UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA

UNITED STATES OF AMERICA,

U.S. v. City of Phildalphia

Plaintiff,

™

V

HH HH

• • • •• I

NH-PA-002-002

v.

Civ. No. 98-Lj

THE CITY OF PHILADELPHIA; EDWARD G. RENDELL, MAYOR OF THE CITY OF PHILADELPHIA; ESTELLE B. RICHMAN, COMMISSIONER, HEALTH DEPARTMENT; EPISCOPAL LONG TERM CARE, AS OPERATORS OF THE PHILADELPHIA NURSING HOME,
Defendants.

UNITED STATES' UNCONTESTED MOTION
The United- States of America, by and through counsel, hereby moves the Court to approve and enter the Settlement Agreement in this matter, which is being filed contemporaneously with the Complaint and this Motion. This Motion is uncontested.
This case was instituted by the United States pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, and pursuant to the False Claims Act, 31 U.S.C. § 3729 et SSSL-

For the purpose of avoiding protracted and adversarial

litigation, theparties entering into this Settlement Agreement

agree to theprovisions set forth herein. Theparties agree that

the provisions of the Settlement Agreement are a lawful, fair and

appropriate resolution of this case.

Therefore, the United States hereby respectfully requests

that the Court approve the accompanying Settlement Agreement and

enter it as an Order of theCourt.

Respectfully submitted,

MICHAEL R. STILES United States Attorney Eastern District of
Pennsylvania

BILL LANK LEE Acting Assistant
Attorney General Civil Rights Division

JAMES 6. SHEEHAN Assistant U.S. Attorney Chief, Civil Division Eastern District of
Pennsylvania

STEVEN H. ROSENBADM Chief Special Litigation Section
ROBINSUE FROHBOESE Deputy Chief Special Litigation Section

R.
Assistant U.S. Attorney Eastern District of
Pennsylvania 615 Chestnut Street Suite 1250 Philadelphia, PA 19106 (215) 451-5337

RICTARD *97\FARANO Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section P.O. Box 66400 Washington, DC 20035-6400 (202) 307-3116
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CERTIFICATE OF SERVICE
I, David R. Hoffman, Assistant United States Attorney,
hereby certify that a true and correct copy of the within United
States' Uncontested Motion to Enter Settlement Agreement was sent
via first class mail to:
Lewis Morris Assistant Inspector General for Legal Affairs U.S. Dept. of Health and Human Services 330 Independence Ave., S.W. Washington, D.C. 20201
Stephanie. L. Franklin-Suber Philadelphia City Solicitor Law Department 1515 Arch Street, 17th Floor Philadelphia, PA 19102
Mark H. Gallant, Esq. Cozen & O'Connor 1900 Market Street Philadelphia, PA 19103

Date: August 13, 1998

DAVID R. HOFFMAN//' Assistant Unitea States Attorney

 
 IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA

UNITED STATES OF AMERICA

: CIVIL ACTION

V.

:

THE CITY OF PHILADELPHIA, et al.: NO. 98-4253

QBESE

AND NOW, this 14th day of August, 1998, upon

consideration of the United States' uncontested motion to enter

the settlement agreement, and in view of the Court's continuing

involvement contemplated in, inter alia. Sections II.D. and XIX

of the Settlement Agreement, and the Court finding that the

Settlement Agreement is lawful, fair, and an appropriate

resolution of this case, it is hereby ORDERED that:

1. The United States' uncontested motion to enter the

settlement agreement is GRANTED;

2. the Settlement Agreement is APPROVED; and

3. The Settlement Agreement is hereby ENTERED as a

judgment and Decree of this Court.

BY THE COURT:

Stewart DalzeTf, J.
U.S. v. City of Phildalphia
NH-PA-002-003

TOTRL P.02

 
 .U ? -Y .9 V

NH-PA 002-004 "
UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA

UNITED STATES OF AMERICA, Plaintiff,

v.
THE CITY OF PHILADELPHIA; EDWARD G. RENDELL, MAYOR OF THE CITY OF PHILADELPHIA; ESTELLE B. RICHMAN, COMMISSIONER, HEALTH DEPARTMENT; EPISCOPAL LONG TERM CARE, AS OPERATORS OF THE PHILADELPHIA NURSING HOME,
Defendants.

Civ. No. 98-

COMPLAINT 1. The Attorney General of the United States brings this action on behalf of the United States of America, pursuant to the Civil Rights of Institutionalized Persons Act of 1980 ("CRIPA"), 42 U.S.C. § 1997, to enjoin the named Defendants from depriving persons residing at the Philadelphia Nursing Home ("PNH") of their legal rights, and of rights, privileges or immunities secured or protected by the Constitution of the United States and federal statutes.

2. The United States of America, through the United States Attorney for the Eastern District of Pennsylvania, also brings this civil action under the False Claims Act, 31 U.S.C. §§ 3729 e_t £££u, and alleges that the City of Philadelphia, PNH, and Episcopal Long-Term Care, submitted or caused the submission of false or fraudulent claims to the United States for payment for care that was not adequately rendered to elderly individuals, to individuals with developmental disabilities, and to individuals with mental illness residing at PNH.
JURISDICTION. STANDING AND VENUE 3. This Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331, 1345 and 31 U.S.C. §§ 3729 fit seq. 4. The United States has standing to maintain this action pursuant to 42 U.S.C. § 1997a and 31 U.S.C. §§ 3730 and 3732. 5. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein. 6. Venue is proper in the United States District Court for the Eastern District of Pennsylvania pursuant to 28 U.S.C. §§ 1391(b) and (c). All claims set forth in the Complaint arose in said District.
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PARTIES 7. Plaintiff is the UNITED STATES OF AMERICA acting for itself, and on behalf of the Department of Health and Human Services, Office of Inspector General, the Medicare* Trust Fund, the Medical Assistance Program, and the beneficiaries thereof. 8. Defendant CITY OF PHILADELPHIA ("City") owns PNH, a nursing home housing individuals with special needs including the elderly, those with developmental disabilities, and those with mental illness, located in Philadelphia, Pennsylvania. 9. Defendant EDWARD G. RENDELL is the Mayor of the City of Philadelphia, and in this capacity heads the Executive Branch of the City's government and, among other duties, reviews and approves budget requests submitted by Executive Branch agencies. He selects and appoints the Commissioner of the City's Health Department. 10. Defendant ESTELLE B. RICHMAN is the Commissioner of the City's Health Department and, in this capacity, exercises administrative control of, and responsibility for, PNH. 11. Defendant EPISCOPAL LONG TERM CARE ("ELTC") is the operator of PNH pursuant to a contract with the City, and is responsible for the day-to-day operations of PNH.
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12. The individual Defendants named in 11 9 and 10 above are officers of the Executive Branch of the City of Philadelphia and are sued in their official capacities.
13. PNH is an institution as that term is defined in 42 U.S.C. §§ 1997(1)(A), (1)(B)(i) and (1)(B)(v).
14. Defendants are legally responsible, in whole or in part, for the operation of and conditions at PNH, as well as for the care and treatment of persons residing at that institution.
15. At all relevant times, Defendants have acted or failed to act, as alleged herein, under color of state law.
NURSING HOME REFORM ACT 16. The Nursing Home Reform Act (the "Act") mandates that nursing facilities comply with federal requirements relating to the provision of services. 42 U.S.C. §§ 1396r et seg. See also 42 U.S.C. §§ 1395i-3 fit 2&Q- Specifically, in terms of the quality of life for residents of nursing facilities, the Act states that: "A nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident." 42 U.S.C. § 1396r(b)(1)(A). See also 42 U.S.C. § 1395i-3(b)(1)(A); 42 C.F.R. § 483.15.
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17. In addition, the Act mandates that a nursing facility: provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care which — (A) describes the medical, nursing,'- and psychosocial needs of the resident and how such needs will be met;...
42 U.S.C. § 1396r(b)(2)(A). See also 42 U.S.C. § 1395i-3(b)(2)(A); 42 C.F.R. § 483.25.
18. A duty is placed on the nursing facility to fulfill the residents' care plans by providing, or arranging for the provision of, inter alia, nursing and related services and medically-related social services that attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, pharmaceutical services, and dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident, and treatment and services required by residents with mental illness and/or mental retardation. 42 U.S.C. §§ 1396r(b)(4)(A)(i-vii). See also
42 U.S.C. §§ 1395i-3(b)(4)(A)(i-vii). 19. The Act mandates that nursing homes that participate in
the Medical Assistance Program ("Medicaid") and the Medicare Program meet certain specific requirements in order to qualify for such participation. These requirements are set forth at
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42 C.F.R. §§ 483.1 afc. seg. and "serve as the basis for survey-
activities for the purpose of determining whether a facility
meets the requirements for participation in Medicare and
Medicaid." 42 C.F.R. § 483.Kb).
20. Federal regulations, when addressing quality of care
concerns, mandate that "[e]ach 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." 42 C.F.R. § 483.25.
21. As a pre-requisite to enrollment as a provider in the
Medicaid Program, PNH entered into a provider agreement and
agreed to the following provisions:
1. That the submission by, or on behalf of, the Facility of any claim, either by hard copy or electronic means, shall be certification that the services or items from which payment is claimed actually were provided to the person identified as a medical assistance resident by the person or entity identified as the Facility on the dates indicated.
******* 5. That the Facility's participation in the [Medicaid] Program is subject to the laws and regulations effective as to the period of participation, including all of those that may be effective after the date of the agreement and that the Facility has the responsibility to know the law with respect to participation in the [Medicaid] Program.
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22. At all times relevant to this action, PNH was a "provider" with a valid provider agreement with the Pennsylvania Department of Public Welfare.
FACTUAL ALLEGATIONS COUNT I: CIVIL RIGHTS OF INSTITUTIONALIZED PERSONS ACT 23. The above paragraphs are incorporated herein by reference as if fully set forth. 24. Defendants have failed to ensure the reasonable safety and personal security of the PNH residents. Defendants have failed to adequately supervise, monitor and protect the residents from harm and risk of harm. 25. Defendants have failed to provide adequate basic care and related services to PNH residents. 26. Defendants have failed to provide residents with adequate, appropriate and meaningful activities. 27. Defendants have failed to ensure that PNH residents are free from undue or unreasonable restraint and that restraints are administered to PNH residents by appropriately qualified professionals in keeping with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff.
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28. Defendants have failed to provide adequate mental health care and services to PNH residents.
29. Defendants have failed to provide adequate medical and health care and services to PNH residents and to ensure that medications are prescribed and administered to PNH residents by appropriately qualified professionals in keeping with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff.
30. Defendants have failed to provide adequate nursing care and services to PNH residents.
31. Defendants have failed to provide adequate physical and occupational therapy services to PNH residents.
32. Defendants have failed to provide a sufficient number of adequately trained professional and direct care staff to render the essential care and treatment outlined above in paragraphs 24 through 31.
33. Defendants have failed to ensure that PNH residents are evaluated by appropriate professionals for placement in the most integrated setting and appropriately placed into the most integrated setting according to their individualized needs.
34. Defendants have failed to meet the requirements of the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C.
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§§ 12101 fit seq.e and the regulations promulgated pursuant thereto, by excluding the PNH residents, by reason of their disability, from participation in or by denying them the benefits of the services, programs, or activities of the City, or by subjecting them to discrimination, and by failing to administer services, programs, and activities in the most integrated setting appropriate to their needs. For purposes of Title II of the ADA, the Defendants are a "public entity," and the residents of PNH are "qualified individual[s] with a disability."
35. Defendants have failed to meet the requirements of the Medicaid Program established under Title XIX of the Social Security Act, 42 U.S.C. §§ 1396r fit seg,. and the regulations promulgated pursuant thereto.
36. Defendants have failed to meet the requirements of the Medicare Program established under Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395i-3 fit seq.. and the regulations promulgated pursuant thereto.
37. The acts and omissions alleged in paragraphs 24 through 36 infringe upon the PNH residents' legal rights and substantive liberty interests and constitute resistance to their full enjoyment of rights, privileges or immunities secured or protected by the Constitution or laws of the United States, and
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deprive the PNH residents of such rights, privileges or immunities.
38. Unless restrained by this Court, Defendants will continue to engage in the conduct and practices set forth in paragraphs 24 through 36 that deprive residents of PNH of their legal rights under law and the rights, privileges, or immunities secured or protected by the Constitution of the United States, and cause irreparable harm to PNH residents.
COUNT TI; FALSE CLAIMS ACT 39. The above paragraphs are incorporated herein by reference as if fully set forth. 40. The United States charges that the Defendants submitted or caused the submission of false or fraudulent claims to the United States for payment for care that was not adequately rendered to elderly individuals, to individuals with special needs, to individuals with developmental disabilities, and to individuals with mental illness residing at PNH. 41. PNH is a licensed long-term care (nursing) facility under federal and state law and is certified to participate in the Medicaid and Medicare Programs. 42. A synopsis of the factual basis for which this cause of action is based is incorporated herein and is attached hereto as
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Exhibit A. 43. The provision of adequate medical care, nursing care
and psychiatric care, pertaining to the appropriate use of psychotropic drugs for PNH residents and monitoring; for sideeffects of these medications, was the responsibility of PNH medical and nursing staff.
44. The provision of adequate wound care to PNH residents was the responsibility of the PNH nursing and medical staff.
45. The provision of adequate nutrition to PNH residents was the responsibility of not only the PNH nutritionists and dietary staff but included the PNH nursing and medical staff as well.
46. The provision of a safe environment in which PNH residents were free from any abuse, included all PNH disciplines, including but not limited to PNH medical, nursing, and facility management staff.
47. Defendants' agents and/or employees were responsible for the provision of medical care, nursing care, psychiatric care, appropriate medications and monitoring thereof, wound care, nutritional services, and safe conditions for all of the PNH residents.
48. Defendants' agents and/or employees billed the United
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States (through the Pennsylvania Department of Public Welfare) for care provided to the PNH residents for reimbursement by the Medicaid Program. Defendants' agents and/or employees billed the United States for care provided to the PNH resident's for reimbursement by the Medicare Program.
49. Defendants' agents and/or employees submitted or caused to be submitted false or fraudulent claims to the Medicaid and Medicare Programs for payment or approval of the provision of medical care, nursing care, psychiatric care, appropriate medications and monitoring thereof, wound care, nutritional services, and safe conditions that were not adequately rendered to PNH residents for the time period January 1995 through December 1996.
50. Defendant City of Philadelphia, as licensee for PNH, was responsible for the care rendered to residents at PNH and submitted or caused to be submitted the repeated submission of false or fraudulent claims for payment or approval to the Medicaid and Medicare Programs, for the provision of medical care, nursing care, psychiatric care, appropriate medications and monitoring thereof, wound care, nutritional services, and safe conditions that were not adequately rendered to PNH residents for the period January 1995 through December 1996. 31 U.S.C. § 3729.
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51. Defendants knowingly did not ascertain the truth or falsity of the claims for services submitted or caused to be submitted to the Medicaid and Medicare Programs, for payment or approval on behalf of PNH residents, all of whom were Medicaid recipients and/or Medicare beneficiaries. 31 U.S.C. § 3729.
52. Defendants acted in reckless disregard and/or deliberate ignorance of the care and services ordered and actually provided to PNH residents when billing the Medicaid and Medicare Programs. 31 U.S.C. § 3729.
53. Upon information and belief, the United States alleges that the care rendered to the residents identified in Exhibit A was representative of the care rendered to residents of PNH. The claims for reimbursement for the care of these residents would thus constitute false claims actionable under the False Claims Act to the same extent as the claims for the individuals identified in Exhibit A.
54. The United States was damaged as a result of the conduct described above.
COT7NT ITT: UNJUST ENRICHMENT 55. The above paragraphs are incorporated herein by reference as if fully set forth.
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56. The conduct described in the foregoing paragraphs caused all Defendants to receive, directly or indirectly, benefits from the United States.
57. Under the circumstances described in the'.foregoing paragraphs, as between the United States and each Defendant in this Count, retention by each Defendant of the benefits conferred by the United States would be unjust.
PRAYER FOR RELIEF WHEREFORE, Plaintiff, the United States of America, prays, with regard to Count I of this Complaint, that this Court enter an order permanently enjoining Defendants, their agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, practices and omissions at PNH set forth in paragraphs 24 through 36 above, and to require Defendants to take such action as will provide legal and constitutional conditions of care to persons who reside at PNH. The United States further prays that this Court grant such other and further equitable relief as it may deem just and proper. WHEREFORE, Plaintiff, the United States of America, demands and prays, with regard to Count II of this Complaint, that judgment be entered in its favor and against the Defendants,
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jointly and severally, as follows: a. an amount equal to the number of false or fraudulent claims that will be proven at trial, multiplied as provided for in 31 U.S. C. § 3729 (a), and imposition of '-$10, 000.00 per claim; b. three times that total amount of damages sustained by the United States because of the acts complained of; c. costs of this action; d. such other and further relief as the Court shall deem proper. WHEREFORE, Plaintiff, the United States of America, demands
and prays, with regard to Count III of this Complaint, that judgment be entered in its favor and against the Defendants, jointly and severally, as follows:
a. an amount equal to the gain to the Defendants as a result of the activities complained of; b. interest according to law; c. costs of this action; and d. such other and further relief as this Court may deem proper.
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Respectfully submitted,

J*NET RENO Attorney General of the
United States

MICHAEL R. STILES U.S. Attorney
Eastern District of Pennsylvania

BILL LANK LEE Adting Assistant
/Attorney General Civil Rights Division

cAssistant U.S. Attorney Chief Civil Division Eastern District of
Pennsylvania

STEVEN E. ROSENBAUM Chief Special Litigation Section
ROBINSUE FROHBOESE Deputy ChiefSpecial Litigation Section

DAVID R.

j

Assistant U.S. Attorney

Eastern District of

Pennsylvania

615 Chestnut Street

Suite 1250

Philadelphia, PA 19106

(215) 451-5337

RICHARD 4. FARANO Senior Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section P.O. Box 66400 Washington, DC 20035-6400 (202) 307-3116
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20530

CERTIFICATE OF THE ATTORNEY GENERAL

I, Janet Reno, Attorney General of the United States, certify that with regard to -the foregoing Complaint, United States v. City of Philadelphia. ££.fll^,I have complied with all subsections of 42 U.S.C. § 1997b(a)(1). I certify as well that I have complied with all subsections of 42 U.S.C. § 1997b(a)(2). I further certify, pursuant to 42 U.S.C. § 1997b(a)(3), my belief that this action by the United States is of general public importance and will materially further the vindication of rights, privileges or immunities secured or protected by the Constitution or laws of the United States.

In addition, I certify that I have "reasonable cause to believe" as set forth in 42 U.S.C. § 1997a to initiate this action. Finally, I certify that all prerequisites to the initiation of this suit under 42 U.S.C. § 1997, e_L seq.f have been met.

Pursuant to 42 U.S.C. § 1997a(c), I have personally signed the foregoing Complaint. Pursuant to 42 U.S.C. § 1997b(b), I am personally signing this Certificate.

Signed this 7 d a v of &"*&*?"' / fffr- at

Washington, D.C.

7

JANET RENO At/torney General
the United States

EXHIBIT A

VS. Department of Justice Civil Rights Division

Office of the Assistant Attorney General

-

Wuhington, D.C 20035

December 19, 1996

The Honorable Edward G. Rendell Mayor of the City of Philadelphia Office of the Mayor 215 City Hall Philadelphia, PA 19107
Re: Investigation of the Philadelphia Nursing Home
Dear Mayor Rendell:
On July 28, 1995, we notified you, pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, of our intent to investigate conditions at the Philadelphia Nursing Home ("PNH") in Philadelphia, Pennsylvania. We conducted our investigation by reviewing facility records, including residents' medical charts and other documents relating to the care and treatment of PNH residents, interviewing administrators, staff, and residents, and conducting on-site tours of the facility with three expert consultants: Blaine S. Greenwald, M.D., a geriatric psychiatrist, Ronald D. Adelman, M.D., a geriatric physician, and Geraldine Mendelson, R.N., M.Ed., M.A., C.N.A.A., a geriatric nurse. Following these tours, we obtained and analyzed survey reports from independent consultants retained by the City to evaluate conditions at PNH. Consistent with CRIPA's statutory requirements, we are now writing to inform you of our findings.
Based on our comprehensive investigative review, we have concluded that there are numerous conditions and practices at PNH that violate the constitutional and federal statutory rights of PNH residents. This conclusion should come as little surprise given that throughout our visit, a number of PNH administrators and professional and direct care staff readily admitted that many service areas were insufficient and needed remedial attention. Our independent conclusions and findings were also supported by the conclusions and findings contained in the City's own documents summarizing its many internally generated on-site reviews of the facility. We have set forth below the facts supporting our findings of unlawful and unconstitutional conditions at PNH.
Before addressing the substantive violations, we would like to express our appreciation to the PNH administrators and staff and the City of Philadelphia representatives who extended their

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cooperation and courtesy while we visited the facility. We would especially like to recognize Mollie Hess, Executive Director of PNH, and Jim Casey of PNH for their professionalism, hard work and diligent efforts in supplying us with the information we needed to conduct a thorough and accurate investigation of PNH. Indeed, both repeatedly stressed their sincere desire to improve conditions and practices at the facility. We hope to be able to continue to work with the City and PNH officials in such an atmosphere of cooperation and good faith.
I. PNH IS FAILING TO ENSURE THE SAFETY OF ITS RESIDENTS AND TO PROVIDE ADEQUATELY FOR THEIR BASIC CARE NEEDS
Individuals residing in a state or municipally operated institution have a fundamental Fourteenth Amendment due process right to basic care and reasonably safe conditions. Younabera v. Romeo, 457 U.S. 307 (1982). Federal statutes governing the operation of nursing homes create similar rights. See, e.g.. Grants to States for Medical Assistance Programs (Medicaid), 42 U.S.C. § 1396r, Health Insurance for Aged and Disabled (Medicare), 42 U.S.C. § 1395i-3, and their implementing regulations, 42 C.F.R. § 483, Subpart B. PNH fails to provide adequately for the most basic care needs of many of its residents and fails to ensure resident safety, thereby violating the legal rights of its residents.
A. PNH Fails To Ensure Resident Safety
PNH violates residents' rights by failing to provide a safe environment. Protection from harm is a fundamental constitutional right and a basic requirement of facilities, such as PNH, receiving Medicare and Medicaid funds. Younaberg v. Romeo. 457 U.S. 307 (1982); 42 C.F.R. §§ 483.13, 483.15 (residents have the right to be free from verbal, sexual, physical, and mental abuse, and corporal punishment; the facility must also provide a "safe" environment).
The facility's incident reports and special abuse investigations reveal a high level of injuries and dangerous situations that place residents at risk of harm. Many of these incidents are preventable and reflect systemic deficiencies at PNH including lack of adequate staffing, failure to supervise residents, and inadequate assessment and treatment of mental illness, cognitive impairments, and behavior problems. A number of the incidents result from aggressive PNH residents attacking other residents. For example, in the space of a few weeks during the summer months just prior to our tour, the following incidents occurred at PNH: J.S "assaulted" J.C. by punching her in her left eye; a day earlier, J.S. punched her in the right jaw; F.F. punched W.W. in the head and chest and hit D.D. giving her a bruised eye; T.W. "attacked" J.F. with a glass vase, striking him on the head causing an occipital laceration; B.W. and P.S. were

- 3-
hitting each other on the arms and shoulders; N.S. entered B.M.'s room and punched her in the face; C.Q. punched E.M. in the chest; J.R. hit A.S. three times in the head causing a lump on A.S.'s head; J.R. threw a cup of coffee and his walker at E.A.; and V.M. hit N.S. in the chest. During the same few weeks, a PNH aide allegedly "started slapping Mr. E. [a resident] invthe face." Other injuries and harmful situations have resulted from unsupervised residents who elope or abuse alcohol while in the facility. These are merely representative examples of other similar preventable incidents that are routinely occurring throughout the facility that demonstrate a systemic failure to protect residents from harm.
B. PNH Often Fails To Provide Basic Care To Residents
PNH also often fails to meet the most basic care needs of its residents. While we found a relatively clean facility at the time of our tour, we also uncovered a number of disturbing examples where residents' basic care needs were not met. For example, we discovered foul odors on residents and in resident rooms, and unkempt and dirty residents wearing unsanitary clothes that were malodorous and covered with food or fluid. Upon smelling a "severe urine odor" coming from one resident's room, our nurse consultant discovered a resident in a bed that was soaking wet in which he had apparently been left for some time. Dr. Greenwald reports that the "stench was hardly bearable" in another resident's room. Dr. Greenwald concludes that these "neglectful situations could be interpreted as a kind of passive abuse ... [which] trespassed beyond the typical range of hygienic conditions that one encounters in nursing homes." During our tour, several PNH care aides freely admitted dismay about the lack of staff concern and attention paid to the residents' basic care needs.
The City has documented similar problems in its on-site reviews of conditions at PNH. For instance, City surveyors in March 1995 found "a lack of overall cleanliness [at PNH] . Odors were prevalent throughout the building, residents' rooms were linkempt, wheelchairs and geri chairs were dirty and in ill repair." Perhaps most troubling was the City surveyors' conclusion that PNH failed to remedy these basic care problems even after having been alerted to them on prior occasions.
A number of different PNH residents spoke to us freely and at length about the many substandard conditions and practices at PNH. The independent observations and conclusions of the residents reinforced one another as our tour progressed. Some residents complained that units are short-staffed, especially on the weekends and evenings, and that staff members generally do not assist the residents. Virtually all residents we spoke to complained that PNH nurses failed to respond in a timely fashion to their calls for assistance. One resident felt that conditions

- 4 - .-
had improved somewhat since the recent arrival of the newer health care staff, but he felt that the newer staff members were inexperienced and not properly trained to care for the population at PNH. Most troubling, this resident expressed concern about the staff's slow response to his emergency needs. He related that when he has experienced shortness of breath, ^experienced a rapid heartbeat, or has run out of his supply of oxygen, it has taken PNH staff twenty minutes to come to help him. This conclusion is consistent with the City's independent on-site review findings in October 1995 that a number of PNH staff do not tend to the residents' needs while on duty, including residents who have medical orders to receive one-to-one supervision.
In addition, more than' one resident indicated that the PNH staff members are generally insensitive towards the residents, that the PNH aides talk to the residents with a disrespectful, often verbally abusive tone, and that their personal belongings are stolen. The PNH administration, having taken the positive step of regularly attending resident council meetings, acknowledged to us that many of the residents' concerns are legitimate.
II. PNH FAILS TO PROVIDE ADEQUATE ACTIVITIES TO RESIDENTS AND USES UNREASONABLE RESTRAINTS
PNH is failing to engage its residents in adequate, appropriate and meaningful activities in violation of their federal statutory rights. See, e.g.. 42 C.F.R. § 483.15 ("facility must provide for an ongoing program of activities designed to meet ... the interests and the physical, mental, and psychosocial well-being of each resident").
Even the City's on-site review has uncovered that often no activities take place at PNH and that " [t]here-are not enough activities scheduled for the diversity of this population." The City's November 1995 on-site review discovered PNH activities staff reading the newspaper, listening to the radio or watching television instead of engaging the residents in activities. PNH residents have expressed similar concerns.
One consequence of the lack of meaningful activity may be resident abuse of alcohol resulting from boredom and lack of staff supervision and involvement with residents. This problem appears to be widespread at PNH. For example, the City's October 1995 on-site review reveals that one verbally abusive and physically aggressive resident had a persistent problem with "smelling of alcohol," and being found sleeping in the lounge with bottles of alcohol present. An August 11, 1995 PNH special abuse notification letter indicates that another resident left the facility in his wheelchair via the front gate while he was intoxicated. During our tour, one PNH mental health consultant

- 5-
acknowledged that there is a great need for programming and treatment for residents with alcoholism at PNH.
In addition, PNH frequently uses restraints as a substitute
for keeping the residents engaged. This practice violates the
constitutional and federal statutory rights of residents. Younabero v. Romeo, 457 U.S. 307 (1982); 42 C.F.R/§ 483.13 ("resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms").
Moreover, PNH restraint practices do not comport with accepted professional standards. During our tour, we discovered that many residents were in restraints or in bed with the bed rails up, restricting their ability to leave the bed, without proper physicians' orders. Indeed, PNH is failing to provide its residents with adequate evaluations prior to the use of or initiation of an order for restraints. The City's own on-site reviews of PNH confirm our findings.!/ We also found that some residents were not released from their restraints every two hours as is generally accepted. These inappropriate restraint practices violate PNH residents' rights.
III. PNH IS FAILING TO PROVIDE ADEQUATE HEALTH CARE FOR ITS RESIDENTS
In addition to basic care and safety, all residents of state or municipally operated institutional facilities have a fundamental Fourteenth Amendment due process right to adequate health care. Younabera v. Romeo. 457 U.S. 307 (1982). See also 42 U.S.C. § 1396r(b) (4) (A) , 42 U.S.C. § 1395i-3(b)(4)(A) (facility must provide for medical, nursing and related services to "attain or maintain the highest practicable.physical, mental, and psychosocial well-being of each resident," and provide adequate treatment and services required by mentally ill and mentally retarded residents), and their implementing regulations, 42 C.F.R. § 483, Subpart B. However, PNH fails to provide its residents with medical, nursing and psychiatric care and services that comport with generally accepted practices.
t/ For example, the November 1995 on-site review indicates "no orders when restraint use indicated in record ... orders for side rails many times not seen ... no assessment of restraint use." Similarly, the October on-site review reveals: "[s]ide rails up on beds throughout facility, but no orders for them"; "[e]vening shift documents that side rails are up, but no physician's order is seen"; "[n]ursing documented at 10 p.m. that side rails were up. but no order was written for them." The September on-site review again reveals that PNH often places residents in restraints without proper orders: "use of 'leg restraint' - no order seen for such"; "[r]esident needs order for side rails."

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A. Psychiatric Practices And Mental Health Services Are Inadequate And Do Not Meet The Needs Of The Residents
PNH is not providing its mentally ill residents with adequate psychiatric and mental health services in accordance with generally accepted standards. Psychiatric practices at P N H are typically characterized by superficial evaluations, inadequate follow-ups, a lack of non-drug treatment approaches, a lack of cogent treatment planning, a lack of multidisciplinary input into psychiatric treatment decisionmaking, and a lack of psychiatric inservices.
The City, through its on-site review documents and the statements of its employees, readily admits deficiencies in mental health services at PNH. For example, the City's own November 1995 on-site review reveals "zero percent" compliance with professional standards in its review of antipsychotic therapy at PNH. During our tour, both PNH's mental health consultants and nurses freely admitted deficiencies in psychiatric care and mental health services at PNH.
1. Mental Health Assessments, Diagnoses And Treatments Are Inappropriate
PNH is generally failing to appropriately assess, diagnose and treat its residents who need mental health services. For example, although many residents have cognitive impairments and dementia, PNH does not perform proper cognitive examinations and does not develop adequate and appropriate dementia work-ups. These failures can lead to needless resident deterioration and to the development of irreversible conditions in residents that might have been reversible. In addition, PNH charts often lack consistent or appropriate diagnoses. An adequate diagnosis is essential to develop appropriate treatment. As Dr. Greenwald notes, an inadequate diagnosis "can lead to improper treatment that could harm the resident, either by subjecting him or her to needless medication and its attendant side effects, and/or by failing to treat the underlying mental illness, thereby exposing the resident to negative target behaviors that are not properly controlled."
As a result of the flawed assessment process and inadequate diagnostic formulation, treatments are often not appropriate. For example, several PNH residents have been inappropriately placed on multiple psychotropic drugs without clearly documented benefit. Such polypharmacy treatment places these residents at unnecessary risk of harm of medication side effects and improperly medicates them without the benefit of productively treating their mental illness. In this regard, Dr. Greenwald concludes that PNH has engaged in "cavalier" polypharmacy practice which is "dangerous," and "likely-to-be harmful."

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PNH also fails to provide its residents with adequate and necessary non-drug mental health services. Resident care plans generally fail to substantively address mental health treatment. A number of PNH residents who could benefit from psychosocial treatment do not receive these services. Because of this, Dr. Greenwald concludes that the residents "may remain mired in a state of institutionalized dysfunctionality, when their potential to improve may be significant."
Moreover, there is a marked discrepancy between published PNH policies and the reality of practice at PNH. Contrary to what is written in the Administrative Policies and Procedures guidelines, care plans do not seriously "build on resident's strengths" or "have treatment objectives with measurable outcomes" that are actually measured, and the facility does not ensure that residents "who use antipsychotic drugs receive gradual dose reductions, drug holidays or behavioral programming."
2. Psychiatric Drug Side Effects Monitoring Is Inadequate
Medication side effects monitoring at PNH is inadequate and fails to meet generally accepted standards. Residents are often needlessly subjected to the risks of side effects of the treating medication, thus further exacerbating their already fragile condition. Because of the increased sensitivity to medications among the elderly, it is important that PNH actively monitor side effects. However, PNH does not provide adequate side effects monitoring. For example, PNH's abnormal involuntary movement monitoring is inconsistent at best and typically inaccurate. This failure is especially troubling given that some abnormal involuntary movement side effects associated with antipsychotics may be irreversible for some of the residents.
PNH chart notes rarely reflect that specific drug side effects are considered in the treatment equation. The consult psychiatrist has largely abdicated side effect monitoring for antipsychotics to a form that nurses are supposed to fill out, but rarely if ever do. Several PNH nursing staff even admitted to us that they do not know what side effects to look for. We found that side effects data collection is inadequate in that the PNH forms are haphazardly filled out and, when they are filled out, are.often inaccurate. The City's on-site review findings consistently confirm these deficiencies in side effects monitoring.
As a result of these deficiencies, PNH often chronically administers psychotropic medications that have not proven to be effective. PNH therefore unnecessarily subjects its residents to medication side effects. Dr. Greenwald concludes that the consequence of this practice is that "potentially successful psychiatric treatment and rehabilitation is undermined, and in

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selected residents, longer-than-necessary institutionalization maintained and potential re-entry to mainstream society derailed. All of these deficiencies contribute to either harming the residents or placing them at increased risk of harm."
3. Psychiatric Progress Notes, Forms And Documentation Are Inadequate
Psychiatric chart documentation at PNH is inadequate and conveys little meaningful information. Our experts found that progress notes, behavior/side effect monitoring forms, and problem lists do not accurately summarize current clinical circumstances. The PNH notes are usually superficial, employ generalities, are not tied to residents' symptoms or diagnoses, and do not identify goals of treatment. Moreover, even when clinical findings are documented, they often do not yield appropriate and needed treatments.
4. Mental Health Resources And Expertise Are Insufficient
PNH does not provide a sufficient number of psychiatry consult hours to meet the needs of the residents. The current consult psychiatrist admitted that he did not see every resident with mental illness at PNH at least once a year as required by professional standards. In fact, he admitted that he only sees residents on a referral basis rather than proactively instituting a case-identification protocol and appropriate follow-up system. As a result, the psychiatrist admitted that some residents have not been seen who should have been seen simply because no referral had been made. Indeed, Dr. Greenwald found residents with mental illness who have exhibited violent or threatening behaviors who have not had any psychiatric consultations. Even the new PNH mental health team acknowledged that more psychiatric time was necessary at PNH given the large number of residents with mental health concerns.
We uncovered several instances where a psychiatric consult was ordered but the psychiatrist did not actually see the resident for weeks. This practice is improper and compromises attentive resident care because the condition prompting the psychiatric consult may become dramatically exacerbated in the intervening weeks. Dr. Greenwald found that it produces the likelihood of "untoward and potentially dangerous" incidents that could occur, placing the resident or others at risk of harm.
Overall, Dr. Greenwald concludes that "this kind of loose oversight compromises patient care and is heavily dependent upon good nursing staff-psychiatrist communication. However, at PNH, nursing staff-psychiatrist communication is erratic and superficial." There is little if any multidisciplinary involvement in psychiatric treatment decisionmaking at PNH. We found little evidence that the treating psychiatrist is aware of,

or has explored, considered and incorporated relevant and important nursing information. The City's own on-site reviews document that the consult psychiatrist fails to consider important behavioral information contained in the nursing notes.
In addition, there is a general need for continuing education among the PNH staff at large with respect to mental health and psychiatric concerns among its residents. There is a conspicuous lack of continuing education and inservices regarding mental health issues at PNH.
B. Medical Care And Services At PNH Are Inadequate To Meet The Residents' Needs
PNH also fails to provide its residents with adequate and appropriate health care in a number of other areas.
1. Neurological Care Is Inadequate
Neurological care and services at PNH are inadequate. PNH primary care physicians, rather than neurologists, provide most of the neurological care at the facility. As a result, many residents with neurological problems, including those with complex and difficult conditions, do not receive the needed specialty services of a neurologist. For example, the PNH physicians did not refer to a neurologist a number of residents who had drug levels that were chronically difficult to control.
In addition, PNH physicians often fail to adequately address residents' anti-seizure medication where they have sub-therapeutic or above therapeutic levels. For instance, for one resident whose Dilantin level fluctuated from high to low to high again, the PNH physician failed to adjust the medication dose, failed to discuss an approach to deal with this problem, and failed to procure expert neurological consult help. The same inadequate documentation and approach was present in the care of another resident who exhibited a high Dilantin level and a sub-therapeutic Tegretol level. As Dr. Adelman concludes for yet another resident, "there is a danger that this resident may be needlessly exposed to medication that is not providing him with any benefit." The City's own on-site reviews reveal a number of similar concerns surrounding neurological care at PNH, including consults not being performed in a timely manner and inadequate documentation of laboratory tests.
PNH also does not have a protocol for proper treatment of emergency seizure situations, known as "status epilepticus." Contrary to generally accepted practice, PNH uses intramuscular injection to.treat such emergency situations rather than intravenous treatment. This practice places PNH residents at active risk of harm. In light of the number of PNH residents with seizures and other neurological complications, the

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facility's deficiencies in neurological care compromise the health of a significant number of residents.
2. Interdisciplinary Communication Is Inadequate
Interdisciplinary communication between physicians and other health care professionals at PNH is inadequate andK does not comport with generally accepted standards. The City's September 1995 on-site review reveals that "interdisciplinary communication is lacking, i.e., no follow-up by other disciplines after findings or recommendations are made." During our tour, even the PNH Medical Director admitted to us that the functioning of the interdisciplinary team needed improvement.
Poor communication between the doctors and the nurses at PNH may have contributed to the death of at least one PNH resident. Dr. Adelman made this conclusion after reviewing the circumstances surrounding the death of a resident who had been receiving Coumadin, a blood thinning medication. Despite the presence of blood in the resident's urine, PNH continued to provide the resident with Coumadin, contrary to accepted professional standards. As Dr. Adelman concluded, this death reveals "a disturbing lack of understanding on the part of nursing about the meaning of [blood in the urine], and therefore, poor communication with the [PNH] physician."
3. Physician Orders Are Inappropriate, Incomplete, Unclear
The orders of the PNH physicians are often inappropriate, incomplete, or unclear. For example, the City's October 1995 on-site review reveals that PNH physicians continue to rely inappropriately on verbal and telephone verbal orders rather than written orders for treatment. The October on-site review also found that physicians' medical diagnoses are often lacking on the physician order sheet. Moreover, Geri Mendelson, our nursing consultant, concludes that physicians' orders are often not clear and that the nurses exacerbate the problem by not taking steps to clarify the orders before trying to implement them. These deficiencies create the danger that orders will not be carried out as intended, thus jeopardizing the health and welfare of the PNH residents who need appropriate treatment.
4. - Medical Notes And Documentation Are Inadequate
As is true with psychiatric notes and documentation, PNH general medical notes and documentation are also incomplete and fail to comport with generally accepted standards. PNH physician notes vary dramatically in quality and generally fail to express adequately the needed approach to care for specific issues and to address abnormal medical findings appropriately.

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The City's November 1995 on-site review revealed "patterns of non-compliance" with respect to chart notes and documentation. In fact, the on-site review found deficiencies with physician progress notes, physician orders, X-rays, labs and consults. Specifically, the on-site review concluded that physicians' orders were "unacceptable" and that the physicians' progress notes revealed a lack of follow-up to problems identified by staff. The review also found that PPD [purified protein derivative] documentation in the residents' charts is "not complete." During our expert tours of PNH, we also discovered that a large number of resident charts contained no obvious record of PPD test results indicating the presence or absence of tuberculosis. Although many of the charts had a designated sheet to track vaccinations and PPD tests, they were unfilled in half of the charts reviewed. In light of the significant increase in tuberculosis in nursing homes, these deficiencies pose significant risk to PNH residents.
PNH physicians are also failing to complete monthly notes in the residents' charts on a timely basis. The City's November 1995 on-site review found "zero percent" compliance with respect to the completion of monthly summaries. It also found no evaluation of current care plan goals and no review of significant resident issues or episodes occurring during the month.
In addition, PNH often fails to obtain timely laboratory data and weights and to provide appropriate follow-up'. We uncovered a number of examples at PNH where there were unacceptably long delays in obtaining consult results, initiating medical tests, obtaining the test results, and providing appropriate treatment. As Dr. Adelman concludes, "[a] better mechanism for tracking tests and obtaining test results in a timely manner should be a priority."
5. Staffing And Resource Concerns
State surveyors in June 1995 found the ratio of physicians to residents at PNH was extraordinarily poor; each PNH physician was responsible for the health care of two hundred or more residents. Just prior to our tour, however, PNH quickly added physicians to its staff. The picture presented to us at the time of our tour was even more skewed because the resident census had been"artificially reduced for months due to a ban on admissions and re-admissions that was imposed on PNH after the June 1995 certification survey. At the time of our tour, re-admissions of discharged PNH residents had just resumed, and 'new admissions were about to start again. Even so, the resident census at the time of our tour was at least 150 residents below where PNH projects it to be in the future. Many of the residents scheduled to be re-admitted were some of the most medically fragile individuals at the nursing home. As Dr. Adelman suggests, given

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the artificially reduced census and the presence of new staff physicians, a "re-evaluation" of the medical department should be conducted when the full resident census is reached.
C. Nursing Care And Services At PNH Fail To Meet Generally Accepted Practices
There are deficiencies in the delivery of nursing care and services at PNH which breach generally accepted standards of clinical practice and which seriously jeopardize the residents.
1. Nurses Fail To Follow Standard Infection Control Procedures
PNH nurses fail to adhere to universally accepted treatment protocols with respect to infection control procedures and maintaining aseptic conditions at treatment sites. The PNH Director of Nursing admitted to us that she has concerns about the nursing staff's competency in and knowledge of proper wound care to reduce the possibility of infection. Our nursing consultant concludes that "the PNH nurses did not follow generally accepted procedures to reduce the risk of infection -.. and generally did not' follow universally accepted procedures related to maintaining cleanliness and sterility ... Generally, the PNH nurses ... did not demonstrate the knowledge or skills to provide appropriate nursing services to residents." The City's own November 1995 on-site review indicates that " [t]reatments did not meet standards of practice utilizing aseptic technique." The City's March on-site review again found that PNH staff do not practice Universal Precautions for infection control, emphasizing that "this area is of serious concern." Once again, it is troubling that PNH failed to correct this deficiency months after it was clearly cited as a problem.
2. Care Of Residents With Diabetes Is Inadequate
PNH fails to provide adequate and acceptable health care to residents with diabetes. Specifically, the practice of evaluating blood sugars and providing subsequent treatment is not acceptable at PNH. Our nursing consultant concludes that the practice of providing care and treatment to PNH residents with insulin dependent diabetes mellitus (a serious form of diabetes) is "not acceptable," and that these residents are "at great risk."
We uncovered many incidents where PNH staff had administered incorrect and/or inaccurate doses of insulin, did not properly monitor certain diabetic residents or inform the physician of their status, and generally did not accurately document insulin administration. In one case, PNH provided a resident with twenty-two straight days of incorrect insulin doses. For another resident who was suffering with an elevated blood sugar level,

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PNH failed to provide an appropriate follow-up note about the continuing status of the resident or even a note indicating that the physician had been notified. Our nursing consultant concludes that the nursing practice in this case was "not acceptable," and if left to continue, "could cause harm or even death to the resident." The PNH nursing staff also improperly treated another resident with low blood sugar without first obtaining a physician's order. Our nursing consultant concludes that because this was not done, "the resident could have gone into shock." Dr. Adelman discovered multiple instances where PNH staff failed to follow the generally accepted practice of calling the supervising registered nurse and physician when residents' diabetic levels were too low or too high. We found a number of examples where neither the nurse nor the physician even addressed abnormal blood glucose levels. It appeared in each case that the physician was never notified or not timely notified. Consistent with this finding, the City's October 1995 on-site review reveals that even PNH nursing supervisors fail to obtain a physician's order before treating diabetic residents.
3. Medication Administration Is Inadequate And Nurses Fail To Follow Physicians' Orders
PNH nurses fail to consistently provide accurate and timely medication administration to PNH residents. The use and reporting of controlled drugs is not acceptable at PNH. During our tour, we uncovered many different medication errors that compromise resident care. The City's on-site reviews also conclude that medication passes are unacceptable at PNH, with medication error administration rates as high as thirty-eight percent. One such review found that medication administration records and treatment administration records were all virtually one hundred percent out of compliance with professional standards. The- City's review concluded: "These areas reflect repeated gaps in documentation, not just on one dose omission. This is a serious liability and one that must be addressed. immediately."
PNH nurses are also not meeting generally accepted standards because they routinely fail to follow physicians' orders which places the PNH residents in jeopardy. During our tour, we discovered that PNH nurses had failed to perform a number of physician-ordered treatments; there was no documentation in the residents' charts as to why the treatments were not done or even that the physician was notified.
4. Skin Care Is Inadequate
PNH fails to perform needed skin assessments on new admittees to determine which residents might be at risk for skin breakdown. Moreover, PNH residents at risk of developing pressure ulcers do not receive required assistance from the

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facility to ensure that their activities of daily living are maintained and that their individual physical and functional abilities do not decrease. Once skin breakdowns occur, PNH does not provide adequate and appropriate treatments. Nurses do not treat wounds from skin breakdowns with proper aseptic techniques and do not follow physicians' orders about turning, and re-positioning residents.
5. Nutritional Intake Concerns
PNH's practices in a number of areas are not adequate to meet its residents' nutritional needs. First, the facility fails to monitor residents' nutritional intake adequately during meals and fails to provide substitute meals for residents when appropriate. The City has documented these deficiencies repeatedly during its on-site reviews of PNH. Residents have lost significant amounts of weight while under PNH's care, yet the facility fails to weigh residents on a regular basis. When it does weigh residents, the weights are often inaccurate. Even in situations where a significant weight loss is actually accurately recorded, doctors, nurses, and dieticians do not address the problem. During our tour, the PNH dietician acknowledged that the facility has no formal mechanism to notify appropriate health care professionals that residents are losing weight. The City has found other pervasive deficiencies in this area at PNH, including a failure to conduct appropriate nutritional assessments and to provide appropriate diets.
Second, PNH fails to provide adequate assessments and treatment to residents who have swallowing disorders or who cannot eat orally. For example, during its November on-site review, the City found that the facility's therapist was not following accepted standards of practice in performing screenings to identify residents with swallowing problems."- Other reviews have documented deficiencies in PNH's practices with respect to residents who are unable to eat and must be fed with a tube. The deficiencies include a failure to conduct adequate assessments of these residents' dietary needs, a failure to provide residents with sufficient calories, protein, vitamins and minerals, and a failure to make a concerted effort to wean residents off of tube feeders.
Finally, during our tour, we also heard many complaints from residents about the adequacy of food they receive. The resident council meeting minutes are rife with resident complaints about food, drink and meals generally. During our tour, we further discovered that PNH is failing to provide its residents with consistently fresh drinking water. We observed that the residents were left to consume water that had been sitting around for days in a styrofoam cup.

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6. Nurses Do Not Timely Respond To Resident Calls For Help

A recurring refrain among residents was that PNH nurses and staff did not respond to resident call bells in a timely manner. A number of residents stated that it has taken nurses over forty-five minutes to respond to resident calls for assistance. In one case, a resident was forced to turn off his'oxygen machine to sound a loud alarm just to get the attention of the staff. He said he more regularly uses a flash light siren to attract the staff after they fail to respond to his call bell. We also found that some call bells were not appropriately placed near the more immobile residents so that they could access them.

7. Nursing Documentation Is Inadequate

As is true in the other disciplines discussed above, nursing documentation and charting is deficient at PNH. The City's November 1995 on-site review reveals "patterns of non-compliance" with respect to PNH nursing chart notes and documentation. In fact, the on-site reviews found deficiencies with nursing history and assessment, nurses notes, monthly nursing summaries, weights and vital signs, medication and treatment cardexes, care plans, dietary and skin assessments. Similar findings, including the need for inservicing nursing staff about appropriate documentation, appear in earlier on-site City reviews of PNH.

8. Nurse Staffing Is Inadequate

Nurse staffing levels are unacceptable at PNH. The City's own on-site review acknowledges that "[s]taffing continues to be an issue." At the time of our tour, there were many nursing vacancies and an unacceptably high use of contract nurses. The PNH Director of Nursing admitted to us that current permanent nurse staffing is not sufficient and that the facility must rely instead on contract nurses to meet residents' needs. The figures contained in the City's on-site reviews reveal "significant" use of contract agency nurses at PNH: in October 1995, PNH used agency nurses for about twenty-six percent of its registered nurse positions, and used agency nurses for over seventy-one percent of its licensed practical nurse positions. Not only is the overuse of contract nurses inefficient and costly, but it also compromises resident care. The PNH Director of Nursing admitted -that the use of agency nurses poses problems with continuity of care. The City's on-site review also concurs with this conclusion.

9. Nurses Require Additional Education/Inservices

Nurses, indeed staff in a broad range of disciplines at PNH, need better education about how best to care for PNH residents. Dr. Adelman concluded that PNH nurses had insufficient knowledge and experience to meet the residents' needs. Members of the PNH

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infection control team also acknowledged that staff education is an area that needs improvement at the facility. Some of the other areas in need of additional training that PNH administrators and staff identified include: basic quality nursing care, assessment skills, prevention strategies, interdisciplinary communication, general staff inservicing, and documentation.
In sum, the deficiencies in medical and nursing care at PNH outlined above constitute a systemic failure to meet residents' health care needs, in violation of their constitutional and federal statutory rights.
IV. CERTAIN PNH RESIDENTS ARE NOT BEING SERVED IN THE MOST INTEGRATED SETTING APPROPRIATE TO THKIR NEEDS
Finally, some PNH residents' rights are being violated as a result of their continuing confinement at the facility. Pursuant to Title II of the Americans with Disabilities Act ("ADA"), 42 U.S.C. § 12132, "no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of services, programs, or activities of a public entity, or be subjected to discrimination by any such entity." Applicable ADA regulations provide: "A public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities." 28 C.F.R. § 35.130(d). In a recent case involving PNH, the Court of Appeals for the Third Circuit held that Idell S., a PNH resident, had a right under the ADA to receive the support services she needed in her own home rather than being required to live in a nursing home to receive them since Pennsylvania already had a program to provide in-home attendant care services. Helen L. v. DiDario. 46 F.3d 325 (3d Cir.), cert, denied. _J^ U.S. , 116 S. Ct. 64 (1995).
There is a group of individuals with physical disabilities at PNH, like Idell S. in the Helen L. case, who professionals have evaluated and determined can live outside of the nursing home with appropriate attendant care services. Also like Idell S., the only reason these individuals must continue to live at PNH is because of a lack of available attendant care services in the Philadelphia area. As the Federal Court of Appeals for the Third Circuit has already decided, this is not an acceptable reason under the ADA to deny individuals the opportunity to be served in a more integrated setting. In addition, mentally ill PNH residents have not been evaluated by professionals to determine whether they can be served in a more integrated setting. The facility's failure to assess these individuals to determine whether continued confinement in a nursing home is
necessary or whether there is a more integrated setting appropriate to meet their needs is also a violation of the ADA.

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V. MINIMAL REMEDIAL MEASURES
In order to remedy these deficiencies and to protect the rights of PNH residents, the following measures, at a minimum, need to be implemented promptly.
1. PNH must fully comply with all applicable provisions of the Medicare and Medicaid statutes and their implementing regulations that govern conditions of care at PNH.
2. . PNH must ensure that the staff members are providing residents with appropriate basic care services that meet the residents' needs.
3. PNH must provide a safe environment for its residents. Staff members must adequately monitor and safeguard the residents, especially those with histories of exhibiting behaviors that cause injury to themselves or others. Residents must be protected from being victimized by other aggressive residents.
4. PNH must provide residents with sufficient, meaningful activities. For those residents who abuse alcohol, PNH must provide them with appropriate productive activities and programming to address their alcohol abuse.
5. PNH must ensure that bodily restraints are used only pursuant to accepted professional standards and that they are never used as punishment or for the convenience of staff. Appropriate physicians' orders must be obtained and followed before restraints are utilized. The facility must ensure that residents are released from any restraints at least every two hours.
6. PNH must provide adequate and appropriate psychiatric and mental health services in accordance with accepted professional standards to residents who need such services. PNH must procure adequate psychiatry consult hours to meet the needs of the residents. Psychotropic medication must only be used in accordance with accepted professional standards and where there is an appropriate psychiatric or neuropsychiatric diagnosis. It must not be used as punishment, in lieu of a training program, for behavior control, or for the convenience of staff. In order to accomplish this, PNH must:
a. Conduct a comprehensive assessment of each PNH resident receiving psychotropic medication or who has documented mental illness; provide the resident with an appropriate differential diagnosis of mental illness;
b. Develop an overall treatment plan for each resident with a diagnosis of mental illness that describes clear,

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objective and measurable short-term, intermediate and long range goals and objectives for each resident, including time frames for the achievement of each;
c. Provide on-going monitoring of the efficacy of treatment and make revisions in the treatment plan when warranted;
d. Document that, prior to using psychotropic medication for behavior modification, other, less restrictive techniques have been systematically tried and have been demonstrated to be ineffective;
e. Develop and implement an adequate system for detecting, reporting, and responding to any drug-induced side effects of psychotropic medication; and
f. Provide an adequate array of non-pharmacological mental health services for those residents who need them, with special emphasis on those individuals who have exhibited aggressive or other maladaptive behaviors.
7. PNH must ensure that its residents receive adequate preventive, chronic, routine, acute, and emergency medical care in accordance with generally accepted standards of care. PNH must ensure adequate and appropriate interdisciplinary communication among relevant professionals, and PNH physicians must write appropriate, complete and clear orders pursuant to generally accepted practice. Further, PNH primary care physicians must:
a. Conduct comprehensive evaluations of all residents for whom they are responsible;
b. Determine what specialized medical services are required for the residents for whom they are responsible and ensure that such services are timely provided whenever necessary to evaluate or treat the individual's medical problems;
c. Ensure that each individual has an integrated medical plan of care to address any chronic medical problem; and
d. Ensure that each individual's medical status and progress in response to the individual's medical plan of care is "regularly and adequately reviewed.
In concert with the above steps, PNH must provide adequate and appropriate routine, chronic, and emergency seizure management to all individuals with epilepsy at PNH in accordance with accepted professional standards of care. Specifically, the City must procure a sufficient number of neurology consult hours to meet the needs of the residents, provide adequate seizure documentation and recordkeeping, and improve diagnostic

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techniques. PNH must put in place an emergency protocol for the treatment of status epilepticus and "inservice" staff on how to implement it. PNH must immediately stop the use of intramuscular medication to treat status.
8. PNH must ensure that its residents receive adequate nursing care, and that nurses perform their responsibilities in keeping with accepted professional standards of care by adequately identifying health care problems, notifying physicians of health care problems, monitoring and intervening to ameliorate such problems, and keeping appropriate records of residents' health care status. To this end, PNH nurses must:
a. Conduct adequate, comprehensive assessments;
b. Develop nursing diagnoses and develop and implement adequate and appropriate comprehensive nursing care plans to address each resident's health care needs;
c. Routinely perform on-going monitoring of serious medical conditions, including such basic procedures as taking vital signs and measuring weights;
d. Develop and implement a system for recording important information about a resident's status to monitor changes;
e. Communicate essential information to physicians; and
f. Follow physicians' orders.
In addition, PNH nurses and staff must ensure that they follow standard infection control procedures, maintain aseptic technique and conditions at treatment sites, ensure that diabetic residents receive appropriate care and services-, reduce medication errors, perform skin care assessments and ongoing treatments and therapy to prevent skin breakdown, and respond promptly to resident calls for assistance. The City must also procure sufficient nursing staff to ensure adequate continuity of resident care so that the facility is no longer reliant on temporary contract nurses.
9. PNH must ensure that residents' nutritional intake is adequate,- that weights are routinely and accurately recorded, and that "residents receive appropriate diets, adequate amounts of food, and sufficient quantities of fresh water to ensure proper hydration. In addition, PNH must assess and treat residents with swallowing problems and residents who are unable to eat orally in accordance with accepted professional procedures.
10. PNH must establish and maintain an adequate, unified record for each individual that comports with accepted professional standards and includes current information with respect to the

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individual's.care, medical treatment, and training, and must require staff to utilize such records in making care, medical treatment and training decisions.
11. The City must ensure that a sufficient number of professional and non-professional staff, including, outside consultants, are employed to fully meet the needs of the PNH residents.
12. PNH must comply with the clinical practice guidelines on the treatment of pressure ulcers promulgated by the Public Health Service of the United States Department of Health and Human Services.
13. PNH must ensure that the staff members are adequately trained to perform its duties. PNH must implement a training program for all personnel, including physicians, nurses and dieticians regarding, at a minimum, nutrition, wound care and infection control, abuse and neglect, appropriate drug .therapies for the elderly, mental health needs of residents, and a coordinated interdisciplinary approach to providing care to residents.
14. PNH must implement professional decisions that a resident can be served in a more integrated setting by transferring the resident to the alternative setting. The City of Philadelphia must ensure that before any resident is transferred to a more integrated setting, the setting is capable of meeting the resident's needs and, once the transfer takes place, that the resident's needs are met. Residents who are mentally ill must be assessed to determine whether they are being served in the most integrated setting appropriate to their needs.
The remedial measures outlined above are the minimal steps needed to redress the constitutional and statutory deficiencies at PNH. In order to ensure compliance with the remedial measures, an effective monitoring and reporting scheme is essential.
Given our positive experience with the City thus far, we hope to be able to resolve this matter amicably and cooperatively. As such, we will be contacting your attorneys in the near future to arrange a meeting to discuss in greater detail the measures needed to fully remedy the deficiencies outlined above. We look forward to working with you to resolve this matter in a reasonable and practical manner.

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If you have any questions, please contact Richard Farano at 202-307-3116, or David R. Hoffman at 215-451-5337.
Sincerely,
Devi Assistant Attorney General
Civil Rights Division
cc: Stephanie Franklin-Suber, Esq. Acting City Solicitor City of Philadelphia Law Department
Ms. Estelle B. Richman Commissioner City of Philadelphia Health Department
Ms. Mollie Hess Executive Director Philadelphia Nursing Home
Michael R. Stiles, Esq. United States Attorney Eastern District of Pennsylvania

 
 U.S. Department of Justice Civil Rights Division

Office of the Assistant Attorney General

Wishing/on, D.C. 20035

December 19, 1996

The Honorable Edward G. Rendell
215 City Hall Philadelphia, PA 19107

CRIPA Investigation
I HII 1111I |Il l| l l IIIIII IIII I I IIII || II ||||||II NH PA-004-006 ""••"""" '"

Re: Investigation of the Philadelphia Nursing Home

Dear Mayor Rendell:
On July 28, 1995, we notified you, pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, of our intent to investigate conditions at the Philadelphia Nursing Home ("PNH") in Philadelphia, Pennsylvania. We conducted our investigation by reviewing facility records, including residents' medical charts and other documents relating to the care and treatment of PNH residents, interviewing administrators, staff, and residents, and conducting on-site tours of the facility with three expert consultants: Blaine S. Greenwald, M.D., a geriatric psychiatrist, Ronald D. Adelman, M.D., a geriatric physician, and Geraldine Mendelson, R.N., M.Ed., M.A., C.N.A.A., a geriatric nurse. Following these tours, we obtained and analyzed survey reports from independent consultants retained by the City to evaluate conditions at PNH. Consistent with CRIPA's statutory requirements, we are now writing to inform you of our findings.
Based on our comprehensive investigative review, we have concluded that there are numerous conditions and practices at PNH that violate the constitutional and federal statutory rights of PNH residents. This conclusion should come as little surprise given that throughout our visit, a number of PNH administrators and professional and direct care staff readily admitted that many service areas were insufficient and needed remedial attention. Our independent conclusions and findings were also supported by the conclusions and findings contained in the City's own documents summarizing its many internally generated on-site reviews of the facility. We have set forth below the facts supporting our findings of unlawful and unconstitutional conditions at PNH.

Before addressing the substantive violations, we would like to express our appreciation to the PNH administrators and staff and the City of Philadelphia representatives who extended their

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cooperation and courtesy while we visited the facility. We would especially like to recognize Mollie Hess, Executive Director of PNH, and Jim Casey of PNH for their professionalism, hard work and diligent efforts in supplying us with the information we needed to conduct a thorough and accurate investigation of PNH. Indeed, both repeatedly stressed their sincere desire to improve conditions and practices at the facility. We hope to be able to continue to work with the City and PNH officials in such an atmosphere of cooperation and good faith.
I. PNH IS FAILING TO ENSURE THE SAFETY OF ITS RESIDENTS AND TO PROVIDE ADEQUATELY FOR THEIR BASIC CARE NEEDS
Individuals residing in a state or municipally operated institution have a fundamental Fourteenth Amendment due process right to basic care and reasonably safe conditions. Younabera v. Romeo, 457 U.S. 307 (1982). Federal statutes governing the operation of nursing homes create similar rights. See. e.g.. Grants to States for Medical Assistance Programs (Medicaid), 42 U.S.C. § 1396r, Health Insurance for Aged and Disabled (Medicare), 42 U.S.C. § 1395i-3, and their implementing regulations, 42 C.F.R. § 483, Subpart B. PNH fails to provide adequately for the most basic care needs of many of its residents and fails to ensure resident safety, thereby violating the legal rights of its residents.
A. PNH Fails To Ensure Resident Safety
PNH violates residents' rights by failing to provide a safe environment. Protection from harm is a fundamental constitutional right and a basic requirement of facilities, such as PNH, receiving Medicare and Medicaid funds. Younqberg v. Romeo, 457 U.S. 307 (1982); 42 C.F.R. §§ 483.13, 483.15 (residents have the right to be free from verbal, sexual, physical, and mental abuse, and corporal punishment; the facility must also provide a "safe" environment).
The facility's incident reports and special abuse investigations reveal a high level of injuries and dangerous situations that place residents at risk of harm. Many of these incidents are preventable and reflect systemic deficiencies at PNH including lack of adequate staffing, failure to supervise residents, and inadequate assessment and treatment of mental illness, cognitive impairments, and behavior problems. A number of the incidents result from aggressive PNH residents attacking other residents. For example, in the space of a few weeks during the summer months just prior to our tour, the following incidents occurred at PNH: J.S "assaulted" J.C. by punching her in her left eye; a day earlier, J.S. punched her in the right jaw; F.F. punched W.W. in the head and chest and hit D.D. giving her a bruised eye; T.W. "attacked" J.F. with a glass vase, striking him on the head causing an occipital laceration; B.W. and P.S. were

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hitting each other on the arms and shoulders; N.S. entered B.M.'s room and punched her in the face; C.Q. punched E.M. in the chest; J.R. hit A.S. three times in the head causing a lump on A.S.'s head; J.R. threw a cup of coffee and his walker at E.A.; and V.M. hit N.S. in the chest. During the same few weeks, a PNH aide allegedly "started slapping Mr. E. [a resident] in the face." Other injuries and harmful situations have resulted from unsupervised residents who elope or abuse alcohol while in the facility. These are merely representative examples of other similar preventable incidents that are routinely occurring throughout the facility that demonstrate a systemic failure to protect residents from harm.
B. PNH Often Fails To Provide Basic Care To Residents
PNH also often fails to meet the most basic care needs of its residents. While we found a relatively clean facility at the time of our tour, we also uncovered a number of disturbing examples where residents' basic care needs were not met. For example, we discovered foul odors on residents and in resident rooms, and unkempt and dirty residents wearing unsanitary clothes that were malodorous and covered with food or fluid. Upon smelling a "severe urine odor" coming from one resident's room, our nurse consultant discovered a resident in a bed that was soaking wet in which he had apparently been left for some time. Dr. Greenwald reports that the "stench was hardly bearable" in another resident's room. Dr. Greenwald concludes that these "neglectful situations could be interpreted as a kind of passive abuse ... [which] trespassed beyond the typical range of hygienic conditions that one encounters in nursing homes." During our tour, several PNH care aides freely admitted dismay about the lack of staff concern and attention paid to the residents' basic care needs.
The City has documented similar problems in its on-site reviews of conditions at PNH. For instance, City surveyors in March 1995 found "a lack of overall cleanliness [at PNH]. Odors were prevalent throughout the building, residents' rooms were •unkempt, wheelchairs and geri chairs were dirty and in ill repair." Perhaps most troubling was the City surveyors' conclusion that PNH failed to remedy these basic care problems even after having been alerted to them on prior occasions.
A number of different PNH residents spoke to us freely and at length about the many substandard conditions and practices at PNH. The independent observations and conclusions of the residents reinforced one another as our tour progressed. Some residents complained that units are short-staffed, especially on the weekends and evenings, and that staff members generally do not assist the residents. Virtually all residents we spoke to complained that PNH nurses failed to respond in a timely fashion to their calls for assistance. One resident felt that conditions

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had improved somewhat since the recent arrival of the newer health care staff, but he felt that the newer staff members were inexperienced and not properly trained to care for the population at PNH. Most troubling, this resident expressed concern about the staff's slow response to his emergency needs. He related that when he has experienced shortness of breath, experienced a rapid heartbeat, or has run out of his supply of oxygen, it has taken PNH staff twenty minutes to come to help him. This conclusion is consistent with the City's independent on-site review findings in October 1995 that a number of PNH staff do not tend to the residents' needs while on duty, including residents who have medical orders to receive one-to-one supervision.
In addition, more than one resident indicated that the PNH staff members are generally insensitive towards the residents, that the PNH aides talk to the residents with a disrespectful, often verbally abusive tone, and that their personal belongings are stolen. The PNH administration, having taken the positive step of regularly attending resident council meetings, acknowledged to us that many of the residents' concerns are legitimate.
II. PNH FAILS TO PROVIDE ADEQUATE ACTIVITIES TO RESIDENTS AND USES UNREASONABLE RESTRAINTS
PNH is failing to engage its residents in adequate, appropriate and meaningful activities in violation of their federal statutory rights. See, e.g., 42 C.F.R. § 483.15 ("facility must provide for an ongoing program of activities designed to meet ... the interests and the physical, mental, and psychosocial well-being of each resident").
Even the City's on-site review has uncovered that often no activities take place at PNH and that "[t]here are not enough activities scheduled for the diversity of this population." The City's November 1995 on-site review discovered PNH activities staff reading the newspaper, listening to the radio or watching television instead of engaging the residents in activities. PNH residents have expressed similar concerns.
One consequence of the lack of meaningful activity may be resident abuse of alcohol resulting from boredom and lack of staff supervision and involvement with residents. This problem appears to be widespread at PNH. For example, the City's October 1995 on-site review reveals that one verbally abusive and physically aggressive resident had a persistent problem with "smelling of alcohol," and being found sleeping in the lounge with bottles of alcohol present. An August 11, 1995 PNH special abuse notification letter indicates that another resident left the facility in his wheelchair via the front gate while he was intoxicated. During our tour, one PNH mental health consultant

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acknowledged that there is a great need for programming and treatment for residents with alcoholism at PNH.
In addition, PNH frequently uses restraints as a substitute for keeping the residents engaged. This practice violates the constitutional and federal statutory rights of residents. Younabera v. Romeo, 457 U.S. 307 (1982); 42 C.F.R. § 483.13 ("resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms").
Moreover, PNH restraint practices do not comport with accepted professional standards. During our tour, we discovered that many residents were in restraints or in bed with the bed rails up, restricting their ability to leave the bed, without proper physicians' orders. Indeed, PNH is failing to provide its residents with adequate evaluations prior to the use of or initiation of an order for restraints. The City's own on-site reviews of PNH confirm our findings. 1/ We also found that some residents were not released from their restraints every two hours as is generally accepted. These inappropriate restraint" practices violate PNH residents' rights.
III. PNH IS FAILING TO PROVIDE ADEQUATE HEALTH CARE FOR ITS RESIDENTS
In addition to basic care and safety, all residents of state or municipally operated institutional facilities have a fundamental Fourteenth Amendment due process right to adequate health care. Younabera v. Romeo, 457 U.S. 307 (1982). See also 42 U.S.C. § 1396r(b)(4)(A), 42 U.S.C. § 1395i-3(b)(4)(A) (facility must provide for medical, nursing and related services to "attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident," and provide adequate treatment and services required by mentally ill and mentally retarded residents), and their implementing regulations, 42 C.F.R. § 483, Subpart B. However, PNH fails to provide its residents with medical, nursing and psychiatric care and services that comport with generally accepted practices.
i/ For example, the November 1995 on-site review indicates "no orders when restraint use indicated in record ... orders for side rails many times not seen ... no assessment of restraint use." Similarly, the October on-site review reveals: "[s]ide rails up on beds throughout facility, but no orders for them"; "[e]vening shift documents that side rails are up, but no physician's order is seen"; "[n]ursing documented at 10 p.m. that side rails were up, but no order was written for them." The September on-site review again reveals that PNH often places residents in restraints without proper orders: "use of 'leg restraint' - no order seen for such"; "[r]esident needs order for side rails."

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A. Psychiatric Practices And Mental Health Services Are Inadequate And Do Not Meet The Needs Of The Residents
PNH is not providing its mentally ill residents with adequate psychiatric and mental health services in accordance with generally accepted standards. Psychiatric practices at PNH are typically characterized by superficial evaluations, inadequate follow-ups, a lack of non-drug treatment approaches, a lack of cogent treatment planning, a lack of multidisciplinary input into psychiatric treatment decisionmaking, and a lack of psychiatric inservices.
The City, through its on-site review documents and the statements of its employees, readily admits deficiencies in mental health services at PNH. For example, the City's own November 1995 on-site review reveals "zero percent" compliance with professional standards in its review of antipsychotic therapy at PNH. During our tour, both PNH's mental health consultants and nurses freely admitted deficiencies in psychiatric care and mental health services at PNH.
1. Mental Health Assessments, Diagnoses And Treatments Are Inappropriate
PNH is generally failing to appropriately assess, diagnose and treat its residents who need mental health services. For example, although many residents have cognitive impairments and dementia, PNH does not perform proper cognitive examinations and does not develop adequate and appropriate dementia work-ups. These failures can lead to needless resident deterioration and to the development of irreversible conditions in residents that might have been reversible. In addition, PNH charts often lack consistent or appropriate diagnoses. An adequate diagnosis is essential to develop appropriate treatment. As Dr. Greenwald notes, an inadequate diagnosis "can lead to improper treatment that could harm the resident, either by subjecting him or her to needless medication and its attendant side effects, and/or by failing to treat the underlying mental illness, thereby exposing the resident to negative target behaviors that are not properly controlled."
As a result of the flawed assessment process and inadequate diagnostic formulation, treatments are often not appropriate. For example, several PNH residents have been inappropriately placed on multiple psychotropic drugs without clearly documented benefit. Such polypharmacy treatment places these residents at unnecessary risk of harm of medication side effects and improperly medicates them without the benefit of productively treating their mental illness. In this regard, Dr. Greenwald concludes that PNH has engaged in "cavalier" polypharmacy practice which is "dangerous," and "likely-to-be harmful."

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PNH also fails to provide its residents with adequate and necessary non-drug mental health services. Resident care plans generally fail to substantively address mental health treatment. A number of PNH residents who could benefit from psychosocial treatment do not receive these services. Because of this, Dr. Greenwald concludes that the residents "may remain mired in a state of institutionalized dysfunctionality, when their potential to improve may be significant."
Moreover, there is a marked discrepancy between published PNH policies and the reality of practice at PNH. Contrary to what is written in the Administrative Policies and Procedures guidelines, care plans do not seriously "build on resident's strengths" or "have treatment objectives with measurable outcomes" that are actually measured, and the facility does not ensure that residents "who use antipsychotic drugs receive gradual dose reductions, drug holidays or behavioral programming."
2. Psychiatric Drug Side Effects Monitoring Is Inadequate
Medication side effects monitoring at PNH is inadequate and fails to meet generally accepted standards. Residents are often needlessly subjected to the risks of side effects of the treating medication, thus further exacerbating their already fragile condition. Because of the increased sensitivity to medications among the elderly, it is important that PNH actively monitor side effects. However, PNH does not provide adequate side effects monitoring. For example, PNH's abnormal involuntary movement monitoring is inconsistent at best and typically inaccurate. This failure is especially troubling given that some abnormal involuntary movement side effects associated with antipsychotics may be irreversible for some of the residents.
PNH chart notes rarely reflect that specific drug side effects are considered in the treatment equation. The consult psychiatrist has largely abdicated side effect monitoring for antipsychotics to a form that nurses are supposed to fill out, but rarely if ever do. Several PNH nursing staff even admitted to us that they do not know what side effects to look for. We found that side effects data collection is inadequate in that the PNH forms are haphazardly filled out and, when they are filled out, are often inaccurate. The City's on-site review findings consistently confirm these deficiencies in side effects monitoring.
As a result of these deficiencies, PNH often chronically administers psychotropic medications that have not proven to be effective. PNH therefore unnecessarily subjects its residents to medication side effects. Dr. Greenwald concludes that the consequence of this practice is that "potentially successful psychiatric treatment and rehabilitation is undermined, and in

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selected residents, longer-than-necessary institutionalization maintained and potential re-entry to mainstream society derailed. All of these deficiencies contribute to either harming the residents or placing them at increased risk of harm."
3. Psychiatric Progress Notes, Forms And Documentation Are Inadequate
Psychiatric chart documentation at PNH is inadequate and conveys little meaningful information. Our experts found that progress notes, behavior/side effect monitoring forms, and problem lists do not accurately summarize current clinical circumstances. The PNH notes are usually superficial, employ generalities, are not tied to residents' symptoms or diagnoses, and do not identify goals of treatment. Moreover, even when clinical findings are documented, they often do not yield appropriate and needed treatments.
4. Mental Health Resources And Expertise Are Insufficient
PNH does not provide a sufficient number of psychiatry consult hours to meet the needs of the residents. The current consult psychiatrist admitted that he did not see every resident with mental illness at PNH at least once a year as required by professional standards. In fact, he admitted that he only sees residents on a referral basis rather than proactively instituting a case-identification protocol and appropriate follow-up system. As a result, the psychiatrist admitted that some residents have not been seen who should have been seen simply because no referral had been made. Indeed, Dr. Greenwald found residents with mental illness who have exhibited violent or threatening behaviors who have not had any psychiatric consultations. Even the new PNH mental health team acknowledged that more psychiatric time was necessary at PNH given the large number of residents with mental health concerns.
We uncovered several instances where a psychiatric consult was ordered but the psychiatrist did not actually see the resident for weeks. This practice is improper and compromises attentive resident care because the condition prompting the psychiatric consult may become dramatically exacerbated in the intervening weeks. Dr. Greenwald found that it produces the likelihood of "untoward and potentially dangerous" incidents that could occur, placing the resident or others at risk of harm.
Overall, Dr. Greenwald concludes that "this kind of loose oversight compromises patient care and is heavily dependent upon good nursing staff-psychiatrist communication. However, at PNH, nursing staff-psychiatrist communication is erratic and superficial." There is little if any multidisciplinary involvement in psychiatric treatment decisionmaking at PNH. We found little evidence that the treating psychiatrist is aware of,

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or has explored, considered and incorporated relevant and important nursing information. The City's own on-site reviews document that the consult psychiatrist fails to consider important behavioral information contained in the nursing notes.
In addition, there is a general need for continuing education among the PNH staff at large with respect to mental health and psychiatric concerns among its residents. There is a conspicuous lack of continuing education and inservices regarding mental health issues at PNH.
B. Medical Care And Services At PNH Are Inadequate To Meet The Residents' Needs
PNH also fails to provide its residents with adequate and appropriate health care in a number of other areas.
1. Neurological Care Is Inadequate
Neurological care and services at PNH are inadequate. PNH primary care physicians, rather than neurologists, provide most of the neurological care at the facility. As a result, many residents with neurological problems, including those with complex and difficult conditions, do not receive the needed specialty services of a neurologist. For example, the PNH physicians did not refer to a neurologist a number of residents who had drug levels that were chronically difficult to control.
In addition, PNH physicians often fail to adequately address residents' anti-seizure medication where they have sub-therapeutic or above therapeutic levels. For instance, for one resident whose Dilantin level fluctuated from high to low to high again, the PNH physician failed to adjust the medication dose, failed to discuss an approach to deal with this problem, and failed to procure expert neurological consult help. The same inadequate documentation and approach was present in the care of another resident who exhibited a high Dilantin level and a sub-therapeutic Tegretol level. As Dr. Adelman concludes for yet another resident, "there is a danger that this resident may be needlessly exposed to medication that is not providing him with any benefit." The City's own on-site reviews reveal a number of similar concerns surrounding neurological care at PNH, including consults not being performed in a timely manner and inadequate documentation of laboratory tests.
PNH also does not have a protocol for proper treatment of emergency seizure situations, known as "status epilepticus." Contrary to generally accepted practice, PNH uses intramuscular injection to treat such emergency situations rather than intravenous treatment. This practice places PNH residents at active risk of harm. In light of the number of PNH residents with seizures and other neurological complications, the

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facility's deficiencies in neurological care compromise the health of a significant number of residents.
2. Interdisciplinary Communication Is Inadequate
Interdisciplinary communication between physicians and other health care professionals at PNH is inadequate and does not comport with generally accepted standards. The City's September 1995 on-site review reveals that "interdisciplinary communication is lacking, i.e., no follow-up by other disciplines after findings or recommendations are made." During our tour, even the PNH Medical Director admitted to us that the functioning of the interdisciplinary team needed improvement.
Poor communication between the doctors and the nurses at PNH may have contributed to the death of at least one PNH resident. Dr. Adelman made this conclusion after reviewing the circumstances surrounding the death of a resident who had been receiving Coumadin, a blood thinning medication. Despite the presence of blood in the resident's urine, PNH continued to provide the resident with Coumadin, contrary to accepted professional standards. As Dr. Adelman concluded, this death reveals "a disturbing lack of understanding on the part of nursing about the meaning of [blood in the urine], and therefore, poor communication with the [PNH] physician."
3. Physician Orders Are Inappropriate, Incomplete, Unclear
The orders of the PNH physicians are often inappropriate, incomplete, or unclear. For example, the City's October 1995 on-site review reveals that PNH physicians continue to rely inappropriately on verbal and telephone verbal orders rather than written orders for treatment. The October on-site review also found that physicians' medical diagnoses are often lacking on the physician order sheet. Moreover, Geri Mendelson, our nursing consultant, concludes that physicians' orders are often not clear and that the nurses exacerbate the problem by not taking steps to clarify the orders before trying to implement them. These deficiencies create the danger that orders will not be carried out as intended, thus jeopardizing the health and welfare of the PNH residents who need appropriate treatment.
4. Medical Notes And Documentation Are Inadequate
As is true with psychiatric notes and documentation, PNH general medical notes and documentation are also incomplete and fail to comport with generally accepted standards. PNH physician notes vary dramatically in quality and generally fail to express adequately the needed approach to care for specific issues and to address abnormal medical findings appropriately.

