff.

/

/

F-519

Transfer Agreement. The facility must have in effect a
written transfer agreement with one or more hospitals
approved for participation under the Medicare and
Medicaid programs, that reasonably assures timely
admission to the hospital when transfer is medically
appropriate.

/

/

5.29

F-520

Quality Assessment & Assurance. The facility must
maintain a quality assessment and assurance committee
consisting of designated key members that identify
quality deficiencies, develops and implements plans of
action to correct these quality deficiencies, including
monitoring the effect of implemented changes and
making needed revisions to the action plans.

/

/

F-522

Disclosure of Ownership. The facility must comply
with disclosure requirements by providing written
notice to the State agency responsible for licensing the
facility at the time of change, if a changes occurs in:
1. Persons with an ownership or control interest.
2. The officers, directors, agents, or managing
employees.
3. The corporation, association, or other company
responsible for the management of the facility.
4. The facility’s administrator or director of nursing.
5. Notice must include the identity of each new
individual or company.

/

/

5.30

QUALITY INDICATOR REPORT RESULTS
QI/QM PROFILE RESULTS
A. SENTINEL EVENT
Fecal Impaction
Dehydration
Pressure Ulcers, Low Risk
B. Flagged 90th percentile

SPECIFIC QI/QM

RESIDENTS APPLIED TO

1. Prevalence of Fecal Impaction:
2. Prevalence of Dehydration:
3. Prevalence of Pressure Ulcers, Low
Risk
1.
2.
3.
4.

th

C. Unflagged 75 percentile

5.
1.
2.
3.
4.
5.

D. Concerns

1.
2.
3.
4.
5.

Pre-select residents for the Phase 1 sample to represent the concerns that have been selected, including selecting residents who have sentinel event QI conditions (if multiple residents have a sentinel event QI condition it is not necessary to select them all).

5.31

Process – Survey Tasks
Survey Task
One:
Survey Preparation

Responsible

Team

Action Item
Review QI Profile, Facility Characteristics Report, OSCAR Data, Survey History of facility

Reference
Survey Manual: Appendix P
Pages P-5 to P-11

Phase One – Sample selection from 6 month QI Profile and Resident Level QI Summary. Select one half of sample size that Table 1 (p-23) would indicate.

Before FQR

Pre-identify any possible focus areas (flagged indicators, sentinel events, above th
75 )
Make copies of all Exhibit Worksheets
Two:
Entrance
Conference

Team

Conduct entrance conference with Administrator and Department Heads. Request materials (Survey Readiness Book).
Identify facility personnel to assist with tour.

Day One

Survey Manual: Appendix P
Pages P-11 to P-15
CMS-805 Resident Review Worksheet CMS-803
General Observation of Facility First
Impressions Checklist

Three:
Initial Tour

Team

possible other residents to add to the Phase One sample.

Day One
Four:
Sample Selection

Validate that residents pre-selected in Task One are still present. Identify

Survey Manual: Appendix P
Pages P17 to P-23

Identify other issues that may require investigation (i.e. restraint use, hydration, grooming, elopements, reportable events, falls)
Team

Finalize Phase One sample. Pull records and begin comprehensive/focused reviews.

Survey Manual: Appendix P
Pages P-17 to P-23

Team

Discuss focused areas based on results of comprehensive reviews and day one observations.

Survey Manual, Pages P-7 to P-21
CMS-805 Resident Review Worksheet

Day One
Day Two
Morning

Select Phase Two Sample. Conduct focused reviews.
Complete focused reviews (if not completed on day one)

5.32

Process – Survey Tasks
Survey Task
Four: (continued)
Day Two
Morning

Responsible
Nursing Team

Action Item
Observe Medication Pass

Observe Treatments

Reference
Task 5-E Medication Pass, Pages P-59 to P60
CMS-677 Medication Pass Worksheet
Treatment Observation Sheet

Adm

Review Facility quality Assurance Program

Task 5-F LTC Manual

Determine if committee has method to identify, respond and evaluate identified problems.

Wandering and At
Risk for Elopement Policies

Review 3 months minutes/Actions Plans and Follow-Up.
Interview 1 CNA, 1 Nurse and 1 Department Head regarding QA Program knowledge
Adm

Conduct Resident Group Interviews. Review

Safety Committee
Meeting Minutes
CMS-806B Group Interview

Activity and Grievance programs.
Adm

Resident Trust Fund – Internal Audit Criteria
Facility Petty Cash – Internal Audit Criteria

Five:
Information
Gathering

Team

Conduct comprehensive reviews. Record any concerns on Exhibit Worksheets. Begin focused reviews. Record any concerns on Exhibit Worksheet

Survey Manual, Exhibit 93, Pages 1-4
Survey Manual, Exhibit 95

Day One
All Day

Team

Kitchen Observation

CMS-804 Kitchen/Food Observation

12:00 noon
Team lunch to
review morning
findings

Meal Observation
Focused Review: Weight Loss/Hydration

5.33

Process – Survey Tasks
Survey Task
Five: (continued)
End of Day
Team conference to
review findings to
plan Day Two

Responsible
Team

Action Item
Conduct Individual resident Interviews x 2

Reference

CMS-806A Resident Interview

Observe non-interviewable resident x 2
Mean Observation

CMS-806A Observation of noninterviewable resident

Environment Review
Abuse Prevention
Review smokers for Smoking Standard Compliance
Review the criteria in the RCC Addendum, if applicable

CMS-806C Family Interview
CMS-803 General Observations of
facility
Smoking Policy

Six:
Determine
Deficiencies
Day Two Afternoon
Seven:
Exit Conference

Team

Decide which F-Tags and Standards are not in place.

Team

Review Findings with facility team.

Day Two Afternoon

5.34

MEAL MONITOR ASSIGNMENT AND TIMES

Date:

Breakfast:
Person assigned to Main Dining Room:
Person assigned to Hall Trays:
Person assigned to Other Dining Room
Specify exactly where:
Person assigned to Other Dining Room
Specify exactly where:
Person assigned to Other Dining Room
Specify exactly where:

Time:_____________
_

Time:_____________
Time:
Time:
Time:

Lunch:
Person assigned to Main Dining Room:

Time:_____________

Person assigned to Hall Trays:

Time:_____________

Person assigned to Other Dining Room
Specify exactly where:
Person assigned to Other Dining Room
Specify exactly where:
Person assigned to Other Dining Room
Specify exactly where:

Time:
Time:
Time:

Dinner:
Person assigned to Main Dining Room:

Time:_____________

Person assigned to Hall Trays:

Time:_____________

Person assigned to Other Dining Room
Specify exactly where:
Person assigned to Other Dining Room
Specify exactly where:
Person assigned to Other Dining Room
Specify exactly where:

Time:
Time:
Time:

5.35

MOCK SURVEY ASSIGNMENTS
Prior to Mock:
Complete Survey History (OSCAR):
Ready upon entrance:
Complete and gather all survey preparation documentation:
Within 1 hour of entrance:
Complete CMS 802 form (Roster Sample Matrix)
Within 24 hours of entrance:
Complete CMS 672 form (Resident Census & Condition)
Upon arrival of Mock Team:
Print out QI/QM for last 6 months:
First 4 hours of survey:
Review the Quality Indicators and choose a sample group.
Team Leader:
Entrance Conference:
Exit Conference:
Activities:
Date & Time of Resident Council:
Administration:
Environment:
Nursing:
Med Pass:
Treatments:
Dietary:
Social Services;
Mock Summary Form Completion:
5.36

SURVEY SCOPE & SEVERITY GRID
Appendix B
Table 1: Deficiency and CMS Remedy Table
Scope of the Deficiency
Severity of the
Deficiency

Isolated

Pattern

Widespread

Immediate
jeopardy to
resident health or
safety

J PoC Required:
Cat. 3 Optional:
Cat. 1 Optional:
Cat. 2

K poC Required:
Cat. 3 Optional:
Cat. 1 Optional:
Cat. 2

L PoC Required:
Cat. 3 Optional:
Cat. 2 Optional:
Cat. 1

Actual harm that is
not immediate

G PoC Required*
Cat. 2 Optional:
Cat. 1

H PoC Required*
Cat. 2 Optional:
Cat. 1

I PoC Required*
Cat. 2 Optional:
Cat. 1 Optional:
Temporary Mgmt.

No actual harm
with potential for
more than
minimal harm that
is not immediate
jeopardy

D PoC Required*
Cat. 1 Optional:
Cat. 2

E PoC Required*
Cat. 1 Optional:
Cat. 2

F PoC Required*
Cat. 2 Optional:
Cat. 1

No actual harm
with potential for
minimal harm

A No PoC No
remedies
Commitment to
Correct

B PoC

C PoC

Source: State Operations Manual. February 25, 2004.
http://www.cms.hhs.gov/manuals/pub07pdf/pub07pdf.asp

Table Notes: *Required only when a decision is made to impose alternate remedies instead of or in addition to termination. Deficiencies in F, H, I, J, K and L categories are considered substandard quality of care (darker shade). Deficiencies in A, B and C are considered substantial compliance (lighter shade). PoC refers to a plan of correction (a plan by the facility for correcting the deficiency).

5.37

There are three remedy categories referred to on the table (Cat. 1, Cat. 2, Cat. 3). These categories as associated with the following penalties:

Category 1 (Cat.1)

Category 2 (Cat.2)

Category 3 (Cat.3)

Directed Plan of Correction
State Monitor; and/or
Directed In-Service
Training

Denial of Payment for New
Admissions Denial of Payment for All
Individuals Imposed by CMS; and/or
Civil Money Penalties: Up to $3,000
per day $1,000 - $10,000 per instance

Temp. Mgmt. Termination
Optional: Civil Money
Penalties 3,050-$10,000 per
day $1,000 - $10,000 per
instance

Denial of payment for new admissions must be imposed when a facility is not in substantial compliance within 3 months after being found out of compliance. Denial of payment and State monitoring must be imposed when a facility has been found to have provided substandard quality of care on three consecutive standard surveys. NOTE: Termination may be imposed by the State or CMS at any time.

5.38

DEPARTMENT OF HEALTH AND HUMAN
SERVICES CENTERS FOR MEDICARE &
MEDICAID SERVICES

RESIDENT REVIEW WORKSHEET
Facility Name:

Provider
Resident
Number:
Name:
Resident Identifier:

Surveyor Name:
Surveyor Number:

Birthdate:
Discipline:

Unit:

Orig. Admission Date:

Rm #:
Readmission

Date: Survey Date:
Payment Source: Admission:
Current:
Interviewable:
Yes
No
Type of Review:
Comprehensive
Focused
Selected for Individual Interview:
Yes
No
Selected for Family Interview and Observation of Non-Interviewable Resident: Yes
Focus/Care Areas:

Closed Record
No
__
__

Instructions: Any regulatory areas related to the sampled resident’s needs are to be included in this review. • Initial that each section was reviewed if there are no concerns. • If there are concerns, document your investigation.

• Document all pertinent resident observations and information from resident, staff, family interviews and record reviews for every resident in the sample.
SECTION A: RESIDENT ROOM REVIEW: Evaluate if appropriate requirements are met in each of the following areas, including the accommodation of needs:


Adequate accommodations are made for resident
privacy, including bed curtains.



Call bells are functioning and accessible to residents



Resident is able to use his/her bathroom without difficulty.



Adequate space exists for providing care to residents.

• Resident with physical limitations (e.g., walker,
wheelchair)
is able to move around his/her room.



Environment is homelike, comfortable and attractive;
accommodations are made for resident personal items
and his/her modifications.



Bedding, bath linens and closet space is adequate
for resident needs.



Resident care equipment is clean and in good repair.



