Regulations Flashcards
Facility
Skilled nursing facility or nursing facility that may include a distince part of an institution but does not include an institution fo rth ementally retarded or related conditions.
Skilled Nursing Facility
institution which is primarily engaged in providing skilled nursing care and related services for residents who require medical, nursing or rehab care and is not primarily fo rthe care of mental diseases and has a transfer agreement with 1 or more hospitals
Nursing Facility
institution which is primarily engaged in providing skilled nursing care and related services for residents who require medical, nursing or rehab care, or on a regualar basis health related care and services to people who because of their mental or physical condition reuqire care above room and board which can on be provided through institutional facilities and is not primarily fo rthe care of mental diseases and has a transfer agreement with 1 or more hospitals
Resident Rights
Exercise rights
Be informed about rights and responsibilities
Have facility manage personal funds
Choose physician, treatment, participate in decisions and care planning
Privacy and confidentiality
Voice grievances and have facility respond
Examine survey results
Work or not work
Privacy in sending and receiving mail
Visit and be visited by others from outside
Use telephone in privacy
Retain and use personal possessions to extent space and safety allow
Share room with spouse if mutally agreeable
Self administer meds if determined safe
Refuse transfer from distinct part of facility
Rights - Exercise rights
Resident has coice to max possible about how they wish to live and receive care subject to facility rules (that do not violate regs)
Rights - Reprisal
To protect resident in exercise of rights.
Facility must not retaliate, behaviors must support and encourage resident participation in using rights
Rights - Incompetent Resident
Rights are exercised by person appointed by court, State law or legal-surrogate
Rights - Records
Resident or legal representative has right upon oral or written request have access to all records including current clinical records within 24 hours (not including holidays or weekends)
Rights - Records copies
After receipt of records for inspection they have the right to purchase any portion of them upon request with 2 working days notice (cost is community standard or set by state)
Rights - Language
Resident has right to be fully informed in language they can understand of total health status, including medical condition.
Total health status
functional status, medical care, nursing care, nutrititional status, rehavilitation and restorative potential, activities potential, cognitive status, oral health status, psychosocial status, sensory and physical impairments
Rights - Informed
Resident has the right to be fully informed in advance about care and treatment adn any changes in care or treatment that may affect well being
Rights - Refuse
Resident has right to refuse treatment, participate in experimental research, formulate advance directive
Treatment
care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms
Experimental research
development and testing of clinical treatments, such as investigational drug therapy involving treatment and/or control groups
Advance directive
wirtten instruction, such as living will, durable power of attorney for health care
Rights refusal - facility responsible to
Facility should determine what and why for refusal, address concerns, assess reasons for refusal, clarify and educate resident of consequences of refusal, offer alternative treatments, continue to provide other services.
Rights refusal - significant change
Facility should reassess resident and institute care plan changes, must still provide highest practicable physical, mental and phychosocial well being in context of making the refusal
Rights - Informed rights
Facility must inform orally and in writing in language resident understands of their rights, including any State developed under the Act, and rules and regulations governing resident conduct and responsibilities during stay. Notification must be made prior to or upon admission and during the resident stay, receipt must be acknowledged in writing including any amendments to it
Rights - Inform Medicaid benefits
Inform each resident who is entitled to Medicaid in writing at admission or when resident becomes eligible - items which are included and that may not be charged to resident AND other items and services offered which the resident may be charged, and the amount charged, residents must be informed when there are changes
Rights - charges
Residents should be told in advance when charges will occur in their bills
Periodically (charges)
whenever changes are being intorduced that will affect the residents liability and whenever there are changes in services
Rights - charges Medicare
Facility must inform each resident before or at time of admission and periodically during stay of services available in facility and charges for services including any charges for services not covered under Medicare or by facility per diem rate
Rights - description
Facility must furnish written description of legal rights
Rights - description personal funds