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The City's November 1995 on-site review revealed "patterns of non-compliance" with respect to chart notes and documentation. In fact, the on-site review found deficiencies with physician progress notes, physician orders, X-rays, labs and consults. Specifically, the on-site review concluded that physicians' orders were "unacceptable" and that the physicians' progress notes revealed a lack of follow-up to problems identified by staff. The review also found that PPD [purified protein derivative] documentation in the residents' charts is "not complete." During our expert tours of PNH, we also discovered that a large number of resident charts contained no obvious record of PPD test results indicating the presence or absence of tuberculosis. Although many of the charts had a designated sheet to track vaccinations and PPD tests, they were unfilled in half of the charts reviewed. In light of the significant increase in tuberculosis in nursing homes, these deficiencies pose significant risk to PNH residents.
PNH physicians are also failing to complete monthly notes in the residents' charts on a timely basis. The City's November 1995 on-site review found "zero percent" compliance with respect to the completion of monthly summaries. It also found no evaluation of current care plan goals and no review of significant resident issues or episodes occurring during the month.
In addition, PNH often fails to obtain timely laboratory data and weights and to provide appropriate follow-up. We uncovered a number of examples at PNH where there were unacceptably long delays in obtaining consult results, initiating medical tests, obtaining the test results, and providing appropriate treatment. As Dr. Adelman concludes, "[a] better mechanism for tracking tests and obtaining test results in a timely manner should be a priority."
5. Staffing And Resource Concerns
State surveyors in June 1995 found the ratio of physicians to residents at PNH was extraordinarily poor; each PNH physician was responsible for the health care of two hundred or more residents. Just prior to our tour, however, PNH quickly added physicians to its staff. The picture presented to us at the time of our tour was even more skewed because the resident census had been artificially reduced for months due to a ban on admissions and re-admissions that was imposed on PNH after the June 1995 certification survey. At the time of our tour, re-admissions of discharged PNH residents had just resumed, and new admissions were about to start again. Even so, the resident census at the time of our tour was at least 150 residents below where PNH projects it to be in the future. Many of the residents scheduled to be re-admitted were some of the most medically fragile individuals at the nursing home. As Dr. Adelman suggests, given

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the artificially reduced census and the presence of new staff physicians, a "re-evaluation" of the medical department should be conducted when the full resident census is reached.
C. Nursing Care And Services At PNH Fail To Meet Generally Accepted Practices
There are deficiencies in the delivery of nursing care and services at PNH which breach generally accepted standards of clinical practice and which seriously jeopardize the residents.
1. Nurses Fail To Follow Standard Infection Control Procedures
PNH nurses fail to adhere to universally accepted treatment protocols with respect to infection control procedures and maintaining aseptic conditions at treatment sites. The PNH Director of Nursing admitted to us that she has concerns about the nursing staff's competency in and knowledge of proper wound care to reduce the possibility of infection. Our nursing consultant concludes that "the PNH nurses did not follow generally accepted procedures to reduce the risk of infection ... and generally did not follow universally accepted procedures related to maintaining cleanliness and sterility ... Generally, the PNH nurses ... did not demonstrate the knowledge or skills to provide appropriate nursing services to residents." The City's own November 1995 on-site review indicates that "[t]reatments did not meet standards of practice utilizing aseptic technique." The City's March on-site review again found that PNH staff do not practice Universal Precautions for infection control, emphasizing that "this area is of serious concern." Once again, it is troubling that PNH failed to correct this deficiency months after it was clearly cited as a problem.
2. Care Of Residents With Diabetes Is Inadequate
PNH fails to provide adequate and acceptable health care to residents with diabetes. Specifically, the practice of evaluating blood sugars and providing subsequent treatment is not acceptable at PNH. Our nursing consultant concludes that the practice of providing care and treatment to PNH residents with insulin dependent diabetes mellitus (a serious form of diabetes) is "not acceptable," and that these residents are "at great risk."
We uncovered many incidents where PNH staff had administered incorrect and/or inaccurate doses of insulin, did not properly monitor certain diabetic residents or inform the physician of their status, and generally did not accurately document insulin administration. In one case, PNH provided a resident with twenty-two straight days of incorrect insulin doses. For another resident who was suffering with an elevated blood sugar level,

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PNH failed to provide an appropriate follow-up note about the continuing status of the resident or even a note indicating that the physician had been notified. Our nursing consultant concludes that the nursing practice in this case was "not acceptable," and if left to continue, "could cause harm or even death to the resident." The PNH nursing staff also improperly treated another resident with low blood sugar without first obtaining a physician's order. Our nursing consultant concludes that because this was not done, "the resident could have gone into shock." Dr. Adelman discovered multiple instances where PNH staff failed to follow the generally accepted practice of calling the supervising registered nurse and physician when residents' diabetic levels were too low or too high. We found a number of examples where neither the nurse nor the physician even addressed abnormal blood glucose levels. It appeared in each case that the physician was never notified or not timely notified. Consistent with this finding, the City's October 1995 on-site review reveals that even PNH nursing supervisors fail to obtain a physician's order before treating diabetic residents.
3. Medication Administration Is Inadequate And Nurses Fail To Follow Physicians' Orders
PNH nurses fail to consistently provide accurate and timely medication administration to PNH residents. The use and reporting of controlled drugs is not acceptable at PNH. During our tour, we uncovered many different medication errors that compromise resident care. The City's on-site reviews also conclude that medication passes are unacceptable at PNH, with medication error administration rates as high as thirty-eight percent. One such review found that medication administration records and treatment administration records were all virtually one hundred percent out of compliance with professional standards. The City's review concluded: "These areas reflect repeated gaps in documentation, not just on one dose omission. This is a serious liability and one that must be addressed immediately."
PNH nurses are also not meeting generally accepted standards because they routinely fail to follow physicians' orders which places the PNH residents in jeopardy. During our tour, we discovered that PNH nurses had failed to perform a number of physician-ordered treatments; there was no documentation in the residents' charts as to why the treatments were not done or even that the physician was notified.
4. Skin Care Is Inadequate
PNH fails to perform needed skin assessments on new admittees to determine which residents might be at risk for skin breakdown. Moreover, PNH residents at risk of developing pressure ulcers do not receive required assistance from the

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facility to ensure that their activities of daily living are maintained and that their individual physical and functional abilities do not decrease. Once skin breakdowns occur, PNH does not provide adequate and appropriate treatments. Nurses do not treat wounds from skin breakdowns with proper aseptic techniques and do not follow physicians' orders about turning and re-positioning residents.
5. Nutritional Intake Concerns
PNH's practices in a number of areas are not adequate to meet its residents' nutritional needs. First, the facility fails to monitor residents' nutritional intake adequately during meals and fails to provide substitute meals for residents when appropriate. The City has documented these deficiencies repeatedly during its on-site reviews of PNH. Residents have lost significant amounts of weight while under PNH's care, yet the facility fails to weigh residents on a regular basis. When it does weigh residents, the weights are often inaccurate. Even in situations where a significant weight loss is actually accurately recorded, doctors, nurses, and dieticians do not address the problem. During our tour, the PNH dietician acknowledged that the facility has no formal mechanism to notify appropriate health care professionals that residents are losing weight. The City has found other pervasive deficiencies in this area at PNH, including a failure to conduct appropriate nutritional assessments and to provide appropriate diets.
Second, PNH fails to provide adequate assessments and treatment to residents who have swallowing disorders or who cannot eat orally. For example, during its November on-site review, the City found that the facility's therapist was not following accepted standards of practice in performing screenings to identify residents with swallowing problems. Other reviews have documented deficiencies in PNH's practices with respect to residents who are unable to eat and must be fed with a tube. The deficiencies include a failure to conduct adequate assessments of these residents' dietary needs, a failure to provide residents with sufficient calories, protein, vitamins and minerals, and a failure to make a concerted effort to wean residents off of tube feeders.
Finally, during our tour, we also heard many complaints from residents about the adequacy of food they receive. The resident council meeting minutes are rife with resident complaints about food, drink and meals generally. During our tour, we further discovered that PNH is failing to provide its residents with consistently fresh drinking water. We observed that the residents were left to consume water that had been sitting around for days in a styrofoam cup.

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6. Nurses Do Not Timely Respond To Resident Calls For Help
A recurring refrain among residents was that PNH nurses and staff did not respond to resident call bells in a timely manner. A number of residents stated that it has taken nurses over forty-five minutes to respond to resident calls for assistance. In one case, a resident was forced to turn off his oxygen machine to sound a loud alarm just to get the attention of the staff. He said he more regularly uses a flash light siren to attract the staff after they fail to respond to his call bell. We also found that some call bells were not appropriately placed near the more immobile residents so that they could access them.
7. Nursing Documentation Is Inadequate
As is true in the other disciplines discussed above, nursing documentation and charting is deficient at PNH. The City's November 1995 on-site review reveals "patterns of non-compliance" with respect to PNH nursing chart notes and documentation. In fact, the on-site reviews found deficiencies with nursing history and assessment, nurses notes, monthly nursing summaries, weights and vital signs, medication and treatment cardexes, care plans, dietary and skin assessments. Similar findings, including the need for inservicing nursing staff about appropriate documentation, appear in earlier on-site City reviews of PNH.
8. Nurse Staffing Is Inadequate
Nurse staffing levels are unacceptable at PNH. The City's own on-site review acknowledges that " [s]taffing continues to be an issue." At the time of our tour, there were many nursing vacancies and an unacceptably high use of contract nurses. The PNH Director of Nursing admitted to us that current permanent nurse staffing is not sufficient and that the facility must rely instead on contract nurses to meet residents' needs. The figures contained in the City's on-site reviews reveal "significant" use of contract agency nurses at PNH: in October 1995, PNH used agency nurses for about twenty-six percent of its registered nurse positions, and used agency nurses for over seventy-one percent of its licensed practical nurse positions. Not only is the overuse of contract nurses inefficient and costly, but it also compromises resident care. The PNH Director of Nursing admitted that the use of agency nurses poses problems with continuity of care. The City's on-site review also concurs with this conclusion.
9. Nurses Require Additional Education/Inservices
Nurses, indeed staff in a broad range of disciplines at PNH, need better education about how best to care for PNH residents. Dr. Adelman concluded that PNH nurses had insufficient knowledge and experience to meet the residents' needs. Members of the PNH

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infection control team also acknowledged that staff education is an area that needs improvement at the facility. Some of the other areas in need of additional training that PNH administrators and staff identified include: basic quality nursing care, assessment skills, prevention strategies, interdisciplinary communication, general staff inservicing, and documentation.
In sum, the deficiencies in medical and nursing care at PNH outlined above constitute a systemic failure to meet residents' health care needs, in violation of their constitutional and federal statutory rights.
IV. CERTAIN PNH RESIDENTS ARE NOT BEING SERVED IN THE MOST INTEGRATED SETTING APPROPRIATE TO THEIR NEEDS
Finally, some PNH residents' rights are being violated as a result of their continuing confinement at the facility. Pursuant to Title II of the Americans with Disabilities Act ("ADA"), 42 U.S.C. § 12132, "no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of services, programs, or activities of a public entity, or be subjected to discrimination by any such entity." Applicable ADA regulations provide: "A public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities." 28 C.F.R. § 35.130(d). In a recent case involving PNH, the Court of Appeals for the Third Circuit held that Idell S., a PNH resident, had a right under the ADA to receive the support services she needed in her own home rather than being required to live in a nursing home to receive them since Pennsylvania already had a program to provide in-home attendant care services. Helen L. v. DiDario, 46 F.3d 325 (3d Cir.), cert, denied, U.S. , 116 S. Ct. 64 (1995) .
There is a group of individuals with physical disabilities at PNH, like Idell S. in the Helen L. case, who professionals have evaluated and determined can live outside of the nursing home with appropriate attendant care services. Also like Idell S., the only reason these individuals must continue to live at PNH is because of a lack of available attendant care services in the Philadelphia area. As the Federal Court of Appeals for the Third Circuit has already decided, this is not an acceptable reason under the ADA to deny individuals the opportunity to be served in a more integrated setting. In addition, mentally ill PNH residents have not been evaluated by professionals to determine whether they can be served in a more integrated setting. The facility's failure to assess these individuals to determine whether continued confinement in a nursing home is necessary or whether there is a more integrated setting appropriate to meet their needs is also a violation of the ADA.

- 17 -
V. MINIMAL REMEDIAL MEASURES
In order to remedy these deficiencies and to protect the rights of PNH residents, the following measures, at a minimum, need to be implemented promptly.
1. PNH must fully comply with all applicable provisions of the Medicare and Medicaid statutes and their implementing regulations that govern conditions of care at PNH.
2. PNH must ensure that the staff members are providing residents with appropriate basic care services that meet the residents' needs.
3. PNH must provide a safe environment for its residents. Staff members must adequately monitor and safeguard the residents, especially those with histories of exhibiting behaviors that cause injury to themselves or others. Residents must be protected from being victimized by other aggressive residents.
4. PNH must provide residents with sufficient, meaningful activities. For those residents who abuse alcohol, PNH must provide them with appropriate productive activities and programming to address their alcohol abuse.
5. PNH must ensure that bodily restraints are used only pursuant to accepted professional standards and that they are never used as punishment or for the convenience of staff. Appropriate physicians' orders must be obtained and followed before restraints are utilized. The facility must ensure that residents are released from any restraints at least every two hours.
6. PNH must provide adequate and appropriate psychiatric and mental health services in accordance with accepted professional standards to residents who need such services. PNH must procure adequate psychiatry consult hours to meet the needs of the residents. Psychotropic medication must only be used in accordance with accepted professional standards and where there is an appropriate psychiatric or neuropsychiatric diagnosis. It must not be used as punishment, in lieu of a training program, for behavior control, or for the convenience of staff. In order to accomplish this, PNH must:
a. Conduct a comprehensive assessment of each PNH resident receiving psychotropic medication or who has documented mental illness; provide the resident with an appropriate differential diagnosis of mental illness;
b. Develop an overall treatment plan for each resident with a diagnosis of mental illness that describes clear,

- 18 -
objective and measurable short-term, intermediate and long range goals and objectives for each resident, including time frames for the achievement of each;
c. Provide on-going monitoring of the efficacy of treatment and make revisions in the treatment plan when warranted;
d. Document that, prior to using psychotropic medication for behavior modification, other, less restrictive techniques have been systematically tried and have been demonstrated to be ineffective;
e. Develop and implement an adequate system for detecting, reporting, and responding to any drug-induced side effects of psychotropic medication; and
f. Provide an adequate array of non-pharmacological mental health services for those residents who need them, with special emphasis on those individuals who have exhibited aggressive or other maladaptive behaviors.
7. PNH must ensure that its residents receive adequate preventive, chronic, routine, acute, and emergency medical care in accordance with generally accepted standards of care. PNH must ensure adequate and appropriate interdisciplinary communication among relevant professionals, and PNH physicians must write appropriate, complete and clear orders pursuant to generally accepted practice. Further, PNH primary care physicians must:
a. Conduct comprehensive evaluations of all residents for whom they are responsible;
b. Determine what specialized medical services are required for the residents for whom they are responsible alid ensure that such services are timely provided whenever necessary to evaluate or treat the individual's medical problems;
c. Ensure that each individual has an integrated medical plan of care to address any chronic medical problem; and
d. Ensure that each individual's medical status and progress in response to the individual's medical plan of care is regularly and adequately reviewed.
In concert with the above steps, PNH must provide adequate and appropriate routine, chronic, and emergency seizure management to all individuals with epilepsy at PNH in accordance with accepted professional standards of care. Specifically, the City must procure a sufficient number of neurology consult hours to meet the needs of the residents, provide adequate seizure documentation and recordkeeping, and improve diagnostic

- 19 -
techniques. PNH must put in place an emergency protocol for the treatment of status epilepticus and "inservice" staff on how to implement it. PNH must immediately stop the use of intramuscular medication to treat status.
8. PNH must ensure that its residents receive adequate nursing care, and that nurses perform their responsibilities in keeping with accepted professional standards of care by adequately identifying health care problems, notifying physicians of health care problems, monitoring and intervening to ameliorate such problems, and keeping appropriate records of residents' health care status. To this end, PNH nurses must:
a. Conduct adequate, comprehensive assessments;
b. Develop nursing diagnoses and develop and implement adequate and appropriate comprehensive nursing care plans to address each resident's health care needs;
c. Routinely perform on-going monitoring of serious medical conditions, including such basic procedures as taking vital signs and measuring weights;
d. Develop and implement a system for recording important information about a resident's status to monitor changes;
e. Communicate essential information to physicians; and
f. Follow physicians' orders.
In addition, PNH nurses and staff must ensure that they follow standard infection control procedures, maintain aseptic technique and conditions at treatment sites, ensure that diabetic residents receive appropriate care and services, reduce medication errors, perform skin care assessments and ongoing treatments and therapy to prevent skin breakdown, and respond promptly to resident calls for assistance. The City must also procure sufficient nursing staff to ensure adequate continuity of resident care so that the facility is no longer reliant on temporary contract nurses.
9. PNH must ensure that residents' nutritional intake is adequate, that weights are routinely and accurately recorded, and that residents receive appropriate diets, adequate amounts of food, and sufficient quantities of fresh water to ensure proper hydration. In addition, PNH must assess and treat residents with swallowing problems and residents who are unable to eat orally in accordance with accepted professional procedures.
10. PNH must establish and maintain an adequate, unified record for each individual that comports with accepted professional standards and includes current information with respect to the

- 20 -
individual's care, medical treatment, and training, and must require staff to utilize such records in making care, medical treatment and training decisions.
11. The City must ensure that a sufficient number of professional and non-professional staff, including outside consultants, are employed to fully meet the needs of the PNH residents.
12. PNH must comply with the clinical practice guidelines on the treatment of pressure ulcers promulgated by the Public Health Service of the United States Department of Health and Human Services.
13. PNH must ensure that the staff members are adequately trained to perform its duties. PNH must implement a training program for all personnel, including physicians, nurses and dieticians regarding, at a minimum, nutrition, wound care and infection control, abuse and neglect, appropriate drug therapies for the elderly, mental health needs of residents, and a coordinated interdisciplinary approach to providing care to residents.
14. PNH must implement professional decisions that a resident can be served in a more integrated setting by transferring the resident to the alternative setting. The City of Philadelphia must ensure that before any resident is transferred to a more integrated setting, the setting is capable of meeting the resident's needs and, once the transfer takes place, that the resident's needs are met. Residents who are mentally ill must be assessed to determine whether they are being served in the most integrated setting appropriate to their needs.
The remedial measures outlined above are the minimal steps needed to redress the constitutional and statutory deficiencies at PNH. In order to ensure compliance with the remedial measures, an effective monitoring and reporting scheme is essential.
Given our positive experience with the City thus far, we hope to be able to resolve this matter amicably and cooperatively. As such, we will be contacting your attorneys in the near future to arrange a meeting to discuss in greater detail the measures needed to fully remedy the deficiencies outlined above. We look forward to working with you to resolve this matter in a reasonable and practical manner.

- 21 If you have any questions, please contact Richard Farano at 202-307-3116, or David R. Hoffman at 215-451-5337.
Sincerely,
Devi Assistant Attorney General
Civil Rights Division cc: Stephanie Franklin-Suber, Esq.
Acting City Solicitor City of Philadelphia Law Department Ms. Estelle B. Richman Commissioner City of Philadelphia Health Department Ms. Mollie Hess Executive Director Philadelphia Nursing Home Michael R. Stiles, Esq. United States Attorney Eastern District of Pennsylvania
IT

 
 0 7 / 1 4 / 1 9 9 5 14=04 FROM HCFfl RO 111 DEPARTMENT OF HEALTH & HUMAN SERVICES
To-

TD

-

9 4515349 P.01

Heartr uare J-marong

Admtr.istratjon

Regional Office Ml P.O. Box 7760, 3535 Market St. Philadelphia. PA *91O1

; 4 7525

Ms. MoUie Hess

Executive Director

~^

Philadelphia Nursing Home

Girard Avenue & Corinthian Street

Philadelphia., Pennsylvania 19130

CRIPA Investigation

Provider Number: 39-5478 Dear Ms. Hess:

• •• • • • • • • « • • • • • • • • • • • • • • •
NH-PA-004-003

Our letter of June 23, 1995, informed you that deficiencies identified by the Pennsylvania Department of Health (state survey agency) during the survey conducted June 1, 2 and June 516, 1995, constituted an immediate and serious threat to the health and safcry cf your residents. As a result, we determined that your facility wculc be terminated from participation :n the Medicare program, effective July 9. 1995. A revisit conducted by the Pennsylvania Department of Health on July 7 and July 10-11. 1995,. found that the immediate threat tc resident health and safety had been removed. Therefore, we have rescinded the July 9. 1995 termination.

The following Level A deficiencies were cited during the June 1. 2 and Juoe 5-16, survey:

42 CFR 483.13 - Resident behavior and facility practices 42 CFR 483.15 - Quality of life 42 CFR 483.20 - Resident assessment 42 CFR 483.25 - Quality of care 42 CFR 483.30 - Nursing services 42 CFR 483.35 - Dietary services 42 CFR 483.65 - Infection control 42 CFR 483.70 - Physical environment 42 CFR 483.75 - Administration

The July 7, and July 10-11 revisit found that all of the above level A requirements remained out of compliance.

The deficiencies which remained during the revisit are of such a serious nature =»$ to substantially limit the facility's capacity to provide adequate care to its residents. Therefore, we are ass'gning a new Medicare tennination date consistent with that finding, to be effective September 1^. 1995. This action is taken pursuant tc the authority contained in Section 1866(b)(2) of the Ac;. As required by program regulations, we will arrange to publish a notice in The Philadelphia
o advise the public of the termination.

for

07/14/1995 14:04 FROM HCF.fi R Q III

TO

9 4515349P.02

Page 2 - Ms. Mcllie Hess
The Philadelphia Nursing Home is also certified as a nursing facility in the Title X K (Medicaid) program in Pennsylvania. To participate in the Medicaid program as a provider of nursing facility services, a facility must meet all the provisions of Section 1919 (b). (c), and (d) of the Act. Questions concerning the Medicaid status cf the facility should be directed -o the Pennsylvania Welfare Department.
If you believe this determination is not correct, you may request a hearing before an Administrative Law Judge of the Department of Health and Human Services, Departmental Appeals Board. Procedures governing this process are set out in regulations at 42 CFR 498.40 et seq. A writrer request for a hearing must be filed no later than 60 days from the date of receipt of this letter. Such a request may be made to:
Claudette V. Campbell Associate Regional Administrator Division of Health Standards and Quality Health Care Financing Administration P. O. Box 7760 - Mail Stop 13 Philadelphia, Pa. 19101
A request for a hearing should identify the specific issues, and the findings of fact and conclusions of law with which you disagree. It should also specify the basis for contending that • the findings and conclusions are incorrect. You may be represented by counsel at a hearing at your own expense.
To forestall termination of the Philadelphia Nursing Home's participation in Medicare, you must correct the Level A deficiencies and your facility must be in compliance with the Requirements for Long Term Care Facilities. After you have taken the necessary steps to correct the deficiencies, you must provide mis office with a credible allegation of compliance. We will evaluate the allegation of compliance and determine whether a resurvey is warranted. If a resurvey verifies :hat the Philadelphia Nursing Home has taken the necessary steps to comply with die Requirements for Long Term Care Facilities, we will rescind the decision to terminate your Medicare participation and notify you of this ir writing.
If the Philadelphia Nursing Home is terminated, the Medicare program will rot make payment for skilled nursing facility services furnished to patients who are admitted on or after September 14. For patients admitted prior to September 14. payment may continue to be made for a maximum of 30 days for services furnished on or after mat date. A list showir^ tfte pames_and health insurance dafrr numbers of beneficiaries in your facility on September 14 should be forwarded to mv attention.

tor '•a/uaLitu

07/14/1995 14:05 FROM HCFfl RO" III

TO

9 4515349 P.03

Page 3 - Ms. Mcllie Hess
If you do not take corrective action as herein indicated and your participation in the Medicare program is terminated, the Philadelphia Nursing Home will not be readmitted to the Medicare program unless ycu can demonstrate to HCFA that the reason for termination has been removed and there is a reasonable assurance that it will not recur.
Sincerely.

Claudette V. Campbell Associate Regional Administrator Health Standards and Quality

 
 Wk IPfulak^ftia |mi uircr

11 vmJUM o
Brfcvw 3 2

Expos 4 Cubs 3
Dodgers 6 Astros 5

AL Indtans 14 Rangers 5 Bosox 5 Chteox 3

Angels 10 Jays 2 Brewers 7 Mariners 6

Ex-lover calls Smith 'suicidal'
Says he saw her 3 times on day she says she drownedsons. A3.

TkarMkry, July 20,1995

Heat 'alert' What's returns today for free?
Hot, humid days are forecast; A calculator. See area death toll hits 35. Bl. coupon on A4.
35C«rts

Inspectors' June visit to city nursing home found 'total chaos'

Artault, mfteet and sexual abuses are

ln| aa Invettlfatton. A 4J-r*ar-old mala patient with a
history of sexually aggressive behav-

iitlitwH in • i
City drfitialB say

tor had oral sax with a frail. B-jttar-

M

g

d'

The staff offered the woman month-

problem* an) corrected.

wash. She was not examined by a doctor. The raps crisis center was

ByiblarMcheekt

not called, and the Incident was not reported to Mate health officials or

iNquuaarrtrrwun* , the police.

A 74-pott4 laadrtptat* Was These are bat a few of the abases

stripped of clothing df Ut tldarly described by the state Department of

roommin It OM PhtlMtolpbU N u » Health In a l<»-page report on the

ID| Horn* kM month, ntMd onto Philadelphia Nursing Horns made

hir ttoaiach and ptuM ttnwtli « public yesterday.

tMttraM ana toddln«. H«r tall b«fl The report was compiled after the

ma anplun**. ao BO on* hitU« how state completed In annual Investiga-

long the WM trapptd. i

tion of the nursing home on June 16.

A nnnint aaUtant altoiadly hli • Its grim, detailed findings explsln

•7-raar-old haul* pallral In th« «ra why the stale has threatened to (hut

and kicked her tn the Hjol l«( dor down the SXttwd home, which the

Ing an overnight ihlft fire weaki ReDdeU administration privatised

a|o. The viola* r1|ll araiWai'rad last year.

and twollen, ami her rtfht kaaa The mayor's office has often touted

•ported a Innp the tin of a taaeWU. Its decision to tarn management or

The employee was laiptndad pand-

8esMMt onAtO

"Os >=

12

°O=S
oi

OB

SO)

State deta" > abuses itfound at city nursing home in June

[bom At

better off In this project to have pening again, the report says.

the home over to Episcopal tang simply asserted, 'Listen, all the rest As It happened, the assailant later

Term Care, a subsidiary of Episcopal of you guys,stand out of our way and punched another resident In the

Hospital, as an Innovative move that let us run It If you need to pick up face, the report says.

has saved taxpayers more than checks or do whatever you need to The report raises sharp questions

M million.

do, do that. But leave us alone and let about the competence of the employ-

David L Cohen. Rendell's chief of us run II right.'"

ees. Residents susceptible to bed-

staff, said the state's blistering report The state report depicts a nursing sores weren't given the appropriate

was ho reason to give up on the home In crisis, a place where doctors attention from the nursing staff, the

nursing home, a shelter of last resort and family •embers aren't notified report states.

for some of the city's poorest and when patients are assaulted; where A doctor bad prescribed treatment

sickest residents

one resident was seen lying In bed for one patlenl suffering from bed-

"None of those conditions are pres- covered In his own feces; where bed- sores, but there were no signs the

ent today." Cohen said yesterday. sores are allowed to fester; and orders were carried out. Documenta-

"We took Incredibly aggressive ac- where residents spend empty days In tion was missing. "When the matter

tion to address all those Issues In the hot, airless rooms.

was discussed with the staff... they

fastest possible lime frame. And, In The report criticizes virtually stated. 'We didn't do It. We dldnt

fact, they have been addressed."

every aspect of the Institution, from know about It,'" the report says.

; Molly Hess, executive director of the lukewarm temperature of the . The report says infection-control

the nursing home, did not return a juice to the filthy bedclothes.

practices were weak, apd sites eer-

telephone call seeking comment.

During a visit to one nursing unit eral supporting examples. On June 6.

The state report, briefly summa- on June 10, Inspectors said they the report says, a nurse treating a

rized by the Health Department a found "total chaos."

patient for bedsores failed to change

month ago. Is based on a two-week At 1:30 a.m. they observed:

bis gloves after they were soiled

Inspection In early June. The depart- • A resident lying In bed covered with the patient's feces. The nurse

ment's conclusions were so harsh with feces.

persisted In applying treatment

that It barred new ad-

a A resident sitting on wearing the same dirty gloves.

missions to the nursing home and threatened

OneeMeriy

a wheelchair In a thin On June 5, Inspectors found a congown open so that her tainer of urine sitting atop a bedside

to cut off funding. The patient was
facility was given a

bare buttocks were di- table next to a container of nutrition-

rectly on the seal

al supplement.

three-week deadline to

• A resident sitting na- On June 2, they watched as a real-

redeem Itself.

mottthwath

Earlier this month, stale health Inspectors

after a sexual

ked on the side of his dent was served breakfast while fe-

bed, with the privacy ces lay In a bedpan sitting nearby.

curtain open,

The Inspectors say they also saw a

re-examined the facility and found that the most serious threats to residents' health and safety had been lifted.

assault, the inspectors reported.

a Three residents eating breakfast without assistance and spilling food on themselves, their beds and the

nurse go from room lo room without changing gloves. Soap was not available In five different rooms, the report shows.
The overall environment was dirty

The Health Department

floor.

and uncomfortable, acoordlng to the

has given the nursing home until After an hour and 15 minutes, con- report. Everywhere, It says, the

September lo make further Improve- ditions on the unit hadn't Improved, floors were stained and Uttered with

ments or risk losing IU license.

the report states.

debris. Alr-condltloning units were

Eplscopal's recent attempts to re- The report also alleges multiple broken, raising the temperature In-

fcjrm the Philadelphia Nursing Home Instances of physical abuse.

side lo as high as M degrees.

Included firing Diversified Health For Its part, management of the Despite the heat, water was often

Services, a Plymouth Meeting com- home failed to prevent, Investigate hard to come by. The report slates

pany that ran the Institution on a or follow up on cases where resi- that water containers were not

day-UHiay basis.

dents assaulted each other, or staff placed within residents' easy reach,

Diversified Health executives pre- members abused residents, the re- that meal trays were served without

dict the problems won't disappear port says.

beverages, that water fountains were

simply because they've been ousted. As an example, the report says that broken, and that residents were

They contend that an ungainly bu- one resident burned two fellow resi- given unwieldy drinking containers

reaucracy had emerged lo run the dents with cigarettes between April they couldn't hold.

nursing home, consisting of their and May. In the same lime period, he Through It all, even the youngest

company, the city, the two attending threatened another resident with a residents would spend the days

physicians — Gene Newton and Theo- lorn soda! can. The Incidents were watching TV or sitting Idly In their

dore Burden — and a subcontractor documented by nurses, but the staff rooms, the report says.

hired to ensure compliance with state took no slept to prevent a recur- 'These are snapshots and correct-

standards. The layered lines of au- rence, the report says.

able problems," said Cohen. "The

thority hindered swift and efficient In March, a bedridden teyearold state survey shows that there was

decision-making, thus allowing major female patient suffering from conges- not an acceptable level of care being

problems to go unresolved, Diversi- tive heart failure was punched In the provided at the Philadelphia Nurs-

fied Health officials said.

face by another resident, the report ing Home. It provides specifics why

One Diversified Health executive, says. Nothing In the medical records that was not the case. We agree with

\

who asked lo remain anonymous, suggests that the staff probed the that, and we're taking steps to deal said: "Maybe we would have been Incident or tried to stop It from hap- with it "

 
 CRIPA Investigation
NH-PA-004-005
T. 7/28/95
DLP:LK:AEP:RF:RJF:cmw DJ 168-62-33
The Honorable Edward G. Rendell Mayor of the City of Philadelphia Office of the Mayor 215 City Hall Philadelphia, PA 19107
Re: Investigation of the Philadelphia Nursing Home
Dear Mayor Rendell:
I am writing to inform you of our intention to investigate conditions at the Philadelphia Nursing Home ("PNH"). This investigation will be conducted pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997.
The purpose of the investigation will be to determine whether conditions at PNH violate the residents' constitutional and statutory rights. We will be looking at, among other things, resident safety, the adequacy of medical, nursing and basic care, training, staffing, the use of psychotropic medication, and issues involving community placement. The initiation of this investigation does not indicate a prejudgment on our part that federal rights have been violated. If any violations are found, we intend to confer with you and your staff concerning any appropriate corrective action.
We would like to initiate this investigation as soon as possible. In that regard, an attorney from my office will contact your staff within the next week to arrange a tour of PNH by our consultants and Civil Rights Division personnel. The attorney responsible for this matter is Richard Farano ((202) 307-3116).
cc: Records Chrono Peabody Frohboese Farano Hold

- 2Thank you for your cooperation.
Sincerely,
Loretta King Acting Assistant Attorney General
Civil Rights Division cc: Joseph A. Dworetzky, Esq.
City Solicitor City of Philadelphia Law Department Ms. Estelle B. Richman Commissioner City of Philadelphia Health Department Ms. Mollie Hess Executive Director Philadelphia Nursing Home Michael R. Stiles, Esq. United States Attorney Eastern District of Pennsylvania
i i

 
 „ 08/13/98 THU 14:28 FAX

U.S. v. City of Phildalphia II I II I 1111 I I II II II I III H U M

till III H H l l HIM • • • • • •••• •••••• ••••
NH-PA-002-001
nf

FOR IMMEDIATE RELEASE THURSDAY, AUGUST 13. 1998

CR (202) 616-2765 TDD (202) 514-1888

IMPROVE CONDITIONS AT WfTT^ADELyWTA NURSING HOME

WASHINGTON- A Philadelphia mining home will upgrade conditions to ensure that

dderty and disabled ITSMWI^Tare free from »h"—»and neglect and receive adequate care and treatment, under anMH"*"IT**reachedtoday with the Justice Department and the U.S.

Department of Health and Human Services (HHS).

The agreement, filed together with a lawsuit in U.S. District Court in Philadelphia, stems

from complaints about conditions at the Phikddphia Nursing Home (PNH) which were

investigated by the Department of Justice. Today's agreement, which is subject to approval by

the Court, resolves all allegations in the lawsuit

"Almost every American knows a person living in a nursing home," said BUI Lann Lee,

Acting Assistant Attorney General for Civil Rights. "When dose family members are placed in

nursing homes, we trust they are being treated properly. When we find out that's not the case, we

will not hesitate to act."

Under the agreement, the City of Philadelphia and Episcopal Long Term Care (ELTC),

the City's contractor, will:

-

ensure that residents are free from mistreatment, abuse and neglect;

•

provide adequate psychiatric, medical and nursing care, including dairy activities that

(more)

08/13/98 THU 14:29 FAX

1^)003

-2enable the residents to reach their highest practical level of physical and mental well-being; limit the use of restraints; work with a Federal monitor to implement the agreed upon procedures; pay the federal government $50,000 to resolve False Claims Act violations; and, create a S 15.000 fund for a special project, authorized by the United States, that will improve the quality of life for residents at PNH. "Thejoint effort by two components of the Justice Department to ensure that quality care is provided to the frail and vulnerable residents at PNH, demonstrates our commitment to investigate and prosecute quality of care cases by all available means," said Michael R Stiles, U.S. Attorney in Philadelphia. Stiles emphasized that the care rendered to residents at PNH has greatly improved, noting that the City and ELTC should be commended for their efforts to improve conditions for nursing home residents at PNH. The case marks the first time that the Civil Rights Division hasjoined with a U.S. Attorney's Office and HHS to investigate and resolve issues concerning nursing home care. The case was based on the Civil Rights for Institutionalized Persons Act (CRIPA) and the False Claims Act — the first time the government has used CRIPA in combination with the False Claims Act to challenge conditions at a nursing home "The protection of our senior citizens is of paramount importance," said June Gibbs Brown, Inspector General for HHS. "Today's announcement of this settlement should send a message that we will continue to work to ensure beneficiaries residing in nursing homes receive the highest quality of care. We will hold nursing homes responsible for safeguarding the welfare of our most vulnerable citizens."
(more)

0 8 / 1 3 / 9 8 THU 14:29 FAX
-3Several weeks ago, President Clinton held a press conference to emphasize the importance of providing quality care to older adults living in nursing homes. He stressed the important role the federal government should play in protecting the fights of nursing home residents and ensuring that they receive die care and treatment they need. Hie government's investigation was conductedjointly with the Justice Department's Civil Rights Division, the U.S. Attorney's Office in Philadelphia, and the U.S. Department of Health and Human Services, Office of Inspector General.
### 98-368

 
 U.S. v. City of Phildalphia

NH-PA-002-005
UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA

UNITED STATES OF AMERICA, Plaintiff,

v.

)

Civ. No. 98-

THE CITY OF PHILADELPHIA; EDWARD )

G. RENDELL, MAYOR OF THE CITY OF )

PHILADELPHIA; ESTELLE B. RICHMAN, )

COMMISSIONER, HEALTH DEPARTMENT; )

EPISCOPAL LONG TERM CARE, AS

)

OPERATORS OF THE PHILADELPHIA

)

NURSING HOME,

)

)

Defendants.

)

SETTLEMENT AGREEMENT I. INTRODUCTION
A. This case was instituted by the United States pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA") , 42 U.S.C. § 1997, and pursuant to the False Claims Act, 31 U.S.C.
§ 3 7 2 9 e_£ SfijJ.
B. This Court has jurisdiction over this action pursuant to 28 U.S.C. § 1345 and 31 U.S.C. § 3729.
C. Venue is appropriate pursuant to 28 U.S.C. § 1391(b).

D. 42 U.S.C. § 1997a and 31 U.S.C. §§ 3730 and 3732 give the United States standing to file a complaint under CRIPA and the False Claims Act.
E. The Defendants are the City of Philadelphia, Edward G. Rendell, Mayor of the City of Philadelphia ("the City") , Estelle B. Richman, Commissioner, Health Department (collectively "City Defendants") ; and Episcopal Long Term Care ("ELTC"). All individual City Defendants are named in their official capacities. ELTC is named in its capacity as operator of the Philadelphia Nursing Home ("PNH") under contract with the City.
F. The Defendants have authority and responsibility for the operation of PNH which, at the time of the filing of this Settlement Agreement, is a certified "Provider" under Title XVIII (Medicare) and Title XIX (Medicaid) of the Social Security Act. The individual Defendants are officers of the Executive Branch of the City of Philadelphia. ELTC provides essential health care and related services to residents at PNH pursuant to a contract with the City of Philadelphia.
1. ELTC is responsible for corrective action under this Settlement Agreement only for conditions and practices that have occurred and are occurring while it is the PNH contractor.
- 2-

2. Nothing herein is intended to waive or release any claims or rights as against Service Master Diversified Health Services, Inc. and/or Service Master Diversified Health Services L.P., which previously operated PNH under a subcontract with ELTC. 3. In the event that ELTC is no longer the PNH contractor and the City should hire another contractor to operate PNH, any future successor shall similarly be bound by the provisions of this Settlement Agreement and the responsibilities under this Settlement Agreement will be transferred to such successor. G. On August 17, 1995, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, notified the Mayor of the City of Philadelphia, the City Solicitor of the City of Philadelphia, the Commissioner of the City of Philadelphia Health Department, and Mary K. ("Molly") Hess, the individual appointed by ELTC to serve as the Executive Director of PNH pursuant to contractual arrangements between the City and ELTC, of her intention to investigate allegations of unconstitutional and unlawful conditions at PNH pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997.
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H. In November 1995, the Civil Rights Division, in cooperation with the United States Attorney's Office for the Eastern District of Pennsylvania, commenced an investigation into the care being provided to residents of PNH. Thereafter, on December 19, 1996, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, informed the Mayor of the City of Philadelphia, the Acting City Solicitor of the City of Philadelphia, the Commissioner of the City of Philadelphia Health Department, and Molly Hess, the Executive Director of PNH, that the Attorney General concluded that she had reasonable cause to believe that persons residing in PNH ("residents") were being subjected to conditions that deprived them of their federal statutory rights and of their rights, privileges, and immunities secured by the Constitution of the United States.
I. The parties agree that the care, treatment, and conditions of residency of PNH residents implicate rights that are secured and protected by the Constitution of the United States and implicate their rights under Titles XVIII and XIX of the Social Security Act (Medicare/Medicaid) and the Americans with Disabilities Act. The parties entering into this Settlement Agreement, for the purpose of avoiding protracted and adversarial
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litigation, agree to the provisions set forth herein. J. In entering into this Settlement Agreement, neither City
Defendants nor ELTC admit to any violation of law or admit any fact, and this Settlement Agreement may not be used as evidence of liability against the parties to this Settlement Agreement in any other civil proceeding. Nothing herein is intended to waive any rights or claims with respect to third parties who are not parties to this Settlement Agreement.
K. The parties agree that the provisions of this Settlement Agreement are a lawful, fair and appropriate resolution of this case.
L. This Settlement Agreement, voluntarily entered into, shall be entered by the United States District Court for the Eastern District of Pennsylvania and shall be enforceable as an order of the Court solely to the extent set forth herein.
M. This Settlement Agreement is legally binding and judicially enforceable by the parties and it shall be applicable to and binding upon all of the parties, their officers, agents, employees, assigns, and successors.
Now, therefore, the parties hereby agree as follows:
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II. COMPLIANCE WITH FEDERAL LAW AND ATTACHED PROTOCOLS A. In the operation and management of PNH and in providing
services to PNH residents, the Defendants shall comply fully with the particular provisions of the Nursing Home Reform Act as embodied in Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395 e_£ ££o^_, and Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 e_L seq.f and the regulations and guidelines promulgated pursuant to these statutes. S_e_e. attached Exhibit 1, 42 C.F.R. § 483, Subparts B, C, D, and E, § 483.1 through § 483.206. The parties agree that the language in 42 C.F.R. § 483.1 through § 483.206, as well as the attached long term care guidelines, are incorporated by reference into this Settlement Agreement and that the provisions of this Settlement Agreement are to be construed consistent therewith. Defendants shall also comply fully with the particular provisions of the PNH protocols attached to this Settlement Agreement and incorporated by reference herein. Defendants agree that their obligation to comply fully with the language of the attached protocols does not limit their obligation to comply fully with federal law or with the provisions of this Settlement Agreement.
B. Defendants1 submission of plans of correction and/or certification by the Health Care Financing Administration (HCFA)
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does not in and of itself constitute compliance with this Settlement Agreement. The conclusion of the Monitor (as defined in § XVII of this Agreement) that Defendants are out of compliance with the Settlement Agreement does not in and of itself constitute noncompliance with the Settlement Agreement.
C. Defendants shall comply fully with the Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101 e_L seq. , and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794, and the regulations promulgated pursuant to these statutes.
D. Since the events in 1995 that led to the initiation of this matter, ELTC has developed and implemented a number of policies, procedures, protocols and action plans (collectively or individually hereinafter referred to as "protocols") which pertain to the subject matter in this Settlement Agreement, copies of which have been provided to the United States. Many of these documents have been attached as Exhibits to this Settlement Agreement and incorporated hereunder.
1. If the Defendants seek to modify a PNH protocol which has been attached to and incorporated into this Settlement Agreement, the Defendants shall first submit any proposed modification to the United States and the Monitor for review.
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2. The United States or the Monitor may provide the Defendants with comments or recommendations regarding the proposed protocol modification within 30 days of receipt of the proposed modification. 3. If the United States or the Monitor does not submit any comments or recommendations, the Defendants shall submit the modification to the Court and the protocol modification shall become final upon submission to the Court with appropriate notice of filing to the Court, all parties and the Monitor. 4. In the event that the United States or the Monitor submits any comments or recommendations, the Defendants shall consider the comments and recommendations. If the Defendants decline to adopt the recommendations or comments of the United States or the Monitor, they shall so notify the United States and the Monitor, and the parties and the Monitor shall confer within 30 days. 5. If the parties reach agreement to modify a protocol, the parties shall submit the modification to the Court and the protocol modification shall become final upon submission to the Court with appropriate notice of filing to the Court, all parties and the Monitor. If the parties do not reach
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agreement, Defendants may seek modification of the protocol with the Court by motion and the United States may present its objections. 6. A modified protocol may be implemented immediately, if necessary, due to emergency conditions or to comply with a change in the law. However, Defendants' modified protocol shall not be deemed a permanent modification until Defendants comply with §§ II.D.1-5 above. III. RESIDENT SAFETY A. Defendants shall provide a safe and functional environment for the residents. Defendants shall ensure that all PNH residents are free from mistreatment, verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. B. Defendants shall comply fully with the particular provisions of the PNH protocols entitled "Interdisciplinary Environmental Rounds Process" and "Resident Accountability," attached as Exhibits 2 and 3 and incorporated by reference herein. C. Defendants shall adequately supervise, monitor and safeguard the residents, especially those with histories of exhibiting behaviors that cause injury to themselves or others.
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Residents shall be protected from being victimized by other aggressive residents.
D. The parties recognize that during the pendency of this matter, a behavioral unit, a dementia unit, and an adult unit have been created, along with program outlines and implementation schedules as more fully described in Exhibit 4, attached hereto and incorporated herein.
E. Defendants shall notify the United States monthly of any resident death, specifying for each death, the first name and last initial of the resident, the date of death, and, to the extent that such information is available to Defendants, a brief description of the events surrounding the death. Defendants shall also submit to the United States monthly a copy of all investigation letters sent to the Commonwealth of Pennsylvania Department of Health, as required by law, detailing matters investigated at PNH. IV. BASIC CARE
Defendants shall ensure that the PNH staff members provide residents with appropriate basic care services that meet the residents1 needs. Among other things, Defendants shall ensure that all residents are bathed as scheduled and with sufficient frequency, that residents are shaved appropriately, that
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residents are properly positioned, that residents' fingernails are clean and trimmed, and that residents are given proper oral and hair care. V. COMPREHENSIVE ASSESSMENT AND CARE PLAN
A. Defendants shall ensure that there is a timely, complete, and accurate minimum data set (MDS) in each resident's chart; Defendants shall ensure that there is a current, complete and accurate interdisciplinary care plan in each resident's chart.
B. Defendants shall ensure that each resident's comprehensive care plan is implemented by appropriate and adequately trained staff.
C. Defendants shall comply fully with the particular provisions of the PNH protocols entitled "MDS/RAP: The Resident Assessment Instrument" and "Interdisciplinary Resident Plan of Care," attached as Exhibits 5 and 6 and incorporated by reference herein. VI. ACTIVITIES
A. Defendants shall provide residents with sufficient, meaningful activities both during the week and on the weekends to ensure that the residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.
B. For those residents who abuse alcohol, Defendants shall - 11 -

provide them with appropriate productive activities and programming to address their alcohol abuse; Defendants shall comply fully with the particular provisions of the PNH protocol entitled "Assessment of Resident with Acute Mental Status Change or Suspected Intoxication," attached as Exhibit 7 and incorporated by reference herein. VII. RESTRAINTS
A. Defendants shall ensure that physical or mechanical restraints are used only pursuant to accepted professional standards and that they are never used as punishment or for the convenience of staff. Defendants shall assess, document and ensure that any restraints used are the least restrictive restraints appropriate for the resident and the situation.
B. Defendants shall ensure that appropriate physicians' orders are obtained and followed before physical or mechanical restraints are utilized.
C. Defendants shall ensure that residents are released from any physical or mechanical restraints at least every two hours and are provided with adequate supervision, hydration, and circulation while in restraints.
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VIII. PSYCHIATRIC CARE AND RELATED SERVICES A. Defendants shall provide necessary mental health care and
services to residents to enable them to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with a comprehensive assessment and plan of care that comport with federal regulations and guidelines.
B. Defendants shall provide adequate and appropriate psychiatric and mental health services in accordance with accepted professional standards to residents who need such services.
C. Defendants shall collect and document in the residents' records appropriate behavioral data for each resident requiring behavioral services. Consistent with accepted standards of practice, Defendants shall ensure that such data is incorporated into nurses' notes and psychiatrist's treatment plans for each resident.
D. Defendants shall comply fully with the particular provisions of the PNH protocol entitled "Mental Health Services," attached as Exhibit 8 and incorporated by reference herein. IX. MEDICAL CARE
A. Defendants shall ensure that the PNH residents receive adequate preventive, chronic, routine, acute, follow-up, and
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emergency medical care in accordance with generally accepted standards of care. Defendants shall provide the necessary health 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.
B. Defendants shall comply fully with the particular provisions of the PNH protocol entitled "Medical Services," attached as Exhibit 9 and incorporated by reference herein. To the extent they have not already done so, Defendants shall ensure that:
1. Physicians promptly obtain, review and document lab and test results in the residents' charts and take appropriate actions to address any abnormal results; 2. Physicians complete monthly notes in the residents' charts on a timely basis; 3. Physicians do not rely inappropriately on telephone orders in treating residents; Defendants shall comply fully with the particular provisions of the PNH protocol entitled "Verbal Order Policy," attached as Exhibit 10 and incorporated by reference herein; 4. Physicians address promptly residents' significant or undesirable weight loss and personally provide continual
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follow-up until the situation is adequately addressed; 5. Health care of insulin dependent diabetic residents comports with generally accepted medical practice; 6. All individuals with seizure disorders at PNH are provided with adequate and appropriate seizure management in accordance with accepted professional standards of care and with adequate and appropriate seizure documentation and with adequate and appropriate diagnostic techniques; 7. Residents currently receiving anticonvulsant medication receive the type of medication(s) that is (are) appropriate and effective for the type of seizure and represents the fewest number of medications appropriate for effective seizure management; 8. There are a sufficient number of neurology consult hours to meet the needs of the residents and to provide each resident with a seizure disorder with an annual neurology review; and 9. As indicated by accepted professional standards of care, in the event of a medical emergency involving a resident, including status epilepticus, facility staff will immediately call an ambulance, and will initiate appropriate emergency interventions while awaiting arrival of the
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ambulance prior to transport of the resident to the closest available tertiary facility. X. NURSING CARE Defendants shall ensure that the PNH residents receive adequate and appropriate nursing care, and that nurses perform their responsibilities in keeping with accepted professional standards of care by adequately identifying health care problems, notifying physicians of health care problems, monitoring and intervening to ameliorate such problems, and keeping appropriate records of residents' health care status. Defendants shall provide the necessary nursing care and services to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. To the extent they have not already done so, Defendants shall take, at a minimum, the following measures: 1. Conduct adequate, comprehensive nursing assessments, with quarterly updates, of the nursing care needs of the residents; 2. Develop and implement adequate and appropriate comprehensive nursing care plans to address each resident's health care needs;
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3. Routinely perform ongoing monitoring of serious medical conditions, including such basic procedures as taking vital signs and measuring weights; 4. Comply fully with the particular provisions of the PNH protocol entitled "Twenty-Four Hour Report Form," attached as Exhibit 11 and incorporated by reference herein; 5. Regularly monitor the progress of the PNH residents to ensure that staff members are continually taking whatever nursing steps are necessary for the health care of the individual; 6. Communicate essential information to physicians; 7. Follow physicians' orders or document fully why a physician's order was not expressly followed; 8. Administer medications in a timely manner consistent with accepted nursing practice and provide the necessary supervision and training to minimize medication errors; comply fully with the particular provisions of the PNH protocols entitled "Medication Procedures," "Resident Medication Refusal," and "Narcotic and Barbiturate Count Procedure," attached as Exhibits 12, 13, and 14 and incorporated by reference herein; when a medication error occurs, promptly investigate the error, properly document it
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and take appropriate corrective action; 9. Ensure that residents are provided with adequate skin care, nutrition, turning and positioning to decrease the likelihood of skin breakdown; while not bound to all provisions of Clinical Practice Guidelines Number 15 entitled "Treatment of Pressure Ulcers," promulgated by the Agency for Health Care Policy Research, use the Clinical Practice Guidelines as a basis to establish PNH's plan for skin and wound care; and comply fully with the particular provisions of the PNH protocols entitled "Skin Assessment," "Wound Assessment," "Skin Care Guidelines," "Braden Scale," "Pressure Ulcer Treatment Guidelines," and "Medical Nutrition Therapy for Residents with Pressure Ulcers," attached as Exhibits 15, 16, 17, 18, 19, and 20 and incorporated by reference herein; 10. Follow standard infection control procedures, maintain aseptic technique and conditions at treatment sites; require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice; comply fully with the particular provisions of the PNH protocol entitled "Aseptic Technique," attached as Exhibit 21 and incorporated by reference herein;
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11. Comply fully with the.particular provisions of the PNH protocol entitled "Resident Call Bell," attached as Exhibit 22 and incorporated by reference herein; 12. Ensure that residents' nutritional intake is adequate, that weights are routinely and accurately recorded, and that residents receive appropriate diets, adequate amounts of food, and sufficient quantities of fresh water to ensure proper hydration; comply fully with the particular provisions of the PNH protocol entitled "Provision of Fresh Water," attached as Exhibit 23 and incorporated by reference herein; ensure that each resident receives food prepared by methods that conserve nutritive value, flavor, and appearance, and that is palatable, served at the proper temperature, and prepared in a form designed to meet individual needs; offer substitutes of similar nutritive value to residents who refuse food served; comply fully with the particular provisions of the PNH protocols entitled "Meal Delivery System," "Meal Consumption Record," and "Resident's Weight," attached as Exhibits 24, 25 and 26 and incorporated by reference herein; 13. Ensure nurses provide adequate and acceptable health care to residents with diabetes, including properly
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evaluating blood sugars and providing appropriate treatment when necessary; ensure nurses promptly notify a supervising registered nurse and/or physician when necessary to meet the residents' needs; ensure nurses follow physicians' express orders with respect to the care and treatment of diabetic residents; 14. Comply fully with the particular provisions of the PNH protocol entitled "Nutritional Assessments," attached as Exhibit 27 and incorporated by reference herein; utilizing an interdisciplinary approach, properly assess and appropriately treat residents with swallowing problems and residents who are unable to eat orally in accordance with accepted professional procedures,- to this end, (a) provide adequate care for those residents at risk of aspirating, take any appropriate steps to ameliorate the individual's aspiration risk, and develop and implement an individualized feeding and positioning plan for each individual identified as at risk of aspirating; and (b) to the extent that Defendants have not already done so, train staff in how to properly implement the feeding and positioning plans, and shall develop and implement a system to regularly monitor the progress of the residents who are at risk of aspirating
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to ensure that the staff is continually taking whatever assessment, diagnostic, supervision and treatment steps are necessary to ameliorate the individual's risk; comply fully with the particular provisions of the PNH protocols entitled "Restorative Dining Program," "Dysphagia Team," "Gastrostomy (Peg) Tube Feeding," "Enteral Feedings," and "Weaning from Enteral Feedings," attached as Exhibits 28, 29, 30, 31 and 32 and incorporated by reference herein; 15. Comply fully with the particular provisions of the PNH protocol entitled "Tuberculosis Skin Testing Program," attached as Exhibit 33 and incorporated by reference herein; and 16. Take reasonable steps to procure sufficient nursing staff to ensure adequate continuity of resident care so that the facility is not excessively reliant on temporary contract nurses; procure sufficient nursing staff to provide nursing and related services on a 24-hour basis to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
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XI. THERAPY SERVICES Defendants shall provide each resident in need of therapy
services with adequate and appropriate physical therapy and occupational therapy services. Defendants shall comply fully with the particular provisions of the PNH protocol entitled "Rehabilitation Services," attached as Exhibit 34 and incorporated by reference herein. XII. RECQRDKEEPING
Defendants shall ensure that PNH maintains medical records for each individual and Defendants shall comply fully with the particular provisions of the PNH protocol entitled "Medical Records," attached as Exhibit 35 and incorporated by reference herein. XIII. STAFFING
A. Defendants shall ensure that a sufficient number of professional and non-professional staff are made available to fully meet the needs of the PNH residents as provided herein.
B. Defendants shall establish and maintain consult neurology and psychiatry consultation hours sufficient to meet the needs of the residents as provided herein.
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XIV. MOST INTEGRATED SETTING A. Defendants shall ensure that appropriate professionals
evaluate each resident to determine whether the resident is being served in the most integrated setting appropriate to the resident's needs. An initial evaluation shall occur within fourteen days of admission as part of a comprehensive assessment of each resident. Each resident shall be re-evaluated at least every three months or sooner if there is a significant change in the resident's physical or mental condition.
B. Defendants shall implement professional decisions that a resident can be served in a more integrated setting by transferring the resident to the alternative setting to the extent required by law.
C. Prior to discharging a resident pursuant to § XIV.B, above, Defendants shall prepare a discharge plan specifying the needs of the resident and how those needs will be met at the alternative setting. For purposes of this Settlement Agreement, "discharge" shall mean the point at which an individual's active involvement with PNH is terminated and PNH no longer maintains active responsibility for the care of the individual.
D. Defendants shall provide the Monitor and the United States with a copy of the discharge plan for their review and
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comment prior to discharging the resident. If the Monitor or the United States has any concern about the discharge plan or the alternative placement and so notifies Defendants, the parties shall meet in an effort to resolve the concern prior to discharge so long as the meeting can be timely convened in a manner to facilitate the placement to a more integrated setting.
E. In order to review the adequacy of the alternative placements during the term of this Settlement Agreement, the Monitor and the United States may visit the alternative settings. The Monitor and the United States will be responsible for arranging the visits. XV. STAFF TRAINING
A. Defendants shall provide a training program to ensure that all professional and direct care staff who provide services to PNH residents are adequately trained to implement the requirements of this Settlement Agreement and are thereafter provided with in-service training on a regular basis. Consistent with the ELTC corrective action plan, Defendants shall provide a training program for all personnel, including physicians, nurses and dieticians regarding, at a minimum: nutrition; wound care and infection control; abuse and neglect; appropriate drug therapies for the elderly; mental health needs of residents,- and a
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coordinated interdisciplinary approach to providing care to residents.
B. Defendants shall also encourage its medical staff to regularly attend continuing medical education programs. XVI. RETENTION OF TECHNICAL ASSISTANCE
If and to the extent that the Defendants require additional outside technical assistance to comply with the provisions of this Settlement Agreement, they shall obtain such technical assistance and provide to the Monitor a list of the professionals providing the assistance and a list of topics addressed by the professionals. XVII. MONITOR
A. Rebecca Berlin shall be appointed as Monitor who shall have full authority to monitor the Defendants' compliance with the provisions of this Settlement Agreement consistent with the terms thereof. The Monitor shall assess independently Defendants' compliance with this Settlement Agreement, with the attached protocols, with 42 C.F.R. § 483.1 through § 483.206, as well as the attached long term care guidelines as incorporated into this Settlement Agreement. Any separate outcome measures utilized by the Monitor to assess compliance with the protocols incorporated under this Settlement Agreement will be developed in
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consultation with the parties. In addition, the Monitor shall advise PNH management and staff as to possible procedures that, in the Monitor's view, may be implemented to facilitate compliance with this Settlement Agreement.
1. The Monitor shall not be bound in her conclusions, in whole or in part, on the basis of any certification by the Health Care Financing Administration. 2. Defendants are not bound by the Monitor's conclusions and may contest the same. B. Defendants will afford the Monitor access to PNH at any time to assess compliance with this Settlement Agreement. Subject to the budget provided pursuant to this Settlement Agreement, the Monitor shall visit PNH at least monthly until this action is dismissed consistent with § XIX of this Settlement Agreement, and shall have prompt "access to all nursing home residents and their records. Except as otherwise provided in this Agreement, the Monitor shall also have access to relevant PNH and ELTC documents and records. The Monitor shall maintain the confidentiality of information obtained through this engagement in dealings with non-parties to this Settlement Agreement. C. The Monitor shall attempt to coordinate her activities
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with relevant PNH personnel in order to minimize disruption in the day to day operations of the facility. At all times, the Monitor shall respect the privacy and dignity of the PNH residents. The parties recognize that DePaul Health Care Company ("DePaul") is acting as the City's Contract Monitor regarding the conditions at PNH. Upon reasonable notice by the City that its Contract Monitor, DePaul, will be visiting PNH for its quarterly on-site visit, the Monitor agrees that she will not visit PNH during the one week period, except if conditions in PNH may constitute an immediate and serious jeopardy to the health and safety of the "residents.
D. The Monitor shall create a report documenting any adverse findings relating to compliance with this Settlement Agreement and shall present the report within ten calendar days of the site visit to the Defendants, the United States Attorney's Office, the Civil Rights Division of the U.S. Department of Justice, and the U.S. Department of Health and Human Services, Office of Inspector General ("HHS-OIG"). The Monitor shall submit to the parties a quarterly status report regarding the City's compliance with the terms of this Settlement Agreement.
E. The Monitor shall submit to the parties within thirty days of her designation an initial budget for monitoring
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activities. Subject to the budget provided pursuant to this Settlement Agreement, the Monitor may retain independent consultants, as needed, to meet her obligations under this Settlement Agreement. Defendants shall bear all reasonable costs of the Monitor consistent with the budget. The parties anticipate that the annual cost of the Monitor will not exceed Eighty-Five Thousand Dollars ($85,000.00). In the event that this action is not dismissed after one year for lack of compliance with this Settlement Agreement, and the Monitor's budget has been exhausted, Defendants agree to fund the Monitor until this action is dismissed at the same annualized rate. The Monitor may confer and correspond with the parties on an ox parte basis.
F. Rebecca Berlin may be removed from the Monitor position solely at the discretion of the United States. In the event the Monitor is replaced, the United States shall submit the name(s) and curricula vitae of the new proposed Monitor to the Court and the Defendants shall have the right to present to the Court their position as to the new proposed Monitor. XVIII. ACCESS TO PNH
The Monitor, the United States and its agents shall have the right to request, inspect, review and copy facility records,
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resident charts and other documents, including all financial data pertaining to PNH, conduct interviews with residents and staff outside the presence of supervisory staff, and observe activities normally conducted at PNH to assess compliance with this Settlement Agreement. The United States agrees to provide Defendants with reasonable notice before seeking such access. The Monitor, the United States and its agents agree to respect the privacy and dignity of the PNH residents.
Non-public surveys conducted by the City's Contract Monitor and City Health officials shall not be part of the Monitor's or the United States' routine reviews of Defendants' compliance. For purposes of ensuring coordination of responses to identified problems, the Monitor shall confer regularly with the City's Contract Monitor and City Health officials about their findings and any proposed recommendations. The United States reserves the right to seek copies of the City's Contract Monitor and City Health surveys through discovery or an Inspector General subpoena and the Defendants reserve the right to challenge such request. XIX. TERMINATION AND ENFORCEMENT OF SETTLEMENT AGREEMENT
A. The Defendants shall implement all provisions in the Settlement Agreement upon entry of this Settlement Agreement by the Court. The parties contemplate that the Court shall retain
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jurisdiction of this action for one year to enforce the terms of this Settlement Agreement. In any event, the Court shall retain jurisdiction of this action for all purposes under this Settlement Agreement until Defendants shall have implemented and maintained implementation of all provisions of the Settlement Agreement and this action is dismissed.
B. On or after the date on which the Defendants shall have implemented and maintained implementation of all provisions of this Settlement Agreement, the Defendants may move that the case be closed on the grounds that Defendants have implemented and maintained all provisions of this Settlement Agreement.
C. By stipulation of the parties, dismissal shall be granted unless, within 60 days after receipt of the Defendants' motion, the United States objects to the motion. If the United States makes such an objection, the Court shall hold a hearing on the motion and the burden shall be on the Defendants to demonstrate that they have implemented and maintained implementation of all provisions of this Settlement Agreement.
D. During the term of this Settlement Agreement, nothing in this Settlement Agreement precludes the parties from conducting discovery pursuant to the Federal Rules of Civil Procedure nor shall be construed as a waiver of any legal or equitable rights,
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remedies, defenses or privileges. E. The parties reserve the right to withdraw consent to this
Settlement Agreement in the event that this Settlement Agreement is not approved by the Court in its entirety.
F. If the United States or the Monitor determines that Defendants are failing to comply with a provision or provisions of the Settlement Agreement:
1. The United States or the Monitor shall provide Defendants with prompt written notification of such determination. 2. Before seeking Court enforcement, the United States agrees to allow Defendants seven days from receipt of the notification within which either: (1) to cure the Defendants' alleged failure to comply with a provision or provisions of the Settlement Agreement, or (2) to reply in writing, in opposition to the notification, that Defendants disagree with the conclusion of the United States or the Monitor that they are failing to comply with a provision or provisions of the Settlement Agreement. Upon receipt of such a written reply from Defendants, or if the seven days lapse without receipt of a written reply from Defendants, the United States shall notify Defendants if it intends to seek specific enforcement of the Settlement Agreement in
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Court. 3. If the Defendants' failure to comply with the Settlement Agreement creates a condition or practice at PNH that rises to the level of an emergency, the period of cure specified in \ 2 above shall not apply. In an emergency, the United States may seek curative action of Defendants immediately upon notification or proceed immediately to Court. 4. The United States agrees to pursue judicial enforcement of this Settlement Agreement in the first instance by seeking specific enforcement of the provisions of the Settlement Agreement. Defendants agree that specific enforcement of the Settlement Agreement is an available and appropriate form of remedy. 5. The United States may seek a finding of contempt if the Court orders Defendants to specifically comply with a provision or provisions of the Settlement Agreement and Defendants have failed to comply with the Court's order or any other Court order in this matter. At any time during the course of this Settlement Agreement, the United States may also seek other equitable, remedial relief as may be appropriate, and Defendants may raise any appropriate defenses to such relief.
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G. All parties shall bear their own costs, including attorney fees. XX. RETALIATION
Defendants and its agents, employees, contractors, and/or subcontractors agree not to take any retaliatory action against any individual or individuals who cooperated with this investigation and/or who cooperates with the United States or the Monitor throughout the pendency of this Settlement Agreement. XXI. PAYMENTS
Upon execution of this Settlement Agreement, Defendants agree to pay the sum of Fifty Thousand Dollars ($50,000.00) to the United States of America under the False Claims Act. Payment of this amount shall be made to the United States Attorney's Office, 615 Chestnut Street, Suite 1250, Philadelphia, PA 19106, Attention: David R. Hoffman.
Defendants also agree to set aside the amount of Fifteen Thousand Dollars ($15,000.00) to be used to enhance the quality of life of residents at PNH. This $15,000.00 amount shall be used for a special project that the United States authorizes, in consultation with the Monitor, and shall not be used to meet the minimum requirements for compliance with this Settlement Agreement.
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XXII. RELEASES A. In consideration for such repose and on the terms and
conditions contained herein, and upon payment in full of the amount due in § XXI of this Settlement Agreement, and as expressly provided below, the United States releases and discharges Edward G. Rendell, Mayor of the City of Philadelphia, Estelle B. Richman, Commissioner of the Health Department, Molly Hess and Episcopal Hospital, and ELTC and its officers and directors, from any and all civil and administrative monetary claims, demands, damages, liability and causes of action for money damages, penalties and costs of investigation under the False Claims Act, 31 U.S.C. §§ 3729 e£ seq. , the Civil Monetary Penalties Law, 42 U.S.C. §§ 1320a-7a-7(b),(d), or the Program Fraud Civil Remedies Act, 31 U.S.C. §§ 3801-3812, or the common law theories of payment by mistake, unjust enrichment, breach of contract, and fraud, for the billing for alleged inadequate care rendered to residents of PNH from January 1, 1995 through January 1, 1998, in violation of regulations governing standards of care applicable to long-term care facilities as described in §§ I-IV of the investigative report dated December 19, 1996 ("Investigative Report") submitted by the Department of Justice to the Mayor of the City of Philadelphia, the Health Commissioner
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and PNH's Administrator. HHS-OIG agrees to release and refrain from instituting, directing or maintaining any administrative claim or any action seeking exclusion from the Medicare, Medicaid or other Federal health care programs (as defined in 42 U.S.C. § 1320a-7b(f)) against Defendants under 42 U.S.C. § 1320a-7a (Civil Monetary Penalties Law), or 42 U.S.C. § 1320a-7(b) (permissive exclusion), for the above-stated conduct.
B. The parties agree that the release given in the preceding paragraph specifically excludes the following:
1. Any civil or administrative disputes, adjustments or claims relating to matters other than the alleged violation of standards of care rendered to residents of PNH from January 1, 1995 through January 1, 1998 or any conduct that is beyond the scope of the review conducted by the Department of Justice as set forth in §§ I-IV of the Investigative Report; 2. Any disputes or claims arising under the Internal Revenue Code ; 3. Any disputes or claims arising under any express or implied warranties relating to products or services; and 4. Any disputes or claims arising under the criminal laws of the United States,-
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5. Any enforcement proceedings based upon the Defendants' violations of this Settlement Agreement; 6. Any claims for personal injury or property damage or for other consequential damages arising from the conduct set forth in §§ I-IV of the Investigative Report; 7. Any HHS-OIG administrative exclusion action or sanction pursuant to 42 U.S.C. 1320a-7(t>) or 42 U.S.C. 1320a-7(d), or 42 U.S.C. §§ 1395i-3(h), 1396r(h), based on events occurring after the date of execution of this Settlement Agreement; and 8. Any intentional fraud committed by Defendants. C. Defendants fully and finally release, dismiss, and forever discharge the United States, its agencies, employees, servants, and agents, from any and all claims, causes of action, liabilities, losses and damages, including attorney's fees, costs, and expenses, which Defendants have asserted or could have asserted against the United States, its agencies, employees, servants, and agents, related to any aspects of the care rendered to residents of PNH from January 1, 1995 through January 1, 1998, or to the matters described in §§ I-IV of the Investigative Report, or related to the United States' investigation or prosecution of any of these matters. This paragraph does not
- 36 -

apply to claims for payments made by Defendants from the Medicare and/or Medicaid programs for care adequately provided in the normal course of business and which was not the subject of or related to this investigation or prosecution by the United States, from January 1, 1995 through the date of this Settlement Agreement.
D. Defendants agree that all costs (as defined in the Federal Acquisition Regulation ("FAR") § 31.205-47 and in Titles XVIII and XIX of the Social Security Act, 42 U.S.C. §§ 1395 e_L seg. and §§ 1396 e_L seq. , and the regulations promulgated thereunder) incurred by or on behalf of Defendants, in connection with: (l) the government's investigations, and Defendants' investigations and defense of the matters covered by this Settlement Agreement, (2) the negotiation of this Settlement Agreement, (3) any corrective action undertaken by Defendants for the released acts from January 1, 1995 until the termination of this Settlement Agreement, including but not limited to, the cost of the Monitor and the $15,000.00 amount set forth in paragraph XXI, and (4) the payments made to the United States pursuant to this Settlement Agreement, shall be unallowable costs for government contract accounting and for Medicare, Medicaid, CHAMPUS, VA and FEHBP reimbursement purposes. These amounts
- 37 -

shall be separately estimated and accounted for by Defendants, and Defendants will not charge such costs directly or indirectly to any contracts with the United States or any State Medicaid program, or to any cost report, cost statement, or information statement submitted by Defendants, CHAMPUS, VA or FEHBP programs. Defendants agree further that within 60 days from execution of this Settlement Agreement by all parties, they will identify to applicable Medicare and CHAMPUS fiscal intermediaries, carriers and/or contractors, and Medicaid fiscal agents any unallowable costs (as defined in this paragraph) included in payments sought in any cost reports, cost statements or information reports already submitted by Defendants or any of its subsidiaries and will request that such cost reports, cost statements or information reports, even if already settled, be adjusted to account for the effect of the inclusion of the unallowable costs. Defendants agree that the United States is entitled to recoup any overpayment as a result of the inclusion of such unallowable costs. Any payments due after the adjustments have been made shall be paid to the United States at the direction of the Department of Justice, and/or the affected agencies. The United States reserves its rights to disagree with any calculations submitted by Defendants or any of their subsidiaries on the
- 38 -

effect of inclusion of unallowable costs (as defined in this paragraph) on Defendants' or any of their subsidiaries' cost reports, cost statements or information reports. Nothing in this Settlement Agreement shall constitute a waiver of the rights of HHS, or any Medicare or CHAMPUS fiscal intermediary or contractor, or any Medicaid fiscal agent, to examine or reexamine the unallowable costs described in this paragraph. XXIII. SIGNATURES
This Settlement Agreement may be executed in two or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument.
- 39 -

CONSENTED TO BY THE UNDERSIGNED; FOR THE UNITED STATES:

MICHAEL R. STILES U.S. Attorney Eastern District of
Pennsylvania

BILL LANN LEE Act/ing Assistant
Attorney General Civil Rights Division

ssistant U.S. Attorney Chief Civil Division Eastern District of
Pennsylvania

STEVEN H. ROSENBAUM Chief Special Litigation Section
ROBINSUE FROHBOESE Deputy Chief Special Litigation Section

DAVID R. HOFFMAN/ Assistant U.S^f Attorney Eastern District of
Pennsylvania 615 Chestnut Street Suite 1250 Philadelphia, PA 19106 (215) 451-5337

RICfi^RD J. FA^ANO Sea/or Trial^Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section P.O. Box 66400 Washington, DC 20035-6400 (202) 307-3116
- 40 -

08/12/98 06:44 ©202 401 0400

ana uiv»

LEWIS MORRIS Assistant Inspector General
for Legal Affairs U.S. Department of Health
and Human S e r v i c e s 330 Independence Avenue, SW Washington, DC 202OX 202-205-0602

- 41 -

FOR THE DEFENDANTS:

t*J&**+
S-fEPHANIE L. FRANKLIN-SUBER Philadelphia City Solicitor Law Department 1515 Arch Street - 17th Floor Philadelphia, PA 19102-1595 (215) 683-5003

MARK H. GALLANT, ESQ. Cozen & O'Connor 1900 Market Street Philadelphia, PA 19103 (215) 665-4136 For Episcopal Long Term Care

WHEREFORE, the parties to this action having agreed to the provisions in the Settlement Agreement set forth above, and the Court being advised in the premises, this Settlement Agreement is hereby entered as the ORDER and JUDGMENT of this Court.

IT IS SO ORDERED, this , PA.

day of

1998, at

UNITED STATES DISTRICT JUDGE

- 42 -

FOR THE DEFENDANTS:

STEPHANIE L. FRANKLIN-SUBER Philadelphia City Solicitor Law Department 1515 Arch Street - 17th Floor Philadelphia, PA 19102-1595 (215) 683-5003

MARK H. GALLANT, ESQ. Cozen & O'Connor 1900 Market Street Philadelphia, PA 19103 (215) 665-4136 For Episcopal Long Term Care

WHEREFORE, the parties to this action having agreed to the provisions in the Settlement Agreement set forth above, and the Court being advised in the premises, this Settlement Agreement is hereby entered as the ORDER and JUDGMENT of this Court.

IT IS SO ORDERED, this , PA.

day of

1998, at

UNITED STATES DISTRICT JUDGE

- 42 -

 
 CONTENTS

b >

i=SooJ

UNITED STATES OF AMERICA V. CITY OF PHILADELPHIA. ET AL.
Settlement Agreement Exhibits
1. HHS Regulations and Guidelines
2. Interdisciplinary Environmental Rounds Process 3. Resident Accountability 4. Behavioral Unit, Adult Unit, Dementia Unit 5. MDS/RAP: The Resident Assessment Instrument 6. Interdisciplinary Resident Plan of Care 7. Assessment of Resident with Acute Mental Status Change or Suspected Intoxication 8. Mental Health Services 9. Medical Services 10. Verbal Order Policy 11. Twenty-Four Hour Report Form 12. Medication Procedures 13. Resident Medication Refusal 14. Narcotic and Barbiturate Count Procedure 15. Skin Assessment (Routine Skin Care Prevention Protocols, Incontinence Protocol) 16. Wound Assessment (Wound Staging Process) 17. Skin Care Guidelines 18. Braden Scale 19. Pressure Ulcer Treatment Guidelines 20. Medical Nutrition Therapy for Residents with Pressure Ulcers 21. Aseptic Technique 22. Resident Call Bell 23. Provision of Fresh Water 24. Meal Delivery System 25. Meal Consumption Record 26. Resident's Weight 27. Nutritional Assessments 28. Restorative Dining Program 29. Dysphagia Team 30. Gastrostomy (Peg) Tube Feeding 31. Enteral Feedings 32. Weaning from Enteral Feedings 33. Tuberculosis Skin Testing Program 34. Rehabilitation Services 35. Medical Records

TAG NUMBER
150

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
S483.5 Definitions. For purposes of this eubpart-"Faclllty" seans, a skilled nursing facility (SNF) or a nursing facility (NF) which meets the requirements of sections 1819 or 1919(8), (b), (c), and (d) of the Act. "Facility" may Include a distinct part of an institution specified in $440.40 of this chapter, but does not include an institution for the mentally retarded or persons with related conditions described in $440,150 of this chapter. For Medicare and Medicald purposes (Including eligibility, coverage, certification, and payment), the "facility" Is always the entity which participates in the program, whether that entity is comprised of all of, or a distinct part of a larger institution. For Medicare, a SNF (see section 1819(a)(l)), and for Medicaid, a NF (see section 1919(a)(l)) nay not be an institution for mental diseases as defined in S435.1OO9.

GUIDANCE TO SURVEYORS
Guidelines: $483.5 The following are the statutory definitions at SS1819(a) and 1919(a) of the Social Security Act (the Act) for a SNF and a NF:
"Skilled nursing facility" Is defined as an institution (or a distinct part of an Institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of Injured, disabled, or sick persons, and Is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of $1861(1)) with one or more hospitals having agreements In effect under $1866; and maets the requirements for a SNF described In subsections (b),(c), and (d) of this eection.
"Nursing facility" is defined as an institution (or a distinct part of an Institution) which is primarily engaged In providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, healthrelated care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and Is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of $1861(1)) with one or more hospitals having agreements in effect under $1866; and meets the requirements for a NF described in subsections (b), (c), and (d) of this section.
If a provider does not meet one of these definitions, it cannot be certified for participation in the Medicare and/or Medicald programs.
NOTE: IF THE SURVEY TEAM FINDS SUBSTANDARD CARE IN $5483.13, 483.15, OR 483.25, FOLLOW THE INSTRUCTIONS FOR PARTIAL EXTENDED OR EXTENDED SURVEYS.

Rev. 274

06-95

PP-1

TAG NUMBER

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
$483.10 Resident rights.
The resident has a right to a dignified existence/ self-determination, and communication with and access to persons and services Inside and outside the facility. A facility must protect and promote the rights of each resident, Including each of the following rights:

GUIDANCE TO SURVEYORS
Guidelines: S4B3.1O All residents In long tern care facilities have rights guaranteed to them under Federal and State law. Requirements concerning resident rights are specified in SS483.10, 483.12, 483.13, and 483.15. Section 483.10 1 B intended to lay the foundation for the remaining resident's rights requirements which cover more specific areas. These rights Include the resident's right to:
o Exercise his or her rights (S483.10(a)); o Be Informed about what rights and responsibilities he or she has ($483.10(b)); o If he or she wishes, have the facility manage his personal funds ($483.)' ,'; o Choose a physician and treatment and participate in decisions and care planning ($4B3.10(d)); o Privacy and confidentiality ($483.10(e)); o Voice grievances and have the facility respond to those grievances ($483.1O(f)); o Examine survey results (S483.10(g)); o Work or not work ($483.10(1))); o Privacy in sending and receiving mall ($483.10(1)); o Visit and be visited by others from outside the facility (S483.10(j)); o Use a telephone in privacy ($483.10(k)); o Retain and use personal possessions ($483.10(1)) to the maximum extent that apace and safety permit; o Share a room with a spouse, If that Is mutually agreeable ($483.10(m)); o Self-administer medication, if the interdisciplinary care planning team determines it is safe ($483.10(n)); and o Refuse a transfer from a distinct part, within the institution <S483.10(o)).
A facility must promote the exercise of rights for each resident, Including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be Incompetent, should be able to assert these rights based on his or her degree of capability.

F151

(a) Exercise of rights.

(1) The resident has the right to exercise his or her rights as a resident of the facility and aa a citizen or resident of the United States.
Rev. 274

Guidelines: S483.1O(a)(l) Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long aa those rules do not violate a regulatory requirement.

06-95

PP-2

TAO NUMBER
F151 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.

GUIDANCE TO SURVEYORS
Intent: S483.10(a)(2) This regulation is intended to protect each resident In the exercise of his or her rights.
Guidelines: S483.1O(a)(2) The facility muBt not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights. Facility behaviors designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not Interference or coercion.
Examples of facility practices that may limit autonomy or choice In exercising rights Include reducing the group activity time of a resident trying to organire a residents' group; requiring residents to seeK prior approval to distribute information about the facility; discouraging a resident froa hanging a religious ornament above his or her bed; singling out residents for prejudicial treatment such aa isolating residents in activities; or purposefully assigning Inexperienced aides to a resident with heavy care needs because the resident and/or hiB/her representatvlve, exercised his/her rights.
Procedures: S483.10(a)(2)
Pay close attention to resident or staff remarks and staff behavior that may represent deliberate actions to promote or to limit a resident's autonomy or choice, particularly In ways that affect Independent functioning. Because reprisals may indicate abuse, if the team determines that a facility has violated this requirement through reprisals taken against residents, then further determine If the facility has an effective system to prevent the neglect and abuse of residents. (S4B3.13(c), F224-F225.)