Room is safe and comfortable in the following areas:
temperature, water temperature, sound level and lighting.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on Surveyor Notes sheet page 4. SECTION B: RESIDENT DAILY LIFE REVIEW: Evaluate if appropriate requirements are met in each of the following areas: • Resident appears well groomed and reasonably

attractive
(e.g., clean clothes, neat hair, free from facial hair).


Staff treats residents respectfully and listens to resident
requests. Note staff interaction with both
communicative and non-communicative residents.



Staff is responsive to resident requests and call bells.



Residents are free from unexplained physical injuries
and there are no signs of resident abuse. (e.g. residents
do not appear frightened around certain staff members.)



Facility activities program meets resident’s
individually assessed needs and preferences.



Medically related social services are identified and
provided when appropriate.



Restraints are used only when medically necessary.
(see 483.13(a))



Resident is assisted with dining when necessary.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on Surveyor Notes sheet page 4. Form CMS-805 (07/95)

5.39

RESIDENT REVIEW WORKSHEET
(continued)
SECTION C: ASSESSMENT OF DRUG THERAPIES
Review all the over-the-counter and prescribed medications taken by the resident during the last 7 days. •

Evaluate drug therapy for indications/reason, side
effects, dose, review of therapy/monitoring, and
evidence of unnecessary medications including
antipsychotic drugs.



If you note concerns with drug therapy, review the
pharmacist’s report. See if the physician or facility
has responded to recommendations or concerns.

• Correlate drug therapy with resident’s clinical
condition.
THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Medications/Dose/Schedule

Medications/Dose/Schedule

Medications/Dose/Schedule

Document concerns and follow-up on page 4.
SECTION D: RAI/CARE REVIEW SHEET (Includes both MDS and use of RAPS): Reason for the most current RAI:
Date of Most Recent RAI

Annual

Initial

Significant Change

Date of Comparison/Quarterly RAI



For a comprehensive review complete a review of all care areas specific to the resident, all ADL functional areas, cognitive status, and MDS categories triggering a RAP.



For a focused review:
Phase I: Complete a review of those requirements appropriate to focus and care areas specific to the resident. Phase II: Complete a review of requirements appropriate to focus areas.



For both comprehensive and focused reviews record only the applicable sections and relevant factors about the clinical status indicating an impairment or changes between reviews.



If the current RAI is less than 9 months old, scan and compare with the previous RAI and most recent quarterly review.



If the RAI is 9 months or older, compare the current RAI with the most recent quarterly review.



Note any differences for the applicable areas being reviewed.



Review the RAP summary and care planning.



Look for implementation of the care plan as appropriate to the comprehensive or focused review.



Note specifically the effects of care or lack of care.



If the resident declined or failed to improve relative to expectations, determine if this was avoidable or unavoidable.



For closed records, complete a review of the applicable areas of concern.



Use the additional MDS item blocks on page 3 to document other sections or additional concerns.



Dining observation; If there are concerns with weight loss or other nutritional issues, observe resident dining and review adequacy of meals served and menus..

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on page 4.

5.40

RESIDENT REVIEW WORKSHEET
(continued)
Care

MDS Items

RAI
Status/Comparison

Plan
Y/N

Notes/Dates/Times/Source and Tag: Observations and Interview for resident and implementation of care plan and TX, including accuracy, completeness, and how information from use of RAPs is incorporated into the resident's care. Outcome: improve/failure to improve/same/decline. If a decline or failure to improve occurred, was it avoidable or unavoidable?

Cognitive/
Decisionmaking
Mood/Behavior/
Psychosocial
Transfer

Ambulation

Dressing

Eating

Hygiene/ Bathing

ROM Limits

Bowel

Bladder

Activities

5.41

RESIDENT REVIEW WORKSHEET
(continued)
Tag/Concerns

Source*

Surveyor Notes (including date/time)

*Source: O=Observat1on, RR=Record Rev1ew, l=lnterv1ew

5.42

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

GENERAL OBSERVATIONS OF THE FACILITY
Facility Name:

Surveyor Name:

Provider Number:

Surveyor Number:

Observation Dates: From

Discipline:

To

Instructions: Use the questions below to focus your observations of the facility. Include all locations used by residents (units, hallways, dining rooms, lounges, activity and therapy rooms, bathing areas, and resident smoking areas). Also check other areas that affect the residents, such as storage and utility areas. Initial that there are no concerns or note concerns and your follow-up in the space provided. Begin your observations as soon as possible after entering the facility and continue throughout the survey. Note, these tags are not all inclusive.

LIST ANY POTENTIAL CONCERNS FROM OFFSITE SURVEY PREPARATION. 1. HANDRAILS: Do corridors have handrails? Are handrails affixed to walls, intact, and free of splinters? (F468) 2. ODORS: Is the facility free of objectionable odors? Are resident areas well ventilated? Especially observe activity areas and the dining room during activities and lunch, when the residents are using them. Are nonsmoking areas smoke free? Do smoking areas provide good quality of life for residents who smoke? (F252) 3. CLEANLINESS: How clean is the environment (walls, floors, drapes, furniture)? (F252) 4. PESTS: Is the facility pest free? (F469)

5. LINEN: Is the linen processed, transported, stored and handled properly to prevent the spread of infection? (F445) 6. HAZARDS: Is the facility as free of accident hazards as possible? Are water temperatures safe and comfortable? Are housekeeping/hazards, compounds, and other chemicals stored to prevent resident access? (F252, 323) 7. CALL SYSTEM: Is there a functioning call system in bathing areas and resident toilets in common areas? (F463) 8. SPACE: Do the space and furnishings in dining and activity areas appear sufficient to accommodate all activities? (F464) 9. FURNISHINGS: Are dining and activity rooms adequately furnished? (F464) 10. DRUG STORAGE: Are drugs and biologicals stored properly (locked and at appropriate temperatures)? (F432) 11. EQUIPMENT: Is the resident equipment in common areas sanitary, orderly, and in good repair? (Equipment in therapy rooms, bathing rooms, activity areas, etc.) Are equipment and supplies appropriately stored and handled in clean and dirty utility areas (sterile supplies, thermometer, etc.)? (F253)

12. EQUIPMENT CONDITION: [Excluding the kitchen] Is essential equipment in safe and effective operating condition (e.g. boiler room equipment, nursing unit/medication room equipment, unit refrigerators, laundry equipment, therapy equipment)? (F456)

13. SURVEY POSTED: Are survey results readily accessible to residents? Are the survey results or a notice concerning survey results posted? (F167)
14. INFORMATION POSTED: Is information about Medicare, Medicaid and contacting advocacy agencies posted? (Fl56) 15. POSlTlONING: Is correct posture and comfortable positioning and assistance being provided to residents who need assistance — especially check residents who are dining or participating in activities? (F246, 311, 318) 16. EMERGENCY: Are staff prepared for an emergency or disaster? Ask two staff and a charge nurse to describe what they do in emergencies (include staff from different shifts). Evaluate the responses to determine their correctness and preparedness. (F518) 17. EMERGENCY POWER: Is there emergency power? Are staff aware of outlets, if any, powered by emergency source? (F455) 18. WASTE: Is waste contained in properly maintained (no breaks) cans, dumpsters or compactors with covers? (F454, 371) THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on back of page: Form CMS-803 (7-95)

5.43

GENERAL OBSERVATIONS OF THE FACILITY
Tag I Concerns

Source *

Surveyor Notes (including date/time)

*Source. 0= Observation, RR=Record Review, I=- Interv1ew
Form C::\IS-803 (7-95)

5.44

FIRST IMPRESSIONS CHECKLIST
Item to be Inspected

Met

Not
met

Corrective Action

Date
corrected

Facility signage visible, well lit, clean, sturdy and in good repair. Parking lot is clean, striped and well lit.
Handicap stall is present and clearly marked with signage.
Lawn /grounds are well kept, neat in appearance and wellmanicured without trash or clutter. Shrubbery is trimmed and flowerbeds weeded.
Lawn furniture is clean, in good repair and adequate.
Lawn hoses are stored and do not pose a tripping hazard.
Entrance landscaped seasonally. Out of season decorations removed timely. Outside potted plants alive & well groomed.
Entrances clean, well lit and without clutter.
Front door clean, in good repair with weather stripping secure. Sidewalk poses no tripping hazards and is in good repair.
Receptacle for cigarettes available at entrance and is emptied regularly.
Lobby neatly organized, lighting appropriate (all bulbs working), low noise levels (including overhead paging).
Greeted upon entrance by a staff member.
Inside “potted” plants alive / well groomed.
Staff members appropriately dressed with name badge.
Visible office spaces neatly organized and clutter free.
All areas odor free.
Public restrooms clean and comfortable.
Public posting information is well organized and easily accessible (i.e., State Survey Results, other required info by law).
Facility has a feel of comfort and is not institutional.
Hallways are free of obstruction.
Dining areas are clean, neat and offer a home like appeal.
Resident smoking area clean of cigarette butts and other trash. Available ashtrays and trash cans cleaned/dumped at least daily if not more often. Patio furniture clean, good repair and adequate. Patio poses no tripping hazards and is in good repair.

Staff smoking area clean of cigarette butts and other trash. Available ashtrays and trash cans cleaned/dumped at least daily if not more often.
Area around dumpsters are clean and clutter free. Lids on
dumpsters are closed.
Laundry and Dietary outside areas clean and uncluttered.
Surrounding area outside storage buildings clean and uncluttered. Gutters and down spouts securely attached and function properly. Siding/brick is in good repair, not chipped, cracked or broken nor is paint chipped.

Window panes are in good condition without chipped paint and no broken windows.
Window screens are clean, not torn and in good repair.

5.45

DEPARTMENT OF HEALTH AND HUMAN
SERVICES CENTERS FOR MEDICARE &
MEDICAID SERVICES

SURVEYOR NOTES WORKSHEET
Facility Name:

Surveyor
ProviderName:
Number:
Surveyor Number:

Observation Dates: From ---------

TAG/CONCERNS

Discipline:

To ------

DOCUMENTATION

Form CMS-807 (7/95)

5.46

ADMINISTRATION CHECKLIST
Area
Past survey reports displayed
Medicare/Medicaid benefit information displayed
Resident Trust Fund Balanced
Surety Bond equals one and one half times the total amount of the average resident fund balance
Ombudsman information posted
Private access to a telephone available for residents
Administrator licensure current
Contract book current
Safety Committee meetings held regularly
Disclosure of ownership
Bed Reconciliation form
Waiver(s) available if applicable
Daily Nursing staffing posted and current

Yes

No

Comments

5.47

CONTRACT BOOK CHECKLIST
Contract
Activities Consultant
Audiologist
Background Check
Barber/Beauty
Biohazardous Waste
Blood Products
Cable TV
CLIA Waiver
Dentist
Dialysis (all providers)
Electrical
E.T. Nurse (Wound Nurse)
Facility Insurance
Fire Alarm P/M
Hospice (all providers)
Laboratory
Landscaping
Medical Director
Medical Records Consultant
Mobile x-ray
Modified Barium Study
Nursing Agency (supplemental staffing)
Optometrist
Oxygen
Pest Control
Pharmacy
Pharmacy Consultant
Podiatrist
Psychiatrist
Psychologist
RT Agreement
Radon Testing
Dietitian Consultant
Social Services Consultant
Sprinkler System P/M
Surety Bond
Therapy PT
Therapy OT
Therapy SLP
Therapy RT
Transfer Agreement
Utilization Review

License Insurance

N/A

N/A

Comments

N/A

N/A
N/A
N/A

N/A
N/A

N/A

N/A
N/A

N/A

N/A
N/A

N/A

5.48

PERSONNEL FILE CHECK LIST
Instructions:
1.

2.
3.
4.
5.