Description of manner of protecting personal funds - resident has right to manage their financial affairs, facility may not require resident to deposit personal funds with facility - upon written authorization facility must hold, safeguard, manage and account for personal funds of resident deposited with facility - funds over $50 must be deposited in interest bearing account separate from any facility operating acounts, in pooled accounts there must be separate accounting for each residents share - funds less than $50 in non-interest bearing accounts, interest bearing account, or petty cash fund - exception is Medicare SNF resident minimum is $100 to interest bearing account
Personal funds accounting and records
Facility must establish and maintain system with full complete and separate accounting of each resident’s personal funds entrusted to facility - must preclude any commingling of resident funds with facilitiy funds or funds of any person other than another resident - individual record must be available through quarterly statements and on request to resident or legal representative
Personal funds notice of certain balances
Facility must notify each residents that receives Medicaid when amount in account reaches $200 less than SSI resource limit for 1 person - If amount in addition to value of residents other nonexempt resources reaches SSI resource limit for 1 person, the resident may lose eligibility for Medicaid or SSI
Personal funds conveyance upon death
Upon death of resident with personal fund deposited with the facility, the facilty must convey within 30 days the resident’s funds and final accounting of those funds to individual or probate jurisdiction administering the estate
Personal funds assurance of financial security
The facilty must purchase a surety bond or toherwise provide assurance for the security of all personal funds of residents deposited with the facility
Personal funds limits on charges
Facilty may not charge agains personal funds any item or services which payment is made under Medicaid or Medicare (except applicable deductible and coinsurance) - facility may charge for requested services more expensive than or in excess of covered services
Services/items which may not be charged under Medicare or Medicaid
Nursing services, dietary services, activitiy programs, room/bed maintenance, routine personal hygiene items and services (hair, soap, cleansing agents, razor, toothbrush, lotion, deodorant, incontinence, towels, OTC drugs, laundry, ect.), medically related social services
Services/Items which may be charged under Medicare or Medicaid
May be charged if requested by resident, if facility informs resident there will be charge and there is no MA or MC payment - telephone, personal TV/radio, personal comfort items (smoking, novelties, confections), cosmetic/grooming in excess of covered items, personal clothing, personal reading matter, gifts, flowers/plants, socal events and entertainment outside scope of activities programs, noncovered special care services (private nurse/aide), private room unless therapeutically required (isolation), specially prepared or alternative food instead of what is offered by facility
Personal funds requests for items/services
Facility must not charge resident for any item or service on requested by resident, facility may not require resident request any item or services as condition of admission or stay, facility must inform resident of charge for any item or service and what charge will be
Rights - eligibility for Medicaid
description of requirements and procedures for establishing eligibility for Medicaid, including right to request and assessment which determines extent of couples non-exempt resources at the time of admission and attributes to the community spouse an equitable share of resources which can’t be considered available for payment toward the cost of admitted spouses medical care in his or her process of Medicaid spending down
Protection and Advocacy network
refers to system established to prtect and advocate the rights of individuals with developmental disabilities, and the prtection and advocacy system established under the protection and advocacy for mentally ill individuals act
Rights - posted information
posting of names, addresses, phone numbers to all pertinent state client advocacy groups such as State survey and certification agency, licensure office, ombudsman, protection and advocacy network, and Medicaid fraud control, and a statement that the resident my file a complaint with the agency concerting abuse, neglect, misappropriation of resident property and noncompliance with advance directives
Rights - Advance Directives
Facilty must maintain written policies and procedures regarding advance directives, including provisions to inform and provide written information to all residents concerning the right to accept or refuse medical or surgical treatment and the individuals option, formulate an advance directive, including wirtten descripton of facilities policies to inplement advance directives and applicable State law
Rights - Physician information
Facility must inform each resident of name, specialty and way to contact the physician responsible for their care
Rights - Medicare/Medicaid benefits appy
Facility must prominently display written information and provide residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and receive refunds for previous payments covered by such benefits
Rights - Notification of change