F152

(3) 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.
(4) In the case of a resident who has not been adjudged incompetent by the State court, any legalsurrogate designated In accordance with State law nay exercise the resident's rights to the extent provided by State law.

Rev. 274

Guidelines: S4B3.10(a)(3) and (4) When reference is made to "resident" in the Guidelines, it also refers to any person who may, under State law, act on the resident's behalf when the resident is unable to act for himself or herself. That person is referred to as the resident's surrogate or representative. If the resident has been formally declared incompetent by a court, the surrogate or representative is whoever waa appointed by the court - a guardian, conservator, or committee. The facility should verify that a surrogate or representative has the necessary authority. For example, a court-appointed conservator might have the power to make financial decisions, but not health care decisions.
A resident may wish to delegate decision-making to specific persons, or the resident and family may have agreed among themselves on a decision-making process. To the degree permitted by State law, and to the maximum extent practicable, the facility must respect the resident's wishes and follow that process.

06-95

PP-3

TAG NUMBER
F1S2 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
The rights of the resident that nay be exercised by the surrogate or representative Include the right to make health care decisions. However, the facility nay seek a health care decision (or any other decision or authorization) from a surrogate or representative only when the resident Is unable to Bake the decision. If there is a question as to whether the resident Is able to make a health care decision, staff should discuss the matter with the resident at a suitable tine and judge how well the resident understands the information. In the case of a resident who has been fomally declared Incompetent by a court, lack of capacity la presumed. Notwithstanding the above, if such a resident can understand the situation and express a preference, the resident should be informed and his/her wishes respected to the degree practicable. Any violations with respect to the resident's exercise of rights should be cited under the applicable tag number.
The Involvement of a surrogate or representative does not automatically relieve a facility of its duty to protect and promote the resident's Interests. For example, a surrogate or representative does not have the right to insist that a treatment be performed that is not medically appropriate, and the right of a surrogate or representative to reject treatment may be subject to State law limits.
Procedures: S483.10(a)(3) and (4) Determine as appropriate if the rights of a resident who has been adjudged Incompetent or who has a representative acting on his/her behalf to help exercise his/her rights are exercised by the legally appointed individual.

Refer to F1S6

(b) Notice of rights and aervlces.

(1) The facility mist 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 developed under $1919(e)(6) of the Act. Such notification oust be Bade prior to or upon admission and during the resident's stay. Receipt of such

Intent: $483.10(b)(1) This requirement is Intended to assure that each resident know his or her rights and responsibilities and that the facility communicates this Information prior to or upon admission, as appropriate during the resident's stay, and whan the facility's rules change.
Guidelines: S483.1O(b)(l) "In a language that the resident understands" Is defined as communication of information concerning rights and responsibilities that Is clear and understandable to each resident, to the extent possible considering impediments which may be created by the resident's-health and mental status. If the resident's knowledge of English or the predominant language of the facility la Inadequate for comprehension, a moans to communicate the information concerning rights and responsibilities in a language familiar to the resident must be available and Implemented. For foreign languages

Rev. 274

06-9S

PP-4

TAG NUMBER

GUIDANCE1 TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATIOH
Information, and any amendments to it, must be acknowledged in writing;

GUIDANCE TO SURVEYORS
comaonly encountered in the facility locale, the facility should have written translations of Its statements of rights and responsibilities, and should Bake the services of an interpreter available. In the case of leas commonly encountered foreign languages, however, a representative of the resident nay sign that he or she has explained the statement of rights to the resident prior to his/her acknowledgement of receipt. For hearing impaired residents who conaunicate by signing, the facility is expected to provide an Interpreter. Large print texts of the facility's statement of resident rights and responsibilities should also be available.
"Both orally and in writing," means if a resident can read and understand written materials without assistance, an oral summary, along with the written document, la acceptable.
Any time State or Federal laws relating to resident rights or facility rules change during the resident's stay in the facility, he/she must promptly be Informed of these changes.
"All rules and regulations" relates to facility policies governing resident conduct. A facility cannot reasonably expect a resident to abide by rules he or she has never been told about. Whatever rules the facility has formalized, and by which It expects residents to abide, should be Included In the statement of rights and responsibilities.

F153

(2) The resident or his or her legal representative has the right--
(i) 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
(ii) After receipt of his or her records for Inspection, to purchase at a cost not to exceed the comminlty standard photocopies of the records or any portions of them upon request and 2 working daya advance notice to the facility.

Rev. 274

Guidelines: S483.1O(b)(2) An oral request is sufficient to produce the current record for review.
In addition to clinical records, the term "records" Includes all records pertaining to the resident, such as trust fund ledgers pertinent to the resident and contracts between the resident and the facility.
"Purchase" la defined as a charge to the resident for photocopying. If State statute has defined the "community standard" rate, facilities should follow that rate. In the absence of State statute, the "cost not to exceed the community standard" is that rate charged per copy by organizations such as the public library, the Post Office or a commnrclal copy center, which would be selected by a prudent buyer in addition to the cost of the clerical time needed to photocopy the records. Additional fees for locating the records or typing forma/envelopes may not be assessed.

06-95

PP-5

TAG NUMBER
F154

OUIDAMCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(3) The resident has the right to be fully Informed In language that he or she can understand of his or her total health status, Including but not limited to, his or her medical condition;

GUIDANCE TO SURVEYORS
Guidelines: S483.10(b)(3) "Total health status" includes functional status, medical care, nursing care, nutritional status, rehabilitation and restorative potential, activities potential, cognitive status, oral health status, psychoaoclal status, and sensory and physical Impairments. Information on health status must be presented in language that the resident can understand. This includes minimizing use of technical Jargon In communicating with the resident, having the ability to communicate in a foreign language and the use of sign language or other aids, as necessary. (See S483.1O(d)(3), F17S for the right of the resident to plan care and treatment.)
Procedures: S483.1O(b)(3, Look, particularly during observations and record reviews, for on-going efforts on the part of facility staff to keep residents Informed. Look for evidence that Information Is congunicated In a manner that is understandable to residents and communicated at times it could be most useful to residents, such as when they are expressing concerns, or raising questions, as well as on an on-going basis.

F155

(4) The resident has the right to refuse treatment, to refuse to participate In experimental research, and to formulate an advance directive as specified In paragraph (B) of this section; and

Guidelines: S483.10(b)(4) "Treatment" la defined as care provided for purposes of maintaining/restoring health, Improving functional level, or relieving symptoms.
"Experimental research" is defined as development and testing of clinical treatments, such as an lnvestlgatlonal drug or therapy, that Involve treatment and/or control groups. For example, a clinical trial of an lnveatlgatlonal drug would be experimental research.
"Advance directive" means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated.
As provided under State law, a resident who has the capacity to make a health car* decision and who withholds consent to treatment or makes an explicit is.' -) of treatment either directly or through an advance directive, may not be treated against his/her wishes.
A facility may not transfer or discharge a resident for refusing treatment unless the criteria for transfer or discharge are met. (See {483.12(a)(l) and (2).)

Rev. 274

06-95

PP-6

TAG HUMBER
F155 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCB TO SURVEYORS
If the resident la unable to sake a health care decision, a decision by the resident's surrogate or representative to forego treatment nay, subject to State law, be equally binding on the facility. The facility should detemlne exactly what the resident Is refusing and why. To the extent the facility Is able, it should address the resident's concern. For example, a resident requires physical therapy to learn to walk again after sustaining a fractured hip. The resident refuses therapy. The facility is expected to assess the reasons for this resident's refusal, clarify and educate the resident as to the consequences of refusal, offer alternative treatments, and continue to provide all other services.
If a resident's refusal of treatment brings about a significant change, the facility should reassess the resident and institute care planning changes. A resident's refusal of treatment does not absolve a facility from providing a resident with care that allows him/her to attain or maintain his/her highest practicable physical, mental and paychoaoclal well-being in the context of making that refusal.
The resident has the right to refuse to participate In experimental research. A resident being considered for participation In experimental research must be fully informed of the nature of the experiment (e.g., medication, treatment) and understand the possible consequences of participating. The opportunity to refuse to participate in experimental research oust occur prior to the start of the research. Aggregated resident statistics that do not Identify Individual residents may be used for studies without obtaining residents' permission.
Procedures; S483.1O(b)(4) If the facility participates in any experimental research Involving residents, does It have an Institutional Review Board or other committee that reviews and approves research protocols? In this regard, S483.7S(c) Relationship to Other HBS Regulations applies (I.e., the facility must adhere to 45 CFR Part 46, Protection of Human Subjects of Research).
See S483.10(b)(8) F156 with respect to the advance directive requirement.

Rev. 274

06-95

PP-7

TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES GUIDANCE TO SURVEYORS

F156

(5) The facility must—
(I) Inform each resident who Is entitled to Medlcald benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicald o f —
(A) The items and services that are Included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other Items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(II) Inform each resident when changes are made to the Items and services specified in paragraphs (5)(1)(A) and (B) of this section.

Guidelines; S483.1O(b)(5) and (6) Residents should be told In advance when changes will occur In their bills. Providers must fully Inform the resident of services and related changes.
"Periodically" means that whenever changes are being introduced that will affect the residents liability and whenever there are changes in services.
A Medicare beneficiary who requires services upon admission that are not covered under Medicare may be required to submit a deposit provided the notice provisions of S4B3.10(b)(6), If applicable, are met.
Procedures: S483.1O(b)(5) and (6) See S483.10(c)(B) for those Items and services that must be Included In payment under skilled nursing and nursing facility benefits.

(6) The facility must Inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available In the facility and of charges for those services, Including any charges for services not covered under Medicare or by the facility's per diem rate.

Rev. 274

06-95

PP-8

TAO
NUMBER
F156 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(7) The facility Bust furnish a written description of legal rights which Includes—
(1) A description of the manner of protecting personal funds, under paragraph (c) of this section;
(11) A description of the requirements and procedures for establishing eligibility for Medlcaid, Including the right to request an assessment under section 1924(c) which determines the extent of a couple's nonexempt resources at the tine of institutionallzation and attributes to the community spouse an equitable share of resources ' which cannot be considered available for payment toward the cost of the Institutionalized spouse's medical care in his or her process of spending down to Hedicald eligibility levels;
(111) A posting of names. addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency. the Stats licensure office, the State ombudsman program, the protection and advocacy network. and the Hedicald fraud control unit; and
(iv) A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse. neglect, and misappropriation of resident property in the facility.

GUIDANCE TO SURVEYORS
Guidelines: S483.1O(b)(7) "The protection and advocacy network" refers to the system established to protect and advocate the rights of individuals with developmental disabilities specified in the Developmental Disabilities Assistance and Bill of Bights Act, and the protection and advocacy system established under the Protection and Advocacy for Mentally 111 Individuals Act.
Procedures: S4B3.10(b)(7) At the Entrance Conference, request a copy of the written Information that is provided to residents regarding their rights and review it to determine if it addresses the specified requirements. Additional requirements that address the Implementation of these rights are cross-referenced below.

Rev. 274

06-95

PP-9

TAO NUMBER
F156 Cont.

GUIDANCB TO SURVEYORS - LONO TEHM CMUS FACILITIES

REGULATION
(B) The facility aust coaply with the requirements specified In subpart I of part 489 of this chapter relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse nodical or surgical treatment and, at the individual's option, formulate an advance directive. This Includes a written description of the facility's policies to implement advance directives and applicable State law.

GUIDANCE TO SURVEYORS
Guidelines; S483.1O(b)(8) This provision applies to residents admitted on or after December 1, 1991. 42 CFR 489.102 specifies that at the tine of admission of an adult resident, the facility must:
o Provide written Intonation concerning his/her rights under State law (whether or not statutory or recognized by the courts of the State) to make decisions concerning medical care, including the right to accept or refuse medical or aurglcal treatment, and the right to formulate advance directives;
o Document In the resident's medical record whether or not the individual has executed an advance directive;
o Not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advanca directive;
o Ensure compliance with requirements of State law regarding advance directives; o Provide for educating staff regarding the facility's policies and procedures on advance directives; and o Provide for community education regarding the right under State law (whether or not recognized by the courts of the State) to formulate an advance directive and the facility's written policies and procedures regarding the implementation of these rights, Including any limitations the facility may have with respect to implementing this right on the basis of conscience.
The facility is not required to provide care that conflicts with an advance directive. In addition, the facility is not required to Implement an advanca directive if, aa a matter of conscience, the provider cannot implement an advance directive and State law allows the provider to conscientiously object. (See *483.10(b)(4), F1SS.)
The sum total of the community education efforts must Include a summary of the State law, the rights of residents to formulate advance directives, and the -lllty's Implementation policies regarding advance directives. Video and audio tapes may be used In conducting the community education effort. Individual education programs do not have to address oil the requirements if it would be inappropriate for a particular audience.
Procedures; $483.10(b)(8) During Resident Review, review the records of two selected sampled residents admitted on or after December 1, 1991, for facility compliance with advance directive notice requirements.
o Determine to what extent the facility educates its staff regarding advanca directives.
o Determine to what extent the facility provides education for the community regarding one's rights under state law to formulate advance directives.

Rev. 274

06-95

PP-10

TAG HUMBER
F156 Cont.

REGULATION
(9) The facility must lnforn each resident of the name, specialty, and way of contacting the physician responsible for his or her care.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVBYORS
Guidelines: S«83.10(b)(9) "Physician responsible for his or her care" is defined as the attending or primary physician or clinic, whichever Is responsible for managing the resident's radical care, and excludes other physicians whom the resident may see fron time to time. When a resident has selected an attending physician, it is appropriate for the facility to confirm that choice when complying with this requirement. When a resident has no attending physician, it Is appropriate for the facility to assist residents to obtain one In consultation with the resident and subject to the resident's right to choose. (See S4B3.10(d)(l), F163.)
If a facility uses the services of a clinic or similar arrangement, it may be sufficient for residents to have the name and contact information for the primary physician and/or a central number for the clinic itself.

(10) The facility Bust prominently display In the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicald benefits, and how to receive refunds for previous payments covered by such benefits.

Guidelines: S483.10(b)(10) To fulfill this requirement, the facility may use written materials Issued by the State Medicald agency and the Federal government relating to these benefits. Facilities may fulfill their obligation to orally Inform residents or applicants for admission about how to apply for Medicaid or Medicare by assisting them in contacting the local Social Security Office or the local unit of the State Medicald agency. Numing facilities are not responsible for orally providing detailed Information about Medicare and Medicald eligibility rules.
"Refunds for previous payments" refers to refunds due as a result of Medicald and Medicare payments when eligibility has been determined retroactively.
As part of determining Medicald eligibility, at the time of admission, a married couple has the right to request and have the appropriate State agency assess the couple's resources.

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PP-M

TAG NUMBER
F157

REGULATION
(11) notification of changes.
(1) A facility must lnmedlately info™ the resident; consult with the resident's physician; and If known, notify the resident's legal representative or an interested fanlly Bomber when there i s —
(A) An accident involving the resident which results in Injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosaclal status (I.e., a deterioration In health, mental, or pnychoBOclsl status In either life-threatening conditions or clinlca.1 coaplicatlons);
(C) A need to alter treatment significantly (i.e., a need to discontinue an existing ( o n of treatment due to adverse consequences, or to commence a new fora of treatment); or
(D) A decision to transfer or discharge the resident froa the facility ae specified In $483.12(a).
(11) The facility aust also promptly notify the resident and, if known, the resident's legal representative or Interested faally nember when there I s —
(A) A change In rooa or roommate assignment as specified in $483.15<e)(2); or

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidelines; $483.10(b)(11) For purposes of $483.10(b)(11)(1)(B), life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset or recurrent periods of delirium, recurrent urinary tract Infection, or onset of depression. A need to alter treatment "significantly" means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new fora of treatment to, deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before).
In the case of a competent individual, the facility aust still contact the resident's physician and notify Interested faally members. If known. That Is, a family that wishes to be informed would designate a member to receive calls. Even when a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially In the case of sudden illness or accident.
The requlreasnts at $483.10(b)(l) require the facility to Inform the resident of his/her rights upon admission and during the resident's stay. This includes the resident's right to privacy (S4S3.1O(e), F164). If, after being informed of the right to privacy, a resident specifies that he/she wishes to exercise this right and not notify family members in the event of a significant change as specified at this requirement, the facility should respect this request, which would obviate the need to notify the resident's interested family aaaber or legal representative, if known. If a resident specifies that he/she does not wish to exercise the right to privacy, then the facility is required to comply with the notice of change requirements.
In the case of a resident who is Incapable of Baking decisions, the representative would Bake any decisions that have to be Bade, but the resident should still be told what Is happening to him or her.
In the case of the death of a resident, the resident's physician is to be notified immediately In accordance with State law.
The failure to provide notice of room changes could result In an avoidable decline In physical, mental, or psychosoclal well-being.

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PP-12

TAQ NUMBER
F157 Cont.

REGULATION
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (b)(l) of this section.
(ill) The facility Bust record and periodically update the address and phone number of the resident's legal representative or interested family menber.

F15B

(c) Protection of Resident Funds.
(1) The resident has the right to manage hiB or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility.

F1S9

(2) Management of personal funds. 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, as specified in paragraphs (c)(3)(8) of this section.

(3) Deposit of funds.
(1) Funds in excess of $50. The facility must deposit any residents' personal funds In excess of $50 In an interest bearing account (or accounts) that 1B separate from any of the

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GUIDANCE TO SURVEYORS GUIDANCE TO SURVEYORS

Guidelines: S483.10(c)(l) through (3) This requirement is intended to assure that residents who have authorized the facility In writing to manage any personal funds have ready and reasonable access to those funds. If residents choose to have the facility manage their funds, the facility may not refuse to handle these funds, but is not responsible for knowing about assets not on deposit with it.
Placement of residents' personal funds of less than $50.00 ($100.00 for Medicare residents) in an interest bearing account is permitted. Thus, a facility may place the total amount of a resident's funds, including funds of $50.00 ($100.00 for Medicare residents) or less, into sn Interest-bearing account. The law and regulations are Intended to assure that residents have access to $50.00 ($100.00 for Medicare residents) in cash within a reasonable period of time, when requested. Requests for less than $50.00 ($100.00 for Medicare residents) should be honored within the same day. Requests for $50.00 ($100.00 for Medicare residents) or more should be honored within three banking days. Although the facility need not maintain $50.00 ($100.00 for Medicare residents) per resident on Its premises, it is expected to maintain amounts of petty cash on hand that may be required by residents.
If pooled accounts are used. Interest must be prorated per individual on the basis of actual earnings or end-of-quarter balance.
Residents should have access to petty cash on an ongoing basis and be able to arrange for access to larger funds.
"Bold, safeguard, manage and account for," means that the facility must act as fiduciary of the resident's funds and report at least quarterly on the status of these funds in a clear and understandable manner. Managing the resident's financial affairs Includes money that an Individual gives to the facility for the sake of

06-95

PP-13

TAG NUMBER
F159 Cont.

REGULATION
facility's operating accounts, and that credits all Interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.)
(11) Funds less than $50. The facility must maintain a resident's personal funds that do not exceed $50 in a non-Interest bearing account, interest-bearing account, or petty cash fund.
NOTE: The Social Security Amendments of 1994 amended S1819(c)(6)(B)(l) to raise the limit from $50.00 to $100.00 for the minlnun amount of resident funds that facilities oust entrust to an interest bearing account. This increase applies only to Medicare SNF residents. While a facility may continue to follow a minlmun of $50.00, the regulations do not require it.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
providing a resident with a noncovered service (such aa a permanent wave). It is expected that In these instances, the facility will provide a receipt to the gift giver and retain a copy.
"Interest bearing" means a rate of return equal to or above the passbook savings rate at local banking institutions in the area.
Although the requirements are silent about oral requests by residents to have a facility hold personal funds, under the provisions regarding personal property ($483.10(1)), and misappropriation of property (S483.13(c)), residents may make oral requests that the facility temporarily place their funds in a safe place, without authorizing the facility to manage those funds. The facility has the responsibility to Implement written procedures to prevent the misappropriation of these funds.
If you determine potential problems with funds through interviews, follow-up using the following procedures as appropriate:
If the facility does not have written authorization to handle resident's funds, but la holding funds for more than a few days, determine if the facility is managing these funds without written authorization. There must be written authorization for the facility to be In compliance with this requirement.
To assure that facilities are not using oral requests by residents as a way to avoid obtaining written authorization to hold, manage, safeguard and account for resident's funds, make Bure that:
o There is a written declaration by the resident that the funds are being held for no more than a few days by the facility at the resident's request;
o These funds are not held for more than a few days; and o The facility provides the resident a receipt for these funds and retains a copy for its records.
Review the administrative or business file and the bookkeeping accounts of residents selected for a comprehensive review who have authorized the facility to handle their personal funds.
o Are residents' funds over $50.00 ($100.00 for Medicare residents) or, at the facility's option, all resident funds, in an Interest bearing account(B)?
o What procedure was followed when residents requested their funds? o How long does It take for residents to receive: (a) petty cash allotments; (b)

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PP-14

TAG HUNBER
F159 Cont.

REGULATION

(4) Accounting and record*. The facility nust establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(I) The system nust preclude any coamingling of resident funds with facility funds or with the funds of any person other than another resident.
(II) The individual financial record miBt be available through quarterly atatenents and on request to the resident or his or her legal representative.

GUIWlHCE TO SURVEYORS GUIDANCB TO SURVEYORS

funds needing to be withdrawn from bank accounts? o Were Units placed on amounts that could be withdrawn? If yes, was the reason
baaed on resident care needs or facility convenience? o Are funds recordB treated with privacy as required at F164?

NOTB:

Banks may charge the resident a fee for handling their funds. Facilities nay not charge residents for managing residents' funds because the services are covered by Medicare or Hedicaid.

If problems are identified, review also S483.1O(b(7), F156.

Monies due residents should be credited to their respective bank accounts within a few business days.

Guidelines: S483.1O(c)(4) This requirement constitutes the overall response of the facility to the resident's right to have the facility manage the resident's funds.
"Generally accepted accounting principles" neans that the facility employs proper bookkeeping techniques, by which It can determine, upon request, the amount of individual resident funds and, in the case of an Interest bearing account, how much Interest these funds have earned for each resident, as last reported by the banking institution to the facility.
Proper bookkeeping techniques would Include an individual ledger card, ledger sheet or equivalent established for each resident on which only those transactions involving his or her personal funds are recorded and maintained. The record should have Information on when transactions occurred, what they were, as well as maintain the ongoing balance for every resident.
Anytime there is a transaction the resident should be given a receipt and the facility retains a copy.
Monies due residents should be credited to their respective bank accounts within a few bualness days.

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PP-15

TAG NUMBER
F1S9 Cont.

REGULATION

F160 F161

(S) Notice of certain balances. The facility must notify each resident that receives Medlcald benefits--
(1) When the aaount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(11) That, If the amount in the account, in addition to the value of the resident's other nonexenpt resources, reaches the SSI resource U n i t for one person, the resident nay lose eligibility for Hedicald or SSI.
(6) 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.
(7) 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 residents deposited with the facility.

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GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
"Quarterly statements," are to be provided In writing to the resident or the resident's representative within 30 days after the end of the quarter.
Guidelines: S483.10(c)(b) The Social Security District Office can provide you with intonation concerning current SSI resource limits.
Procedures: S483.10(c)(5) If problems are identified for sampled residents who are Medlcald recipients, review financial records to determine if their accounts are within $200.00 of the SSI Unit. If there are sampled residents in this situation, ask them ox their representatives if they have received notice.

Procedures: S483.10(c)(6) As part of closed records review, determine if within 30 days of death, the facility conveyed the deceased resident's personal funds and a final accounting to the Individual or probate jurisdiction administering the individual's estate as provided by State law.

Guidelines: S483.10(c)(7) A surety bond is an agreement between the principal (the facility), the surety (the Insurance company), and the obligee (depending on State law, either the resident or the State acting on behalf of the resident), wherein the facility and the insurance company agree to compensate the resident (or the State on behalf of the resident) for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for.

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PP-16

TAG NUMBER
161 :ont.

RBGUIATION

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GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
The purpose of the surety bond is to guarantee that the facility will pay the resident (or the State on behalf of the resident) for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the residents' funds, i.e., losses occurring as a result of acts or errors of negligence, Incompetence or dishonesty.
Unlike other types of Insurance, the surety bond protects the obligee (the resident or the State), not the principal (the facility), from loss. The surety bond differs from a fidelity bond, which covers no acts or errors of negligence, Incompetence or dishonesty.
The surety bond is the commitment of the facility In an objective manner to meet the standard of conduct specified In $483.10(c)(2), that the facility will hold, safeguard, manage and account for the funds residents have entrusted to the facility. The facility assumes the responsibility to compensate the obligee for the amount of the loss up to the entire amount of the surety bond.
Reasonable alternatives to a surety bond must:
o Designate the obligee (depending on 8tate law, the resident individually or in aggregate, or the State on behalf of each resident) who can collect in case of a loss;
o Specify that the obligee may collect due to any failure by the facility, whether by commission, bankruptcy, or omission, to hold, safeguard, manage, and account for the residents' funds; and
o Be managed by a third party unrelated in any way to the facility or Its management.
The facility cannot be named as a beneficiary.
Self-Insurance Is not an acceptable alternative to a surety bond. Likewise, funds deposited in bank accounts protected by the Federal Deposit Insurance Corporation, or similar entity, also are not acceptable alternatives.
Procedures; S*61.10(c)(7) As part of Phase 2, if your team has any concerns about residents' funds, check the amount of the surety bond to make sure it is at least equal to the total amount of residents' funds, ai of the most recent quarter.

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PP-17

TAQ NUMBER
161 Cont.

REGULATION

F162

(8) Limitation or charges to personal funds. The facility may not Impose a charge against tha personal funds of a resident for any item or services for which paynent la made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts).
The facility may charge the resident for requested services that are more expensive than or In excess of covered services In accordance with S489.32 of this chapter. (This does not affect the prohibition on facility charges for lteas and services tor which Medicald haa paid. See $447.15, which limits participation in the Medicald program to providers who accept, as payment in full, Medicald paynent plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual.)

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GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
If tha State survey agency datemlnea that individual circumstances associated with a facility's surety bond or its alternative are such that the survey agency cannot determine whether or not the facility is in compliance with the requirements at $483.1O(c)(7), then it would be appropriate to make the referral to the State's fiscal department.
If a corporation has a surety bond that covers all of ita facilities, there should be a separate review of the corporation's aurety bond by the appropriate State agency, such as the State's fiscal departaent, to ensure that all the residents in the corporation's Caclllties within the State are covered against any loaeea due to acts or errors by the corporation or any of its facilities. The focus of the review should be to ensure that if the corporation were to go bankrupt or otherwise cease to operate, the funds of the residents In the corporation's facilities would be protected.

Intenti S483.10(c)(8) The intent of this requirement la to specify that facilities not charge residents for items and services for which payment la made under Medicare or Medicald.
guidelines: $483.10(c)(8) The facility may charge the resident the difference for requested services that are more expensive than or In exceas of covered services In accordance with S489.32 of this chapter. (This does not affect the prohibition on facility chargea for Items and services for which Medicald haa paid. 8ee 1447.15, which limits participation In the Medicald program to providers who accept, aa payment in full, Medicaid payment plus any deductible, coinsurance, or co-payment required by the plan to be paid by tha Individual.) If a State plan does not cover an Item or service, such as eyeglasses, the resident may purchase that item or service out of his/her funds. See S483.15(g), F250 for the facility's responsibility to assist the resident In obtaining those services.
S483.1O(c)(8)(l)(B): Prescription drugs are part of tha pharmaceutical services that facilities are required to provide. (See $483.25(1) and (m), and $483.60.) However, at tines, a resident needs a medical service that la recognized by State law, but not covered by the State plan. Such a medical service Includes a prescription drug that is not on the State's formulary or that exceeds the number of medications covered by Medicald. It may alao Include prescription eyeglasses or dentures. If a resident needs a recognized medical service over what is allowed by the State plan, the resident has the right under the Medicaid statute to apend his/her income on that service. If the service is more than what Medicald pays, the reaident may deduct the actual cost of

06-95

PP-18

TAG NUMBER
F162 Cont.

REGULATION
(1) Services included In Medicare or Medlcald payment. During the course of a covered Medicare or Medlcaid stay, facilities nay not charge a resident for the following categories of Items and services:
(A) Nursing services as required at $483.30 of this subpart.
(B) Dietary services as required at $483.35 of this subpart.
(C) An activities program as required at S483.1S(f) of this subpart.
(D) Room/bed maintenance services.
(E) Routine personal hygiene items and services BB required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight Infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant. Incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry.

GUIDANC8 TO SURVEYORS
GUIDANCE TO SURVEYORS
the service from the Medlcald share of the coat. The facility must assist the resident in exercising his or her right to the uncovered medical expense deduction and may not charge the resident for such services.
"Hair hygiene supplies" referB to conb, brush, shampoos, trlaa and simple hair cuts provided by facility staff as part of routine grooming care. Hair cuts, permanent waves, hair coloring, and relaxing performed by barbers and beauticians not employed by a facility are chargeable.
"Nail hygiene services" refers to routine trimming, cleaning, filing, but not polishing of undamaged nails, and on an individual basis, care for Ingrown or damaged nails.
"Basic personal laundry" does not Include dry cleaning, Bending, washing by hand, or other specialty services that need not be provided. A resident may be charged for these specialty services If he or she requests and receives them.
S483.10(c)(8)(il)(I) Social events. Facilities are required by S483.15(f) to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental, and psychosocial well-being of each resident, and cannot charge residents for these services, whether they occur at the facility or off-Bite. Resident funds should not be charged for universal items such as bookmobile services or local newspaper subscriptions intended for use by more than one resident. However, If a resident requests and attends a social event or entertainment that Is not part of the activities assessment and care plan for that resident, a facility may charge that resident's account only for actual expenses. Further, because of expenses associated with transportation, escorts and other related costs, a resident may be charged for actual expenses for an event or entertainment he or she requests and attends that nay be free to the public.
S483.10(c)(8)(ll)(L) Specially prepared food. A resident may refuse food usually prepared and food substitutions of similar nutritive value because of personal, religious, cultural, or ethnic preference. If the resident requests and receives food that is either not commonly purchased by the facility or easily prepared, then the facility may charge the resident. For example, the facility may charge the resident's account for specially prepared food if the facility has a restricted diet policy and notified the resident on admission of the fact, in accordance with S483.10(b). The facility may not charge the resident's account for specially prepared foods that are required by the physician's order of a therapeutic diet. If a facility changes Its menu so that the menu no longer reflects the food preferences of residents, see F165, F242 and F243 to determine compliance with these requirements.

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PP-19

TAG NUMBER
162 Cont.

REGULATION
(F) Medically-related social services as required at S483.15(g) of this subpart.
(ii) Items and services that way be charged to residents' funds. Listed below are general categories and examples of items and services that the facility nay charge to residents' funds If they are requested by a resident, If the facility Informs the resident that there will be a charge, and If payment is not made by Medicare or Medlcaid:
(A) Telephone;
(B) Television/radio for personal use;
(C) Personal contort Items, including smoking materials, notions and novelties, and confections;
(D) Cosmetic and grooming items and services in excess of those for which paynent la made under Hedlcald or Medicare;
(E) Personal clothing;
(F) Personal reading matter;
(G) Gifts purchased on behalf of a resident;
(H) Flowers and plants; and
(I) Social events and entertainment offered outside the

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
S483.10(c)(8)(lli) Requests for items and services. A facility may not charge a resident or the resident's representative for Iteas and services that are not requested by the resident or representative, whether or not the Item or services Is requested by a physician. The item or service ordered by the physician should fit in with the resident's care plan.
Procedures: S483.10(c)(8) As appropriate during Phase 2 of the survey, review the written information given to Medlcare/Medlcald eligible residents and family members on admission that notifies them of the Items and services that are covered under Medicare or the State plan. Review a sample of residents' monthly statements to ensure that personal funds are not used to pay for covered services. If charges found on monthly statements indicate that residents may have paid for covered Items or services, determine If these items or services are over and above what Is paid by Medicare or Medicald.
If, through observations or Interviews of residents selected for comprehensive or focused review, the team determines that families or residents hire sitters, and/or that a large number of residents or families are paying for outside food, determine if these practices reflect Inadequate staffing and/or food.

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PP-20

TAO NUMBER
F162 Cont.

RBGUUTIOH
scope of the activities progran. provided under S483.15(f) of this subpart.
(J) Roncovered apeclal care services such aa privately hired nurses or aides.
(K) Private rooa, except when therapeutically required (for example, isolation for infection control).
(I>) Specially prepared or alternative food requested Instead of the food generally prepared by the facility, as required by S483.35 of this subpart.
( H i ) Requests for Items and services. (A) The facility Bust not charge a resident (or his or her representative) for any lte» or service not requested by the resident.
(B) The facility Bust not require a resident (or his or her representative) to request any itea or service as a condition of admission or continued stay.
(C) The facility Bust lnfora the resident (or hiB or her representative) requesting an itea or service for which a charge will be Bade that there will be a charge for the item or service and what the charge will be.

GUIDANCE TO SURVEYORS GUIDMCB TO SURVEYORS

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PP-21

TAG NUMBER
F163

REGULATION
(d) Free Choice. The resident has the right to(1) Choose a personal attending physician;

Refer to F154

(2) Be fully lnforoed In advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; and

Rev. 274

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GUIDANCE TO SURVEYORS
Guidelines: S483.10(d)(l) The right to choose a personal physician does not mean that the physician must or will serve the resident, or that a resident must designate a personal physician. If a physician of the resident's choosing fails to fulfill a given requirement, such as S483.25(l)(l), Unnecessary drugs, $483.25(1)(2), Ahtlpsychotic drugs, or S4B3.4O frequency of physician visits, the facility will have the right, after informing the resident, to seek alternate physician participation to assure provision of appropriate and adequate care and treatment. A facility may not place barriers in the way of residents choosing their own physicians. For example, if a resident does not have a physician, or if the resident's physician becomes unable or unwilling to continue providing care to the resident, the facility must assist the resident in exercising his or her choice in finding another physician.
Before consulting an alternate physician, one mechanism to alleviate a possible problem could involve the facility's utilization of a peer review process for cases which cannot be satisfactorily resolved by discussion between the medical director and the attending physician. Only after a failed attempt to work with the attending physician or mediate differences in delivery of care should the facility request an alternate physician when requested to do so by the resident or when the physician will not adhere to the regulations.
If It is a condition for admission to a continuing care retirement center, the requirement for free choice is met if a resident is allowed to choose a personal physician fron among those who have practice privileges at the retirement center.
A resident In a distinct part of a general acute care hospital can choose his/her own physician, unless the hospital requires that physicians with residents In the distinct part have hospital admitting privileges. If this is so, the resident can choose his/her own physician, but cannot have a physician who does not have hospital admitting privileges.
If residents appear to have problems in choosing physicians, determine how the facility makes physician services available to residents.

Guidelines: S483.1O(d)(2) "Informed In advance" means that the resident receives information necessary to make a health care decision, including information about his/her medical condition and changes in medical condition, about the benefits and reasonable risks of the treatment, and about reasonable available alternatives.

06-95

PP-22

TAG NUMBER

REGULATION

Refer to '260

(3) Unless adjudged Incompetent or otherwise found to be Incapacitated under the laws of the State, participate In planning care and treatment or changes In care and treatment.

F164

(a) Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidelines: S483.10(d)(3) "Participates in planning care and treatment" means that the resident Is afforded the opportunity to Beleet from alternative treatments. This applies both to initial decisions about care and treatment and to decisions about changes In care and treatment. The resident's right to participate in care planning and to refuse treatment are covered in J$483.20(d)(2) and 4B3.1O(b)(4).
A resident whose ability to make decisions about care and treatment Is Impaired, or a resident who has been formally declared incompetent by a court, should, to the extent practicable, be kept Informed and be consulted on personal preferences.
Whenever there appears to be a conflict between a resident's right and the resident's health or safety, determine if the facility attempted to accommodate both the exercise of the resident's rights and tha resident's health, including exploration of care alternatives through a thorough care planning process in which the resident may participate.
Procedures: S483.1O(d)(3) Look for evidence that tha resident was afforded tha right to participate In cara planning or was conaulted about care and treatment changes (e.g., ask residents or their representatives during interviews).
Guidelines: S483.10(a) "Right to privacy" means that the resident has the right to privacy with whomever the resident wishes to be private and that this privacy should Include full visual, and, to the extent desired, for visits or other activities, auditory privacy. Private space may be created flexibly and need not be dedicated solely for visitation purposes.
For example, privacy for visitation or meetings might be arranged by using a dining area between meals, a vacant chapel, office or room; or an activities area when activities are not in progress. Arrangements for private apace could be accomplished through cooperation between the facility's administration and resident or family groups so that private space is provided for those requesting it without Infringement on the rights of other residents.

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06-95

PP-23

TAQ NUMBER
P164 Cont.

REGULATION
(1) Peraonal privacy includes accommodations, nodical treatment, written and telephone coamunications, personal care, visits, and Beatings of fanily and resident groups, but this does not require the facility to provide a private rooa for each resident;
(2) Except aa provided in paragraph (e)(3) of this section, the resident nay approve or refuse the release of personal and clinical records to any individual outside the facility;
(3) The realdent's right to refuse release of personal and clinical records does not apply when—
(I) The resident is transferred to another health care institution; or
(II) Record release Is required by law.

(f) Grievances. A resident has the right t o —

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
With the exception of the explicit requirement for privacy curtains in all initially certified facilities (see $483.7O(d)(l)(v)), the facility is free to Innovate to provide privacy for its residents, as exemplified In the preceding paragraph. This may, but need not, be through the provision of a private rooa.
Facility staff must examine and treat residents in a Banner that maintains the privacy of their bodies. A resident must be granted privacy when going to the bathroom and In other activities of personal hygiene. If an Individual requires assistance, authorized staff should respect the individual's need for privacy. Only authorized staff directly involved in treatment should be present when treatments are given. People not Involved in the care of the individual should not be present without the individual's consent while he/she is being examined or treated. Staff should pull privacy curtains, close doors, or otherwise remove residents from public view and provide clothing or draping to prevent unnecessary exposure of body parts during the provision of personal care and services.
Personal and clinical records include all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated or other.
Additional guidelines on mall, visitation rights and telephone communication are addressed In $483.10(1), (J) and (It). See S483.7O(d)(l)(iv) for full visual privacy around beds.
Procedures; S«B3.10(e)(l) - (3) Docunent any Instances where you observe a resident's privacy being violated. Completely document how the resident's privacy was violated (e.g.. Resident 112 left without gown or bed covers and unattended), and where and when this occurred (e.g., 2B Corridor, 3:30 pn, February 25). If possible. Identify the responsible party.
Intent: S4B3.1O(t) The Intent of the regulation is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution.

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TAG NUMBER
F165

REGULATION
(1) Voice grievances without discrinination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; and

F166

(2) Prompt efforts by the facility to resolve grievances the resident nay have, including those with respect to the behavior of other residents.

F167 F168

(g) Examination of survey results.
A resident has the right t o —
(1) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with reBpect to the facility. The facility oust nake the results available for examination in a place readily accesaible to residents and must post a notice of their availability; and
(2) Receive Information froa agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidelines: $483.10(1) "Voice grievances" is not limited to a formal, written grievance process but may Include a resident's verbalized complaint to facility staff.
"Prompt efforts...to resolve" Include facility acknowledgment of complaint/grievances and actively working toward resolution of that complaint/grievance.
If residents' responses indicate problems In voicing grievances and getting grievances resolved, determine how the facility deals with and makes prompt efforts to resolve resident complaints and grievances.
o With permission, review resident council minutes, o Interview staff about how grievances are handled, o Interview staff about communication (to resident) of progress toward resolution of complaint/grievance.
If problems are identified, also investigate compliance with S483.10(b)(7)(ill).
"Results of the most recent survey" means the Statement of Deficiencies (BCPA-2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and Gaunyideslubisneeqsu:entS4e8x3t.e1nOd(egd)(slu)r-v(e2y)s, and any deficiencies resulting from any subsequent complaint lnvestigatlon(s).
"Made available for examination" means that survey results and approved plan of correction, if applicable, are available in a readable form, such as a binder, large print, or are provided with a magnifying glasB, have not been altered by the facility unless authorized by the State agency, and are available to realdents without having to ask a staff person.
"Place readily accessible to residents" is a place (such as a lobby or other area frequented by most residents) where Individuals wishing to examine survey results do not have to ask to see them.

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TAG NUMBER
F169

REGULATION
(h) Work.
The resident has the right t o -
ll) Refuse to perfora service* for
the facility;
(2) Perfora services for the facility, if he or she chooses, when—
(1) The facility has documented the need or desire for work In the plan of care;
(11) The plan speciflea the nature of the services parforaed and whether the services are voluntary or paid;
(111) Compensation for paid services is at or above prevailing rates; and
(iv) The resident agrees to the work arrangement described In the plan of care.

F170

(1) Mall.
The resident has the right to privacy In written coaminlcatlons, including the right t o —
(1) Send and promptly receive Ball that is unopened; and

GUHMMCB TO SURVBTORS
GUIDANCE TO SURVEYORS
Guidelines: S483.10(h)(l)-(2) "Prevailing rate" Is the wage paid to workers In the coanunlty surrounding the facility for essentially the sane type, quality, and quantity of work requiring conparable skills. All resident work, whether of a voluntary or paid nature, aust be part of the plan of care. A resident's desire for work is subject to discussion of nodical appropriateness. As part of the plan of care, a thvapeutlc work assignment must be agreed to by the resident. The resident also has the right to refuse such treatment at any time that he or she wishes. At the time of development or review of the plan, voluntary or paid work can be negotiated. Procedures: $483.I0(h)(l)-(2) Axe residents engaged In what aay be paid or volunteer work (e.g., doing housekeeping, doing laundry, preparing meals)? Pay special attention to the possible work activities of residents with mental retardation or mental Illness. If you observe such a situation, determine If the resident Is in fact performing work and, If so, is this work, whether voluntary or paid, described in the plan of care?
Guidelines! S483.10(l)(l)-{2) "Promptly1' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (Including a post office box) and delivery of outgoing mall to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service.

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F171 F172

(2) Have access to stationery, postage, and writing Implements at the resident's own expense.
(J) Access and Visitation RlghtB.
(1) The resident has the right and the facility mist provide immediate access to any resident by the following:
(I) Any representative of the Secretary;
(II) Any representative of the State;
(III) The resident's individual physician;
(iv) The State long tern care ombudsman (established under Bection 307 (a)(12) of the Older Americans Act of 1965);
(v) The agency responsible for the protection and advocacy system for developmentally disabled individuals (established under part C of the Developmental Disabilities Assistance and Bill of RlghtB Act);
(vi) The agency responsible for the protection and advocacy system for mentally ill Individuals (established under the Protection and Advocacy for Mentally 111 Individuals Act);

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GUIDANCB TO SURVEYORS OUIDANCB TO SURVEYORS

Guidelines; 5463.10(j)(1) and (2) The facility must provide Immediate access to any representative of the Secretary of the Department of Health and Human Services, the State, the resident's Individual physician, the State long term care ombudsman, or the agencies responsible for the protection and advocacy of development-ally disabled or mentally ill individuals. The residents cannot refuse to see surveyors. Representatives of the Department of Health and Hunan Services, the State, the State ombudsman system, and protection and advocacy agencies for mentally ill and mentally retarded individuals are not subject to visiting hour limitations.

Immediate family or other relatives are not subject to visiting hour limitations or other restrictions not Imposed by the resident. However, the facility may try to change the location of visits to assist care giving or protect the privacy of other residents, if these visitation rights infringe upon the rights of other residents in the facility. For example, a resident's family visits in the late evening, which , prevents the resident's roommate from sleeping.

Non-fanlly visitors must also be granted "immediate access" to the resident. The facility may place reasonable restrictions upon the exercise of this right such as reasonable visitation hours to facilitate care giving for the resident or to protect the privacy of other residents, such as requiring that visits not take place in the resident's room if the roommate is asleep or receiving care.

An individual or representative of an agency that provides health, social, legal, or other services to the resident has the right of "reasonable access" to the resident, which means that the facility may establish guidelines regarding the timing or other circumstances of the visit, such as location. These guidelines must allow for ready access of residents to these services.

Procedures: $493.

and (2)

If you identify problems during interviews, determine how the facility ensures access

to:

o Representatives of the State;

o Representatives of the U.S. Department of Health and Human Services;

o The resident's individual physician;

o Representatives of the State long-term care ombudsman;

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TAO NUMBER
F172 Cont.

RBGUUTIOM
(vli) Subject to the resident's right to deny or withdraw consent at any tine, lnmedlate family or other relatives of the resident; and (vlll) subject to reaaonable restrictions and the resident'a right to deny or withdraw consent at any time, others who are visiting with tha consent of the resident.
(2) The facility isust provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.

F173

(3) Tha facility Bust allow representatives of the State Ombudsman, described In paragraph (j)(l)(lv) of this section, to examine a resident's clinical records with the permission of the resident or the resident's legal representative, and consistent with State law.

F174

(k) Telephone. The resident has the right to have reasonable access to the use of a telephone where calls can be Bade without being overheard.

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GUIDANCE TO SURVEYORS
GUIDANCE TO 8URVBYOR8
o Representatives of agencies responsible for protecting and advocating rights of persons with nental Illness or developmental disabilities;
o Faaily or relatives; and o Other visitors.

Procedures: S463.10(j)(3) Ask the ombudsman if tha facility allows him/her to examine residents' clinical records with the permission of the resident, and to the extent allowed by State law.

Guidelines: S483.1O(k) Telephones in staff offices or at nurses' stations do not meet the provisions of this requirement. Bxanples of facility accommodatlona to provide reasonable access to the use of a telephone without being overheard Include providing cordless telephones or having telephone jacks in residents* rooms.
"Reasonable access" Includes placing telephones at • height accessible to residents who use wheelchairs and adapting telephones tor use by tha resident* with impaired hearing.

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TAG NUMBER

REGULATION

Refer to F252

(1) Personal Property. The resident has the right to retain and use personal possessions, 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.

F175

(m) 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.

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GUIDAHCB TO SURVEYORS
GUIDANCE TO SURVEYORS
Intent: 5483.10(1) The intent of thlB regulation is to encourage residents to bring personal possessions into the facility, as space, safety considerations and fire code permits.
Guidelines: 8483.10(1) All residents' possessions, regardless of their apparent value to others, must be treated with respect, for what they are and for what they nay represent to the resident. The right to retain and use personal possessions assures that the residents' environment be as homelike as possible and that residents retain as much control over their lives as possible. The facility has the right to limit the resident's exercise of this right on grounds of space and health or safety.
Procedures: S4B3.1O(1) If residents' rooms have few personal possessions, ask residents, families and the local ombudsman if:
o Residents are encouraged to have and to use them; o The facility informs residents not to bring In certain items and for what reason; o Personal property is safe in the facility.
Ask staff if the facility sets limits on the value of the property that residents may have In their possession or requires that residents put personal property in the facility's safe.
See S483.15(h)(l) F252 for "use of his or her personal belongings to the extent possible, when the resident is not allowed to use his/her own personal possessions within the facility, or when the facility does not encourage the resident to retain and use his/her personal property.

Guidelines: S4B3.10(m) The right of residents who are married to each other to share a room does not give a resident the right, or the facility the responsibility, to compel another resident to relocate to accommodate a spouse. The requirement Deans that when a room is available for a married couple to share, the facility must permit them to share it If they choose. If a married resident's spouse is admitted to the facility later and the couple want to share a room, the facility must provide a shared room as quickly as possible. However, a couple Is not able to share a room If one of the spouses has a different payment source for which the facility is not certified (If the room 1 B in a distinct part, unless one of the spouses elects to pay for his or her care).

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TAG NUMBER
F176

REGULATION
(n) Self-Administration of drugs. An Individual resident nay seltadmlnlster drugs If the Interdisciplinary team, as defined by S483.2O(d)(2)(ii), has determined that this practice is safe.

F177

(0) Refusal of Certain Transfers.

(1) An Individual has the right to refuse a transfer to another room within the institution, if the purpose of the transfer is to relocate--

(1) A resident of a 8NF, from the distinct part of the institution that Is a SMF to a part of the institution that is not a SNF, or

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GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidelines: S483.10(n) If a resident requests to self-adBlnlster drugs, it is the responsibility of the interdisciplinary team to determine that it is safe for the resident to self-administer drugs before the resident nay exercise that right. The Interdisciplinary team nust also determine who will be responsible (the resident or the nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration (e.g., resident's room, nurses' station, or activities room). Appropriate notation of these determinations should be placed in the resident's care plan.
The decision that a resident has the ability to self-administer medlcatlon(s) is subject to periodic re-evaluation based on change in the resident's status. The facility nay require that drugB be administered by the nurse or medication aide. If allowed by State law, until the care planning team has the opportunity to obtain information necessary to make an assessment of the resident's ability to safely selfadminister medications. If the resident chooses to self-administer drugs, this decision should be made at least by the time the care plan Is completed within seven days after completion of the comprehensive assessment.
Medication errors occurring with residents who self-administer drugs should not be counted In the facility's medication error rate (see Guidelines for S483.25(m)), but should call into question the judgment made by the facility in allowing self-adminlBtratlon for those residents.
Probes: S483.1O(n) For residents selected for a comprehensive review or a focused review, as appropriate:
o Does resident self-administer drugs? Which ones? How much? How often? o Does the care plan reflect self-admlnlstratlon?

Guidelines: S4B3.1Q(o) This requirement applies to transfer within a physical plant.
These provisions allow a resident to refuBe transfer from a room in one distinct part of an institution to a room in another distinct part of the Institution for purposes of obtaining Medicare or Medlcald eligibility. If a resident refuses to transfer from a portion of the institution that Is not Medicare certified, the resident forgoes the possibility of Medicare coverage for the care received there. It that portion of the institution is Medlcald certified and the resident Is Medlcald-ellglble, then Hedicald covered services would be paid by Medlcaid. If the resident la Medlcald-ellglble, but that portion of the institution is not Medlcaid certified, then the resident would assume responsibility for payment for the services. If the resident is unable to pay

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TAG NUMBER
F177 Cont.

REGULATION
(11) A resident of a NF, from the distinct part of the institution that la a NF to a distinct part of the institution that Is a SNF.
(2) A resident's exercise of the right to refuse transfer under paragraph (o)(l) of this section does not affect the Individual's eligibility or entitlement to Medicare or Medicaid benefits.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
for those services, then the facility nay, after giving the resident a 30-day notice, transfer the resident under the provisions of S4B3.12(a).
When a resident occupies a bed in a distinct part NF that participates In Medicaid and not In Medicare, he or she may not be moved Involuntarily to another part of the institution by the facility (or required to be noved by the State) solely for the purpose of assuring Medicare eligibility for payment. Such moves are only appropriate when they occur at the request of a resident (for example, when a privately paying Medicare beneficiary believes that adnlaslon to a bed in a Medicare-participating distinct part of the institution nay result In Medicare payment).
See Guidelines: S483.12 for further discussion regarding transfers.
For tranBterB of residents between Hedicare or Medicaid approved distinct parts:
o Is there a documented medical reason for the transfer? o Was the resident transferred because of a change In payment source? o If a Medicare or Medicaid resident Is notified that he/she Is no longer eligible, does the facility transfer the resident? Did the facility give the resident , the opportunity to refuse the transfer? How? What happened? o Ask the local onbudBnan about facility compliance with transfer requirements. See also S463.12 - Criteria for Transfer.

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PP-31

TAG NUMBER

REGULATION

5483.12 AdBisslon. transfer and discharge rights.
(a) Transfer and discharge:
(1) Definition: Transfer and discharge Includes movement of a 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.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidelines: 5483.12 This requirement applies to transfers or discharges that are initiated by the facility, not by the resident. Whether or not a resident agrees to the facility's decision, these requirements apply whenever a facility initiates the transfer or discharge. "Transfer" is moving the resident from the facility to another legally responsible Institutional setting, while "discharge" is moving the resident to a non-Institutional setting when the releasing facility ceases to be responsible for the resident's care.
If a resident Is living in an Institution participating In both Medicare and Medlcaid (SNF/NF) under separate provider agreements, a move from either the SNF or HF would constitute a transfer.
Transfer and discharge provisions significantly restrict a facility's ability to transfer or discharge a resident once that resident has been adultted to the facility. The facility may not transfer or discharge the resident unless:
1. The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be net In the facility;
2. The transfer or discharge is appropriate because the resident's health has Improved sufficiently so the resident no longer needs the services provided by the facility;
3. The safety of individuals in the facility is endangered;
4. The health of Individuals In the facility would otherwise be endangered;
5. The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; or
6. The facility ceases to operate.
To demonstrate that any of the events specified in 1 - 5 have occurred, the law requires documentation In the resident's clinical record. To demonstrate situations 1 and 2, the resident'a physician must provide the documentation. In situation 4, the documentation must be provided by any physician. (See S483.12(a)(2).)

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TAG NUMBER

REGULATION

Rev. 274

GUIDANCE TO 8URVBY0RS
GUIDANCE TO SURVEYORS
Moreover, before the transfer or discharge occurs, the law requires that the facility notify the resident and, If known, the family member, surrogate, or representative of the transfer and the reasons for the transfer, and record the reasons In the clinical record. The facility's notice must Include an explanation of the right to appeal the transfer to the State as well as the name, address, and phone number of the State long-tern care ombudsman. In the case of a developmentally disabled Individual, the notice must include the name, address and phone number of the agency responsible for advocating for the developmentally disabled, and In the case of a Mentally 111 individual, the name, address and phone number of the agency responsible for advocating for mentally 111 Individuals. (See S483.12(a)(3) and (5).)
Generally, this notice must be provided at least 30 days prior to the transfer. Exceptions to the 30-day requirement apply when the transfer is effected because of<
o Endangerment to the health or safety of others In the facility; o When a resident's health has Improved to allow a more Immediate transfer or discharge; o When a resident's urgent medical needs require more Immediate transfer; and o When a resident has not resided In the facility for 30 days. In these cases, the notice must be provided as soon as practicable before the discharge. (See S483.12(a)(4).)
Finally, the facility 1 B required to provide sufficient preparation and orientation to residents to ensure Bafe and orderly discharge from the facility. (See S4B3.12(a)(6).)
Under Medicaid, a participating facility is also required to provide notice to its residents of the facility's bed-hold policies and readmisslon policies prior to transfer of a resident for hospitallzatlon or therapeutic leave. Upon such transfer, the facility must provide written notice to the resident and an Immediate family member, surrogate or representative of the duration of any bed-hold. With respect to readnisslon in a Medlcald participating facility, the facility must develop policies that permit residents eligible for Medicaid, who were transferred for hospitalizatlon or therapeutic leave, and whose absence exceeds the bed-hold period as defined by the State plan, to return to the facility In the first available bed. (See 5483.12(b).)
A resident cannot be transferred for non-payment if he or she has submitted to a third party payor all the paperwork necessary for the bill to be paid. Non-payment would occur if a third party payor, including Medicare or Medicaid, denies the claim and the resident refused to pay for his or her stay.
S483.10(o), F177 addresses the right of residents to refuse certain transfers within an Institution on the basis of payment status.

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TAG NUMBER
F201

REGULATION
(2) Transfer and discharge requirementa. The facility nust pernlt each resident to remain In the facility, and not transfer or discharge the resident from the facility unleBs-
(1) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be net in the facility;
(li) The transfer or discharge is appropriate because the resident's health haB Improved sufficiently so the resident no longer needs the services provided by the facility;
(ill) The safety of individuals in the facility is endangered;
(lv) The health of Individuals in the facility would otherwise be endangered;
(v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medlcald) a stay at the facility. For a resident who becomes eligible for Medlcald after admission to a nursing facility, the nursing facility nay charge a resident only allowable charges under Medicald; or

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GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidelines; S4B3.12(a)(2) and (3) If transfer is due to a significant change In the resident's condition, but not an emergency requiring an Immediate transfer, then prior to any action, the facility aunt conduct the appropriate assessment to determine if a new care plan would allow the facility to meet the resident's needs. (See S483.20(b)(4)(lv), F274, for information concerning assessment upon significant change.)
Conversion from a private pay rate to payment at the Medlcald rate does not constitute non-payment.
Refusal of treatment would not constitute grounds for transfer, unless the facility is unable to meet the needs of the resident or protect the health and safety of others.
Documentation of the transfer/discharge may be completed by a physician extender unless prohibited by State law or facility policy.
Procedures; S483.12(a)(2) and (3) During closed record review, determine the reasons for transfer/discharge.
o Do records document accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary lnterventiona, accommodation of individual needs and attention to the resident's customary routines?
o Did the resident's physician document the record If: The resident was transferred/discharged for the sake of the resident's welfare and the resident's needs could not be met In the facility (e.g., a resident develops an acute condition requiring hospltallzatlon)? or The resident's health improved to the extent that the transferred/discharged resident no longer needed the services of the facility.
o Did a physician document the record if residents were transferred because the health of Individuals in the facility is endangered?
o Do the records of residents transferred/discharged due to safety reasons reflect the process by which the facility concluded that In each Instance transfer or discharge was necessary? Did the survey team observe residents with similar safety concerns In the facility? If so, determine differences between these residents and those who were transferred or discharged.
o Look for changes in source of payment coinciding with transfer. If you find such tranafet, determine If the transfers were triggered by one of the criteria specified in S483.12(a)(2).
o Ask the ombudsman if there were any complaints regarding transfer and/or discharge. If there were, what was the result of the ombudsman's investigation?
o If the entity to which the resident was discharged la another long tern care facility, evaluate the extent to which the discharge summary and the resident's physician Justify why the facility could not meet the needs of this resident.

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TAG NUMBER '202
F203

REGULATION
(3) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (a)(2)(l) through (v) of this section, the resident's clinical record must be docunented. The documentation must be made b y —
(1) The resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(il) of this section; and
(11) A physician when transfer or discharge is necessary under paragraph (a)(2)(lv) of this section.
(4) Notice before transfer. Before a facility transfers or discharges a resident, the facility roust—
(1) Notify the resident and. If known, a family menber 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.
(11) Record the reasons In the resident's clinical record; and
(111) Include in the notice the items described in paragraph (a)(6) of this section.

GUIDANCE TO SURVEYORS GUIDANCE TO SURVEYORS
Procedures: S483.12(a)(4)-(6) If the team determines that there are concerns about the facility's transfer and discharge actions, during closed record review, look at notices to determine if the notice requirements are net, Including:
o Advance notice (either 30 days or, as soon as practicable, depending on the reason for transfer/discharge);
o Reason for transfer/discharge; o The effective date of the transfer or discharge; o The location to which the resident was transferred or discharged; o Right of appeal; o How to notify the ombudsman (nama, address, and telephone number); and o How to notify the appropriate protection and advocacy agency for residents with mental illness or mental retardation (mailing address and telephone numbers). Determine whether the facility notified a family member or legal representative of the proposed transfer or discharge.

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TAG
NUMBER
F2O3 Cont.

REGULATION
(5) Timing of the notice.
(1) Except when specified in paragraph (a)(5)(li) of this Bectlon, the notice of transfer or discharge required under paragraph (a)(4) of this section oust be nade by the facility at leaBt 30 days before the resident is transferred or discharged.
(11) Notice may be made as soon as practicable before transfer or discharge when-
(A) the Bafety of the individuals in the facility would be endangered under paragraph (a)(2)(lli) of this section;
(B) The health of individuals in the facility would be endangered. under (a)(2)(lv) of this section;
(C) The resident's health Improves Bufflclently to allow a nore lranedlate transfer or discharge. under paragraph (a)(2)(il) of this section;
(0) An lmedlate transfer or discharge Is required by the resident's urgent medical needs. under paragraph (a)(2)(l) of this section; or
(E) A resident has not resided in the facility for 30 days.
(6) Contents of the notice. The written notice specified In paragraph (a)(4) of this section •uot Include the following:

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GUIDANCE TO SURVEYORS GUIDANCE TO SURVEYORS
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TAG NUMBER
F203 Cont.

REGULATION
(1) The reason for transfer or discharge;
(11) The effective date of transfer or discharge;
(111) The location to which the resident is transferred or discharged;
(lv) A statenent that the resident has the right to appeal the action to the State;
(v) The name, address and telephone number of the state long tern care oabudsnan;
(vl) For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developnental Disabilities Assistance and Bill of Rights Act; and
(vll) For numlng facility residents who are mentally ill. the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally 111 Individuals Act.

QUIDANCB TO SURVEYORS GUIDANCE TO SURVEYORS

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TAG NUMBER
F204

REGULATION
(7) Orientation for transfer or discharge. A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge fron the facility.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
Guidellneg: S483.12(a)(7) "Sufficient preparation" means the facility Inform the resident where he or she Is going and takeB steps under Its control to assure safe transportation. The facility should actively involve, to the extent possible, the resident and the resident's fanlly In selecting the new residence. Some exanples of orientation may include trial visits. If possible, by the resident to a new location; working with family to ask their assistance in assuring the resident that valued possessions air: ,_>t left behind or lost; orienting staff in the receiving facility to resident's dally patterns; and reviewing with staff routines for handling transfers and discharges In a manner that minimizes unnecessary and avoidable anxiety or depression and recognizes characteristic resident reactions identified by the resident assessment and care plan.

Procedures: S4B3.12(a)(7) During Resident Review, check social service notes to see If appropriate referrals have been Bade and, If necessary, if resident counseling has occurred.

F2O5

(b) Notice of bed-hold policy and readnlsslon —
(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility oust provide written information to the resident and a family member or legal representative that speclfles—

Guidelines; 5483.12(b)(l) and (2) The nursing facility's bed-hold policies apply to all residents. These sections require two notices related to the facility's bed-hold policies to be Issued. The first notice of bed-hold policies could be given well In advance of any transfer. However, relssuance of the first notice would be required If the bed-hold policy under the State plan or the facility's policy were to change. The second notice, which specifies the duration of the bed-hold policy, must be Issued at the time of transfer.

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TAG « UMBER
F205 Cont.

REGULATION
(I) The duration of the bed-hold policy under the State plan, If any, during which the resident la permitted to return and resume residence In the nursing facility; and
(II) The mining facility's policies regarding bed-hold periods, which oust be consistent with paragraph (b)(3) of this section, permitting a resident to return.

(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospltalizatlon or therapeutic leave, a nursing facility must provide to the resident and a fanlly member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(l) of thiB section.

F206

(3) Permitting resident to return to facility. A nursing facility oust establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bedhold period under the State plan, is readmitted to the facility lnmedlately upon the first availability of a bed in a sealprivate roon if the resident—

GUIDANCE TO SURVBYORS
GUIDANCE TO SURVEYORS
In cases of emergency transfer, notice "at the time of transfer" Deans that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement la met If the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.
Bed-hold for days of absence in excess of the State's bed-hold limit are considered non-covered services which means that the resident could use his/her own income to pay for the bed-hold. However, if such a resident does not elect to pay to hold the bed, readmlssion rights to the next available bed are specified at S483.12(b)(3). NonMedicald residents may be requested to pay for all days of bed-hold.
If residents (or their representatives in the case of residents who are unable to understand their rights) are unsure or unclear about their bed-hold rights, review facility bed-hold policies.
o Do policies specify the duration of the bed-hold? o Is this tine period consistent with that specified in the Stats plan? During closed record review, look at recordB of residents transferred to a hospital or on therapeutic leave to determine if bed-hold requirements were followed. Was notice given before and at the tine of transfer?
During closed record review, look at records of residents transferred to a hospital or on therapeutic leave to determine If bed-hold requirements were followed. Was notice given before and at the time of transfer?
Guidelines: S483.12(b) (3) "First available bed In a semi-private room" means a bed In a room shared with another resident of the same sex. (See $4B3.10(m) for the right of spouses to share a room.)
Medlcald-ellgible residents who ere on therapeutic leave or are hospitalized beyond the State's bed-hold policy must be readmitted to the first available bed even if the residents have outstanding Medlcald balances. Once readmitted, however, these residents nay be transferred if the facility can demonstrate that non-payment of charges exists and documentation and notice requirements are followed. The right to readmlssion is applicable to individuals seeking to return from a transfer or discharge as long as all of the specific qualifications set out In S483.12(b)(3) are net.

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TAG NUMBER
F206 Cont.

REGULATION
(I) Requires the services provided by the facility; and (II) Is eligible for Hedlcaid nursing facility services.

F207

(c) Equal access to quality care.
(1) A facility Bust establish and maintain Identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all individuals regardless of source of payment;
(2) The facility nay charge any amount for services furnished to non-Medicaid residents consistent

GUIDANCE TO SURVBYORS
GUIDANCE TO SURVEYORS
Procedures: S483.12(b)(3) For Hedlcaid recipients whose hoapitalizotion or therapeutic leave exceeds the bed-hold period, do facility policies specify readnlsslon rights?
Refer to the Minima Data Set (MDS), Section A. 10, Discharge Planned; KD3 2.0, section Q, Discharge Potential and Overall Status.
Review the facility's written bed-hold policy to deteraine if It specifies legal readnlsslon rights. Ask the local ombudsman If there are any problems with residents being readmitted to the facility following hospltallzatlon. In closed record review, deteraine why the resident did not return to the facility.
Ask the social worker or other appropriate staff what he/she tells Medlcald-ellglble residents about the facility's bed-hold policies and the right to return and how Medicaid-eligible residents are assisted in returning to the facility.
If potential problem are identified, talk to discharge planners at the hospital to which residents are transferred to deteraine their experience with residents returning to the facility.
Guidelines: S483.12(c) Facilities BUBt treat all residents alike when Baking transfer and discharge decisions.
"Identical policies and practices" concerning services Beans that facilities Bust not distinguish between residents based on their source of payaent when providing services that are required to be provided under the law. All nursing services, specialized rehabilitative services, social services, dietary services, pharmaceutical services, or activities that are mandated by the law aust be provided to residents according to residents' Individual needs, as determined by assessaents and care plans.
Procedures; S4B3.12(c) Determine if residents are grouped in separate wings or floors for reasons other than care needs.

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TAG NUMBER
•207
:ont.

REGULATION
with the notice requirement In S483.1O(b)(5)(l) and (b)(6) describing the charges; and
(3) The State Is not required to offer additional services on behalf of a resident other than services provided in the State plan.

(d) Admissions policy.

F208

(1) The facility mist—
(i) not require residents or potential residents to waive their rights to Medicare or Modlcaid; and
(ii) Mot require oral or written assurance that residents or potential residents are not eligible for, or will not apply for. Medicare or Modlcaid benefits.

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GUIDANCE* TO 8URVBYORS
GUIDANCE TO SURVEYORS

Guidelines; t483.12(d)(1) This provision prohibits both direct and indirect request for waiver of rights to Medicare or Medlcald. A direct request for waiver, for example, requires residents to sign admissions documents explicitly praising or agreeing not to apply for Medicare or Medicald. An indirect request for wslver Includes requiring the resident to pay private rates for a specified period of tine, such as two years ("private pay duration of stay contract") before Medlcald will be accepted as a payment source for the resident. Facilities Bust not seek or receive any kind of assurances that residents are not eligible for, or will not apply for. Medicare or Medicald benefits.
Procedures: S463.12(d)(l) If concerns regarding admissions procedures arise during interviews, review admissions packages and contracts to determine if they contain prohibited requirements (e.g., "side agreements" for the resident to be private pay or to supplement the Medlcald rate).
Ask staff what factors lead to decisions to place residents in different wings or floors. Note if factors other than medical and nursing needs affect these decisions. Do staff know the source of payment for the residents they take care of?
Ask the ombudsman if the facility treats residents differently in transfer, discharge and covered services based on source of payment.
With respect to transfer and discharge, if the facility appears to be sending residents to hospitals at the time (or shortly before) their payment source changes from privatepay or Medicare to Medlcaid, call the hospitals and ask their discharge planners if they have detected any pattern of dumping. Also, ask discharge planners if the facility readmits Medlcaid recipients who are ready to return to the facility. During the tour, observe possible differences in services.

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TAO HUMBBR
F2O8 Cont.

RBGULKnOH

(2) The facility suit not require a third party guarantee of payment to the facility as a condition of adnlaslon or expedited admission, or continued stay In the facility. However, the facility say require an individual who has legal access to a resident's incase or resources available to pay for facility care to sign a contract, without Incurring personal financial liability, to provide facility payment from the resident's Income or resources.
(3) In the case of a person eligible for Medlcald, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,—
Rev. 274

OUTDANCE TO 8URVEYORB
GUIDANCE TO SURVBYORS
o Observe if there are separate dining rooms, if so, are different foods served in these dining roons? For what reasons? Are residents excluded from some dining rooms because of source of payment?
o Observe the placement of residents in rooms in the facility. If residents are segregated on floors or wings by source of payment, determine if the facility Is providing different services based on source of payment. Be particularly alert to differences In treatment and services. For example, determine whether lees experienced aides and nursing staff are assigned to Medlcaid portions of the facility. Notice the condition of the roons (e.g., carpeted in private-pay wings, tile in Hedlcald wings, proximity to the nurses' station, quality of food served as evening snacks).
As part of closed record review, determine if residents have been treated differently in transfers or discharges because of payment status. For example, determine if the facility is sending residents to acute care hospitals shortly before they become eligible for Medlcald as a way of getting rid of Medlcald recipients.
Ask social services staff to describe the facility's policy and practice on providing services, such as rehabilitative services. Determine If services are provided based on source of payment, rather than on need for services to attain or maintain functioning.
Guidelines; j463.12(d)(2) The facility may not require a third person to accept personal responsibility for paying the facility bill out of his or her own funds. However, he or she may use the resident's money to pay for care. A third party guarantee is not the same as a third party payor, e.g., an Insurance company; and this provision doss not preclude the facility from obtaining Information about Medicare or Medicald eligibility or the availability of private insurance. The prohibition against third-party guarantees applies to all residents and prospective residents in all certified long term care facilities, regardless of payment source.

Guidelines; S«83.12(d)(3) This requirement applies only to Medlcald certified nursing facilities.
Facilities may not charge for any service that is Included In the definition of "nursing facility services" and, therefore, required to be provided as part of the dally rate. Facilities may not accept additional payment from residents or their families as a prerequisite to admission or to continued stay in the facility. Additional payment includes deposits from Medlcaid-eligible residents or their families, or any promise to pay private rates for a specified <lod of time.

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TAG NUMBER
F221 F222 Cont.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
been provided to the resident. (See S«83.10(a)(3) and (4).) However, the surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident's nodical symptoms. That Is, the facility may not use restraints In violation of the regulation Bolely because a surrogate or representative has approved or requested them.
"Physical restraints" Include, but are not Halted to, leg restraints, a m restraints, hand mitts, soft ties or vests, lap cushions and lap trays the resident cannot renove. Also Included as restraints are facility practices that Beet the definition of a restraint, such as:
o Using bed rallB to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while In bed;
o Tucking in a sheet so tightly that a bed bound resident cannot move; o Using wheel chair safety bars to prevent a resident frosj rising out of a chair; o Placing a resident in a chair that prevents rising; and o Placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising.
Orthotlc body devices may be used solely for therapeutic purposes to improve overall functional capacity of the resident.
Bed rails nay be used to restrain residents or to assist in nobility and transfer of residents. The use of bed rails as restraints is prohibited unless they are necessary to treat a resident's nodical symptoms. Bed rails used as restraints odd risk to the resident. They potentially increase the risk of more significant injury from a fall from a bed with raised bed rails than tram a fall from a bed without bed rails. They also potentially Increase the likelihood that the resident will spend more tine in bed and fall when attempting to transfer fron bed. Other interventions that the facility night incorporate in care planning include:
o Providing restorative care to enhance abilities to stand safely and to walk; o A trapeze to increase bed nobility; o Placing the bed lower to the floor and surrounding the bed with a soft mat; Equipping the resident with a device that monitors attempts to arise; o Providing frequent staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or o Furnishing visual and verbal reminders to use the call ball for residents who are able to comprehend this information.
When used for nobility or transfer, assessment should Include a review of the resident's:

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PP-4S

TAO NUMBER
221 F222 Cont.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES

GUIDANCE TO SURVEYORS
o Bed Bobillty (e.g., would the use of the bed rail assist the resident to turn froa side to side? Or, Is the resident totally lmoblle and cannot shift without assistance?); and
o Ability to transfer between positions, to and froa bed or chair, to stand and toilet (e.g., does the raised bed rail add risk to the resident's ability to transfer?).
However, as with other restraints, for residents who have been restrained by bed rails, it is expected that the process facilities enploy to reduce the use of bed rails as restraints Is systematic and gradual (e.g., lessening the time the bed rail la used while increasing visual and verbal reminders to use the call bell).
Before a resident is restrained, the facility Bust deaaonstrate the presence of a specific medical symptoa that would require the use of restraints, and how the use of restraints would treat the cause of the symptom and assist the resident In reaching his or her highest level of physical and psychosodal well-being. Appropriate exercise, therapeutic interventions such as orthotlc devices, pillows, pads, or lap trays often assist in achieving proper body position, balance and alignment, without the potential negative effects associated with restraint use.
Restraints say not be used to perait staff to adninlater treatment to which the resident has not consented. However, If the resident needs emergency c» restraints aay be used for brief periods to peralt aedlcal treatment to proceed unless the facility has a notice indicating that the resident has previously Bade a valid refusal of the treatment In question.
Procedures-. S483.U(a) Since continued restraint usage Is associated with a potential for a decline in functioning If the risk is not addressed, determine if the Interdisciplinary team addressed the risk of decline at the time restraint use was initiated and that the care plan reflected measures to minimize a decline. Also determine if the plan of care was consistently laplemented. Determine whether the decline can be attributable to unavoidable disease progression, versus Inappropriate use of restraints.
Determine If the facility follows a systematic process of evaluation and care planning prior to using restraints. For saapled residents observed as ;' slcally restrained during the survey or whose clinical records show the use of phju.ual restraints within 30 days of the survey, determine the Intended use of the restraint — convenience or discipline, or a therapeutic Intervention for specified periods to attain and maintain the resident's highest practicable physical, mental or psychosocial well-being.
Probes; S4B3.13(a) This systematic process should answer these questions:

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PP-46

TAG NUMBER
'208 :ont.

REGULATION
(I) A nursing facility nay charge a resident who la eligible for Medlcald for items and services the resident has requested and received, and that are not specified in the State plan as Included in the tern "nursing facility services" BO long asthe facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and
(II) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organlxation or from a person unrelated to a Medlcald eligible resident or potential resident, but only to the extent that the contribution la not a condition of admission, expedited admission, or continued stay In the facility for a Medlcald eligible resident.
(4) States or political subdivisions may apply stricter adnlssions standards under State or local laws than are specified in this section, to prohibit discrimination against Individuals entitled to Medicaid.

GUIDANCE TO SURVEYORS
GUIDANCE TO SURVEYORS
A nursing facility may charge a Medicaid beneficiary for a service the beneficiary has requested and received, only If:
o That service is not defined In the State plan as a "nursing facility" service; o The facility informs the resident and the resident's representative In advance that this is not a covered service to allow them to make an Informed choice regarding the fee; and o The resident's admission or continued stay is not conditioned on the resident's requesting and receiving that service.
Procedures: S483.12(d)(3) Review State covered services. Compare with the list of Items for which the facility charges to determine if the facility is charging for covered services.
Determine If the facility requires deposits from residents. If you identify potential problems with discrimination, review the files of one or more residents selected for a focused or comprehensive review to determine if the facility requires residents to submit deposits as a precondition of admission besides what may be paid under the State plan.
If Interviews with residents suggest that the facility may have required deposits from Medlcald recipients at admission, except those admitted when Medlcald eligibility Is pending, corroborate by, for example, reviewing the facility's admissions documents or interviewing family members.

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PP-43

TAG NUMBER
F221 F222*

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
$463.13 Resident behavior and Facility Practices
(a) Restraints. The resident has the right to be free Iron any physical or cheaical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's nodical symptoas.
1%
Use tag IF221 for deficiencies concerning physical restraints.
Use tag IF222 for deficiencies concerning cheaical restraints.

GUIDANCE TO SURVEYORS
Intent: S4B3.13(a) The Intent of this requirement Is foreach person to reach his/her highest practicable well-being In an environment that prohibits the use of restraints for discipline or convenience and Halts restraint useto clrcuastances In which theresident has nodical synptona that warrant the use of restraints.
Guidelines; S483.13(a) "Physical restraints" are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to tha resident's body that the Individual cannot remove easily which restricts freedom of movement or normal access to one's body.
"Chemical Restraint" la defined as a paychopharmacologlc drug that Is used for discipline or convenience and not required to treat medical symptoms.
"Discipline" is defined as anyaction taken by tha facility fortha purpose of punishing or penalizing residents.
"Convenience" Is defined as any action taken by tha facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not In the residents' best interest.
Restraint use may constitute an accident hazard and professional standard* of practice have eliminated the need for physical restraints except under limited medical circumstances. Therefore, medical symptoms that would warrant tha use of restraints should be reflected in the comprehensive assessment and care planning. It is further expected that forthose residents whose care plans Indicate the need for restraints that the facility engage In a systematic and gradual process toward reducing restraints (e.g., gradually Increasing the time for ambulation and muscla strengthening activities).
The resident's right to participate In care planning andtharight to refuse treatment are addressed at SS483.2O(d) and 483.10(b), respectively, and Include the right to accept or refuse restraints.
For the resident to make an informed choice about tha usa of restraints, tha facility should explain to tha resident the negative outcomes of restraint use. Potential negative outcomes Include Incontinence, decreased range of motion, and decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact.
In the case of a resident who Is Incapable of making a decision, tha surrogate or representative mayexercise this right based on tha same Information that would have

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PP-44

TAG NUMBER
221 '222 :ont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONO TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
1. What are the synptoms that led to the consideration of the use of restraints? 2. Are these symptoms caused by failure to:
a. Meet individual needs In accordance with section III of the MDS, Customary Daily Routines (MDS version 2.0 section AC), In the context of relevant information in sections I and II of the MDS (MDS version 2.0 sections AA and AB)?
b. Use aggressive rehabilitative/restorative care? c. Provide meaningful activities? d. Manipulate the resident's environment, including seating? 3. Can the cause(s) be removed? 4. If the cause)B) cannot be removed, then has the facility attempted to use alternatives in order to avoid a decline in physical functioning associated with restraint use? (See Physical Restraints Resident Assessment Protocol (RAP), paragraph I). 5. If the alternatives have been tried and found wanting, does the facility use the least restrictive restraint for the least amount of time? Does the facility monitor and adjust care to reduce negative outcomes while continually trying to find and use less restrictive alternatives? 6. Did the resident make an informed choice about the use of restraints? Here risks, benefits, and alternatives explained? 7. Does the facility use the Physical Restraints RAP to evaluate the appropriateness of restraint use? 8. Has the facility re-evaluated the need for the restraint, made efforts to eliminate its use and maintained resident's strength and mobility?
If responses to these questions Indicate that restraint use may not comply with these requirements, is there evidence of restraints used for staff convenience: restrained residents left alone for long periods, not toileted and not provided with exercise. Refer to MDS sections Customary Daily Routine, K, N, E, H, L, (MDS version 2.0 sections AC, J, M, G, B and K respectively) and relevant RAPS, and to notes from other health professionals to determine if restrained residents have maintained their physical, mental, psychosoclal and functional status; or if the use of restraints has been associated with an increase in falls, urinary or fecal incontinence, pressure sores, loss of muscle tone, loss of Independent mobility, Increased agitation, loss of balance, symptoms of withdrawal or depression, reduced social contact, or decreased appetite.
Refer to SS483.20, Resident Assessment, 483.25, Quality of Care and 483.15, Quality of Life to assist in determining compliance with this requirement.

