CH 2 Flashcards
enforcement activity means ___
imposition of remedies such as civil money penalties; appointment of a receiver or temporary manager; conditional licensure; suspension or revocation of a license; a directed plan of correction; intermediate restrictions or conditions
individual licencees must notify the department of health at least ___ prior to any name change or any other contact information
30 days
a provisional license shall be valid for ___
90 days
except for ALF a 2nd provisional license may be issued if ___
substantial progress continues to be made and it is likely compliance can be achieved by date of expiration of second provisional license
licensee seeking renewal shall submit renewal application ___ prior to expiration of the existing license
60 days
applicants have ___ to respond to written notice of any application defect
14 days
a change of ownership requires the department of health to be notified of said change __ before the change takes place
90 days
change of ownership for assisted living, home health, hospice with less than 16 in patient beds shall notify the department at least ___ days before the change
30 days
conversion of a health care entities legal structure or legal structure of an entity that has direct ownership interest in a health care entity is not a change of ownership unless ____
the conversion includes a transfer of at least 50% of the direct ownership to one or more new owners
the department shall review an applicants fitness to conduct a licensed operation by ___
completing an on-site inspection or other appropriate investigation
the department shall not issue or renew any license unless it has received ____
certificate of compliance from division of fire prevention and control
the department may allow admission above the licensed capacity for no longer than ___ if ___ and ___
no longer than 1 month
if the patient requires immediate admission and there is no alternative source of admission
in the event of a health emergency involving multiple ill or injured persons, health care entities may admit above their max bed capacity for a period of no more than ___. One extension for no more than ___ may be requested
14 consecutive days
a license issued by the department may be revoked, suspended, limited, or modified at any time because of ___
licensees failure to comply with applicable statutes or regulations
if conditions are imposed at the same time as an initial or renewal license the applicant shall
pay the applicable initial or renewal license fee plus conditional fee
if a licensee holds a conditional license it shall post a clearly legible copy of the license conditions in a ___
in a conspicuous public place
each license or certificate of compliance shall become invalid when the licensee fails to timely renew the license, ceases operation, or there is a final agency action. In this case the license shall be returned within ___
10 calendar days
when health care entity surrenders its license it shall inform the department in writing of specific plan for storage and retrieval of records within ___
10 calendar days
within __ days of closure the facility shall inform all residents in writing how to obtain their records
10 calendar days
the department has a discretion to deny a requested increase in license capacity if ___
they determine potential risk to the health, safety or welfare of the patients
routine unannounced on site inspections by a department member shall be made only between the hours of ___
7am and 7pm
the department may use ___ and ___ measures to ensure a licensees full compliance with the statutory and regulatory criteria.
- unscheduled or unannounced reviews
2. plan of correction
plan of correction shall include ___
- description of how licensee will correct deficiency
- description of how licensee will monitor the corrective action
- timeline with the expected implementation and completion date.
the plan of correction implementation date shall be no longer than ___
30 calendar days from the date of mailing of the deficiency to the licensee
a plan of correction must be submitted back to the department within ___ of the departments notice of deficiencies and must be signed by ___
10 calendar days
the administrator
if the plan of correction is accepted, the department shall notify the entity in ___
writing
if the plan of correction is unacceptable the department shall notify the licensee in writing and the licensee shall resubmit the changes within ___
time frame prescribed
if the licensee fails to implement the actions agreed to by the correction date in the approved plan of correction the department may ___
impose disciplinary sanctions
the department may deny an application for a license for reasons including ___
the applicant ….
- has not complied with local state and federal laws.