Complete review on charts indicated in columns across
Indicate with a √ if complete
Utilize “I” for incomplete
Utilize “N/A” for not applicable
D/H = department head

Criteria
Hiring
Information
Orientation

Separate
Personnel
Records
(keep in a
separate
location from
personnel file
and with very
limited
access)
Other

Requirement
Pre-Employment References

R.N.

R.N.

L.P.N.

L.P.N.

C.N.A.

C.N.A.

D/H

D/H

HRLY

HRLY

Comments

Credentials/License Verified
Checklist for General
Orientation
Checklist for Dept. Orientation
Signature Resident Rights
Standards of Conduct
Employee Handbook
> Facility Policies
Fire & Disaster Plan
State Specific:
Abuse & Neglect
Medical File:
TB Testing
HepB
Consents/documentation
Criminal Background checks
I-9 Information
EDL checked

Family Care Registry
C.N.A. Registry
OIG
Drug testing

5.49

ENVIRONMENT

5.50

PHYSICAL PLANT ROUNDS - INITIAL TOUR
Facility:

TAG #

Date:

STANDARD

MET
NOT MET COMMENTS
INFECTION CONTROL: EXTERIOR OF BUILDING

F-372
Trash Control
F-372
Dumpster Secure
F-469, F-371 Pest Control
INTERIOR OF BUILDING
F-252, F-253
F-253, F-441
F-469, F-371
F-371
F-371
F-371
F-371
F-371
F-371
F-441, F-253
F-441,F-431
F-441, F-431
F-441, F-431
F-441, F-431
F-441, F-431
F-441, F-431
F-441, F-431
F-441, F-431
F-441, F-431
F-441, F-431

Odor
Cleanliness
Pest Control
Thermometers in refrigerator
Freezer 0 degrees or below
Refrigerator <41 degrees
Refrigerator Clean
No employee food unless so designated
Juice/Food labeled, covered, dated <72 hours old
Housekeeping carts off units during meal service
TF pumps, poles clean and TF labeled
Formula
Time Started/Date
Rate
Initials
IV’s labeled
Contents
Rate
Date/Time
Initials

5.51

PHYSICAL PLANT ROUNDS - INITIAL TOUR (continued)
TAG #
STANDARD
MET
NOT MET
INTERIOR OF BUILDING (cont)
F-253
Personal care items separate, not co-mingled
F-253
Urine graduates labeled for individual pt.
F-253
Bedpans, urinals stored properly
F-254
Linen
F-253
Catheters off floor
F-441
Oxygen tubing off floor
F-253, F-441 Suction caths, machines
LAUNDRY
F-441,F-456 Ceiling filters
F-441, F-456 Dryer filters
F-441
Doors closed between clean and soiled area
F-441
PPE available and used
F-441
Shield/Goggles
F-441
Gown (impervious gown or apron)
F-441
Gloves
F-254
Clean linen stain free and free from tears/holes
F-323
Chemicals secure
SAFETY
F-456
Appropriate door closures
F-517
Doors not propped open
F-456
Fire extinguishers checked monthly
Fire alarm panel has tag within last year marked
F-456
“functional”
F-455
Exit signs

COMMENTS

5.52

TAG #
F-323
F-468
F-323
F-323
F-456
F-517
F-323
F-323
F-371
F-253, F-456
F-323
F-323
F-323
F-323
F-323
F-431
F-431
F-257
F-456
F-323
F-456
F-464
F-252, F-323
F-463, F-241
F-456, F-323
F-456
F-246
F-323

PHYSICAL PLANT ROUNDS - INITIAL TOUR (continued)
STANDARD
MET
NOT MET
SAFETY (cont)
Biohazardous Waste locked with appropriate signage
Handrails
Safety hazards
Water temperature 105-120 degrees
Emergency outlets red
Corridors unobstructed
Storage off floors/18 “below ceiling
Chemicals labeled
Chemicals stored properly/not left unattended
Equipment inspected
Oxygen signage
Oxygen storage
Liquid Oxygen (5 ft from electrical outlet)
Tank storage
Functional call lights
Med carts secured
Treatment carts secured
Air temperature (71-81 degrees F)
Penetration of smoke barrier
Shut-off valves labeled
Exhaust fans working
Designated smoking area
Extension cords 3-pronged
Call system
Cords not frayed
Garbage cans fire rated
Safe storage of patient items
Wet floor signs

COMMENTS

5.53

TAG #
F-441
F-431, F-323
F-455
F-518

PHYSICAL PLANT ROUNDS - INITIAL TOUR (continued)
STANDARD
MET
NOT MET

COMMENTS

MSDS current
OTC drugs stored in rooms?
Emergency power
Emergency procedure training

DIGNITY/RESIDENT RIGHTS
F-174
Hearing impaired phone access for resd in private area
F-252
Homelike environment
F-258
Sound level
F-241
Resident Rights respected
F-241
Knocking before entering
F-241
Privacy/no exposure
F-241
Addressed appropriately
F-241
No standing while feeding
F-368
Meal times posted
F-363, F-366 Menu and alternates posted
F-248
Activity Calendar posted
F-246,311,318 Positioning appropriate
F-246,311,318 Bed/Chair
F-246,311,318 Dining
F-172
Private meeting place (visitors)
ADMINISTRATIVE
F-464
Space adequate
F-464
Furnishings
F-156
Information Posted
F-167
Prior Survey
F-172
Ombudsman Information
F-172
MC/MA info

5.54

TAG #
F-172
F-323
F-165
F-441
F-492
F-492
F-491
F-502
F-203
F-456
F-456
F-241

PHYSICAL PLANT ROUNDS - INITIAL TOUR (continued)
STANDARD
MET
NOT MET

COMMENTS

No solicitation
Smoking Policy
Grievance Procedure
Biohazard waste generating permit
Facility license
Occupational license
NHA license
Pharmacy license
CLIA Waiver
Underground/above ground (over 500 gal) tank permit
Boiler certificate of compliance
ID Badges worn by staff
REHAB ROOM
F-323
Hydrocollator log temps; water color
F-441
No food in patient care areas
F-254
Linen storage
F-323
Chemicals stored appropriately
F-323
MSDS current (ultrasound gel)
F-241
Patient privacy during treatment
F-454
Oxygen storage appropriate
MED ROOM
F-323, F-441 Sharp disposal
F-431
Meds separated/stored appropriately
F-431
Externals separate from internals
F-431
Biologicals and vials dated when opened

5.55

TAG #
F-431
F-431
F-431
F-441
F-431
F-281
F-431
F-281
F-492

PHYSICAL PLANT ROUNDS - INITIAL TOUR (continued)
STANDARD
MET
NOT MET
Glucose strips dated when opened
Narcotics double-locked
All meds current/check expiration dates
No employee food in refrigerator
Opened meds stored separately from closed meds
Blood glucose control log up to date
Respiratory/Treatment meds stored appropriately
E-Kit Policies & Procedures followed
E-Kit contents posted in nurses’ station
GENERAL COMMENTS

COMMENTS

5.56

FIRE DRILL GRID

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

7-3

3-11

11-7

Weekend

Holiday

Directions:
Plot actual fire drills by shift and month.
Minimum compliance is one drill per month, quarterly on each shift. Include weekend drills. Schedule fire drills in advance to assure compliance. You may add internal and external disaster drills to your schedule.

5.57

QA Review
DEPARTMENT OF HEALTH AND HUMAN
SERVICES HEALTH CARE FINANCING
ADMINISTRATION

SURVEYOR NOTES WORKSHEET
Facility Name:
Provider Number:

Surveyor Name:
Surveyor Number:

Observation Dates: From

Discipline:

to

Part 1 -complete after Phase 2 Sampling meeting:
I.

List the committee members or attach a list provided by facility:

Name:

Department/Title:

ll.
Review the facility ·l- plan or written description of the Committee’s process for identifying quality deficiencies. Recap the methods.

Ill.

Interviews with administrative staff and QNA Committee members:

Person interviewed:

Can list the
members of the
committee:

Y-N
Y-N
Y-N
Y-N

Can state how
often the
committee
meets?

Y-N
Y-N
Y-N
Y-N

Can state methods of
identifying issues in the
facility which require
QA/A activities?

Y-N
Y-N
Y-N
Y-N

Verbalizes methods to
respond to identified
quality deficiencies and
that evaluates the
effectiveness of that
response?

Y-N
Y-N
Y-N
Y-N

FORM HCFA-807 (7-951

5.58

SURVEYOR NOTES WORKSHEET
Part 2 - complete if/when deficient practice/s have been identified as Pattern or Widespread: Interviews with:

Committee member
name:

Direct care staff
name:

Knows quality Identifies some systems that Can identify areas that have Describe a sample of the
have been developed &
been evaluated or will be
deficiencies the
quality deficiencies they have
implemented to address evaluated for the effectiveness
facility
identified and dealt with.
those deficiencies?
of the planned intervention?
identified?

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y- N

Y-N

Knows how
the QNA
Committee
functions?

Knows
what the
QNA
process is?

Knows how to
Identifies if the
Verbalizes specific
access the
QNA Committee is
plans for care
QNA
responsive to the
described by the
process &
concerns submitted
QNA Committee
to it?
Committee?

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Y-N

Comments:

FORM HCFA-807 {7-95)

5.59

NURSING

5.60

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

RESIDENT REVIEW WORKSHEET
Facility Name:
Provider Number:
Surveyor Name:
Surveyor:
Number:

Discipline:

Resident Name:
Resident Identifier:
Birthdate:
Unit: Rm #:
Orig. Admission Date:
Readmission Date:
Survey Date:
Payment Source: Admission:
Current:

Diagnosis:
Interviewable: Yes
No
Type of Review: Comprehensive
Focused
Selected for Individual Interview: Yes
No
Selected for Family Interview and Observation of Non-Interviewable Resident: Yes Focus/Care Areas:

Closed Record
No

Instructions: Any regulatory areas related to the sampled resident’s needs are to be included in this review. • Initial that each section was reviewed if there are no concerns. • If there are concerns, document your investigation.

• Document all pertinent resident observations and information from resident, staff, family interviews and record reviews for every resident in the sample.
SECTION A: RESIDENT ROOM REVIEW: Evaluate if appropriate requirements are met in each of the following areas, including the accommodation of needs:
• Adequate accommodations are made for resident
privacy, including bed curtains.
• Call bells are functioning and accessible to residents
• Resident is able to use his/her bathroom without difficulty. • Adequate space exists for providing care to residents.
• Resident with physical limitations (e.g., walker,
wheelchair)
is able to move around his/her room.

• Environment is homelike, comfortable and attractive;
accommodations are made for resident personal items and
his/her modifications.
• Bedding, bath linens and closet space is adequate for resident needs.
• Resident care equipment is clean and in good repair.
• Room is safe and comfortable in the following areas:
temperature, water temperature, sound level and lighting.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on Surveyor Notes sheet page 4. SECTION B: RESIDENT DAILY LIFE REVIEW: Evaluate if appropriate requirements are met in each of the following areas: • Resident appears well groomed and reasonably attractive

(e.g., clean clothes, neat hair, free from facial hair).

• Facility activities program meets resident's individually assessed needs and preferences.

• Staff treats residents respectfully and listens to resident requests. Note staff interaction with both communicative
and non-communicative residents.

• Medically related social services are identified and provided when appropriate.

• Staff is responsive to resident requests and call bells. • Residents are free from unexplained physical injuries and there are no signs of resident abuse. (e.g. residents do not appear frightened around certain staff members.)

• Restraints are used only when medically necessary.
(see 483.13(a))
• Resident is assisted with dining when necessary.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on Surveyor Notes sheet page 4. Form CMS-805(7-95)

5.61

RESIDENT REVIEW WORKSHEET
(continued)
SECTION C: ASSESSMENT OF DRUG THERAPIES
Review all the over-the-counter and prescribed medications taken by the resident during the last 7 days. • Evaluate drug therapy for indications/reason, side
effects, dose, review of therapy/monitoring, and evidence
of unnecessary medications including antipsychotic drugs.