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PP-47

TAG NUMBER
F223

GUIDANCB TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(b) Abuse. The resident has the right to be free fro* verbal, sexual, physical, and mental abuse, corporal punishment, and Involuntary Becluaion.

GUIDANCE TO SURVEYORS
Guidelines; S483.13(b)(c) These requirements specify the right of each resident to be free from abuse, corporal punishment, and Involuntary seclusion, and the facility's responsibilities to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property, that If left unchecked, lead to abuse.
Residents must not be subjected to abuse by anyone. Including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other Individuals.
"Abuse" is defined as the willful Infliction of Injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an Individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosoclal well-being. This presumes that instances of abuse of all residents, even those In a coma, cause physical harm, or pain or mental anguish.
"Verbal abuse" Is defined as any use of oral, written or gestured language that willfully Includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse Include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again.
"Sexual abuse" includes, but Is not limited to, sexual harassment, sexual coercion, or sexual assault.
"Physical abuse" Includes hitting, slapping, pinching and kicking. It also Includes controlling behavior through corporal punishment.
"Mental abuse" Includes, but Is not limited to, humiliation, harassment, threats of punishment or deprivation.
"Involuntary seclusion" is defined as separation of a resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered Involuntary seclusion and may be permitted if UBed for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs.

Rev. 274

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PP-48

TAG NUMBER
223 ont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

GUIDANCE TO SURVEYORS

Procedures; S483.13(b) Offslte, presurvey review of complaints can focus the survey team's on-slte review of actual Incidents and predisposing factors to abuse or neglect and misappropriation of property.

Report and record any instances where the survey team observes an abusive incident. Completely document who committed the abusive act, the nature of the abuse, and where and when it occurred. Ensure that the facility addresses that Incident immediately.

If the survey team's observations and residents' responses signal the presence of abuse, determine how the facility prevents and reports abusive behavior as described in $483.13(c).

If a resident is being temporarily separated from other residents, i.e., for less than 24 hours, as an emergency short-term intervention, answer these questions:

1. What are the symptoms that led to the consideration of the separation?

2. Are these symptoms caused by failure to:

a. Meet individual needs In accordance with section III (MDS version 2.0

section

AC), Customary Daily Routines, in the context of relevant information in

sections I (MDS and II of the MDS (MDS version 2.0 sections AA and AB)?

b. Provide meaningful activities?

c. Manipulate the resident's environment?

3. Can the cause(s) be removed?

4. If the causefs) cannot be removed, has the facility attempted to use

alternatives short of separation?

5. If these alternatives have been tried and found wanting, does the facility use

the separation for the least amount of time?

6. To what extent has the resident, surrogate or representative participated In

care planning and made an informed choice about separation?

7. Does the facility monitor and adjust care to reduce negative outcomes, while

continually trying to find and use less restrictive alternatives?

8. If residents are temporarily separated in secured units, staff should carry

keys to these units at all times.

9. If the purpose of the unit Is to provide specialized care for residents who are

cognltlvely impaired (through a program of therapeutic activities designed to

enable residents to attain and maintain the highest practicable physical, mental or

psychosocial well-being) then placement In the unit is not in violation of resident

rights, as long as the resident's individual care plan indicates the need for the

stated purpose and services provided in the unit and the resident, surrogate, or

representative has participated in the placement decision.

10. If the purpose of the unit is to provide an emergency short-term monitored separation tor a resident who showed temporary behavior problems (such as brief

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PP-49

TAG NUMBER F223 Cont. F224
F22S

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(c) Staff treatment of residents. The facility m a t develop and Implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
(1) The facility muet—
(I) Hot use verbal, mental, aexual, or physical abuse, corporal punishment, or Involuntary seclusion;
(II) Not employ individuals who have been—
(A) Found guilty of abusing, neglecting, or mistreating residents by a court of law; or
(B) Have had a finding entered Into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and
(III) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfltneas for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities.

GUIDANCE TO SURVEYORS
catastrophic reactions or combative or aggressive behaviors which pose a threat to the resident, other residents, staff or others In the facility) then answer the questions with regard to temporary separation set out above.
Intent: S483.13(c) The intent of this regulation is to assure that the facility has in place an effective system that regardless of the source (Btaff, other residents, visitors, etc), prevents mistreatment, neglect and abuse of residents, and misappropriation of resident's property. However, such a system cannot guarantee that a resident will not be abused; it can only assure that the facility does whatever is within Its control to prevent mistreatment, neglect, and abuse of residents or misappropriation of their property.
Such steps Include, but are not limited to. Identification of residents whose personal histories render them at risk for abusing other residents, an assessment of appropriate Intervention strategies to prevent occurrences, monitoring the resident for any changes that would trigger abusive behavior, and reassessment of the strategies on a regular basis.
For each sampled resident in a secured unit, determine the facility's stated purpose for the unit and the facility's Intent in placing the individual in the unit.
Guidelines; S483.13(c) "Heglect", is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (See Older Americans Act, S302(a)(19).) Heglect occurs on an individual basis when a resident does not receive s lack of care in one or more areas (e.g., absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces). "Misappropriation of resident property" Is defined as the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.
Procedures: S483.13(c)(2)(3)(4) During Sample Selection:
1. If the team has identified problems in mistreatment, neglect or abuse of residents or misappropriation of their property, then requests a. A copy of the facility's policies and procedures regarding abuse prevention; note particularly the extent to which those policies concern the areas uncovered through complaints and/or previous survey; b. Reports of action)s) by a court of law against employees; c. Reports of alleged violations Involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident's property; d. Reports of the results of these investigations; e. Records of corrective actions taken;

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PP-50

TAG NUMBER
225 :ont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

(2) The facility unit ensure that all alleged violations Involving mistreatment, neglect, or abuse. Including injuries of unknown source and misappropriation of resident property are reported imediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
(3) The facility Bust have evidence that all alleged violations are thoroughly investigated, and Bust prevent further potential abuse while the investigation is in progress.
(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

In addition, spot check employment:
3. Applications for questions about convictions or mistreatment, neglect or abuse of residents, or misappropriation of their property. Determine if applicants have answered these questions and If affirmative answers had resulted in rejections of employment candidates.
4. Records for contact with State Nurse Aide Registry. Determine if applicants with a finding concerning Blstreatnent, neglect, abuse of residents or misappropriation of their property have been rejected.
5. New employees for registry entries.
Ask for the results of any in-house investigations of mistreatment, neglect, or abuse of residents, misappropriation of their property, or injuries of unknown source. o Was the administrator notified of the Incident and when? o Did investigations begin promptly after the report of the problem? o Is there a record of statements or interviews of the resident, suspect (If one la
identified), any eye witnesses and any circumstantial witnesses? o Was relevant documentation reviewed and preserved (e.g., dated dressing which was
not changed when treatment record recorded change)? o Was the alleged victim exaalned promptly (if Injury was suspected) and the finding
documented in the report? o What steps were taken to protect the alleged victim from further abuse
(particularly where no suspect has been identified?) o What actions were taken as a result of the investigation? o What corrective action was taken, Including informing the nurse aide registry.
State licensure authorities, and other agencies (e.g., long term care ombudsman; adult protective services; Hedlcald fraud and abuse unit)7

Intent: S483.13(c)(l)(ll) The Intent of this regulation Is to prevent employment of individuals who have been convicted of abusing, neglecting, or mistreating individuals in a health care related setting, e.g., residents of a nursing facility or patients in a hospital. Facilities oust be thorough in their investigations of the past histories of individuals they are

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PP-51

TAG NUMBER
'225 :ont.

REGULATION

GUIDANCE TO SURVEYORS - U3NG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
considering hiring. In addition to Inquiry of the State nurse aide registry or other licensing authorities, the facility should check all references and Bake reasonable efforts to uncover Intonation about any past criminal prosecutions.
Guidelines: S483.13(c)(l)(ll) "Found guilty...by a court of law" applies to situations where the defendant pleads guilty, is found guilty, or pleads nolo contendere.
"Finding" Is defined as a determination Bade by the State that validates allegations of abuse, neglect, mistreatment of residents or misappropriation of their property.
Guidelines: 8«B3.13(c)(l)(lll) An aide or other facility staff found guilty of neglect, abuse, or mistreating residents or misappropriation of property by a court of law, must have his or her name entered into the nurse aide registry, or reported to the licensing authority, if applicable. Further, if a facility determines that actions by a court of law against an employee are such that they indicate that the individual is unsulted to work in a nursing haste (e.g., felony conviction of child abuse, sexual assault, or assault with a deadly weapon), then the facility must report that Individual to the nurse aide registry (If a nurse aide) or to the State licensing authorities (if a licensed staff member). Such a determination by the facility is not limited to mistreatment, neglect ,and abuse of residents and misappropriation of their property, but to any treatment of residents or others Inside or outside the facility which the facility determines to be Buch that the individual should not work in a nursing home environment.
If, during a survey, the survey team Is made aware of a previous Incident of neglect or abuse, evaluate current residents for evidence of similar problems that might Indicate that the facility has not addressed systemic problems to protect residents from neglect, abuse and misappropriation of property.

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PP-52

TAG NUMBER F240
F241

GUIDANCE TO SURVEYORS - LONG TBRH CARE FACILITIES

REGULATION
S4B3.1S Quality of life.
A facility nuat care for its residents In a Banner and In an environment that promotes maintenance or enhancement of each realdent'a quality of life.
The facility muat promote care for residents in a manner and in an environment that maintains or enhances each realdent'a dignity and respect In full recognition of his or her Individuality.

GUIDANCE TO SURVEYORS
Guidelines: S483.15 The intention of the quality of life requirements is to specify the facility's responsibilities toward creating and sustaining an environment that humanlies and individualizes each reaident. Compliance decisions here are driven by the quality of life each resident experiences.

Guidelines: S483.15(a) "Dignity" means that in their interactions with residents, staff carry out activities which assist the resident to maintain and enhance his/her self-esteem and self-worth. For example:

o Grooming realdents as they wish to be groomed (e.g., hair combed and styled, beards shaved/trimmed, nails clean and clipped);
o Assisting residents to dress in their own clothes appropriate to the time of day and Individual preferences;
o Assisting resldenta to attend activities of their own choosing; a Labelling each resident's clothing in a way that respects his or her dignity; o Promoting resident independence and dignity in dining (sucb as avoidance of day-to-day uae of plastic cutlery and paper/plaatlc dlshware, bib* instead of napkins, dining room conducive to pleasant dining, aides not yelling); o Respecting resident's private space and property (e.g., not changing radio or television station without resident's permission, knocking on doors and requesting permission to enter, closing doors aa requested by the resident, not saving or inspecting resident's personal possessions without permission); o Respecting realdent'a social status, speaking respectfully, listening carefully, treating residenta with respect (e.g., addreasing the reaident with a name of the resident's choice, not excluding residents from conversations or dlacussing residents in community setting); and o Focusing on realdents aa Individuals when they talk to thesj and addressing residents as individuals when providing care and services.

Procedures: S483.15(a)

,

For sampled resldenta, use the Resident Assessment Instrument (RAI) and comprehensive

care plan to consider the resident's former life style and personal choices made while

In the facility to obtain a picture of characteristic resident behaviors. Aa part of

the team*a Information gathering and decision-making, look at the actiona and omissions

of staff and the unlqueneaa of the individual sampled reaident and on the needs and

preferences of the resident, not on the actions and omissions the—elves.

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PP-53

TAG NUMBER
'241 :ont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Throughout the survey, observe: Do staff show respect for residents? When staff interact with a resident, do staff pay attention to the resident as an individual? Do staff respond in a timely Banner to the resident's requests for assistance? In group activities, do stsff focus attention on the group of residents? Or, do staff appear distracted when they interact with residents? For example, do staff continue to talk with each other while doing a "task" for a resldent(s) as if she/he were not present?
If the survey team identifies potential compliance issues regarding the privacy of residents during treatment, refer to S4B3.1O(e) F164.

F242

(b) Self-determination and participation.
The resident has the right t o -

ll) Choose activities, schedules, and health care consistent with hiB or her interests, assessments, and plans of care;
(2) Interact with Bombers of the ccoununity both Inside and outside the facility; and
(3) Hake choices about aspects of his or her life in the facility that are significant to the resident.

Procedures; S483.15(b) Observe how well staff know each resident and what aspects of life are important to him/her. Determine if staff Bake adjustments to allow residents to exercise choice and self-determination.
Review ma Background Information III (MDS version 2.0 section AC) for customary routines. For sampled residents, review M>s to determine level of participation in assessment and care planning by resident and family members. Review MD8, Section 0 1 (MDS version 2.0 section F) for Psychosoclal Well-Balng and Care Planning.
If the facility has failed to reasonably accommodate the preferences of the resident consistent with interests, assessments and plan of care, see F246, $4B3.15(e).
Guidelines: S483.15(b)(3) The intent of this requirement is to specify that the facility must create an environment that is respectful of the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. For example, if a facility changes its policy and prohibits smoking, it Bust allow current residents who smoke to continue smoking in an area that maintains the quality of life for these residents. Weather permitting, this may be an outside area. Residents admitted after the facility changes its policy must be informed of this policy at admission. (See S483.10(b)(l).) Or, if a resident mentions that her therapy is scheduled at the time of her favorite television program, the facility should accommodate the resident to the extent that it can.

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PP-54

TAO RUHBER F243
F244 F24S

GUIDAHCB TO SURVEYORS - LOMO TERM CARE FACILITIES

REGULATION
(c) Participation In resident and family groups.
(1) A resident has the right to organize and participate in resident groups in the facility;
(2) A resident's faally has the right to meet In the facility with the families of other residents in the facility;
(3) The facility oust provide a resident or family group, if one exists, with private space;
(4) Staff or visitors nay attend •eetings at the group's invitation;
(5) The facility suet provide a designated staff person responsible for providing assistance and responding to written requests that result torn group meetings;
(6) When a resident or family group exists, the facility nust listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.
(d) Participation In other activities.
A resident has the right to participate in social, religious, and community activities that do

GUIDANCE TO SURVEYORS
Guidelines: S4B3.15(c) This requirement does not require that residents' organize a residents or faally group. However, whenever residents or their families wish to organize, facilities must allow then to do so without interference. The facility Bust provide the group with space, privacy for meetings, and staff support. Normally, the designated staff person responsible for assistance and liaison between the group and the facility's administration and any other staff members attend the meeting only if requested.
"A resident's or fanlly group" is defined as a group that meets regularly to: o Discuss and offer suggestions about facility policies and procedures affecting
residents' care, treatment, and quality of life; o Support each other; o Plan resident and family activities; o Participate in educational activities; or o For any other purpose.
The facility Is required to listen to resident and family group recommendations and grievances. Acting upon these issues does not mean that the facility nust accede to all group recommendations, but the facility must seriously consider the group's recommendations and must attempt to accommodate those recommendations, to the extant . practicable, in developing and changing facility pollciea affecting resident care and life In the facility. The facility should communicate Its decisions to the resident and/or family group.
Procedures: 5483.15(c) If no organized group exists, determine if residents have attempted to form one and have been unsuccessful, and, if so, why.
Guidelines: S483.15(d) The facility, to the extent possible, should accommodate an Individual's needs and choices for how he/she spends time, both Inside and outside the facility.
Ask the social worker or other appropriate staff how they help residents pursue activities outside the facility.

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TAG NUMBER F245 Cont.
F246
F247

REGULATION

GUIDANCE TO SURVEYORS - LONG TERN CARE FACILITIES GUIDANCE TO SURVEYORS

not Interfere with the rights of other residents In the facility.
(e) Accommodation of needs. A resident has the right t o -
ll) 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; and
(2) Receive notice before the resident's room or roommate In the facility is changed.

Guidelines; S4B3.15(e) "Reasonable accommodations of individual needs and preferences," is defined as the facility's efforts to individualize the resident's environment. The facility's physical environment and staff behaviors should be directed toward assisting the resident in maintaining and/or achieving Independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own preferences, assessment and care plans. The facility should attempt to adapt such things as schedules, call systems, and room arrangements to accommodate residents' preferences, desires, and unique needs.
This requirement applies to areas and environment In accordance with needs and preferences HOT addressed at: SS483.1O(k), Telephone; 463.10(1), Personal property; 483.10(m), Harried couples; 4B3.15(b), Self-Determination and participation; 483.15(f)(l), Activities; 463.15(g)(1), Social services; 483.15(h)(l), Bomalike environment; 483.25(a)(2) and (3), Treatment and Services, Activities of dally living; 483.25(f)(l), Psychosoclal functioning; 483.25(h)(2), Accidents, Preventlon-asslBtlve devices; 483.35(d)(3), Food prepared in a form designed to meet individual needs.
The facility must demonstrate that it accommodates residents' needs. For example, if the resident refuses a bath because he or she prefers a shower, prefers It at a different time of day or on a different day, does not feel well that day, is uneasy about the aide assigned to help or Is worried about falling, the staff should make the necessary adjustments realizing the resident Is not refusing to be clean but refusing the bath under the circumstances provided. The facility staff should nest with the resident to make adjustments in the care plan to accommodate his or her needs.
This includes learning the resident's preferences and taking them into account when discussing changes of room or roommates and the timing of such changes. In addition, this also Includes making necessary adjustments to ensure that residents are able to reach call cords, buttons or other communications mechanisms, as well as accommodating food, activities or room choices.
Procedures: S483.15(e) Observe resident-staff interaction and determine to what extent staff attempt to accommodate residents' preferences. For those areas not addressed in other regulations, determine what happens when a resident states a preference in the form of a refusal. Bow does the staff attempt to learn what the resident is refusing, and why, and make adjustments to an extent practicable to meet the resident's needs?

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PP-S6

TAG NUMBER
'247 !ont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Probea: S483.15(e) o Axe rooms arranged such that residents in wheel chairs can easily access
personal items and transfer in and out of bed? o Does the facility respond to residents* stated needs and preferences? o If the resident is unable to express needs and preferences that would
individualize care, has the family expressed the resident's routine and has the facility responded?
Guidelines: S483.15(a)(1) Review the extent to which the facility adapts the physical environment to enable residents to maintain unassisted functioning. These adaptations Include, but are not Halted to:
1. Furniture and adaptive equipment that enable residents to: a. Stand independently; b. Transfer without assistance (e.g., arm supports, correct chair height, firm
support); c. Maintain body symmetry; and d. Participate in resident-preferred activities.
, 2. Measures that: a. Enable residents with dementia to walk freely; b. Reorient and reactivate residents with restorative potential (e.g.,
displaying easily readable calendars and clocks, wall hangings evocative of the lives of residents);
c. Promote conversation and socialization (pictures and decorations that speak to the resident's age cohort); and
d. Promote mobility and independence for disabled residents In going to the bathroom (e.g., grab bars, elevated toilet seats).
Determine If staff use appropriate aeasures to facilitate communication with residents who have difficulty communicating. For example, if necessary, does staff get at eye level, allow the resident to read lips, or remove a resident from noisy surroundings?
Determine if staff communicate effectively with residents with cognitive Impairments, such as referring in a non-contradictory way to what residents are saying, and addressing what residents are trying to express to the agenda behind their behavior.
Probes: S483.15(e)(1)(2) How have residents' needs been accommodated? Do environmental adaptions enhance residents' independence, self-control, and highest practicable well-being? Is the fit between residents' needs and environment positive?

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PP-S7

TAG NUMBER
F248

GUIDAHCB TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATIOH
(f) Activities.
(1) The facility Bust provide for an ongoing program of activities designed to neat, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosoclal well-being of each resident.

GUIDAHCB TO SURVEYORS
Guidelines: S4B3.15(f)(l) Because the activities program should occur within the context of each resident's comprehensive assessment and care plan, it should be nultl-faceted and reflect each Individual resident's needs. Therefore, the activities program should provide stimulation or solace; promote physical, cognitive and/or emotional health; enhance, to the extent practicable, each resident's physical and mental status; and promote each resident's self-respect by providing, for example, activities that support selfexpression and choice.
Activities can occur at anytime and are not limited to formal activities being provided by activity staff. Others involved may be any facility staff, volunteers and visitors.
Probes: SIB3.15(f)(l) Observe individual, group and bedside activities. 1. Are residents who are confined or choose to remain In their rooms provided with In room activities In keeping with life-long Interests (e.g., music, reading, visits with Individuals who share their Interests or reasonable attempts to connect the resident with such individuals) and in-rooa projects they canwork on Independently? Do any facility staff members assist theresident with activities he or shecan pursue independently?
2. If residents sit for long periods of time with no apparently meaningful activities, is the cause:
a. Resident choice; b. Failure of any staff or volunteers either to Inform resident* when activities are occurring or to encourage resident Involvement In activities; c. Lack of assistance with aabulatlon; d. Lack of sufficient supplies and/or staff to facilitate attendance and participation In the activity programs. e. Program design that fails to reflect tha interests or ability levels of residents, such as activities that are too complex?
For residents selected fora comprehensive review, or a focused review, as appropriate, determine to what extent the activities reflect the Individual resident's assessment. (See especially MOS III.l and Sections B, C, D, and I; M>S version 2.0 sections AC, B, C, D and M.)
Review the activity calendar for the month prior to the survey to determine If the formal activity program:

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PP-58

TAG NUMBER F248 Cont.
F249

CUIDANCB TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(2) The activitiea program nuat be directed by a qualified professional who--
(1) la a qualified therapeutic recreation specialist or an activitiea professional w h o —
(A) Is licensed or registered, if applicable, by the State in which practicing; and
(B) Is eligible for certification as a therapeutic recreation specialist or aa an activitiea profesalonal by a recognized accrediting body on or after October 1, 1990; or
(il) Has 2 years of experience In a social or recreational prograa within the laat 5 years, 1 of which was full-tine in a patient activitiea prograa in a health care setting; or
(ill) la a qualified occupational therapist or occupational therapy assistant; or
(lv) Has completed a training courae approved by the State.

GUIDANCE TO SURVEYORS
o Reflects the schedules, choices and rights of the residents; o Offers activities at hours convenient to the residents (e.g., morning, afternoon, some evenings and weekends); o Reflects the cultural and religious Interests of the resident population; and o Would appeal to both men and women and all age groups living In the facility.
Review clinical records and activity attendance records of residents receiving a comprehensive review, or a focused review, as appropriate, to determine if:
o Activities reflect Individual resident history Indicated by the comprehensive assessment;
o Care plans address activities that are appropriate for each resident based on the comprehensive assessment;
o Activities occur as planned; and o Outcones/responses to activities interventions are identified in the progress notes of each resident.
Guidelines: S483.15(f>(2) A "recognized accrediting body" refers to those organizations or associations recognized as such by certified therapeutic recreation specialists or certified , activity professionala or reglstared occupational therapists.
Procedures: S483.15(f)(2) If there are problems with provision of activities, determine if these services are provided by qualified staff.

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PP-59

TAG NUMBER
F25O

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(g) Social Services.
(1) The f a c i l i t y mist provide
medically-related social services to attain or nalntaln the highest practicable physical, mental, and paychosoclal well-being of each resident.

GUIDANCE TO SURVEYORS
Intent: $4B3.15(g) To assure that sufficient and appropriate social services are provided to Beet the resident's needs.
Guidelines; S483.15(g)(l) Regardless of size, all facilities are required to provide for the medically related social services needs of each resident. This requirement specifies that facilities aggressively identify the need for medically-related social services, and pursue the provision of these services. It Is not required that a qualified social worker necessarily provide all of these services. Rather, It Is the responsibility of the facility to Identify the medically-related social service needs of the resident and assure that the needs are met by the appropriate disciplines.
"Medically-related social services" means services provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosoclal needs. These services might Include, for example:
o Making arrangements for obtaining needed adaptive equipment, clothing, and personal items;
o Maintaining contact with family (with resident's permission) to report on changes in health, current goals, discharge planning, and encouragement to participate In care planning;
o Assisting staff to Inform residents and those they designate about the resident's health status and health care choices and their ramifications;
o Making refettala and obtaining services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation);
o Assisting residents with financial and legal matters (e.g., applying for pensions, referrals to lawyers, referrals to funeral homes for preplanning arrangements);
o Discharge planning services (e.g., helping to place a resident on a waiting list for community congregate living, arranging Intake for home care services for residents returning home, assisting with transfer arrangements to other facilities);
o Providing or arranging provision of needed counseling services; o Through the assessment and care planning process, identifying and seeking ways to support residents' individual needs and preferences, customary routines, concerns and choices; o Building relationships between residents and staff and teaching staff hew to understand and support residents' Individual needs; o Promoting actions by staff that maintain or enhance each resident's dignity in full recognition of each resident's individuality; o Assisting residents to determine how they would like to make decisions about their health care, and whether or not they would like anyone else to be Involved in those decisions;

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PP-60

TAG NUMBER
250 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

GUIDANCE TO SURVEYORS
o Finding options that most meet the physical and enotlonal needs of each resident;
o Providing alternatives to drug therapy or restraints by understanding and communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff Bust meet;
o Meeting the needs of residents who are grieving; and o Finding options which most Beet their physical and emotional needs.
Factors with a potentially negative effect on physical, mental, and psychosoclal wellbeing Include an unmet need for:
o Dental/denture care; o Podiatric care; o Eye care; o Hearing services; o Equipment for mobility or asslstlve eating devices; and o Meed for home-like environment, control, dignity, privacy.
Where needed services are not covered by the Medicald State Plan, nursing facilities are still required to attempt to obtain these services. For example, if a resident requires transportation services that are not covered under a Hedlcald State Plan, the facility is required to arrange these services. This could be achieved, for example, through obtaining volunteer assistance.
Types of conditions to which the facility should respond with social services by staff or referral include:
o Lack of an effective family/social support system; o Behavioral symptoms; o If a resident with dementia strikes out at another resident, the facility should evaluate the resident's behavior. For example, a resident nay be re-enacting an activity he or she used to perform at the same time everyday. If that resident senses that another is In the way of his or her re-enactment, the resident may Btrlke out at the resident Impeding his or her progress. The facility is responsible for the safety of any potential resident victims while it assesses the circumstances of the resident's behavior); o Presence of a chronic disabling medical or psychological condition (e.g., multiple sclerosis, chronic obstructive pulmonary disease, Alzheimer's disease, schizophrenia); o Depression; o Chronic or acute pain; o Difficulty with personal interaction and socialization skills; o Presence of legal or financial problems; o Abuse of alcohol or other drugs; o Inability to cope with loss of function; o Need for emotional support;

06-95

PP-61

TAG NUMBER
F250 Cont.

RBGULATIOH

GUIDANCE TO SURVEYORS - U W O TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
o Changes In family relationships, living arrangements, and/or resident's condition or functioning; and
o A physical or chemical restraint.
For residents with or who develop mental disorders as defined by the Diagnostic and Statistical Manual for Mental Disorders (DSM-IVJ, see. S481.45, F4O6.
Probes: S483.15(g)(l) For residents selected for a comprehensive or focused review as appropriate:
o How do facility staff implement social services Interventions to assist the resident in meeting treatment goals?
o How do staff responsible for social work monitor the resident's progress In improving physical, mental and psychosoclal functioning? Has goal attainment been evaluated and the care plan changed accordingly?
o How does the care plan link goals to psychosoclal functioning/well-being? o Have the staff responsible for social work established and maintained relationships with the resident's family or legal representative? o (NFe) What attempts does the facility make to access services for Medlcald recipients when those services are not covered by a Medlcald State Plan?
Look for evidence that social services interventions successfully address residents' needs and link social supports, physical care, and physical environment with residents' needs and Individuality.
For sampled residents, review MDS, Section H.

F251

(2) A facility with sore than 120 bads aust ••ploy a quail{lad social worker on a full-time basis.
(3) Qualification* of a social worker. Ik qualified social worker Is an Individual with—
(1) A bachelor's degree In social work or a bachelor's degree in a human services field including but not Halted to sociology, special education, rehabilitation counseling, and psychology; and

Rev. 274

Procedures: S483.15(g)(2) and (3) If there are problems with the provision of social services in a facility with over 120 beds, determine If a qualified social worker Is employed on a full time basis. See also F2S0.

06-95

PP-62

TAG NUMBER
•251 :ont.

OUTDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION

GUIDANCE TO SURVEYORS

(11) One year of supervised social work experience in a health care setting working directly with individuals.

(h) Environment. The facility must provide—

F2S2

(1) A safe, clean, comfortable and

homelike environment,

allowing the resident to

use his or her personal

belongings to the extent

possible;

Guidelines: S4B3.15(h)(1) For "safe" environment, also see Guidelines for SS483.25(h), Accidents, and 483.70(a), Life Safety Code.
For personal belongings, also see SS483.10(l), Personal property. For "cosifortable" environment, see Guidelines for 483.15(h)(5), Adequate and comfortable lighting levels; 483.15(h)(6), Comfortable and safe temperature levels; and 483.15(h)(7), Comfortable sound levels.
A determination of "comfortable and homelike" should include, whenever possible, the resident's or representative of the resident's opinion of the living environment.
The absence of a personalized, homelike environment in a resident's room, is not meaningful unless the survey team determines that the absence of personal belongings Is a result of facility practices, rather than the result of resident choice or circumstances (e.g., lack of resident funds, lack of family support system, resident's reason for being in the facility, such as short-term rehabilitation).
A "homelike environment" is one that de-emphasizes the Institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the Individuality and autonomy of the resident, provides an opportunity for self-expression and encourages links with the past and family members. Use this Tag when the facility falls to allow the resident to personalize his or her individual environment to the extent possible. Use Tag F224 (483.15(c)) if the facility falls to have a system in place to prevent the misappropriation of resident's property. See S483.10(l) for the requirement regarding personal property.
For purposes of this requirement, "environment" refers to any environment in the facility that is frequented by residents, including the residents' rooms, bathtf hallways, activity areas, and therapy areas.
If the survey team observes that the rooms of residents with dementia do not appear to be homelike, determine if this decision was made in the context of assessment and care planning; i.e., that this environment assists these residents to maintain their highest practicable functioning levels.

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PP-63

TAG NUMBER
F252 Cont.

REGULATION

GUIDMCB TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
If the team observes non-honellke environments for residents with dementia, determine If each of these residents have the same plan of care and the reason why each of these residents have the sane plan of care.
By observing the residents' surroundings, what can the survey team learn about their everyday life and interests? Their life prior to residing in the facility? Observe family photographs, books and magazines, bedspreads, knlckknacks, mementos, and furniture that belong to the residents. For residents who have no relatives or friends, and have few assets, determine the extent to which the facility has assisted these residents to nake their rooms hornlike, if they so dealre.

F253

(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Intent; S483.15(h)(2) The Intent of this requirement is to focus on the facility's responsibility to provide effective housekeeping and maintenance services.
Guidelines; S483.15(h)(2) "Sanitary" includes, but is not limited to, preventing the spread of dleeaee-caualitg organisms by keeping resident care equipment clean and properly stored. Resident care equipment Includes toothbrushes, dentures, denture cups, glasses and water pitchers, emesis basins, hair brushes and combe, bed pans, urinals, feeding tubes, leg bags and catheter bags, pads and positioning devices.
For kitchen sanitation, see S483.70(h), Physical Environment, other environmental conditions.
For facility-wide sanitary practices affecting the quality of care, see $481.65, Infection Control.
"Orderly" Is defined as an uncluttered physical environment that is neat and wellkept.
Procedures; S483.15(h)(2) Balance the resident's need for a homelike environment and the requirements of having a "sanitary" environment In a congregate living situation. For example, a resident may prefer a cluttered room, but does this clutter result In unsanitary or unsafe conditions?
Probes; S483.15(h)(2) Is resident care equipment sanitary? Is the area orderly? I* the area uncluttered and In good repair? Can residents and staff function unimpeded?

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PP-64

TAG NUMBER
F254

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(3) Clean bed arid bath linens that are In good condition;

GUIDANCE TO SURVEYORS
Probes: S483.15(h)(3) Are bed linens clean and in good condition? Are there clean towels and wash cloths in good condition available for the resident?

F255

(4) Private closet space in each resident room, as specified in S483.70(d)(2)(lv) of this part;

Guidelines: $483.1S(h)(4) S483.70(d)(2)(lv) states: "The facility must provide each resident with individual closet space in his/her bedroom with clothes racks and shelves accessible to the resident."
ProbeB: S483.15(h)(4) Are there individual closet spaces with accessible shelves?
Also see F47O.

F2S6

(5) Adequate and comfortable lighting levels in all areas;

Guidelines: S483.15(h)(5) "Adequate lighting" is defined as levels of Illumination suitable to tasks the resident chooses to perform or the facility staff must pertorn. For some residents (e.g., those with glaucoma), lower levels of lighting would be more suitable.
"Comfortable" lighting la defined as lighting which minimizes glare and provides maximum resident control, where feasible, over the Intensity, location, and direction of illumination so that visually impaired residents can maintain or enhance Independent functioning.
Procedures: S483.15(h)(5) Are there adequate and comfortable lighting levels for Individual resident and staff work needs?
Consider the illumination available from any source, natural or artificial. For hallways, observe the illumination that is normally present. For resident rooms or for other spaces where residents can control the lighting, turn on the lights and make the rating under these conditions.

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TAG NUMBER F257
F258

GUIDANCE TO SURVEYORS - LONG TEHM CARE FACILITIES

REGULATION (6) Comfortable and safe temperature levels. Facilities Initially certified after October 1, 1990 oust maintain a temperature range of 71-81* F; and
(7) For the nalntenance of comfortable sound levels.

GUIDANCE TO SURVEYORS
Procedures; S483.15(h)(6) "Comfortable and safe temperature levels" means that the ambient temperature should be In a relatively narrow range that Minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. Although there are not explicit temperature standards for facilities certified on or before October 1, 1990, these facilities still must maintain safe and comfortable temperature levels.
For facilities Initially certified after October 1, 1990, temperatures may exceed the upper range of 61° Fahrenheit for facilities in geographic areas of the country (primarily at the northernmost latitudes) where that temperature Is exceeded only during rare, brief episodes of unseasonably hot weather. This Interpretation would apply In cases where It does not adversely affect resident health and safety, and would enable facilities in areas of the country with relatively cold climates to avoid the expense of Installing air conditioning equipment that would only be needed very Infrequently. Conversely,, the temperature may fall below 71* Fahrenheit for facilities In areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and colds).
Measure the air temperature above floor level in resident rooms, dining areas, and common areas. If the temperature Is out of the 71-81 degree range, then ask staff what actions they take when residents complain of heat or cold, e.g., provide extra fluids during heat waves and extra blankets and sweaters In cold.
Guidelines; S483.15(h,,,) "Comfortable" sound levels do not Interfere with resident's hearing and enhance privacy when privacy is desired, and encourage interaction when social participation Is desired. Of particular corn n to comfortable sound levels Is the resident's control over unwanted noise.
Procedures: S483.15(h)(7) Determine if the sound levels are comfortable to residents. Do residents ?-*•>" staff have to raise their voices to communicate over background sounds? Are sound levels suitable for the activities occurring In that space during observation?
Consider whether residents have difficulty hearing or making themselves heard because of background sounds (e.g., overuse or excessive volume of Intercom, shouting, loud TV,

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TM
NUMBER
258 Cont.

REGULATION

GUIDANCE -TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
cleaning equlpnent). Consider If it la difficult for residents to concentrate because of distractions or background noise such as traffic, w a l e , equipment, or staff behavior. Conalder the comfort of sound levels baaed on the needs of the residents participating in a particular activity, e.g., the sound levels may have to be turned up for hard of hearing individuals watching TV or listening to the radio. Consider the effect of noise on the contort of residents with dementia.
o During realdent reviews, ask residents if during evenings and at nlghttlae, sounds are at confortable levela? (If yes) Have you told staff about it and how have they responded?

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TAG NUMBER

REGULATION

Refer to F272

$483.20 Resident assessment.

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

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCB TO SURVEYORS
Intent: S483.20 To provide the facility with the Information necessary to develop a care plan and to provide the appropriate care and services for each resident.
Guidelines: S483.20 The guidelines for resident assessment are consistent with the requirements for each State's specified RAI. Each State's RAI Includes at least the MDS and connon definitions, triggers, and utilization guidelines developed by HCFA, which include the RAPa. Refer to F272.

F271

(a) Admission orders.
At the tine each resident Is adaitted, the facility oust have physician orders for the resident's immediate care.

F272

(b) Comprehensive assessments.
(1) The facility nust make a coaprehenslve assessment of a resident's needs which--
(I) Is based on a uniform data set specified by the Secretary and uses an Instrument that Is specified by the State and approved by the Secretary; and
(II) Describes the resident's capability to perfora daily life functions and significant impairments in functional capacity.

Intent: 5483.20(a) To ensure the resident receives necessary care and services.
Guidelines: S483.20(a) "Physician orders for immediate care" are those written orders facility staff need to provide essential care to the resident, consistent with the resident's nental and physical status upon admission. These orders should, at a minima. Include dietary, drugs (If necessary), and routine care to maintain or Improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan.
Guidelines: S«B3.2O(b)(l)(2) The Information required In S483.20(b)(2)(i - xlll) is Incorporated Into the HDS, which forms the core of each State's approved RAI. Additional assessment Information la also gathered using triggered RAPS.
Each facility must use its State specified RAI (which Includes both the MDS and utilization guidelines which Include the RAPs) to assess newly adaitted residents, annual review and those residents who experience a significant change in status. The facility is responsible for addressing all needs and strengths ot residents regardless of whether the Issue is Included in the MDS or RAP3. The scope of the RAI does not limit the facility's responsibility to assess and address all care needed by the resident. Furthermore, the facility is responsible for addressing the resident's needs from the moment of admission.

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TAG NUMBER
272 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION (2) The comprehensive assessment Bust Include at least the following Information: (1) Medically defined conditions and prior medical history;
(11) Medical status measurement;
(111) Physical and ental functional status;
(iv) Sensory and physical impairments;
(v) Nutritional status and requirements; (vi) Special treatments or procedures;

GUIDANCE TO SURVEYORS
All references to version 2.0 (v. 2.0) of the MDS are effective when the State respeclfies its RAI.
(This corresponds to MDS Identification Information 1.11-12 and Section J; MDS v. 2.0 Section AB9-10 and Section I, Disease Diagnosis, respectively.) "Medically defined conditions and prior medical history" Is defined as the resident's medical history before admission and a description of current medical diagnoses. It includes history of mental retardation and current mental Illness, If applicable.
(This corresponds to MDS sections Bl-6, Jl-2, Kl and K3, and Pl-2; MDS v. 2.0 sections Bl-6, 11-2, Jl-3, 5 and PI and 9.) "Medical status measurement" is defined as objective measurements of a resident's physical and mental abilities Including, but not limited to, Information on vital signs, clinical laboratory values, or diagnostic test.
(This corresponds to MDS sections 81-8 and Gl-3; MDS v. 2.0 sections Gl-9 and Fl-3.) "Physical and mental functional status" Is defined as the resident's ability to perform activities of daily living including bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, or other communication systems. Includes determining the resident's need for staff assistance and asslatlve devices or equipment to maintain or Improve functional abilities and the resident's ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility.
(This corresponds to MDS sections Cl-6, Dl-3, E4 and Fl-4; MDS v. 2.0 sections Cl-7, Dl-3, G4, and Hl-4.) "Sensory and physical impairments" are defined as neurological or muscular deficits. For example, a decrease In vision or hearing, paralysis, or bladder Incontinence.
(Thin corresponds to MDS section Ll-4; MDS v. 2.0 section Kl-6.) "Nutritional status and requirements" are defined as weight, height, hematologlc and biochemical assessments, clinical observations of nutrition, nutritional intake, resident's eating habits and preferences, and dietary restrictions.
(This corresponds to MDS sections L4, Nl-4, PI; MDS v. 2.0 sections KS, M5, and PI.) "Special treatments or procedures" are defined as treatments and procedures that are not part of basic services provided. For example, treatment for pressure sores, nasogastrlc feedings, specialized rehabilitation services, or respiratory care.

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TAG NUMBER
F272 Cont.

REGULATION

GUIDANCE TO SURVBYORS - LONG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

(vil) Mental and psychoaoclal status; (vlll) Discharge potential; (lx) Dental condition;
(x) Activities potential;
(xl) Rehabilitation potential; (xll) Cognitive status; and (xlll) Drug therapy.

(This corresponds to MDS sections III (customary routine), 01-3 and B; HDS v. 2.0 sections AC, Fl-3, and E.) "Mental and psychosoclal status" Is defined as the resident's ability to deal with life. Interpersonal relationships and goals, nake health care decisions, and indicators of resident behavior and mood.
(This corresponds to MDS section AID; MDS v. 2.0 section Q.) "Discharge potential" Is defined as the facility's expectation of discharging the resident fron the facility within the next three months.
(This corresponds to MDS section M; MDS v. 2.0 section L.) "Dental condition" is defined as the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communication abilities, or quality of life. The assessnent should Include the need for, and use of, dentures or other dental appliances.
(This corresponds to MDS sections I (activities pursuit) and III (customary routine); MDS v. 2.0 sections N and AC.) "Activities potential" Is defined as the resident's ability and desire to take part In activities which naintaln or Improve, physical, Mental, and psychosoclal well-being. Activity pursuits refer to any activity outside of activities of dally living (ADLs) which a person pursues in order to obtain a sense of well-being. Also, Includes activities which provide benefits in self-esteem, pleasure, coafort, health education, creativity, success, and financial or emotional independence. The assessment should consider the resident's normal everyday routines and llfetine preferences.
(This corresponds to MDS section E7; MDS v. 2.0 section 08.) "Rehabilitation potential" is defined as the ability to lsprove Independence In functional status through restorative care program.
(This corresponds to MDS section Bl-6; MDS v. 2.0 section Bl-6.) "Cognitive status" is defined as the resident's ability to proble solve, decide. remember, and be aware of and respond to safety hazards.
(This corresponds to MDS section O; v.2.0 section O.) "Drug therapy" is defined as all prescription and over-the-counter Medications taken by the resident, Including dosage, frequency of administration, and recognition of significant aide effects that would be most likely to occur In the resident. This Information need not appear in the assessment. However, it must be in the resident's clinical record and Included in the care plan.

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TAG NUMBER
F272 Cont.

REGULATION

GUIDAMCB TO SURVEYORS - LCMG TBRM CARE FACILITIES
GUIDANCE TO SURVEYORS
Probes: S493.20(b)(l)(2) o Baa each resident In the sample been comprehenalvely aaaeased using the State
•peel(lad RAI within the regulatory tlneframas (I.e., within 14 days of admission, on significant change In status, and at least annually)?
o Baa the facility gathered supplemental assessment information baaed on triggered RAPs prior to establishing the care plan?
o Does Information in the RAI correspond with information obtained during observations of and interviews with the resident, facility ataff and resident's family?

F273

(4) Frequency, Assessments must be conducted--
(1) No later than 14 days after the date of admission;
(li) For current NF residents not later than October 1, 1991;
(ill) For current SNF residents, not later than January 1, 1991;

F274 F275

(iv) Promptly after a significant change in the resident's physical or mental condition; and
(v) In no caae less often than once every 12 months.

Intent! S463.20(b)(4) To assess residents In a timely manner.
Guidelines: S4B3.2O(b)(4) "Admission" to the facility is defined as an Initial stay or a return stay (not a readmlsslon) in the facility. A return stay applies to those residents who are discharged without expectation that they will return to the facility, but who do return to the facility.
A "readalaalon" la an expected return to the facility following a temporary absence for hospltallzatlon, off-site visit or therapeutic leave. A resident who Is readmitted and for whom there is a prior RAI on file does not require a new assessment unless a significant change in status has occurred (see below), and should remain on the same schedule as if there had been no temporary absence.
An MDS/RAI need not be completed for realdents discharged In leas than 14 days, although the facility Is to provide care appropriate to the resident*s needs from adnlsslon to discharge.
If the resident experiences a significant change In status, the next annual assessment Is not due until 365 days after the significant change reassessment.
Facilities may correct errors on the M>S per BCFA policy within 7 days of Its completion.
The following guidance concerning significant change Is applicable until the State reapeclfies its RAI for version 2.0. A "significant change" may include, but Is not limited to, any of the following, or may be determined by a physician's decision if uncertainty exists:

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TAG NUMBER
F275 Cont.

REGULATION

Rev. 274

GUIDANCB TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDAHCB TO SURVEYORS
o Deterioration In two or more ADLs, or any combination of deterioration In two or Bore areas of ADLs, communication, or cognitive abilities that appears permanent. For exanple, pronounced deterioration In function and coasunlcatlon following a stroke;
o Loss of ability to ambulate freely or to use hands to grasp snail objects to feed or groom oneself, such as spoon, toothbrush or comb. Temporary loss of ability, such as during an acute illness, is not Included;
o Deterioration in behavior or mood, to the point where dally problems arise or relationships have become problematic and staff conclude that these changes in the resident's psychosoclal status are not likely to Improve without staff intervention;
o Deterioration in a resident's health status, where this change places the resident's life in danger, e.g., stroke, heart disease, metaatatlc cancer; is associated with a serious clinical complication (e.g., Initial development of a stage III pressure sore, prolonged delirious state, or recurrent decline in level of consciousness); or is associated with an Initial diagnosis of a condition that is likely to affect the resident's physical, mental, or psychosoclal well-being over a prolonged period of time, (e.g., Alzheimer's disease or diabetes) or the onset of significant (unplanned) weight loss (5% in last 30 days, 10% in last 180 days); or
o Improvement In behavior, mood or functional status to the extent that the plan of care no longer addresses the needs of the resident.
Comprehensive resident assessment Is not required If declines in physical, mental or psychosoclal well-being are short-term or insignificant (i.e., do not require a change in the resident's care plan). This may Include:
o Discrete and easily reversible symptoms documented in the resident's record and for which facility staff can initiate corrective action. For example, an anticipated side effect of Introducing a psychotropic medication while attempting to establish a clinically effective dose level;
o Short-term acute lllnesB such as a mild fever secondary to a cold from which facility staff expect a full recovery of the resident's pre-morbid functional abilities and health status;
o Well-established symptoms associated with previously diagnosed cyclical conditions. For example, depressive symptoms in a resident previously diagnosed with bipolar disease; or
o If the resident continues to make steady progress under the current course of care, reassessment is required only when the condition has stabilized.
"Promptly" means that once it is determined that the resident's change In status la significant or likely to be permanent, a full assessment must be completed within 14 days of this determination.
The following definition of and criteria for significant change are effective when the State reaped ties Its RAI:

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TAG NUMBER
275 ont.

REGULATION

Rev. 274

GUIDANCE TO SURVBYORS - LONG TERM CARB FACILITIES

GUIDANCE TO SURVEYORS
A "significant change" la a major change In the resident•• status that la not selfllmltlng, impacts on more than one area of the reaident'a health atatua, and require* Interdisciplinary review and/or revision of the care plan. According to thla definition, a significant change reassessment would be Indicated If decline or improvement la consistently noted In 2 or nore areas of decline or 2 or more areaa of Improvement. Following are examples which could Indicate a significant change.
Decline;
o Any decline in ADL physical functioning where a resident la newly coded »B 3, 4 or 8 (Extensive assistance, Total dependency. Activity did not occur);
o Increase in the number of areas where Behavioral Symptoms are coded aa "not easily altered" (i.e., an increase In the number of code "l'a" for E4B);
o Resident's decision making changes from 0 or 1, to 2 or 3; o Reaident'a incontinence pattern changes from 0 or 1 to 2, 3 or 4, or placement of an Indwelling catheter; o Emergence of aad or anxious mood aa a problem that la not eaaily altered; o Emergence of an unplanned weight loss problem (5% change in 30 daya or 10* change in 180 daya); o Begin to use trunk reatralnt or a chair that prevents rising for a resident when it was not uaed before; o Bmargence of a condition/disease In which a resident la Judged to be unstable; o Bmargence of a pressure ulcer at State II or higher, when no ulcera were previoualy present at Stage II or higher; or o Overall deterioration of resident's condition; resident received acre support (e.g., in ADLa or decision-making).
Improvementi o Any improvement in ADL physical functioning where a resident la newly coded as
0, 1, or 2 when previoualy scored aa a 3, 4, or 8; o Decrease In the number of areaa where Behavioral Symptoms or Sad or Anxious
Hood are coded as "not easily altered"; o Resident's decision making changes from 2 or 3, to 0 or 1; o Resident's Incontinence pattern changes from 2, 3, or 4 to 0 or 1; or o Overall improvement of reaident'a condition; resident receives fewer supports.
If the resident experiences a significant change In status, the next annual assessment Is not due until 365 days after the significant change reassessment.
Probea: S483.20(b)(4) o Baa each resident In the sample bean comprehensively assessed using the State-
specified RAI within the regulatory tlmeframea (I.e., within 14 daya after admission, on significant change in status, and at least annually)?
o Has the facility Identified thoae residents who have experienced a significant change?

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TAG NUMBER F275 Cont.
F276

GUIDANCE TO SURVBYORS - LONG TERM CARB FACILITIES

REGULATION
(S) Review of Assessments. The nursing facility mist examine each resident no less than once every 3 months, and as appropriate, revise the resident's assessaent to assure the continued accuracy of the assesBBent.

GUIDANCB TO SURVEYORS
o Has the facility reassessed residents using the State-specified RAI who had a change in status within 14 days after determining the change was significant or appears to be pernanent?
Intent: S483.2O(b)(5) To assure that the resident's assessBent is accurate and reflects the resident's current status.
Guidelines: S483.2O(b)(5) At least each quarter, the facility shall review each resident with respect to those MDS Items specified under the State's quarterly review requirement. At a alniaua, this would include all items contained in HCFA's quarterly review fora. Until the State respeclfles its RAI for version 2.0, facilities are not required to use HCFA's fora unless specified by the State. However, when the State respeclfles Its RAI, the quarterly review fora will be required. If the resident has experienced a significant change in status, the next quarterly review Is due no later than 3 months after the significant change reassessment.
Until the State respeclfles Its RAI, review at least quarterly: o Cognitive patterns, especially memory and dally decision-asking ability; o Communication/hearing ability, especially the ability to Bake one's self
understood and to understand others; o Physical functioning and AOL abilities; o Continence; o Mood and behavior patterns; o New disease diagnoses that have a relationship to current AOL status, behavior
status, medical treatments, or risk of death; o Weight loss; o Medication use, particularly psychotropic medications; and o Special treatments and procedures, including restraints.
NOTE: These quarterly assessment domains will no longer apply when the State respecifles its RAI.
Probes: S483.20(b)(5) o Is the facility assessing and acting, no less than once every 3 souths, on the
results of resident's functional and cognitive status examinations? o Is the quarterly review of the resident's condition consistent with information
In the progress notes, the plan of care and your resident observations and Interviews?

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TAG NUMBER Refer to F279 F277
F278

GUIDAMCB TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(6) Use. The results of the assessment are uaed to develop, review, and revise the resident's conprehenalve plan of care, under narjinranh Iii\ of this HftTitlon. (7) Coordination. The facility oust coordinate assessments with any State-required preadmission acreenlng program to the naxlauai extent practicable to avoid dupllcatlve testing and effort.
(c) Accuracy of assessments.

6UIDANCB TO SURVEYORS
Procedures; S4B3.2O(b)(6) See S483.2O(d).
Intent: S«B3.20(b)(7) To prevent dupllcative data gathering by using MDS assessment Information for more than one purpose.
Guidelines: S4B3.2O(b)(7) As the facility deternlnes appropriate, if required portions of the comprehensive assessment have been performed as part of a pre-admlsslon screening program, enter the results of the pre-admission screening into the appropriate portion of the comprehensive assessment instrument. Unless a significant change has occurred between preadmission screening and admission, the facility may choose not to repeat those portions of the assessment. For example, medical records containing the resident's history and course of previous hospltallzations, pertinent laboratory results and social history data nay be used where applicable to enter Information on the assessment form.

(1) Coordination.
(1) Each assessment must be conducted or coordinated with the appropriate participation of health professionals.
(11) Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment.

Intent: S483.20(c) To assure that each resident receives an accurate assessment by participation of staff that are qualified to assess relevant care areas and Knowledgeable about the resident's status and needs.
Guidelines: S«83.20(c) "The accuracy of the assessment" means that the appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosoclal problems and identifies resident strengths to maintain or Improve medical status, functional abilities, and psychosoclal statua. The initial comprehensive assessment is the baseline data for ongoing assessments of resident progress.
According to the Utilization Guidelines for each State's RAI, the physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident. Involvement of other disciplines Is dependent upon resident statua and needs.

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TAG NUMBER
F276 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
(2) Certification. Each Individual who completes a portion of the assessment suet sign and certify the accuracy of that portion of the assessment.
(3) Penalty for Falsification. An Individual who willfully and knowingly certifies (or causes another Individual to certify) a •aterlal and false statement In a resident assessment is subject to civil noney penalties. The implementing regulations for this statutory authority are located in Part 1003 of this chapter.
(4) Use of Independent assessors. If a State determines, under a survey or otherwise, that there haa been a knowing and willful certification of false statements ' under paragraph (c)(3) of this section, the State say require (for a period specified by the State) that resident assessments under this•paragraph be conducted and certified by Individuals who are independent of the facility and who are approved by the State.

GUIDANCE TO SURVEYORS

The registered nurse will conduct and/or coordinate the assessment, as appropriate. Whether conducted or coordinated by the registered nurse, he ox she 1* responsible for certifying that the assessment has been completed.
Probes: S483.20(c) o Have appropriate health professionals aasessed the resident? For example, has
the resident's nutritional status been aasessed by someone who Is knowledgeable In nutrition and capable of correctly assessing a resident?
o If the resident's medical status, functional abilities, or psycnosoclal status declined and the decline was not clinically unavoidable, were the appropriate health professionals Involved in assessing the resident?
o Based on your total review of the resident. Is each portion of the assessment accurate?

Procedures: S483.20(c)(3) o If there Is evidence that assessments are knowingly and willingly falsified,
organize all documentation and obtain photostatlc coplea of pertinent resident records. Inform your Immediate supervisor at the State or HCFA RO who should review the findings and initiate any investigative action.

If the State Is notified first. It should then communicate its findings to the RO. If

the DO is notified initially, it should ccrar

te its finding to the State to pursue

an investigation. For Medicare, it is .'.,»

lblllty of the BO to make a formal

request of the appropriate Inspector Geneiai •> H e l d office for further Investigation

of the facility. For Hedicaid, it is the responsibility of the State agency to make a

formal request of the appropriate Inspector General's Office for further Investigation.

(d) Comprehensive care plans.

P279

(1) The facility auat develop a comprehensive cars plan for each resident that Includes measurable objectives and timetables to meet a resident's nodical, nursing, and

Guidelines: $483.2O(d) An Interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The interdisciplinary team should show evidence In the RAP Summary or clinical record of the resident's status In triggered RAP areas and

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TAG NUMBER
F279 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
Dental and paychoaoclal needs that are Identified in the comprehensive assessment. The care plan muBt describe the following-
(1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, nental, and psychosoclal well-being as required under $483.25; and
(ii) Any services that would otherwise be required under S483.25 but are not provided due to the resident's exercise of rights under $483.10, Including the right to refuse treatment under $483.10(b)(4).

GUI DANCB TO SURVEYORS
their rationale for deciding whether to proceed with care planning and that they considered the development of care planning interventions for all RAPs triggered by the KDS. The care plan oust reflect Intermediate steps for each outcome objective if Identification of those steps will enhance the resident's ability to meet his/her objectives. Facility staff will use these objectives to follow resident progress. Facilities may, for some realdenta, need to prioritize needed care. This should be noted In the clinical record or on the plan of care.
The requirements reflect the facility's responsibility to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosoclal well-being, in accordance with the comprehensive asBeasment and plan of care. However, in some cases, a resident may wish to refuse certain services or treatments that professional staff believe may be indicated to assist the resident in reaching his or her highest practicable level of well-being. Desires of the resident should be documented in the clinical record (aee guidelines at $483.10(b)(4) for additional guidance concerning refusal of treatment).
Probes: $483.20(d)(l) o Doea the care plan address the needs, strengths and preferences identified In
the comprehensive resident assessment? o Is the care plan oriented toward preventing avoidable declines In functioning
or functional levels? How does the care plan attempt to manage risk factors? Doea the care plan build on resident strengths?
o Doea the care plan reflect standards of current professional practice? o Do treatment objectlvea have measurable outcomes? o Corroborate information regarding the resident's goals and wishes for treatment In the plan of care by Interviewing residents, especially those Identified as refualng treatment. o Determine whether the facility has provided adequate information to the resident so that the resident was able to make an informed choice regarding treatment. o If the resident has refused treatment, doea the care plan reflect the facility'a efforta to find alternative means to address the problem? NOTE: For Implementation of care plan, see $483.20(d)(3).

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TAG NUMBER
F280

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
(2) A conprehenslve care plan Bust be-
ll) Developed within 7 days after the completion of the comprehensive assessment;
(11) Prepared by an interdisciplinary tean, that Includes the attending physician, a registered nurBe with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and
(ill) Periodically reviewed and revised by a tean of qualified persons after each assessment.

GUIDANCB TO SURVEYORS
Guidelines: S483.2O(d)(2) As used in this requirement, "Interdisciplinary" means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary teaa meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) Is at the discretion of the facility.
The physician must participate as part of the Interdisciplinary team, and may arrange with the facility for alternative methods, other than attendance at care planning conferences, of providing his/her Input, such as one-to-one discussions and conference calls.
The resident has the right to refuse specific treatments and to select among treatment options before the care plan is Instituted. (See SS4B3.1O(d)(2) and (3) and 4B3.1O(b)(4).) The facility should encourage residents, surrogates, and representatives to participate In care planning. Including encouraging attendance at care planning conferences if they so desire.
Probes: S483.2O(d)(2) 1. Was interdisciplinary expertise utilized to develop a plan to Improve the
resident's functional abilities? a. For example, did an occupational therapist design needed adaptive equipment or a speech therapist provide techniques to Improve swallowing ability? b. Do the dietitian and the speech therapist determine, for example, the optimum textures and consistency for the resident's food that provide both a nutritionally adequate diet and effectively use oropharyngesl capabilities of the resident? c. Is there evidence of physician Involvement In development of the car* plan (e.g., presence at care planning meetings, conversations with team members concerning the care plan, conference calls)?
2. In what ways do staff Involve residents and families, surrogates, and/or representatives in care planning?
3. Do staff make an effort to schedule care plan meetings at the best time of the day for residents and their families?
4. Ask the ombudsman If he/she has been involved In a care) planning meeting as a resident advocate. If yes, ask how the process worked.
5. Do facility staff attempt to make the process understandable to the resident/family?
(Individual) Have you had concerns or questions about your c a n and brought them to the attention of facility staff? If yes, what happened as a result?

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TAG NUHBBR F280 Cont.
F2B1 F282

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(3) The services provided or arranged by the facility Bust—
(1) Meet professional standards of quality; and (11) Be provided by qualified persons in accordance with each resident's written plan of care.

GUIDANCE TO SURVEYORS
Guidelines: S4B3.2O(d)(2)(111) See S483.75(g)(2) for Qualified Person.
Probea: S4B3.2O(d)(2)(lll) o Is the cars plan evaluated and revised as the resident's status changes?
Intent: S4B3.20(d)(3) The intent of this regulation is that persons providing services are qualified to do so, that the resident's plan of care Is iapleaented, and that those services provided Beet professional standards of quality.
Intent; S4B3.20(d)(3)(l) The intent of this regulation Is to assure that services being provided Beet professional standards of quality (in accordance with the definition provided below) and are provided by appropriate qualified persons (e.g., licensed, certified).
Guidelines: 54B3.20(d)(3)(l) "Professional standards of quality" Beans services that are provided according to accepted standards of clinical practice. Standards Bay apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices aay be published by a professional organization, licensing board, accreditation body or other regulatory agency. Reconaended practices to achieve desired resident outcomes say also be found in clinical literature. Possible reference sources for standards of practice include:
o Current manuals or textbooks on nursing, social work, physical therapy, etc. o Standards published by professional organizations such as the American Nurses' Association, the National Association of Social Work, the American Dietetic Association, the National Association of Activity Professionals, the American Medical Association, etc. o Clinical practice guidelines published by the Agency for Health Care Policy and Research. o Current professional journal articles.
If a negative resident outcome is determined to be related to the facility's failure to Beet professional standards, and the team determines a deficiency has occurred, it should be cited under the appropriate quality of care or other relevant requirement.
Probes; S483.2O(d)(3) Question only those practices which have a negative outcome or have a potential negative outcome. Ask the facility to produce references upon which the practice la based.
o Do nurseB notify physicians, as appropriate, and show evidence of discussions of acute Bedlcal problems?

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TAG NUMBER F282 Cont.
F283
F284

GUIDANCE TO SURVEYORS - LONG TBRM CARE FACILITIES

REGULATION
(e) Discharge summary. When the facility anticipates discharge a resident mist have a discharge summary that Includes— (1) A recapitulation of the resident's stay; (2) A final summary of the resident's status to include items in paragraph (b)(2) of this section, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative; and (3) A post-discharge plan of care that is developed with the

GUIDANCE TO SURVEYORS
o Are residents with acute conditions who require intensive monitoring and hospital-level treatments that the facility is unable to provide, promptly hospitalized?
o Are there errors in the techniques of medication administration? (Cite actual medication errors at S483.25(m), F333 or F334.)
o Is there evidence of assessment and care planning sufficient to meet the needs of newly admitted residents, prior to completion of the first comprehensive assessment and comprehensive care plan?
o Are physicians' orders carried out, unless otherwise indicated by sn advanced directive?
o Can direct care giving staff describe the care, services and expected outcomes of the care they provide; have a general knowledge of the care and services being provided by other therapists; have an understanding of the expected outcomes of this care, and understand the relationship of these expected outcomes to the care they provide.
guidelines; S483.2O(d)(3)(11) If you find problems with quality of care, quality of life, or resident rights, are these problems attributable to the qualifications of the facility staff, or lack of. Inadequate or incorrect implementation of the care plan? Intent; S483.20(e) To ensure appropriate discharge planning and communication of necessary information to the continuing care provider.
Guidelines: S4B3.2O(e) A post-discharge plan of care for an anticipated discharge applies to a resident whoa the facility discharges to a private residence, to another NF or SNF, or to another type of residential facility such as a board and care home or an Intermediate care facility for mentally retarded individuals. Resident protection concerning transfer and discharge are found at S483.12. A "post-discharge plan of care" means the discharge planning process which includes: assessing continuing care needs and developing a plan designed to ensure the individual's needs will be met after discharge from the facility Into the community.
"Anticipates" means that the discharge was not an emergency discharge (e.g., hospltallzation for an acute condition) or due to the resident's death.
"Adjust to his or her living environment" means that the post-discharge plan, as appropriate, should describe the resident's and family's preferences for care, how the resident and family will access these services, and how care should be coordinated if continuing treatment involves multiple caregivers. It should identify specific resident needs after discharge such as personal care, sterile dressings, and physical therapy, as well as describe resldent/careglver education needs to restore the

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PP-80

TAG NUMBER
F284 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATION
participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment.

GUIDANCE TO SURVEYORS
resldent/caregiver to neet care needs after discharge.
Probes: S483.20(e) o Does the discharge summary have Information pertinent to continuing care for
the resident? o IB there evidence of discharge planning in the records of discharged residents
who had an anticipated discharge or those residents to be discharged shortly (e.g., in the next 7-14 days)?
o Do discharge plans address necessary post-discharge care? o Has the facility aided the resident and his/her fatally In locating and coordinating post-discharge services? o What types of pre-discharge preparation and education has the facility provided the resident and his/her family?

F285

(f) Preadmission screening for mentally 111 Individuals and Individuals with mental retardation.
(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with--
(1) Mental illness as defined In paragraph (f)(2)(l) of this section, unless the State mental health authority has determined, based on an Independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the Individual requires the level of services provided by a nursing facility; and

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Intent: S483.2O(f) To ensure that individuals with mental illness and mental retardation receive the care and services they need in the most appropriate setting.
"Specialized services" are those services the State Is required to provide or arrange for that raise the intensity of services to the level needed by the resident. That Is, specialized services are an "add-on" to NF services—they are of a higher intensity and frequency than specialized rehabilitation services, which are provided by the NF.
The statute mandates preadmission screening (PAS) for all Individuals with mental illness (MI) or mental retardation (MR) who apply to NFS, regardless of the applicant's source of payment, except as provided below. (See S1919(b)(3)(F).) Residents readmitted and individuals who initially apply to a nursing facility directly following a discharge from an acute hospital stay are exempt If:
o They are certified by a physician prior to admission to require a nursing facility stay of less than 30 days; and
o They require care at the nursing facility for the same condition for which they were hospitalized.
The State is responsible for providing specialized services to residents with MI/MR residing in Medicald-certlfied facilities. The facility Is required to provide all other care and services appropriate to the resident's condition. Therefore, If a facility has residents with MI/MR, do not survey for specialized services, but survey for all other requirements, including resident rights, quality of life, and quality of care.

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TAO
NUMBER
F285 Cont.

GUIDANCE TO SURVEYORS - LONG TBRM CARE FACILITIES

RBGULATIOM
(B) If the Individual requires such level of services, whether the individual requires specialized services for aental 111noftB* or
A » A •fl^VS» SV 4 ^* A>
(il) Mental retardation, as defined in paragraph (f)(2)(li) of this section, unless the State nental retardation or developmental disability authority has determined prior to adBlssion-

GUIDANCE TO SURVEYORS
If the resident's PAS report indicates that he or she needs specialized services but the resident is not receiving then, notify the Medlcaid agency. sT services ordinarily are not of the intensity to m e t the needs of residents with MI or MR.
Probes: S4B3.20(f) If sanpled residents have MR or MI, did the State Mental Health or Mental Retardation Authority determine:
o Whether the residents needed the services of a BF7 o Whether the residents need specialized services for their MR or MI?

(A) That, because of the physical and aental condition of the individual, the individual requires the level of services provided by a nursing facility;
and

(B)Indlvldual requires such level of services, whether the individual requires specialized services for siantal retardation.

(2(Definition. For purposes of this section—

(l)An individual is considered to

have "oental illness" if the

individual has a serious aantal

*

Illness as defined at

483.102(b)(l).

(11)An individual is considered to be "aentally retarded" if the individual Is mentally retarded as defined in 483.102(b)(3) or is a person with a related condition as described in 42 CFR 435.1009. F285

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PP-82

TAG NUMBER
F309

GUIDANCE TO SURVEYORS - LONG TEHM CARE FACILITIES

REGULATION
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.
Use F309 for quality of care deficiencies not covered by S483.25(a)-(m).

GUIDANCE TO SURVEYORS
Guidelines; 5463.25 UBO F309 when the survey team determines there are quality of care deficiencies not covered by SS483.2S(«)-(»). "Highest practicable" is defined as the highest level of functioning and well-being possible, limited only by the Individual's presenting functional status and potential for improvement or reduced rate of functional decline. Highest practicable is determined through the comprehensive resident assessment by competently and thoroughly addressing the physical, mental or psychosocial needs of the Individual.
The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and the normal aging process.
In any instance in which there has been a lack of Improvement or a decline, the survey team muBt determine if the occurrence was unavoidable or avoidable. A determination of unavoidable decline or failure to reach highest practicable well-being may be made only if all of the following are present:
o An accurate and complete assessment (see S4S3.2O); o A care plan which is Implemented consistently and based on information from the assessment; o Evaluation of the results of the Interventions and revising the interventions as necessary. Determine If the facility Is providing the necessary care and services based on the findings of the RAJ. If services and care are being provided, determine If the facility is evaluating the outcome to the resident and changing the Interventions if needed. This should be done in accordance with the resident's customary dally routine. Use Tag F3O9 to cite quality of care deficiencies that are not explicit in the quality of care regulations.
Procedures; S483.25 Assess a facility's compliance with these requirements by determining if the services noted In the plan of care, based on a comprehensive and accurate functional assessment of the resident's strengths, weaknesses, risk factors for deterioration and potential for Improvement, is continually and aggressively Implemented and updated by the facility staff. In looking at assessments, use both the K>S and RAPs information, any other pertinent assessments, and resulting care plans.
If the resident has been in the facility for less than 14 days (before completion of all the RAI is required), determine if the facility la conducting ongoing assessment and care planning, and, if appropriate, care and services are being provided.
If quality of care problems are noted In areas of nurse aide responsibility, review nurse aide competency requirements at S483.7S(e).

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PP-83

KAO NUMBER

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATION
(a) Activities of dally living. Based on the comprehensive assessment of a resident, the facility oust ensure that

GUIDANCE TO SURVEYORS
Intent: S483.25(a) The Intent of this regulation la that the facility Bust ensure that a resldent'i abilities in ADLs do not deteriorate unless the deterioration was unavoidable.

F310

(1) A resident's abilities In activities of daily living do not diminish unless clrcunstances of the Individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to-
(I) Bathe, dress, and groom;
(II) Transfer and ambulate;
(III) Toilet;
(lv) Bat; and
(v) Use speech, language, or other functional connunlcatlcm systems.

Guidelines; S483.25(a) The sere presence of a clinical diagnosis, in Itself, Justify a decline in a resident's ability to perforn ADLs. Conditions which Bay demonstrate unavoidable diminution In ADLs Include:
o The natural progression of the resident's disease; o Deterioration of the resident's physical condition associated with the onset of a physical or mental disability while receiving care to restore or maintain functional abilities; and o The resident's or his/her surrogate's or representative's refusal of care and treatment to restore or maintain functional abilities after aggressive efforts by the facility to counsel and/or offer alternatives to the resident, surrogate, or representative. Refusal of such care and treatment should be documented in the clinical record. Determine which Interventions were identified on the care plan and/or could be in place to minimize or decrease complications. Note also that depression is a potential cause of excess disability and, where appropriate, therapeutic interventions should be Initiated.
Appropriate treatment and services includes all care provided to residents by employees, contractors, or volunteers of the facility to maximize the Individual's functional abilities. This includes pain relief and control, especially when it Is causing a decline or a decrease In the quality of life of the resident.
If the survey tean Identifies a pattern of deterioration In ADLs, I.e., a number of residents have deteriorated in Bore than one ADL or a number of residents have deteriorated In only one ADL lor.a In bathing, one in eating, one in toileting) and It Is determined there is deficient practice, cite at F310.
For evaluating a resident's ADLs and determining whether a resident' i abilities have declined. Improved or stayed the same within the last twelve months, use the following definitions as specified in the State's RAI:
1. Independent - Ho help or staff oversight; or staff help/oversight provided only 1 or 2 times during prior 7 days. 2. Supervision - Oversight encouragement or cuing provided 3 or more tlaes during the last 7 days, or supervision plus physical assistance provided only 1 or 2 tlaes during the last 7 days.

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TAG NUMBER
F310 Cont.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

GUIDANCE TO SURVEYORS
1. Limited Assistance - Resident highly Involved in activity, received physical help In guided maneuvering of H u b s , and/or other non-weight bearing assistance 3 or sore tines; or sore help provided only 1 or 2 tines over 7-day period. 4. Extensive Assistance - While resident performed part of activity, over prior 7-day period, help of following type(s) was provided 3 or sore tlaes;
a.Weight-bearing Bupport; or b.Full staff performance during part (but not all) of week. 5. Total Dependence - Full staff performance of activity over entire 7-day period.
BATHING, DRESSING, GROOMING
Guidelines; S483.25(a)(l)(l) This corresponds to MDS section E; version 2.0, section G, when specified for use by the State.
"Bathing" means how resident takes full-body bath, sponge bath, and transfers in/out of tub/shower. Exclude washing of back and hair.
"Dressing" means how resident puts on, fastens, and takes off all Items of clothing, including donning/reaoving prosthesis.
' "Grooming" means how resident maintains personal hygiene. Including preparatory activities, combing hair, brushing teeth, shaving, applying make-up, washing/drying face, hands and perineum. Exclude baths and showers.
Procedures: S483.25(a)(1)(1) BATHING, DRESSING, GROOMING For each sampled resident selected for the comprehensive review or the focused review, as appropriate, determine:
1. Whether the resident's ability to bathe, dress and/or groom has changed since admission, or over the past 12 months;
2. Whether the resident's ability to bathe, dress and groom has improved, declined or stayed the same;
3. Whether any deterioration or lack of Improvement was avoidable or unavoidable by:
4. Identifying if resident triggers RAPs for ADL functional/rehabilitation potential.
a. What risk factors for decline of bathing, dressing, and/or grooming abilities did the facility Identify?
b. What care did the resident receive to address unique needs to maintain his/her bathing, dressing, and/or grooming abilities (e.g., resident needs a button hook to button his shirt; staff teaches the resident how to use It; staff provides resident with dementia with cues that allow him/her to dress him or herself)?

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PP-8S

TAG NUMBER
F310 Cont.

REGULATION

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GUIDANCE ID SURVEYORS - LONG TERM CARB FACILITIES
GUIDANCB TO SURVEYORS
c. Were Individual objectives of the plan of care periodically evaluated, and If the objectives were not net, were alternative approaches developed to encourage maintenance of bathing, dressing, and/or grooaing abilities (e.g., resident now unable to button dress, even with encouragement; will ask family If we oay use velcro In place of buttons so resident can continue to dress herself)?
Probes: 5483.25(a)(l)(l) If the resident's abilities in bathing, dressing, and groaning have been Maintained, what evidence is there that the resident could have improved if appropriate treatment and services were provided:
o Identify relevant Beetlone of the MDS and consider whether assessment triggers the RAFs and the RAPs were followed.
o Are there physical and psychosoclal deficits that could affect improvement in functional abilities?
o Was the care plan driven by resident strengths Identified In the comprehensive assessnent?
o Was the care plan consistently Implemented? What changes were Bade in treatment if the resident failed to progress or when Initial rehabilitation goals were achieved, but additional progress Bight have been possible?
TRANSFER AND ANBULATION Guidelines; S483.25(a)(l)(ll) This corresponds to MDS section E; MDS 2.0 section 0 when specified for use by the State.
"Transfer" means how resident moves between surfaces — to/from: bed, chair, wheelchair, standing position. (Exclude to/from bath/toilet.) "tabulation" Beans how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once In chair.
Procedures; S483.25(a)(l)(li) TRANSFER AND AHBULATIOH Determine for each resident selected for a comprehensive review, or a focused review as appropriate, whether the resident's ability to transfer and ambulate has declined, improved or stayed the sane and whether any deterioration or decline in function was avoidable or unavoidable.
Probes: S«B3.25(a)(1)(11) If the resident's transferring and ambulating abilities have declined, what evidence is there that the decline was unavoidable:
o What risk factors for decline of transferring or ambulating abilities did the facility Identify (e.g., necrotlc area of foot ulcer becoming larger, postural hypotension)?

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TAG NUMBER
F110 Cotlt.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

GUIDMCB TO SURVEYORS
o what care did the resident receive to address risk factors and unique needs to maintain transferring or ambulating abilities (e.g., a transfer board is provided to maintain ability to transfer from bed to wheelchair and staff teaches the resident how to use It)?
o What evidence Is there that sufficient staff time and assistance are provided to maintain transferring and ambulating abilities?
o Has resident been Involved in activities that enhance mobility skills? o Were individual objectives of the plan of care periodically evaluated, and if goals were not met, were alternative approaches developed to encourage maintenance of transferring and ambulatlon abilities (e.g., resident remains unsteady when using a cane, returns to walker, with staff encouraging the walker's consistent use)? o Identify if resident triggers RAP* for ADL functional/rehabilitation potential, psychosoclal well-being, or mood atate and the RAPa are followed.
If the resident's abilities In transferring and ambulating have been maintained, la there evidence that the resident could have Improved if appropriate treatment and services were provided?
o Are there physical and psychosoclal deficits that could affect Improvement in functional abilities?
o Was the care plan driven by resident strengths Identified In the comprehensive assessment?
o Waa the care plan consistently Implemented? What changes were made In treatment If the resident failed to progress or when Initial rehabilitation goals were achieved, but additional progress seemed possible?
TOILETING Guidelines: This corresponds to MOS sections E; KDS 2.0 sections 0 and B when specified for use by the 8tate.
"Toilet use" means how the resident U B B S the toilet room (or commode, bedpan, urinal); transfers on/off the toilet, cleanses self, changes pad, manages ostomy or catheter, adjusts clothes.
Procedures: S«83.25(a)(l)(lll) TOILBTIHO Determine for each resident selected for a comprehensive review, or focused review as appropriate, whether the resident's ability to use the toilet has improved, declined or stayed the same and whether any deterioration or decline In Improvement was avoidable or unavoidable.
Probes: <483.25(a)(1)(111) TOILETING If the resident's toilet use abilities have declined, what evidence la there that the decline was unavoidable.

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PP-87

TAG NUMBER
F310 Cont.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

GUIDANCE TO SURVEYORS
o What d a k factors for the decline of toilet use abilities did the facility Identify (e.g «vere arthritis In hands Bakes use of toilet paper difficult)?
o What care did resident receive to address risk factors and unique needs to maintain toilet use abilities (e.g., asslstlve devices to Maintain ability to use the toilet such as using a renewable elevated toilet seat or wall grab bar to facilitate rising from seated position to standing position)?
o Is there sufficient staff time and assistance provided to maintain toilet use abilities (e.g., allowing residents enough tine to use the toilet Independently or with limited assistance)?
o were Individual objectives of the plan of care periodically evaluated, and if objectives were not met, were alternative approaches developed to encourage maintaining toilet uae abilities (e.g., if resident has not increased sitting stability, seek occupational therapy consult to determine the need for therapy to increase sitting balance, ability to transfer safely and manipulate clothing during the toileting process. For residents with dementia, remind periodically to use the toilet)?
o Identify if resident triggers RAPs for urinary incontinence, and ADL functional/rehabilitation potential and the RAPs were used to assess causal factors for decline or potential for decline or lack of improvement.
If the resident's toilet use abilities have been maintained, what evidence Is there that the resident could have improved if appropriate treatment and services were provided?
o Axe there physical and psychosoclal deficits that could affect Improvement in functional abilities?
o Was the care plan driven by resident strengths identified in the comprehensive assessment?
o Was the care plan consistently Implemented? What changes were made to treatment If the resident failed to progress or when Initial rehabilitation goals were achieved, but additional progress seemed possible?
o Identify If resident triggers RAPs for mood state and psychosoclal well-being.
BATING Guidelines: S<83.25(a)(l)(lv)
This corresponds to MD3 sections B, LI and MI; MDS 2.0 sections G and K when specified for use by the State.
"Eating" Beans how resident ingests and drinks (regardless of self-feeding skill).
Procedures; S483.25(a)(1)(lv) EATING Determine for each resident selected for a comprehensive review, or focused review, as appropriate, whether the resident's ability to eat or eating skills has improved, declined, or stayed the sane and whether any deterioration or lack of Improvement was avoidable or unavoidable.

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PP-88

TAG NUMBER
F310 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
If the resident's eating abilities have declined, is there any evidence that the decline was unavoidable?
1. What risk factors for decline of eating skills did the facility Identify? a. A decrease in the ability to chew and swallow food b. Deficit in neurological and muscular status necessary for moving food onto
a utensil and into the mouth c. Oral health status affecting eating ability d. Depression or confused mental state
2. What care did the resident receive to address risk factors and unique needs to maintain eating abilities?
a. Asslstive devices to improve resident's grasp or coordination b. Seating arrangements to Improve sociability c. Seating in a calm, quiet setting for residents with dementia 3. Is there sufficient staff time and assistance provided to maintain eating abilities (e.g., allowing residents enough time to eat independently or with limited assistance)? 4. Identify if resident triggers RAPs for ADL functional/rehabilitation potantlal, feeding tubes, and dehydration/fluid maintenance, and the RAPs were used to assess causal reasons for decline, potential for decline or lack of Improvement. 5. Were individual objectives of the plan of core periodically evaluated, and if ,the objectives were not met, were alternative approaches developed to encourage maintaining eating abilities?
Probes: S483.25(a)(l)(lv) If the resident's eating abilities have been maintained, what evidence Is there that the resident could have lnproved if appropriate treatment and services were provided:
o Are there physical and psychoaoclal deficits that could affect improvement in functional abilities?
o Was the care plan driven by resident strengths identified in the comprehensive assessnent?
o Was the care plan consistently implemented? What changes are made to treatment if the resident failed to progress or when Initial rehabilitation goals were achieved, but additional progress seemed possible?
USE OF SPEECH, LANGUAGB, OR OTHER FUNCTIONAL 00W4UNICATI0N SYSTEMS Guidelines: $4B3.25(a)(l)(v) This corresponds to MDS, section C; MDS 2.0 sections B and C when specified for use by the State.
"Speech, language or other functional communication systems" is defined as the ability to effectively communicate requests, needs, opinions, and urgent problems; to express emotion, to listen to others and to participate in social conversation whether in

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TAG tlUHBER
P310 Cont.