Facility must immediately inform resident; resident physician;legal representative; interested family member when - an accident involving resident which results in injury and has potential for physician intervention, significan change in physical, mental or psychosocial status, need to alter treatment significantly, decision to transfer or discharge resident from facility, change in room or roommate assignment, change in resident rights
Demographic contact information
Facility must record and periodically update adress and phone number of resident’s legal representative or interested family member
Personal funds
Facility must have written authorization,
Basic personal laundry
does not include dry cleaning, mending, washing by hand or other specialty services resident may be charged for these services
Hair hygiene supplies
refers to combs, brush, shapmoo, trims, simple hari cuts provided by faciltiy staff as part of routine grooming, hair cuts, ect performed by beauticians not employed by facility may be charged
Nail hygiene services
routine trimming, cleaning, filing and individually care for ingrown or damaged nails but not polishing of undamaged nails
Rights - personal physician
Resident has right to choose peronal physician - however if physician fails to fulfill requirements, facility has the right after informing resident to seek alternate physician participation to assure provision of appropriate and adequate care/treatment, facility may not place barriers to resident choosing own physician, facility may require physician be choosed from ones with practice privileges at facility
Rights - Privacy and confidentiality
Resident has right to privacy and confidentiality of personal and clinical records
Rights - Personal privacy
includes accommondations, medical treatment, written and phone communications, personal care, visits, meetings of family and resident groups, does not require private rooms
Rights - Records
Resident may approve or refuse release of personal and clinical records to any individual outside facility, right to refuse does not apply when resident is transferred to another health institution or release is required by law
Rights - Confidential records
Facility must keep all information in resident records regardless of form or storage except when release is required by - transfer to another health care institution, law, thrid party payment contract, the resident
Rights - Grievances
Resident has right to voice grievances without descrimination or reprisal, including respect to treatment, furnished or not furnished
Rights - Resolve grievances
Prompt efforts by facility to resolve grievances including those regarding behavior of other residents
Rights - Survey
Resident has right to examine results of most recent survey, results placed readily accessible to residents and post notice of their availablility
Rights - client advocacy
resident has right to receive information from agencies and have the opportunity to contact these agencies
Rights - Work
resident may refuse to perform services for facility, perform services for facility if they choose when - faciliyt documents the need or desire for work in plan of care, plan specifies the nature of services and if voluntary or paid, compensation for paid services are at or above prevailing wages, resident agrees to arrangement in plan of care
Rights - Mail
Resident has right to privacy in written communications, send and receive mail promptly and unopened, access to stationery, postage, writing implements at residents own expense
Promptly - regarding mail
Delivery of mail to resident within 24 hours of delivery by postal service, delivery to postal service within 24 hours except when there is no scheduled postal delivery or pick up
Rights - Access and visitation
Resident has right and facility must provide immediate access to any resident - any representative of the secretary, representative of the state, residents individual physician, ombudsman, agency responsible for protection for develpmentally disabled, agency responsible for protection of mentally ill, immediate family or other relatives, others who are visiting with consent of resident, reasonable access by any entity providing health, social, legal or other services to resident
Ombudsman access
Facility must allow ombudsman to examine resident’s clinical records with permission of resident or representative
Rights - Telephone
Resident has right to reasonable access to phone where calls are not overheard, reasonable access means phones at hright accessible to wheelchairs, adapting phones for impared hearing
Rights - Personal Property
Resident has right ot retain and use personal items including furnishing, appropriate clothing, as space permits unless it would infringe upon rights, health or safety of other residents
Rights - Married couples
Resident has right to share room with spouse when in same facility and both consent, payment sources may prevent this, the facility is not required to compel another resident to relocate to accomidate a spouse
Rights - Self Administration of Drugs
Resident may self administer durgs if the interdisciplinary team determines this is safe
Rights - Refusal of transfer
Resident has right to refuse transfer to another room if purpose is to relocate - from SNF to non SNF room or NF to SNF room, refusal to transfer does not affect eligibility or entitlement to Medicare or Medicaid benefits
Transfer & Discharge definition