• Correlate drug therapy with resident's clinical condition. • If you note concerns with drug therapy, review the
pharmacist's report. See if the physician or facility has
responded to recommendations or concerns.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)

Medications/Dose/Schedule

Medications/Dose/Schedule

Medications/Dose/Schedule

Document concerns and follow-up on page 4.
SECTION D: RAI/CARE REVIEW SHEET (Includes both MDS and use of RAPS): Reason for the most current RAI: Annual
Initial
Significant Change
Date of Most Recent RAI
Date of Comparison/ Quarterly RAI
• For a comprehensive review complete a review of all care areas specific to the resident, all ADL functional areas, cognitive status, and MDS categories triggering a RAP.
• For a focused review:
Phase I: Complete a review of those requirements appropriate to focus and care areas specific to the resident. Phase II: Complete a review of requirements appropriate to focus areas. • For both comprehensive and focused reviews record only the applicable sections and relevant factors about the clinical status indicating an impairment or changes between reviews.

• If the current RAI is less than 9 months old, scan and compare with the previous RAI and most recent quarterly review. • If the RAI is 9 months or older, compare the current RAI with the most recent quarterly review. • Note any differences for the applicable areas being reviewed. • Review the RAP summary and care planning.

• Look for implementation of the care plan as appropriate to the comprehensive or focused review. • Note specifically the effects of care or lack of care.
• If the resident declined or failed to improve relative to expectations, determine if this was avoidable or unavoidable. • For closed records, complete a review of the applicable areas of concern. • Use the additional MDS item blocks on page 3 to document other sections or additional concerns. • Dining observation; If there are concerns with weight loss or other nutritional issues, observe resident dining and review adequacy of meals served and menus.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on page 4.

Form CMS-805(7-95)

5.62

RESIDENT REVIEW WORKSHEET
(continued)

MDS Items

RAI
Status/Comparison

Care Notes/Dates/Times/Source and Tag: Observations and Interview for resident plan and implementation of care plan and TX, including accuracy, completeness, Y
and how information from use of RAPs is incorporated into the resident's care. Or
Outcome: improve/failure to improve/same/decline. If a decline or failure to N
improve occurred, was it avoidable or unavoidable?

Cognitive/Decision
making
Mood/Behavior/
Psychosocial
Transfer
Ambulation
Dressing
Eating
Hygiene/Bathing
ROM Limits
Bowel
Bladder
Activities

Form CMS-805(7-95)

5.63

RESIDENT REVIEW WORKSHEET
(continued)
Tag/Concerns

Source*

Surveyor Notes (including date/time)

*Source: O=Observation RR=Record Review, I=Interview
Form CMS-805(7-95)

5.64

QUALITY OF CARE
Use probes regarding Anticoagulants, blood glucose, pain, falls, smoking, change of condition, pressure ulcers & abuse investigation to guide information gathering.
Compare any negative answers to the intent of the regulation. Deficiencies should be cited only if the intent of the regulation is not met. Missing standard components addressed only under “standards not in compliance” section of FQR Score. F309 Anticoagulants:

The lab work for residents on Coumadin is completed as ordered? Documentation of Physician notification and assessment complete for abnormal INR/PT results? F309 Blood Glucose:
Are Blood Glucose levels obtained as ordered?
Is assessment of resident with abnormal levels present?
F309 Pain
Pain assessment, interventions and follow-up documentation are clearly evident? F323 Falls:
Post falls assessment completed and appropriate?
Interventions on plan of care are evident on physical review of resident? Care plan appropriate to falls?
F323 Smoking:
Are smoking safety assessments completed on all residents who smoke? When observing the resident that smoke is it evident that the safety interventions identified are in place? F309/F157 Change of Condition:

Timely assessment and physician notification is evident on any acute change of condition episodes. F314 Skin/Pressure Ulcers:
Residents with pressure ulcers have had timely accurate assessment of wound? When resident with pressure ulcers are observed are all interventions identified on the care plan observed to be in place? F225 Verification of Investigation:

All incidents are thoroughly investigated and documentation includes evidence of determining causal factors and recommendations to prevent reoccurrence?
Recommendations to prevent reoccurrence identified o the investigations are observed on visual checks of resident or environment.

5.65

MDS AUDIT TOOL
Date:

Resident Name

Room #

MDS Dates
Correct?

CAA
Care Plan
CAA Summary Completed for
Required
Addresses Each
Each
Signed &
Signatures
Problem?
Triggered
Dated?
Present?
(Proceed)
Area?

Location of
Care Plan Goals
Info
Have
Change in
Complete
Timeframes? Condition?
and
Measureable?
Correct?

5.66

INVESTIGATIVE PROTOCOL
HYDRATION
Objectives:


To determine if the facility identified risk factors which lead to dehydration and developed an appropriate preventative care plan; and



To determine if the facility provided the resident with sufficient fluid intake to maintain proper hydration and health.

Task 5C: Use:
Use this protocol for the following situations:


A sampled resident who flagged for the sentinel event of dehydration on the Resident Level Summary;



A sampled resident who has one or more QI conditions identified on the Resident Level Summary, such as:
o
o
o
o
o
o



#11 - Fecal impaction;
#12 - Urinary tract infections;
#13 - Weight loss;
#14 - Tube feeding;
#17 - Decline in ADLs;
#24 - Pressure Ulcer

A sampled resident who was discovered to have any of the following risk factors: vomiting/diarrhea resulting in fluid loss, elevated temperatures and/or infectious processes, dependence on staff for the provision of fluid intake, use of medications including diuretics, laxatives, and cardiovascular agents, renal disease, dysphagia, a history of refusing fluids, limited fluid intake or lacking the sensation of thirst.

Procedures:


Observations/interviews conducted as part of this procedure should be recorded on the Forms CMS-805 and/or the Form CMS-807.



Determine if the resident was assessed to identify risk factors that can lead to dehydration, such as those listed above and also whether there were abnormal laboratory test values which may be an indicator of dehydration.

NOTE: A general guideline for determining baseline daily fluid needs is to multiply the resident’s body weight in kilograms (kg) x 30ml (2.2 lbs = 1 kg), except for residents with renal or cardiac distress, or other restrictions based on physician orders. An excess of fluids can be detrimental for these residents. 

Determine if an interdisciplinary care plan was developed utilizing the clinical conditions and risk factors identified, taking into account the amount of fluid that the resident requires. If the resident is receiving enteral nutritional support, determine if the tube feeding orders included a sufficient amount of free water, and whether the water and feeding are being administered in accordance with physician orders? 5.67



Observe the care delivery to determine if the interventions identified in the care plan have been implemented as described.
o What is the resident’s response to the interventions? Does staff provide the necessary fluids as described in the plan? Do the fluids provided contribute to dehydration, e.g., caffeinated beverages, alcohol? Was the correct type of fluid provided with a resident with dysphagia? o Is the resident able to reach, pour and drink fluids without assistance? Is the resident consuming sufficient fluids? If not, is staff providing the fluids according to the care plan? o Is the resident’s room temperature (heating mechanism) contributing to dehydration? If so, how is the facility addressing this issue?

o If the resident refuses water, are alternative fluids offered that are tolerable to the resident? o Are the resident’s beverage preferences identified and honored at meals? o Does staff encourage the resident to drink? Are they aware of the resident’s fluid needs? Is staff providing fluids during and between meals?

o Determine how the facility monitors to assure that the resident maintains fluid parameters as planned. If the facility is monitoring the intake and output of the resident, review the record to determine if the fluid goals or calculated fluid needs were met consistently.



Review all related information and documentation to look for evidence of identified causes of the condition or problem. This inquiry should include interviews with appropriate facility staff and health care practitioners, who by level of training and knowledge of the resident, should know of, or be able to provide information about the causes of a resident’s condition or problem.

NOTE: If a resident is at an end of life stage and has an advance directive, according to State law, (or a decision has been made by the resident’s surrogate or representative, in accordance with State law) or the resident has reached an end of life stage in which minimal amounts of fluids are being consumed or intake has ceased, and all appropriate efforts have been made to encourage and provide intake, then dehydration may be an expected outcome and does not constitute noncompliance with the requirement for hydration. Conduct observations to verify that palliative interventions, as described in the plan of care, are being implemented and revised as necessary, to meet the needs/choices of the resident in order to maintain the resident’s comfort and quality of life. If the facility has failed to provide the palliative care, cite noncompliance with 42 CFR 483.25, F309, Quality of Care.



Determine if the care plan is evaluated and revised based on the response, outcomes, and needs of the resident.

Task 6: Determination of Compliance:


Compliance with 42 CFR 483.25(j), F327, Hydration:
o



For this resident, the facility is compliant with this requirement to maintain proper hydration if they properly assessed, care planned, implemented the care plan, evaluated the resident outcome, and revised the care plan as needed. If not, cite at F327.

Compliance with 42 CFR 483.20(b)(1) & (2), F272, Comprehensive Assessments: o For this resident in the area of hydration, the facility is compliant with this requirement if they assessed factors that put the resident at risk for dehydration, whether chronic or acute. If not, cite at F272.



Compliance with 42 CFR 483.20(k)(1), F279, Comprehensive Care Plans: o For this resident in the area of hydration, the facility is compliant with this requirement if they 5.68

developed a care plan that includes measurable objectives and timetables to meet the resident’s needs as identified in the resident’s assessment.
If not, cite at F279.


Compliance with 42 CFR 483.20(k)(3)(ii), F 282, Provision of care in accordance with the care plan: o For this resident in the area of hydration, the facility is compliant with this requirement if qualified persons implemented the resident’s care plan. If not, cite at F282.

Objectives:


To determine if each resident is provided with nourishing, palatable, attractive meals that meet the resident’s daily nutritional and special dietary needs;



To determine if each resident is provided services to maintain or improve eating skills; and



To determine if the dining experience enhances the resident’s quality of life and is supportive of the resident’s needs, including food service and staff support during dining.

Task 5C: Use
This protocol will be used for:


All sampled residents identified with malnutrition, unintended weight loss, mechanically altered diet, pressure sores/ulcers, and hydration concerns; and



Food complaints received from residents, families and others.

General Considerations:


Use this protocol at two meals during the survey, preferably the noon and evening meals.



Record information on the Form CMS-805 if it pertains to a specific sampled resident, or on the Form CMS-807 if it relates to the general observations of the dining service/dining room. o

Discretely observe all residents, including sampled residents, during meals keeping questions to a minimum to prevent disruption in the meal service.



For each sampled resident being observed, identify any special needs and the interventions planned to meet their needs. Using the facility’s menu, record in writing what is planned in writing to be served to the resident at the meal observed.



Conduct observations of food preparation and quality of meals.

Procedures:
1. During the meal service, observe the dining room and/or resident’s room for the following: 

Comfortable sound levels;



Adequate illumination, furnishings, ventilation; absence of odors; and sufficient space; 5.69



Tables adjusted to accommodate wheelchairs, etc.; and



Appropriate hygiene provided prior to meals.

2. Observe whether each resident is properly prepared for meals. For example: 

Resident’s eyeglasses, dentures, and/or hearing aids are in place;



Proper positioning in chair, wheelchair, gerichair, etc., at an appropriate distance from the table (tray table and bed at appropriate height and position); and



Assistive devices/utensils identified in care plans provided and used as planned.