REGULATION

GUIDMICB TO SURVEYORS

speech, writing, gesture or a calcination of these (e.g., a a electronic augmentative cosiaunlcatlon device).

mication board or

Procedures; S4B3.25(a)(l)(v) USB OF SPEECH, LMICUACB OH OTHER FUNCTIONAL COMMUNICATION SYSTEMS Determine for each resident selected for a comprehensive review, or focused review, as appropriate, if resident's ability to communicate has declined. Improved or stayed the sane and whether any deterioration or lack of improvement was avoidable or unavoidable,
o Identify if resident triggers RAPs for cctmunlcation, psychosocial wellbeing,
nood state, and visual function, and if the RAPs were used to assess causal factors for decline, potential for decline or lack of improvement.

Probes: <483.25(a)(l)(v) If the resident's comunicatlon abilities have diminished. Is there any evidence that the decline was unavoidable:
o What risk factors for decline of coasninlcation abilities did the facility identify and how did they address them (e.g., dysarthrla, poor fitting dentures, few visitors, poor relationships with staff, Alzheimer's disease)?
o Bas the resident received audlologlc and vision evaluation? If not, did the resident refuse such services? (See also S483.10(b)(4).)
o what unique resident needs and risk factors did the facility Identify (e.g., does the resident have specific difficulties in transmitting messages, comprehending messages, and/or using a variety of communication skills such as questions and commands; does the resident receive evaluation and training in the use of asslstlve devices to Increase and/or maintain writing skills)?
o What care does the resident receive to Improve communication abilities (e.g., nurse aides communicate in writing with deaf residents or residents with severe hearing problems; practice exercises with residents receiving speech-language pathology services; increase number of resident's communication opportunities; non-verbal means of communication; review of the effect of medications on communication ability)?
o Is there sufficient staff time and assistance provided to maintain communication abilities?
o Were Individual objectives of the plan of care periodically evaluated, and if the objectives were not met, were alternative approaches developed to encourage maintenance of communication abilities (e.g., if drill-oriented therapy is frustrating the resident, a less didactic approach should be attempted)?

Probes: S4B3.25(a)(l)(v) USB OP SPEECH, LAHGUACB OR OTHER FUmCTIOKM. C O H K U H I O T I O H SYSTEMS If the resident's speech, language, and other communication abilities have been maintained, what evidence is there that the resident could have Improved If appropriate treatment and services were provided:
o Are there physical and psychosocial deficits that could affect Improvement in functional abilities?
o Was the care plan driven by resident strengths identified in the comprehensive assessment?

TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES GUIDANCE TO SURVEYORS

F311

(2) A resident Is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(l) of thlB section; and

F312

(3) A resident who Is unable to carry out activities of dally living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Rev. 274

o Was the care plan consistently Implemented? What changes were Bade to treatment if the resident failed to progress or when Initial rehabilitation goals were achieved, but additional progress seemed possible?
Intent: S483.25(a)(2) The Intent of thlB regulation is to stress that the facility is responsible for providing maintenance and restorative programs that will not only maintain, but improve, as Indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome.
Procedures: S4B3.25(a)(2) Use the survey procedures and probes at S463.25(a)(l)(i) through (v) to assist in making this determination.

Intent: S463.25(a)(3) The intent of this regulation is that the resident receives the care and services needed because he/she is unable to do their own ADL care independently.
Guidelines: S483.25(a)(3) This corresponds to MDS section L; HDS 2.0 section K when specified by the State.
"Unable to carry out ADLs" means those residents who need extensive or total assistance with maintenance of nutrition, grooming and personal and oral hygiene, receive this assistance from the facility.
Methods for maintenance of good nutrition may Include hand feeding of foods served on dishes; tube feedings provided through naso-gastric, gastrostomy, or other external tubes; or total parenteral nutrition provided through a central Intravenous line.
"Grooming": See S483.25(a)(l)(l) for definition.
"Personal hygiene": Those activities described in dressing and bathing as defined in S483.25(a)(l)(i).
"Oral hygiene" means nalntalning the mouth in • clean and intact condition and treating oral pathology such as ulcers of the mucosa. Services to maintain oral hygiene may Include brushing the teeth, cleaning dentures, cleaning the mouth and tongue either by assisting the resident with a mouth wash or by manual cleaning with a gauze sponge; and application of medication as prescribed.

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TAG NUMBER F312 Cont.
F313

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
(b) Vision and hearing. To ensure that residents receive proper treatment and assistlve devices to maintain vision and hearing abilities, the facility •ust. If necessary, assist the resident-(1) In naking appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing Impairment or the office of a professional specializing in the provision of vision or hearing assistlve devices.

GUIDANCE TO SURVEYORS
Procedures; S483.25(a)(3) For residents selected for a comprehensive review, or focused review, as appropriate, who are unable to carry out these ADIiB without extensive assistance, determine if poor nutritional status, poor grooming, or lack of effective personal and oral hygiene exist. To what extent are these negative outcomes attributable to the lack of receiving necessary services?
Identify if residents trigger RAPs for nutritional status, ADL functional/rehabilitation potential, behavior problems, and dental care. Consider whether the RAPs were used to assess causal factors for decline, potential for decline, or lack of Improvement. Determine If the facility proceeded properly with care planning and delivery of care for these residents.
Intent: t«S3.25(b) The Intent of this regulation Is to require a facility to assist residents In gaining access to vision and hearing services by making appointments and arranging for transportation, and assistance with the use of any devices needed to maintain vision and hearing.
Guidelines: S4B3.25(b) This corresponds to MDS, sections C and 0; MDS 2.0 sections C, D and P when specified for use by the State.
Assistlve devices to maintain vision Include glasses, contact lenses, and magnifying glasses. Assistlve devices to maintain hearing Include hearing aids.
This requirement does not mean that the facility must provide refractions, glasses, contact lenses, conduct comprehensive audlologlcal evaluations (although screening la a part of the required assessment In S483.20(b)) or provide hearing aids. The facility's responsibility is to assist residents and their families In locating and utilizing any available resources (e.g.. Medicare or Medlcald program payment, local health organizations offering Items and services which are available free to the community) for the provision of the services the resident needs. This includes making appointments and arranging transportation to obtain needed services.
Probes: $4B3.25(b) o Identify if resident triggers RAPs for visual function, and communication.
Consider whether the RAPs were used to assess causal factors for decline, potential for decline or lack of Improvement.
o If the resident needs, and/or requests and does not have vision and/or hearing assistlve devices, what has the facility done to assist the resident In making appointments and obtaining transportation to obtain these services?

Rev. 274

06-95

PP-92

TAG DUMBER
F313 Cont.
F314

GUIDANCB TO SURVEYORS - LONG TERM CARE FACILITIBS

REGULATION
(c) Pressure sores.
Baaed on the comprehensive assessment of a resident, 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; and

GUIDANCE TO SURVEYORS
o If the resident has asalstlve devices but Is not using then, why not (e.g., ar repairs or batteries needed)?
Intent: S463.25(c) The Intent of this regulation is that the resident does not develop a pressure sore while in the facility. If the resident is admitted with or develops a pressure sore, he or she receives care and treatment to heal and prevent further development of pressure sores. For additional information on prevention, staging and treatment, refer to the staging systen found in the booklet "Pressure Ulcers in Adults: Prevention and Treatment, Public Health Service Agency for Health Care Policy and Research."
Guidelines: S483.25(c) This corresponds to MDS, section N; HDS 2.0 section I M and P when specified for use by the State.
"Pressure sore" means lschemlc ulceratlon and/or necrosis of tissues overlying a bony prominence that has been subjected to pressure, friction or shear. The staging system presented below is one method of describing the extent of tissue damage in the pressure sore. Pressure sores cannot be adequately staged when covered with eschar or necrotlc tissue. Staging should be done after the eschar has sloughed off or the wound has been debrided. Vascular ulcers due to Peripheral Vascular Disease (PVD) have to be considered separately. They usually occur on the lower legs and feet and are very persistent even with aggressive treatment.
Stage I: A persistent area of skin redness (without a break In the skin) that Is nonblanchable. Redness can be expected to be present for one-half to three-fourths as long as the pressure applied that has occluded blood flow to the areas. For example: If a resident Is laying on his right side for 30 minutes and turned to his back, redness may be noticed over his right hip bone. Redness in that area can be expected to remain for up to 20 minutes. The survey team then would check to see if the area is nonblanchable. Just having the redness does not Indicate a stage I. To Identify the presence of stage I pressure ulcers In residents with darkly plgmented skin, look for changes such as changes in skin color (grayish hue), temperature, swelling, and tenderness or texture. Stage II: A partial thickness loss of skin layers either dermls or epidermis that presents clinically as an abrasion, blister, or shallow crater. Stage III: A full thickness of skin is lost, exposing the subcutaneous tissues presents as a deep crater with or without undermining adjacent tissue. Stage IV: A full thickness of skin and subcutaneous tissue Is lost, exposing muscle and/or bone.
Procedures: S483.25(c) Identify it resident triggers RAPs for urinary Incontinence, nutritional status, cognitive loss/dementia, psychotroplc drug use, and physical restraints. Consider

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Cont.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

GUIDANCE TO SURVEYORS
whether the RAPs were used to assess causal factors for decline, potential for decline or lack of Improvement.
If the resident 1 B moribund (I.e., the resident Is terminally 111; seal-comatose or comatose) and llfe-sustalnlng neasures have been withdrawn or discouraged as documented in the record, pressure sores nay be clinically difficult to prevent.
A determination that development of a pressure sore was unavoidable Bay be made only if routine preventive and dally care was provided. Routine preventive care neans turning and proper positioning, application of pressure reduction or relief devices, providing good skin care (I.e., keeping the akin clean. Instituting Measures to reduce excessive moisture), providing clean and dry bed linens, and maintaining adequate nutrition and hydratlon as possible.
Clinical conditions that are the primary risk factors for developing pressure sores Include, but are not limited to, resident immobility and:
1. The resident has two or sore of the following diagnoses! a. Continuous urinary incontinence or chronic voiding dysfunction; b. Severe peripheral vascular disease; c. Diabetes; d. Severe chronic pulmonary obstructive disease; a. Severe peripheral vascular disease; f. Chronic bowel incontinence; g. Continuous urinary Incontinence or chronic voiding dysfunction; h. Paraplegia; 1. Quadrlplegla; j. Sepsis; k. Terminal cancer; 1. Chronic or end stage renal, liver, and/or heart disease; • . Disease or drug-related lawmosuppresslon; or n. Pull body cast.
2. The resident receives two or more of the following treatments: a. Steroid therapy; b. Radiation therapy; c. Chemotherapy; d. Renal dialysis; or e. Bead of bed elevated the majority of the day due to medical necessity.
3. Malnutrition/dehydration, whether secondary to poor appetite or another disease process, places resident at risk for poor healing, and may be Indicated by the following lab values:
a. Serun albumin below 3.4 g/dl b. Height loss of BD.JJ i M n 10% during last month

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TAG NUMBER
F314 Cont.

GUIDANCE TO SURVEYORS - LONG TERM CARE F A C I L I T I E S

REGULATION
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

GUIDANCE TO SURVEYORS
c. Serum transferrIn level below 180 mg per dl d. Hgb less than 12 ng per dl.
Use these values In conjunction with an evaluation of the resident's clinical condition.
4. If laboratory data are not available, clinical signs and aynptons of Balnutrltlon/dehydratlan may be:
a. Pale skin; b. Red, swollen lips; c. Swollen and/or dry tongue with scarlet or Magenta hue; d. Poor skin turgor; e. Cachexla; f. Bilateral edema; g. Muscle wasting; h. Calf tenderness; or 1. Reduced urinary output.
Probea: J483.25(c)(1) For each sampled resident selected for the comprehensive review, or the focused review at risk of developing pressure sores, determine, as appropriate. If aggressive preventive care Is provided?
For sampled residents, who upon Initial admission to the facility, did not have a pressure sore and now have one, determine If pressure sore development may have been avoided:
o Did the facility identify the resident as being at risk for pressure sors(s)? o Did the facility provide aggressive/appropriate preventive measures and care specific to addressing the resident's unique risk factors (e.g., if serum albumin is below 3.4 mg per dl, provide additional protein In daily snacks)? o Was this preventive care plan implemented consistently?
Probes; 483.25 (c)(2) For all sampled residents who have pressure sores at the time of the survey. Including those readmitted from the hospital with a pressure sore that developed in the hospital:
o Are measures to assist healing provided per the plan of care (e.g., relieving pressure, moving the resident without causing shearing. Instituting topical therapy which creates a favorable environment for healing, and debrldlng eschar7
o Are measures to prevent further contamination followed (e.g., wash hands before caring for sore? Observe clean or sterile technique, as Indicated, when dressing is changed). All wounds are contaminated (soiled/contain organisms). An Infected wound Is accompanied by local or systemic synptons. Clean technique Is adequate when caring for a non-infected wound.

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PP-95

TAG NUMBER
F315

GUIDANCE TO SURVEYORS - LONG TEBM CARE FACILITIES

REGULATION
(d) Urinary Incontinence.
Based on the resident's comprehensive assessment, the facility must ensure that--
(1) A resident who enters the facility without an Indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterizatlon was necessary; and

GUIDANCE TO SURVEYORS
o Are universal precautions used during all wound care? (See S483.65, Infection Control.)
o Have the care plan objectives been evaluated? If the pressure sore is not healing, getting larger, or signs of additional skin breakdown are evident, have alternative interventions been considered or attempted?
o Has improvement been noted?
Guidelines; S«83.25(d)(l) This corresponds to MDS section F; fOS 2.0 sections a and a when specified by the State.
Intent: $483.25(d)( 1) The Intent of this regulation is to ensure that an indwelling catheter la only to be used when there is valid nodical justification. The resident should be assessed for and provided the care and treatment needed to reach his or her highest level of continence possible.
The facility is expected to show evidence of any medical factors which caused the Intervention.
Examples of clinical conditions demonstrating that catheterizatlon may be unavoidable Include:
1. Urinary retention that: a. Is causing persistent overflow incontinence, symptomatic Infections, and/or
renal dysfunction; b. Cannot be corrected surgically; or c. Cannot be managed practically with intermittent catheter use.
2. Skin woundB, pressure sores, or irritations that are being contaminated by urine;
3. Terminal illness or severe impairment, which makes bed and clothing changes uncomfortable or disruptive (i.e., as in the case of Intractable pain).
ProbeB-. S«B3.2S(d)|l) For sampled residents selected for a comprehensive or focused review who entered the facility without a catheter and are now catheterized, determine as appropriate if the use of an indwelling catheter was unavoidable.
o Was the resident continent upon admission? o If continent at admission, was the resident Identified as having risk factors of incontinence (e.g., frequency of urination, with limited mobility)? o What care did the resident receive to promote maintenance of continence? o Did the facility attempt to manage the incontinence and increase bladder function without the use of an indwelling catheter (e.g., a bladder training program, prompted voiding schedule, extern*! .*>>••<•) 7

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TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

F316

(2) A resident who 1 B Incontinent of bladder receives appropriate treatment and services to prevent urinary tract Infections and to restore as much normal bladder function as possible.

o Identify if resident triggers RAPs for urinary Incontinence, ADL functional/rehabilitation potential, and cognitive loss/dementia and the RAPa were used to assess causal factors for decline, potential for decline or lack of Improvement.
If the resident has an Indwelling catheter: o Is the staff following the facility's protocol and/or written procedures for
catheterizatlon? o Do all personnel wash their hands before and after caring for the
catheter/tublng/collectlng bag? o Does the facility assess for continued need for use of the catheter, as
appropriate, utilizing the evaluative data as described and implemented in the care plan?

Guidelines: S483.25(d)(2) For purposes of this regulation, "urinary tract infection (UTI)" Is defined as colonization (growth of bacteria) of the urinary tract with signs or symptom of VII. Asymptomatic colonization Is not a UTI. Care should be provided based on the type, severity, and cause (if known) of the urinary Incontinence. Antibiotic therapy should be reserved for residents with active symptoms of UTI. Routine and overzealous use could lead to resistance of organisms.

I
Rev. 274

Probes: 54B3.25(d)(2) For each incontinent sampled resident selected for the comprehensive, or focused review determine, as appropriate:
o Has the facility Identified (or attempted to Identify) the cause of the incontinence?
o Is the resident adequately hydrated? o How many residents currently have a UTI? Differentiate between bacterial colonization vs. acute infection. (See also S483.65, Infection Control.) o Are risk factors for UTI monitored and managed (e.g., poor fluid Intake, previous UTIs)? Are residents with a history of UTI adequately assessed and provided care and treatment to prevent UTI? o Are infection control procedures in place (e.g., adequate fluid intake)? o What care did the resident receive, consistent with the comprehensive assessment, to restore or improve bladder functioning (e.g., pelvic floor exercises, habit training, or maintaining adequate hydratlon)? o Have the individualized goals of this treatment program been evaluated periodically, and If goals were not reached, have alternative goals and approaches been developed? o If staff determine that continence cannot be Improved or maintained, has a plan been Implemented to prevent Incontinent-related complications and to maintain resident dignity (e.g., skin care will be provided after each episode of Incontinence, adult sanitary padding will be worn at all times when the resident is out of bed)?

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PP-97

TAG
NUMBER
F316 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
o Identify If resident triggers RAPs for urinary incontinence, ADL functional/rehabilitation potential, and dehydratlon/fluld maintenance. Consider whether the RAPs were used to assess causal factorB for decline, potential for decline. or lack of improvement.

P317 File

(e) Range of notion. Based on the comprehensive assessment of a resident, the facility must ensure that-- '
(1) A resident who enters the facility without a limited range of notion does not experience reduction in range of notion unless the resident's clinical condition demonstrates that a reduction in range of notion is unavoidable; and
(2) A resident with a United range of notion receives appropriate treatment and services to increase range of notion and/or to prevent further decrease in range of notion.

Intent: S483.25(e) The Intent of this regulation Is to ensure, that the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline of range of notion.
Guidelines: S«83.25(e) This corresponds to HDS section E; MDS 2.0 sections G and P when specified for use by the State.
"Range of notion (ROM)" is defined as the extent of movement of a joint.
The clinical condition that nay demonstrate that a reduction in RON is unavoidable Is: llnbs or digits immobilized because of injury or surgical procedures (e.g., surgical adhesions).
Adequate preventive care may Include active ROM perforated by the resident's passive ROM performed by staff; actlve-asslstlve ROM exercise performed by the resident and staff; and application of splints and braces, if necessary.
Exanples of clinical conditions that are the primary risk factors for a decreased range of notion are:
o Immobilization (e.g., bedfast); o Deformities arising out of neurological deficits (e.g., strokes, multiple sclerosis, cerebral palsy, and polio); and o Pain, spasms, and immobility associated with arthritis or late state Alzheimer's disease.
This clinical condition nay demonstrate that a reduction In ROM is unavoidable only if adequate assessment, appropriate care planning, and preventive care was provided, and resulted In limitation in ROM or muscle atrophy.

Rev. 2?«

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PP-9B

TAG NUMBER
F318 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Procedures: S483.25(e) For each resident selected for a comprehensive review, or focused review, as appropriate, who needB routine preventive care:
o Observe staff providing routine ROM exercises. Are they done according to the care plan?
Probes: S483.25(e) Is there evidence that there has been a decline in sampled residents' ROM or muscle atrophy that was avoidable?
o Was the resident at risk for decline in ROM? If so, why? o What care did the facility provide, including routine preventive measures that addressed the resident's unique risk factors (e.g., use nuscle strengthening exercises in residents with muscle atrophy}? o Was this care provided consistently?
For all sampled residents who have Halted ROH, what Is the facility doing to prevent further declines In ROM?
o Are passive ROM exercises provided and active ROM exercises supervised per the plan of care?
o Have care plan objectives identified resident's needs and has resident progress been evaluated?
o Is there evidence that care planning is changed as the resident's condition changes?
o Identify if resident triggers RAPs for ADL functional/rehabilitation potential, visual function, and coranunlcatlon. Consider whether the RAPs used to assess causal factors for decline, potential for decline or lack of improvement.

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PP-99

TAG NUMBER
F319

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(f) Mental and Paychoaoclal functioning.
Based on the comprehensive assessment of a resident, the facility must enBure that—
(1) A resident who displays nental or psychosoclal adjustment difficulty, receives appropriate treatment and services to correct the assessed problem; and

GUIDANCE TO SURVEYORS
Intent: S463.2S(f) The Intent of this regulation is that the resident receives care and services to assist hln or her to reach and maintain the highest level of nental and psychosoclal functioning.
Guidelines: 5483.25(f) This corresponds to MDS, sections 6, J and PI; MDS 2.0 sections B, F, E, and I when specified for use by the State.
"Mental and psychosoclal adjustment difficulties" refer to problems residents have In adapting to changes in life's circumstances. The former focuses on Internal thought processes; the latter, on the external manifestations of these thought patterns. Mental and psychosocial adjustment difficulties are characterized primarily by an overwhelming sense of loss of one's capabilities; of family and friends; of the ability to continue to pursue activities and hobbies; and of one's possessions. This sense of loss Is perceived as global and uncontrollable and Is supported by thinking patterns that focus on helplessness and hopelessness; that all learning and essentially all meaningful living ceases once one enters a nursing home. A resident with a mental adjustment disorder will have a Bad or anxious mood, or a behavioral symptom such as aggression.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM/IV), specifies that adjustment disorders develop within 3 months of a stressor (e.g., moving to another room) and are evidenced by significant functional Impairment. Bereavement with the death of a loved one is not associated with adjustment disorders developed within 3 months of a stressor.
Other manifestations of mental and psychosoclal adjustment difficulties may, over a period of time. Include:
o Impaired verbal communication; o Social isolation (e.g., loss or failure to have relationships); o Sleep pattern disturbance (e.g., disruptive change in sleep/rest pattern as related to one's biological and emotional needs); o Spiritual distress (disturbances In one's belief system); o Inability to control behavior and potential for violence (••„ aslve behavior directed at self or others); and o Stereotyped response to any stressor (I.e., the sane characteristic response, regardless of the stimulus).
Appropriate treatment and services tot; psychosoclal adjustment difficulties nay include providing residents with opportunities for self-governance; systematic orientation programs; arrangements to keep residents in touch with their conaunltles, cultural heritage, former lifestyle, and religious practices; and maintaining contact with friends and family.

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TAG NUMBER
F319 Cont.

REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Appropriate treatment for Dental adjustment difficulties may Include crisis intervention services; Individual, group or fanily psychotherapy, drug therapy and training In monitoring of drug therapy and other rehabilitative services. (See S4B3.45(a).)
Clinical conditions that nay produce apathy, malaise, and decreased energy levels that can be mistaken for depression associated with mental or psychosoclal adjustment difficulty are: (This list Is not all Inclusive.)
o Metabolic diseases (e.g., abnormalities of Benin glucose, potassium, calcium, and blood urea nitrogen, hepatic dysfunction);
o Endocrine diseases (e.g., hypothyroidlsm, hyperthyroidlsm, diabetes, hypoparathyroidlsm, hyperparathyroldlsm, Cushlng's disease, Addlson's disease);
o Central nervous system diseases (e.g., tuners and other mass lesions, Parkinson's disease, multiple sclerosis, Alzheimer's disease, vascular disease);
o Miscellaneous diseases (e.g., pernicious anemia, pancreatic disease, malignancy, infections, congestive heart failure);
o Over-medication with anti-hypertensive drugs; and o Presence of restraints.
Probes: $4B3.25(f)(1) For sampled residents selected for a comprehensive or focused review, determine, as appropriate, for those residents exhibiting difficulties In mental and psychosoclal adjustment:
o Is there a complete accurate assessment of resident's usual and customary routines?
o What evidence Is there that the facility makes accommodations for the resident's usual and customary routines?
o What programs/activities has the resident received to improve and maintain maximum mental and psychoBocial functioning?
o Has the resident's mental and psychosoclal functioning been maintained or improved (e.g., fewer symptoms of distress)? Have treatment plans and objectives been re-evaluated?
o Has the resident received a psychological or psychiatric evaluation to evaluate, diagnose, or treat her/his condition, if necessary?
o Identify if resident triggers RAPs for activities, mood state, psychosocial well-being, and psychotroplc drug use. Consider whether the RAPs were used to assess the causal factors for decline, potential for decline or lack of Improvement.
o How are mental and psychosoclal adjustment difficulties addressed in the care plan?
See S483.45(a), F406 for health rehabilitative services for mental illness and mental retardation.

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TAG NUMBER F319 Cont.
F32O

GUIDANCE 1O SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
(2) A resident whose assessment did not reveal a rental or psychoaoclal adjustaent 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.

GUIDANCE TO SURVEYORS
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 was unavoidable.
Procedures: S4B3.25(f)(2) For sampled residents whose assessment did not reveal a mental or psychosocial adjustment difficulty, but who display decreased social interaction or increased withdrawn, angry, or depressed behaviors, determine, as appropriate, was this behavior unavoidable:
Probes: S«83.25(f)(2) o Old the facility attempt to evaluate whether this behavior was attributable to
organic causes or other risk factors not associated with adjusting to living in the nursing facility?
o What care did the resident receive to maintain his/her mental or psychosocial functioning?
o Were Individual objectives of the plan of care periodically evaluated, and If progress was not made in reducing, maintaining, or Increasing behaviors that assist the resident to have his/her needs met, were alternative treatment approaches developed to maintain mental or psychosocial functioning?
o Identify if resident triggers RAPs for behavior problem, cognitive loss/dement ia, and psychosoclal well-being. Consider whether the RAPs were used to assess causal factors for decline, potential for decline or lack of improvement.
o Did the facility use the RAPs for behavior problems, cognitive loss/dementia, and psychosocial well-being to assess why the behaviors or change in mental or psychosocial functioning was occurring?

(g) Naso-gastrlc tubes.
Based on the comprehensive assessment of a resident, the facility nust ensure that'-

P321

ll) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastrlc tube unless the resident's clinical condition demonstrates that use of a

Intent: S«B3.25(g) The Intent of this regulation Is that a naso-gastrlc tube feeding Is utilized only after adequate assessment, and the resident's clinical condition makes this treatment necessary.
Guidelines: 5*83.25(g) This corresponds to MDS, section L; MDS 2.0 sections G, K, P when specified for use by the State.
This requirement is also Intended to prevent the use of tube feeding when ordered over the objection of the resident. Decisions about the appropriateness of tube feeding for a resident are developed with the resident or his/her family, surrogate or representative as part of determining the care plan.

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PP-102

TAG NUMBER F321 Cont.
F322

GUIDANCE TO SURVBYORS - LONG TERM CARB FACILITIES

REGULATION
naso-gaatric tube was unavoidable; and
(2) A resident who Is fed by a naso-gastrlc or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneunonla, diarrhea, vomiting, dehydration, netabollc abnormalities, and nasalpharyngeal ulcers and to restore, if possible, normal eating skills.

GUIDANCE TO SURVEYORS
Complications in tube feeding are not necessarily the result of Improper care, but assessment for the potential for complications and care and treatment are provided to prevent complications in tube feeding by the facility.
Clinical conditions demonstrating that nourishment via an naso-gastric tube is unavoidable include:
o The Inability to swallow without choking or aspiration. I.e., in cases of Parkinson's disease, pseudobulbar palsy, or esophageal dlverticulum;
o Lack of sufficient alertness for oral nutrition (e.g., resident comatose); and o Malnutrition not attributable to a single cause or causes that can be isolated and reversed. There Is documented evidence that the facility has not been able to maintain or Improve the resident's nutritional status through oral Intake.
Probes: S«83.25(g) For sampled residents who, upon admission to the facility, were not tube fed and now have a feeding tube, was tube feeding unavoidable? To determine if the tube feeding was unavoidable, assess the following:
o Did the facility identify the resident at risk for malnutrition? o What did the facility do to maintain oral feeding, prior to Inserting a feeding tube? Did staff provide enough assistance In eating? Did staff cue resident as needed, assist with the use of asslstive devices, or feed the resident, if necessary? o Is the resident receiving therapy to Improve or enhance swallowing skills, as need, is identified in the comprehensive assessment? o Was an assessment done to determine the cause of decreased oral Intake/weight loss or malnutrition? o If there was a dietitian consultation, were recommendations followed?
For all sampled residents who are tube fed: o Is the NG tube properly placed? o Are staff responsibilities for providing enteral feedings clearly assigned
(i.e., who administers the feeding, formula, amount, feeding intervals, flow rate)? o Do staff monitor feeding complications (e.g., diarrhea, gastric distension,
aspiration) and administer corrective actions to allay complications (e.g., changing rate of formula administration)?
o Are there negative consequences of tube use (e.g., agitation, depression, self-
extubatlon. Infections, aspiration and restraint use without a medical reason for the restraint)?
o When long term use is anticipated, is G tube placement considered?
Is the potential for complications from feedings minimized by: o Use of a small bore, flexible naso-gastrlc tube, unless contralndlcated; o Securely attaching the tube to the nose/face;

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PP-103

TAG NUMBER F322 Cont.
F323

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(h) Accidents. The facility mint ensure that(1) The resident environment remains as free of accident hazards as Is possible; and

GUIDANCE TO SURVEYORS
o Checking for correct tube placement prior to beginning a feeding or administering medications and after episodes of vomiting or sectioning;
o Checking a resident with a newly Inserted gastric tube for gastric residual volume every 2-4 hours until the resident has demonstrated an ability to enpty his/her stomach;
o Properly elevating the resident's head; o Providing the type, rate and volume of the feeding as ordered; o Using universal precautions and clean technique and as per facility/manufacturer'a directions when stopping, starting, flushing, and giving dedications through the tube; o Using hang tine recommendations by the manufacturer to prevent excessive microbial growth; o Implement the procedures to ensure cleanliness of supplies, e.g. Irrigating syringes changed on a regular bases as per facility policy. It is not necessary to change the Irrigating syringe each tlms it la used; o Using a pump equipped with a functional alarm (if pump used); o The facility's criteria for determining that • resident may be able to return to eating by mouth (e.g., a resident whose Parkinson's symptoms have been controlled); o There are sampled residents meet these criteria; o If so, the facility has assisted them In returning to normal eating; and o Identify if resident triggers RAPs for feeding tubes, nutritional status, and dehydration/fluid maintenance. Consider whether the RAPs were used to assess causal factors for decline, potential for decline and lack of improvement.
Intent: S483.25(h)(1) The Intent of this provision is that the facility prevents accidents by providing an environment that Is as free from hazards over which the facility has control.
Guidelines; S483.25(h)(1) This corresponds to HDS, section K2; HDS version 2.0 section J, when specified for use by the State.
"Accident hazards" are defined as physical features in the MF environment that can endanger a resident's safety, including but not limited to:
o Physical restraints (see physical restraints S483.13); o Poorly maintained resident equipment (e.g., wheelchairs or geri-chalrs with nonworklng brakes, and loose nuts and bolts on walkers); o Bathing facilities that do not have nonslip surfaces; o Hazards (e.g., electrical appliances with frayed wires, cleaning supplies easily accessible to cognltlvely impaired residents, wet floors that are not obviously labeled and to which access is not blocked);

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TAG NUMBER
'323 :ont.

REGULATION

GUIDANCE TO SURVEYORS - ICHO TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
o Handrails not securely fixed to the wall, difficult to grasp, and/or with sharp edges/splinters; and
o Water temperatures In hand alnkB or bath tubs which can scald or harm residents.
Probes: S483.25(h)(l) (See F221 for guidance concerning the use of bedralls.) See also $483.70(h) - Safe Bnvlronnent.

F324

(2) Bach resident receives adequate supervision and assistance devices to prevent accidents.

Intent S483.25(h)(2) The intent of this provision is that the facility identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents.
An "accident is an unexpected, unintended event that can cause a resident bodily injury. It does not include adverse outcomes associated as a direct consequence of treatment or care, (e.g., drug side effects or reactions).
Procedures; S483.25(h)(2) o If a resident(•) selected for a ccnprehenslve or focused review has hod an
accident, review the facility's Investigation of that accident and their response to prevent the accident froai recurring.
o Identify if the resident triggers RAPs for falls, cognitive loss/deswitla, physical restraints, and psychotropic drug use and whether the RAPs were used to assess causal factors for decline or lack of Improvement.
o If the survey tean identifies a number of or pattern of accidents, in Phase II sampling, review the quality assurance activities of the facility to determine the facility's response to accidents.
Probes; S«83.25(h)(2): 1. Are there a number of accidents or Injuries of a specific type or on any
specific shift (e.g., falls, skin Injuries)? 2. Are residents who smoke properly supervised and monitored? 3. If the survey teaa Identifies residents repeatedly Involved In accidents or
sanpled residents who have had an accident: a. Is the resident assessed for being at risk for falls? b. What care-planning and iaplenentation is the facility doing to prevent
accidents and falls for those residents identified at risk? c. How did the facility fit, and monitor, the use of that resident's assistlve
devices? d. How were drugs that may cause postural hypotension, dizziness, or visual
changes monitored?

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TAG NUMBER
F325
F326

GUIDANCE TO SURVEYORS - LONG TERM CARE F A C I L I T I E S

REGULATION
(1) Nutrition.
Based on a resident's comprehensive assessment, the facility m a t ensure that a resident—
(1) 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; and
(2) Receives a therapeutic diet when there Is nutritional problen.

GUIDANCE TO SURVEYORS

Intent S4B3.25(i) The Intent of this regulation Is to assure that the resident Maintains acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate intervention, when there is a nutritional problen.

Guidelines: S483.25(l) This corresponds to MDS, section L; MDS 2.0 sections G, I, J, K and L when specified for use by the state.

Parameters of nutritional status which are unacceptable Include unplanned weight loss as well as other indices such as peripheral edema, cachexla and laboratory tests indicating malnourlshmant (e.g., serum albumin levels).

Weight: Since Ideal body weight charts have not yet been validated for the institutionalized elderly, weight loss (or gain) Is a guide in determining nutritional status. An analysis of weight loss or gain should be examined In light of the individual's former life style as well as the current diagnosis.

Suggested parameters for evaluating significance of unplanned and undealred weight loss are:

Interval

Significant Loss

Severe Loss

1 month 3 months 6 months

5% 7.5% 10%

Greater than 5% Greater than 7.5% Greater than 10%

The following formula determines percentage of loss:

% of body weight loss - usual weight - actual weight x 100 usual weight
In evaluating weight loss, consider the resident's usual weight through adult life; the assessment of potential for weight loss; and care plan for weight management. Also, was the resident on a calorie restricted diet, or If newly admitted and obese, and on a normal diet, are fewer calories provided than prior to admission? Was the resident edematous when Initially weighed, and with treatment, no longer has edema? Hasthe resident refused food?

Suggested laboratory values are:

Albumin >60 yr.: 3.4 - 4.8 g/dl (good for ex slnlng marginal protein depletion) Plasma Transferrln >60 yr.:180-300 g/dl. (Rla t with iron deficiency anemia. More persistent indicator of protein status.)

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TAG NUMBER
F326 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Hemoglobin Males: 14-17 g/dl Females! 12-15 g/dl
Hematocrit Males: 41 - 53 Females: 36 - 46
Potassium 3.5 - 5.0 mBq/L Magnesium 1.3 - 2.0 mEg/L
Some laboratories nay have different "normals" Determine range for the specific laboratory.
Because sons healthy elderly people have abnormal laboratory values, and because abnormal values can ba expected in some disease processes, do not expect laboratory values to be within normal ranges for all residents. Consider abnormal values in conjunction with the resident's clinical condition and baseline normal values.
MOTE: There is no requirement that facilities order the tests referenced above.
Clinical Observations: Potential Indicators of malnutrition are pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, cachexla, bilateral edema, and muscle wasting.
Risk factors for malnutrition are:
1. Drug therapy that may contribute to nutritional deficiencies such as: a. Cardiac glycosldes; b. Diuretics; c. Anti-inflammatory drugs; d. Antacids (antacid overuse); e. Laxatives (laxative overuse); f. Psychotropic drug overuse;
* g. Anticonvulsanta; h. Antlneoplastic drugs; 1. PhenothiazineB; J. Oral hypoglycemlca;
2. Poor oral health status or hygiene, eyesight, motor coordination, or taste alterations;
3. Depression or dementia; 4. Therapeutic or mechanically altered diet; 5. Lack of accesB to culturally acceptable foods; 6. Slow eating pace resulting in food becoming unpalatable, or in staff removing the tray before resident haB finished eating; and 7. Cancer.

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F326 Cont.

REGULATIOH

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES
GUIDANCE TO SURVEYORS
Clinical conditions demonstrating that the maintenance of acceptable nutritional status nay not be possible Include, but are not Halted to:
o Refusal to eat and refusal of other Methods of nourishment; o Advanced disease (I.e., cancer, nalabsorption syndrome); o Increased nutritional/caloric needs associated with pressure sores and wound healing (e.g., fractureB, burns); o Radiation or chemotherapy; o Kidney disease, alcohol/drug abuse, chronic blood loss, hyperthyroldlsm; o Gastrointestinal surgery; and o Prolonged nausea, vomiting, diarrhea not relieved by treatment given according to accepted standards of practice.
" Therapeutic diet " means a diet ordered by a physician as part of treatment for a disease or clinical condition, to eliminate or decrease certain substances In the diet, (e.g., sodium) or to Increase certain substances in the diet (e.g., potassium), or to provide food the resident is able to eat (e.g., a mechanically altered diet).
Procedures: 5*83.25(1) Determine If residents selected for a comprehensive review or focused review as appropriate, have maintained acceptable parameters of nutritional status. Where Indicated by the resident's medical status, have clinically approprlata therapeutic diets been prescribed?
Probes: 1463.25(11 For sampled residents whose nutritional status is Inadequate, do clinical conditions demonstrate that maintenance of Inadequate nutritional status was unavoidable:
o Did the facility identify factors that put the resident at risk for\ malnutrition?
o Identify if resident triggered RAPs fox nutritional status, ADL functional/rehabilitation potential, feeding tubes, psychotroplc drug use, and dehydratlon/fluld balance. Consider whether the RAPs were used to aasess the causal factors for decline, potential for decline or lack of improvement.
o What routine preventive measures and care did the resident receive to address unique risk factors for malnutrition (e.g., provision of an adequate diet with supplements or modifications as indicated by nutrient needs)?
o Were staff responsibilities for maintaining nutritional status clear, including monitoring the amount of food the resident is eating at each meal and offering substitutes?
o Was this care provided consistently? o Were individual goals of the plan of care periodically evaluated and If not met, were alternative approaches considered or attempted?

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TAG NUMBER
F327

GUIDMICK TO SURVEYORS - U N O TERM CMtB FACILITIES

REGULATION
(j) HydratIon. The facility Bust provide each resident with sufficient fluid Intake to maintain proper hydratlon and health.

GUIDANCE TO SURVEYORS

Intent: S483.25(j) The Intent of this regulation Is to assure that the resident receives sufficient anount of fluids based on Individual needs to prevent dehydration.

Guidelines; S«83.25(j) This corresponds to MDS, section L; MDS 2.0 sections G, K, I, J and L when specified for use by the State.
"Sufficient fluid" means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid Intake) and maintain health. The amount needed Is specific for each resident, and fluctuates aa the resident's condition fluctuates (e.g., increase fluids if resident has fever or diarrhea).

Risk factors for the resident becoming dehydrated are: o Coma/decreased sensorium; o Fluid loss and Increased fluid needs (e.g., diarrhea, fever, uncontrolled
diabetes); o Fluid restriction secondary to renal dialysis; o Functional impairments that make it difficult to drink, reach fluids, or
ccamunlcate fluid needs (e.g., aphasia); o Desnntla in which resident forgets to drink or forgets how to drink; o Refusal of fluids; and o Did the MDS trigger RAPs on hydratlon? What action was taken based on the RAP?

Consider whether assessment triggers RAFs and are RAPs used to assess the causal factors for decline, potential for decline or lack of Improvement. A general guideline for determining baseline dally fluids needs is to multiply the resident's body weight in kg times 30cc (2.2 lbs - lkg), except for residents with renal or cardiac distress. An excess of fluids can be detrimental for these residents.

Procedures: S«83.25(j) Identify if resident triggers RAPs for dehydration/fluid loss.

alntenance, and cognitive

Probes: S«83.25(j) Do sampled residents show clinical signs of possible insufficient fluid Intake (e.g., dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever), abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium, chloride, sodium, albumin, transferrln, blood urea nitrogen (BUR), or urine specific gravity)? Has the facility provided residents with adequate fluid Intake to maintain proper hydratlon and health? If not:
o Did the facility Identify any factors that put the resident at risk of dehydration?

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TAG NUMBER F327 Cont.
F328

GUIDANCB TO SURVBYORS - LONG TERM CARB F A C I L I T I E S

REGULATION
(k) Special needs. The facility Bust ensure that residents receive proper treatment and care for the following special services:
(1) Injections;

GUIDAHCB TO SURVEYORS
o What care did the facility provide to reduce those risk factors and ensure adequate fluid Intake (e.g., keep fluids next to the resident at all times and assisting or cuing the resident to drink)? Is staff aware of need for maintaining adequate fluid intake? and
o If adequate fluid Intake is difficult to maintain, have alternative treatment approaches been developed, attempt to Increase fluid Intake by the use of popslcles, gelatin, and other similar non-liquid foods?
Intent: 463.25(fc) The Intent of this provision Is that the resident receives the necessary care and treatnent including nodical and nursing care and services when they need the specialized services as listed below.
Guidelines: $483.25(k) This corresponds to MDS section P; MDS 2.0 section P when specified by for use by the State.
The non-avallablllty of program funding does not relieve a facility of Its obligation to ensure that its residents receive all needed services listed in SlB19(b)(4)(A) of the Act for Medicare and S1919(b)(4)(A) of the Act for Medlcald. For services not covered, a facility is required to assist the resident in securing any available resources to obtain the needed services.
Probes: S4B3.25(k)(l) For sampled residents receiving one or more of these services within 7 days of the survey:
o Is proper administration technique used (i.e., maintenance of sterility; correct needle size, route)?
o Are there signs of redness, swelling, lesions from previous Injections? o If appropriate. Is resident observed for adverse reaction after the Injection? o Are syringes and needles disposed of according to facility policy and accepted practice (e.g.. Centers for Disease Control and Prevention and Occupational Safety and Health Administration guidelines)? o Do nursing notes indicate, as appropriate, the resident's response to treatment (e.g., side effects/adverse actions; problems at the injection Bite(s); relief of pain)?

(2) Parenteral and enteral fluids;

Probes: S4B3.25(k)(2) This corresponds to MDS, sections L4 and PI; MDS 2.0 sections L6 and PI when specified for use by the State.

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TAG NUMBER
F328 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
For residents selected (or a comprehensive review, or focused review as appropriate, receiving one or more ot these services within 7 days of the survey:
o Are there signs of Inflammation or Infiltration at the Insertion site? o If the IV site, tubing, or bottle/bag is changed, la sterile technique Maintained? o Is the rate of administration that which la ordered by the physician? Baa the resident received the amount of fluid during the paat 24 hours that he/she should have received according to the physician's ordera (allow flexibility up to ISOcc unless an exact fluid Intake is critical for the resident)?
Procedures: S483.25(k)(2) See $4B3.25(g) for enteral feedings (Includes gastrostomy).

(3) Coloatomy, ureterostoay, or ileostosy care;

Procedures: t483.25(k)(3) This corresponds to MDS 2.0 sections 0, B and P when specified for use by the State.
Identify If resident triggers RAPs for urinary incontinence, nutritional status, pressure ulcers (skin care).
Probes: S483.25(k)(3) o If appropriate, is the resident provided with self-care instructions? Does the
staff member observe and respond to any signs of resident'* diacomfort about the oatomy or ita care?
o Is akin surrounding the ostomy free of excoriation (abrasion, breakdown)? o If excoriation la present, does the clinical record Indicate an onset and a plan of care to treat the excoriation?

(4) Tracheoatomy care; Rev. 274

Procedures: $4»3.25(k)(4) (Includes care of the tracheoatomy site) This corresponds to MDS, sections N and P; MDS 2.0 sections M and P when specified for use by the State.
Observations for tracheostomy care are moat appropriate for residents with new or relatively new tracheostomiea, and may not be appropriate for those with tracheostomles of long standing.
Probes: S483.25(k)(4) (Includes care of the tracheostomy site) o Is the skin around the tracheoatomy clean and dry? Are the dressing and the
ties clean and dry, with the cannula secure?

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F328 Cont.

REGULATION

(5) Tracheal auctioning; (6) Respiratory care;

Rev. 274

GUIDAHCB TO SURVEYORS - LONG TBRM CARB FACILITIES
GUIDAHCB TO SURVEYORS
o Does the resident have signs of an obstructed airway or need for auctioning (e.g., secretions draining fraai south or tracheotomy; unable to cough to clear chest; audible crackles or wheezes; dyspnelc, restless or agitated)?
o If appropriate for a specific resident, is there a suction machine and catheter lmediately available?
o Is there an extra cannula of the correct size at the bedside or other place easily accessible if needed in an energency?
For sampled residents receiving one or sore of these services within 7 days of the survey:
o Is suction machine available for immediate use, clean, working, and available to a source of emergency power?
o Is there an adequate supply of easily acceaaible auction catheters?
Probes: S483.25(k)(5) This corresponds to MDS, section P; MDS 2.0 section P whan specified for uae by the State.
Procedures: S483.25(k)(6) This corresponds to MDS, section P; MDS 2.0 section P when epeclfled for use by the State.
Includes use of respirators/ventilators, oxygen, intermittent positive pressure breathing (IPPB) or other Inhalation therapy, pulmonary care, humidifiers, and other methode to treat conditions of the respiratory tract. Identify if resident triggers RAPs for dellrlua and dehydration/fluid maintenance.
Probes: S483.25(K)(6) For sampled residents receiving one or more of these services within 7 4- ' the survey:
o If oxygen Is in use, are precautions observed (e.g., no smoking signs; cylinders secured)?
o If the survey team observes a treatment being administered, is the resident encouraged and Instructed on how to assist in the treatment?
o Is the staff following the facility's protocol and/or written procedures for ventilators (e.g., functioning alarms); frequency of staff monitoring; monitoring of resident response (e.g., use of accessory muscles to breathe, cleanliness of mouth, Bkin irritation), and availability of manual resuscltators?
o If the resident is ventilator dependent, la routine machine maintenance and care done (e.g., water changes/tubing changes, safety checks on alarms, and machine functioning checks)?

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TAG NUMBER
F328 Cont.

REGULATION (7) Foot care; and

(8) Prostheses.

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Procedures: S483.25(fc)P) This corresponds with MDS, section M6; MDS 2.0 sections O and H when specified for use by the State.
Includes treatment of foot disorders by qualified persons, e.g., podiatrist, Doctor of Medicine, Doctor of Osteopathy), Including, but not limited, to corns, neuroma, calluses, bunions, heel spurs, nail disorders, preventive care, to avoid foot problems in diabetic residents and residents with circulatory disorders.
Probes: S483.25(k)(7) For residents selected for a comprehensive review, or focused review, as appropriate:
o Do nails, corns, calluseB, and other foot problems appear unattended; do these foot problems Interfere with resident mobility?
o Are residents able to see a qualified person when they want? o What preventive foot care do staff provide diabetic residents?
Probes: S4B3.25(K)(B) MDS 2.0 sections D, G, L, M and P when specified for use by the State. Includes artificial limbs, eyes, teeth.
For residents selected for a comprehensive review, or focused review, as appropriate: o Is resident able to put on the prosthesis by himself/herself or with some
assistance? o Are residents wearing their proatheaes? o Does the prosthesis fit cori<jctly? o Is skin/mucous membrane In contact with the prosthesis free of abrasions,
wounds, irritation?

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TAQ NUMBER

GUI DANCE TO SURVEYORS - LOHO TERM CARB FACILITIES

REGULATION
(1) Unnecessary drugs.
(1) General. Bach resident's drug reglaen Bust be free tram unnecessary drugs. An unnecessary drug la any drug when used:

GUIDANCE ID SUKVBYOR8
It Is important to note that these regulations and Interpretive guidelines are not •leant to cast a negative light on the use of psychopharaacologlcal drugs In long t e n care facilities. The use of psychopharaacological drugs can be therapeutic and enabling for residents suffering froa Mental Illnesses such as schizophrenia or depression. The goal of these regulations and guidelines Is to stimulate appropriate differential diagnosis of "behavioral ayaptoaa." so the underlying cause of the symptoms Is recognized and treated appropriately. This treatment say Include the use of environmental and/or behavioral therapy, as well as, psychopharmacological drugs. The goal of these regulations la also to prevent the use of psychopharaacological drugs when the "behavioral syaptoa" is caused by conditions such as< (1) environmental stressors (e.g., excessive heat, noise, overcrowding, etc.); (2) psycbosocial stressors (e.g., abuse, taunting, not following a resident's customary dally routine); or (1) treatable nodical conditions (e.g., heart disease, diabetes, Chronic Obstructive Pulmonary Disease). Behavioral syaptoas resulting frcsi these causes should not be "covered up" with sedating drugs.
An excellent differential diagnostic process for behavioral symptoms Is described in the RAP on Behavior Problems (soon to be known as behavioral symptoms). Also, a number of very practical manuals are now available that teach nursing personnel how to assess and provide Individualized care for behavioral syaptoa*, which leads to the avoidance of physical restraints, and unnecessary drugs. These manuals Include, but are not Halted to, the following list:
1. "Managing Behavior Problems In Nursing Boas Residents" Department of Preventive Medicine Vanderbllt University School of Medicine
2. "Retrain, Don't Restrain" American Association of Bones and Services for the Aging, or The American Health Care Association
3. "Innovations In Restraint Reduction" American Health Care Association
4. "Avoiding Physical Restraint Use: New Standards In Care", and "Avoiding Drugs Used as Chemical Restraints: New Standards in Care" National Citizens' Coalition for Nursing Borne Reform

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TAG HUMBER
F329

GUIOAHCB TO SURVEYORS - LONG TBBN CARS FACILITIES

REGULATION
(I) In excessive dose (Including duplicate therapy); or
(II) for excessive duration; or
(III) without adequate monitoring; or
(lv) without adequate indications for Its UBe; or
(v) in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(vl) any combinations of the reasons above.

GUIOAHCB TO SURVEYORS

Guidelines: S483.25(l)(l)

A. Long-Acting Benzodiazepine Drugs

The following long-acting benzodiazepine drugs should not be used In residents unless an attempt with a Bhorter-acting drug (i.e., those listed under B. Benzodiazepine or Other Anxlolvtic/Sedatlve Drugs, and under C. Drugs Used for Sleep Induction) has failed.

After an attenpt with a shorter-acting benzodiazepine drug has failed, a long-acting benzodiazepine drug should not be used unless:

o Evidence exists that other possible reasons for the resident's distress have been considered and ruled out. (See $463.25(1)(l)(lv);)
o Its use results in naintenance or inprovenent in the resident's functional status (to evaluate functional status, see S483.25(a) through (k) and NDS, sections B through P; MDS 2.0 sections B through F ) . (See S483.25( 1)(1)(iv);)
o Dally use Is less than four continuous months unless an attenpt at a gradual dose reduction is unsuccessful (see S483.2S(1)(1)(11)); and
o Its use Is less than, or equal to, the following listed total dally doses unless higher doses (as evidenced by the resident's response and/or the resident's clinical record) are necessary for the naintenance, or improvement in the resident's functional status. (See S483.2S(1) (1)(i).)

LONG-ACTING BENZODIAZEPINES

NOT HAXIMUM DOSES

GENERIC

BRAND

DAILY ORAL DOSAGB

Flurazepan Chlordiazepoxide Clorazepate Diazepau Clonazepam Quazepan Ualazepam

(Da Inane) (Llbrlua) (Tranxene) (Vallum) (Klonopln) (Doral) (Paxlpan)

15ng 20ng I5»g 5ng 1.5mg 7.5ng 40ng

NOTES: When diazepan Is used for neuronuscular syndromes (e.g., cerebral palsy, tardive dysklnesla or seizure disorders), this guideline does not apply.

When long-acting benzodiazepine drugs are being used to withdraw residents fro short-acting benzodiazepine drugs, this guideline does not apply.

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TAG NUMBER
F329 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

When clonazepam la used In bl-polar disorders, management of tardlve dyaklneala, nocturnal myoclonus or seizure disorders, this guideline does not apply.
The dally doses listed under long-acting Benzodiazepines are doses (usually administered in divided doses) for "geriatric" or "elderly" residents. The facility is encouraged to Initiate therapy with lower doses and whan necessary only gradually Increase doses. The facility Bay exceed these doses if it provides evidence (see Survey Procedures and Probes) to show why it was necessary for the maintenance or improvement in the resident's functional status.
"Duplicate drug therapy" is any drug therapy that duplicates a particular drug effect on the resident. For example, any two or more drugs, whether from the same drug category or not, which have a sedative effect. Duplicate drug therapy should prompt the facility to evaluate the resident for accumulation of the adverse effects.
For drugs in this category, a gradual doae reduction should be attempted at leaat twice within one year before one can conclude that the gradual dose reduction Is clinically contralndicated.

H. Benzodlazepine or other Anxiolytlc/Sedatlva Druga
Use of listed Anxiolytlc/Sedatlva drugs for purposes other than sleep induction should only occur when:
1. Evidence exists that other possible reasons for the resident's distress have been considered and ruled out. (See S4B3.25(l)(l)(lv);)
2. Use results In a maintenance or improvement in the resident's functional status, (to evaluate functional status, see S483.25(a) through (k) and MIS, sections B through P; MDS 2.0 sections B through P ) . (Sea $4B3.25(l)(l)(lv);)
3. Dally use (at any dose) is IBSB than four continuous months unless an attempt at a gradual tkme reduction Is unsuccessful. (See S*83.25(l)(1)(11);)
4. Use Is for one of the following indicationa as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-1V) or subsequent editions. (See S4B3.25(l)(l)(iv):)
a. Generalized anxiety disorder; b. Organic mental syndromes (now called "delirium, dementia, and amnestic and other cognitive disorders" by DSN-IV) with associated agitated behaviors, which are quantitatively and objectively documented (see note number one) which are persistent and not due to preventable reasons and which constitute sources of distress or dysfunction to the resident or represent a danger to the resident or others;

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REGULATION

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GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

GUIDANCE TO SURVEYORS

c. Panic disorder; d. Symptomatic anxiety that occurs In residents with another diagnosed psychiatric disorder (e.g., depression, adjustment disorder); and S.o Use is equal to or less than the following listed total dally doses, unless higher doses (as evidenced by the resident response and/or the resident's clinical record) are necessary for the inprovenent or aaintenance in the resident's functional status. (See S483.2S(1)(1)(1), F342.)

NOT MAXIMUM DOSES

GENERIC

BRAND

Lorazepam

(Atlvan)

Oxazepam

(Serax)

Alprazolam

(Xanax)

Bstazolam

(ProSoa)

OTHER ANXIOLYTIC AND SEDATIVE DRUGS

Dlphenhydramine

(Benadryl)

Hydroxyzlne

(Atarax.Vlstarll

Chloral Hydrate

(Many Brands)

DAILY ORAL DOSAGE 2 mg 30mg 0.75mg 0.5mg
50mg 50mg 750mg

NOTES:

1. This documentation Is often referred to as "behavioral Monitoring charts" and is necessary to assist In: (a) assessing whether the resident's behavioral symptom Is In need of BOBS fora of Intervention, (b) determining whether the behavioral symptom Is transitory or permanent, (c) relating the behavioral symptom to other events in the resident's life in order to learn about potential causes (e.g., death in the family, not adhering to the resident's customary dally routine), (d) ruling out environmental causes such as excessive heat, noise, overcrowding, etc., (e) ruling out medical causes such as pain, constipation, fever, Infection. For a more complete description of behavioral monitoring charts and how they can assist In the differential diagnosis of behavioral symptoms see the RAP on behavior problems (soon to be Know as behavioral symptoms).
2. The dally doses listed under Short-Acting Benzodlazepines are doses (usually administered in divided doses) for "geriatric" or "elderly" residents. The facility Is encouraged to Initiate therapy with lower doses and, when necessary, only gradually Increase doses. The facility may exceed these doses if it provides evidence (see survey procedures and probes) to show why It was necessary for the maintenance or improvement in the resident's functional status.
3. For drugs in this category, a gradual dose reduction should be attempted at least twice within one year before one can conclude that a gradual dose reduction Is clinically contralndlcated.
4. Diphenhydramlne, hydraxyzlne and chloral hydrate are not necessarily drugs of choice for treatment of anxiety disorders. They are only listed here In the event of their potential use.

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F329 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

C. Drugs for Sleep Induction

Drugs used for sleep Induction Bhould only be used If:

o Evidence exists that other possible reasons for Insomnia (e.g., depression, pain, noise, light, caffeine) have been ruled out. (See S483.25(l)(l)(lv))j
o The use of a drug to induce sleep results In the maintenance or laproveasnt of the resident's functional status (to evaluate functional status, see S4B3.25(a) through (k) and KDS, Sections B through P; M>S 2.0 sections B through F ) . (See $483.25(l)(l)(iv);)
o Dally use of the drug Is less than ten continuous days unless an attempt at a gradual dose reduction is unsuccessful. (See S*83.25(l)(l)(ll);) and
o The dose of the drug is equal or less than the following listed doses unless higher doses (as evidenced by the resident response and/or the resident's clinical record) are necessary for maintenance or improvement in the residents functional status. (Sea S4B3.25(1)(1)(1).)

HYPNOTIC DRUGS

HOT MAXIMUM DOSES

GENERIC Temazepaa Trlaxolam Lorazepaa Oxazepam Alprezolam Bstazolam Dlphenhydramlne Hydroxyzine Chloral Bydrate Zolpidem

BRAND (Reatorll) (Halclon) (Atlvan) (Serax) (Xanax) (ProSom) (Benadryl) (Atarax,Vlstarll) (Many Brands) (Aablen)

DOSB BY MOUTH 7.5mg 0.125mg
1*9
ISmg O.25mg 0.5mg 25mg 50ng 500mg
5»g

NOTES: 1. Diminished sleep in the elderly is not necessarily pathological.

2. The doses listed are doses for "geriatric" or "elderly" residents. Toe facility is encouraged to initiate therapy with lower doses and when necessary only gradually increase doses. The facility may exceed these doses if It provides evidence (see survey proce^.res and probes) to show why it was necessary for the maintenance or improvement in the resident's functional status.

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GUIDMCE TO SURVEYORS - LOSO TBRM CARE FACILITIES

GUIDANCE TO SURVEYORS

3. Dlphenhydranine, hydroxyzine, and chloral hydrata ara not necasaarlly drugs of choice Cor sleep disorder*. They ara listed here only in the event of their potential use.

I. For drugs In this category, a gradual dose reduction should be attespted at least three times within six ninths before one can conclude that a gradual dose reduction is clinically contraindlcated.

D. Miscellaneous Hypnotlc/Sedatlve/Anxiolytic Drugs

The Initiation of the following hypnotic/sedatlve/anxlolytlc drugs should not occur in any dose for any resident. (See Notes for exceptions.) Residents currently using these drugs or residents admitted to the facility while using these drugs should receive gradual dose reductions as part of a plan to eliminate or nodify the syaptosa for which they are prescribed. A gradual dose reduction should be atteapted at least twice within one year before one can conclude that the gradual dose reduction Is clinically contraindlcated. Newly adaltted residents using these drugs aay have a period of adjustment before a gradual dose reduction is attempted.

(CAUTION: DO NOT ENCOURAGE RAPID WITHDRAWAL OF THBSE DRUGS. THIS MIGHT RESULT I> SEVERE PHYSIOLOGICAL WITHDRAWAL SYMPTOMS. )

BARBITURATES (EXAMPLES)
GENERIC Amobarbltal Butabarbltal Pentobarbital Secobarbltal Phenobarbltal Amobarbltal-Secobarbltal Barbiturates with
other drugs

BRAND (Aaytal) (Butlsol, others) (Neabutal) (Seconal) (Many Brands) (Tuinal) (e.g., Fiorlnal)

MISCELLANEOUS BYPNOTIC/SEDATIVE/ANXIOLYTICS

GENERIC Glutethlsilde Methprylon Ethch lorvynol Meprobaaate Paraldehyde

BRAND (Dorlden) (Noludar) (Placldyl) (Equinal, Miltown) (Many Brands)

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QUIDMICE TO SURVEYORS

NOTES: 1. Any sedative drug Is excepted fro» this Guideline when used as a single dose sedative for dental or nodical procedures.
2. Phenobarbital la excepted froa this Guideline when used In the treatment of seizure disorders
3. When Miscellaneous Hypnotic/Sedative/Anxiolytlc Drugs are used outside these Guidelines they Bay be unnecessary drugs aa a result of Inadequate indications for use. (See Survey Procedures and Probes.)

B. ANTIPSYCHOTIC DRUG DOSAGE LEVELS

The following exaaplea of antlpsychotlc drugs should not be used in excess of the listed doses for residents with organic snntal syndroass (now called "dellrlua, dementia, and aanestlc and other cognitive disorders" by D8M-IV) unless higher doses (as evidenced by the resident's response or the resident's clinical record) are necessary to sialntaln or improve the resident's functional status. To evaluate functional atatua, see SS483.25(a) through (k) and M>8, sections B through P| MDS 2.0 sections B through P.

AHTXFSYCHOTIC DRUGS
OEMKHIC Chlorpronazlne ProBszine Trifluproaazlne Thioridazine Mesoridazine Acetophenazlne Perphenazlne Fluphenazlne
Trlfluoperazlne Chlorprothixene Thlothixene Haloperidol Mollndone Loxaplne Clozaplne Prochlorperazlne Risperldone

BBAHD (Thorazlne) (sparlne) (Vesprln) (Mellar11) (Serentil) (Tlndal) (Trilafon) (Prolixln,
Penltll) (Stelaxlne) (Taractan) (Mavane) (Baldol) (Hoban) (Loxltane) (Clozarll) (Coapaxlne) (Risperdal)

MOT MAXIMUM DOSES DAILY AHTIPSYCBOTIC ORAL DOSAGE FOR RESIDENTS WITH ORGANIC MENTAL SYNDROMES MO/DAY
75 150 20 75 25 20 8
4 8 75 7 4 10 10 50 10
4

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GUIDANCE 10 SURVEYORS - LONG TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
NOTBBnUdefltB *i*msoadstfed —nataTaiAiniliiiswi ((•mliijl liis)iimsHilU>ii.lirsMn11llmV iismlii) for Aanestlc and other cognitive disorders by DSM-IV). The facility la encouraged to Initiate therapy with lower doses and when necessary only gradually Increase doses. The facility nay exceed these doses if It provides evidence (sea Survey Procedures and Probes) to show why it Is necessary for the maintenance or Improvement in the resident's functional status.
2. The "specific conditions" for use of antlpsychotlc drugs ara listed under the Guideline for S$483.25(l)(1) and (2).
3. The dose of prochlorperazlne nay be exceeded for short tern (savan day) treatment of nausea and vomiting. Residents with nausea and voaiting secondary to cancer or cancer chemotherapy can also be treated with higher doses for longer periods of tine.
4. When antipsychotlc drugs are used outside these Guidelines without valid reasons for the higher dose, they may be deemed unnecessary drugs am a result of excessive dose.
F. Monitoring for Antlpsychotlc Drug Side Effects
The facility assures that residents who are undergoing antipsychotlc drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on the following:
o Tardlva dyskinesla; o Postural (orthostatic) hypotension; o Cognitive/behavior Impairment; o Akathisla; and o Parkinsonism.
NOTES: For a nore detailed description of these aide effects, see the RAP: Psychotroplc Drug Use, pg. F-72, Resident Assessment Instrument Training Manual and Resource Guide, 1990 edition.
When antlpsychotlc drugs are used without Monitoring for these side effects, they may be unnecessary drugs because of inadequate monitoring.

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GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
QUIDAHCB TO SURVBICRS
0. Antldepressant Drugs
The under diagnosis and under treatment of depression In nursing hoaes has been documented In a Journal of the American Medical Association paper entitled "Depression and Mortality In the Nursing H o w " (JAMA, February 27, 1991-vol. 265, No. 8). HCFA continues to support the accurate identification and treatment of depression in nursing

The surveyor should not urge a facility to use behavioral •onltoring charts (e.g., documenting quantitatively (nuaber of episodes) and objectively (e.g., withdrawn behavior such as staying in their rooa, refusal to speak, etc.) when antldepressant drugs are used In nursing hones. Such charts are prosnted In the Interpretative guidelines for antipsychotlc and benzodlazaplne and other anxiolytic/sedatlve drugs (see pages P-185 and P-176), but NOT for antldepressant drugs. These charts Bay be helpful for Monitoring the effects of antldepressant drugs in nursing h o w s , but they may place additional paperwork burden on the facility and thus act as a deterrent to the appropriate diagnosis and treatment of this condition.

The following is a list of cooannly used antldepressant drugs: Antldepressant Drugs

Generic Hasa

Brand

Amltrlptyllne* Aaoxapine Deslpranlna Doxepin* Iaipraalne* Maprotlline Nortrlptyline Protriptyllne Trialpraalne* Flucocetine Sertraline

(Blavll) (Asendin) (Norpraaln, Pertofrana) (Slnequan) (Tofranll) (Ludieail) (Avantyl, Paaelor) (Vivactil) (Sunontil) (Prozac) (Zoloft)

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Generic Name
Trazodone Clomipranlne* Faroxetine Buproplon Isocarboxazld* Phenelzlne* Tranylcyproslne* Venlafaxlne Nefazodone Fluvoxamlne

Antldepresaant Drugs (Cont.)
Brand Nane
(Desyrel) (Anafranll) (Paxll) (Wellbutrln) (Marplan) (Nardil) (Farnate) (Effexor) (Serzone) (Luvox)

* These are not necessarily drugs of choice for depression In the elderly, They are listed here only in the event of their potential use.
Procedures: S483.25(l)(l) Consider drug therapy "unnecessary" only after determining that the facility's use of the drug les
o In excessive dose (Including duplicate drug therapy); o For excessive duration; o Without adequate monitoring; o Without adequate indications of use; o In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or o Any combination of the reasons above.
Allow the facility the opportunity to provide a rationale for the use of drugs prescribed outside the preceding Guidelines. The facility Bay not justify the use of a drug prescribed outside the proceeding Guidelines solely on the basis of "the doctor ordered it." This justification would render the regulation meaningless. The rationale must be based on sound risk-benefit analysis of the resident's syaptoas and potential adverse effects of the drug.
Examples of evidence that would support a justification of why a drug is being used outside these Guidelines but in the best Interests of the resident may include, but are not limited to:

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REGULATIOM
(2) Antlpaychotlc Drugs Based on a comprehensive aasessnent of a resident, the facility oust ensure that--

GUIDANCE TO SURVEYORS

o A physician's note Indicating for exanple, that the dosage, duration. Indication, and monitoring are clinically appropriate, and the reasons why they are clinically appropriate; this note should demonstrate that the physician has carefully considered the risk/benefit to the resident in using drugs outside the Guidelines;
o A medical or psychiatric consultation or evaluation (e.g.. Geriatric Depression Scale) that conflms the physician's judgment that use of a drug outside the Guidelines is In the best Interest of the resident;
o Physician, nursing, or other health professional documentation indicating that the resident Is being monitored for adverse consequences or complications of the drug therapy;
o Documentation confirming that previous attempts at dosage reduction have been unsuccessful;
o Documentation (including HDS documentation) showing resident's subjective or objective improvement, or maintenance of function while taking the medication;
o Documentation showing that a resident's decline or deterioration is evaluated by the interdisciplinary team to determine whether a particular drug, or a particular dose, or duration of therapy, may be the cause;
o Documentation showing why the resident's age, weight, or other factors would require a unique drug dose or drug duration, indication, monitoring; and
o Other evidence the survey team may deem appropriate.

If the survey team determines that there is a deficiency in the use of antlpsychotlcs, cite the facility under either the "unnecessary drug" regulation or the "antlpaychotlc drug" regulation, but not both.

NOTE:

The unnecessary drug criterion of "adequate Indications for use" does not simply mean that the physician's order must Include a reason for using the drug (although such order writing Is encouraged). It means that the resident lacks a valid clinical reason for use of the drug as evidenced by the survey evaluation of some, but not necessarily all, of the following: resident assessment, plan of care, reports of significant change, progress notes, laboratory reports, professional consults, drug orders, observation and interview of the resident, and other information.

Guidelines: S483.25(l)(2)(l) For a list of examples of commonly used antlpsychotlc drugs, Guideline for S4B3.25 (1)(1), Unnecessary drug.

E. under Interpretive

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CUIDANCB 1O SURVEYORS - LONG TERM CUBE FACILITIES

REGULATION
(1) Residents who have not used antipaychotic drugs are not given these drugs unless antlpsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented In the clinical record; and

GUIDANCE TO SURVEYORS
Antlpsychotic drugs should not be used unless the clinical record docunenta that the resident has one or more of the following "specific conditions":
1.Schizophrenia; 2.Schiro-affective disorder; 3.Delusional disorder; 4.Psychotic mood disorders (Including mania and dapreaaion with psychotic features); b.Acute psychotic episodes; 6.Brief reactive psychosis; 7.Schizophreniforn disorder; 8.Atypical psychosis; 9.Tourette's disorder; lO.Buntington's disease; 11.Organic mental syndromes (now called delirium, dementia, and amnestic and other cognitive disorders by DSM-IV) with associated psychotic and/or agitated behaviors:
a. Which have been quantitatively and objectively documented. This documentation la necessary to assist in: (1) assessing whether the resident's behavioral symptom is in need of some form of intervention, (2) determining whether the behavioral symptom Is transitory or permanent, (3) relating the behavioral symptom to other events in the resident's life in order to learn about potential causes (e.g., death in the family, not adhering to the resident's customary daily routine), (4) ruling out environmental causes such as excessive heat, noise, overcrowding, (5) ruling out medical causes such as pain, constipation, fever, Infection. For a more complete description of behavioral monitoring charts and how they can aaalat in the differential dlagnoals of behavioral symptoms see the RAP on behavior problems (soon to be known as behavioral symptoms); and
b.Which are persistent, and
c.Which are not caused by preventable reasons; and
d.Which are causing the resident to:
(l)Present a danger to himself/herself or to others, or
(2)Contlnuously scream, yell, or pace If these specific behaviors cauae an impairment in functional capacity (to evaluate functional capacity, see $483.25 (a) through (k) and MDS sections B through P; MDS 2.0 sections B through P ) , or

Rev. 274

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GUIDANCE TO SURVEYORS - LOHO TERM CAR8 FACILITIES

REGULATION
(11) Residents who use antlpsychotlc drugs receive gradual dose reductions, and behavioral Interventions, unless clinically contraindicatad, in an effort to discontinue these drugs.

GUIDANCE TO SURVEYORS
(3)Bxperlence psychotic synptons (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as screwing, yelling, or pacing but which cause the resident distress or Impairment in functional capacity; or
12. Short-term (7 days) syaptonatic treatment of hiccups, nausea, vaulting or pruritus. Residents with nausea and voaltlng secondary to cancer or cancer chemotherapy can be treated for longer periods of tine.
Antlpsychotlcs should not be used If one or Bore of the following is/are the only indication:
o Wandering, o Poor self care, o Restlessness, o Inpalred memory, o Anxiety, o Depression (without psychotic features), o Insomnia, o Unsoclabillty, o Indifference to surroundings, o Fidgeting, o Nervousness, o Uncooperatlveness, or o Agitated behaviors which do not represent danger to the resident ox others.
Guidelines: S483.25(l)(2)(ll) Residents Bust, unless clinically contralndlcated, have gradual dose reductions of the antipsycbotic drug. The gradual does reduction should be under close supervision. If the gradual dose reduction is causing an adverse effect on the resident and the gradual dose reduction la discontinued, documentation of this decision and the reasons for It should be Included in the clinical record. Gradual dose reductions consist of tapering the resident's dally dose to determine If the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether.
"Behavioral Interventions" nsans nodifleatlon of the resident's behavior or the resident's environment. Including staff approaches to care, to the largest degree possible to acconaodate the resident's behavioral symptoms.

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GUIDANCE TO 8URVEYOR8 - LONG TERM CARS FACILITIES
GUIDANCE TO SURVEYORS
"Clinically contraindicated" means that a resident REED HOT UNDERGO A gradual dose reduction" or "behavioral interventions" IF:
1. The resident has a "specific condition" (aa Hated under one through tan on page P-185) and has a history of recurrence of psychotic symptoms (e.g., delusions, hallucinations), which have been stabilized with a maintenance dose of an antlpsychotic drug without incurring significant side effects,
2. The resident has organic mental syndrome (now called--"Delirium, Dementia, and Amnestic and other Cognitive Disorders" by DSM IV) and has had a gradual dose reduction attenpted TWICE in one year and that attempt resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation In the gradual dose reduction, or a return to previous dose reduction waa necessary; or
3. The resident's physician provides a Justification why the continued use of the drug and the dose of the drug is clinically appropriate. This justification should Include: (a) a diagnosis, but not simply a diagnostic label or code, but the description of symptoms, (b) a discussion of the differential paychlatric and aedlcal diagnosis (e.g., why the resident's behavioral symptom is thought to be a result of a dementia with associated psychosis and/or agitated behaviors, and not the result of an unrecognized painful Medical condition or a psychosocial or environmental stressor), (c) a description of the Justification for the choice of a particular treatment, or treatments, and (d) a discussion of why the present dose is necessary to aanage the symptane of the resident. This information need not necessarily be in the physician's progress notes, but oust be a part of the resident's clinical record.
Procedures; S483.25(1)(2)(1) and (11) In determining whether an antlpsychotic drug Is without a specific condition or that gradual dose reduction and behavioral Interventions have not been performed, allow the facility an opportunity to Justify why using the drug outside the Guidelines is in the best Interest of the resident.
Examples of evidence that would support a justification of why a drug la being used outside the Guidelines, but in the best interest of the resident, may include, but are not limited to:
o A physician'8 note indicating that the use of the drug, or continued use of the drug is clinically appropriate, and the reasons why this use is clinically appropriate. This note oust demonstrate that the physician haa carefully considered the risk/benefit to the resident In using drugs outside these Guidelines.
o A nodical or psychiatric consultation or evaluation (e.g.. Geriatric Depression Scale) that confirms the physician's Judgment that use of a drug outside the Guidelines is in the best Interest of the resident.

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GUIDANCB TO SURVEYORS
o Physician, nursing, or other health professional documentation indicating that the resident is being monitored for adverse consequences or complications of the drug therapy,
o Documentation confining that previous attempts at dosage reduction have been unsuccessful,
o Documentation (Including MDS documentation) showing resident's subjective or objective Improvement or maintenance of function while taking the medication,
o Documentation showing that a resident's decline or deterioration is evaluated by the interdisciplinary tean to determine whether a particular drug, or a particular dose, or duration of therapy, may be the cause,
o Documentation showing why the resident's age, weight, or other factors would require a unique drug dose or drug duration,
o Other evidence the surveyor may deem appropriate.
while the facility can refer to a physician's justification as a valid Justification for use of a drug, it may not justify the use of a drug. Its dose. Its duration, solely on the basis that "the doctor ordered It."
If the survey team determine that there Is a deficiency in the use of antlpsychotlcs, cite the facility under either the "unnecessary drug" regulation or the "antlpaychotlc

F332 F333

(a) Medication Errors. The facility Bust ensure that-*
(1) It is free of medication error rates of five percent or greater; and
(2) Residents are free of any significant medication errors.

Rev. 274

Guidelines: S483.25(n) "Medication error" means a discrepancy between what the physician ordered and what the survey team observe during an observation of an Individual or several different individuals administering drugs to residents In the facility.

"Significant medication error" means one which causes the resident discomfort or jeopardizes his or her health and safety. Criteria for judging significant medication errors as well as examples are provided under significant and non-slgniflcant medication errors.

"Medication error rate" is determined by calculating the percentage of errors. The

numerator in the ratio Is the total number of errors that the survey team observes,

both significant and nonsignificant. The denominator Is called "opportunities for

errors" and includes all the doses the survey team observed being administered plus the

doses ordered but not administered. The equation for calculating a medication error

rate is as follows:

Medication Error Rate -

Number of Errors Observed divided by the Opportunities

for Errors X 100.

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GUIDANCE TO SURVEYORS - LONG TERM CAKE FACILITIES
GUIDANCE TO SURVEYORS
"Medication error rate" --A medication error rate of 5% or greater Include* both significant and nonsignificant medication errors. It Indicates that the facility has aystenlc problems with lta drug distribution system and a deficiency should be written.
But the error rate must be St or greater. Rounding of a lower rate (e.g., 4.6%) to a 5% rate is not permitted.
Significant and Nonsignificant Medication Errors
"Determining Significance".--The relative significance of Dedication errors is a natter of professional judgment. Follow three general guidelines in determining whether a Dedication error la significant or not:
o Resident Condition.—The resident's condition Is an important factor to take into consideration. For example, a potent diuretic erroneously adnlniatered to a dehydrated resident may have serious consequences, but If administered to a resident with a normal fluid balance may not. If the resident's condition requires rigid control, a single Biased or wrong dose can be highly significant.
o Drug Category.--If the drug Is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxlclty. This is eapeclally important if the half life of the drug is short. Examples of drug categories which require titration of resident blood levels Include anticonvulaants, anticoagulants, and antiarrhythmlc, anti-anginal and antlglaucoma agents.
o Frequency of Error.—If an error is occurring with any frequency, there Is more reason to classify the error as significant. For example, if a resident's drug was omitted several times, as verified by reconciling the number of tablets delivered with the number administered, classifying that error as significant would be more in order. This conclusion should be considered In concert with the resident's condition and the drug category.
Examples of Significant and Non-Slgnlfleant Medication Errors.--Examples of medication errors that have actually occurred In long tern care facilities are presented below. Some of these errors are identified as significant. This designation is based on expert opinion without regard to the atstus of the resident. Most experts concluded that the significance of these errors. In and of themselves, have a high potential for creating problems for the typical long term care facility resident. Those errors Identified as nonsignificant have also been designated primarily on the basis of the nature of the drug. Resident status and frequency of error could classify these errors as significant.

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GUIDAHCB TO SURVEYORS

Omissions (Drug ordered but not administered at least once):

DRUG ORDER

SIGNIFICANCE

Haldol lag BID

NS*

Motrin 400ng TID

NS

Quinldlne 200mg TID

S"

Tearisol Drops 2 both eyes TID

NS

Indocin 25ng TID pc

NS

Lioresal lOng TID

NS

Thorazine 25mg BID

MS

Ampicillin 500mg TID

NS

Hetamucll one packet BID

NS

Inderal 20ag one every 6 hours

S

Multlvitanin one daily

NS

Mylanta Susp. one ox., TID AC

NS

Hitrol Olnt. one inch

S

Llbrlua lOng one TID

NS

Cortlsporin Otic drop 4 to 5

left ear QID

NS

Aldactone 25mg QID

NS

Not Significant Significant

Unauthorized Drug (Drugs administered without a physician's order):

DRUG ORDER

SIGNIFICANCE

Feosol

NS

Counadln 4ng

S

Lasix 40BKJ

S

Zylopria lOOmg

NS

Tylenol 5 gr

NS

Trlavll 4-25

NS

Multlvitamins

NS

Motrin 400ng

NS

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GUIDANCE TO SURVEYORS

Wrong Dose: DRUG ORDER
laoptocarplne 1% one drop In the left eye TID
Bplnal 1% one drop In eyes BID
Dlgoxln 0.125mg everyday
Laalx 2Oaxj one dally
Aaphojel 30cc QID

ADMINISTERED
Three drops In each eye
Three drops In each eye
0.25ng
40ng
IScc

SIGNIFICANCE
NS HS B HS HS

Slow K two TID

one

HS

Dllantln 125 SUSP

2cc

12cc

S

Laslx 40ng dally

20«g

NS

Wrong Route of Administration:

DRUG ORDER

ADMINISTERED

SIGNIFICANCE

Byderglne 0.5 ng

Resident

SL.L BID

Swallowed

NS

Cortlsporln Otic

Left Eye

Drops 4 to 5 left

ear QID

S

Wrong Dosage Forn:

DRUG ORDER

ADMINISTERED

SIGNIFICANCE

Colace Liquid

Capsule

lOOng BID

NS

Mellarll 10ng

Concentrate

NS*

Dllantln Kapseals

Prompt Phenytoln

100 ng three

100 ng three

Kapseala p.o. US

capsules p.o. HS

8««

*

If correct dose was given.