includes movement of resident to a bed outside of the certified facility whether that bed is in the same physical plant or not, transfer and discharge does NOT refer to movement of a resident to a bed within the same certified facility
Transfer
moving the resident from the facility to another leggally responsible institutional setting, including moving resident from FN bed to SNF bed withing facility if they are under separate provider agreements
Discharge
moving resident to a non-intitutional setting when the releasing facility ceases to be responsible for the residents care
Transfer & Discharge restrictions
may not transfer or discharge unless - is necessary to meet welfare and the welfare can’t be met in facility, appropriate because health has improved services no longer needed, saftey of individuals in facility is endangered or would otherwise be endangered, resident has failed after notice to pay for stay, facility ceases to operate, any of these must be documented in clinical record, notice must be given including right to appeal
Exception to 30 day notice
Endangerment to health or safety of others, resident’s health improved to allow immedicate transfer or discharge, urgent medical needs, has not resided in facility for 30 days
Transfer & Discharge documentation
If transfered for welfare or improved health documentation must be made by residents physician
Rights - Notice before transfer
Before transfer or discharge facility must - notify resident and if known family member or legal representative of transfer or discharge and reasons for move in writing and language they understand, record reasons in clinical record
Rights - Timing of Notice
Except in exception notice of transfer or discharge must be made by the facility at least 30 days before transfer or discharge
Rights - Contents of notice
Written notice must include - reason for transfer or discharge, effective date, location to which resident is being transfered or discharged to, statement that resident has right to appeal to State, contact information for ombudsman, contact information for agency providing advocacy for developmentally disabilities, contact information for agency providing advocacy for mentally ill
Rights - Orientation for transfer or discharge
Facility must provide sufficient preparation oand orientation to residents to ensure safe and orderly transfer or discharge
Notice bed hold policy notice before transfer
2 notieces required, first notice of bed-hold policies provides written infomration of duration of bed-hold policy under State plan may be issued ahead of time but must be reissued if State or facility bed-hold policy changes, second notice specifies duration of the bed-hold policy must be issued at time of transfer, in ER it must be provided with written notification within 24 hours of transfer requirement is met if notice is sent with other papers accompanying the resident to hospital
Bed-hold days in excess
considered non-covered swervices which resident could use own income to pay ofr bed-hold, Non Medicaid residents may be requested to pay for all days of bed-hold
Return to facility
Facility must establish written policy which resident whose hospitalization or leave exceeds the bed-hold period under State plan, is readmitted to facility immediately upon first availablitliy of bed in semi-private room if resident requires services of facilty and is eligible for Medicaid facility services
Equal access to quality care
facility must establish and maintain identical policies and practices regarding transfer, discharge and services under the State plan for all individuals regardless of source of payment
Charges
Facility may charge any amount for services frnished to non-Medicaid residents consistent with notice requirements and describing the charges
Admission policy
Facility must not require residents or potential residents to waive rights to Medicare or Medicaid, require oral or written assurance that they will not apply for Medicare or Medicaid
Payment - third party guarantee
facility may not require third party guarantee of payment as condition of admission or stay however facility may require individual with legal access to residents income to pay for facility to sign contract with no personal financial liablility to provide payment from residents income
Restraints
resident has right to be free from any physical or chemical restraints imposed for discipline or convenience and not required to treat the resident’s medical symptoms
Physical restraints
any manual method, physical or mechanical device, material, equipment attached or adjacent to resident’s body that individual conat remove easily which restricts freedom oof movement or normal access to one’s body
Chemical restraints
any drug that is used for disipline of convenience and not required to treat medical symptoms
Discipline
any action taken by facility for the purose of punishing or penalizing residents
Convenience
any action taken by the faciltiy to control a residents behavior or manage a residents behavior with a lesser amount of effort by the facility and not in the residents best interest
Medical symptom
an indication or characteristic of a physical or psychological condition
Rights - Abuse
resident has right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion, from anyone
Abuse