3. Observe the food service for:


Appropriateness of dishes and flatware for each resident. Single use disposable dining ware is not used except in an emergency and in other appropriate dining activities. Except those with fluid restriction, each resident has an appropriate place setting with water and napkin;



Whether meals are attractive, palatable, served at appropriate temperatures and are delivered to residents in a timely fashion.
o
o



Did the meals arrive 30 minutes or more past the scheduled mealtime? If a substitute was needed, did it arrive more than 15 minutes after the request for a substitute?

Are diet cards, portion sizes, preferences, and condiment requests being honored?

4. Determine whether residents are being promptly assisted to eat or provided necessary assistance/cueing in a timely manner after their meal is served. 

Note whether residents at the same table or in resident rooms, are being served and assisted concurrently.



If you observe a resident who is being assisted by a staff member to eat or drink, and the resident is having problems with eating or drinking, inquire if the staff member who is assisting them is a paid feeding assistant. If so, follow the procedures at tag F373.

5. Determine if the meals served were palatable, attractive, nutritious and met the needs of the resident. Note the following:


Whether the resident voiced concerns regarding the taste, temperature, quality, quantity and appearance of the meal served;



Whether mechanically altered diets, such as pureed, were prepared and served as separate entree items (except when combined food, e.g., stews, casseroles, etc.);



Whether attempts to determine the reason(s) for the refusal and a substitute of equal nutritive value was provided, if the resident refused/rejected food served; and



Whether food placement, colors, and textures were in keeping with the resident’s needs or deficits, e.g., 5.70

residents with vision or swallowing deficits.
Sample Tray Procedure
If residents complain about the palatability/temperature of food served, the survey team coordinator may request a test meal to obtain quantitative data to assess the complaints. Send the meal to the unit that is the greatest distance from the kitchen or to the affected unit or dining room. Check food temperature and palatability of the test meal at about the time the last resident on the unit is served and begins eating. 6. Observe for institutional medication pass practices that interfere with the quality of the residents’ dining experience. This does not prohibit the administration of medications during meal service for medications that are necessary to be given at a meal, nor does this prohibit a medication to be given during a meal upon request of a resident who is accustomed to taking the medication with the meal, as long as it has been determined that this practice does not interfere with the effectiveness of the medication. 

Has the facility attempted to provide medications at times and in a manner to support the dining experience of the resident, such as:
o Pain medications being given prior to meals so that meals could be eaten in comfort; o Foods served are not routinely or unnecessarily used as a vehicle to administer medications (mixing the medications with potatoes or other entrees).

7. Determine if the sampled resident consumed adequate amounts of food as planned. 

Determine if the facility is monitoring the foods/fluids consumed. Procedures used by the facility may be used to determine percentage of food consumed, if available; otherwise, determine the percentage of food consumed using the following point system:

o Each food item served except for water, coffee, tea, or condiments equals one point. Example: Breakfast: juice, cereal, milk, bread and butter, coffee (no points) equals four points. If the resident consumes all four items in the amount served, the resident consumes 100% of breakfast. If the resident consumes two of the four food items served, then 50% of the breakfast would have been consumed.

o If three-quarters of a food item is consumed, give one point; for one-half consumed, give .5 points; for one- fourth or less, give no points. Total the points consumed x 100 and divide by the number of points given for that meal to give the percentage of meal consumed. Use these measurements when determining the amount of liquids consumed: Liquid measurements: 8 oz. cup = 240 cc, 6 oz. cup = 180 cc, 4 oz. cup = 120 cc, 1 oz. cup = 30 cc.

o Compare these findings with the facility’s documentation to determine if the facility has accurately recorded the intake. Ask the staff if these findings are consistent with the resident’s usual intake; and

o Note whether plates are being returned to the kitchen with 75% or more of food not eaten.

8. If concerns are noted with meal service, preparation, quality of meals, etc., interview the person(s) responsible for dietary services to determine how the staff are assigned and monitored to assure meals are prepared according to the menu, that the meals are delivered to residents in a timely fashion, and at proper temperature, both in the dining rooms/areas and in resident rooms. NOTE: If concerns are identified in providing monitoring by supervisory staff during dining or concerns with assistance for residents to eat, evaluate nursing staffing in accord with 42 CFR 483.30(a), F353, and quality of care at 42 CFR 483.25(a)(2) and (3).

5.71

Task 6: Determination of Compliance:


Compliance with 42 CFR 483.35(d)(1)(2), F364, Food
o The facility is compliant with this requirement when each resident receives food prepared by methods that conserve nutritive value, palatable, attractive and at the proper temperatures. If not, cite F364.



Compliance with 42 CFR 483.35(b), F362, Dietary services, sufficient staff o

The facility is compliant with this requirement if they have sufficient staff to prepare and serve palatable and attractive, nutritionally adequate meals at proper temperatures. If not, cite F362.

NOTE: If serving food is a function of the nursing service rather than dietary, refer to 42 CFR 483.30(a), F353.


Compliance with 42 CFR 483.15(h)(1), F252, Environment

5.72

NON-STERILE DRESSING CHANGE
Facility:

Nurse:

Date:

Objective: To prevent cross contamination and maintain standard infection control techniques. Item #
Procedure
Check
treatment
order
1
Gather necessary equipment:
2
- Plastic bag
- Bed protector
- Clean towel or towel paper for clean
field
- Dressing supplies
- Cleaning solution – check expiration date
- Medication ordered of treatment, if any
- Gloves
Inform resident of procedure; provide
privacy, position resident; place bed
3
protector on bed
Wash hands; put on gloves
4
Remove dirty dressing and place in plastic
5
bag
Remove gloves and place in plastic bag
6
Wash hands
7
Set up clean field; prepare supplies (open
8
dressings, etc.)
Put on gloves
9
Perform treatment (wound can be measured
10
at this time)
a. Clean from inner edge of wound out
b. Perform treatment according to orders
and apply dressing
c. Discard all waste in plastic bag
Remove gloves and place in plastic bag
11
Wash hands
12
Reposition resident for comfort
13
Record treatment and return supplies to
14
proper areas

Met

Not Met

Comments

General Comments:

5.73

DISCHARGE RECORDS REVIEW
(Select at least 3 records)

Name of Resident & D/C Location

Summary
Summary ReDate of
Signed by
Discharge
Caps Stay
MD

Is There a D/C
Plan of
Care?

1. Does D/C Plan cover pertinent issues? OR
2. Is there an RN Pronouncement &
Supporting Documentation?

Other Comments

(D/C to Home)

(D/C to Hospital and didn’t return to
the facility)

(Expired in the facility)

(D/C to Other)

5.74

CHART AUDIT TOOL
FOCUS REVIEW RELATED TO:
Change of condition of
Focus Documentation (Medicare/Hospice/Dialysis) Incident
Admission
Discharge

Date:
Patient:

Area of review
Resident Physical Assessment
positioning:
preventative devices:
catheter positioning:
ADL care:
dated equipment:
call light:
water in reach:
personal care items:
Consents
restraints:
advance directives:
non-compliance:
H&P
signed:
timely:
Physicians Orders
DNR:
TB testing:
certification:
timely:
Telephone Orders
written correctly:
return timely:
transcribed:
Nursing Assessment / Summary
complete:
timely:
accurate:
Nurses Notes
family / Dr. notified:
accurate descriptive:
follow-up evident:
vital signs:
MDS 3.0
MDS
accurate/CAA:
date:
Quality
updated:
date timely:
complete:

Rm#:

Met

Admit Date:

Not
Met

N/A

Comments

5.75

change of condition reassessment:
Care Plan
HCP
goal measurable:
date:
Review
accurate:
date interdisciplinary:
resident participates:
Lab / X-Ray
drawn timely:
evaluated:
follow-up:
Dr. notified:
Miscellaneous
treatment sheet:
MAR:
flow sheet:
weight sheet:
follow-up intervention:
timely assessments:
Social Services
room moves:
behavior problems:
follow-up intervention:
timely assessments:
Activities
patient possessions list:
timely assessments:
unusual needs:
Dietary
complete diet assessment:
adequate documentation:
recommendations follow-up:
Restorative
assessment timely:
complete:
accurate:
weekly progress notes:
monthly summary:
care planned:
Rehabilitation
timely screens:
assessment timely:
complete:
accurate:
weekly progress notes:
physician orders clarified / accurate:
care planned:
Completed By:
Comments:
5.76

MED PASS TECHNIQUE
Resident Name/Room #:
Date:

LPN / QMA Name:

Schedule Pass Time:

Actual Start Time:

Stop Time:

INSTRUCTIONS: This tool may be used by an Administrator, Consultant, or Licensed Nurse to obtain information on types and numbers if errors, and general adherence of staff to accepted policies and procedures and regulations. A mark is to be made in the appropriate space at each occurrence of an error. The survey may be interrupted if there is an anticipated error that might endanger the resident.

MET
1.0

2.0

3.0

4.0

NOT MET

MED ADMIN
Resident Identified
Dose administered
Authorized doze
Correct dose time
Correct route or form of dose
Correct strength of dose
Correct drug
Right resident
TECHNIQUE
Hand washing before starting / between patients
Checks medication with order
Checks pulse or BP as required before administering
Omits medication when indicated per M.D. order
Correct handling of medication
Medication ingestion observed
Bedside medication checked
Prepares site properly
Cart cleaned properly
PREPARATION AND CHARTING
Dose preparation
Dose measurements
Crushing tablets or emptying capsules
Proper dilution
Charts immediately after administering
PRN reason and result charted
Prepouring
OTHER
Security of cart and med room
Efficiency
Resident needs are met
Handles interruptions appropriately
Infection control / aseptic technique correct

Comments:

NOTE: The medication pass survey criteria should be used as needed to assist in conducting a med pass survey.

Name of Observer:

5.77

CMS-677
MEDICATION PASS WORKSHEET
1. Observe 10 opportunities for error. If one or more errors are found, observe another five opportunities. 2. Record your observation for each opportunity for error on the Medication Pass Worksheet. 3. Compare your record with the Physician Orders.

4. Calculate and note error rate. (For calculation, see CMS-677)

5.78

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICATION PASS WORKSHEET
Provider Number

Surveyor Name

Date

Error Rate

Instructions:
1. Observe Pass for 20-25 opportunities for error. If one or more errors is found observe another 20-25 opportunities for error. 2. Record your observation of each opportunity for error.
3. Compare your record with physician orders.
4. Calculate and note error rate
Deficiency Formulas:
Significant Error + Non-Significant Error
X 100 ≥ 5% = Deficiency
1. One or more Significant Errors = Deficiency
2.
Doses given + Doses ordered but not given

Identifier

Pour

Resident’s Full Name

Drug Prescription Name,
Dose and Form

Pass

Record

Observation of Administration

Drug Order Written As
(when different from observation)

FORM CMS-677 (07/95)

5.79

MEDICATION PASS WORKSHEET
Identifier

Pour

Pass

Record

Resident's Full Name

Drug Prescription Name,
Dose and Form

Observation of Administration

Drug Order Written As
(when different from observation)

FORM CMS-677 (07/95)