- application or documents contain false statement
- fails to respond timely
- refuses any part of on site inspection
- fails to comply with acceptable plan of correction
- background check reveals issues
- failed to cooperate with investigation
- has pattern of non compliance
healthcare entity shall be eligible for a performance incentive if ___
- licensee has no significant deficiencies
- licensee has fully cooperated during on site inspection
- department has found no documented actual or potential harm
- plan of correction was submitted and executed within required time
the incentive payment shall be calculated at __ of the agencies renewal license fee
10%
the incentive payment shall be payed to the licensee within ___ days following the acceptance of the validation of correction of sited deficiencies
60 days
every healthcare entity licensed by the department shall establish a ___ program appropriate to the size and type of facility
quality management
quality management program shall include description of cases, problems, or risks to be reviewed and criteria for ___ without limitation
identifying potential risks
quality management program shall include identification of the ___ or ___ responsible for coordinating quality management activities and the means of reporting to the administrator
personnel
or
committees
quality management program shall include description of the method for systematically reporting information to ___ within prescribed time
person designated by the facility
quality management program shall include a method for ___ and ___ the frequency and causes of individual problems
investigating
and
analyzing
quality management program shall include method for taking corrective action to address the problems including ___ and ___ risks
preventing
and
minimizing
quality management program shall include method for ___ of corrective action to determine effectiveness
follow-up
quality management program shall include method for coordinating all pertinent case, problem, or risk review information such as procedures for review of ___, ___, ___, and ___
resident care
employee conduct
grievance system
training programs
quality management committee meeting shall be held at least every ___
90 days
occurrences shall be reported to the department within ___
the next business day
occurrences that require a report to the department by next business day are ___
- occurrence resulting in death of a patient
- occurrence resulting in serious injury to patient
- patient cannot be located for more than 8 hours
- occurrence involving 7 forms of abuse
- occurrence involving drug diversion
- occurrence involving intentional or accidental misuse of patient care equipment that significantly effects patient health
true or false: health care entity must have policy for requiring its employees to report occurrences to it
TRUE
upon receipt of occurrence summary report from the department the health care entity shall be allowed ___ to review, comment, and verify information
7 days
if palliative care is provided the licensee shall have written ___ and ___ for comprehensive delivery of services
policies and procedures
general waiver applications shall include ___
- copy of the posted notice
- schematic drawings of area affected if pertains to physical plant
- services affected by the waiver
- number of residents in facility
- description of applicants efforts to comply with regulation
- explanation of applicants proposed alternatives
- explanation of why waiver would not adversely affect welfare of residents
- description of how federal regulation will be met despite waiver
no later than the date of submitting the waiver the applicant shall post written notice of the application for ___ at all public entrances
30 days
the department shall act on a waiver application within ___ of receipt of the completed application
90 days
within ___ of expiration of waiver the applicant shall submit to the department an attestation
30 days
to prevent automatic termination of a waiver upon change of ownership the new owner may submit a waiver prior to ___
effective date of change of ownership
no waiver shall be granted for a term that exceeds ___ from the date of issuance
1 year
to maintain a waiver beyond stated term applicant must submit new waiver application not less than ___ prior to the expiration of the current waiver
90 days
a patient may inspect his/her patient record within a reasonable time, which should normally not to exceed ___ from request excluding ___
24 hours
weekends and holidays
an acceptable reason not to show a portion of a residents health record to the resident would be
the attending provider feels that said portion would have significant negative psychological impact upon the patient
the facility shall make the discharge record available for inspection within a reasonable time. normally not to exceed ___ excluding ___
10 days
holidays and weekends
financial interest means
direct ownership of 5% or more of stock or property
resident or resident representative has the right to participate in ___ involving treatment
decisions
resident or resident representative has the right to be informed of whether health care entity is participating in ___
teaching programs
resident or resident representative has the right to refuse ___ and be informed of ____ and ___
treatment
risks and benefits
resident or resident representative has the right to care and treatment that is ___ and recognizes a persons ___
respectful
dignity
resident or resident representative has the right to know the names, professional status and ___ of the staff
experience
resident or resident representative has the right to receive upon request the estimated ___
average charge to the patient
upon request an itemized bill shall be made available within ___ of the request or ___ after discharge
10 days
30 days after discharge
resident or resident representative has the right to give informed consent for all __ and ___
treatment
and
procedures
resident or resident representative has the right to register complaints with the healthcare entity and the department and to be informed of ___ for registering complaints
procedures
resident or resident representative has the right to be free of ___ and ___
abuse
and
neglect
resident or resident representative has the right to be free of the inappropriate use of ____
restraints
resident or resident representative has the right to be accepted for care and services to a facility that can ___
meet their identified and reasonably anticipated treatment needs
resident or resident representative has the right to care delivered by the health care entity in accordance with
the needs of the patient
resident or resident representative has the right to confidentiality of ___
medical records
resident or resident representative has the right to receive care in a ___
safe setting
resident or resident representative has the right to know whether referrals to other providers are entities in which the health care entity has a ___
financial interest
resident or resident representative has the right to formulate advanced directives and have the health care entity comply with such directives as applicable and in compliance with ____
applicable state statutes
the health care entity shall disclose patient rights prior to ___ or upon ___
treatment
or
upon admission
must post a clear and unambiguous notice in public location specifying that complaints may be registered with ___, ___, and with the appropriate over sight board at the ___
health care entity
department
DORA
residents shall be able to submit grievances ___ hours per day either ___ or in ___ to health care entity staff member
24 hours a day
orally
writing
the patient care advocate shall investigate the grievance and respond to the patient in writing within ___ working days
15 days
a health care entity may use reprocessed single use device when obtained from ___
a re-processer registered with the FDA
a health care facility shall routinely submit its hospital acquired infection data to ____
national health safety network (NHSN)
if department determines that health facility is out of compliance with any provisions it may impose the following sanctions
- revocation of license
- denial of renewal for license
- civil penalty of up to 1,000 dollars per violation for each day the health facility is deemed to be out of compliance
___ % of employees vaccinated by 12/31/12
60%
___ % of employees vaccinated by 12/31/13
75%
___% of employees vaccinated by 12/31/14 and by 12/31 each year thereafter
90%
annual influenza vaccination report shall be submitted to the department no later than ____ the following year
March 31st