**

Parke Davis KaDseals hava an extended rate of abaorntj on. ProaiDt nhanvtoln

capsuleB do not.

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GUIDANCE TO SURVEYORS

Wrong Drug:

DRUG ORDER

ADMINISTERED

SIGNIFICANCE

Tylenol 325 mg (Routinely)

Ascriptin

Wrong Tine:

DRUG ORDER

ADMINISTERED

SIGNIFICANCE

Indocin 25mg PC

AC

NS

Perlactln 4mg PC

AC

NS

Dlgoxln 0.25ng

At 9:15 am

dally at 8 a.m.

NS

Tetracycllne 250ng

PC

QID AC and US

S

Determining Medication Errora

Tlnlng Errors. — I f a drug la ordered before seala (AC) and administered after seals (PC), always count this as a Medication error. Likewise, if a drug is ordered PC and la given AC, count as a dedication error. Count a wrong tine error if the drug Is administered 60 minutes earlier or later than Its scheduled time of administration, BUT ONLY IF THAT WRONG TIME ERROR CAN CAUSE THE RESIDENT DISCOMFORT OR JEOPARDIZE THE RESIDENT'S HEALTH AND SAFETY. Counting a drug with a long half-life (e.g., dlgoxln) as a wrong tine error when it la IS nlnutea late Is lnproper because this drug has a long half-life (beyond 24 hours) and 15 ninutes has no significant Impact on the realdent. The same Is true (or many other wrong tian errors (except AC AND PC errors) In long tern care facilities.

To determine the scheduled time, examine the facility's policy relative to dosing schedules. The facility's policy should dictate when it administers a.m. doses, or when it administers the first dose in a 4-tiaes-a-day dosing schedule.

Physician's Orders. --The latest recapitulation of drug orders is sufficient for determining whether a valid order exists provided the physician has signed the "recap." The signed "recap" and subsequent orders constitute a legal authorization to administer the drug. Attempts to find original orders In the physician's handwriting are usually too time consuming.

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GUIDANCE TO SURVEYORS - LONG TBRM CARE FACILITIES
GUIDANCE TO SURVEYORS
Procedures; S463.25Q
Medication Brror Detection Methodology. —Use an observation technique to determine medication errors. This Deans that the survey team should observe the administration of drugs, on several different drug "passes", record what Is observed; and reconcile the record of observation with the physician's drug orders to determine whether or not medication errors have occurred.
Do not rely solely on a paper review to determine medication errors. Detection of blank spaces on a medication administration record does not constitute the detection of actual medication errors. Paper review only Identifies possible errors. Experience has shown that facility staff are likely to correct the paper rather than correct the errors.
Observation Technique. — T h e survey team must know without doubt, what druga, In what strength, and dosage forms, are being administered. This Is accomplished prior to drug administration and may be done In a nunber of ways depending on the drug distribution system used (e.g. unit dose, vial system, punch card).
1. Identify the drug product. There are two principal ways to do this. In most cases, they are used In combination:
o Identify the product by Its size, shape, and color. Many drug products are Identifiable by their distinctive site, shape, or color. This technique Is problematic because not all drugs have distinctive slzeB, shapes, or color.
o Identify the product by observing the label. When the punch card or the unit dose systen is used, the survey team can usually observe the label and adequately Identify the drug product. When the vial system Is used, observing the label Is sometimes more difficult. Ask the nurse to identify the medication being administered.
2. Observe and record the administration of druga ("pass"). Follow the person administering drugs and observe residents receiving drugs (e.g., actually swallowing oral dosage forms). Be neutral and as unobtrusive as possible during this process.
Make every effort to observe residents during several different drug "passes" so the survey team will have an assessment of the entire facility rather than one staff on one drug pass.
Note every detail on the surveyor's record of the drug administration. For example, "eye drops administered in both eyes" or "nurse took pulse," or "resident swallowed nitroglycerin" or "all druga crushed and administered In apple sauce."

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TAG NUMBER
F333 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

GUIDANCE TO SURVEYORS

Identifying residents can present a problem. Sone long-ten care facilities do not use arn Identification bands, so assune correctness of the resident by relying on the actions of the nurse and the response of the resident.

3. Reconcile the surveyor's record of observation with physician's orders. Compare the record of observation with the n>st current signed orders for drugs. This comparison Involves two distinct activities:'
o For each drug on the surveyor's list: Was It administered according to the physician's orders? For example. In the correct strength, by the correct route? Was there a valid order for the drug? Was the drug the correct one?
o For drugs not on surveyor's list: Are there orders for drugs that should have been administered, but were not? Examine the record for drug orders that ware not administered and should have been. Such circumstances represent omitted doses - one of the aost frequent types of errors.

The surveyor should now have a complete record of what was observed and what should have occurred according to the physicians' orders. Determine the number of errors by adding the errors on each resident. Before concluding for certain that an error has occurred, discuss the apparent error with the nurse who administered the drugs. There may be a logical explanation for an apparent error. For example, the surveyor observed that a resident had received Laslx 20 mg, but the order was for 40 mg. This was an apparent error In dosage. But the nurse showed the surveyor another more recent order which discontinued the 40 mg order and replaced it with a 20 mg order.

4.

Reporting Errors - Describe to the facility each error that the survey team

detects (e.g., Mary Jones received digoxln In 0.125 Instead of 0.25 mg). The

survey team Is not required to analyze the errors and come to any conclusions on

how the facility can correct them. Do not attempt to categorize errors Into

various classifications (e.g., wrong dose, wrong resident). Stress that an

error occurred and that future errors must be avoided.

5.

Observe Horning "Pass" - It is preferable to watch the morning drug

administration pass because that la when most doses are administered In long

term care facilities and, hence, offers the greatest opportunity to observe

errors and conserve survey time.

6.

Observe Several Individuals - Strive to observe several individuals

administering drugs in the facility so that an assessment of medication errors

will be more broadly based. This requires observation of several "passes" at

the same time or at different times of the day.

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TAQ HU4BER
333 Cont.

REGULATION

GUIDANCE TO 8URVEYORS - LOWO TERM CARE FACILITIES
OUIDAMCB TO SURVEYORS
Poae Reconciliation Technique: Supplement to the Observation Technique. —When an omission error has been detected through the observation technique, the dose reconciliation technique can sometimes enable the auxvey team to learn how frequently an error has occurred In the past. Learning about the frequency of an error can assist In judging the significance of the error. (See Significant and Non Significant Medication Errors above.) The dose reconciliation technique requires a cosparison of the nunber of doses remaining In a supply of drugs with the number of days the drug has been in use and the directions for use. For example, if a drug were in use for 5 days with direction to administer the drug 4 times a day, then 20 doses should have been used. If a count of the supply of that drug shows that only 18 doses were used (I.e., two extra doses exist) and no explanation for the discrepancy exists (e.g., resident refused the dose, or resident was hospitalized), then two oaisBion errors nay have occurred.
Use the dose reconciliation technique In facilities that indicate the number of drugs received, and the date and the specific "pass" when that particular drug was started. Unless this Information in available, do not use this technique. If this information la not available, there is no Federal authority under which the aurvey team may require It, except for controlled drugs.

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PP-135

XAG NUMBER F353
F354

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATION
S483.30 Nursing services.
The facility oust have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychoBoclal well-being of each resident, as deterained by resident assessments and individual plans of care.
(a) Sufficient staff.
(1) The facility Bust provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(1) Except when waived under paragraph (c) of this section, licensed nurses; and
(11) Other nursing personnel.
(2) Except when waived under paragraph (c) of this section, the facility suBt designate a licensed nurse to serve as a charge nurse on each tour of duty.
(b) Registered nurse.
(1) Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

GUIDANCE TO SURVEYORS

Intent; S483.3O To assure that sufficient qualified nursing staff are available on a dally basis to meet residents' needs for nursing care in a manner and In an environment which promotes each resident's physical, mental and psychosocial well-being, thus enhancing their quality of life.
Procedures: $483.30 Fully review requirements of nursing services during an extended survey or when a waiver of RN and/or licensed nurse (RN/LFN) staffing has been requested or granted. Except as licensed nursing personnel are specifically required by the regulation (e.g., an RN for 8 consecutive hours a day, 7 days a week), the determination of sufficient Btaff will be made based on the staff's ability to provide needed care to residents that enable them to reach their highest practicable physical, mental and psychosocial well-being. The ability to meet the requirements of SS483.13, 483.15(a), 483.20, 483.25 and 483.65 determines sufficiency of nurse staffing.

Guidelines: S483.3Q(a) and (b) At a minimum, "staff" is defined aa licensed nurees (RNs and/or LPNs/LVNs), and nurse aides. Nurse aides must meet the training and coapetency requirements described in $483.75(o).

"Full tine" is defined as working 35 or more hours a week.

Except for licensed staff noted above, the determining factor In sufficiency of staff (including both numbers of staff and their qualifications) will be the ability of the facility to provide needed care for residents. A deficiency concerning starting should ordinarily provide examples of care deficits caused by Insufficient quantity and quality of staff. If, however. Inadequate staff (either the number or category) presents a clear threat to resident care, even when adverse effects have not occurred, or there is a lack of residents reaching their highest practicable level of wellbeing, cite this as a deficiency. Provide specific documentation of the threat.

The facility Is required to designate an RN to serve as DON on a full time basis. This requirement can be met when RNa share the position. If RNs share the DON position, the total hours per week must equal 40. Facility staff must understand the shared responsibilities. The facility can only be waived from this requirement If It has a waiver under subsection (c) or (d).

Probes: S483.30(a) and (b) Determine nurse staffing sufficiency for each uniti
o la there adequate staff to meet direct care needs, assei evaluation, supervision?
o Do work loads for direct care staff appear reasonable?

its, planning.

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TAG NUMBBR

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F3S4 Cont.

(2) Except when waived under paragraph (c) or (d) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full tlaw basis.
(3) The director of nursing stay serve as a charge nurse only when the facility has an average dally occupancy of 60 or fewer residents.

o Do residents, family, and oabudsnen report Insufficient staff to neet resident needs?
o Are staff responsive to residents' needs for assistance, and call bells answered promptly?
o Do residents call out repeatedly for assistance? o Are residents, who are unable to call for help, checked frequently (e.g., each half hour) for safety, comfort, positioning, and to offer fluids and provision of care? o Are identified care problens associated with a specific unit or tour of duty? o Is there a licensed nurse that serves as a charge nurse (e.g., supervises the provision of resident care) on each tour of duty (If facility doss not have a waiver of this requirement)? o What does the charge nurse do to correct problens In nurse staff performance? o Does the facility have the services of an RN available 8 consecutive hours a day, 7 days a week (if this requirenent has not been waived)7 o Bow does the facility assure that each resident receives nursing care In accordance with his/her plan of care on weekends, nights, and holidays? o How does the sufficiency (nuabers and categories) of nursing staff contribute to identified quality of care, resident rights, quality of life, or facility practices problens?

(c) Nursing facilities: Waiver of requirenent to provide licensed nurses on a 24-hour basis. To the extent that a facility Is unable to neat the requiresents of paragraphs (a)(2) and (b)(l) of this section, a State nay waive such requlrenents with respect to the facility if --
(1) The facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the cosnunlty prevailing rate for nursing facilities), to recruit appropriate personnel;

Intent: S483.30(c) To give the facility flexibility, in limited circumstances, when the facility cannot neet nurse staffing requlrenents.
Guidelines: S483.30(c) The facility nay request a waiver of the RN requirenent, and/or the 24-hour licensed nurse requirenent. If the facility is Hedicaid-certifled only, the State has the authority to grant the waiver. If the facility la dually-participating, BCFA has the delegated authority to grant the waiver. (See guidelines for 1483.30(d).)
A survey of nursing Services Bust be conducted if a waiver has been granted or requested.

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TAG NUMBER
F355

GUIDANCE TO 8URVBTOR8 - LONG TEHM CARE FACILITIES

REQUIATIQH
(2) The State determine* that a waiver of the requirement will not endanger the health or safety of Individuals staying In the facility;
(3) The State finds that, 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 t e n care ombudsman (established under section 307 (a)(12) of the Older Americana Act of 1965) and the protection and advocacy systen 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 Bombers of their Immediate families of the waiver.

OUIDANCB TO 8URVEYORS
Probes: S463.30(c) Before granting a continuation of this waiver, or during the annual review, at a minimum, determine:
o Is s continuing effort being made to obtain licensed nurses? o Bow does the facility ensure that residents' needs are being met? o Are all nursing policies and procedures followed on each shift during times when licensed services are waived? o Is there a qualified person to assess, evaluate, plan and Implement resident care? o Is care being carried out according to professional practice standards on each shift? o Can the survey team ensure the State that the absence of licensed nurses will HOT endanger the health or safety of reaidents? o Are there trends in the facility, which might be indicators of decreased quality of care as a result of insufficient staffing to meet resident needs (e.g., increases in incident reports, the infection rate, hospitalizatlons)? o Are there Increases in loss of function, pressure sores, tube feedings, catheters, weight loss, mental status? o Is there evidence that preventive measures (e.g., turning, ambulating) are taken to avoid poor quality of care outcomes and avoidable sudden changes in health status? o Is there evidence that sudden changes in resident health status and emergency needs are being properly identified and managed by appropriate facility staff and in a timely manner? o If the facility has a waiver of the requirement to provide licensed nurees on a 24-hour basis, have they notified the ombudsman, residents, surrogates or legal representatives, and members of their immediate families of the waiver, and are there services residents need that are not provided because licensed nurses are not available? o Is there an Increase in hospitalixatlons because licensed personnel are not available to provide appropriate services? o Does the facility meet all applicable requirements to continue to receive a waiver? o Does the staff Indicate that an RH or physician Is available to respond immediately to telephone calls when licensed nurses are not available? -

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TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES GUIDANCE TO SURVEYORS

(d) BNFs; Waiver of the requirement to provide services of a registered nurse for nore than 40 hours a week.
(1) The Secretary may waive the requirement that a SNF provide the services of a registered nurse for nore than 40 hours a week. Including a director of nursing specified in paragraph (b) of this section, if the Secretary finds that —
(I) The facility is located in a rural area and the supply of skilled nursing facility services in the area is not sufficient to meet the needs of individuals residing In the area;
(II) The facility has one fulltime registered nurse who Is regularly on duty at the facility 40 hours a week; and
(ill) The facility either—
(A) Has only patients whose physicians have indicated (through physicians' ordera or admission notes) that they do not require the services of a registered nurae or a physician for a 48-hours period or;
(B) Has made arrangements for a registered nurse or a physician to spend time at the facility, as determined necessary by the physician, to provide necessary skilled nursing services on days
Rev. 274

Guidelines; S483.3O(d) BCFA is delegated the waiver authority for SNFs, including dually-participating facilities (SNF/NFs). The Medicare waiver authority is far more limited than la the States' authority under Medlcaid since a State may waive any element of the nurse staffing requirement, whereas the Secretary may waive only the RN requirement. The requirements that a registered nurse provide services for 8 hours a day, 7 days a week (more than 40 hours a week), and that there be an RN designated as director of nursing on a full-time basis, may be waived by the Secretary In the following circumstances:
o The facility is located in a rural area with an inadequate supply of SNF services to meet area needs. Rural Is defined as "all areas not delineated as 'urban* by the Bureau of Census, based on the most recent census;
o The facility has one full-time registered nurse regularly working 40 hours a week. This may be the same individual, or part-time Individuals. This nurse may or may not be the DON, and may perform some DON and soma clinical duties if the facility so desires; and either;
o The facility has only residents whose physicians have noted, in writing, do not need RN or physician care for a 48 hour period. This does not relieve the facility from responsibility for providing for emergency availability of a physician, when necessary, nor does it relieve the facility from being responsible for meeting all needs of the residents during those 48 hours; or
o A physician or RN will spend the necessary time at the facility to provide care residents need during the days that an RN is not on duty. This requirement refers to clinical care of the residents that need skilled nursing services.
If a waiver of this requirement has been granted, conduct a survey of nursing services during each certification survey. Dually-participating facilities must meet the waiver provisions of the SNF.
Probes: «483.30(d) If the SNF has a waiver of the more than 40 hours a week RN requirement:
o Is there an RN on duty 40 hours a week? o If more than one RN provides the 40 hour per week coverage, how la Information exchanged that maintains continuity of resident care? o Does each clinical record have documentation by the physician that the resident does not need services of a physician or an RN for a 48 hour period each week. o Are there any emergency or routine services that should be, but are not, provided to residents during the days that a registered nurse is not on duty? o If specific skilled care is necessary for a resident during the time that an RN is not on duty, does an RN or physician provide that service on an "as needed" basis? o Did the facility notify residents (or their legal guardians) and their immediate families about the waiver and the ombudsman?

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TAQ MUMBSR

GUIDAHCB TO SURVBTOR3 - LOHO TBBM CARS FACILITIES

RECULATIOH
when the regular full-time registered nurse Is not on duty;
(iv) The Secretary provides notice of the waiver to the State long term care ombudsman (established under section 3O7(a)(12) of the Older Americans Act ol 196S) and the protection and advocacy systen in the state (or the nantally ill and mentally retarded; and
(v) The facility that Is granted such a waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their lnmedlate families of the waiver.
(2) A waiver of the registered nurse requirement under paragraph (d)(l) of this section is subject to annual renewal by the Secretary.

OUIDMCB TO 8UKVBYOHS
8ee also probes at S483.3O(c).
If the SNF requests continuation of the waiver to provide the service* of a registered nurse tor Bore than 40 hours a week, the survey teas Is to provide the Secretary with Information needed to grant this continuation.
o Does the SNF meet all requirements necessary for continuation of the waiver?
Procedures: S4B3.30(a)-(d) If the facility has an approved nurse staffing waiver, it is not considered a deficiency. The facility does not need to submit a POC.
The following procedure should be used to document that a facility has a waiver of nurse staffing requirements. When a facility doss not Beet the nurse staffing requirements, cits the appropriate tag. If the facility does have a waiver, reference the tag nueber based on the type of facility. The type of facility (SHF, HF, or SHF/HF) determines what type of waiver Is granted:
o For SHPs and BHF/HFs which Bay be waived from the requiresent to provide more than 40 hours of registered nurse services a week, and for HFs which have been granted a waiver from the 56 hour registered nurse requirement, cite F354;
o For SFs that nave a waiver of the 24-hour licensed nursing requirement, cite F3S3; or
o Both facility types could be waived for the requirement to designate a registered nurse as the director of nursing on a full-time basis. Cite F35S.
When the BCFA-2567 Is entered into OSCAR, code the waived tag as a "H". Enter the tag number, leave the correction date blank, and enter a "W" in the CP field. This will Indicate that this Is not a deficiency—that the requirement has been waived.

Rev. 274

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PP-140

TAO
NUMBER

REGULATION

GUIDAHCB TO SURVEYORS - U3M0 TERM C A M FACILITIES GUIDANCE TO SURVEYORS

F360 F361

S483.35 Dietary Services.
The facility m a t provide each resident with a nourishing. palatable, well-balanced diet that meets the dally nutritional and special dietary needs of each resident.
(a) Staffing.
The facility Bust employ a qualified dietitian either full-tine, part-tine, or on a consultant basis.
(1) If a qualified dietitian is not employed full-tine, the facility m e t designate a person to serve as the director of food service who receives frequently scheduled consultation fron a qualified dietitian.
(2) A qualified dietitian Is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association, or on the basis of education, training, or experience In Identification of dietary needs. planning, and implementation of dietary programs.

Intent: S483.35(a) The intent of this regulation is to ensure that a qualified dietitian is utilized in planning, managing and Implementing dietary service activities in order to assure that the residents receive adequate nutrition.
A director of food services has no required itinlmum qualifications, but must be able to function collaboratlvely with a qualified dietitian In meeting the nutritional needa of the residents.
Guidelines: S483.3S(a) A dietitian qualified on the basis of education, training, or experience In identification of dietary needs, planning and Implementation of dietary programs has experience or training which includes:
o Assessing special nutritional needs of geriatric and physically Impaired M r AOIIS *
o Developing therapeutic diets; o Developing "regular diets" to neet the specialized needs of geriatric and physically impaired persons; o Developing and Implementing continuing education programs for dietary services and nursing personnel; o Participating in interdisciplinary care planning; o Budgeting and purchasing food and supplies; and o Supervising institutional food preparation, service and storage.
Procedures: S483.35(a) If resident reviews determine that residents have nutritional problems, determine If these nutritional problems relate to Inadequate or Inappropriate diet nutrition/assessment and monitoring. Determine if these are related to dietitian qualifications.
Probes: S483.35(a) If the survey teaa finds problems in resident nutritional status:
o Do practices of the dietitian or food services director contribute to the identified problems in residents' nutritional status? If yes, what are they?

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PP-141

TAG NUMBER
F361 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG 1ERN C M S FACILITIES OUIDANCB TO SURVEYORS
o What axe the educational, training, and axperla:.ca qualifications of the facility's dietitian?

F362

(b) Sufficient staff. The facility aust enploy sufficient support personnel cospetent to carry out the (unctions of the dietary service.

Guidelines: S483.35(b) "Sufficient support personnel" Is defined as enough staff to prepare and serve palatable, attractive, nutritionally adequate steals at proper temperatures and appropriate tlaes and support proper sanitary techniques being utilized.
Procedures: S483.35(b) For residents who have been triggered for a dining review, do they report that aeals are palatable, attractive, served at the proper temperatures and at appropriate tlaes?
Probes: $483.35(b) (Sufficient staff preparation) Is food prepared In scheduled tieefrases in accordance with established professional practices?
Observe food service: Does food leave kitchen In scheduled tlaafraaes? Is food served to residents In scheduled tlsefraaas?

F563

(c) Menua and nutritional adequacy.
Menu* amst—

(1) Meet the nutritional needs of residents In accordance with the recoasended dietary allowances of the Food and Nutrition Board of the National Research Council, National Acadeay of Sciences;
Rev. 274

Intent: S483.3S(c)(l)(2)(3) The Intent of this regulation Is to assure that the seals served seat the nutritional needs of the resident In accordance with the recosaended dietary allowances (RDA's) of the Food and Nutrition Board of the National Research Council, of the Rational Academy of sciences. This regulation also assures that there is • prepared menu by which nutritionally adequate seals have been planned for the resident and followed.
Procedures: S483.35(c)(1) o For sampled residents who have a comprehensive review or a focused review, as
appropriate, observe If seals served are consistent with the planned senu and care plan In the aaounta, types and consistency of foods served.

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TAG NUMBER
F363 Cont.

REGULATION

GUIDANCB TO SURVBYORS - LONG TERM CARB FACILITIES

GUIDANCE TO SURVBYORS

If the survey team observes deviation from the planned menu, review appropriate documentation from diet card, record review, and Interviews with food service Manager or dietitian to support reason(s) for deviation froa the written nenu.

Probes: S483.35(c)(1) o Are residents receiving food In the amount, type, consistency and frequency to
naintain normal body weight and acceptable nutritional values? o If food Intake appears inadequate based on seal observations, or resident's
nutritional status is poor based on resident review, determine if nenus have been adjusted to meet the caloric and nutrient-Intake needs of each resident.
o If a food group is missing froa the resident's daily diet, does the facility have an alternative Beans of satisfying the resident's nutrient needs? If so, does the facility perform a follow-up?

(Menu adequately provides the daily basic food groups) Does the menu neet basic nutritional needs by providing dally food in the groups of the food pyramid system and based on individual nutritional assessment taking Into account current nutritional recommendations?

NOTE:

A standard nsal planning guide (e.g., food pyramid) is used primarily for menu planning and food purchasing. It Is not Intended to meet the nutritional needs of all residents. This guide must be adjusted to consider Individual differences. Some residents will need more due to age, size, gender, physical activity, and state of health. There are many msal planning guides from reputable sources, i.e., American Diabetes Association, American Dietetic Association, American Medical Association, or U.S. Department of Agriculture, that are available and appropriate for use when adjusted to meet each resident's needs.

(2) Be prepared in advance; and

Probesi S483.35(c)(2) (Menu prepared in advance) Are there preplanned nenus for both regular and therapeutic diets?

(3) Be followed. Rev. 274

Probes; S483.35(c)(3) (Menu followed) Is food served as planned? If not, why? There nay be legitimate and extenuating circumstances why food may not be available on the day of the survey and must be considered before a concern is noted.

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XAG HUMBBR

REGULATION

GUIDANCE ID SURVEYORS - LONG TERM CARB FACILITIES GUIDANCE TO SURVEYORS

F364

(d) Pood. 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;

Intent: S483.35(d)(l)(2) The intent of this regulation la to assure that the nutritive value of food is not compromised and destroyed because of prolonged food storage, light, and air exposure; prolonged cooking of foods in a large volume of water and prolong holding on stean table, and the addition of baking soda. Food should be palatable, attractive, and at the proper temperature as determined by the type of food to ensure resident's satisfaction. Refer to S463.15(e) and/or S4B3.1S(a).

Guidelines-. S483.35(d)(l) "Food-palatabllity" refers to the taste and/or flavor of the food. "Food attractiveness" refers to the appearance of the food when served to residents.

Procedures; S463.35(d)(l) Evidence for palatability and attractiveness of food, from day to day and meal to Baal, may be strengthened through sources such ast additional observation, resident and staff interviews, and review of resident council minutes. Review nutritional adequacy In S483.25(1){1).

Probes: f483.35(d)(l)(2) Does food have a distinctly appetizing aro and texture?

and appearance, which Is varied In color

Is food generally well seasoned (use of apices, herbs, etc.) and acceptable to residents?
(Conserves nutritive value) Is food prepared In a way to preserve vitamins? Method of storage and preparation should cause minimum loss of nutrients.
(Food - temperature) Is food served at preferable temperature (hot foods areserved hotandcold foods are served cold) aa discerned by the resident and customary practice? Hot to be confused with the proper holding temperature.

F365

(3) Food prepared In a form designed to meet Individual needs; and

Rev. 274

Intent: S483.35(d)(3)(4) The Intent of this regulation Is to assure that food Is served In a t o n that meets the resident's needs and satisfaction; and that the resident receives appropriate nutrition when a substitute i s offered.

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TAG NUMBER F366
F367

GUIDANCE TO SURVEYORS - LONG TBKM CAKE FACILITIES

REGULATION (4) Substitutes offered of similar nutritive value to residents who refuse food served.
(e) Therapeutic diets. Therapeutic diets Bust be prescribed by the attending physician.

GUIDANCE TO SURVEYORS
Procedures: S483.35(d)(3)(4) Observe trays to assure that food Is appropriate to resident according to as and care plan. Ask the resident how well the food Beets their taste needs. Ask If the resident Is offered or is given the opportunity to receive substitutes when refusing food on the original semi.
Probes: S483.35(d)(3)(4) Is food cut, chopped, or ground for Individual resident's needs?
Are residents who refuse food offered substitutes of stellar nutritive value?
Guidelines: S483.35(d)(4) A food substitute should be consistent with the usual and ordinary food items provided by the facility. For exaaple, if a facility never serves ssoked saloon, they would not be required to serve this as a food substitute; or the facility Bay, Instead of grapefruit Juice, substitute another citrus Juice or vltaaln C rich Juice that thai resident likes.
Intent: S483.35(e) The Intent of this regulation Is to assure that the resident receives and consiuses foods in the appropriate fora and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary teas to support the treatment and plan of care.
Guidelines: S483.35(e) "Therapeutic Diet" is defined as a diet ordered by a physician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients In the diet, (e.g., sodlua) or to increase specific nutrients in the diet (e.g., potassiua), or to provide food the resident Is able to eat (e.g., a Mechanically altered diet).
"Hechanlcally altered diet" Is one in which the texture of a diet is altered. Mien the texture Is modified, the type of texture Modification Bust be specific and part of the physicians' order.
Procedures; S4B3.35(e) If the resident has Inadequate nutrition or nutritional deficits that Manifests into and/or are a product of weight loss or other medical problems, determine if there ie a therapeutic diet that Is aedlcally prescribed.
Probes: S483.35(e) Is the therapeutic diet that the resident receives prescribed by the physician?

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PP-145

TAG NUMBER
P367 Cont.

RBGUIATIOH

GUIDANCE TO SURVBYORS - LONG TERM C M S FACILITIES GUIDANCE TO SURVEYORS
Also, see S483.25(l), Nutritional Status.

P368

(f) Frequency of n a i l .
(1) Each resident receive* and the facility provides at least three reals dally, at regular tinea castpaxable to normal maaltlaes In the community.
(2) There Bust be no more than 14 houra between a substantial evening anal and breakfast the following day, except as provided In (4) below.
(3) The facility auat offer snacks at bedtime dally.
(4) When a nourishing snack la provided at bedtime, up to 16 hours nay elapae between a substantial evening aeal and breakfast the following day if a resident group agrees to this seal span, and a nourishing anack la served.

Intent: S483.35(f)(1)(2)(3}(4) The Intent of this regulation is to assure that the resident receives his/her seals at tines Bost accepted by the community and that there are not extensive tlae lapses between seals. This assures that the resident receives adequate and frequent seals.
Guidelines: $483.35(()(1)(2)(3|(4) A "substantial evening B B B I " I S defined as an offering of three or sore eenu lteas at one tine, one of which includes a high-quality protein such as Beat, fish, eggs, or cheese. The seal should represent no less than 20 percent of the day'a total nutritional requireaents.
"Nourishing snack" is defined a* a verbal offering of lteas, single or in cOBblnatlon, froa the basic food groups. Adequacy of the "nourishing snack" will be dateralned both by resident Interviews and by evaluation of the overall nutritional status of realdente In the facility, (e.g., I B the offered snack usually satisfying?)
Procedures: S483.35(f)(1)(2)(3)(4) Observe naal tines and schedules and determine if there is a lapse in tlae between seals. Ask for resident input on seal service schedules, to verify If there are extensive lapses in tlae between seals.

P369

(g) Aaalatlve devices. The facility aust provide special eating equipment and utensils for residents who need then.

Intentt S483.35(g) The intent of this regulation la to provide residents with assistive devices to aaintaln or laprove their ability to eat Independently. For exaaple, improving poor graap by enlarging silverware handles with foaa padding, aiding residents with Impaired coordination or tremor by Installing plate guards, or providing postural supports for head, trunk, and arms.

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06-95

PP-146

TAG NUMBER
F369 Cont.

REGULATION

GUIDANCE TO SURVBYORB - LOHO TERM CARS FACILITIES
CUIDANCB TO SURVEYORS
Procedures: S483.35(g) Review sampled residents comprehensive assessment for eating ability. Determine II recommendations were Bade for adaptive utensils and If they were, determine if these utensils are available and utiliied by resident. If recommended but not used, determine if this is by resident's choice. If utensils are not being utilized, determine when these were recommended and how their use is being monitored by the facility and if the staff is developing alternative recoonandatlons.

(h) Sanitary conditions, The
facility mist--

F37O F371

(1) Procure food fron sources approved or considered satisfactory by Federal, State or local authorities;
(2) Store, prepare, distribute, and serve food under sanitary conditions; and

Intent; S483.35(h)(2) The Intent of this regulation is to prevent the spread of food borne illness and reduce those practices which result in food contamination and compromised food safety in nursing homes. Since foodborne Illness is often fatal to nursing home residents. It can and must be avoided.
Guidelines: «483.35(h)<2) "Sanitary conditions" is defined as storing, preparing, distributing, and serving food properly to prevent food borne Illness. Potentially hazardous foods must be subject to continuous time/temperature controls In order to prevent either the rapid and progressive growth of Infectious or toxigenlc micro-organisms such as Salmonella or the slower growth of Clostrldlum Botullnum. In addition, foods of plant origin become potentially hazardous when the skin, husk, peel, or rind Is breached, thereby possibly contaminating the fruit or vegetable with disease causing micro-organisms. Potentially hazardous food tends to focus on animal products, including but not limited to milk, eggs and poultry.
Improper holding temperature Is a common contributing factor of foodborne Illness. The facility must follow proper procedures In cooking, cooling, and storing food according to time, temperatures, and sanitary guidelines. Improper handling of food can cause salmonella and E-coll contamination. The 1993 FDA Food Code advises the following precautions:
MOTE: The 1993 FDA Food Code isnot regulation and cannot beenforced as such. The food temperatures cited that are recommended In the 1993 FDA Food Code are target temperatures and give a margin of safety in temperature ranges and to avoid known harmful temperatures.

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TAG NUMBER
F371 Cont.

REGULATION

Rev. 274

GUIDANCE I D 8URVBY0RS - LOHO TERM CARS FACILITIES

GUIDANCE TO SURVEYORS
Refrigerator storage of food to prevent food borne Illness Includes storing raw seat away from vegetables and other foods. Raw seat should be separated from cooked foods and other foods when refrigerated on Its own tray on a bottom shelf so seat Juices do not drip on other foods. Foods of both plant and animal origin Bust be cooked, maintained and stored at appropriate temperatures.
o Foods of both plant and animal origin must be cooked, and Maintained, and stored at appropriate temperatures. These temperatures are better utilized as food hold temperatures rather than the food temperatures as residents receive the food.
o Hot foods which are potentially hazardous should leave the kitchen (or steam table) above 140° F, and cold foods at or below 41* F and freezer temperatures should be at 0° F or below. Refrigerator temperatures should be maintained at 41* F or below. The 1993 FDA Food Code can be used as an authoritative guide to clarify regulatory requirements on how to prepare and serve food to prevent foodbome Illness. As the public becomes more Informed and educated on how to prevent foodbome illness, this code will become the standard of practice the same as the 1976 Food Service Sanitation Manual did prior to 1993.
Procedures: S4B3.35(h)(2) Observe storage, cooling, and cooking of food. Record the time and date of all observations. If a problem is noted, conduct additional observations to verify findings.
Observe that employees are effectively cleaning their hands prior to preparing, serving and distributing food. Observe that food la covered to maintain temperature and protect from other contaminants when transporting meals to residents.
Refrigerated storage: Check all refrigerators and freezers for temperatures. Use the facility's or the surveyor's own properly sanitized thermometer to evaluate the Internal temperatures of potentially hazardous foods with a focus on the quantity of leftovers and the container sizes In which bulk leftovers are stored.
Food preparation: Use a sanitized thermometer to evaluate food temperatures. In addition, how do kitchen staff process leftovers? Are they heated to the appropriate temperatures? Bow la frozen food thawed? Bow is potentially hazardous food handled during multi-step food preparation (e.g., chicken salad, egg salad)? Is hand contact with food minimized?
Food service: Ualng a properly sanitized thermometer, check the temperatures of hot and cold food prior to serving. Bow long is milk held without refrigeration prior to distribution?
Food distribution: Is the food protected from contamination as it la transported to the dining rooms and residents* rooms?

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TAG NUMBER
•371 :ont.

REGULATION

Rev. 274

OUIDAHCI TO SURVEYORS - LCMO TERM CARE F A C I L I T I E S

GUIDANCE TO SURVEYORS
Pest free: Is the area pest free? (See S483.7O(h)(4).) Look for signs of pasts such as Bice, roaches, rats, f i l e s .
(Preventing Contanination) Are handwashlng f a c i l i t i e s convenient and properly equipped for dietary services staff use? (Staff uses good hygienic practices and s t a f f with communicable diseases or infected skin l e s i o n s do not have contact with food If that contact w i l l txanealt the disease.)
(Hazard Free) Are toxic itens (such as Insecticides, detergent, polishes) properly stored, labeled, and used separate from the food?
Probes: S483.35(h)(2) Observe food storage rooms and food storage In the kitchen. Are containers of food stored off the floor and on clean surfaces In a Banner that protects It from contamination? Are other areas under storage shelves sonitored for cleanliness to reduce attraction of pest.
Are potentially hazardous foods stored at 41* F or below and frozen foods kept at 0* F or below?
Do staff handle and cook potentially hazardous foods properly?
Are potentially hazardous foods kept at an Internal taaperature of 41* F or below in cold food storage unit, or at an internal tasiperature of 140* F or above in a hot food storage unit during display and service?
Is food transported in a way that protects agalnat contamination (i.e., covered containers, wrapped, or packaged)?
la there any sign of rodent or insect infestation.
(Dishwashing) The current 1993 Food Code, DBBS, FDA, PH8 recounnds the following water temperatures and manual washing Instructions:
MACHINE: 1. Hot Water: a. 140* F Wash (or according to the manufacturer's specifications or
instructions). b. 180* F Rinse (1B0*, 160* or greater at the rack and dlsh/utenslls surfaces.
2. Low Temperature: a. 120* F • 25 ppm (parts per million) Hypochlorite (household bleach) on dish
8urface.

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TAG NUMBER

REGUUTIOH

OUIDAHCE TO BUKVBTOBS - LOMO I B M CARS FACILITIES OUIDAMCB TO SURVEYORS

F371 Cont.

F372

(3) Dispose of garbage and refuse properly.

HAHUALt 1. 3 Compartment Sink (wash, rinse and sanitise): Sanitizing solution used
according to Manufacture's Instructions. a. 75* F - 50 ppa Rypochlorlte (household bleach) or equivalent, or 12.5 ppm
of Iodine. b. Hot Hater Immersion at 170* F for at leaat 30 seconds.
(Dishwashing) Are food preparation equipment, dishes, and utensils effectively sanitized and cleaned to destroy potential disease carrying organlens and stored In a protected Banner?
Guidelines; S483.35(h)(3) The Intent of this regulation Is to assure that garbage and refuse be properly disposed.
Procedures: S463.35(h)(3) (Garbage/refuse) Observe garbage and refuse container construction, and outside storage receptacles.
Probes: S463.35(h)(3) Are garbage and refuse containers In good condition (no leaks) and la waste properly contained in dunpstars or compactors with lids or otherwise covered? Are areas such as loading docks, hallways, and elevators used for both garbage disposal and clean food transport kept clean, free of debris and free of foul odors and waste fat7 Is the garbage storage area maintained In a sanitary condition to prevent the harborage and feeding of pests? Are garbage receptacles covered when being removed from the kitchen area to the dumpster?

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06-95

PP-1S0

TAO NUMBER
F385

OUIDAHCB TO SURVEYORS - LGNQ TERN CARE FACILITIES

HBOU1ATICN
S4B3.4O Physician aervlcea. K physician Bust personally approve In writing a reccaonendatlon that an Individual be admitted to a facility. Each resident must remain under the care of a physician.
(a) Physician supervision. The facility Bust ensure that—
(1) The radical care of each resident is supervised by a physician; and
(2) Another physician supervises the Bedleal care of residents when their attending physician Is unavailable.

GUIDMCX TO BURVBYWS
Intent; S483.40 The Intent of this regulation is to ensure the nodical supervision of the care of nursing hone residents by a personal physician.
Guidelines: S483.40 A physician's "personal approval" of an admission recommendation Bust be in written torn. The physician's admission orders for the resident's Immediate care as required in S483.20(a) will be accepted as "personal approval" of the admission.
"Supervising the medical care of residents" means participating in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the facility. It also Includes, but is not limited to, prescribing new therapy, ordering a resident's transfer to the hospital, conducting required routine vlaits or dalagatlng and supervising follow-up visits to nurse practitioners or physician assistants. Bach resident should be allowed to designate a personal physician. (See S483.1O(d)(l).) The facility's responsibility in this situation is to simply assist the resident, when necessary, in his or her efforts to obtain those services. For example, the facility could put the resident In touch with the county medical society for the purpose of obtaining referrals to practicing physicians in the area.
Facilities should share MDS and other assessment data with the physician.
Procedures; 8483.40 If there is a deficiency In S483.1O, Resident rights; S483.13, Resident behavior and facility practices; S483.15, Quality of life; or S483.25, Quality of care, fully review all of the tags under this requirement.

Probes: S483.40(a) o Bow was the supervising physician Involved in the resident's assessment and
care planning? o If staff reported a significant change In medical status to the supervising
physician, did the physician respond? o If the supervising physician was unavailable and could not respond, did the
facility have a physician on call? Did this physician respond? o Are residents sent to hospital emergency rooms routinely because the facility
does not always have a physician on call?

Rev. 274

06-95

PP-151

TAG NUHBBR
F386

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION (b) Physician vlalta. The physician oust—
(1) Review the resident's total progran of care, including Dedications and treatments, at each visit required by paragraph (c) of this section;
(2) Write, sign, and date progreas notes at each visit; and
(1) Sign and data all orders.

GUIDANCE TO SURVEYORS
Intent: S483.4O(b) The intent of this regulation la to have the physician take an active role in supervising the care of residents. Thla should not be a superficial visit, but should Include an evaluation of the resident's condition and a review of and decision about the continued appropriateness of the resident's current nodical regime.
Guidelines: S483.40(b) Total progran of care Includes all care the facility provides residents to Maintain or improve their highest practicable mental and physical functional status, as defined by the comprehensive assessment and plan of care. Care Includes Medical services and Dedication Management, physical, occupational, and speech/language therapy, nursing care, nutritional Interventions, social work and activity services that Maintain or laprove psychosoclal functioning.
The physician records residents' progress and probleaa In Maintaining or improving their Mental and physical functional statue. The physician need not review the total plan of care at each visit, but Muat review the total plan of care at visits required by S4B3.40(c). There is no requirement for physician renewal of orders.
In cases where facilities have created the option for a resident's record to be Maintained by coaputer, rather than hard copy, electronic signatures are acceptable. See Guidelines for $483.75(1)(1) for Information on facility safeguards concerning electronic signatures.
Physician orders nay be transmitted by facsimile Machine if the following conditions are Met:
o The physician should nave signed and retained the original copy of the order from which the facaimile was transmitted and be able to provide It upon request. Alternatively, the original may be sent to the facility at a later time and substituted for the facaimile.
o The facility should photocopy the faxed order since some facsimiles fade over time. The facsimile copy can be discarded after facility photocopies it.
o A facility using such a system should establish adequate safeguards to aasure that It is not subject to abuse.
It la not necessary for a physician to re-sign the facsimile order when he/she visits the facility.
When rubber stamp signatures are authorized by the facility's management, the Individual whose signature the stamp represents shall place In the administrative offices of the facility a signed statement to the effect that he/she la the only one who has the stanp and uses It. A list of computer codaa and written signatures Must be readily available and Maintained under adequate aafeguarda.

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PP-152

TAG NUMBER F386 Cont.
F387
F3B8

OUIDANCBTO SURVEYORS - LONG TERM CARS FACILITIES

REGULATIOH
(c) Frequency of physician vi»lta.
(1) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
(2) A physician visit Is considered tlnely if It occurs not later than 10 days after the date the visit was required.
(3) Except as provided In paragraphs (c)(4) and (f) of this section, all required physician visits Bust be made by the physician personally.
(4) At the option of the physician, required visits in 8NFS, after the initial visit, nay alternate between personal visltB by the physician and visits by a

GUIDAHCB TO SURVBYORS
Probes: S483.4O(b) o Do services ordered by a physician show a pattern of care to maintain or
lnprove the resident's level of Independent functioning? For example, how do physician orders reflect the resident's nutritional status and needs?
o Does documentation reflect continuity of care In maintaining or lnprovlng a resident's Dental and physical functional status? For exanple, do the attending physician's rehabilitation service orders show a pattern of consistent restorative progressing?
Guidelines: S4B3.40(c) "Must be seen" nsana that the physician Bust nake actual face-to-face contact with the resident. There Is no requirement for this type of contact at the tine of adalsslon, since the decision to admit an individual to a nursing facility (whether from a hospital or frost the Individual's own residence) generally Involves physician contact during the period lnaedlately preceding the admission.
After the initial physician visit in SNFs, where States allow their use, a qualified nurse practitioner (HP), clinical nurse specialist or physician assistant (PA) Bay Bake every other required visit. (See S483.40(e) Physician delegation of tasks in SNFs.)
In a NF, the physician visit requir it, in accord with State law. Bay be satisfied by NP, clinical nurse specialist or PA. (See S483.40(f).)
The tlBing of physician visits is based on the adalsslon date of the resident. Visits will be Bade within the first 30 days, and then at 30 day Intervals up until 90 days after the admission date. Visits will then be at 60 day intervals. Permitting up to 10 days slippage of a due date will not affect the next due date. However, do not specifically look at the timetables for physician visits unless there Is Indication of inadequate medical care. The regulation states that the physician (or his/her delegate) must visit the resident at least every 30 or 60 days. There Is no provision for physicians to use discretion In visiting at Intervals longer than those specified at S483.40(c).
Policy that allows on NP, clinical nurse specialist, or PA to aake every other required visit, and that allows a 10 day slippage In the time of the visit, does not relieve the physician of the obligation to visit a resident when the resident's Bedical condition makeB that visit necessary.
It Is expected that visits will occur at the facility rather than the doctor's office unless office equipment Is needed or a resident specifically requests an office visit. If the facility has established policy that residents leave the grounds for Bedical care, the resident does not object, and this policy does not infringe on his/her

Rev. 274

06-95

PP-153

TAG NUMBER
F388 Cont.

REGULATION
physician assistant, nurse practitioner or clinical nurse specialist In accordance with paragraph (e) of this section.

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES
GUIDAHCB TO SURVEYORS
rights, there is no prohibition to this practice. The facility should lnforsi the resident of this practice. In accordance with S483.1O(b).
Probes: St83.4O(c) o Bow does the scheduling and frequency of physician visits relate to any
Identified quality of care problems? o When a PA, clinical nurse specialist, or HP per fonts a delegated physician
visit, and determines that the resident's condition warrants direct contact between the physician and the resident, does the physician follow-up promptly with a personal visit?

F389

(d) Availability of physicians for emergency care.
The facility Bust provide or arrange for the provision of physician services 24 hours a day. In case of an emergency.

F39O

(e) Physician delegation of tasks in SNFs.
(1) Except as specified in paragraph (e)(2) of this section, a physician Bay delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist w h o —

Guidelines: S483.4O(d) If a resident's own physician Is unavailable, the facility should attempt to contact that physician's designated referral physician before assuming the responsibility of assigning a physician. Arranging for physician services may Include assuring resident transportation to a hospital emergency room/ward or other medical facility If the facility is unable to provide emergency medical care at the facility.
Probes: S4B3.40(d) o Does the facility have a physician on call for medical emergencies? Does this
physician respond7 o For what reasons are residents sent to hospital emergency rooms? o Did medical management of the emergency affect the resident's maintaining or
improving their functional abilities? o If the resident refused the physician's visit, what has the facility done to
explain to the resident the results and alternatives that may be available?
Guidelines: S483.40(e) "Nurse practitioner" Is a registered professional nurse now licensed to practice in the State and who meets the State's requirements governing the qualification of nurse practitioners.
"Clinical nurse specialist" is a registered professional nurse currently in practice in the State and who meets the State's requirements governing the qualifications of clinical nurse specialists.

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TAO NUMBER

REGULATION

GUIDAHCB TO SURVEYORS - LCWG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

F390 Cont.

(1) Heeta the applicable definition in S491.2 of thia chapter or. In the case of a clinical nurse specialist, la licensed as such by the State;
(11) la acting within the scope of practice as defined by State lav; and
(111) la under the supervision of the physician.

(2) A physician may not delegate a task when the regulations specify that the physician nust perform it personally, or when the delegation la prohibited under State law or by the facility's own policies.
(f) Performance of physician tasks In NFs.
At the option of the State, any required physician task In a NF(Including tasks which the regulationa specify oust be performed personally by the (physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who Is not an employee of the facility but who la working In collaboration with a physician.

"Physician assistant" Is a person who meets the applicable State requirements governing the qualifications for assistants to physicians.
When personal performance of a particular taak by a physician is specified in the regulatlona, performance of that task cannot be delegated to anyone else. The tasks of examining the resident, reviewing the resident's total program of care, writing progress notes, and signing orders may be delegated according to State law. The extant to which physician services are delegated to physician extenders In SNFs will continue to be determined by the provisions of S483.40(e), while the extent to which these services are performed by physician extenders in RFs will be determined by the individual States under S4B3.4O(f).
Probes: S483.40(e) o Do the facility's attending physicians delegate to NPs, clinical nurse
specialists, or PAs? o Do NP/clinlcal nurse speclallst/PA progress notes and orders follow the acope
of practice allowed by State law? o What evidence Is there of physician supervision of NPs or PAs? For example, do
physicians countersign NP/PA orders. If required by State law?
Guidelines! S483.4O(f) If delegation of physician taaka la permitted In your State and the physician extender does not meet the qualifications listed here, cite F388.
Procedures: S483.4O(f) If a nurse practitioner, clinical nurse specialist, or physician assistant la performing required physician tasks In a NF, Is this allowed by the State? Is this person an employee of the facility? (Facility employees are prohibited from serving in thia capacity.)
Probes: S483.40(f) la this person working in collaboration with the physician?

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PP-155

TAO NUMBER
'406

OUIDMICB TO SURVEYORS - LGMO TERM CAWS FACILITIES

KBGULATIOI
S483.45 Specialized rehabilitative services.
(a) Provision of services.
If specia11zed rehabilitative services such as, but not Halted to physical therapy, speechlanguage pathology, occupational therapy, and mental health rehabilitative services for mental Illness and Dental retardation, are required in the resident's comprehensive plan of care, the facility must--
(1) Provide the required services;
(2) Obtain the required services from an outside resource (in accordance with S483.75(h) of this part) from a provider of specialized rehabilitative services.

GUIDANCE TO SURVEV0R8
Intent: S483.45(a)(l)(2) The Intent of this regulation la to assure that residents receive necessary specialized rehabilitative services as determined by the comprehensive assessment and care plan, to prevent avoidable physical and mental deterioration and to assist them in obtaining or maintaining their highest practicable level of functional and psycho-social wellbeing.
"Specialized rehabilitative services" are differentiated from restorative services which are provided by nursing staff. Specialized rehabilitative services are provided by or coordinated by qualified personnel.
Specialized rehabilitative services are considered a facility service and are, thus, included within the scope of facility services. They must be provided to residents who need them even when the services are not specifically enumerated in the State plan. No fee can be charged a Medicald recipient for specialized rehabilitative services because they are covered facility services.
A facility is not obligated to provide specialized rehabilitative services if it does not have residents who require these services. If a resident develops a need for these services after admission, the facility must either provide the services, or, where appropriate, obtain the service from an outside resource.
POT a resident with MI or HR to have his or her specialized needs set, the individual must receive all services necessary to assist the individual in maintaining or achieving as much Independence and self-determination as possible. They are:
"Specialized services for MI or MR" refers to those services to be provided by the State which can only be delivered by personnel or programs other than those of the HP (e.g., outside the HP setting), because the overall level of HP services is not as Intense as necessary to meet the individuals needs.
The Preadmission Screening and Annual Resident Review (PASARR) report indicates specialized services required by the resident. The State la required to list those services in the report, as well as provide or arrange for the provision of the services. If the state determines that the resident does not require specialized services, the facility is responsible to provide all services necessary to meat the resident's mental health or mental retardation needs.
••Mental health rehabilitative services for MI and HR", refers to those services of lesser frequency or Intensity to be implemented by all levels of nursing facility staff who come into contact with the resident who Is mentally ill or who has mental retardation. These services are necessary regardless of whether or not they are required to be subject to the PASARR process and whether or not they require additional services to be provided or arranged for by the State as specialized services.

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PP-156

TAG NUHBBB
F4O6 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONO TERM CARB FACILITIES

GUIDANCE TO SURVEYORS
The facility should provide Interventions which complement, reinforce and are consistent with any specialized service* (as defined by the resident's PASARR) the Individual la receiving or Is required to receive by the State. The individual's plan of care should specify how the facility will Integrate relevant activities throughout all hours of the individual's day at the MF to achieve this consistency and enhancement of PASARR goals. The surveyor should see competent Interaction by staff at all tinea, in both formal and l n f o m a l settings in accordance with the individual's needs.
Mental health rehabilitative services tor MI and MR Bay Include, but are not H a l t e d to:
o Consistent Implementation during the resident's dally routine and across settings, of systematic plans which are designed to change inappropriate behaviors;
o Drug therapy and monitoring of the effectiveness and side effects of medications which have been prescribed to change Inappropriate behavior or to alter manifestations of psychiatric illness;
o Provision of a structured environment for those Individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward Isolation and withdrawal);
o Development, maintenance and consistent implementation across settings of those programs designed to teach Individuals the daily living skills they need to be more Independent and self-determining Including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skills, health, drug therapy, mental health education, money management, and maintenance of the living environment;
o Crisis Intervention services; o Individual, group, and family psychotherapy; o Development of appropriate personal support networks; and o Formal behavior modification programs.
Procedures! S483.45(«)(1)(2) For sampled residents, whose comprehensive assessment Indicates physical, psychosoclal, and/or communications rehabilitation potential (See MDS Sections B, C, 0, B. In version 2.0, sections 0, C, F, B. References to version 2.0 of the MDS are effective when the State respeclfles its R A I ) , observe for unmet needs for rehabilitative services. Determine the extent of follow through with comprehensive care plan using probes outlined below. Verify from the chart that resident Is receiving frequency and type of therapy as outlined In the care plan.
Probes; S483.«5(a)(l)(2) 1. (For physical therapy) a. What did the facility do to Improve the resident's muscle strength? The
resident's balance? b. What did the facility do to determine if an aeslstlve device would enable
the resident to reach or maintain his/her highest practicable level of physical function?
c. If the resident has an asslstive device, Is he/she encouraged to use It on a regular basis?

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TAB HUMBBR
406 Cont.

RBGULATIOR

Rev. 274

GUIDANCE TO 8URVBYDRS - U N O TOTH CARS FACILITIES
OUIDMCB TO SURVCTOHS
d. What did tha facility do to Increase the amount of physical activity tha resident could do (for example, the number of repetitions of an exercise, the distance walked)?
e. What did the facility do to prevent or minimize contracturaa, which could lead to decreased mobility and Increased risk of pressure ulcer occurrence?
2. (For occupational therapy) a. What did the facility do to decrease the amount of assistance neaded to
perform a task? b. What did the facility do to decrease behavioral symptoms? c. What did the facility do to Improve gross and fine motor coordination? d. What did the facility do to iaprova sensory awareness, visual-spatial
awareness, and body Integration? e.What did the facility do to iaprova memory, problem solving, attention span,
and tha ability to recognize safety hazards? 3. For speech-language pathology a. What did the facility do to iaprova auditory comprehension such as
understanding common, functional words, concepts of time and place, and conversation? b. What did the facility do to improve speech production? c. What did the facility do to Improve expressive behavior such as tha ability
to name common, functional Items? d. What did the facility do to Improve the functional abilities of residents
with moderate to severe hearing loss who have received an audiologlc evaluation? For example, did the facility Instruct the resident how to affectively and Independently use environmental controls to compensate for hearing loss such as eye contact, preferential seating, use of the better ear?
e. For the resident who cannot speak, did the facility aasass for a communication board or an alternate means of coamunlcatlon?
4. (For health rehabilitative services for MI and MR) a. What did the facility do to decrease Incidents of inappropriate behaviors,
for individuals with MR, or behavioral symptoms for persons with MI? To Increase appropriate behavior?
b. What did the facility do to identify and treat the underlying factors behind tendencies toward Isolation and withdrawal?
c. What did the facility do to develop and maintain necessary daily living skills?
d. Bow has the facility modified the training strategies it uses with its residents to account for the special learning needs of its residents with MI or MR?
e. (Questions to ask individuals with MI or MR:) (l)Who do you talk to when you have a problem or need something? (2)What do you do when you feel happy? Feel sad? Can't sleep at night? (3)In what activities are you Involved, and how often?

06-95

PP-1S8

TAG NUMBER
'406 :ont.
F407

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(b) Quailflcatlona. Specialized rehabilitative services oust be provided under the written order of a physician by qualified personnel.

GUIDANCE TO SURVEYORS
Intent: S463.45(b) The Intent of this regulation is to assure that the rehabilitative services are medically necessary aa prescribed by a physician and provided by qualified personnel to maximize potential outcc
Specialized rehabilitative services are provided for Individual's under a physician's order by a qualified professional. Once the assessment for specialized rehabilitative services is completed, a care plan must be developed, followed, and monitored by a licensed professional. Once a resident has met his or her care plan goals, a licensed professional can either discontinue treatment or Initiate a maintenance program which either nursing or restorative aides will follow to maintain functional and physical status.
Guidelines: S4B3.45(b) "Qualified personnel" means that professional staff are licensed, certified or registered to provide specialized therapy/rehabilitative services In accordance with applicable State laws.
Health rehabilitative services for MI and MR must be Implemented consistently by all staff unless the nature of the services is such that they are designated or required to be implemented only by licensed or credentlaled personnel.
Procedures: S483.45(b) Determine if there are any problems in quality of care related to maintaining or improving functional abilities. Determine if these problems are attributable In part to the qualifications of specialized rehabilitative services staff.
Determine from the care plan and record that rehabilitative services are provided under the written order of a physician and by qualified personnel. If a problem in a residents rehabilitative care Is identified that is related to the qualifications of the care providers, it nay be necessary to validate the care providers qualification.
Probes: S463.45(b) If the facility does not employ professional staff who have experience working directly with or designing training or treatment programs to meet the needs of Individuals with MI or MR, how has the facility arranged for the necessary direct or staff training services to be provided?

Rev. 274

06-95

PP-159

TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - UWO • tBM C A M FACILITIES GUIDANCE ID SURVBYWS

F411

$483.55 Dental (eivlcea.
The facility must assist residents In obtaining routine and 24-hour emrgency dental care.
(a) Skilled nursing facilities.
A facility
(1) Must provide or obtain from an outalde resource. In accordance with S483.75(h) of this part, routine and emergency dental service* to Beet the needs of each resident;

(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

(3) Must If necessary, aaslst the resident—
(I) In naklng appointments; and
(II) By arranging for transportation to and from the dentist's office; and
(4) Promptly refer residents with lost or damaged dentures to a dentist.

Rev. 274

Intent; t483.55 The Intent of this regulation is to ensure that the facility be responsible for assisting the resident In obtaining needed dental services. Including routine dental services.
Guidelines: §483.55 This requirement Bakes the facility directly responsible for the dental care needs of its residents. The facility oust ensure that a dentist is available for residents, i.e., employ a ataff dentlat or have a contract (arrangement) with a dentist to provide services.
For Medicare and private pay realdenta, facilities are responsible for having the services available, but they nay impose an additional charge for the services.
For all residents of the facility, if they are unable to pay for needed dental services, the facility should attempt to find alternative funding sources or alternative service delivery systems so that the resident is able to maintain his/her highest practicable level of well-being. (See S483.15(g).)
The facility la responsible for selecting a dentist who provides dental services la accordance with professional standards of quality and timeliness under S483.75(h)(2).
"Routine dental services" aeans an annual inspection of the oral cavity for signs of disease, diagnosis of dental dlaeaaa, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor dental plate adjustments, smoothing of broken teeth, and limited proathodontlc procedures, e.g., taking impressions for dentures and fitting dentures.
"Emergency dental services" Includes services needed to treat an episode of acute pain in teeth, guns, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity, appropriately treated by a dentist that requires Immediate attention.
"Prompt referral" meana, within reason, as soon as the dentures are lost or damaged. Referral does not mean that the resident must see the dentist at that time, but does mean that an appointment (referral) is made, or that the facility la aggressively working at replacing the dentures.
Probes; 5463.55 Do residents selected for comprehensive or focused reviews, as appropriate, with dentures use them? Are residents alsslng teeth and may be in need of dentures? Do sampled residents have problems eating and maintaining nutritional status because of poor oral health or oral hygiene? Are resident's dentures Intact? Proper flt7

06-95

PP-160

TAG NUMBER
F412

REGULATION (b) Huralng facilities.

GUIDANCE TO SURVEYORS - LONG TBRM CARE FACILITIES GUIDANCE TO SURVEYORS

The facility

(1) Must provide or obtain frora an outalde resource, in accordance with S483.75(h) of this part, the following dental Bervlces to neet the needs of each resident:

(1) Routine dental services (to the extent covered under the State plan); and

(ii)

gency dental services;

(2) Must, if necessary, assist the resident—

(1) In making appointments; and

(ii) By arranging for transportation to and froa the dentist's" office; and

(3) Must promptly refer residents with lost or damaged dentures to a dentist.

Guidelines: t4B3.55(b)(l)(l) For Hedlcaid residents, the facility Bust provide the resident, without charge, all emergency dental services, as well as those routine dental services that are covered under the State plan.

Rev. 274

06-95

PP-161

TAO NUMBER
P42S

GUIDANCE TO SUHVKYOB3 - UXO TBFM CABS FACILITIES

REGULATION
S483.6O Pharnacy services.
The facility oust provide routine and emergency drugs and blologlcals to Its residents, or obtain then under an agreeaent described in $483.75(h) of this part. The facility say pernlt unlicensed personnel to adnlnlster drugs If state law penits, but only under the general supervision of a licensed nurse.

GUIDANCE TO SURVEYORS
Guidelines: S483.60 The facility Is responsible under $483.75(h) for the "tlaellness of the services."
A drug, whether prescribed on a routine, emergency, or as needed basis, »ust be provided In a timely manner. If failure to provide a prescribed drug In a tinely •anner causes the resident discomfort or endangers his or her health and safety, then this requirement is not net.
Procedures: S463.60 During the surveyor's observation of the drug pass, are all ordered aedlcatlons available?

F426

(a) Procedures.
A facility mist provide pharmaceutical services (Including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and blologlcals) to m e t the needs of each resident.

F427

(b) Service consultation.
The facility must eaploy or obtain the services of a licensed pharmacist w h o —

(1) Provides consultation on all aspects of the provision of pharaacy services in the facility;

(2) Establishes a systea of records of receipt and disposition of all controlled drugs In sufficient detail to enable an accurate reconciliation; and

Guidelines: $483.60(b)(2) and (3) A record of receipt and disposition of controlled drugs does not need to bs proof of use sheets. The facility can use existing docuaantation such as the Medication Administration Record (MAR) to accoapllah this record.

Rev. 274

PP-162

TAG NUMBER
•427
:ont.

GUIDANCB TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
(3) Determines that drug records are in order and that an account of all controlled drugs la maintained and periodically reconclled.

GUIDANCE TO SURVEYORS
Periodic reconciliations should be monthly. If they reveal shortages, the pharmacist and the director of nursing may need to initiate more frequent reconciliations. In situations in which loss of controlled drugs is evident, the facility may have to utilize proof of use sheets on all controlled drugs for all shifts. However, when the source of shortage is located and remedied, the facility may go back to periodic reconciliation by the pharmacist.
Please note that the regulation does not prohibit shortages of controlled drugs - only that a record be kept and that it be periodically reconciled. If the survey reveals that all controlled drugs are not accounted for, refer the case to the State nursing hone llcensure authority, or to the State Board of Pharmacy.

(c) Drug regimen review.

F428

(1) The drug regimen of each

resident mist be reviewed at least

once a month by a licensed

pharmacist.

Guidelines; S483.60(c)(l) It may be necessary to review more frequently (e.g., every week) depending on the residents' condition and the drugs they are taking.
Procedures; S483.6O(c)(1) Refer to Part One of Appendix N for detailed information concerning the survey of this requirement. If the survey team find one or more of the drug therapy circumstances in Part One of Appendix N and there Is no documentation that the pharmacist has Identified and notified the attending physician and the director of nursing of this circumstance, and that circumstance can cause or does cause significant harm to the resident, then document the observation on the Resident Review Worksheet (BCFA-805).

Rev. 274

PP-163

TAG HUMBBR P429
F430

GUIDANCE TO SURVEYORS - LGHQ TERM CARE FACILITIES

REGULATION
(2) The pharnacist must report any Irregularities to the attending physician and the director of nursing, and
these reports must be acted upon.

GUIDANCE 10 SURVEYORS
Guidelines: S483.60(c)(2) The director of nursing and the attending physicians are not required to agree with the pharnacist1s report, nor are they required to provide a rationale for their "acceptance" or "rejection" of the report. They must, however, act upon the report. This may be accomplished in many ways, i.e., indicating acceptance or rejection of the report and signing their names. The facility is encouraged to provide the medical director with a copy of drug regimen review reports and to involve the medical director in reports that have not been acted upon.

F431

(d) Labeling of drugs and biologicals. Drugs and biologicals used in the facility •ust be labeled in accordance with currently accepted professional principles, and Include the
appropriate accessory and cautionary instructions, and the expiration data when applicable.

Guidelines: S483.60(d) This section imposes currantly accaptad labeling requirements on facilities, even though the pharmacies will be immediately responsible for accomplishing the task.
The critical elements of the drug label in a long-tars care facility are the name of the drug and its strength.
The names of the resident and the physician do not have to be on the label of the package, but they must be identified with the package in such a manner as to assure that the drug is administered to the right patient.
All drugs approved by the Food and Drug Administration must have expiration dates on the manufacturer's container. "When applicable" means that expiration dates must be on the labels of drugs used in long term care facilities unless State law stipulates

F432

(a) Storage of drugs and biologicals.
(1) In accordance with Stata and Federal laws, the facility Bust store all drugs and biologicals in locked compartments under proper temperature controls, and penslt only authorized personnel to have access to the keys.

Rev. 274

Guidelines: 5463.60(e) Compartments in the context of these regulations include but are not United to drawers, cabinets, roans, refrigerators, carts, and boxes. The provisions for authorized personnel to have access to keys must be determined by the facility management in accordance with Federal, State, and local laws and facility practices.
"Separately locked" means that the key to the separately locked Schedule II drugs is not the same key that is used to gain access to the non-Schedule II drugs.
Probes: S4B3.60(e) Are all drugs and biologicals stored properly, locked and at proper temperature?
PP-164

TAO NUMBER
F432 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM C A M FACILITIES GUIDANCE TO SURVEYORS

(2) The facility Bust provide separately locked, permanently affixed compartments for storage of controlled drugs listed In Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugB subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Rev. 274

PP-16S

TAG NUMBER
F425

QUIDAHCB TO SURVEYORS - LOMO TBHH C A M FACILITIES

RBGULATIOM
S483.6O Pharmacy cervices.
The facility suet provide routine and emergency drugs and biologleala to It* residents, or obtain then under an agreement described In S483.75(h) of this part. The facility nay permit unlicensed personnel to administer drugs If State law permits, but only under the general supervision of a licensed nurse.

GUIDANCE TO SURVBYGM
Guidelines: S483.60 The facility Is responsible under S483.75(h) for the "timeliness of the services."
A drug, whether prescribed on a routine, emergency, or as needed basis, must be provided In a timely manner. If failure to provide a prescribed drug in a timely manner cauaes the realdent discomfort or endangers his or her health and safety, then this requirement is not met.
Procedures: S483.60 During the surveyor's observation of the drug pass, are all ordered medications available?

F426

(a) Procedures.
A facility must provide pharmaceutical services (Including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological*) to meet the needs of each resident.

F427

(b) Service consultation.
The facility nuat employ or obtain the services of a licensed pharmacist w h o —

(1) Provides consultation on all aspects of the provision of pharmacy services in the facility;

(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

Guidelines: S4B3.6O(b)J2) and (3) A record of receipt and disposition of controlled drugs does not need to be proof of use sheets. The facility can use existing documentation such as the Medication Adnlnlstration Record (HAR) to accomplish this record.

Rev. 274

06-95

PP-162

TAG NUMBER
F427 Cont.

GUIDAHCB TO SURVEYORS - LOHO TERM CARE FACILITIES

REGULATION
(3) Determines that drug records are In order and that an account of all controlled drugs Is maintained and periodically reconciled.

OUIDAHCB TO SURVEYORS
Periodic reconciliations should be nonthly. If they reveal shortages, the pharnacist and the director of nursing nay need to Initiate more frequent reconciliations. In situations In which loss of controlled drugs is evident, the facility Bay have to utilize proof of use sheets on all controlled drugs for all shifts. However, when the source of shortage is located and remedied, the facility may go back to periodic reconciliation by the pharmacist.
Please note that the regulation doss not prohibit shortages of controlled drugs - only that a record be kept and that it be periodically reconciled. If the survey reveals that all controlled drugs are not accounted for, refer the case to the State nursing home licensure authority, or to the State Board of Pharmacy.

F428

(c) Drug regimen review.
(1) The drug regimen of each resident Bust be reviewed at le once a nonth by a licensed pharmacist.

Guidelines: S4B3.60(c)(l) It may be necessary to review more frequently (e.g., every week) depending on the residents' condition and the drugs they are taking.
Procedures: i«63.60(c)(l) Refer to Part One of Appendix N for detailed Information concerning the survey of this requirement. If the survey team find one or more of the drug therapy circumstances in Part One of Appendix M and there Is no documentation that the pharmacist has identified and notified the attending physician and the director of nursing of this circumstance, and that circumstance can cause or does cause significant harm to the resident, then document the observation on the Resident Review Worksheet (HCFA-805).

Rev. 274

06-95

PP-163

TAG NUMBER F429
F43O

GUIDANCE TO SURVEYORS - LONG TBRN CARE FACILITIES

REGULATION
(2) The pharmacist oust report any irregularities to the attending physician and the director of nursing, and
these reports nust be acted upon.

GUIDANCE TO SURVEYORS
Guidelines: S4B3.60(c)(2) The director of nursing and the attending physicians are not required to agree with the pharmacist's report, nor are they required to provide a rationale for their "acceptance" or "rejection" of the report. They Bust, however, act upon the report. This aay be accomplished in many ways, i.e., indicating acceptance or rejection of the report and signing their nones. The facility is encouraged to provide the nodical director with a copy of drug reglnen review reports and to involve the nedlcal director In reports that have not been acted upon.

(d) Labeling of drugs and biologicals. Drugs and blologlcals used in the facility Bust be labeled in accordance with currently accepted professional principles, and include the
appropriate accessory and cautionary instructions, and the expiration date when applicable.

Guidelines: $483.60(d) This section lnposea currently accepted labeling retirements on facilities, even though the pharmacies will be lnaediately responsible for accomplishing the task.
The critical elements of the drug label in a long-term care facility are the none of the drug and its strength.
The names of the resident and the physician do not have to be on the label of the package, but they Bust be identified with the package in such a Banner as to assure that the drug is administered to the right patient.
All drugs approved by the Food and Drug Administration must have expiration dates on the manufacturer's container. "When applicable" Beans that expiration dates must be on the labels of drugs uBed in long term care facilities unless State law stipulates

F432

(e) Storage of drugs and blologlcals.
(1) In accordance with State and Federal laws, the facility nust store all drugs and biologicals in locked compartaaenta under proper temperature controls, and permit only authorized personnel to have access to the keys.

Rev. 274

Guidelines: {463.60(8) Compartments in the context of these regulation* include but are not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes. The provisions for authorized personnel to have access to keys must be determined by the facility manavjenant In accordance with Federal, State, and local laws and facility practices.
"Separately locked" means that the key to the separately locked Schedule II drugs is not the sane key that is used to gain access to the non-Schedule II drugs.
Probes: S483.60(e) Are all drugs and blologlcals stored properly, locked and at proper temperature?

06-95

PP-164

TAG NUMBER
F432 Cont.

RBGU1ATION

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES GUIDAHCB TO SURVEYORS

(2) The facility oust provide aeparately locked, permanently affixed coapartnentB for Btorage of controlled drugs listed In Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution system In which the quantity stored Is alnlaal and a Biasing dose can be readily detected.

Rev. 274

06-95

PP-165

TAB NUMBER
F441

OUIt MICE TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATION
S483.65 Infection control.
The facility oust establish and naintaln 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.
(a) Infection control program.
The facility must establish an Infection control program under which I t — (1) Investigates, controls, and prevents infections in the facility;
(2) Decides what procedures, such as Isolation should be applied to an individual resident; and
(3) Maintains a record of incidents and corrective actions related to infections.

GUIDANCE TO SURVEYORS
Intent: S483.65(a) The intent of this regulation la to assure that the facility has an infection control program which Is effective for Investigating, controlling, and preventing Infections. If infection control has been identified as an area of concern during Phase 1 of the survey, investigate aspects of the program, as appropriate, during Phase 2.
Guidelines; S483.65(a) The facility's infection control program must have a system to monitor and investigate causes of Infection (nosocomlal and community acquired ) and manner of spread. A facility should, for example, maintain a separata record on infection that identifies each resident with an Infection, states the date of Infection, the causative agent, the origin or site of infection, and describes what cautionary measures ware taken to prevent the spread of the infection within the facility. The system must enable the facility to analyze clusters, changes in prevalent organisms, or Increases in the rate of infection in a timely manner.
Surveillance data should be routinely reviewed and recommendations made for the prevention and control of additional cases.
The written infection control program should be periodically reviewed by the facility and revised as indicated.
Current standards for Infection control program address the following. The following are not regulatory requirements but provide guidance for evaluating the facility's program.
o Definition of nosocomial/faclllty acquired infections and communicable dis oRlsk assessment of occurrence of communicable diseases for both residents and staff that is reviewed annually, or more frequently if Indicated. o Methods for identifying, documenting and investigating nosocomlal infections and communicable diseases. The infection control program should be able to Identify new Infections quickly, paying particular attention to residents at high risk of infection of infection (e.g. residents who are Immobilized, have invasive devices or procedures, have pressure sores, have been recently discharged from a hospital to the long term care facility, have MI or MR, have decreased mental status, are nutritionally compromised or have altered Immune systems). o Early detection of residents who have signs and symptoms of TB and a referral protocol to a facility where TB can be evaluated and managed appropriately. o Measures for prevention of Infections, especially those associated with lntravascular therapy. Indwelling urinary catheters, tracheostomy care, atoms care, respiratory care, lnnunosuppreaBlon, pressures sores, bladder and bowel incontinence and any other factors which compromise a resident's resistance to infections.

Rev. 274

06-95

PP-166

TAG NUMBER
F441 Cont.

REGULATION

Rev. 274

GUIDANCE TO SURVEYORS - LONG TBRH CARS FACILITIES
GUIDANCE TO SURVEYORS
o Measures for the prevention of communicable dlaeaaa outbreaks, Including tuberculosis, flu, hepatltlB, scabies, MRSA.
o Procedures to lnforn and Involve a local or State epidemiologist, as required by the State for non-sporadic, facility-wide Infections that are difficult to control. o Isolation procedures and requirements for infected and at risk or lnmunosuppressed nursing hone residents. o Use of and lnservlce education regarding standard precautions, (e.g., universal precautions/body substance isolation). o Handwashing, respiratory protection, linen handling, housekeeping, needle and hazardous waste disposal, as well as other neans for Halting the spread of communicable organisms. o Authority, Indications, and procedures for obtaining and acting upon microbiological cultures from residents and for isolating residents. o Proper use of disinfectants, antiseptics and germicides in accordance with the manufacturers1 instructions and EPA of FDA label specifications to avoid harm to staff, residents and visitors and to ensure Its effectiveness. o Orientation of all new facility personnel to the Infection control program and periodic updates for all staff. o Measures for the screening of the health care workers for communicable diseases, and for the evaluation of workers exposed to residents with communicable diseases Including TB and Blood Borne Pathogens. o Work restriction guidelines for an employee that Is Infected or ill with a communicable disease. o Measures which address prevention of infection common to nursing home residents (e.g., vaccination for influenza and pneumococcal pneumonia as appropriate) TB screening and testing. o Sanitizatlon of tubs, whirlpools and multiple use equipment to be performed according to manufacturer's recommendations.
Observe whether staff Including direct care, housekeeping, kitchen staff, use gloves in accord with aseptic principles.
Determine if there is consistent use of aseptic technique for dressing changes.
If breaks in technique are observed, verify that the facility has a system in place for routine monitoring of staff Infection control practices.
Ask direct care giver staff what do they do and who do they notify when an Infection is noted.
06-95

TAG
KU4BBR
F441 Cont.

REGULATION

GUII MCB TO SURVEYORS - LONG TBBM C M S FACILITIES
GUIDJWCB TO summons
Procedures: S4S3.65(a) Observe sanitation of tub, shower, Multiple residents' whirlpool and care equipment, as necessary.
Identify all residents In the sample who are currently on antibiotic therapy and verify that these residents are reported on the facility's infection control logs/records to ensure that infections are being Identified timely and that these residents are being adequately Monitored for Infection.
Review policies related to infection control If observation, record review, or staff interview Indicate a problea with infection control.
Observe direct care staff routinely washing their hands according to facility written protocols.
Probes: $483.65(a) o Are there unexplained and/or similar infections? For sanpled residents at high risk of infection, what has staff dona to reduce
residents' risk of Infection? o Do surveillance data show a significant increase in the rate of infection from
•onth to month? Over several months? Bow Is this being addressed? o What Infection control policies does the facility use for persons with AIDS,
TB, or hepatitis B? Do these policies conform with Occupational Safety and Health Administration's requirements for protecting employees and current accepted standards of practice recommended by Centers for Disease Control and Prevention (CDC)? Does the staff follow Its own procedures?
o Bow does the facility define and dispose of its infectious waste?

(b) Preventing spread of Infection.

F442

(1) When the Infection control program determines that a resident needs Isolation to prevent the spread of Infection, the facility •ust Isolate the resident.

Intent: S4B3.65(b) The Intent of this regulation Is to assure that the facility Isolates residents appropriately to prevent the spread of Infection. If Infection control has been Identified as an area of concern during Phase 1 of the survey, investigate aspects of the program, as appropriate, during Phase 2.

Rev. 274

06-95

PP-16B

TAQ NUMBER
442 Cont.

REGULATION

Rev. 274

OUIt MICE DO SURVEYORS - LONG TERM CARE FACILITIES

GUIDANCE TO SURVEYORS
Guidelines: S4B3.65(b) Procedures mist be followed to prevent cross-contamination, Including handwashlng and/or changing gloves after providing personal care, or when poxforming tasks among Individuals which provide the opportunity for cross-contamination to occur. Facilities for handwashlng oust exist and be available to staff. The facility should follow the CDC'i Guideline for Handwashlng and Hospital Environmental Control, 1985 for handwashlng.
The facility should Isolate infected residents only to the degree needed to Isolate the Infecting organism. The method used should be the least restrictive possible, while maintaining the integrity of the process. For example, the HIV virus la present in blood and other body fluids. The facility should take universal or standard blood and body fluid precautions related to BIV contamination for the following:
o Blood;
o Vaginal secretions; o Cerebrosplnal fluid; o Synovlal fluid; o Pleural fluid; o Peritoneal fluid; o Pericardial fluid; o Aunlotlc fluid; and/or o Fluids with visible blood.
Residents, visitors and employees should be protected from these fluids. Although the resident infected with BIV should not be Isolated routinely, the resident should be isolated If he/she is in the communicable stages of an opportunistic Infection, his/her body fluids cannot be contained or he/she has very poor hygiene and the likelihood of spillage is high. MOTE: TB Isolation rooms are not needed If the facility does not provide care to
active TB patients/residents.
"Universal precautions" or "Standard blood and body fluid precautions" Is an approach to Infection control where all human blood and certain human body fluids are treated as if known to be Infectious for BIV, BBV, and other bloodborne pathogens.
Probes: S4B3.65(b) o For Isolated residents, does the facility need to segregate them to control the
Infectious agent? o For residents who have been isolated appropriately, does staff use correct
procedures consistently? For example. If isolation procedures require wearing gowns, do all staff put on and dispose of the gown in a way that lessens the spread of Infection?

06-95

PP-169

TAG NUMBSR F442 Cont.
F443
F444

OUII hMCS TO SURVEYORS - LONG TERM CARB FACILITIES

RBCUUTION
(2) The facility m a t prohibit employees with a conuanlcable disease or infected akin lesions froai direct contact with resldenta or their food. If direct contact will transmit the disease.
(3) The facility Bust require staff to wash their handa after each direct resident contact for which handwashing ia indicated by accepted professional practice.