willful infliction of injury, unreasonable confinement, intimidation, or punishment with resultin gphysical harm, pain or mental anguish, this also includes the deprivation of an individual of goods or services necessary to attain or maintain well-being
Verbal abuse
useof oral, wirtten or gestured language that willfully includes disparaging and derogatory terms to residents or their families within their hearing distance,m regardless of age, comprehension or disability
Sexual abuse
sexual harassment, seual coercion, or sexual assault
Physical abuse
hitting, slapping, pinching and kicking, controlling behavior thorugh corporal punishment
Mental abuse
humiliation, harassment, threats of punishment or deprivation
Involuntary seclusion
separation of resident from other residents or from their room or to their room against residnts will, ER or short term selclusion may be permited if limied time and as therapeutic intervention to reduce agitation until plan of care to meet needs is made
Staff treatment of residents
facility must develop and implement written polices and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of property
Neglect
failure to provide goods and services necessary to avoid physical harm, mental naguish, or mental illness
Misappropriation of resident property
deliberage misplacement, exploitation, or wrongful, temporary or permanent use of resident’s belongings or money withouth the resident’s concent
7 components for abuse policies
screening, training, prevention, identification, investigation, protection and reporting/response
Screening
screen potential emplloyees for history of abuse, neglect, mistreating residents through references, checking licensure, registires
Training
through orientation, sessions on issues about abuse, appropriate interventions for aggressive or catastrophic reactions of residents, how to report allegations, how to recognize burnout, frustration, stress, what constitutes abuse, neglect, misappropriation
Prevention
Provide information to reseidents, families and staff on how and whom to report concerns, incidents, grievances and provide feedback regarding concerns expressed, analysis of phsical environment such as secluded areas, deployment of staff in sufficient numbers to meet needs of residents, supervision of staff to identify inappropriate behaviors, assessment, care planning and monitoring of resident swit hneeds and behaviors which might lead to conflict or neglect such as residents with agressive behaviors, self-injurious behaviors, communication disorders, heavy nursing care
Identification
Identify events such as bruising of residents, occurrences, patterns and treands
Investigation
have procedures to investigate different types of incidents, identify staf memeber responsible for inititial reproting, investigation of alleged violations and reporting of results to authorities
Protection
Procedures to protect residents from harm during investigation
Reporting/Response
Procedures to reprot all alleged violations and substantiated incidents to state agency and other agencies as required, and take corrective actions depending on results, reprot to nurse aide registry or licensing authorities any knowledge of any actions by court of law indicating employee unfit for service, determine what changes are needed if any to prevent further occurances
Employment requirements
Facility must not employ individuals found guilty o fabuse, neglect or mistreating residents by court of law, or have finding entered into State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of property
Finding
determination made by State that validates allegations of abuse, neglect, mistreatment of residents, or misappropriation o ftheri property
Investigation results
All investigation results must be reported within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken
Investigation documentation
Facility must have evidence that all alleged violations are throughly investigated and must prevent further potential abuse while investigation is in progress
Injury of unknown source
Both conditions met - source of injury not observed by any person or the source could not be explained by the resident AND injury is suspicious because of extent of injury or the location or number of injuries observed at one particular point in time, or the incidence of injuries over time
Immediately
As soon as possible but out not exceed 24 hours after discovery of incident
Quality of Life
Facility must care for its residents in a manner and environment that promotes maintenance or enhancement of each resident’s quality of life
Dignity
Facility must promote care for residents in manner and environment that maintains or enhances each residents dignity and respect in full recognition of their individuality
Dignity examples
grooming as resident wishes, dressing in own clothes, attending activities of choosing, labeling clothing respectfully, avoiding plastic cutlery, paper dishware, bibs instead of napkins, staff standing over residents to help eat, staff talking to each other rather than residents, respecting residnts space and property, speaking respectfully to residents, avoiding labels for residents, addressing residents as individuals when providing care, focusing on residents, maintaining environment with no signs posted in resident rooms or public including personal or confidential information, cover catheter bags, comply with toileting assistance requests, restricting from use of common areas
Rights - Self Determination, Participation