5.80

DIETARY

5.81

DIETARY OBSERVATIONS
1x per month until survey window: then weekly
Place a check under the Yes or No column and N/A if practice not observed GENERAL OBSERVATIONS
Proper uniform per facility policy
Clean apron
Closed toed shoes
Minimal Jewelry (watch, wedding ring, stud earrings)
Hair restraints covering ALL hair (facial restraint if needed) Fingernails short and clean
Visible wounds gloved at all times
No eating, drinking or chewing gum
Name tag worn
MEAL PREPARATION OBSERVATIONS
Hands washed before beginning meal preparation
Hands washed and/or gloves changed when soiled
Gloves worn when handling ready to eat foods or tongs used (i.e. potato chips, cookies, etc.) Fruits & vegetables (not heated.. carrot sticks, celery, bananas, etc.) Bread/bread products
Non-Rethermalized foods (food that won’t be reheated, i.e. chicken salad, chief salad) Utensils used when ungloved
STEAM TABLE/SERVING LINE OBSERVATIONS
Hands washed before beginning meal service
Utensils/dedicated gloved hand used appropriately
Hands washed before gloves applied
Hands washed and/gloves changed when contaminated
Changing tasks (refrigerator, dishwasher, trash can) Sneezing or coughing
Touching body or someone else
Touching unclean equipment or work surface
Plates handled by edges only
Bowls, cups, glasses handled by outside only
Second helpings served on new plate, bowl, etc.
Meal ticket/card available and used for each resident
Appropriate scoops used
PUREED MEAL OBSERVATION
Recipe available for meal being served
Recipe followed:
Correct Ingredients? Accurate measurements?
Finished product correct consistency?
If not, appropriate corrective action taken? (i.e. change recipe and have R.D. approve) Reheated and/or cooled to appropriate temperatures

Yes

No

N/A

Date: __________
Meal observed (circle one): Breakfast Noon Evening
Observation by: _________________________________
Reviewed by: __________________________________

5.82

MONTHLY MEAL QUALITY REVIEW
DATE:

FACILITY:

AREAS OF OBSERVATION
1. The dining room is neatly arranged, tables have clean,
matching, unworn tablecloths and/or center pieces, clean
floor, soiled dishes removed.
2. The meal begins on time according to a posted
schedule/menu is posted in dining area(s).
3. Diet is correctly served, preferences are noted/followed. 4. FIRST IMPRESSION of prepared trays is favorable –
colorful, neatly served, garnished.
5. Trays are dispersed timely.
6. Water is served to residents with meals.
7. Serving in the dining room follows a rotation.
8. Meal complies with written menu or substitutions are
documented/alternates are on the trayline/ pureed items are
according to menu.
9. Hot food is >140F/cold food is <41F on trayline.
10. Temperatures of food on the line are recorded prior to the beginning of the meal.
11. Serving utensils are appropriate according to the menu
(scoop sizes, ladles, etc.)
12. Dessert portions, cake squares, cornbread squares, etc. are even/uniform sizes.
13. A full compliment of utensils is provided unless the reason why not is appropriately documented.
14. Given glass with milk unless straw requested.
15. Condiments are available for those eating in their rooms. Appropriate condiments on the dining room table.
16. Rehab. dining areas are designated and used.
17. Staff sit while feeding residents.
18. Residents’ faces are kept clean during meals and all residents are adequately assisted. Clothing protectors are available.
19. There is no loud talking/arguing by staff during meal service. 20. The dining area is quiet/clean/no odors.
21. Disruptive residents do not create an unpleasant environment for alert, independent diners.
22. Food down halls is covered with hot >120 degrees F.
23. There is adequate food to meet all resident needs at
mealtimes.
24. The dietary manager observes on the line and in all dining areas whenever possible.
25. Dining room service is completed within 20 minutes.
26. Residents’ meals are not rushed by clean-up crew.
27. Employees visit with residents, not with each other.
28. Food has a good taste/regular food is seasoned/rolls are brushed with margarine/beverages have unmelted ice.
29. A monthly residents’ choice meal is provided.

REVIEWER:
POINTS
8

2

0

4

2

0

4

2

0

8

5

0

3
3
3

1
1
1

0
0
0

4

2

0

4

2

0

3

1

0

4

2

0

3

1

0

3

1

0

3

1

0

3

1

0

3
3

1
1

0
0

3

1

0

3
3

1
1

0
0

2

1

0

2

1

0

3

1

0

4

2

0

2
3
2

1
1
1

0
0
0

4

2

0

3

1

0

COMMENTS

CIRCLE POINTS ACCORDING TO FINDINGS. COMMENT ON ALL COLUMN 3 FINDINGS. Column 1 = Excellent; Column 2 = Improvements needed; Column 3 = Unacceptable RECORD THE SUM OF ALL POINTS CIRCLED _______________ (THERE ARE 100 POSSIBLE POINTS.) A SCORE OF LESS THAN 75 REQUIRES FOLLOW-UP BY ADMINISTRATOR & MANAGER WITHIN 7 DAYS.

5.83

MONTHLY SANITATION/INFECTION CONTROL REVIEW
DATE:

FACILITY:

AREAS OF OBSERVATION
1. FIRST IMPRESSION of dietary cleanliness from dietary
entrance is favorable.
2. Floor is clear of trash and food particles.
3. Walls are free of splatters, damage, peeling paint, paper clutter, etc. Papers are all in covers on clean bulletin board(s). 4. Ceiling is in good repair and appears clean, with clean,
unbroken light fixtures - all bulbs working/bulbs covered.
5. Hood is free of grease, operational, lights work, extinguisher nozzles free of grease/dust, filters clean.
6. In dry storage, food is off floor by 6”, on sanitizable shelves, 18” from ceiling, all food is in enclosed clean containers if opened. Food is neatly arranged/dated and FIFO. No empty
boxes and damaged products are grouped for return.
7. In refrigerated/freezer storage, food is neatly arranged on clean shelving. Thermometers register less than 41 degrees F. or 0 degrees F. for freezer.
8. All opened food is labeled/dated, and covered.
9. There are no smudges, fingerprints, dried food particles on refrig./freezer outside surfaces.
10. Nonfood and chemicals are stored away from food.
11. Walk-in, floors dry, clean fans, covered lighting.
12. Inside and outside of all cooking equipment is clean.
13. All work surfaces, under shelves and legs are free of
food/dirt/dust/grease build-up.
14. All surfaces are free of rust.
15. Prep. equipment/dishes/utensils are effectively sanitized and properly stored.
16. Food transport prevents contamination.
17. Sewage and plumbing meet state or local law.
18. All refuse containers are covered/clean/adequate.
19. Frozen foods are thawed properly.
20. Safe water source with sufficient hot/cold water under
pressure.
21. The can opener is clean/blade not badly worn
22. There are sufficient cleaning cloths in good condition.
23. The pot/pan sink is used properly.
24. Hairnets are on/dress appropriate/no nail polish.
25. All carts are clean – including wheels.
26. Manager’s office is free of clutter/organized.
27. Only NSF approved food storage containers are used for
leftovers, opened items, etc.
28. Slicer and mixer bowl are covered when unused.
29. There is no sign of pest infestation.
30. All equipment is working properly.
31. Mops are hung-up, brooms, etc. stored properly.

REVIEWER:
POINTS
8

4

0

4

2

0

4

2

0

4

2

0

4

2

0

4

2

0

4

2

0

4

2

0

2

1

0

3
2
4

1
1
2

0
0
0

3

1

0

2

1

0

4

2

0

3
3
3
3

1
1
1
1

0
0
0
0

3

1

0

3
2
3
3
2
3

1
1
1
1
1
1

0
0
0
0
0
0

3

1

0

2
3
3
2

1
1
1
1

0
0
0
0

COMMENTS

CIRCLE POINTS ACCORDING TO FINDINGS. COMMENT ON ALL COLUMN 3 FINDINGS. Column 1 = Excellent; Column 2 = Improvements needed; Column 3 = Unacceptable RECORD THE SUM OF ALL POINTS CIRCLED _______________ (THERE ARE 100 POSSIBLE POINTS.) A SCORE OF LESS THAN 75 REQUIRES FOLLOW-UP BY ADMINISTRATOR & MANAGER WITHIN 7 DAYS.

5.84

MEAL AUDIT TOOL
Date:
Person assigned:
Specific area to monitor:
Time meal starts: B_________ L

Breakfast

D

Lunch

Dinner

Meals are posted and served
per menu.
Alternate is posted.
Residents are served in a
timely manner.
Correct diets are served to
the residents according to
their meal card.
Staff are assisting residents
with meals as needed and not
talking over residents to
other staff.
Meal started on time.
Staff washed hands before
passing trays and as needed
during meal service.
Residents are appropriately
groomed and ready for meal
service.

5.85

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS
FOR MEDICARE & MEDICAID SERVICES

KITCHEN/FOOD SERVICE OBSERVATION
acility Name:
Provider Number:
Observation Dates/Times:

Surveyor Name:
Surveyor Number:

Discipline:

Instructions:
Use the questions below to focus your observations of the kitchen and the facility's storage, preparation, distribution and service of food to residents. Initial that there are no identifiable concerns or note concerns and follow-up in the space provided. All questions relate to the requirement to prevent the contamination of food and the spread of food-born illness. (F371 This tag is not all inclusive.)

LIST ANY POTENTIAL CONCERNS FROM OFFSITE SURVEY PREPARATION: FOOD STORAGE
1. Are the refrigerator and freezer shelves and floors clean and free of spillage, and foods free of slime and mold? 2. Is the freezer temperature 0 degrees F or below and refrigerator 41 degrees F or below (allow 2-3 degrees variance)? Do not check during meal preparation.

3. Are refrigerated foods covered, dated, labeled, and shelved to allow air circulation? 4. Are foods stored correctly (e.g., cooked foods over raw meat in refrigerator, egg and egg rich foods refrigerated)? 5. Is dry storage maintained in a manner to prevent rodent/pest infestation?

FOOD PREPARATION
6. Are cracked eggs being used only in foods that are thoroughly cooked, such as baked goods or casseroles? 7. Are frozen raw meats and poultry thawed in the refrigerator or in cold, running water? Are cooked foods cooled down safely? 8. Are food contact surfaces and utensils cleaned to prevent cross-contamination and food-borne illness?

FOOD SERVICE/SANITATION
9. Are hot foods maintained at 140 degrees F or above and cold foods maintained at 41 degrees F or below when served from tray line?
10. Are food trays, dinnerware, and utensils clean and in good condition? 11. Are the foods covered until served? Is food protected from contamination during transportation and distribution? 12. Are employees washing hands before and after handling food, using clean utensils when necessary and following infection control practices?

13. Are food preparation equipment, dishes and utensils effectively sanitized to destroy potential food borne illness? Is dishwasher's hot water wash 140 degrees F and rinse cycle 180 degrees F or chemical sanitation per manufacturer's instructions followed?

14. Is facility following correct manual dishwashing procedures (i.e., 3 compartment sink, correct water temperature, chemical concentration, and immersion time)?

