Definition 1 of 80
-1. facility must develop a written comprehensive care plan for each resident that includes
measurable objectives and timetables to meet a residents medical, nursing, mental, and
psychosocial needs that are identified in the comp. assessment
-2. care plan must be developed within 7 days after the completion of the comprehensive
assessment and be prepared by interdisciplinary team that includes physician, registered nurse,
and other appropriate staff in disciplines determined by residents' needs
-3. the residents care shall be available for use by all personnel caring for the resident
Comprehensive Care Plan
Pressure Sores
Plan of Correction
On-line Reporting System
Definition 2 of 80
2. Resident shall be encouraged or assisted to be as independent as possible, including having
self help and ambulation devices readily available to meet the current needs of the resident with
devices in good repair
3. Resident has the right to refuse care and treatment to restore or maintain functional abilities
after efforts by the facility to counsel an/or offer alternatives to the resident. refusal of such care
and treatment should be documented in the clinical record
Personnel
ADLs cont.
Protection of Resident Funds
Infection Control
,Definition 3 of 80
facility should provide reasonable visiting hours, at least 9 hours a day
Transfer and Discharge Rights
Access and Visitation Rights
Screening and Training Employees
Environment and Physical standards
Definition 4 of 80
1. Traditional survey process - complaints only
2. Quality Indicator Survey (QIS)
Scope and Severity
QIS Survey Forms
Assistive Devices
Two Survey Processes
,Definition 5 of 80
-Quality Indicator Survey
-Began in 2009
-In affect in IN 2011
-annual survey
-Survey process transformed by CMS
-Goals: improve consistency and accuracy of care ...
-make the process more systematic
-there is no window for when inspection can be
-digital, computerized and used on laptops & this helps to tell whether an issue needs an
inspection or can be let go
-designed to take 4-5 days with 4 surveyors (can be extended with reason)
-10% of surveys have to be during off hours or holidays
-surveyors get info from MDS prior to this QIS
-huge interview portion
-entrance conference
-focus on resident, family, and staff interviews
Dietary Services
QIS
Nursing Staffing Information
Activities of Daily Living (ADL)
Definition 6 of 80
-facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff,
and the public
Dietary services
Access and Visitation rights
Environment and Physical standards
Nursing services
, Definition 7 of 80
-immediate access to the current active clinical record
-upon oral or written request, to access all other records pertaining to himself within 24 hours
-right to be fully informed of his total health status
-right to refuse treatment
-right to be informed by the facility at least 30 days in advance of any change in rates or services
that rates cover
Critical Element Pathways (CEP)
The resident has the right to:
Surveyors' Offsite Preparation
QIS relies on MDS information
Term 8 of 80
Activities
-pets may be permitted at facility but cannot create a nuisance or safety hazard
-must have periodic vet exams and required immunizations in accordance w state and local
health regulations
-facility must provide a safe, functional, sanitary, and comfortable environment for
residents, staff, and the public
facility must provide an ongoing program of activities designed to meet in accordance w
the comprehensive assessment, the interests and the physical, mental, psychosocial well
being of each resident
-facility must deposit any of the personal funds if more then $50 in an interest bearing
account that is separate from the facility's operating account and credits all interest earned
on the patients funds to his or her account
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