GUIDANCB TO SURVEYORS
o Bow doea the facility control the spread of Infection by persons who visit infectious residents? Ia there a written protocol?
o Do persons with a conmunlcable disease or Infected skin lesions provide care to residents?
o Have any realdents developed a coaaranlcabla disease as defined by State law while in the facility? If so, have appropriate barrier or laolatlon precautions been followed to control further spread of infection?
Procedures: S483.65(b)(l) Verify that all realdenta who require isolation as determined by the infection control prograa are isolated. Observe residents that have been Isolated. Determine what level of isolation they are required to have. Bvaluate Isolation procedures utilized by staff members. Determine If the facility has isolated the resident In the least restrictive environment possible.
Intent! S463.65(b)(2) The Intent of this regulation is to prevent the spread of communicable diseases from . employees to residents when the employee has a cooaninlcable disease or an Infected akin lesion.
State law deflnea comunlcable diseases for purposes of defining facility policies. Skin lesions should be considered Infected If they have purulent drainage, or are res, hot. Indurated without purulent drainage.
Procedures! S483.65(b)(2) Determine If the facility prohibits employees with diseases communicable through direct contact or Infected skin lesions frost having direct contact with realdents. To sake this determination, observe residents* condition and treatments provided. Interview facility staff, and review relevant facility policies and procedures for preventing the spread of infection.
Intenti S483.65(b)(3) The intent of this regulation Is to assure that staff use appropriate handwashing techniques to prevent the spread of infection from one resident to another.
Guidelines: S483.65(b)(3) Procedures Bust be followed to prevent cross-contaeination. Including handwaablng or changing gloves after providing personal care, or when performing tasks among individuals which provide the opportunity for cross-contamination to occur. Facilities for handwashing must exist and be readily available to staff. The facility should follow the CDC'a Guideline for Handwashing and Hospital Environmental Control, 1985 for handwashing.

Rev. 274

06-95

PP-170

TAG NUMBER
F444 Cont.

REGULATION

OUH MICE TO SURVEYORS - LONG TERM C A M FACILITIES

GUIDANCE TO SURVEYORS

Procedures: S483.65(b)(3) Verify that the facility has policy that requires staff to wash their hands after each direct resident contact when Indicated. Observe hand washing by staff after direct contact with residents.

It Is important for the surveyor to begin a thorough investigation of the facility's Infection control program when poor resident outcomes and poor practices are observed.

Probes: S4B3.65(b)(3)

o Does the facility have a written protocol describing handwaahlng practices and

is it consistent with the latest published standards?

o Do staff follow the facility policy and protocol for handwashlng?

^^

F445

(c) Linens.
Personnel Bust handle, store, process, and transport linens so as to prevent the spread of Infection.

Intent: S483.65(c) The Intent of this regulation is to prevent the spread of infection through linens.
Guidelines: S483.65(c) Soiled linens should be handled to contain and to minimize aerosollzation and exposure to any waste products. Soiled linen storage areas should be well ventilated and maintained under a relative negative air pressure. The laundry should be designed to eliminate crossing of soiled and clean linen.
Probes: S4B3.65(c) o Do staff handle linens on the resident care floors and In the laundry area to
prevent the spread of Infection? o Do staff follow the facility's protocols for handling linens? o Are linens processed, transported, stored, and handled properly?

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TAG NUMBER

REGUUTIOH

GUIDANCE TO SURVBYORS - LONG TERM CARB FACILITIES GUIDANCE TO SURVEYORS

F4S4

S483.70 Physical environment.
The facility Bust be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

Guidelines: S483.7O(a) A waiver of specific provisions of the Life Safety Code la reviewed each tine a facility is certified. The State fire authority will determine If the waiver continues to be Justified, In that compliance with the requirement would result in an unreasonable hardship upon the facility and does not adversely affect the health and safety of residents or personnel. The State fire authority will forward its findings and reconnendation as soon as possible to the State survey agency which will forward it to the HCFA RO for a decision on granting a waiver.
Procedures: S483.70(a) The survey for safety frosi fire is normally conducted by the designated State fire authority. The state agency must establish a procedure fox the State fire authority to notify then whether the facility is or is not In compliance with the requirement. If the survey team observes fire hazards or possible deficiencies In life safety from fire, they must notify the designated State fire authority or the RO.

(a) Life safety from fire.
Except as provided In paragraph (a)(l) or (a)(3) of this section, the facility must meet the applicable provisions of the 1965 edition of the Life Safety Code of the National Fire Protection Association (which is incorporated by reference). Incorporation of the 1985 edition of the National Fire Protection Association's Life Safety Code (published February 7, 1985; ANSI/NFPA) was approved by the Director of the Federal Reglater in accordance with 5 U.3.C. 552(a) and 1 CFR Part 51 that govern the uae of incorporations by reference. The Code Is available for inspection at the Office of the Federal Information Center, Room 8301, 1110 L Street N.W., Washington, D.C. Copies may be obtained from the National Flra Protection Association, Batterymarch Park, Qulncy, Mass. 02200. If any changes in this code are also to
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GUIDANCE TO SURVEYORS - LONG TERM CARB FACILITIES

REGULATION
be Incorporated by reference, a notice to that effect will be published In the Federal Register.

OUIDANCE TO SURVEYORS

(1) A facility la considered to be In conpllance with this requirement as long as the facility--
(1) On Hoveober 26, 1962, compiled with or without waivers, with the requirements of the 1967 or 1973 editions of the Life Safety Code and continues to reaaln In compliance with those editions of the Code; or
(11) On Hay 9, 1988, complied, with or without waivers, with the 1981 edition of the Life Safety Code and continues to remain In compliance with that edition of the Code.
(2) After consideration of Btate survey agency findings, HCFA may waive specific provisions of the Life Safety Code which. If rigidly applied, would result In

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GUIDANCB I D SURVBY0R8 - UXO TBKM CARB FACILITIES GUIDAHCB 10 SURVEYORS

unreaaonable hardship upon the facility, but only if the waiver doe* not adversely affect the health and safety of residents or personnel•
(3) The provisions of the Life Safety Code do not apply in a State where HCFA finds, in accordance with applicable provisions of sections 1819(d)(2)(B)(ll) and 1919(d)(2)(B)(ll) of the Act, that a fire and safety code Imposed by State law adequately protects patients, residents and personnel in long tern care facilities.

F45S

(b) Emergency power. (1) An energency electrical power system must supply power adequate at least for lighting all entrances and exits; equipment to nalntaln the fire detection, alarm, and extinguishing systems; and life support systems in the event the nor M l electrical supply is interrupted.

Guidelines: S483.7O(b)(l} "Bnergency electrical power syataaf' includes, at a mlnlsua, battery-operated lighting for all entrances and exlta, fire detection and alarm systems, and extinguishing systems.
An "exit" is defined as a means of egress which is lighted and has three components: an exit access (corridor leading to the exit), an exit (a door), and an exit discharge (door to the street or public way). We define an entrance aa any door through which people enter the facility. Furthermore, when an entrance also serves aa an exit, its components (exit access, exit, and exit discharge) must be lighted. A waiver of lighting required for both exits and entrances is not permitted.
Procedures: S483.7O(b)(l) Review results of Inspections by the designated State flra safety authority that the emergency power system has been tested periodically and la functioning in accordance with the Life Safety Code.
Check placement of lighting system to ensure proper coverage of the listed areas. Test all batteries to ensure they work.

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REGULATION

GUIDANCB TO SURVEYORS - LOHG TERM CARE FACILITIES
GUIDANCB TO SURVEYORS
Probes: $483.70(b)(1) Is emergency electrical service adequate?
Additional guidance Is available In the National Fire Protection Association's Life Safety Code 99 and 101 (NFPA 99 and NFPA 101), 12-5.1.3 which is surveyed In tags K105 and K106 of the Life Safety Code survey.

(2) When life support systems are used, the facility oust provide emergency electrical power with an emergency generator (as defined In NFPA 99, Health Care Facilities) that Is located on the prenlBes.

Guidelines: S483.7O(b)(2) "Life support systens" is defined as one or sore electro-mechanical devlce(s) necessary to sustain life, without which tha resident will have a likelihood of dying (e.g., ventilators, suction machines if necessary to maintain an open airway). The determination of whether a piece of equipment Is life support is a medical determination dependent upon the condition of the individual residents of tha facility (e.g., a suction machine may be required "life support equipment" in a facility, depending on the needs of its residents).
Procedures: S483.7O(b)(2) If life support systems are used determine if there is a working emergency generator at the facility. A generator la not required If a facility does not use life support systems. Check that the emergency generator atarta and transfers power under load conditions within 10 seconds after Interruption of normal power. Where residents are on life support equipment, do not test transfer switches by shutting off the power unless there is an uninterruptible power supply available.
Probes: $483.70(b)(2) Is there a working generator If the facility is using life support systems?

(c) Space and equipment. The facility Bust—

Refer to F246

(1) Provide sufficient space and equipment In dining, health services, recreation, and prograa areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident's plan
of care; and

Rev. 274

Intent: »483.70(c)(l) The Intent of this regulation la to ensure that dining, health services, recreation, activities and program areas are large enough to comfortably accommodate the needs of the residents who usually occupy this space. Therefore, if the survey team determines that there is a negative effect on a resident, refer to F246.
Dining, health services, recreation, and program areas should be large enough to ccmfortably accommodate the persona who usually occupy that apace, including the wheelchairs, walkers, and other aabulation alda used by the many residents who require more than standard movement spaces. "Sufficient space" means the resident can access the area, it la not functionally off-llmlta, and the resident's functioning is not restricted once access to the space is gained.

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RBOUIATIGH

OUIDMCE TO SURVEYORS - LOaO TBHM CARB FACILITIES
GUIDANCE TO SURVEYORS
Prograa areas where resident groups engage In activities focused on manipulative skills and hand-eye coordination should have sufficient apace for atorage of their supplies and "works In progress."
Progran areas where residents receive physical therapy should have sufficient apace and equipment to aeet the needa of the resident's therapy requirement.
Recreation/activities area seans any area where residents can participate In those activities Identified in their plan of care.
Procedures: S483.70(c)(l) In the uae of apace, consider If available apace allows residents to pursue actlvltlaa and receive health services and program aa Identified In their care plan. If the team determines that there la Inadequate apace and equipment to enable staff to provida residents with needed services, refer to F246.

F4S6

(2) Maintain all essential mechanical, electrical, and patient care equipment In aafe operating condition.

Probes: S483.70(c)(2) la essential equipment (e.g., boiler rooai equipment, nuralng unlt/aedlcatlon rooa refrigerators, kitchen refrigerator/freezer and laundry equipment) In aafe operating condition? la equipment maintained according to manufacturers recommendations.

Refar to F252

(d) Resident roona.
Resident rooma Bust be designed and equipped for adequate nursing care, comfort, and privacy of residents.

Guidelines: S483.7O(d) If the survey teas determines that the facility doea not provide rooms designed and equipped for adequate care, comfort and privacy, refer to F2S2.

F457

(1) Bedrooms oust—
(1) Accommodate no sore than four residents;

Guidelines: »4«3.7O(d)(l)(i) See S483.7O(d)(3) regarding variations.
Probes: S483.70(d)(l)(l) Unlesa a variation has been applied for and approved under S483.7O(d)(3), do the residents' bedrooms acconmodate no more than four residents?

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TAG NUMBER
F458

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATION
(11) Measure at least 80 square feet per resident In niltlple resident bedrooms, and at least 100 square feet In single resident rooms;

GU IDWICK TO SURVEYORS
Guidelines: S483.7O(d)(l)(11) See $483.70(d)(3) regarding variations.
The measurement of the square footage should be based upon the useable living space of the room. Therefore, the minimum square footage In resident rooms should be measured based upon the floor's measurements exclusive of toilets and bath areas, closets, lockers, wardrobes, alcoves, or vestibules. However, if the height of the alcoves or vestibules reasonably provides useful living area, then the corresponding floor area may be included in the calculation.
The space occupied by movable wardrobes should be excluded from the useable square footage in a room unless It is an Item of the resident's own choice and It is in addition to the individual closet space In the resident's room. Non-permanent items of the resident's own choice should have no effect in the calculation of useable living space.
Protrusions such as columns, radiators, ventilation systems for heating and/or cooling should be Ignored in computing the useable square footage of the room if the area Involved Is minimal (e.g., a baseboard heating or air conditioning eystem or ductwork that does not protrude more than 6 to 8 Inches from the wall, or a column that is not more than 6 to 8 inches on each side) and does not have an adverse effect on the resident's health and safety or does not Impede the ability of any resident in that room to attain his or her highest practicable well-being. If these protrusions are not minimal they would be deducted from useable square footage computed in determining compliance with this requirement.
The swing or arc of any door which opens directly into the resident's room should not be excluded from the calculations of useable square footage in a room.
Procedures: S483.7O(d)(l)(11) The facility layout may give square footage measurements. Carry a tape measure and take measurements If the room appears small.
Probes: S«83.7O(d)(l)(ll) Unless a variation has been applied for and approved under S483.70(d)(3), are there at least 80 square feet per resident In multiple resident rooms and at least 100 square feet for single resident rooms?

F459

(111) Have direct access to an exit corridor;

Guidelines: S483.7O(d)(l)(111) There is no authority under current regulations to approve a variation to this requirement. Additional guidance la available in the National Fire Protection Association's Life Safety Code 101 (NFFA 101), 12-2.5.1, which is tag K41 of the Life Safety Code survey.

TAG NUHBBR
P460

GUIDMCB TO SUHVBYORS - LOW B M CARS FACILITIES

REGULATION (iv) Be designed or equipped to assure full visual privacy for each resident;
(v) In facilities initially certified after March 31, 1992, except in private roone, each bed Bust have celling suspended curtalna, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains;

GUIDANCE TO SURVEYORS

Guidelines: S483.70(d)(l)(lv) "Full visual privacy" Means that residents have a means of coepletely withdrawing troa public view while occupying their bed (e.g., curtain, moveable screens, private rooe).

The guidelines do not intend to H a l t the provisions of privacy to solely one or more curtains, movable screens or a private rooa. Facility operators are free to use other aeans to provide full visual privacy, with those means varying according to the needs and requests of residents. However, the requirement explicitly states that bedrooas aust "be designed or equipped to assure full visual privacy for each resident." For example, a resident with a bed by the window cannot be required to remain out of his or her rooa while his/her rooonate is having a dressing change. Rooa design or equipment auat provide privacy. Surveyors will aasess whether the Beans the facility is using to assure full visual privacy meets this requlreaent without negatively affecting any other resident rights.

Procedures; S463.70(d)(l(lv) There are no provisions for physician eta the requirement! for full visual privacy.

it* to be used as a basis for variation of

Probes: S4a3.70(d)(l)(lv) Observe whether each resident selected for a comprehensive ox focuaed review baa a aeans to achieve full visual privacy.

Guidelines: j«B3.70(d)(l)(v) The tern "Initially certified" is defined aa all newly certified nursing facilities (NFS) or SNFs as well as NFs and SHFs after March 31, 1992, which re-enter the Medicare or Medicald prograas, whether they voluntarily or involuntarily left the prograa.
It la not necessary for the bed to be accessible froa both sloes when the privacy curtain in pulled.

Additional guidance la available In the Rational Fire Protection Association's Life Safety Code 101 (NFPA 101), 31-1.4.1, 31-4.5, which is tag K74 of the Life Safety Code

P461

(vl) Have at least one window to the outside; and

Rev. 274

Guidelines: S483.70(d)(l)(vl) A facility with resident rooa windows, as defined by section 13-3.8.1 of the 1985 edition of the Life Safety Code, that open to an atrium in accordance with Life Safety Code 6-2.2.3.5 can aset this requirement for a window to the outside.

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F461 Cont.

REGULATION

GUIDANCE TO 8URVBTOR3 - LONQ TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
In addition to conforming with tha Life Safety Code, this requirement was Included to aaalst the resident's orientation to day and night, weather, and general awareness of space outside the facility. The facility is required to provide for a "safe, clean, comfortable and homelike environment" by deemphaeizlng tha Institutional character of the setting, to the extent possible. Windows are an Important aspect In assuring the homelike environment of a facility.
Probes: S483.70(d)(l)(vl) Is there at least one window to the outside?

(vii) Rave a floor at or above grade level.

Guidelines: S483.70(d)(l)(vii) "At or above grade level" is defined aa a room In which tha floor is at or above ground level.
Probes: S4B3.7O(d)(l)(vli) Are the bedrooms at or above ground level?
Additional guidance Is available In the National Fire Protection Association's Life Safety Code 101 (NFPA 101), 12-2.5.1, 12-2.5.7, which Is tag K41 of the Life Safety Code survey.

Refer to F246

(2) The facility m a t provide each resident with--

(1) A separata bed of proper size and height for the convenience of the resident;
(ii) A clean, comfortable nattreas;
(ill) Bedding appropriate to the weather and climate; and

Procedures: J463.70(d)(2)<i)(ll)(iii) If the survey team determines that these requirements are not met, refer to F246.
Probes: S4B3.70(d)(2)(l), (11) and (ill) Are mattresses clean and comfortable? Is bedding appropriate to weather and climate?

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OUIDAHCB TO aURVBVORS - LOBO I B M CAM FACILITIES aurPAHat TO SURVEYORS

Refer to F246

(lv) Functional furniture appropriate to the resident's needs, and Individual closet apace In the resident's bedrooa with clothes racks and shelves accessible to the resident.

Guidelines: I4a3.70(d)(2)(lv) "Functional furniture appropriate to the residents' needs" Beans that the furniture In each realdent'a rooa contributes to the resident attaining or maintaining his or her highest practicable level of Independence and well-being. In general, furnishings Include a place to put clothing away In an organized Banner that will let It remain clean, free of wrinkles, and accessible to the resident while protecting It froa casual access by others, a place to put personal effects such aa pictures and a bedside clock, and furniture suitable for the contort of the resident and visitors (e.g., a chair).
There Bay be instances in which individual raaldenta deteraina that certain lteaa are not necessary or will lapede their ability to maintain or attain thalr highest practicable well-being (e.g.. Both the resident and spouse use wheelchairs. They visit •ore easily without another chair in the rooai.) In this case, the resident's wishes should dateralne the furniture needs.
"Shelves accessible to the resident" Beans that the resident. It able, or a staff person at the direction of the resident, can gat to their clothea whenever they choose.
Probes: i4a3.70|d)(2)(lv) Functional furniture la there functional furniture, appropriate to reeldents' needs? Closet apace le there individual closet apace with accessible clothes racks and shelves?

(3) BCFA, or In the caaa of a nuralng facility the survey agency, Bay permit variations In requirements specified In paragrapha (d)(l)(l) and (11) of thla aectlon relating to rooms In Individual caaes when the facility demonatrates in writing that the variations-
(1) Are In accordance with the special needs of the realdenta; and
Rev. 274

Guidelines: S483.7O(d|(3) A variation Bust be In accordance with the special needs of the realdenta and muat not adversely affect the health or safety of residents. Facility hardship la not part of the basis for granting a variation. Since the special needs of residents may change periodically, or different resldenta may be tranafarred into a room that has been granted a variation, variations must be reviewed and considered for renewal whenever the facility la certified. If the needs of the residents within the room have not changed since the laat annual inspection, the variance ehould continue If the facility ao desires.
Guidelines: $«83.7O(d)(l)(l): Aa raaldenta are transferred ox discharged from rooms with aore than four residents, bads should be removed from the variance until the number of residents occupying the rooa doea not exceed four.

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FP-UO

TAO NUMBER

REGULATION
(11) Hill not adveraely affect resident*1 health and aafety.

GUIDAMCB TO SURVEYORS - LONG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

F462

(e) Toilet facilities.
Each resident room m a t be equipped with or located near toilet facilities.

F463

(f) Resident call system. The nurses' station must be equipped to receive resident calls through a communication system from—
(1) Resident rooms; and
(2) Toilet and bathing facilities.

F464

(g) Dining and resident activities. The facility must provide one or more room designated for resident dining and activities.

Guidelines: S483.7O(e) "Toilet facilities" Is defined as a apace that contains a lavatory and a toilet. If the resident's room Is not equipped with an adjoining toilet facility, then "located near" means residents who are Independent In the use of a toilet. Including chalrbound residents, can routinely use a toilet In the unit.
Probes: $483.7O(e) Are resident rooms equipped with or located near toilet and bathing facilities?
Intent: $483.70(f) The intent of this requirement Is that residents, when In their rooms and toilet and bathing areas, have a means of directly contacting staff at the nurse's station. This communication may be through audible or visual signals and may include "wireless systems".
Guidelines: S483.7O(f) This requirement Is met only if all portions of the system are functioning (e.g., system Is not turned off at the nurses' station, the volume too low to be heard, the light above a room or rooms is not working).
Probes: $483.70(1) Is there a functioning communication system from rooms, toilets and bathing facilities?

Guidelines: S483.7O(g)(1) "Well lighted" Is defined as levels of illumination that are suitable to tasks performed by a resident.

Probes: $483.70(g)(l) Are there adequate and comfortable lighting levels? Are illumination levels appropriate to tasks with little glare? maintenance of independent functioning and task performance?

Does lighting support

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TAO HUMBBR
F464 Cont.

REGUIATIC*

QUIDJlMCB TO SURVEYORS - LCWO TERM CARE FACILITIES CUIDANCS TO SURVEYORS

These rooaa must— (1) Be well lighted; (2) Ba wall vantllatad, with nonsmoking areas Identified;
(3) Ba adequately furnished; and

Guidelines: S483.70(g)(2) "Well ventilated" la defined aa good air circulation, avoidance of drafta at floor level, and adequate snake exhaust renewal.
"Noneaoklng areas Identified" la defined aa signs poated In accordance with State law regulating Indoor Banking policy and facility policy.
Probes i S4B3.7O(a)(2) Bow well la the apace ventilated? la there good air movement? Are temperature, humidity, and odor levels all acceptable?
Are non-smoking areas Identified?
Guidelines: »4B3.7O(g)(3) An "adequately furnished" dining are* accommodates different residents' physical and social needs. An adequately furnished organised actlvltlea area accommodates tha specific activities offered by the facility.
Probesi S483.7O(g)(3) Bow adequate are furnishings? Are furnishings structurally aound and functional (e.g., chain of varying alias to aaet varying needs of residents, wheelchairs can fit under tha dining rooa table)?

(4) Have sufficient space to ai T i Mandate all activitlaa.

Guidelines: $*83.7O(g)(4> "Sufficient apace to accommodate all activities" aeana that the apace available la adaptable to a variety of uaea and residents' needs.
Probes: f483.7O(g)(4)
Bow sufficient Is space In dining, health services, recreation and progrsa areas to accosssodsta all activitlaa? Are apacaa adaptable for all Intended uaea? la realdent accese to apace Halted? Do residents and staff have maximum flexibility la arranging furniture to accoaandate residents who use walkera, wheelchairs, and other nobility alda? la there realdent crowding?

P46S

(h) Other anvlronBental
conditions. Tha facility Bust
provide a safe, functional.
sanitary, and coafortable environment for residents, staff and the public.

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pp-iez

TAG NUMBER F466
'467

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
The facility must— (1) Establish procedures to ensure that water Is available to essential areas when there Is a loss of normal water supply;
(2) Have adequate outside ventilation by Beans of windows, or mechanical ventilation, or a combination of the two;

GUIDANCE TO SURVEYORS
Guidelines: J4B3.7O(h)(1) The facility should have a written protocol which defines the source of water provisions for storing the water, both potable and non-potable, a method for distributing water, and a method for estimating the volune of water required. Procedures: S4B3.7O(h)(l) During the entrance conference, ask the administrator the facility's procedure to ensure water availability.
Probes: S4B3.70(h)(2) Bow well la the space ventilated? la there good air movement? Are tamperature, humidity, and odor levels all acceptable?

F468

(3) Bquip corridors with firmly secured handrails on each side; and

F469

(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Guidelines: |483.7O(h)(3) "Secured handrails" means handrails that are firmly affixed to the wall.
Probes: S483.7O(h)(3) Are handrails secure?
Guidelines: J483.7O(h)(4) An "effective pest control program" is defined as measures to eradicate and contain cannon household pests (e.g., roaches, ants, mosquitoes, flies, mice, and rats).
Procedures: S483.70(h)(4) As part of the overall review of the facility, look for signs of vermin. Evidence of pest infestation in a particular apace la an Indicator of noncompllanca.
Probes: $483.70(h)(4) Is area pest free?

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REGULATION

GUIDAflCB TO SUKVKYORS - LOBO TBHM CADE FACILITIES' GUIDAHCB TO SURVEYORS

F490

C483.75 Administration.
A facility oust 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 well-being of each resident.

F491

(a) Licensure. A facility mist be licensed under applicable 8tate and local law.

Procedures: S483.75 If there is a deficiency in S483.13, Resident behavior and facility practices; 1483.15, Quality of life; or S483.2S, Quality of care, which has the scope and/or severity to be defined as substandard quality of care, fully review for compliance all the tags within this section (S483.75).
Guidelines: S483.75(a) Applicable licenses, permits and approvals sust be available to you for Inspection upon request. Procedures: S483.75(a) If there are problems with car* provided or supervised by licensed personnel, verify applicable licenses, permits and approvals.

P492

(b) Compliance with Federal, State, and local laws and professional standards. 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.

Intent: S483.75(b) The Intent of this regulation Is to ensure that a facility is In compliance with Federal, State, and local lawa, regulations, and codes relating to health, safety, and sanitation.
Guidelines: S483.75(b) The State is responsible for making decisions about whether there are violations of State laws and regulations. Licenses, permits and approvals of the facility must be available to you upon request. Current reports of Inspections by State and/or local health authorities are on file, and notations are Bade of action taken by the facility to correct deficiencies.

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TAG NUMBER

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES

REGULATION
(c) Relationship to other HH8 regulations•
In addition to compliance with the regulations set forth In this subpart, facllltlea are obliged to meet the applicable provision! of other HBS regulations, Including but not United to those pertaining to nondlscrlalnatlon on the basis of race, color, or national origin (45 CFR part 80); nondlscrlminatlon on the basis of handicap (45 CFR part 84); nondlscrlnlnatlon on the basis of age (45 CFR psxt 91); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455). Although these regulations are not In theswelves considered requirements under this part, their violation nay result in the termination or suspension of, or the refusal to grant or continue payment with Federal funds.

GUIDANCE TO SURVEYORS
Procedures: S483.75(b) If resident/family interviews reveal possible problems with admission contracts, review these contracts for violations of requirements at $$463.10 and 483.12. As appropriate, refer problems to an ombudsman or other agencies, e.g.. Office for Civil Rights. Some State or local laws are more stringent than the Federal requirement on the same issue. Failure of the facility to meet a Federal, State or local law may be cited at this tag only when the authority having jurisdiction has both made a determination of noncompllance and has taken a final adverse action aa a reault.
Accepted professional standards and principles Include the various practice acts and scope of practice regulations In each State, and current, commonly accepted health standards established by national organizations, boards and councils.
If Interviews with residents suggest that the facility nay have required deposits from Medicare residents at admission, review the facility's admissions documents.
Procedures: S483.75(c) If during the survey you Identify problems relating to one or more of these requirements, which are under the purview of another Federal agency, forward the Information to the RO, who will forward I t to the appropriate Federal agency.

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TAG NUMBBR
F493

REOULATICM

OUIDAHCg TO BURVBTOM - LONG TERM CARB FACILITIES GUIDANCB TO SURVEYORS

(d) Governing body.
(1) The facility aust have a governing body, or designated persons functioning as a governing body, that Is legally responsible (or establishing and Implementing policies regarding the management and operation of the facility; and

Guidelines: S483.75(d)(2)f1) The administrator must be licensed where required by the State.

(2) The governing body appoints the administrator who i s —
(1) Licensed by the State where licensing Is required; and
(11) Responsible for the nanagsnent of the facility.

(e) Required training of nursing aides—
(1) Definitions. Licensed health professional means a physician; physician assistant; nurse practitioner; physical, speech, or occupational therapist; physical or occupational therapy assistant; registered professional nurse; licensed practical nurse; or licensed or certified social worker.
Hurse aide Beans any Individual providing nursing or nursingrelated services to residents In a facility who la not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay.

Guidelines: S483.75(e) Volunteers are not nurse aides and do not cone under the nurse aide training provisions of these requirements. Unpaid students In nursing education prograsa who use facilities as clinical practice sites under the direct supervision of an RM are considered volunteers.
Private duty nurse aides who are not employed or utilized by the facility on a contract, per diem, leased or other basis, do not cone under the nurse aide training provisions.

Rev. 274

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TAO NUMBER
F494

GUIDANCE TO SURVEYORS - LOHO I B M CARE FACILITIES

REGULATION
(2) General rule. A facility Bust not use any Individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless:
(1) That individual Is competent to provide nursing and nursing related services; and
(11)(A) That Individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of SJ483.1514S3.154 of this part; or
(B) That Individual has been deemed or determined competent as provided In S483.150(a) and (b).
(3) Hon-parmanent employees. A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in paragraphs (e)(2)(l) and (ii) of thia section.

GUIDANCE TO SURVEYORS
Guidelines; S483.75(e)(2 - 4) Facilities may use, as nurse aides, any Individuals who have successfully completed either a nurse aide training and competency evaluation program or a competency evaluation program. However, If an Individual has not completed a program at the time of employment, a facility may only use that individual as a nurse aide If the individual is In a nurse aide training and competency evaluation program (not a competency evaluation program alone) and that individual Is a permanent employee In his or her first four months of employment In the facility.
Facilities may not use non-permanent employees as nurse aides unless they have either completed a training and competency evaluation program, or a competency evaluation program.
Probes: S483.75(e)(2 - 4) During an extended or partial extended survey:
o Have all nurse aides completed a nurse aide training and competency evaluation program or a competency evaluation program? If not, are those nurse aides permanent employees enrolled in a training and competency evaluation program who have worked in the facility for 4 months or less?
o Ask nurse aides where they received their training, how long the training was and how long they have worked In the facility as a nurse aide. ' During all surveys!
o If Incorrect nurse aide work performance Is observed during the survey, check to see If the nurse aide received training and licensed nurse supervision to correctly carry out the task.
A "permanent employee" is defined as any employee you expect to continue working on an ongoing basis.
Procedures: S483.75(e)(2-4) Review competency requirements for nurse aides if you identify potential deficient care practices in quality of care, resident rights, resident behavior and facility practice or quality of life which may be related to nurae aide competency. Is there evidence that the nurse aide has successfully completed the competency evaluation program, or has the individual been grandfathered In by the State?

Rev. 274

06-95

PP-187

no
NUMBER
F495

CUIDAHCB TO 3URVBY0R3 - LONG TBRM CARE FACILITIES

RBCUIATIOM
(4) Competency. A facility nust not use any Individual who has worked less than 4 nonths as a nurse aide In that facility unless the individual—
(1) la a full-tine enployee In a State-approved training and competency evaluation program;
(11) Has demonstrated competence througb satisfactory participation In a State-approved nurse aide training and coopetency evaluation program or competency evaluation program; or
(111) Has been deemed or determined competent as provided In S4B3.150(a) and (b).

OUIDAHCS TO SURVEYORS
If you Identify deficient care practices by nurse aides who do not have evidence of having successfully completed a coapetency evaluation program, determine;
o if the aide ia currently receiving training an a State approved Nurse Aide Training Program;
o if the aide Is under the supervision of a licensed nurse; and o if the aide has been trained and determined to be proficient for the tasks to which he or she is assigned. See S483.152 for specific training that the aide is to receive. This training includes: o at least 16 hours of training In the following subjects before any direct contact with the resident:
communication and Interpersonal skills; Infection control; safety and emergency procedures. Including the Belmlich Maneuver; promoting resident'* Independence; and respecting resident's rights. o Basic nursing skills; o Personal care skills; o Hental health and social services of residents; o Care of cognltlvely impaired residents; o Basic restorative services; and o Resident's rights.

F49G

(5) Registry verification. Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the Individual has met competency evaluation requirements unless—
(i) The Individual Is a full-time enployee in a training and competency evaluation program approved by the State; or

Rev. 274

06-95

FP-1S6

TAO HUMBBR
'496 :ont.

OUIDAHCB TO SURVEYORS - LCHO TERM CJUUt FACILITIES

REGULATION

OUTDANCE TO SURVEYORS

(ll)Tha Individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been Included In the registry. Facilities must follow up to ensure that such an Individual actually become registered.
(6) Multl-State registry verification. Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections lB19(e)(2)(A) or 1919(e)(2)(A) of the Act the facility believes will Include information on the individual.
(7) Required retraining. If, since an individual's Boat recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursingrelated services for monetary compensation, the individual muat complete a new training and competency evaluation program or a new competency evaluation program.

Guideline.: j483.75(e)(7) If an individual does not wish to be retrained, the individual must establish that he or she perfoned nursing or nursing-related services for monetary compensation for at least one documented day (I.e., 8 consecutive hours) during the previous 24 months. The State is required to remove the Individual's name from the registry if the services are not provided for monetary compensation during the 24-month period. Thus, in the absence of any evidence to the contrary, you can assume that the retraining requirement does not apply to an Individual whose name appears on the registry.

Rev. 274

06-95

FF-1S9

TAO •UMBER
F497

GUIDANCE TO SURVEYORS - LOHQ TBHM CARE FACILITIES

REGULATION
(6) Regular ln-aervlca education. The facility nuat complete a performance review of every nuroa aide at leaat once every 12 months, and m a t provide regular ln-aervlca education baaed on the outcona of these reviews. The inservice training Bust—
(1) Be sufficient to ensure the continuing competence of nurse aidaa, but Bust be no leas than 12 houra per year;
(11) Address areas of weakness a determined in nursa aides' perfomanca reviews and Bay address the special needs of residents as determined by the facility staff; and
(ill) For nurse aides providing services to individuals with cognitive impairments, also address the cars of the cognitively impaired.

GUIDANCE TO SURVEYORS
Guidelines: »483.75(e)(8) The adequacy of the ln-servlca education program la measured not only by documentation of hours of completed in-service education, but also by demonstrated competencies of nurBe aide staff in consistently applying the interventions necessary to meet residents* needs.
If there has been deficient care practices Identified during Phase 1 of the survey, review as appropriate training received by nursa aides In that corresponding subject area. For example. If the facility has deficiencies In Infection control, review the infection control unit In the facility's Inservice nurse aide training program. Bach nurse aide must have no less than twelve hours of in-service education par year. Calculate the date by which a nurse aide must receive annual in-service education by the employment date rather than the calendar year.
Probes; S483.75(e)(8) During an extended or partial extended survey, or during any survey In which nurse aide performance la questioned. (See S483.75(f).)
o Does the facility review the performance of lta nursa aides? o How has in-service education addressed areas of weakness Identified in performance reviews, special resident needs, and needs of residents witb cognltlva Impairments? o Bow has ln-servlce education addressed quality of care problems including those of special care needa and resident rights?

Rev. 274

06-95

PP-190

TAG NUMBER
F«98

GUIDANCE TO SURVEYORS - LONG TERM CARE FACILITIES

REGULATION
(t) Proficiency of Nurse aides. The facility nuat 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.

GUIDANCE TO SURVEYORS
Guidelines: S483.75(f) "Competency In skills and techniques necessary to care for residents' needs" Includes competencies In areas such as communication and personal skills, basic nursing skills, personal care skills, mental health and social service needs, basic restorative services and resident rights.
Procedures: S483.75(f) During the Resident Review, observe nurse aidea.
Probes: S483.75(f) Do nurse aides show competency in skills necessary to: Maintain or Improve the resident's Independent functioning, e.g., performing range of notion exercises, assisting the resident to transfer from the bed to a wheelchair, reinforcing appropriate developmental behavior for persons with MR, or psychotherapeutic behavior for persons with MI; observe and describe resident behavior and status and report to charge nurse; follow instructions; carry out appropriate infection control precautions and safety procedures.

F499

(g) Staff qualifications.
(1) The facility Bust employ on a full-time, part-tiae or consultant basla those professionals necessary to carry out the provisions of these requirements.
(2) Professional staff suat be licensed, certified, or registered In accordance with applicable

Procedures: S463.75(g) If there is reason to doubt the qualifications of teaporary agency personnel working in the facility, check with the appropriate registry or professional licensing board.

FSOO

(b) Use of outside resources.
(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility mist have

Rev. 274

06-95

PP-191

TAG HUMBBR
F5O0 Cont.

REGULATION

OUIDAHCB TO SURVBYORS - U N O TSRM CARS F A C I L I T I E S OUIDAHCB TO SURVEYORS

that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (h)(2) of this section.
(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources nust specify in writing that the facility assumes responsibility for—
(i) Obtaining services that Beet professional standards and principles that apply to professionals providing services in such a facility; and
(11) The timeliness of the services.

F501

(1) Medical director.
(1) The facility Bust designate a physician to serve as medical director.
(2) The medical director is responsible for—
(1) Implementation of resident care policies; and

Guidelines: S«83.75(l) "Resident care policies" include admissions, transfers, and discharges; Infection control; use of restraints; physician privileges and practices; and responsibilities of non-physlclan health care workers, (e.g., nursing, rehabilitation therapies, and dietary servlcos in resident care, emergency care, and resident assessment and care planning). The medical director Is also responsible for policies related to accidents and Incidents; ancillary services such as laboratory, radiology, and pharmacy* use of medications; use and release of clinical Information; and overall quality of care. The medical director is responsible for ensuring that these care policies are Implemented.

Rev. 274

06-95

PP-192

TAQ NUMBER
FSO1 Cont.

QUIDAHCB TO SURVEYORS - IOMQ T B M CARB FACILITIES

REGULATION
(11) The coordination of nodical care In the facility.

GUIDANCE TO SURVEYORS
The medical director'a "coordination role" neana that the nodical director Is responsible for assuring that the facility la providing appropriate care aa required. This Involves monitoring and ensuring Implementation of resident care policies and providing oversight and supervision of physician services and the nodical care of residents. It also Includes having a aignificant role In overseeing the overall clinical care of residents to ensure to the extent possible that care Is adequate. When the medical director Identifies or receives a report of possible inadequate medical care. Including drug irregularities, he or she Is responsible for evaluating the situation and taking appropriate steps to try to correct the problem. This may Include any necessary consultation with the resident and hla or her physician concerning care and treatment. The medical director's coordination role also Includes assuring the support of essential medical consultants aa needed. A medical director whose sole function is to approve resident care policies does not neat this requirement.
Probes: $463.75(1) o What does the medical director do to coordinate medical care services for
residents of the facility? o How does the medical director Identify and confirm problems of Inadequate care?

F5O2

(j) Laboratory service*.
(1) The facility m a t provide or obtain laboratory aervlcea to neat the needs of ita residents. The facility Is responsible for the quality and timeliness of the services.

Intent: S483.75(j)(l) The intent of this regulation la to assure that laboratory services are accurate and timely so that the utility of laboratory testing for diagnosis, treatment, prevention or assessment is maximized. The facility la responsible for quality and timely laboratory services whether or not services are provided by the facility or an outside agency.
Guidelines: S483.75(j)(l) A "laboratory service or teat" Is defined as any examination or analysis of materials derived from the human body for purposes of providing information for the diagnosis, prevention, or treatment of any diaease or impairment of, or the assessment of the health of human beings.
Services provided must be both accurate and timely. Timely means that laboratory tests are completed and results are provided to the facility (or resident's physician) within tlnefranea normal for appropriate Intervention. All laboratories providing services for facility residents must meet applicable requirements of 42 CFR Part 493. The purpose of this requirement is to assist In assuring quality of laboratory services.

Rev. 274

06-95

PP-193

TAO NUMBER
FS03

QUIDANCE TO SURVEYORS - LO«a TERM CARB FACILITIES

REGULATION
(I) If the facility provides Its own laboratory services, the services Bust Beet the applicable requirements for laboratories specified in part 493 of this chapter.
(II) If the facility provides blood bank and transfusion services. It Bust Beet the applicable requirements for laboratories specified In Part 493 of this chapter.

GUIDANCE TO SURVEYORS
Procedures: S«83.75(j)(1) Verify that laboratory services are provided to Beet the needs of the residents. If a problea In quality of care leads you to suspect a problea In laboratory services, timeliness or quality, refer to the interpretive guidelines for laboratory testing found in Appendix C.
Probes: S483.75(J)(1) Are problems attributable to:
o An Inability to order laboratory tests in a tlaely Banner, Including delays in transporting the resident to and froa the source of service, if needed?
o A delay of treatment due to untimely receipt of lab results? o A large lag tine between an order for a test and the recording of the results that Bay have resulted in poor care?

(Ill) If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialtles of services in accordance with the requirement* of part 493 of this chapter. (lv) If the facility does not provide laboratory services on site, it oust have an agreement to obtain these services from a laboratory that Beets the applicable requirements of part 493 of this chapter.
Rev. 274

Intent; S483.

- (lv)

The Intent of this regulation Is to assure that laboratory services, bloodbank and

transfusion services are obtained from an entity that meets the requirements of 42 CFR

Part 493 In order to provide a standard of quality for laboratory and transfusion

services. If the long term care facility does not provide laboratory services on site,

there must be an agreement to obtain these services froa a laboratory that meets the

same requirements.

Guidelines: S4B3.75(J)(1)(1) - (lv) If a facility provides its own laboratory services, the provisions of 42 CFR Part 493 apply.

The facility Bust have a Clinical Laboratory Inprovement Amendments (CLIA) certificate appropriate for the level of testing performed. An application for a certificate of waiver may be Bade If the facility performs only those tests categorized as waived under CLIA.

Direct questions concerning the application of these requirements to your State laboratory consultant or the HCPA RO.

Procedures: S483.75Q) (1)( 1) - (lv) Deternine if all laboratory services provided for the facility are provided by • laboratory that meets the requirements of 42 CFR Part 493. The surveyor should determine if the facility has an arrangement in writing to assume responsibility for (a) obtaining services that maet professional standards and principles that apply to professionals providing services In such a facility; and (b) the timeliness of the services.

06-95

PP-194

TAO NUMBER
F503 Cont.

REGULATION

(2) The facility Bust—

OUIDMCB TO SURVEYORS - LCMO TERM CARE FACILITIES
GUIDANCE TO SURVEYORS
Probes: S483.75 (j)(l)(i) - (lv) Are problems attributable to:
o Lack of an arrangement to provide or obtain clinical laboratory services froa a source that Beets the applicable conditions for coverage of the services?
o Delays in interpreting the results of laboratory tests?
Intent: S483.75(j)(2)(1) The Intent of this regulation is to assure that only Medically necessary laboratory services are ordered.

F504

(1) Provide or obtain laboratory services only when ordered by the attending physician;

Procedures: $483.75(J)(2)(i) Verify that all laboratory services received were ordered by the attending physician.

F5O5

(11) Pronptly notify the attending physician of the findings;

F506

(ill) Assist the resident In making transportation arrangenants to and from the source of service, If the resident noedB assistance; and

Rev. 274

Intent: S«83.75(j)(2)(11) The Intent of this regulation is to assure that the physician is notified of all lab results so that proapt, appropriate action Bay be taken if indicated for the resident's care.
Procedures: S«83.75(j)(2)(li) If you have reason to believe that a physiclan(s) nay not have been notified of laboratory results in a timely Banner, detemlne if the facility has a policy/procedure for routine notification of physicians and If the procedure is implemented.
Probes: S483.75(J)(2)(11) o Are any problens identified as relating to lack of proapt notification of the
attending physician, contributing to delays in changing the course of treatment or care plan?

Intent: $483.75(J)(2)(111) The Intent of this regulation is to assure that residents are able to get to and receive necessary laboratory testing when the testing is conducted outside of the facility.
Probes: S483.75{J)(2)(lii) o Does the resident ever have to cancel lab service appolntnents due to
difficulties with transportation?

06-95

PP-195

TAO NUMBER
F507

GUIDANCE TO SURVEYORS - LOHG TERM CARS FACILITIES

REGULATION
(lv) File In the resident'a clinical record laboratory reports that are dated and contain the nane and address of the testing laboratory.

GUIDANCE TO SURVEYORS
Intent: S463.75(j)(2)(lv) The intent of this regulation is to assure that the laboratory performing the tests is Medicare approved, and that test results are accurate and are available for clinical management.

(k) Radiology and othar diagnostic services.

F508

(1) The facility Bust 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.

F509

(i) If the facility provides Its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained In $482.26 of this subchapter.
(11) If the facility does not provide it's own diagnostic services, it oust have an agreement to obtain these services from a provider or supplier that is approved to provide these

Intent: S4B3.75(K)(1) The Intent of this regulation is to assure that the resident receives quality radlologlc and diagnostic services in a timely Banner to neat his/her needs for diagnosis, treatment, and prevention.
Probes: S483.75(k)(l) If problem are identified in radiology or other diagnostic services, are problems attributable tot
o An Inability to order radiological and diagnostic services in a tlasly Manner, including delays In transporting the resident for these services?
o Delays in interpreting the results of X-rays and other tests? o Lack of prompt notification. In writing, of test results to the attending physician, contributing to delays in changing care plans or the course of treatment?

(2) The facility m u s t -

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06-95

PP-196

TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - LONG I S M CARS FACILITIES GUIDANCE TO SURVEYORS

F510 F511 F512 F513
FS14

(1) Provide or obtain radiology and other diagnostic services only when ordered by the attending physician;
(11) Promptly notify the attending physician of the findings;
(ill) Aaalat the realdent in Baking transportation arrangements to and froa the source of service, if the reaident needa assistance; and
(lv) File In the realdent's clinical record algned and dated reports of x-ray and other diagnoatic services.
(1) Clinical records.
(1) The facility must maintain clinical records on each resident in accordance with accepted profesaional standards and practices that are--
(1) Complete;
(ii) Accurately documented;
(ill) Readily accessible; and
(iv) Systematically organized.

Intent: $«B3.75(1)(1) To assure that the facility maintains accurate, complete and organized clinical information about each realdent that la readily accessible for realdent cara.
Guidelines: S483.7S(1)(1) A complete clinical record contains an accurate and functional representation of the actual experience of the individual In the facility. It must contain enough information to show that the facility knows the atatua of the individual, has adequate plana of care, and provides sufficient evidence of the affects of the care provided. Documentation should provide a picture of the resident's progress, Including response to treatment, change in condition, and changes In treatment.
The facility determines how frequently documentation of an Individual'a progress takes place apart from the annual comprehensive assessment, periodic reassessments when a significant change In atatua occurs, and quartarly monitoring assessments. Good practice indicates that for functional and behavioral objectives, the clinical record should document change toward achieving care plan goala. Thus, while there la no "right" frequency or format for "reporting" progress, there Is a unique reporting achedule to chart each realdent's progress In maintaining or improving functional abilities and mental and peychosoclal status. Be more concerned with whether the staff has sufficient progresa information to work with the reaident and leaa with how often that Information is gathered.

Rev. 274

06-95

PP-197

TAG NUMBER

REGULATION

GUIDANCE TO SURVEYORS - LCHG TERM CARE FACILITIES GUIDANCE TO SURVEYORS

P515

(2) Clinical records m a t be retained for—
(I) The period of tine required by State law; or
(II) Five years froa the date of discharge when there la no requirement in State law; or,
(III) For a minor, three years after a resident reaches legal age under State law.

F516
Refar to FI64

(3) The facility Bust safeguard clinical record Information againat loss, destruction, or unauthorized use;
(4) The facility Bust keep confidential all Information contained in the resident's records, regardless of the form or storage method of the records, except when releaae la required by~
(I) Tranafer to another health care Institution;
(II) Lav;

In casea in which facilities have created the option for an individual's record to be nalntalned by computer, rather than hard copy, electronic signatures are acceptable. In cases when such atteatatlon la done on computer records, safeguards to prevent unauthorized acceas, and reconstruction of Information Bust be In place. The following guideline Is an example of how auch a systea Bay be set up:
o There la a written policy, at the health care facility, describing the attestation policy(ies) in force at the facility.
o The computer has built-in safeguards to minimize the possibility of fraud. o Each person responsible for an attestation has an Individualized identifier. o The date and ties is recorded from the computer's Internal clock at the time of entry o An entry la not to be changed after It has been recorded. o The computer program controls what sections/areas any individual can access or enter data, based on the individual's personal identifier (and, therefore his/her level of professional qualifications).
Procedures: S4B3.75(1)(1) In reviewing sampled residents' clinical records:
o Is there enough record documentation for staff to conduct care programs snd to revise the program, as necessary, to respond to the changing status of the resident as a result of lnterventlone?
o Bow la the clinical record used in managing the resident's progress in nalntaining or improving functional abilities and mental and peychosoclal status?
Intent: S4B3.75(1)(3)(4) To nalntaln the aafety and confidentiality of the resident'a record.
Guidelines: S483.75(l)(3) and (4) "Keep confidential" la defined as safeguarding the content of Information Including video, audio, or other computer stored information from unauthorised disclosure without the consent of the Individual and/or the Individual's surrogate or representative.
If there is Information considered too confidential to place In the record used by all staff, such as the faaily'a financial assets or sensitive medical data, it may be retained in a secure place in the facility, auch as a locked cabinet in the administrator's office. The record should show the location of this confidential information.
Procedures: S483.75(l)(3) and (4) Determine through observations and interviews with staff, the policy and implementation of that policy, for maintaining confidentiality of residents' records.

Rev. 274

06-95

PP-19S

TAG NUMBER

REGULATION

GUIDAKCE TO SURVEYORS - LQNQ TERM CARE FACILITIES GUIDANCE TO SURVEYORS

(ill) Third party payment contract; or
(iv) The resident.

Refer to F514

(S) The clinical record must contain—
(i) Sufficient Information to identify the resident;
(11) A record of the resident's assessments;
( H i ) The plan of care and services provided;
(lv) The results of any preadnieslon screening conducted by the State; and
(v) Progress notes.
(•) Dlsaater and emergency preparedness.

F517

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

FS18

(2) The facility must train all employees In emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff.

Probes: S483.75(l)(3) and (4) o How does the facility ensure confidentiality of resident records? o If there la a problem with confidentiality, is it systemic, that is, does the
problem lie In the recordkeeplng system, or with a staff person's use of records, e.g., leaving records In a place easily accessible to residents, visitors, or other unauthorized persons?
Guidelines: S483.75(m) The facility should tailor its disaster plan to its geographic location and the types of residents it serves. "Periodic review" is a Judgment Bade by the facility based on Its unique circumstances. Changes in physical plant or changes external to the facility can cause a review of the disaster plan. The purpose of a "staff drill" is to test the efficiency, knowledge, and response of institutional personnel In the event of an emergency. Unannounced staff drills are directed at the responsiveness of staff, and care should be taken not to disturb or excite residents. Procedures; 8483.75(a) Review disaster and Brgency preparedness plan. Including plans for natural or manmade disasters. Probes: S483.75(m) Ask two staff persons separately (e.g., nurse aide, housekeeper, maintenance person) and the charge nurse:

o If the fire alarm goes off, what do you do? o If you discover that a resident is missing, what do you do?

Rev. 274

06-95

PP-199

TAO OTJMBBR
F518 Cont.

OUIDARCB ID SURVEYORS - LOBO TSRN CARS FACILITIES

REGULATION
and carry out unannounced staff drills using those procedures.

OUIPAMO TO SURVEYORS

o What Mould you do If you discovered a fire In a resident's rocn? Where are fire alarms and fire extinguisher(•) located on this unit?
o Bow do you use the fire extinguisher?

Notes

: Also, construct probes relevant to geographically specific natural emergencies (e.g., for areas prone to hurricanes, tornadoes, earthquakes, floods, each of which nay require a different response).

Are the answers to these questions correct (staff answers predict competency in assuring resident safety}?

F519

(n) Transfer agreement.
(1) In accordance with section 1861(1) of the Act, the facility (other than a nursing facility which is located In a State on an Indian reservation) must nave In effect a written transfer agreenent with one or more hospitals approved for participation under the Medicare and Medlcald program that reasonably asaurss that—
(I) Residents will be transferred froa the facility to the hospital, and ensured of tlnely adnisalon to the hospital when transfer is nodically appropriate, as determined by the attending physician; and
(II) Medical and other Information needed for care and treatnent of residents, and, when the transferring facility deems it appropriate, for determining whether such residents can be adequately cared for In a less expensive setting than either the facility or the hospital, will be exchanged between the institutions.

Rev. 274

06-95

PP-200

TAO NUMBER
F519 Cont.

REGULATION

GUIDANCE TO SURVEYORS - LONG TERM CARS FACILITIES
GUIDANCE TO SURVEYORS

(2) The facility is considered to have a transfer agreement in effect if the facility has attenpted in good faith to enter into an agreement with a hospital sufficiently close to the facility to sake transfer feasible.

F52O

(o) Quality assessnent and assurance.

(1) A facility must maintain a quality assessment and assurance committee consisting o f —

(1) The director of nursing services;

(li) A physician designated by the facility; and

(111) At least 3 other the facility's staff.

trs of

F521

(2) The quality assessnent and assurance carnal ttee—
(1) Meets at least quarterly to identify Issues with respect to which quality assessment and assurance activities are necessary; and

Intent: S483.75(o) The intent of this regulation is to ensure the facility has an established quality assurance committee in the facility which identifies and addresses quality issues, and implements corrective action plans as necessary.
Guidelines: S483.75(o) The quality assessment and assurance conmittee la responsible for identifying Issues that necessitate action of the connlttee, such as issues which negatively affect quality of care and services provided to residents. In addition, the committee develops and Implements plans of action to correct Identified quality deficiencies. The medical director may be the designated physician who serves on this committee pursuant to S4B3.75(o)(l)(il).
Procedures: S483.75(o) This requirement is reviewed only after completion of phase 2 sampling. There are two phases to the quality assurance review. During phase 1 for all facilities:
o The survey team should review how the quality assurance committee functions. Determine through interviews with administrative staff and Quality Assessment and Assurance Committee members if the facility has a Quality Assurance Conmittee which meets the requirements in S483.7S(a).
o Determine If the committee has a formal method to identify Issues inthe facility which require quality assessment and assurance activities. The facility should also have a method to respond to identified issues and a means to evaluate the response to these Issues.
Phase 2 of the review should be conducted if the survey team has identified quality issues. During Phase 2:
o Verify, through interviews with committee members and, as necessary, direct care staff that the committee has established a protocol or method for addressing specific quality problems in the facility that the facility believes have now been resolved.

Rev. 274

06-95

PF-201

TAO
NUMBER
F521 Cont.

RBQUIATICM

QUIDANCE TO 8URVBY0BB - W H O TERM CARE FACILITIES GUIDANCE TO SURVEYORS

(11) Develops and implements
appropriate plans of action to correct identified quality deflclenclea. (3) A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. (4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Do not review committee records identifying details of the specific quality deficiencies. Surveyors should not focus on if the quality assurance coanlttee has Identified and addressed deficiencies which the survey team identifies. Concentrate on verifying that the facility has a quality assurance committee which addresses quality concerns and that staff know how to access that process.
Probes: S4B3.7S(o) When conducting interviews:
o How are facility policies and clinical policies revised based on quality assurance findings?
See Task 5F for detailed information concerning survey procedures.

F522

(p) Disclosure of ownership.
(1) The facility must comply with the disclosure requirements of $$420,206 and 455.104 of this chapter.
(2) The facility must provide written notice to the State agency responsible for licensing the facility at the tine of change, if a change occurs in--
(1) Persons with an ownership or control Interest, as defined In SS420.201 and 455.101 of this chapter;
(11) The officers, directors. agents, or managing employees;
(ill) The corporation. association, or other company responsible for the management of the facility; or

Rev. 274

06-95

PF-202

TAG NUMBER
F522 Cont.

OUIDMCE SURVEYORS - LONG TERM CARS FACILITIES

REGULATION

GUIDANCE TO 8URVKYQRS

(lv) The facility1* administrator or director of nursing.

(3) The notice specified In the paragraph (p)(2) of this section •ust Include the Identity of each new Individual or company.

Rev. 274

06-95

PP-203

PHILADELPHIA NURSING HOME
Inter-disciplinary Environmental Rounds Process
Purpose:
The purposes of performing environmental rounds are as follows: 1. Develop a process to ensure compliance with State survey requirements with regard to environmental standards relating to Resident dignity and quality of life issues. 2. Develop a process to maintain routine compliance through internal monitoring. 3. Provide and encourage involvement of every clinical and non-clinical department
Participants: The rounds will be initiated by inter-disciplinary teams, composed of members from the following departments: 1. Nursing 2. Infection Control 3. Administration 4. Plant Operations 5. Environmental Services 6. Recreation Therapy 7. Fiscal Department 8. Human Resources 9. Central Supply 10. Quality Improvement 11. Admissions Office 12. Physical Therapy 13. Social Service 14. Medical Records Team Development: 1. Every resident and non-resident unit( except a dietary department) has a team composed of at least four to five team members, a team leader and if possible, one alternate team member. 2. Team leaders are individuals from Administration &/or management
Audit Tool: A standardized audit tool will be utilized during team rounds. The audit tool is composed of those items which evaluate key environmental and infection control practices. The audit tool will indicate which area did not meet institutional standards and provide space to incorporate action to correct those noncompliant areas, (see copy of audit tool attached )

page two of two Environmental Round Process
Rounding process: Rounding will be done daily on each unit. By the end of every week, all units will have been completely evaluated. The specifics of the process are as follows: 1. Each day, one team member conducts rounds on every unit. 2. Resident rooms on each unit are divided among unit team members. Team members visit community areas and assigned rooms/residents, on assigned day. 3. Before beginning rounds, the team member asks the Unit Manager or licensed staff on the resident floors or the director/manager of the nonresident floors, to select one person working on the unit to accompany and assist with rounds. 4. Any item that can be easily fixed on the rounds is corrected(example: towel on a bathroom floor is picked up and placed in dirty linen). 5. Following rounds, all staff available on theunit along with a Unit Manager or licensed personnel on resident units and manager/director on nonresident units, will gather for a 3-5 minute meeting to discuss findings. The Unit Manager or licensed personnel &/or director/manager will assign corrective actions and document actions on rounds form. The Unit Manager/licensed personal/director/manager will communicate concerns, corrective actions and system changes with all shift supervisors and unit staffs. 6. One copy of the rounds form is kept on the floor. Other copies will go to Administration, team leaders, Director of Nurses, Director of Housekeeping, Director of Plant Operations and Director of Quality Improvement, for follow-up. 7. Team leaders will meet weekly for the first two months to discuss system issues identified. Team leaders will explore systems improvement ideas with unit staff. 8. Tracking of areas for improvement will be aggregated quarterly and presented to the Quality Improvement Committee.

I Philadelphia Nursing Home

UNIT ROUNDS CHECKLIST

NAME:. Circle item # if out of compliance with regulation.
ITEM NUMBER

UNIT:.

AREA:_

DATE:_

Comment below, t necessary. All suggestions for system improvement are welcome!

WHO/WHAT/WHERE

ACTION TAKEN

1. Evidence of privacy and dignity maintained.

RESIDENTS

2. Resident personal care: hair, nails, mouth, clean, shaven

3 Clothing: clean, neat, footwear appropriate

4. Call lights accessible and operational
5. Bathroom area clean, no personal items or housekeeping cleaners present.
6. Oxygen set-ups dated, cannula covered when not in use. Filters clean. Suction machines in working condition.
7. Gloves are appropriately dispensed and disposed.
8. Resident rooms neat, clean, no dust. Working overbed lights, spreads on bed. Overbed tables, chests and closets clean. Privacy curtain clean and operational.
9. Resident rooms: personal care items appropriately labeled and stored. Linen handled appropriately. Food in appropriate containers.
10. Water cups with fresh water and appropriately dated.

RESIDENT ROOMS

11. Feeding pumps exterior clean & feedings appropriately dated.
12. Foley catheters in appropriate placement for drainage and appropriately covered, if resident out of bed.
13 Irrigation trays dated and marked with name.

14. Furniture appropriately labeled with Resident name.

15. Wheelchairs/ger-chairs clean and in good repair.
16. Halls clean, free of obstacles, equipment to one side of hall. Emergency doors clear.
17. Water fountains clean and operational

COMMUNITY I ENVIRONMENT

18. Unit free from odor.

19. Floors clean. No dirt build-up in corners or around edges

20. Staff complies with dress code. Identification badge visible

21 Dirty/clean carts are covered and emptied on timely basis. Dirty carts are at least 4 ft. from clean linen carts.

22. Medication carts locked if unattended and clean in & out.

23. MEDICATION ROOM: clean, neat, locked Refrigerator clean, temperature 35-45. no food. Approp items dated
24. NURSES STATION: Desk and floor clean. Chart rack free of dust. No food at station.
25. EMERGENCY STORAGE: Floor clean, shelves appropriately stocked. Check sheet appropriately labeled.
26. TUB AND SHOWER ROOMS: Floors and walls clean. No resident care Items available. Thermometer present.

27. DINING ROOM: Tables/chairs clean and free of spills.

28. PANTRY: Door closed, trash container with lid. Ice machine clean and operational. Floor and cabinet clean. Refrigerator clean, temperature 35-40. Approp. items dated.

29. SUPPLY ROOMS: Linen, wheelchairs clean and area neat. 18" clearance from items to ceiling. Door locked.
30. DIRTY UTILITY ROOM: Floor, counter clean. Door locked. Trash in carts with covered lids. Bio-hazard label on appropriate cans. Soap and paper towels available. No trash build-up.
31. CLEAN UTILITY ROOM: Floor, counter clean. Door locked. Sterile items with appropriate expiration date. Treatment carts locked, if unattended and clean inside & outside. Soap and paper towels available.

32. Residents smoking in appropriate lounge with appropriate monitoring by staff.
33. PLANT OPERATIONS: No loose toilet seats. CeiKng. walls, floors in good repair Heat, electric, air condition units and plumbing operational and in good repair Call light operational with appropriate length pull string.

ELTC-SOO 2/98

ROUTING— Administration, Team Leader, Unit Manager

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

-r r\ c>

RESIDENT ACCOUNTABILITY

POLICY:
It is the intention of Episcopal Long Term Care/Philadelphia Nursing Home to provide residents with as much access to self determination conceming movement as possible. Within that intent, we have developed a monitoring program which provides for resident accountability.
PURPOSE:
To provide a system which assumes and communicates that residents are present in the facility.
PROCEDURE:
1. Census must be utilized every shift by the Unit Manager or Charge Nurse to account for each resident on each unit. (See attached sample)
2. Census rounds will be done at 3:00 p.m. , 11:00 p.m. and 7:00 a.m. with the Charge Nurse going off-duty and the Charge Nurse coming on duty. During these rounds resident whereabouts are to be accounted for by noting a checkmark (•) in the appropriate column on the resident identification log. The checkmark (•) means that the resident is physically present on his/her assigned unit.
If the resident is in a location in the facility, other than their assigned unit, or at another facility for doctors appointments, programs, procedures, etc., their location is to be recorded in the log.
For example:
• If the resident is on the Patio record PATIO • if the resident is in the X-ray Department record X-RAY • If the resident is at Einstein Program record EINSTEIN • If the resident is at Episcopal Hospital Emergency Room record EH/ER • If the resident was admitted to a hospital record ADMITTED • If the resident was transferred to another unit record TRANSFER/UNIT • if the resident was discharged record DISCHARGED • If the resident expired record EXPIRED

When rounds arr completed, the Charge Nurse coming on-auty ana me onarge Nurse going-off duty are to affix their signature at the bottom of the log labeled "SIGNATURES" in the appropriate column.
3. Unit Managers/Shift Supervisor are responsible to verify that the resident census and presence in the facility is accurate.
The census report and resident identification log will be utilized by Unit Manager/Shift Supervisor each shift as a check that rounds are conducted and each resident is accounted for on each unit.
Unit Manager and Shift Supervisor are also responsible to conduct room-to-room rounds. At the completion of rounds the Unit Manager/Shift Supervisor will affix their signtures on the bottom of the log labeled "UM/SUP" in the appropriate column.
4. Any resident not accounted for will be reported to the Unit Manager or Supervisor and a search of the building and grounds will be conducted immediately.
5. Once it has been determined that the resident is not in the building nor on the grounds, the Unit manager or nursing Supervisor will contact the following: from the hours of 7:00 a.m. - 3:30 p.m.; Administrator, Director of Nursing, attending physician, responsible relative and from the hours of 3:00 p.m. - 11:30 p.m. and 11:00 p.m. - 7:30 a.m.; Administrator on call, Nurse Administrator on call, attending physician, responsible relative. If the resident is determined to be AWOL, the Department of Health and police are notified.
6. An incident report will be completed and an investigation as to the causes will be conducted. Trending reports will be completed and presented to Quality Assurance committee on a quarterly basis.
7. The census report and resident identification log are to be retained on each unit attached to assignment sheets.
The Unit Manager is responsible for maintaining these records in an orderly fashion.
B :\rita.lnf\resacct.pro 9/97

EPISCOPAL LONG TERM CARE PHIT A f t ^ p i p A NURSING HOME
BEHAVIORAL UNIT Program Outline and Implementation Schedule
Goal:
• Focus facility resources in one wing to meet the complex needs of residents with problematic behavior
• Provide the least restrictive, home-like environment for residents with problematic behaviors while ensuring the safety of all residents and staff.
Location: 2 East (25 beds)
Admission Criteria
• Males who are current residents of PNH or after admission to PNH demonstrate problematic behavior who have been deemed appropriate by the Admissions Team. The problematic behaviors include:
Difficulty in relating to other residents or staff, including verbal and physical outbursts
Non-compliant in participating in routine activities of daily living including bathing, dressing, etc.
Non-compliant with interdisciplinary plan of care which contributes/exacerbates problematic behavior
Requires behavior intervention when in contact with other residents' personal belongings
• Need for coordinated, consistent behavioral modification program in order to minimize problem behavior.
• Demonstrates ability to respond to behavioral intervention and redirection.
Admission Process:
• Interdisciplinary team will recommend psychiatric consult and/or neuropsychology testing to confirm residents appropriateness for the behavioral unit.
• The Admissions Committee, comprised of the Director of Nursing or designee, Medical Director, Director of Social Work, Director of Admission, Unit Manager and Psychiatric Nurse Specialist will review all medical information including psychiatric consult in determining a resident's appropriateness for admission to the Behavioral Unit.
etaikhVbehav.unt

Behavioral Unit (Continued)

2 East

Discharge Criteria:
• Residents of the Behavioral Unit who care needs necessitate transfer to a more appropriate unit. These care needs include:
• Compliant in participating in routine activities of daily living for sixty (60) days. • No episodes of verbal or physical outbursts for ninety (90) days. • Significant changes in medical status which eliminates either non-compliant and/or
verbal or physical outbursts.
• Interdisciplinary team will recommend a resident's discharge from the behavioral unit. • The Admissions Committee will review all medical information and determine resident's
appropriateness for discharge from the behavioral unit.
Staffing:
• Nursing 2 East @ 4.0 hours PPD
Under the supervision of an ADON, the unit will be managed by a unit manager who with the Psychiatric Nurse Specialist and IDT will define and conduct an educational program consistent with the behavioral interventions that will be utilized.
• Social Service
.5 FTE MSW with demonstrated skill in group dynamics and behavioral interventions
- complete in depth psychosocial history for each resident. - participate in therapeutic regimen including support groups and individual/family
counseling. - act as a liaison between family, facility and resident - act as a liaison between facility and community mental health system. - coordinate all discharge planing for the unit. - educate other disciplines regarding the psychosocial needs of residents.
• Recreation Therapy
25 FTE Recreation Therapists with demonstrated skill in behavioral intervention - J5Q FTE Recreation Aide

c\mkb\bchav.um

Behavioral Unit (Continued)

2 East

• Psychiatric Services
- Psychiatrist participate in development of behavioral plan monitor medications educate team as to underlying causes for problematic behavior
Psychiatric Nurse Specialist participate in development of behavioral plan provide initial and ongoing staff education monitor behavioral approaches for each resident monitor resident reaction to medication regimen
Clinical Psychologist provide neuropsychological testing as required provide individual and small group counseling
• Interdisciplinary Team
Interdisciplinary Team will include Nursing, Psychiatric Nurse Specialist, Social Worker, Recreational Therapist, Clinical Dietitian, Respiratory Therapy and Rehabilitation Services as appropriate.
Interdisciplinary Care Conferences will occur on a weekly basis.
- Stand-up IDT meetings with follow-up documentation will occur daily to develop and/or assess current interventions.
- Schedule for daily and weekly care conferences will be determined by the Unit Manager in cooperation with the team.

CmkhVbehav.uiu

Action

Resident Pre-Relocation screening

• Psychiatric consults

,

• Neuropsychotogicals if indicated • Complete recommendations to
Admissions Committee including roommate matches.

• Relocation of Current Residents to Other 1CF Units (16) • Maximum - 2-3 residents/week

AEMC Psychiatric Team in place

• Psychiatric Nurse Specialist • Psychiatry 24 hour/In House

• Clinical Psychology Available for pre-screening

and consultations

• Unit Staffing • Psychiatric Nurse Specialist

assessment of residents with problematic behaviors

Responsible Party PNH Medical Staff and AEMC Psychiatry AEMC Psychiatry AEMC Psychiatry/rnterdisciplinary Team
Admissions/Social Service/Nursing
AEMC Psychiatry AEMC Psychiatry
AEMC Psychiatry AEMC Psychiatry AEMC Psychiatry

in conjunction with Interdisciplinary Team develop behavior interventions as indicated.

AEMC Psychiatry/Interdisciplinary Team

Inservicing of all Interdisciplinary staff on behavioral interventions/approaches.

AEMC Psychiatry/Interdisciplinary Team department directors

Target Date 10/20/95 11/03/95 11/03/95
11/10/95
10/16/95 10/02/95
09/25/95 10/16/95 11/03/95 11/10/95 and ongoing
10/16/95 and ongoing

tint

Action Recreational Therapy • assignment of appropriate
therapist and aide • development resident
specific and unit programming with input from Recreational Therapy consultant and Interdisciplinary Team
initiation of new programming
• attendance at all appropriate inservices
• participate in IDT conferences • Social Services
• assignment of MSW with demonstrated skill in group dynamics and behavioral interventions
• participation in Interdisciplinary Team conferences
• attendance at all appropriate inservices

Responsible Party
Recreational Therapy/Assistant Administrator
Recreational Therapy/Consultant Assistant Administrator

Target Date 11/10/95
11/03/95 and ongoing

Recreational Therapy/Assistant Administrator Recreational Therapy/Assistant Administrator Recreation Therapy/Assistant Administrator Director of Social Services
Director of Social Services Director of Social Services

I I/I7/95 and ongoing
10/16/95 and ongoing
11/03/95 9/25/95
11/03/95
11/03/95

ichiv.unl

Nursing Recruitment and/or reassignment of appropriate licensed and'ancillary nursing staff

Responsible Party Director of Nursing and/or designee

Staffing appropriate for: - eight residents

Director of Nursing and/or designee

- ten residents

- twelve residents

- fourteen residents

- see unit phase in schedule

attendance at all appropriate inservices

Director of Nursing and/or designee

participation in Interdisciplinary Team conferences
Unit Phase-In • Problematic Resident to 2 East • 8 relocated residents • 8 residents plus 2 relocated residents • 10 residents plus 2 relocated residents • 12 residents plus 2 relocated residents • 14 residents plus 2 relocated residents • 16 residents plus 2 relocated residents • 18 residents plus 2 relocated residents • 20 residents plus 2 relocated residents • 22 residents plus 2 relocated residents

Director of Nursing and/or designee Interdisciplinary Team

•chav.unl

Target Pate
9/21/95 and ongoing
11/13/95 11/20/95 11/27/95 12/04/95
10/16/95 and ongoing
11/03/95
11/13/95 11/20/95 UlTl 195 12/04/95 12/11/95 12/18/95 12/25/95 01/01/96 01/08/96

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME

ADULT UNIT

Program Outline and Implementation Schedule

Mission:

To provide the least restrictive home-like environment for young or middle aged residents, while focusing facility resources on wing/unit to meet the complex psychosocial needs of this group of residents.

Location: 5 East

Admission Criteria

Young/Middle Aged Adults who are current residents of PNH or after admissions have demonstrated the following:
• psychological need for interpersonal interaction and activities consistent with unit
• ability and interest in participating in specially developed activities and groups
• ability to communicate needs and wishes • willingness to attend facility based substance abuse program if active
personal substance abuse history exists
• proven record of complying with facility rules • care needs can be appropriately met by the unit's interdisciplinary team
and nursing staff

Admission Process

Interdisciplinary teams will recommend residents for the unit based on the admission criteria.
Social Worker will interview all potential residents for interest/willingness to relocate to the unit. Resident must agree via behavioral contract to comply with rules of the unit and participate in appropriate counseling and groups. The admissions team comprised of Assistant Director of Nursing, Social Worker, Unit Manager and Medical Director or designee will review all information and determine resident's appropriateness for admission.

Adult Unit Program Outline and Implementation Schedule December 4, 1995
Discharge Criteria
• Unit interdisciplinary team will recommend resident for transfer off the unit based on one or more of the following: - significant change in medical condition which decreases resident's ability to participate in unit's psychosocial programs. - significant change in resident's care needs that unit's interdisciplinary team are unable to provide. - unwillingness to participate in facility-based programs. - physical or verbal outbursts. - failure to comply with units' rules.
• The admission team will review all information and determine resident's appropriateness for transfer from the unit.
Staffing • Nursing 5 East @ 3.5 aours PPD
- Under the supervision of an Assistant Director, the wing will be managed by a unit manager who with the social worker and recreational therapist will define or conduct a program consistent with these residents physical and complex psychosocial needs.
• Social Service - .5 FTE MSW with demonstrated skill in group dynamics, substance abuse and young adult disabilities. - complete update indepth psychosocial history for each resident - negotiates behavioral contract for all residents appropriate for admission - acts as a liaison between family, facility and resident - coordinates all discharge planning for the unit - participates in staff education of other disciplines regarding the psychosocial needs of these residents
• Recreation Therapy - .25 FTE Recreation Therapists with demonstrated skill in program development which includes interactive groups, recreational and educational activities
c\mkh\policy\[;04.Adm

Adult Unit Program Outline and Implementation Schedule December 4, 1995

Rehabilitation Services - .2 FTE Exercise disabilities

to coordinate exercise program consistent with physical

Space - Expand common space available for informal and fonnal activities - Discuss conversion of large three bed room to second lounge - Increased use of Pavilion for large group activities - Discussion location of smoking areas

Equipment - Exercise equipment - Video games (? donation) - Expand cable potential on 5 East - Activity Supplies - Library

Interdisciplinary Team - Interdisciplinary Care Conferences will occur on a weekly basis. Residents will be
encouraged to attend.

crmkh\poIicyU204.Adm

Adult Unit Program Outline and Implementation Schedule December 4, 1995
Action • Resident relocation screening to include
- willingness to relocate and behavioral contract to abide by rules of unit. •
• Relocation of Current Residents to Other ICF Units (6 residents/week)
• Adult Unit Task Force will meet weekly to continue program development.
• Activity Programming Presentation to Adult Unit Task Force - Programming revisions supplies/ equipment requirements - Program implementation
• Substance Abuse Counseling - 1 on 1 - AA community group - group counseling

Responsible Party Social Worker

Target Date J/5/96

Admissions/Social Service/Nursing
Executive Director/ Social Worker/Recreational Therapists/Residents
Recreational Therapist

2/2/96
Ongoing - Thursdays, 4PM Auditorium
12/7/95

12/21/95 1/15/96

Social Worker Social Worker Social Worker

Ongoing 1/15/96 1/08/96

c:\iiikl>\policy\l2CMA<lm

Adult Unit Program Outline and Implementation Schedule December 4, 1995
Action • Educational Programs
- development of program - recruitment of tutors/training - implementation
• Space requirements determined; evaluate need for renovation; determine need for second floor smoking area
• Assess area electrical requirements due to concentration of motorized wheelchairs
Unit Phase - In • Adult Resident to 5 East
- 6 relocated residents - 6 relocated residents - 6 relocated residents - 4 relocated residents .

Responsible Party
Social Worker/ Recreation Therapist
Specialty Unit Task Force and Plant Operations

Target Date
1/15/96 1/29/95 2/12/96
1/5/96

1/5/96
1/08/96 1/15/96 1/22/96 1/29/96

c:\mkh\policy\l2W.Adm

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSTNC HOME,
DEMENTIA UNIT
Program Outline Goaj; • Focus facility resources in one wing to meet the complex needs of residents with dementia
related behavioral problems • Provide the least restrictive, home-like environment for residents dementia-related problems
while ensuring the safety of all residents and staff.
Location: 5 West (49 beds) Admission Criteria • Current residents of PNH or after admission to PNH who demonstrate dementia - related
behavioral problems and who have been deemed appropriate by the Interdisciplinary Team. Dementia - related behaviors include:
Wandering which results in disruption of other residents Difficulty in relating to other residents or staff, including verbal and/or physical outbursts Requires behavioral intervention when in contact with other residents personal belongings
Admission Process: • Interdisciplinary team will review resident's medical record including all consults to confirm
the resident's appropriateness for the dementia unit.
Discharge Criteria: • Residents of the Dementia Unit whose care needs necessitate transfer to a more appropriate
unit. These care needs include: Significant changes in medical status which eliminates either non-compliant and/or verbal or physical outbursts and wandering.
The Interdisciplinary Team will recommend a resident's discharge from the dementia unit. The team will communicate the need for a room change to the Admission's department.
c:\fflkh\behavior\dementia.2

Staffing-
• Nursing 5 West @ 3.7 hours PPD
Under the supervision of an ADON, the unit will be managed by a unit manager and with the cooperation with behavioral health professionals conduct an educational program consistent with the behavioral interventions that will be utilized.
• Social Service
- .5 FTE Social Work with demonstrated skill in group dynamics and behavioral interventions - complete in depth psychosocial history for each resident. - participate in therapeutic regimen including support groups and individual/family counseling. - act as a liaison between family, facility and resident. - act as a liaison between facility and community mental health system. - coordinate all discharge planning for the. unit. - educate other disciplines regarding the psychosocial needs of residents.
• Recreation Therapy
.50 FTE Recreation Therapists with demonstrated skill in behavioral intervention .50 FTE Recreation Aide
Mental Health Services
Psychiatrist - provide consultant function as required - monitor medication in accordance with accepted standards of care - assist IDT in identification of underlying causes of behavior .
Psychiatric Nurse Specialist participate in development implementation of IDT plan of care monitor resident's responses to behavioral approaches monitor resident responses to medication regimen when indicated
Psychotherapist provide individual and group psychotherapist participate in development implementation of IDT plan of care
Interdisciplinary Team
Interdisciplinary Team will include Attending Physician, Physician Assistant, Nursing, Psychiatric Nurse Specialist, Social Worker, Psychotherapist, Recreational Therapist, Clinical Dietitian, Respiratory Therapy and Rehabilitation Services as appropriate.
c:\mkh\behavior\dememia.2

Action
Develop Program Outline
Educate clinical interdisciplinary staff re: behavioral care planning and interventions Review of resident safety systems
surveillance cameras code alert system Facility - Unit based Interdisciplinary Teams will initiate recommendations for meet admission criteria
Resident Admission Screening and Approval
review of medical record communications with both sending and admitting IDT
Nursing - all staff assigned attend all appropriate education programs participate and implement interdisciplinary plan of care participation in interdisciplinary therapeutic activity programs
Recreational Therapy assignment of therapist and recreation aide attend all appropriate education programs participate and implement
llMirll.miil VtlrinrilH.