Resident has right to - choose activities, schedules, and health care consistant with interests, assessments and plans of care, interact with members of community in and out of facility, make choices about life in facility that are significant to resident
Rights - Resident and Family groups
Resident has right to organize and participate in resident groups, family has right to meed in facility with other families, facility must provide private space for these meetings, staff or visitors may attend with invitation, facility must provide staff responsible for assistance and responding to requests from group, facility must lesten to and act upon grievances and recommendations of group
Resident or Family group
group that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents care, treatment and quality of life, support each other, plan activities, participate in educational activities, for any other purpose
Resident or Family groups responsibilites
Not requried, however must be allowed without interferance if desired, facility must listen to recommendations and grievances, facility does not have to accede to recommendations but must seriously consider recomendations and attampt to accomodate to the extent practiable, facility should communicate decisions to group
Rights - Participate in other activities
Resident has right o participate in social, religious, and community activities that do not interfere with right s of other residents in facility
Rights - Accomodation of Needs
Resident has right to reside and receive services in faciltiy with reasonable accomodations on needs and preferences, except when health or safety of the individual or another would be endangered
Rights - Room changes
Resident has right to receive notice before the residents room or roommate in the facility is changed
Activities
Facility must provide ongoing program of activities designed to meet, in accordance wiht assessment the interests, physical, mental and psychosocial well-being of each resident
Activities - definition
any endeavor, other than routine ADL’s that resident participates in intended to enhance the sense of well-being and promote or enhance physical, cognitive and emotional health
One-to-One programming
programming provided to residents who will not or cannot plan their own activities pursuits or residents needing specialized or extended programs to enhance their daily routine and activities
Person Appropriate
idea that each resident has personal identity and history that involves more than just their medical illnessess or functional impairments, Activities should be relevant to specific needs, interests, culture, background o fthe individual whom they are developed
Program of Activity
combination of large and small group, one-to-one and self directed activities and a system that supports the development, implementation and evaluation of the activies provided to the residents
Care Planning - Activites
involves identification o fresident’s interestes, preferences and abilities and any issues concerns, problems or needs affecting resident involvement in activities, information may also be found in separate activity plan , on CNA flow chart, in progress notes
Activity Goals
Should be based on measurable objectives and focused on desired outcomes, not merely on attendance at certain number of activies per week
Activities Director qualifications
Qualified therapeutic recreation specialist or activities professional who - licensed or registered if applicable by State, eligible for certification as therapeutic recriation specialist or activities professional by accrediting body or has 2 years experience in social or recreational program within last 5 years, 1 of which was full time in patient activities program in health care setting, or qualified occupational therapist or occupational therapy assistant or completed training course approved by State
Social Services
Facility must provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident
Medically-related social services
services provided by the facilities staff to assest residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs
Social Services includes -
arrangements for adaptive equpment, clothing, personal items, reproting changes, encouragement to participate in care planning, assisting to inform about health status and health care choices, referrals and obtaining outside services, assisting with financial and legal matters, discharge planning services, arranging or providing counseling services, support individual needs, enhancing and maintinging resident dignity, providing alternatives to drug herapy or restraints, options to help physical and emotional needs,
FT social worker
facility with more than 120 beds must employ qualified social worker full time
Social worker qualifications
bachelors degree in social work or human services field - sociology, special education, rehabilitation, counseling, psychology and 1 year supervised social work experience in health care setting working directly with individuals
Environment
Facility must provide safe, clean, comfortable and homelike environment allwing the resident to use his or her personal belongings to the extent possible
Homelike environment
one tha tde-emphasizes the institutional character of the setting to the extent possible and allows the resident to use those personal belongings that support a homeloke environment.