NOTE: If any nutritional concerns have been identified (such as weight loss) by observation, interviews or record review, check portion sizes and how that type of food is prepared (see guidelines at 483.35). If any concerns are identified regarding meals that are not consistent in quality see guidance at Task 5B and at 483.35. 1/4 C = 2 oz., 1/2 C = 4 oz., 3/4 C = 6 oz., 1 C = 8 oz. SCOOPS: LADLES:

#6 = 2/3 C., #8 = 1/2 C., #10 = 2/5 C., #12 = 1/3 C., #16 = 1/4 C.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS: (Init.) Document concerns and follow-up on back of page.
Form CMS-804 (7-95)

5.86

KITCHEN/FOOD SERVICE OBSERVATION
Tag/Concerns

Source*

Surveyor notes (including date/time)

*Source: 0 =Observation, RR = Record Review\v, I= interview
Form CMS-804 (7-%)

5.87

SOCIAL SERVICES

5.88

SOCIAL SERVICES AUDIT
Date:

Unit #:

Resident Name

Signature:
Room
#

CPR
Status

PASSR or
Equivalent

CPR
Status
On PO

Admission
Assessment
Completed

Quarterly
Notes
Present

D/C Plans D/C Care
Identified Planned

Ack. of
POA or
Advance
Equivalent
Directive in
Identified
Chart

5.89

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS
FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT OBSERVATION OF NON- INTERVIEWABLE RESIDENT

1. Special items to observe:

2. RESIDENT AND ENVIRONMENT:
Physical condition of resident (comfort, positioning, etc.)
(F246)
Appearance (grooming and attire) (F241)
Physical environment (comfort, safety, privacy, infection
control, stimulation, personal belongings,
homelike) (F164, 246, 252, 441, 444, 459)

3. DAILY LIFE:
The agreement of the daily schedule and activities with
assessed interests and functional level (Note during activities if cues/prompts and adapted equipment are provided as
needed and according to care plan.) (F242, 255)

4. INTERACTIONS WITH OTHERS:
Do staff individualize their interactions with this resident, based on her/his preferences, capabilities, and special needs? (F241, 246)
What is the resident's response to staff interactions (smil- ing, attempting to communicate, distressed,
anxious, etc.)? (F241, 246)
Do staff try to communicate in a reassuring way? (Note staff tone of voice and use of speech.) While staff are giving care, do they include resident in conversation or do staff talk to each other as if resident is not there? (F241, 223)

Level of assistance received. Note instances of too much or
too little and resulting problem (e.g., violation of dignity). (F241, 309–312)
Privacy afforded when care is given (F164)
Use of restraints and/or other restrictions on behavior
(F221)
Do staff intervene to assist resident if there is a problem and the resident tries to indicate this? (F312)

Restriction of choices that the resident can make (e.g.,
resident reaching out for a drink or pushing away food or
medication and facility response) (F155, 242)
Consistency of TV or radio being on or off with assessed
interests (F242, 280)

Evidence of a roommate problem that could be ad- dressed
by the facility (F250)
Consistency of opportunities for socializing with regard to
assessed interests and functional level (Note time and
situations when isolated.) (F174, 242, 248, 250)
Location of resident: segregated in some way, in a
special unit, or fully integrated with other residents
(Note any adverse consequences for resident.) (F223)

Use the Resident Review or Surveyor Notes Worksheet to follow-up on any concerns. Share any concerns with the team. Form CMS-806C (07/95)

5.90

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT RESIDENT INTERVIEW
Facility Name:
Provider Number:
Surveyor Name:
Surveyor Number:

Resident Name:
Resident Identifier:
Interview Dates/Times:
Discipline:

Instructions:
For question 1, if you are meeting with the resident in a location away from the resident's room, visit the room before the interview and note anything about the room that you want to discuss. For question 7, review the RAI to determine the ADL capabilities of this resident.

Introduce yourself and explain the survey process and the purpose of the interview using the following concepts. It is not necessary to use the exact wording.
“[Name of facility] is inspected by a team from the [Name of State Survey Agency] periodically to assure that all residents receive good care. While we are here, we make a lot of observations, review the nursing home's records, and talk to residents to help us understand what it's like to live in this nursing home. We appreciate your taking the time to talk to us.” “We ask certain questions because we want to know whether you have a say in decisions affecting your nursing and medical care, your schedule and the services you receive at this facility. We want to know how you feel about your life here and whether the facility has made efforts to accommodate your preferences.” “If it is all right with you, I'd like to meet with you again later. That will give you time to think things over and to provide additional information later.”

In asking the following questions, it is not necessary to use the exact wording. However, do use complete questions, not one-word probes.
Get the resident to talk about actual situations and examples by using open-ended probes, such as: “Can you tell me more about that?” or “How is that done here?” Avoid asking leading questions which suggest a certain response. If a resident gives a response to any question that indicates there may be a concern with facility services, probe to determine if the resident has communicated the problem to facility staff and what their response was. 1. ROOM: (F177, 201, 207, 242, 250, 252, 256, 257)

A good approach for initiating this discussion is to make a comment about something you have noticed about the resident's room, for example, “I notice that you have a lot of plants in your room.” Please tell me about your room and how you feel about it. Do you enjoy spending time in your room?

Is there enough light for you?
Is the room temperature comfortable?
Have you lived in a different room in the facility?
(If yes) What was the reason for the room change?

Did you have a choice about changing rooms?
Where was your other room? What was it like?
Is there anything you would like to change about your
room?
(If yes) Have you talked to the facility about this? How
did they respond?

Form CMS-806A (07/95)

5.91

RESIDENT INTERVIEW
2. ENVIRONMENT: (F252, 258)
I realize that being in a nursing home is not like being in your own home, but do staff here try to make this facility seem
homelike?
We've already talked about your room. How about other
places you use, like the activities room and dining room? Do they seem homelike to you?

Is there anything that would make this facility more
comfortable for you?
Is it generally quiet or noisy here?
What about at night?
Is the facility usually clean and free of bad smells?

3. PRIVACY: (F164, 174)
Are you a person who likes to have privacy sometimes? Are
you able to have privacy when you want it?
Do staff and other residents respect your privacy? Do
you have a private place to meet with visitors?

(If no phone in room) Where do you make phone calls? Do
you have privacy when you are on the phone? (If the
resident indicates any problems with privacy, probe for specific examples. Ask if they talked to staff and what was their
response.)

4. FOOD: (F365)
Tell me about the food here.
Do you have any restrictions on your diet?
How does your food taste?
Are you served foods that you like to eat?
Are your hot and cold foods served at a temperature you
like?

Have you ever refused to eat something served to you? (If
yes) Did the facility offer you something else to eat?
(If the resident refused a food and did not get a substitute) Did you ask for another food? What was the facility's
response?

5. ACTIVITIES: (F242, 248)
How do you find out about the activities that are going on?
Are there activities available on the weekends? Do
you participate in activities?
(If yes) What kinds of activities do you participate in?
(If resident participates) Do you enjoy these activities?

(If resident does not participate, probe to find out why not.) Is there some activity that you would like to do that is not available here?
(If yes) Which activity would you like to attend? Have you
talked to anybody about this? What was the response?

Form CMS-806A (07/95)

5.92

RESIDENT INTERVIEW
6. STAFF: (F223, 241)
Tell me how you feel about the staff members at this
facility. Do they treat you with respect?
Do you feel they know something about you as a person? Are
they usually willing to take the time to listen when
you want to talk about something personal or a
problem you are having?
Do they make efforts to resolve your problems?

Has any resident or staff member ever physically
harmed you?
Has any resident or staff member ever taken anything
belonging to you without permission?
(If yes) Can you tell me who did this?
Has a staff member ever yelled or sworn at you?
(If yes) Please describe what happened.
Can you tell me who did this? Did you report this to
someone?
(If yes) How did they respond?

7. ADLs: (F216, 311, 312)
(Tailor this question to what you have observed and what is
noted in the MDS about ADL capabilities of this resi- dent.) For example: I see that your care plan calls for you to dress with a little help from staff. How is that working for you?

Do you feel that you get help when you need it?
Do staff encourage you to do as much as you can for
yourself?

8. DECISIONS: (F154, 242, 280)
Here at this facility, are you involved in making choices
about your daily activities?
Are you involved in making decisions about your nursing care and medical treatment?
(If not, probe to determine what these choices and decisions are, and relate this information to necessary restrictions that are part of the resident's plan of care.)
Do you participate in meetings where staff plan your
activities and daily medical and nursing care?

If you are unhappy with something, or if you want to
change something about your care or your daily schedule,
how do you let the facility know?
Do you feel the staff members listen to your requests and
respond appropriately?
If the staff are unable to accommodate one of your requests, do they provide a reasonable explanation of why they cannot
honor the request?
Can you choose how you spend the day?
Have you ever refused care or treatment (such as a bath or
certain medication)?
(If yes) What happened then?

Form CMS-806A (07/95)

5.93

RESIDENT INTERVIEW
9. MEDICAL SERVICES: (F156, 163, 164, 250, 411,
412)
Who is your physician?
Did you choose your physician yourself?
(If no, probe for details about who selected the physician
and why the resident did not do it.)
Are you satisfied with the care provided by your
physician?
Can you see your doctor if you need to?

Do you see your physician here or at the office?
(If they say here) Where in the facility does your doctor
see you?
Do you have privacy when you are examined by your
physician?
(If they say they go to the office) How do you get to the
office?
Do facility staff help you make doctor's appointments
and help you obtain transportation?
Can you get to see a dentist, podiatrist, or other
specialist if you need to?

10. (Write here any special items not already discussed that you have noted about this resident or about the facility that you would like to discuss with the resident.)

11. Is there anything else you would like to talk about regarding your life here?

Thank the resident. Review your notes from this interview and determine if there are any concerns you need to investigate further. Share any problems you have found with the team so they may keep them in mind during the remainder of the survey.

5.94

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT FAMILY INTERVIEW
Facility Name:
Provider Number:
Surveyor Name:
Surveyor Number:
Method of Contact: In person

Resident Name:
Resident Identifier:
Person Interviewed:
Discipline:
Phone

Relationship to Resident:
Interview Dates/Times:

Instructions:
This interview is intended to be conducted with a person (family, friend or guardian) who is the one acting on behalf of the resident and authorizing care. Prior to the interview, complete as many questions as you can through review of the resident assessment, care plan and any activities or social service assessment. Adapt these questions and probes as necessary to make them applicable to this resident. Introduce yourself and explain the survey process and the purpose of the interview using the following concepts. It is not necessary to use the exact wording.

“[Name of facility] is inspected by a team from the [Name of State Survey Agency] periodically to assure that residents receive quality care. While we are here, we make observations, review the nursing home’s records, and talk to residents and family members or friends who can help us understand what it's like to live in this nursing home. We appreciate your taking the time to talk to us.

“We ask these questions because we want to know about your opportunity for involvement in decision about ‘s care and schedule, your views on services he/she receives here, and in general, what you think of the facility. We want to know if the facility has obtained information about ’s past and current preferences in order to

provide the highest quality of care. We also want to find out about the admission process and what the facility discussed with you about costs and payment for
’s stay here.
Question 1 below screens the family member to see if she/he knows the resident well enough to complete the rest of the interview. Based on answers to question 1, decide whether you can complete the interview, complete it partially if the family member knows some things, or conclude the interview. If you decide you must conclude this interview, ask a general question that lets the family member say what they wish to say about the facility such as: “Is there anything you would like to tell me about this facility and how your relative is treated?”.

1. (Ask about the nature and extent of the relationship between interviewee and resident both prior to and during nursing home residence):
With whom did your relative/friend live before coming to the nursing home? (If the resident did not live with this person) About how often did you see her/him?

How often do the resident and you see each other now?

Are you familiar with
’s preferences and daily routines when he/she was more independent and more able to make choices and express preferences? (If the resident has had a lifelong disability, ask about choice and preferences prior to moving to this facility. Adapt question 2 and 3 also.)

5.95

FAMILY INTERVIEW
To the extent that the interviewee is knowledgeable about the resident's past life, ask the following: 2. I have some questions about
's life-style and preferences when she/he was more independent and able to express preferences. Would you tell me about:
Did he/she enjoy any particular activities or hobbies?
Was she/he social or more solitary?
Types of social and recreational activities;

Eating habits, food likes and dislikes;
Sleeping habits, alertness at different times of the day;
Religious/spiritual activities;
Work, whether in or out of the home;
Things that gave him/her pleasure.

3. The next questions are about the resident's lifelong general personality. How would you describe: General manner; for example, was she/he thought to
be quiet, happy, argumentative, etc.?
How she/he generally adapted to change, prior to the
current disability. How, for example, did the resident
react to moving to a new residence, to losing a loved one,
and to other changing life situations?

Characteristic ways of talking — was she/he talkative or
usually quiet, likely to express herself/himself or not?

4. Have any of the preferences and personality characteristics that you told me about changed, either due to a change in her/his condition or due to relocation to this facility?
Have her/his daily routines and activities changed in a substantial way since moving here? (If yes) Please describe these differences.