Housekeeping and Maintenance
Services are necessary to maintain a nsanitary, orderly, and comfortable interior
Sanitary
includes but not limited to, preventing spread of disease by keeping resident care equipment clean and properly stored
Orderly
an uncludttered pahysical environment that is neat and well-kept
Linens
Clean bed and bath linens that are in good condition
Lighting
Adequate and comfortable lighting levels in all areas
Adequate lighting
levels of illumination suitable to tasks the resident chooses to perform or the facilty staff must perform
Comfortable lighting
minimizes glare and provides maximum resident control, where feasible, over th eintensity, location and direction of illumination so tha tvisually impaired residents can maintain or enhance independent functioning
Comfortable and safe temperatures levels
the ambient temperature should be a narrow range that minimizes susceptibity to loss of body heat and risk of hypothermia range between 71 - 81 degrees
Comfortable sound levels
levels that do not interfere with resident’s hearing and enhance privacy when provacy is desired and encourage interaction when social participation is desired, particular concern is to resident’s control over unwanted noise
Admission orders
At time resident is admitted the facility must have physician orders for residents immediate care
Resident Assessment
Facility must conduct initially and periodically a comprehensive accurate standardized reproducible assessment of each residents functional capacity
Physicians orders for immediate care
written orders faciltiy needs to provide essential care to resident consistent with residents mental and physical stauts upon admission including at leave dietary, drugs, routine care
Intent of assessment
to provide facility with information to develop care plan to provide appropriate care and services and to modify care plan based on residents status
Resident Assessment Instrument (RAI)
facility must make comprehensive assessemnt of residents needs using RAI specified by the State
RAI - must include
identification and demographic info customary routine cognitive patterns communication vision mood and behavior patterns psychological well-being physical functioning and stuctural problems continence disease diagnosis and health conditions dental and nutritional status skin conditions activity pursuit medications special treatments and procedures discharge potential documenation of participation in assessment documentation of summary information regarding the additional assessment on care areas triggered by completion on MDS
Customary routine
information regarding residents usual community lifestyle and daily routine in the year prior to date of entry to nursing home
Cognitive patterns
residents ability to problem solve, decide, remember, and be aware of and respond to safety hazards
Communitcation
ability to hear, understand others, make understood
Vision
visual acutity, limitations and difficulties and appliances used to enhance vision
Mood and behavior patterns
residents patterns of mood an dbehavioral symptoms
Psychosocial well-being
resident’s positive or negative feelings about self or social relationships
Physical functioning and structural problems
residents physical functional status, ability to perform activities of daily living and residents need for staff assistance and assistive devices or equipment to maintain or improve fuctional abilities
Continence
residents patterns of bladder and bowel continence pattern of elimination and appliances used
Dental condition status
condition of teeth, gums an dother sturctures of oral cavity that may affect residents nutritional status, commuication or quality of life
Nutritional status
weight, height, hematologic and biochemical assessments, clinical observations of nutrition, nutritional intake, residents eating habits and preferences, dietary restirctions, supplements and use of applances
Skin conditions
residents development or risk of development of pressure sores
Activity pursuit
resident’s ability and desire to take part in activities which maintain or improve, physical, mental and psychosocial well-being
Medications
all prescription and over-the-counter medications taken by resident including dosage, frequency of administration and recognition of sidnificant side effects most likely to occur - this does not need to be in assessment but must be in clinical record and care plan
Special treatments and procedures
treatments and procedures not part of basic services provided
Discharge potential
facilities expectation of dischargeing resident from facility within next 3 months
Documentation of participation in assessment
who participated in assessment process, including direct observation and communcation with resident as well as with licensed and nonlicensed care staff
Comprehensive Assessment done within
14 calendar days after admission excluding readmissions in which there is no significant change in physical or mental condition
Assessment after significant change within
14 days after determines or should have determined there has been significan change in physical or mental condition
Significant change