5.96

FAMILY INTERVIEW
5. (For all the items below: If the family member describes any problems, probe for specific information. Ask if they have talked to staff, and what was the facility's response. If the resident's payment source changed from private pay or Medicare to Medicaid, inquire if there were any changes in any of the following after the payment source changed.) Please share with me your observations, either positive things or concerns, about all of the following items. If you have no information about these issues that is OK.

Meals and snacks (F242, 310, 365, 366, 367)
Routines and activities (F242, 245, 248)
Visitor policies and hours, privacy for visits when desired
(F164, 172)
Care by nursing home staff (F241, 309–312)

Noise level of the facility (F258)
Privacy when receiving care (F164)
Transfers (F177, 201, 203–207)
Security and personal property (F159, 223, 252)
Cleanliness and odor (F252–254)

6. Did you participate in the admission process?
(If yes) Were you told anything about using Medicare or Medicaid to pay for ’s stay here?
(If yes) What did they tell you?
(If resident's care is being paid by Medicaid) Were you asked to pay for any extras above the Medicaid rate? (If yes) What were these? Did you have a choice about receiving these services? When your relative/friend moved here, did the facility ask you to pay out of your savings or your relative's savings? (F156, 208)

7. Are you the person who would be notified if
’s condition changed. (If yes) Have you been notified when there have been changes in your relative's condition? Are you involved in ’s care planning? (F157)

8. “Is there anything else that I have not asked that is important to understand about here?”

’s everyday life

When finished: “Thank you for your help. You will be able to examine a copy of the results of this survey in about days.”

5.97

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT GROUP INTERVIEW
Facility Name:
Provider Number:
Interview Dates/Times:

Surveyor Name:
Surveyor Number:
Discipline:

Residents Attending:

Instructions:
Introduce yourself to the group and explain the survey process and the purpose of the interview using the following concepts. It is not necessary to use the exact wording.
“[Name of facility] is inspected by a team from the [Name of State Survey Agency] periodically as one part of a process in which we evaluate the quality of life and quality of care in this facility. While we are here, we make observations, look over the facility's records, and talk to residents about life in this facility.

We appreciate you taking the time to talk to us.
We would like to ask you several questions about life in the facility and the interactions of residents and staff.” 1. RULES: (F151, 242, 243)
Tell me about the rules in this facility.
For instance, rules about what time residents go to bed
at night and get up in the morning?
Are there any other facility rules you would like to
discuss?

2. PRIVACY: (F164, 174)
Can you meet privately with your visitors?
Can you make a telephone call without other people
overhearing your conversation?

Do you as a group have input into the rules of this
facility?
Does the facility listen to your suggestions?

Does the facility make an effort to assure that privacy
rights are respected for all residents?

5.98

GROUP INTERVIEW
3. ACTIVITIES: (F242, 248)
Activities programs are supposed to meet your interests
and needs. Do you feel the activities here do that?
(If no, probe for specifics.)
Do you participate in the activities here?
Do you enjoy them?
Are there enough help and supplies available so that
everyone who wants to can participate?
Do you as a group have input into the selection of the
activities that are offered?
How does the facility respond to your suggestions?

4. PERSONAL PROPERTY: (F252)
Can residents have their own belongings here if they
choose to do so?
What about their own furniture?
How are your personal belongings treated here?
about this? What was their response?

5. RIGHTS: (F151, 153, 156, 167, 168, 170, 280)
How do residents here find out about their rights — such
as voting, making a living will, getting what you need
here?
Are you invited to meetings in which staff plan your
nursing care, medical treatment and activities?
Do you know that you can see a copy of the facility's
latest survey inspection results?
Where is that report kept here?

6. DIGNITY: (F223, 241)
How do staff members treat the residents here, not just
yourselves, but others who can't speak for themselves?
Do you feel the staff here treat residents with respect
and dignity?
staff about this? How did they respond?

Is there anything about the activities program that you
would like to talk about?
Outside of the formal activity programs, are there
opportunities for you to socialize with other residents?
Are there places you can go when you want to be with
other residents?
(If answers are negative) Why do you think that occurs?

Does the facility make efforts to prevent loss, theft, or
destruction of personal property?
Have any of your belongings ever been missing?
(If anyone answers yes) Did you talk to a staff member

Do you know how to contact an advocacy agency such
as the ombudsman office?
Do you know you can look at your medical record?
Have any of you asked to see your record? What was
the facility's response?
Has anyone from the facility staff talked to you about
these things?
Tell me about the mail delivery system here.
Is mail delivery prompt? Does your mail arrive
unopened daily?

Do they try to accommodate residents' wishes where
possible?
(If answers are negative) Please describe instances in
which the facility did not treat you or another
resident with dignity. Did you talk to anyone on the

5.99

GROUP INTERVIEW
7. ABUSE AND NEGLECT: (F223)
Are you aware of any instances in which a resident was
abused or neglected?
Are you aware of any instances in which a resident had
property taken from them by a staff member without
permission?
(If yes) Tell me about it. How did you find out about it?
Are there enough staff here to take care of everyone?
(If no) Tell me more about that.

8. COSTS: (F156, 207)
Are residents here informed by the facility about which
items and services are paid by Medicare or Medicaid
and which ones you must pay for?
If there was any change in these items that you must pay
for, were you informed?

9. BUILDING: (F256, 257, 258,463,465,483)
I'd like to ask a few questions about the building,
including both your bedroom and other rooms you
use such as the dining room and activities room.
Is the air temperature comfortable for you?
Is there good air circulation or does it get stuffy in these rooms?
rooms?
(If yes) Tell me about it.

10. FOOD: (F364, 365, 367)
The next questions are about the food here.
Is the flavor and appearance of your food satisfactory?
Outside of the dietary restrictions some of you may have,
do you receive food here that you like to eat?
If you have ever refused to eat a particular food, did the
facility provide you with something else to eat? (If no,
probe for specifics.)
Is the temperature of your hot and cold foods appropriate?
Are the meats tender enough?

We are willing to discuss any incidents that you know of
in private if you would prefer. If so, just stop me or
one of the other surveyors anytime, and we'll listen
to you.

Are you aware of any changes in the care any resident
has received after they went from paying for their
care to Medicaid paying?
(If answers suggest the possibility of Medicaid discrimination, probe for specific instances of differences in care.)

What do you think about the noise level here? Is it
generally quiet or noisy? How about at night?
Do you have the right amount of lighting in your room
to read or do whatever you want to do?
How is the lighting in the dining rooms and activity
Do you ever see insects or rodents here?

About what time do you receive your breakfast, lunch,
and dinner?
Are the meals generally on time or late?
What are you offered for a bedtime snack?
If you ever had a concern about your food, did you tell
the staff? What was their response?

5.100

GROUP INTERVIEW
11. COUNCIL: (F243)
(If you are speaking with a resident council)
Does the facility help you with arrangements for council
meetings?
Do they make sure you have space to meet?
Can you have meetings without any staff present if you
wish?

12. GRIEVANCES: (F165, 166)
Have any of you or the group as a whole ever voiced a
grievance to the facility?
How did staff react to this? Did
they resolve the problem?

How does the council communicate its concerns to the
facility?
How does the administrator respond to the council's
concerns?
If the facility cannot accommodate a council request, do
they give you a reasonable explanation?

Do you feel free to make complaints to staff? If not, why
not (probe for specific examples)?

13. Identify here any issues you would like to discuss with the group that have not been covered in the questions above.

14. Is there anything else about life here in the facility that you would like to discuss?

Thank the group for their time. After the interview, follow up on any concerns that need further investigation. Document your follow up on Resident Review or Supervisor Notes Worksheets. Share these concerns with the team.

5.101

1.
2.
3.
4.

RESIDENT COUNCIL MEETING AUDIT
Arrange for a Resident Council Meeting with interviewable residents. Use probe questions to ascertain if issues are met/not met.
Circle potential deficiencies.
Facility staff should not be present at this meeting.

TOPIC

TAG#

QUESTIONS/PROBES

Food
Quality
Snacks
Temps
Temps
Mealtime

F-364
F-367
F-364
F-364
F-364
F-366

Snacks
Privacy
Visitors
Phone
Possessions

F-368
F-164
F-172
F-174
F-223

Mail

F-170

Privacy
Choice
Environment
Individual
Choice
Transfer

F-460
F-246
F-252
F-256

Choice

Choice

F-246
F-242
F-465
F-253
F-252
F-155

Physician

F-163

Adv. Dir
Activities

F-156
F-248
F-246
F-246

How does the food taste?
Are you on a special diet?
Are you served food you like to eat?
Are your hot foods hot?
Are your cold foods cold?
Have you ever refused to eat something? Did the
facility offer you something else?
Are you offered snacks in the evening?
Do you like your privacy? Do you get it?
Do you have a private place to meet with visitors?
Where do you make a phone call? Is it private?
Has anyone taken anything of yours without
permission?
Is your mail delivered when received? Is your mail
delivered unopened?
Do you have privacy when examined by a physician?
Tell me about your room and how you feel about it.
Do you enjoy spending time in your room?
Is there enough light for you?
Is the temperature comfortable?
Have you ever lived in a different room in the
facility?
Did you have a choice about room changes? Where
was your other room?
Is there anything you would like to change about your
room?
Have you asked the facility? Is it quiet or noisy?
Does the staff try and make it homey? Can you
choose how you spend the day?
Have you refused a medication or treatment?
What happened then?
Who is your physician?
Did you choose your physician yourself?
Did you choose to do Advanced Directives?
Are there activities on the weekends? How do you
find out about activities?
Is there
activities
you would like to do
Are
yousome
treated
with respect?
that
is
not
available
here?
Does the staff know you as a person?
Havethey
you willing
talked with
anyone
else?if you have a
Are
to listen
to you

Dignity
Grievance

F-201
F-155
F-177

MET

NOT
MET

COMMENTS

F-165
F-166 problem?
Do they try to solve your problems?

5.102

Abuse
Neglect

Call lights
Care needs
met

Medical
Condition

Finance
Charges
Trust Fund
Ombudsman
Survey
Rights

F-223 Has anyone physically harmed you?
F-165 Has any staff member yelled or swore at you?
Did you tell anyone?
What happened?
If you are unhappy with something, how do you let
the facility know?
Does the staff listen and respond to your requests?
If they can’t honor your request, do they give you a
reasonable explanation?
F-241 Does the staff answer your call bell/light when you
put it on?
F-311 Do you get help when you need it?
F-310 Does the staff encourage you to do as much as you
F-328 can for yourself?
How about your nursing care and treatment?
Do you participate in meetings where your care
plan is discussed?
If not, does someone discuss your plan of care with
you?
F-385 Are you satisfied with the care provided by your
F-387 physician?
F-411 Can you see a doctor if you need to?
Do you see the doctor here or at the office?
How do you get to the doctor’s office? Does the
facility help you make appointments and arrange
transportation? Can you see the podiatrist, dentist,
optometrist or other specialist if you need to?
F-156 Do you know how to get in touch with the
F-162 Medicaid & Medicare office about your bill? Does
the facility explain charges to you?
F-159 Can you get money from your trust fund when you
need it?
F-168 Do you know how to call the Ombudsman?
F-169 Have you seen the facility’s survey results?
F-151 Did you have an opportunity to vote in the last
election?

GENERAL COMMENTS:
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

5.103

ACTIVITIES CHART AUDIT TOOL
Area of Review

Resident ID

Assessment
Timely, within 14 days
Thorough
Complete
Care Plan
Modified as needed
Goals discontinued appropriately
MDS
Section F
Progress Notes
Quarterly
Evidence assessment reviewed
Reassessments
Significant change
Annual
Activity Participation Record
Maintained
Separate record each resident
In-Room Activities
3x a week for those unable to leave their room
1x per week for those who refuse group activities
Therapeutic goals documented
Discharge Summary
Completed / Interdisciplinary

5.104

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