Major decline or improvement in residents status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions that has an impact on more than one area of the residents health status, and requires interdisciplinary review or revision of the care plan
Significant change reassessment indicated
resident elects, and revokes hospice benefit
if decline or improvement is consistently noted in 2 or more areas of decline or improvement
Annual resident assessment frequency
Must be completed within 366 days after the ARD of most recent comprehensive resident assessment
Quarterly review assessment frequency
Facility must assess resident using quarterly review instrument specified by State not less than once every 3 months
ARD
Assessement reference date
Resident assessments maintained for
facility must maintain all resident assessments completed within the previous 15 months in the residents active record
Thinned RAI information
after 15 month period RAI information may be thinned from clinical record and stored provided it is easily retrievable if requested
Encoding Data
Within 7 days after factility completes residents assessment facility must encode: admission assessment, annual assessment updates, sidnificant change in status assessments, quarterly review assessments, subset of items upon transfer, reentry, discharge and death, background infomration if no admissionm assessment for each resident in facility
Encoding time frames
7 days after assessment completed facility must be capable of transmitting, must be transmitted withing 14 days after assessment completed
Transmittal requirments
Facility must electronically transmit at least monthly MDS data to state for all assessments conducted during previous month
Data format
Facility must transmit data in format specified or approved by CMS
Encoding
Entering MDS infomration into computer
Transmitting data
electronically sending encoded MDS from the facility to teh QIES ASAP system
Capable of transmitting
facility has encoded and edited according to CMS specifications, the record accurately reflects residents overall clinical status
Passing standard edits
Encoded responses to MDS items are consistent and within range in accordance with CMS standards
Accuracy of assessment - reg
Assessment must accurately reflect the residents status
Accuracy of assessment - def
the appropriate, qualified health professional correctly documents the resident’s medical, functional, psychosocial problems and identifies resident strengths to maintain or improve medical status, functional and psychosocial problems and identifies resident strengths to maintain or improve status, intitial comprehensive assessment provides baseline data for ongoing assessment
Coordination of assessment
RN must conduct or coordinate each assessment wiht the appropriate participation of health professionals
Certification of assessment
RN must sign and certify that assessment is completed, each individual who completes portion of assessment must sign and certify the accuracy of that protion of assessment
Penalty for falsification
CMS any person who certifies a material and false statment in assessment is subject to penalty of not more than $1,000 per assessement, or causes another to certify a false statment in assessment is subject to penalty of not more than $5,000 per assessment - Clinical disagreement does not constitute a material and false statement
Comprehensive care plan
Facility must develop care plan that includes measureable objectives and timetables to meet residents medical, nursing, mental and psychosocial needs that are identified in comprehensive assessment
Care plan must include
services that are to be furnished to attain or maintain highest practicable physical, mental, and psychosocial well being,
any services that would be provided but are not provided due to residents right to refuse
CAA
care area assessment
CAA summary
should show evidence of residents status triggered in CAA areas, facilities rationale for deciding whether to proceed with care planning, evidence thta facility considered the development of care planning interventions for all CAA’s triggered by MDS
Resident participation in care plan
Resident has right unless adjudged incompetent or incapacitated under State law to participate in planning care and treatment or changes in care or treatment
Participate in planning care and treatment
Resident is afforded opportunity to select from alternative treatments, this applies to both initial dcisions and changes in care and treatments
Comprehensive care plan must be - time
developed within 7 days after completion of comprehensive assessment
Comprehensive care plan must be - who
prepared by interdisciplinary team including: attending physician, RN with resonsibilities for resident, other appropriate staff in disciplines as determined by residents needs, resident, residents family or legal representative as practicable
Comprehensive care plan review
periodically reviewed and revised by team of qualified persons after each assessment
Services provided or arranged by facility must
Meet professional standards of quality and be provided by qualified persons in accordance with each residents plan of care
Professional standards of quality
services that are provided according to accepted standards of clinical practice