Responsible Party Speciality Unit Task Force Departments: Medicine, Nursing, Social Work, Therapeutic Recreation, Food Service, Rehabilitation Executive Director, Director of Plant Operations and Security Unit-based Interdisciplinary teams
Five West Interdisciplinary Team Unit-based Interdisciplinary teams
Assistant Director of Nursing
Director of Therapeutic Recreation Director of Social Work and Community Relations

Tareet 09/20/96 and revised 12/97 11/96 and 12/96 reeducate 3/98 Surveillance System: 10/97 Code Alert: 12/97 1/98
3/98 and ongoing
11/96, 12/96 and 3/98
3/98 and ongoing 12/98
3/98 11/96, 12/96,3/98 3/98 and ongoing

Action
interdisciplinary plan of care design resident-specific therapeutic recreation programs develop unit-based recreation programs to be coordinated by the unit certified nursing aide
Social Work assignment of social worker with demonstrated skill in behavioral interventions participation and implementation of Interdisciplinary Team Care Plans attendance at all appropriate education sessions discharge planning as appropriate

Responsible Party
Director of Social Work Director of Social Work Director of Social Services

Target Date 3/98 and ongoing 12/98
3/98 3/98 and ongoing 11/96 and 12/96,3/98

c NiiikhVhcliav UIIAdcuicitiia 2

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

C 7-/
•'

MDS/RAP THE RESIDENT ASSESSMENT INSTRUMENT
POLICY:
The MDS and RAP is completed for each resident within fourteen (14) days of admission/readmission and is completed according to the Minimum Data Set 2.0 Manual.
PURPOSE:
The Resident Assessment Instrument (RAI) is used in order to maintain timely and comprehensive resident assessments as a basis for problem identification and care plan development and to assist the resident to attain and/or maintain the highest practicable physical, mental and psychosocial functioning possible.
PROCEDURE:
1. The Minimum Data Set 2.0 User's Manual is maintained on every unit.
2. The Unit Manager/Charge Nurse is responsible to review the MDS 2.0 Manual and to follow the procedures for completing the MDS and RAPs.
3. The Unit Manager/Charge Nurse is responsible to review the monthly MDS Report in order to identify those residents whose quarterly or yearly MDS is due.
4. The Unit Manager/Charge Nurse is responsible to initiate a complete MDS within fourteen (14) days of admission or readmission, every ninety (90) days (quarterly), and when there is a significant change in the resident's condition.
5. The Unit Manager/Charge Nurse is responsible to complete those sections qQhe MDS and RAPS that involve nursing (see attached flow chart).

400.0 pg. 2 of 2
6. The Unit-Manager/Charge Nurse is responsible, through the Inter-Disciplinary Care Conference, to coordinate the completion of the MOS and RAPs within a timely manner. However, it is the ultimate responsibility of each discipline to complete their sections of the MDS/RAPs within the appropriate time frames. a. The Resident Care Plan is initiated within two (2) weeks and is completed within 21 days of resident admission and is maintained, reviewed and revised throughout the resident's stay. b. The Resident Care Plan is reviewed and revised at least once every three (3) months at the time of the Quarterly and/or Yearly MDS/RAPs review and is revised when the resident has a significant change. « c. The Resident Care Plan is interdisciplinary; therefore, each resident problem is addressed by ail disciplines involved. d. A new Resident Care Plan is initiated only when the resident has been out of the facility for more than thirty (30) days and returns as a new admission.
SEE CARE PLAN POLICY AND PROCEDURE
C1WM3OCSlPOUCY.PftEUMOSRAP.POI. MC.M7

Resident Admission t I
Basic Assessment Tracking Form
(Admissions)

MA Tracking Form (Admissions)

/New Admission >.

No

Yes

MA Tracking Form .- ^ - - Proceed with regular MDS schedule

(Date of Admission unless otherwise specified) (Transfer OFF MA to Non-MA ie. Medicare) (Date of discharge to hospital or other setting) (Date of reentry to facility if on MA)

Quantity MDS
Basic Assessment Tracking Form
(AA#6,«9) Section A = Nursing
Section B » Nursing Section C = Nursing Section E • Social Work Section G = Nursing Section H • Nursing Section I » Nursing Section J * Nursing Section K - Dietary Section M - Nursing Section N = T. Recreation Section O » Nursing S action P 1a = Nursing
1b - Therepies (individual) P2 = Social Work P3 to 9 = Nursing Section Q » Nursing Section R - ALL Section S # 1 thru 3 = Admissions Section S # 4 » Nursing

Annual MDS Basic Assessment Tracking Form
(AA«8.#9) Complete Full MDS 2.0

• Transfer/Discharge
Discharge Tracking Form (Admissions) I
Reentry Tracking Form MA Tracking Form
(Admissions)

I I Merger Form (MDS Office)
• Reassess MDS (Nursing)

MDS 2.0 Face 8heet (Section AB) (Admissions)
Custoomsary Routine (Section AC) (Admissions Cast Manager)
MDS 2.0
Section A • Nursing Section A « 6 , 1 7 = Admissions/ Business Office Section B • Nursing Section C • Nursing Section D * Nursing Section E > Social Work Section F - Social Work Section Q - Nursing Section H - Nursing Section I - Nursing Section J - Nursing Section K • Dietary Section L • Nursing Section M • Nursing Section N - T. Recreation Section O - Nursing Section P
la • Nursing 1 b > Therapies (individual)
P2-Social Work P3 to 9 B Nursing Section Q » Social Work Section R = ALL Section S #1 thru 3 = Admissions Section S #4 • Nursing

/ -
EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING
INTERDISCIPLINARY RESIDENT PLAN OF CARE
POLICY:
A comprehensive and individualized plan of care is maintained in an ongoing basis for each resident. The Plan of Care includes measurable objectives and time tables to meet resident's medical, nursing, mental and psycho-social needs.
The PNH Resident Care Plan is interdisciplinary and addresses problems identified through a comprehensive assessment (See the Resident Assessment Instrument, MDS/RAPs). The Resident Care Plan is addressed by all disciplines involved in the resident's care. The Resident Care Plan becomes a permanent part of the resident's chart.
PURPOSE:
To plan individualized and appropriate care in order to address identified problems and to promote the highest practicable physical, mental and psycho-social functioning as possible.
PROCEDURE:
A. The Interdisciplinary Resident Care Plan is initiated within fourteen (14) days of the resident's admission.
B. The initial Interdisciplinary Resident Care Plan is completed within twenty-one (21) days of the resident's admrssion/readmission and continues until discharge by review and revision as necessary.
C. Information about :he resident is completed on the first page of The Resident Care Plan Form, and includes:
1. Resident name 2. Room number 3. Admission date 4. Admission number 5. Admission location 6. Age

7. Sex 8. Allergies 9. Doctor's name 10. Admission diet 11. Medical diagnosis on admission 12. Additional diagnosis with date of onset 13. The name, telephone number, relationship and availability of the relative or
significant other involved in the resident's care planning. 14. Any updates or changes in the above information 15. Advance Directives review dates

EXAMPLE:

RESIDENT CARE PLAN

ircv.vr OTXM :MTJLV<O ;.V O M « .

-7JVO '

D. The start date and overall goal (Long Term Goal) is documented, using the identified individual problems or needs of the resident.

am

E. The discharge plan is documented (usually by Social Service) EXAMPLE:

. 1 I..MC- I

U.v.tn

F. The resident's strengths are documented. EXAMPLE:

G. The identified problem or need is documented. All items triggered on the RAP sheet, and found to be valid, will be addressed on the Resident Care Plan. If the team does not act on an item triggered, they must document the reason for nc inter/ention. This can be accomplished on the RAP Sheet in the space provided. or explained in the RAP Summary.

H. The interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, develops quantifiable objectives (short term goals) based on the identified needs.

1. Selected short term goals:

EXAMPLES

NOTE:

Examples are designed to assist in the development of the plan of care,
however, the plan of care should-be personal and individualized to the resident.

I. Care planning interventions are developed for all RAPs triggered by the MDS. J. The Interdisciplinary Resident Care Plan will reflect intermediate steps for each
outcome objective (short term goal).
SEE EXAMPLES:

A .,, >( ^4- ;Lif -y

I

K. The Code:
N - Nursing D - Dietary A - Activities TH - therapy SS - Social Service R - Resident SO - Significant Other P - Physician PC - Pharmacy Consultant

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i

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will be used to document involvement in specific intervention

EXAMPLE:

APPROACH INTERVENTION

DISC

1

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1

1

1

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i

i

1

1 V

1

i

TAHGET I DATE DATE ' RESOLVED

L A reasonable target date for the accomplishment of the goal and/or intervention will be documented in the space provided. 1 When the care plan is revised it may be necessary to add a revised target date.
M. The date of resolution is documented in the space provided. 1. When the need is resolved, it is highlighted with yellow highlighter and is no longer carried as a problem.
N The Resident Care Plan is revised at least every three (3) months at the time of me Quar^ly or Yearly MDS/RAP review, but may be revised more frequently rf necessary.
0 . The date of the Care Conference is documented in the space provided.
P. The Resident Care Plan is signed by all disciplines involved.
EXAMPLE:

INTERDISCIPLINARY ORE CONFERENCE
CMI«i:ilN«l LMIN. (I a»n. -

NLMMS.. • i>^.. . . . . •. i i - ' " • - • .!•'••'
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Q In addition Respiratory Therapy and/or the Einstein Program are members of the imerdisdpl'inary team when resident's treatments involve those d,sc,pl.nes.
B:\POUCY.PRO\RESCARE.PLN Revised: 11/4/97

5. In the event of a positive alcohol/drug screen, physician will:
A) Counsel the resident regarding positive screen and encourage cooperation with substance abuse evaluation/Tx.
B) Document resident's response to counseling and referral in medical record.
C) Work with resident, Social Work (Psychiatry if necessary) and IDCT to develop and implement a treatment plan
Social Work Depar**TnoTtt;
1. Arrange evaluation of resident by Certified Addiction Counselor (CAC) within 24 -72 hours of event.
2. CAC will:
A) Complete substance abuse history.
B) Provide addiction education for resident.
C) Work collaboratively with Psychiatry/Psychotherapy in situations of dual diagnosis.
D) Assess resident's motivation for Tx.
E) Recommend treatment regimen and assist unit social worker with referral process.
F) Document assessment and Tx recommendation in Medical Record.
3. Unit Based Social Worker will:
a) Arrange IDCT conference to review Tx. plan
b) Initiate referrals for Tx Programs as defined by CAC
c) Work with transport coordinator to ensure transportation.
d) Monitor resident's compliance with and progress in Tx. program.
e) Keep IDCT abreast of resident's progress in Tx. Program.

f) Counsel resident as appropriate regarding compliance issues.
g) As appropriate and with residents permission, keep family/significant others abreast of situation.
h) Arrange for safe and appropriate discharge of residents when necessary

DRAFT TITLE:

PHILADELPHIA NURSING HOME ASSESSMENT OF RESIDENT WITH ACUTE MENTAL STATUS CHANGE

EFF DATE PAGE 1 Of 4

I. PURPOSE;
To provide a consistent and predictable response to behavioral changes due to substance abuse and other violations of PNH policies/regulations.
II. POLICY STA'
A resident's use of any non-prescribed drugs or illicit psychoactive substance, including alcohol, shall be considered substance abuse. Such use places the resident at grave risk for unpredictable medical and/or behavioral reactions and endangers the well-being of that resident, other residents and/or PNH staff.
Ill• PROCEDURE/RESPONSIBILITY;
1. Any resident with an acute change in mental status, behavior, or in whom acute intoxication is suspected will have a prompt Nursing and Physician assessment, including appropriate diagnostic tests.
2. Any resident who is being treated for chemical dependency or substance abuse, or who is suspected of being intoxicated, who refuses to comply with physician orders for drug or alcohol screening will be considered to be noncompliant with medical evaluation and therapy. She/He may be subject to continued stay assessment with potential for discharge.
3. A resident confirmed to be intoxicated or who refuses a drug screen will be referred to the Social Work Department. The Administrator and Nursing Administrator will be notified.

IV. NURSING STAFF;
1. Will perform an assessment which, will minimally include level of consciousness, vital signs, respiratory status, orientation and behavior.
2. Will then immediately notify the Attending or on-call physician and provide the results of the nursing assessment.
3. Will document assessment information or resident's chart, and initiate steps to ensure resident safety
4. When appropriate, due to resident related behavior problems, will complete an incident report.
5. In the event that a urine sample is required for drug screeing a physicians' order must be obtained. Nursing staff will remain with the resident during process of urine collection and insure safe delivery of specimen to the lab.
1. Will perform an evaluation minimally including review of resident's history, medication, mental status examination and physical examination. The physician will document evaluation information in the resident's chart. After normal working hours and on weekends, the physician will be notified by phone and the evaluation/ exam will take place the next day.
2. Will order diagnostic tests, with screening for alcohol or other drugs of abuse as appropriate. On evenings, nights, weekends and holidays, urine is to be collected and refrigerated until the next business day.
3. The physician will order treatments including medicaions as appropriate and re-evaluate the resident as appropriate (in not less than 24 hours).
4. If intoxication is suspected and the resident refuses alcohol/drug screening, the Physician will:
A) Counsel resident that substance abuse services are available
B) Counsel resident that refusal of medical evaluation may lead to continued stay assessment with potential for discharge
c) Document resident's response in medical record

ThU:

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aadPraeadan
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PURPOSE: To enure the provbiuu of adequaw aid appropriate psychiatric tnd mental health services in accordance with accepted professional standards to facility recidents who require such services.

POLICIES AND RESPONSIBILITIES:
1. bach comuinmr jmychuurist will have medical staff appoimnicnts approved by tbc Govemrag Board of Episcopal Long Term Care/Philadntpliia Nursing Home to provide psycbianlc services to residents of tbc facility. ELTC/PNH shall procure adequate psychiatric consult hours sufficient tu meet tbc mental health care needs of the residcuu.

2. Theptychiattic fellow, psychiatric nurse practitioners andpsychiatric social workers are qualified by aci^nnif mrx^ practical tnixring *»** maintmrn % current license in the Commonwealth of Pennsylvania. The psychiatric fellow delivers care to residents under the supervision of an consultant psychiatrist.

Ciwitnlfr"** Psychiatrist Rtf

1. Each psychiatrist win he assigned sp*rific resident units and be responsible
to provide consulanr services tn residems who require psychiatric services
includingg i compprehensive nvtgm^rg aad/or coggDMve cxuninixioii of resident who presem with any or tilofme followins;
a. Pii«iiwa diagnosis of "yr*"^ illness b. Currently recervins; psychooopie medication e. Preaearing sifna and symptoms of mesial illness

and establish a diagnosis ofmental
as

consistent with DSM-IV codes

PHILADELPHIA NURSING SOME MA

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2. Each psyduatrist will participate in thedevelopment and implementation of a treatment plan consistent with theinterdisciplinary care plan for each xesideat with a diagnosis of mental illness orbehavioral symptoms due to
* tia and/or delirium. Treatment plans mayinclude any following health services consistent with individual resident needs.

a. Pcvchopha aidigic Therapy b. Behavioral intervessons e. Psychotherapy (groap/tadividnil) d. Partial Day Psychiatric Hospital Program e. fopatienrHospttalizan'on
Each psycnlaalsi will monlior dieeffectiveness of the treatment plan on each resident with diagnosis of menal illness cunsinsxii with acceptable
of pnu:iice but not lest than twice a year.

Each psychiatrist will review the use ofpsychotropic medications consistent with accepted professional standards sad adjust medications as indicatedby individual resident TY*c4f including decrease and/or increase in behavioral sympttoms; presence of tide effects and gradual dote reductions.

The consultant psychiatrist, in

with tb*

testn

and the OfDee of Mental Health as appropriate, will timely evaluate and

develop an emergency mwfmem plan for residents who have recently

exhibited violent orthreatening Behaviors.

Reviewed/Revised : 12/97

Tide:

PHILADELPfflA NURSING HOME
Administrative Policy and Procedure

Eff. Date No. Pases

6/95 1 of 3

Medical Services

PURPOSE:

To ensure that quality medical services are provided to each resident the Philadelphia Nursing Home by a qualified primary care physician arid physician assistant

POLICIES AND RESPONSIBILITIES:

1. Each physician and physician assistant will have medical staff appointments approved by the Governing Board of Episcopal Long Term Care/Philadelphia Nursing Home to provide medical services to residents of the facility.

2.

All physicians will meet the appointment criteria as outlined in the

physician credential policy.

3. The physician assistant is qualified by academic and practical training and maintains a current license in the state of Pennsylvania. The physician assistant delivers care to residents under the supervision of a licensed physician.

PRIMARY CARE PHYSICIANS RESPONSIBILITIES:
Each physician will be assigned specific residents and be responsible for the resident's comprehensive medical care including supervising each residents daily care, prescribing the medical regimen, and establishing appropriateness of consulting and ancillary services. The residents retains the right to be seen or treated by a physician of their own choice. A list of physicians and physician assistants and their resident assignment will be maintained by the Medical Director and Unit Managers and updated as appropriate.
Residents will be seen minimally every 30 days and as often as indicated by the residents medical condition.

3.

The scope of physician services should include:

A. Recommend that resident be admitted to the facility and document, in own handwriting, initial visit of each new admission.
B. Review the total program of care including medications and treatments at least every thirty (30) days:

C. Sign all orders.

D. Write, sign, and dates progress notes of each visit.

E. Verbal orders may be given by the physician to the registered nurse and must be countersigned within 48 hours.

F. Review resident advance directive status with resident and/or responsible party at time of admission and annually.

G. Countersign all physician assistant/nurse practioners progress notes and orders.

H. Review and sign monthly computer-generated physician orders.

I.

Provide 24 hours physician coverage in case of emergency. A

schedule of the name of the physician on call will be writing and

posted at telephone operators' desk, Medical Director, Assistant

Administrator, Director of Nursing, Nursing Office, and each

nursing station on a monthly basis.

K. To ensure continuity of care for residents requiring speciality medical services, the primary care will request a consultation for speciality services consistent with resident's medical condition, i.e., Dental Services, Surgical Services, Rehabilitation, etc.

L. Participate in the development and implementation of a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs with the interdisciplinary team.

M. Attend bi-weekly medical staff meetings and participate in ongoing peer review and Quality Assurance programs.

Physician Assistant:

The phya^cajlwill have communication and technical support of designate Physician Assistants.

The Physical Assistant will be responsible for transmitting patientoriented information to the physical as well as preparing chart entries with reference to progress notes, emergency encounters, admission, and annual histories; some physicals problem lists, transfer notes, and laboratory results. In addition, Physician Assistants and physicians will prepare monthly clinical summaries, review monthly orders and prepare physician interim notes when indicted. In accordance with the Pennsylvania Board of Medical Education and Licensure, the physician assistant will inform the resident that he/she is not a physician and will wear an identification tag using the term "Physician Assistant".

The physician assistants may perform the following duties as delegated by the physician:

1. Obtain a complete medical history.

2.

Perform a general physical examination, including accurate

measurement of blood pressure and other vital signs.

3.

Perform a rectal examination.

4. After data gathering, organize the information and present it to the physician so that the physical can perceive the medical problem and determine the treatment.

5. Draw "blood by finger stick and venipuncture.

6. Obtain culture specimens such as sputum, blood, stool, urine, and from the throat and wound for bacteriological examinations.

7. Take an electrocardiogram, reading it for technical accuracy and identifying basic abnormal cardiac rhythms.

8. Test stool specimens for occult blood.

9. Provide patient care information on such matters as specific diagnoses, diets, and other therapy.

10. Catherize the urinary bladder, insert supra pubic tube.

11. Perform cardiopulmonary resuscitation.

12. Write into the medical record.

13. Attend bi-weekly medical staff meeting.

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

VERBAL ORDER POLICY

POLICY:

Verbal (telephone) orders may be taken only by licensed nursing personnel when the physician is not present on the unit.

(Note: Verbal orders may be taken in a Cardiopulmonary Code situation when the physician is at the bedside.)

PURPOSE:

To ensure the accurate and appropriate provision of care.

PROCEDURE:

*••

1. Verbal (telephone) orders may be taken only by the licensed Registered Nurse in accordance with state law.

2. The nurse taking the order writes as follows:

EXAMPLE: 9/24/96 1pm v.o. Dr. Burden/Florence Nightingale, RN

3. As the nurse writes the order, she/he will repeat the order to the physician for confirmation.

4. The order is written exactly as the physician verbalizes it.

5. The order is signed by the nurse taking the order.

6. The order is then transcribed and noted by the RN who has taken the verbal order.
a. The RN transcribing the order shall draw a line around the order and sign, time and date the notation of the order.
EXAMPLE:

NOTE:

Remember the order must be faxed and the order sheet is marked "faxed" with the date, time and signature of the person faxing the order. Orders are faxed by the pharmacy technician on Mondays to Fridays from 9:30am to 6:30pm, with the exception of holidays that fall within those days.

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING
TWENTY-FOUR HOUR REPORT FORM
PURPOSE:
The Twenty-Four Hour Report Form is used to communicate pertinent information regarding the condition of the resident who has experienced:
Admission/discharge for 3 days (5 days on skilled units) Change in mental status/behavicr changes - as needed Change in physical status - as needed Change in skin condition - 24 hours Incidents - 3 days or until resolved Fall or injury - 3 days or until resolved Fractures/alleged abuse - 3 days or until resolved Medication/treatment error - 3 consecutive days Medication refusal, one or more times - as needed Transfer to hospital for medical treatment or evaluation - as needed Return from hospital following med. treatment or eval. - as neededChange in vital signs, including temperature evaluation - 24 hours An invasive procedure - 3 days Attempted or successful elopement - as needed 1:1 or 1:2 nursing care status - as needed Suicidal ideation - as needed Death - as needed The use of a condom catheter - initial 5 days Accu checks, including normal an abnormal values - as needed NOTE: All values <60 or> 250 require intervention; notification of MD, written order and nurses1 note. Significant changes in lab values - 24 hours Altercations or abuse - 3 days or until resolve Family concerns - as needed 302 or 201 - as needed Appointment for study or procedure on the following days and the prep for the study or procedure - as needed Resident's who are NPO(not to include tube feeding residents)-full course

Antibiotic Therapy - full course Vaccines administered - 24 hours Out on pass - until returned Calorie Count - full course Behavioral outburst - for duration of occurrences of behavioral symptoms Any other condition or incident which is reportable to the following shift, supervision, physician or administration - as needed Residents in restraint reduction program - initial 7 days
Equipment: 1. 24 Hour Report Form 2. Ball point pen only. (Write heavily so that information is clear on
all four(4) copies)
A. The 24 Hour Report is a four-part (NCR) form
1. Day shift 2. Evening shift 3. Night shift 4. 24 Hour copy to be retained
B. The 7-330 Charge Nurse will initiate the form by writing the Unit Name and Date in the top margin. (All documentation)
Example:
24-HOUR REPORT Of PATIENTS CONOfTlON AND NURSING UNIT
C. Pertinent information will be documented on the following:
Admission/discharge for 3 days (5 days on skilled units) Change in mental status/behavior changes - as needed Change in physical status - as needed Change in skin condition - 24 hours Incidents - 3 days or until resolved Fall or injury - 3 days or until resolved Fractures/alleged abuse - 3 days or until resolved Medication/treatment error - 3 consecutive days Medication refusal, one or more times - as needed Transfer to hospital for medical treatment or evaluation - as needed

Return from hospital following med. treatment or eval. - as needed Change in vital signs, including temperature evaluation - 24 hours An invasive procedure - 3 days Attempted or successful elopement - as needed 1:1 or 1:2 nursing care status - as needed Suicidal ideation - as needed Death - as needed The use of a condom catheter - initial 5 days Accu checks, including normal an abnormal values - as needed NOTE: All values <60 or> 250 require intervention; notification of MD, written order and nurses' note. Significant changes in lab values - 24 hours Altercations or abuse - 3 days or until resolved Family concerns - as needed 302 or 201 - as needed Appointment for study or procedure on the following days and the prep for the study or procedure - as needed Resident's who are NPO(not to include tube feeding residents)-full course Antibiotic Therapy - full course Vaccines administered - 24 hours Out on pass - until returned Calorie Count - full course Behavioral outburst - for duration of occurrences of behavioral symptoms Any other condition or incident which is reportable to the following shift, supervision, physician or administration - as needed Residents in restraint reduction program - initial 7 days

D. Document Resident Information (Use ballpoint pen only)
1. The resident's room number in the space provided 2. The resident's full name (last name, first name) 3. The resident's diagnosis 4. The attending physician's name 5. Pertinent information regarding the resident's condition in the space
provided.
Example:

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Document logistical Information (us ballpoint pen only)
1. Capacity of the unit 2. Census 3. Number of Admissions 4. Number of discharges 5. Number of transfers 6. Number of deaths
Example:

- F - ' T " ' \w____. ,H» TT::

NOTE:

When a resident is transferred tothe hospital forevaluation, sutures, etc., he/she remain a part of the census. When the resident is admitted to the hospital, he/she is taken offthe census, but is not considered a discharge until after he/she has been in the hospital for fifteen (15) days.

F. Document Information regarding narcotic count (use ballpoint pen only)

1. Time of narcotic count

2. If narcotic counf was correct, circle the word "yes".

3. If narcotic count was incorrect, circle the word "no".

4. The initials ofthe licensed person from the off-going shift who has counted the narcotics.

5. Time of narcotic count (NOTE: The off-going shift will count narcotics together, so the times of narcotic count will be the same).

6. The initials of the licensed person from the on-coming shift who has counted the narcotics.

7. Comments if incorrect.

NOTE: If the narcotic count is incorrect, it must be reported to the Unit Manager, Supervisor, or Nursing Administration prior to the departure of the charge person/medication nurse from the off-going shift.

Example:
G. Responsibility 1. The signature of the charge nurse/licensed person documenting data will be placed in the space provided.
Example:
H. Communication 1. The documentation will be reviewed with the staff, including licensed staff and CNA's of the time of report and rounds. 2. The Unit Manager/Supervisor will remove the appropriate sheet at the end of the shift and will review the information with the on-coming supervisory staff at the time of report. 3. The 11 *" - 730"" Supervisory staff will retain the 11 •"" - 730"• copy for review by Nursing Administration. 4. The Unit Manager/Charge Nurse will retain the final copy with attached Assignment Forms for the same 24 Hour period and the Resident Accountability Form for that date. 5. The above forms will be maintained in the envelope provided and designated for that calendar month and year. 6. These forms will be retained for seven (7) years.
BttWENTY4.!F0RM

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME

DEPARTMENT OF NURSING

RESIDENTS WHO NEED TO 8E ON 24 HOURS REPORT

REASON

PERIOD

Admission/discharge Change in Mental status/behavior changes

3 days/5 days on skilled units as needed

Change in physical status Change in skin condition Incidents FaS or Injury Fractures/alleged abuse Medication/treatment error Medication refusal, one or more times

as needed 24 hours 3 days or untfl resolved 3 days or until resolved 3 days or until resolved 3 consecutive days as needed

Transfer to hospital for medical tieatiiterit or evaluation

as needed

Return from hospital following medical treatment or evaluation

as needed

Change in vital signs, including temperature evaluation An invasive procedure

24 hours 3 days

Attempted or successful elopement 1:1 or 1:2 nursing care status Suicidal ideation Death

as needed as needed as needed as needed

The use of a condom catheter

initial S days

Accu-check, including normal and abnormal values

as needed

Significant changes in lab values Altercations or abuse

24 hours 3 days or until resolved

Family concerns 302 or 201

as needed as needed

Appointment for study or procedure on the following days and the prep for the study or procedure as needed

Resident's who are NPO (excluding those getting tube feedings)

full course

Antibiotic Therapy

fun course

Vaccines administered

24 hours

Out on pass

until returned

Calorie Count

full course

Behavioral outburst

for duration of behavioral symptoms

Any other condition or incident which is reportable to the following shirt, supervision, physician or administration

as needed

Residents on restraint reduction proqram
C:1WPOOC5\POUCYJ>RE\TWENFOURXOG 8.96

initial 7 days

PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

MEDICATION PROCEDURES

Medication Ordering Procedures

A. New medication ordering procedure: written and oral

1.) All new drug orders, induding new admissions orders, shall be transcribed from the physidan's order sheet to the Medication Administration Record by the nurse taking the order from the physician. (All readmission orders will be transcribed to a new Kardex.)
2.) From Monday to Friday (exduding holidays) from 9MAM to 6WPM. The order sheet is placed in the Pharmacy bin at the Nurses' Station and is picked up by the Pharmacy Tech, who faxes the orders to the Pharmacy and takes the order sheet to the in-house pharmacy. The Pharmacy Tech then returns the order sheet to the unit

On weekends, holidays and from 6*>PM to 9"AM, the order sheet is faxed to APS Pharmacy by the Nursing Supervisor or designee and is replaced in the resident's chart.

In all instances for new orders, signed physician order sheets are to go to the pharmacy on the 8th day and the 20th day of the month, (see Recap procedure).

3.) Noting or implementation of the Medication order

a. The licensed nurse will read the order. IF THE ORDER IS NOT CLEAR TO THE NURSE. THE ATTENDING OR THE ON CALL PHYSICIAN WILL BE CONTACTED FOR CLARIFICATION.

b. The nurse then communicates the medication order to the pharmacy via fax, or by pladng the order in the pharmacy bin.

c. The medication order is then listed on the medication administration record of the resident.

d. The spacing and arrangement takes into consideration whether the

order is a routine or a PRN medication. Note: There are separate

Kardexes for

•

Routine medications

PRN medications

*

Nutritional supplements

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e. If the order is time limited or is limited to a certain number of doses, the nurse shall so indicate on the administration record.
EXAMPLE:

4.) Change in Order:

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Pg. 3 of16

a. When a new order changes indosage orintervals of doses on a current medication, the previous listing is discontinued on the medication administration record and the new order is entered in a new space on the form.

EXAMPLE:

5.) Fornew admissions, medication orders may be added to the preprinted admission physician's order and faxed tothe pharmacy. The word "faxed", date, time and initials ofthe person faxing the orders are to be written beside the orders.

EXAMPLE:

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2: ACTIVITIES ri.AN ACCE7TCD AS RECOnnCNOeO
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*'.OUTHOF^BE0 WITH ASSISTANCE AS 7OLCRATC0

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DATE

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DATE

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6.) When the entire procedure is completed, the nurse shall write "noted", date, time and signature on the physician's order sheet.

EXAMPLE:

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7.) a. b. c.

When a resident is admitted to the hospital, the medication and treatment Kardexes are marked "Resident admitted to hospital" and the date's entered.
The Medication and Treatment Kardexes are placed in the resident's chart in the area designated for medications.
When the resident returns to the facility, new Kardexes are written, according to the new orders, and are placed in the Medication Kardex holder.

8.) ORDERING FOR REFILL OF MEDICATION SUPPLY NO UNIT DOSE
a.) Drug orders are to be refilled when a three day supply of the prescription remains. The nurse shall list the medication on the Medication Order Sheet/Action Request Form, being careful to note any change in dosage or interval which has occurred since the original drug order date.

EXAMPLE:

*»"*» TM?y*

ST»Jt A !A^n

1 i

1 i

I

i 1

1

tT"lb. man.ror

1

|

; i
1
1
i

Note: mis rorm is also usea to communicate new energies, changes, discrepancies noted in medications received from pharmacy and any other communication that cannot be accomplished by faxing the order (see Recap Policy and Procedure).
b.) Emergency refills may be telephoned to the pharmacy to expedite delivery.
8.) Obtaining missing doses of medication:
a.) See Section Titled "Drug Administration Procedures" Subsection A3g. "Replacement of missing doses".
9.) Receiving drug orders from the pharmacy:
a.) Any shortage or other problem with the order is to be documented on the daily medication order sheet and communicated to pharmacy.
b.) Before using any prescribed drug, the nurse shai! verify the label content with the order in the resident's health record.
10.) Uss of resident's previously acquired personal medication:
Trie facility prohibits the use of previously acquired medications from home or other facilities.
II. Drug Administration Procedures
NO MEDICATION IS TO BE ADMINISTERED TO A RESIDENT WITHOUT A VALID ORDER ON THE PHYSICIAN'S ORDER SHEET.
A. Procedures for the Administration of Medications
Note: Before any medications are administered, the nurse must positively identify the resident by reading the resident's ID bracelet and by the photograph on the Medication Administration Record.
1.) When Administering oral medication the following procedures apply:
a.) The medication name, dosage and interval will be read from the medication administration record.
b.) The label on each unit-dose medication container will be read twice, when taking it from the drawer of the cassette, and before opening the package, and compare this package to the medication sheet.

EXAMPLE:

300.0 Pg.6of16

NOC 57267-905-42

FSCM13

Transderm-Nitro*
(nitroglycerin) Tw-jtnan

U . L mg/hr Easy-to-Open '.

'MO) S4.-712*

•

AUTOMATEO MUAMACEUTCA. SERVICES

Nonan Kaufian,RP

RXlll-MSl'd

IZ/W%

NITSO PATCH (TnO£lOH<ITRO>

APPLY EXTlSHflLLY I PflTOi TO KM ON flT 4AM OFF flT 12W ROTATE SITE OR f£yTCN,6E>£ PHILA H\ 8226-38

c.) The label on each non-unit dose medication will be read three times, when taking it from the shelf, drawer or cart, before pouring it and when putting it back in the cart.

EXAMPLE:

ioldline NCCMMHMI
Alamag SArCTSEAUO
Ali'mina and Magnesia Oral Suspension
ANTACID

NON-CONSTIPATING SODIUM-FREE*

Utx iiucvfci ;S.-no SSMMIS

-""-

_ _ _ _ SB a^

* taxi wm ufom uswe

• ITMt -T MKM nMKMIUM
12 FL OZ (355 mL)
Comparetotfieactfwe •'. mgrafientsafMaaTax*** -

d.) When it is necessary to calculate a dosage, the licensed person will refer any questions to the supervisor or pharmacist.

300.0 Pg.7of16
e.) To assure administration accuracy, the nurse wilt cross check the
following reference points:
Physician's order - Medication Administration record dedication Administration Record - label on drug container Label on drug container - Physician Order
f.) If the medication is suspension or emulsion, the bottle shall be shaken
before each measurement of a dose.
g.) To pour a liquid medication dose, the bottle is held with the label in
the palm of the hand in order to avoid spilling on the label.
h.) When measuring liquid medications, the medicine cup is held at eye
level and desired volume on the cup is marked with the thumb and the volume is read at the LOW LEVEL OF THE MENISCUS.
I.) Tablets and capsules are handled so that the fingers do not touch
them.
j.) Medications are given at the time or within 60 minutes on either side
of the designated time.
k.) The nurse administering the medication remains with the resident until
medicine is swallowed.
I.) The medication is charted IMMEDIATELY after administration.
m.) When charting administration of any PRN medications, the nurse will include full details including resident's symptoms, method, route and time of administration, affect of medication and signature in the nurse's notes. If the resident's condition warrants, a nurse's note is entered in the Nurse's Progress Notes.
EXAMPLE:

jjrf\ illi

vn»^\*.7?«.Lc/c.

—!.tAd^

J 'nn

^-•A ;•.

A TS\>7\
.I

OUU.U

„*•

P g . 8 o f 1 6 '"'-

2.) Administering Hypodermic Medications, the following instaictions apply:

a.) Only medications for which a doctor's order will be given. b.) The hands are to be washed before preparing the hypodermic
medications.
c.) The gauge of the needle is elected according to the consistency of the drug to be administered (i.e., 21G for heavy suspensions, 25G for light suspensions).
d.) The standard length for an IM needle is VA inches, however for very thin residents, a 1 inch needle may be better.
e.) The length of the needle is determined according to the site to be used, the weight and tissue turgor of the individual resident and the drug to be given.
f.) The label ofthe medication tobe administered is checked three times.
g.) The procedure is explained to the resident and the injectionis administered in privacy.
h.) If a series of injections are being given to the same resident the injection sites are rotated to ensure adequate absorption and lessen discomfort.
I.) The different injection sites are indicated when charting the medication.

EXAMPLES:

INJECTION OR APPLICATION SITE NUMBERS

1 . BUTTOCKS (GLUTEUS) LEFT 2. BUTTOCKS (GLUTEUS) RIGHT 3. ARM (DELTOID) LEFT 4. ARM (DELTOIO) RIGHT

S. THIGH (QUADRICEPS) LEFT 8. THIGH (QUAORICEPS) RIGHT 7. A80OMEN LEFT 8. A80OMEN RIGHT

». UPPER BACK LEFT 10. UPPER SACK RIGHT 11. UPPER CHEST LEFT 12. UPPER CHEST RIGHT

O:.
i —i i n n ;: i v

"•

•

'

'

'

:!LJ

' I' ''

i
T-'

;..:. :..J_'..i.:.: .L»: Ll.Li '

I

, . I i i . ! 1 ! : ! . ! J.LJ •"'

300.0 Pg. 9 of 16
j.) The site for injection is selected and exposed according to the route or administration (i.e., IV, IM, SQ). Upon completion of the injection, the needle is withdrawn from the injection site and the area massaged very gentry.
k.) For policies on the administration of IV medications, refer to the nursing manual.
I.) After administration of the hypodermic injections, the syringe is disposed of in accordance with State regulations (see section "Syringe Inventory and Control".).
j.) The injection is charted by recording the time, site, results if applicable and the name and title of the person administering the injection. When the resident's condition warrants, a note is entered on the Nurse's Progress Notes.
EXAMPLE:

I i 21* Z\ Z 2j 2

y.

• 1 • • ^^^ •

ill*

:[ J:.fci.!-1 1 -

' ' I i !i

.11!

'

I

j.i i

I.I

i t
.1

i I ! |.| III

rrV»»

cceeci

3.) Insulin injection - insulin is measured in units and available in 100 units per cc. a.) Insulin is given subcutaneousiy rotating the site of injection (i.e. arm-area, thighs-anterior, abdomen), b.) Time of onset and duration of the commonly used insulin are as follows:

Preparation

Duration

Rs^ular Insulin Sesilsat: Insulin

Short Shore

lfthr. • 1hr. 1/7 hr • 1 hr.

2-4hrs. 2-Shrs.

6-8 hrs. S-16 hrs.

Lints bsulia

(ncenscdiacs IO hrs.

6-12 hrs. 13-16 hrs.

NPH Insulin

Intermediate 1-2 hr.

6-12 hrs. 13-16 hrs.

Ultra Leate Insulin Long

4-6 hrs.

U-24 hrs. 36 hrs.

70 % NPH.

Premised

1/2 hr.

2-12 hrs. 13-24 hrs.

300.0 Pg. 10 of 16

4.) Charting a.) The nurse administering a medication is responsible for charting the drug.

b.) Charting of medication will be kept current and is completed IMMEDIATELY following the administration of the drug.

c.) The nurse responsible for medications will not report off duty without first checking his/her charting of the medications which he/she administrated. Subsequent administration intervals depend on his/her recordings.

d.) Each dose of medication will initiated on the daily medication report after administration of the drug. The nurse verifies her initial with full signature and title in the space provided on the individual Medication Administration Record Sheet.

EXAMPLE:

CL*.

irn.e

e.) Medications that are given on an as needed basis, PRN, will be recorded in the nurse's notes on the reverse of the Medication Administration Record. Charting shall include:
The resident's subjective symptoms or complaints.
The results of the medication given.
• The nurse's initials.

EXAMPLE:

PRN
E • EFFECTIVE I • INEFFECTIVE N - SEE NURSE'S NOT=S

M«

i

i

•

.• ••

1

1

!

1-

1

:

i

MMC-3 MOICATIQN MOTH

• * . « * ! <• • « * • • * # • • * «v **•< • * " • * - , * • • • * * * •

t VL<. ,\\
0

•300.0 Pg. 11 of 16
5.) Refused, withheld or regurgitated medications.
a.) If a dose of regular interval medication is withheld, refused or regurgitated, the nurse's initials are circled.
b.) A full explanatory note is written on the nurse's notes in back of the medication sheet.
c.) If medication is refused or withheld, the physician will be called and his/her responsive orders will be recorded in the doctor's orders, in the nurse's notes and on the 24 hour Report Sheet.
1. Include on the 24 hour Report Sheet
• Drug • Dose • Physician notified
EXAMPLES:
Medication Administration Kardex

JD
MMnMMCATWMHoru 1f ljt> _ _
1 1
Doe.,
OR.

Nurse's Signatures and Nurse's Medication Notes

«B* *• t • •«T^* * ** t

| ' ..- —

1
i' *"
*i i

|

1

... 1

0

24 Hour Report Sheet
it f\<r(\

\ ^V)

300.0 <•
Pg. 12 of 16 d.) In the Nurse Notes, document
1. The number if attempts made to give the resident his medication.
2. The notification of the Nurse Manger/Nursing Supervisor. EXAMPLE:
6. When a drug is discontinued, the following procedure will be followed: a.) An "x" will be placed in the spaces designated for administration for the next two days. b.) The word "D/C", the date, time and initials of the nurse will be placed after the V s . c.) The entire entry will be highlighted with yellow highlighter. EXAMPLE:
7. When the physician orders a drug to be held, the worcTHOLD" will be placed in the box designated for administration.

300.0 Pg. 13 of 16
EXAMPLES:
ORDER - "Hold AM dose of Dilantin 100 mg on 5/3/96/

p-_J»i-W

And a notation will be made in the nurses' medication notes on the reverse side of the medication Kardex.

MUMlStttMCATIONNOTU

•••« i •»« ; • - n i

t*» • ««••««••• • »•!•«

1 i !

0

1 11

V

1 11

a.) If a medication is held for 24 hours, it is automatically discontinued and a new order must be written.
EXAMPLE:

ALLERGIS3: N"<A is:
8. In the event that the pharmacy has not sent a prescribed medication or has sent an incorrect medication, the following steps should be taken to ensure that the resident receives his/her required dose:
a.) Notify the Nurse Manager/Nursing Supervisor
b.) Retrieve the medication from the back up pharmacy. If the medication is not available from this source, the nurse must:
c.) Call APS, who will contact the satellite pharmacy.
d.) Charting that the medication was "Not Available" is not acceptable. (There is always a mechanism to secure medications on a 24 hour basis.)
B. The following are policy statements covering the administration noncontrolled drugs:
1.) Only licensed personnel are assigned responsibility for preparing,

Pg. 14 of 16
administering and recording of medication, or have access to drug storage areas at each nursing station.
2.) Medication-will always .be prepared and administered by the same licensed personnel. Medications are to be administered promptly after being prepared.
3.) Only licensed personnel, (i.e. RN, LPN) are allowed to pass medications to residents.
4.) Medications supplied for one resident are not administered to another resident.
5.) Medication errors and untoward drug reactions are immediately reported to the attending physician, charted in detail on the nurse's notes and described on an incident report and a medication error report (see attached), and documented on the 24 hour Report Sheet.
6.) Personnel administering drugs will refer to the PDR or its equal when unfamiliar with the pharmacology of the drugs, its potential toxic effect and contraindications.
7.) There is a current PDR or its equivalent for convenient drug reference available at each nursing station. The provider or consultant pharmacist is responsible for providing additional drug information as needed.
8.) There is an adequate supply of disposable containers provided by the facility for the administration of drugs. No disposable container used in the administration of drugs will be re-used.
9.) When measuring dosage of non-unit dose concentrates (i.e. Haldol OR Thorazine) and the required dose does not appear on the calibrated dropper, the dose will be obtained by filling the dropper to a higher dose and dropping it to a lower dose (i.e., for 14 mg. of Haldol, fill dropper to VA mg. And drop it into a medication cup , to 1 mg.). The drug in the medication cup will be %mg.
10.) Hours of administration:
OD = 9:00AM BID = 9:00AM, 5:00PM TID = 9:00AM, 1:00PM, 5:00PM QID = 9:00AM, 1:00PM, 5:00PM, 9:00PM HS = 9:00PM AC = No longer than Vz hour before meals PC = No longer than Vz hour after meals

300.0 Pg. 15 of 16
Q12H = 9:00AM, 9:00PM Q8H = 1:00AM, 9:00AM, 5:00PM Q6H - 12:00AM, 6:00AM, 12:00PM 6:00PM Q4H = 1:00AM, 5:00AM, 9:00AM, 1:00PM, 5:00PM, 9:00PM Insulin Daily = 7:00AM Insulin Bid = 7:00AM, 4:00PM
11.) The nurse has the right to adjust the time of drug administration up to 60 minutes to avoid drug interactions.
12.) Respiratory medication - respiratory therapist will be giving the respiratory treatments at the following times:
QID = 7:00AM, 11:00AM, 3:00PM, 6:30PM TID = 7:00AM, 12:00PM, 6:00PM BID = 7:00AM, 6:00PM
At the end of the 12 hour shift, respiratory will give meds, (previously dispensed by APS pharmacy), to nursing for the residents who receive around the clock therapy.
C. The following are policy statements concerning the administration of controlled drugs:
1.) In addition to the policies and procedures listed under noncontrolled drugs, the following apply:
A.) All non-unit dose controlled drugs shall be counted by two licensed personnel at each shift change. One licensed personnel from each shift will be responsible to count controlled drugs together.
B.) A record of this count is entered on the control order sheet. The sheet is retained for at least five years.

Unit:

Slit,

EXAMPLE:

REVISED 4I9S

DATE

TIME 7AM

. . >

3 PM

11 PM

NAME

COMMENT/ DISCREPANCY
-Q-

REPORTED TO
MIA

EMERGENCY BOX/CLOSET

300.0.
C.) If a controlled substance is wasted, the signatures of two nurses are required (see section entitled, "Disposal of Drugs" Subsection E).

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
RESIDENT MEDICATION REFUSAL
POLICY:
When a resident refuses medication, the drug, dose, and time of refusal shall be documented on the medication kardex and the Twenty-Four Hour Report Sheet. The physician shall be notified.
PROCEDURE:
1. Explain to the resident in layman's terms the reason for the medication, the therapeutic advantages and the disadvantages of not taking their medications.
2. Offer the resident a beverage or snack of their liking to consume with their medications.
3. If family members / friends are visiting, please elicit their assistance in encouraging the resident to take their medications.
4. Try more than once to encourage the resident to take their medications. Document number of attempts made.
5. If the resident addresses concerns regarding the volume of drugs to be taken at one time or preference for liquid medication, please discuss the resident's drug regime with the attending physician and request a change.
6. If the resident comments on the unpleasant taste of the medication, with the residents agreement, mix the mediction in a beverage or soft food product (for example, juice or pudding).
7. If the resident continues to refuse to take the medication, document the drug, dose, time of refusal on the back of the medication kardex.
8. Notify the physician of the resident's refusal to take the medication.
Revised 12/97

300.01 pg. 1 of 4
EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING
NARCOTIC AND BARBITURATE COUNT PROCEDURE
POLICY:
Narcotic count is completed every eight (8) hours at the change of shift by the Nurse going off duty and the nurse coming on duty. Each nurse is responsible to sign the Narcotic and Barbiturate Check Sheet. Emergency equipment is checked every shift and is present and available on each unit.
PURPOSE:
In order to comply with Federal Laws governing schedule II drugs and in order to ensure the maintenance of accurate narcotic and barbiturate counts and to maintain a record of those counts, the Narcotic and Barbiturate Check Sheet is completed. In order to ensure the availability of emergency equipment at all times on each unit.
PROCEDURE:
1. Using a pen, document the units's name in the space provided. 2. Document the date. 3. At 7:00 a.m. change of shift, the 11:00 p.m. - 7:30 a.m. nurse and the 7:00 a.m. -
3:30 p.m. nurse will count the narcotics and barbiturates. 4. Each nurse will sign his/her name in the spaces provided. 5. At the 3:00 p.m. change of shift, the 7:00 a.m. -3:30 p.m. nurse and the 3:00 -
11:30 p.m. nurse will count the narcotics and barbiturates. 6. Each nurse will sign his/her name in the spaces provided.

300.01 pg. 2 of 4
7. At the 11:00 p.m. change of shift, the 3:00 p.m. -11:30 p.m. nurse and the 11:00 p.m. - 7:30 a.m. nurse will count the narcotics and barbiturates.
8. Each nurse will sign his/her name in the space provided.

EXAMPLE:

Unit:
0ATE

TIME 7AM
3 PM

NAME

COMMENT; DISCREPANCY

L ^ T . v7:yT'i..«r<L'| ..

^ ( • n , i ? ff.—1-^.^r, i.

11PM

3 PM 11 ?M

I ~L

REPORTED TO
174-
M.
AlA

EMERGENCY BOX/CLOSET

ilk
I

9. When the nurse works a double shift on the ICF units and he/she is the only scheduled licensed person, the supervisor or another licensed person from another unit will count narcotics/barbiturates with the scheduled nurse.

10. When a discrepancy is found in the count, the discrepancy is documented in the space provided and the discrepancy is reported to the unit manager or supervisor immediately.

a. The name of the person the discrepancy is reported to is written in the space provided.
EXAMPLE:

7 AM

Vfl ' (•• v"V-

11 PM 7 AM

b. An incident report is initiated regarding the discrepancy. c. An investigation of the missing narcotic/barbiturate shall take place. 11. If no discrepancy is found, a zero mark (6f is placed in the space provided.

300.01 pg - 3 of 4

12. The presence of the emergency box in the medication room is checked and the expiration date is checked.
13. The emergency equipment in the emergency closet is checked against the equipment checklist.
14. When both the emergency box is present and current and the appropriate equipment is found to be present in the emergency closet, a check mark ( ) is placed in the space provided.
EXAMPLE:

DATE
'fc

TIME 7AM 3 PM 11 PM 7 AM

11 PM iz.

NAME

COMMENT/ OISCREPANCY

C. TnnlT,tKM L f): •4J

REPORTED TO
?//

EMEFGENCY } BOX/CLOSET I

T y-I.•In-

a. If the emergency box is not present or has expired, a notation is placed in the space provided regarding the action taken.
b. If equipment in the emergency closet is missing or outdated, a notation is placed in the space provided regarding action taken.
EXAMPLE:

9/96

300.01 pg. 4 of 4
EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
Narcotic & Barbiturates Check Sheet

Unit:

DATE

TIME 7AM 3 PM 11 PM 7 AM 3 PM 11 PM 7AM 3 PM 11 PM 7 AM 3 PM 11 PM 7 AM 3 PM 11 PM 7 Ml 3 PM 11 PM 7 AM 3 PM 11.=M

NAME

COMMENT/ DISCREPANCY

REPORTED TO

EMERGENCY BOX/CLOSET

Revised 9196

Philadelphia Nursing Home Episcopal Long Term Care
Department of Nursing
Skin Assessment

PoHcv Statement:
All residents will have a complete body skin assessment on a monthly basis, using the accepted Skin Assessment tool.
Upon admission, or at any time thereafter, if a resident is found to have any alteration in skin integrity (such as skin tears, reddened areas, blisters, and pressure sores), or if the resident has a Braden score of 16 or less, a Weekly Skin Assessment will be completed.
Criteria For Weekly Skin Assessments Are: Those with skin alterations as defined above. Those with Braden Scores of 16 or less.

For residents on weekly sksin assesment the following procedure will be initiated:
- WEEKLY full body skin assessment will be performed and documented by the licensed nurse. This process will occur until the next regularly scheduled quarterly (or full) MDS Assessment.
— At the time of the MDS assessment, the team will determine if the resident should revert to the routine monthly skin assessment schedule. This decision will be documented in the resident's plan of care.

RESPONSIBILITIES:

CNA

1. RN/LPN

If the CNA observes skin changes (i.e. skin tears, reddened areas, blisters and pressure sores or any opening in the skin) AT ANY TIME, the CNA will report the changes to the charge nurse, immediately.

2. The licensed person will:
• validate the CNA's findings. • intiate the weekly skin assessment. " complete a skin assesment when a significant change. ' write a nurse's note in the residents record. • complete the Braden Scale when a significant change
has occurred.

Purpose:
To examine , identify and document any alterations in skin integrity in an effort to prevent breakdown.
Procedure:
1. Each resident will be examined by an RN/LPN on a monthly/ weekly basis as appropriate.
2. Alteration in skin integrity, (including skin tears, blisters, reddened or pressure sores), are to be indicated on the anatomical model.
3. Residents that have pressure sores, are to have areas of breakdown noted on the anatomical model.
4. For residents with NEWLY IDENTIFIED pressure sores, the following steps are necessary:
a. Incident report generated and forwarded to the Unit Manager for initial notification
b. Physician notification by Unit Manager or designee.
c. Family notification by Unit Manager or designee.
d. Photographic documentation on the Weekly Wound Assessment and Evaluation form will be initiated by the licensed staff.
e. Nurses Note by licensed nursing staff in the resident's record.
5. Completed Skin Assessment tools are to be filed in the resident's record under the Skin Care tab. The three most recent monthly assessments should be present in this section. Previous records are to be forwarded to the Medical Records Department for inclusion in the resident's thinned chart.
6. Documentation
Skin Assessment Tool
a. The form is stamped with the resident's addressograph.
b. The resident's name, room number and date are entered in the appropriate spaces.
c. When an abnormality is found upon assessment, the corresponding line is checked.

d. The condition of the fingernails and toenails are documented by checking: yes or no
e. The body diagram is marked to correspond to the assessment (SEE EXAMPLE ATTACHED)
Braden Scale a. See Braden Scale policy and procedure.

Treatment Kardex

a. The appropriate interventions, according to the Skin Care Prevention Protocols, are entered on the Treatment Kardex. (Interventions will be included on recaps).

Included are:

Weekly Skin Assessment Monthly Skin Assessment Wound Care Routine Skin Care Incontinent Care Risk Status (low /moderate risk, high risk)

b. Documentation will occur on the Treatment Kardex according to the Treatment Kardex Policy and Procedure.
c. A laminated copy of the protocols are present in the treatment Kardex. CNA Log

a. The appropriate interventions, according to the Skin Care Prevention Protocols, are entered on the CNA Log by the licensed person taking the order off and by the licensed person reviewing and/or noting the recap.

Included are:

Incontinent care Routine skin care Risk Status

b. A laminated copy of the protocols are present in the CNA Log book.

c. The CNA will place his/her initials next to the care/risk level to indicate that all areas of protocol have been performed (See Skin Care Prevention Protocols) .

Philadelpliki Nursing Home

Gbo«d & CoiiniUon Avenu«i • ftiiloJelphiu, FA 19130

OlV

Patient's Name

*«-

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
Oil I.'11

ADORESSOGRAPN

Lvahjatoi's Name

Data

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Mnc*

W M V I Mi« -

pavMn in cfcw OJb«Jr«U at •>• In* bA

t«liniilxlot«i««lmtlL

wrf Uluatf UM * II»II<C«I«<< I d o t *

on

• on t k*« l«ttf«t oi IPH ••gji

UkkdV^t

l

). f p
kM nAnenl ruidi tlienf*toIIIapca* l W A M I ) ma* MjInMioc gaj4potk*o

4 (<caaV*1.
Fal> uitl cl avtr/ nwal ll««> itluiria ntJi Utaatf aitl ak/»l a(* a n w u n
d and <aWy aiojlucU Q A U
Total Score

HouthtCM

IH5

LEMRHI

Id)

InHlaH

Full Nime

tnMals

FuNNme

(nillals

Full Nam

;itr ,

/.Zl '98 l i : : 0 FR PE L.rTT-D

629 233 a*x5 TO

Ptuladdphia Nursing HORM
19130

Skin Assessment

Resident NsmeyHooin:_____

.

————

Dttr.

Please placa a check mark (/) in tte appropriate apaca » l o w upon completion of me resident fu« bcdy assessment:

(indicate any area marked YES on the anatomical mcc«l)

Yaa

No

1. Skin tears 2. Bruises/discolored areas 3. Rashes 4. Open areas (including wounds) 5. Dry skin 6. Other (tpecify) 7. Are fingernails short? 8. Are fingernails dean? 9. Are toenails short?

LPN or RN Signature: RIGHT

LEFT

LEFT

RIGHT

-a TQ-PL ppcs.es

uare rrevwniun

Routine Skin Care
(Braden Score 17 or higher)
Provld* Shin Hygiene/ Protection
ClMDMiMn * t h Map, ilnsi ft dry partly DAILY ftpm MoMura wltt tatty lollon BID(ft pro) Reslderte, requiring additional mohtuilcers, apply Atrac-taln lotion (oMiln (romCentral
Supply)
lnap«ci sMn eviry dayand during hygiene m i H U M . Notify charge nurse of changes Pad bony •ramlnancat with plllowe or other approprMa adaptive aqhipment (nol blankets Of fOMtO WIMrtSj. PitrM* pailntal cara fw residents who j r » Invnotrila or Inconllnanl (see InconHnanca Policy)

LOW & MODERATE RISK
(Braden Score 16-15) & (Braden Score 13-14)
PROVIDE SKIN HYGIENE/ PROTECTION

HIGH RISK
(Braden Score 12 or <)
PROVIDE SKIN HYGIENE/ PROTECTION

Claanaa sWnwith soap. Hnsa anddry gsntly D A L Y &pro Cleans* waste with Triple C n a Cleamar Immedletily upon soiling M o M u r i n with facility lollon BID(ft pen) Apply Perl-Care olnlmint undtf brief ft to any aiaas
Of delicate sMn Inspect akin daily lot breakdown Avoid shciiIng force ft friction. Lift, do not pull resident. Keep HOB Q 30degrees or < '* Release splints A other adaptive equipment q i h

• Cleanse akin with toap. rinsa and dry gsntly DAILY ft P R N

• Claansa waste wRh Triple Caie Cleanser Immediately upon sotting

• MoWurlze with CiciWy appiov«J lotion BIO (ft pin)

• Inspect sWnq shift for breakdown ft applythe blowing products

In order

I Claanaa with Triple Caie

2 Apply 3 M No Sling SWnBewlerto

glutesl region for incontinirt

residints ( I • 2 applications per 24hour ptrkod),

3 Moitlura SWn wKh tacMy-spprovtd Lotion

4. Apply Peii-Cere Battier oinlmem • Avoid shearing force ft frletkon. Lift, donot pull residsnl.
Keep HOB Q 30 degrees or < " • Release splints ft other adaptive equipment<)4h

Pressure Reduction Relief/ Activity
Encourege ambuliMon. as medically Indicated. Perform ROMactMy unless ordered otherwise. Assure thai chsh and/or wheelchair cushions oi pads sie properly positioned endlnlMad. Turn ft repoallon badbound raaldenta at least q2h sndchslrbound residents q t h Iftllate turning schedule

PRESSURE REDUCTION/ RELIEF ACTIVITY
EncouiageambulatkHi, as insdlcatly Indicated Position body with pillty.vs & other support devic«s to pievant 'skin on skin" Assure that bed linens arediy and wiinWe-lree Static All Matliess 'requires ET Nurae Approval) Initiate turning schadulo for bed-tiound resktanta q 2 hours Assure that residents are welgN-shlltad at least
q1 hour while in the chair Foam ovBilay in place, if ordered * Elevate heats off bed using foam blocks OR piflow

Nutrition

NUTRITION

• Monlor eating andddntdng pattern Noilly ehatga nurse for any changes

• Monitor ealing ft drinking pattern • notify charge nurse of changes t Monitor weight. I ft O es ordered

•requires FT Nurse Approval **unles8 ordered otherwise

PRESSURE REDUCTION/ RELIEF ACTIVITY
• Encourage ambuMloh, en medlcaay ndicbtid « Poa*ion body w«hpillows ft other support devices
to pravant *sMn on sMn' • Elevate heels off bed using foam blocks OR pillow • Assure that badlinens aredryand wrinkle-free • Static Air OR I air loss Mattiass In proper working order • • Initiate turning schedule for bed-bound residents q 2 hours > Assure that residents are weight-shifted at lasst
qi hour white Inthe chair
NUTRITION
. Monitor eating and drinking pattern • notify charge nurse of ching «Monitor weight. I ft O as ordered

Philadelphia Nursing Home Episcopal Long Term Care
Department of Nursing
Routine Skin Care (Prevention) Protocol
Policy Statement:
All residents that are NOT identified as at risk for skin breakdown (Braden score 17 or higher) are to placed on the routine skin care prevention protocol.
Purposes:
-Prevent tissue breakdown -Promote healing of compromised tissue -Assure optimal tissue integrity
Procedure:
1. Turn & reposition bedbound resident at least every 2 hours following the turning schedule policy. Assure that documentation is complete. Assist the chair-bound resident to weight shift at least every 1 hour.
2. Pad bony prominences with pillows or other appropriate adaptive equipment Do not use folded sheets or blankets.
3. Apply facility-approved general usage lotion immediately after bathing daily. For residents requiring additional moisturizers, apply Atrac-tain
- Lotion (obtain fromCentral Supply).
4. Provide perineal care for residents who are immobile or incontinent. (Refer to Incontinence Care Policy).
5. Inspect skin every day and notify charge nurse for any changes.
6. Monitor eating and drinking pattern while feeding or observing residents during meals.
7. Notify charge nurse of changes in food or fluid intake.
8. Keep HOB at lowest degree of elevation (30 degrees is optimal) unless ordered otherwise. Limit the amount of time the HOB is elevated.
9. Documentation of ail measures must be completed in the CNA Care Log:
a. Skin care interventions will be added to the CNA log by the RN/LPN at the time of recap or at any time it becomes necessary.
10. Wound care interventions will be documented on the Treatment Kardex by the RN/LPN.

Philadelphia Nursing Home Episcopal Long Term Care
Department of Nursing
INCONTINENCE PROTOCOL
Purpose:
Assure that skin remains in optimal condition and to prevent excoriation.
Policy:
All residents who require the use of incontinent briefs (or are otherwise found to be incontinent) will receive perinea! care at least every 2 hours and after every incontinent episode. Provision of this care will be documented in the CNA Care Log under incontinence protocol.
Procedure:
1. Assure privacy is provided.
2. Explain procedure to resident.
3. Position resident comfortably on side, draping resident to minimize exposure and maintain dignity.
4. Spray Triple Care Cleanser over entire soiled area of skin.
5. Wipe skin clean and repeat procedure until entire skin area is clean.
6. Apply Peri-Care Petrolatum Ointment to all areas that may come in contact with urine and/or stool
Reminders
• Check the resident every two hours for incontinence
• Avoid use of briefs on residents unless absolutely necessary • For residents on air beds, use special dry-flow incontinence pads (without
application of briefs to residents - this allows optimal air flow and effects of bedrest to reduce pressure and maceration)
• Dispose of soiled linen in linen container following resident care
• Chart care in the CNA Care Log q shift.
NOTE: The CNA Care Log is individualized to include perineal care for the incontinent resident by the RN/LPN at the time of recap or at any time it become necessary.

INCONTINENCE PROTOCOL
• Provide Privacy • Explain procedure lo resident • Position resident comfortably on side, draping to
i exposure & maintain dlgnly • Spray Triple Care Cleanser over entire soiled sres of skin. • Wipe sMn clean and repast procedure untN entire skin area Is clean • Apply Perl-Care Ointment to aN areas that may come In contact with
urine A/br stool. • Check resident q2h for Incontinent episodes • Avoid use of briefs unless absolutely necessary • If resident Is on an air bed, use special dry-flow incontinence pads
(without application of briefs - this allows sir flow) • Dispose of soiled Hnen In Hnen container following resident cere. • Chart care In the CNA Care Log q shift

Philadelphia Nursing Home Episcopal Long Term Care
Skin Care Prevention Protocols

Policy Statement:

All residents will be assessed by the licensed nurse for skin breakdown following facility guidelines using the Braden Scale (see policy). Dependent upon the residents' Braden score, the appropriate skin care protocol (ROUTINE, LOW & MODERATE OR HIGH Risk Incontinent) will be followed for care.

Procedure: 1. Braden score obtained and documented per policy

2. The licensed nurse will check the appropriate level of risk on the APS order sheet.

3. The order will be transcribed to the Treatment Kardex.

4. The RN/LPN will place his/her initials next to the prevention protocol as

ordered to indicate that skin prevention protocols have been performed by the

CNA as ordered.

Example:

z TlUtATMXWTAPMDnSTRATION KARSCX « » .

Qr*iwr*

1 14

iii t i II ,i ; i i i i II

7

II 7 0 t l i ! i n - . . 4 | /

g

2 2 3 12 1 4 3U

Sn'llMdMWaCM

1

*.. .. ... •

• 1| • : •
3.11 V I ' . - >

.11-'-

-JiA.. «-•

-ftf LJ

1 '

' ''' -
• , .

1 , | •• : i 1II

5. The care/risk level will be entered into the CNA Care Log. The CNA will follow all aspects of that level of care as outlined in skin Care PREVENTION PROTOCOLS q shift.

6. The CNA will place his/her initials next to the care/risk level to indicate that all areas of protocol have been performed, (see below). Example:

CTA LOG
t«Ulffi
'IflP IU«iMSUBC<n

.la

I il<

' •1

iU_

1.11 -.W>l
—,-^=j-H--

i i ji i it -i ,i ;t ji ,t 7 p j ! j : ] 2 p olililjUls

;

•

'

'

1I ' I I1 1' ' '

^

_

! j L__ ;

: !_ . ' ; : i : : : : •

*
: '

Philadelphia Nursing Home Episcopal Long Term Care
Wound Assessment
Policy Statement: All wounds (any alteration in skin integrity) will be assessed, measured, and documented on a weekly basis (every Wednesday).
Purposes: 1. To provide consistency and accuracy of wound assessment. 2. To promote the healing process using consistent treatment. 3. To assist in determining the outcome of treatment regimen.
Equipment: • Assessment and Evaluation Form • Skin Assessment Form • Polaroid Camera/Briggs film (once monthly) • Disposable measuring film • Wound Care Binder

Procedure:

1. The nurse will initiate a Wound Assessment and Evaluation Form (attachment #1) on any new wound and at the beginning of each month. Procedure for any new wound is outlined in the SKIN ASSESSMENT POLICY.

2. Licensed personnel will obtain photographs of each wound the first week of the month, using the following technique:

*

Obtain camera from Education Department

*

Using Briggs film, hold camera exactly 10 inches

from wound, using measurer provided with camera.

t

*

After photograph has fully developed, write resident's

name, date, and ulcer location on bottom of print.

3. All assessment and documentation forms related to wound care for the current month are to be filed in the Wound Care Binder. Previous months are to be filed as outlined in the Skin Assessment Policy.
4. Physician rounds on residents with wound are to be accomplished by the Nurse Manager, Treatment Nurse, Wound Care Director and CNA assigned to the resident.
5. Treatment regimens are to be reviewed with the physician and updated as necessary.
6. All treatments that have been ordered by the physician are to be documented in the TAR and on the Weekly Wound Assessment and Evaluation.

rev 10/97ts

Philadelphia Nursing Home Episcopal Long Term Care

Wound Staging Process

Initial Assessment
Assess pressure/venous ulcers using the Stage 1 - 4 scale following the definitions established by NPUAP and adopted by the AHCPR Pressure Ulcer Guideline Panels.

FollOW-Up A s s e s s m e n t - (think of the scale as an assessment of HEAUNG SCALE using the following definitions:

• Stage IV
• Stage III • Stage II • Healed

some necrotic tissue (eschar & slough) in wound base; fascia, muscle, tendon or bone exposed; minimal or no granulation tissue in wound base some granulation tissue in wound base: no necrotic tissue present granulation phase complete; reepithelialization beginning Mark "1 - YES" in section M3 History of Resolved Ulcers on the MDS 2

* Krasner, Diane. (1997). Recommendations for using reverse staging to complete the MDS2, OstomvWound Management. 43: 3, p. 13.
10/29/97 fs

Philadelphia Nursing Home
Glfard & Corinthian Avenues • Philadelphia, PA 19130
WIJS I 0 M

WEEKLY WOUND ASSESMENT AND EVALUATION

RESIDENT

_- WOUND LOCATION,

DATE OF ONSET

WHERE ACQUIRED_

DATE OF ASSESSMENT STAGE (I-1V, NON-STAGED) SIZE (length x width x dcpli) in cm. UNDERMINING/LOCATIONS TUNNELING/ LOCATIONS EXUDATE COLOR/ AMOUNT ODOR/PAIN ( + O R - ) WOUND BASE DESCRIPTION (pale, red, dry. moist) GRANULATION TISSUE (% PRESENT) EPITHIALIZATION (% PRESENT) WOUND EDGES (macerated, irrcg, approximated) PERIWOUND SKIN (macerated, reddened) NECROTIC TISSUE TYPE/ AMOUNT (% PRESENT) CURRENT TREATMENT SUPPORT SERVICE (TYPE, SPECIALITY BED) NUTRITIONAL STATUS (TUBE FEED. GOOD.F.P) MOBILITY (OOB, BEDBOUND, PRONE CART, W/C) DEBRIDEMENT DATE/TYPE (SHARP. SURGICAL) PREVENTION STRATEGIES (TURN, OOB, ETC.) SIGNATURE: TREATMENT NURSE

WEEK1

WEEK 2

ADDRESSOORAPH

WEEK 3

WEEK 4

i

C4-3

Philadelphia Nursing Home Skin Cara Guideline*
| (Paing Produce Guidalinaa available at PNH)

Stage Non-staged
I II III
"IV

Treatment

Rationale

• Debridesient

• Promote granulation

• Relieve pressure * Tegadera • Protective Barrier
(3M, Pericare or Vaseline)

• Prevent tissue destrucrisn

* Transparent Dsg • Tegasorb • Kydrasorb * Gauze/Cint:ner.t • Flexan

• Protect wound • Encourage
epithelialization

* Gauze • ?lexan • Sorbsan • Comfeel • Woun'dres • Fibracol • Mesalt • Santyl
* Tegasorb • Mhirlocol • VAC ? • Sharp debricetnent

• Must determine treatment goal before selecting wound management modality

Same as above

10/3S £3

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING
BRADEN SCALE

POLICY STATEMENT:

All residents will be assessed and scored using the Braden Scale at the following intervals:

•

Upon Admission

Upon transfer

With any significant change in status

•

Concurrent with quarterly MDS

PROCEDURE:

1.

Assessment is documented on Braden form by the licensed nurse.

2. Residents will be scored and categorized as follows • 17 or higher ROUTINE SKIN CARE

• 1 6 - 1 5 LOW RISK for breakdown

• 14-13 MODERATE RISK for breakdown

12 or less HIGH RISK for breakdown

3. Protocol interventions will be initiated and documented.

4. Completed Braden forms are to be filed in the MDS section of the

resident's medical record.

NOTE: Interventions will be documented on the TAR and the CNA Log.

4/9t

Philadelphia Huriing Horn* Kplacopal Long T « m Cars
Pressure Ulcer Treatment Guidelines

Slate

Natruiom

1

* linsure adequate

intake to prevent

Ntmhlanchahle erythema malnutrition.

of intact skin, the

hmrldint lesion of skin * Cintsull Dietician, if

uifemtiim.

necessary.

rrtaan Relief
* Float beds & ankles off of sleep surface
* Use pillows or Kant wedges between huny prominences

* Use pressure-reducing cushion, i fappropriate

I -
1
i i
II

* Dietary Consult

* Develop written turning schedule (q2 turning in bed.ql turning in chair)
* Assure pressure relief from reddened a r m
* Same as above

Partial lluckncss skin loss involving epidermis, dermis. or both.

* Ifmalnourished A. able to eat. assist with oral feedings & oral supplements

Topical Therapy

Other Therapies

* Keep area dean and dry * Use transparent drsg (Tcgadcrm)

* Consider Wound Care
Team Consult

* Moisture Harrier (Clean N Moist, or I'cri-Carc. or JM)

* Consider Kcluh Consult

* Cleanse wound with physiologic solution (Sca-Clms).

• WIHIIUI Care Team Consult

* Hydrncolloid wafer (Tcgasorh). Change <| 3- 5 days ami pm.
• Hydrogd (Wniin'drts) Change daily <fc pm

• Consider Rehab Consult

* Transparent drcwiue f I'cgadcrm) for wounds with MH. ami drainage. Clun^c q5-7days & pm.

HI

' Same as Stage II

Full thickness skin loss involving damage lo or necrosis of SQ tissue (hat may extend down _ fi.k tmt mil through.
.tdcrlying fascia. Ulcer presents dincially as a deep crater with or without undermining adjacent tissue.

* Same as Stage I
* Consider Specialty bed or overlay (rcf|uircs Wound Team Approval)

* Cleanse wound with physiologic solution (Sea-Claw).
• A.(POR MOSTl.Y CIJ-AN. CRANUI^HNG WOUNDS)
* ""llydrnerl wi«h ilamp nufTiil gauze (Woun'ilroi) Clungc daily & pm
(# $© +)
* MSS wet • damp Change daily or qshin A pm
(#$«+)
* Algtnalc packine (Scasorb) Change daily - for mod lo heavy drainage
($#©)
B. WOUNIXS wrni
USCIIAR(<50%of wound)
• ""Enzymatic debriding aecnt (SantyU Kla.sc. Mrcilt)
Clunge daily A pni
($ t + «)
C. H c d , ankle. A other fool wounds
Same as Stage IV
Dry. nnntender liccl csclur should remain open to air & floated lo relieve pressure (per A1ICPR guidelines)

• Wound Care Team Cunsull (nundattiry)
* Consider Rclwh
<*ll||.Stlif
• Consider slu<n-icrai llydrot licrapy

Philadelphia Huraing Horn* Kplacop&l Long Tarn Cars
Pressure Ulcer Treatment Guidelines

Stage

Nutrition

IV
Inill (hickneu skin loss with attentive dcstruction.lis.tuc. necrosis, or damage to muscle, hone or supporting sturcturcs (e.g.. tendon or joinl capsule).

* Same as StaRC II

Pressure Relief
* Same *s .Stage 1
* Consider .Specially lied or overlay (requires Wound Team Approval)

Topical Ttierapj

Other Therapies

\ . Mustly clcnu, Brannlaiiue * .Same as stage III

Team Consult * Kcliali ('INISIIII

R. Wound with R<rluir ( < 5 0 % of wound)
* .Same as .Slagc III

* Coiuiilcr xlMirl-lcriii 11 y«lnttlM.-ra|iy

C. HccL ankle. A oilier root wounds ( < 50% rsrhar)
* llydrncollnid Wafer (Tccasnrb) Clungc q 3 - J days A pm.

Nonstagcd

* .Same as Stage II

* Same as aU>vc

* Krquirei drbridrmrnl Use iraiupareiu lilin until evaluated by WCMIIKI (.'arc Team

• Wimwl Care Tram CIMIMIII
• Kcl»h CIHWIII

" Most prcfcrrcil molhod/prmlurt far this indiratinn I Prnlcct skin surrounding wound from excess moisture by applying a mnisturc barrier (PcriCarc nr 3M) at each dse chnncr + When nreparinK wet («» damp f auxc. unforld jtaozc In «njlc-|ily. moisten. .«|iicer.c mil excess until just damp, and "Hiiir gauze up prior U> placinc over »r
packing into wound t \ drcuio^ material's loosdy into all areas of undermining as well as to (Ul wound crater to skin surface Icrd. V s with nonwoTOi 4x4 gauxc sponecs, AIlD-type pad, foam dressing (llydrasorb), nr nnaadhcrent na<l
I IMTORTANT NOTUS: Allow a minimum of 7 - 10 days of use prior to dunging treatment Report any dramatic deterinralim in a pressure ulcer ASAP to Wound Care Team

TWe:

rXQLADELFHlA NURSING HOME
Administrative Polity tnd Procedure
Medical Nutrition Therapy for Retidi&U with P m j n r t TJlcars

Bff. Daw
So.
Pip*

10/01/97 1 of 1

POLICY:

Rendenu with pressure ulcers receive medical sffiriria* Therapy topromote wouod h"HTg

PURPOSE:

To enrarc midsnxs wob praesur* ukars rtc*iv« rfo necenary nutrilionil therapy.

RESPONSIBILITIES: 1.
2.

Tbe Registered PUntiBa (RS) will iwi»w th* Wound Care Book loeatofl on etch Unn while nuking dlily rounds.
Tic RD will s>-aloflu and document toe nutritioiw) stinii ot rhose r«ldenu pmsure ulcers at least monthly until it U healed TlJe RD will utilize iofonaatioA from me SJffll care assessmcut lurin, u d relcvam physical aad social kformation when determining tbt nutritional plan of care.
The RD will increase tbe auirieots of ifleciad readeou by wiliziag th«

A. Protein:

Sage I Stag* H
Multiple:

1.2 -1.4{a/kg 1.5 - 2.0 gm/Tcg U -2.0xra/kg 2.0 -2.5pn/kg 2.0 -2.5

R.

Flnid

35 • 46 ccAf/day

C.

; as appropriate: A multivitu&ln. Vitamin C, vitamin A,

or £ioc Sullatc (50 • lOOoct;. Eleaental use).

If tlu RD tttabllsBM that rhe resident is not positively rwpoixiius tu t p nutriem prescripCion. i revision to (he (uuaciiption is tecoax&mdad.

5.

H e madical nutrition therapy for each rtsideoi is lsdlvUuillzeU and assessed for

aeeeptaaoe by tbe resident to ensure efteiivBu*a».

6.

Information on prwjnre ulcers is communicated via UK inicrdliciplinirjr resident

Care Conferences.

7.

The £ P wilt reqoest prealbumin tcsdos. ai indicarcd, to determine bftselin*

nutritional soous tod as t monitor of sumeoaal tsnpxavfment.

The RD will evaluate the BKd Ibr »W"»-* medical nnridooal thanp^ «^*n tfa* pressure olccrswouad is nealed.

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

501.0 Pg. 1 of 3

ASEPTIC TECHNIQUE
PURPOSE:
To provide aseptic, uniform dressing changes to long-term care residents.
REPONSIBILITY:
• LPN OR RN
PROCESS:
1. Check wound care cart for cleanliness and properly dated supplies.
2. Check treatment order in treatment book and check for any changes prior to performing treatment.
3. Assemble necessary materials from wound care to take to bedside:
dressings scissors gloves (at least two (2) pair) cleansing solution Rx medication tape reservoir for cleansing solution plastic bags chux
4. Assure that wound care treatment and any anticipated discomfort is explained to the resident.
5. Assure that resident is properly positioned, privacy curtains are drawn and resident is not overly exposed.

501.0 pg. 2 of 3
6. Wash hands and put on gloves before removing dressings.
7. During removal of dressings assure:
a. Tape is removed by grasping edges, anchoring the skin and puililng tape toward the wound.
b. Transparent/Duoderm tape dressings are removed by loosening outer edges and gently pulling toward wound until dressing can be removed.
c. Soiled dressings are discarded in plastic bag with gloved hand.
d. Gloves are removed inside out and discarded into same plastic bag and top of bag is closed.
8. Wash hands and put on second pair of gloves before applying dressings.
9. Tape can be cut/torn in advance.
10. Place one chuck on overbed table or bedside table. (It is unacceptable to place dressings in the bed). Assure that a clean/sterile field is provided for dressings using inside of dressing package or disposable drape contained in dressing kit.
11. During cleansing of wound assure:
a. NSS or prescribed cleansing solution is used.
b. Cleanse wound from least contaminated area to most contaminated area.
c. Gauze used for cleansing is discarded after each wipe.
d If Rx ointment is ordered, a small amount is discarded onto unused gauze prior to dispensing treatment amount.
12. During dressing application, only the outside of the dressing should be touched.
13. Transparent/Duoderm - like dressings are applied by gently laying dressing on skin to prevent shearing and nurse does not stretch dressing before applying.
14. Tape should be applied with half width on the skin and half width on the dressing: excessive use of tape will cause skin breakdown. Assure dressing is secured in place.

501.0 pg. 3 of 3 15. Remove gloves inside out and dispose in lidded trash can in resident's room or in trash outside of resident's room. 16. Wash hands. 17. Resposition resident as needed and make comfortable. 18. Dispose of infectious waste: a. Small tied off bags are placed in a larger plastic bag which is then carried to red infectious waste receptacle.
b:\RrTA.INF\ASEPnCLOQ 9/97

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
RESIDENT CALL BELL
POLICY:
All residents will be provided with a call bell, or alternative means of alerting staff to their need for attention.
PROCEDURE:
1. The call bell will be placed within the reach of each resident when he is in bed. 2. The resident will be instructed in the use of the call bell. 3. Staff will be alert to signals that the call bell is on:
A. Flashing light on intercom B. Beeping of intercom C. Lighted call signal over the resident's door 4. Staff will respond to the call bell on a timely basis by: A. Communicating through the intercom system B. Visiting the resident in his/her room 5. When a resident is unable to use the standard call bell (or while awaiting service) an alternative call device will be obtained from Central Supply, Extension 50914, 50916. 6. When a call bell is out-of-order it shall be reported to Plant Operations immediately at extension 50855. 7. If a call bell is noted to have frayed wiring, it shall be unplugged and taken out of service, marked as "Broken" and Plant Operations shall be notified.
12/95

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

JzT C

PROVISION OF FRESH WATER

POLICY STATEMENT: The resident will be provided with fresh drinking water. PROCEDURE: 1. During the 11p - 730a shift, the CNA will provide fresh water to each resident.
A. If the resident is ordered a fluid restriction, the resident will not receive the 16 oz. container, but will receive the prescribed amount of fluid for each shift.
2. The CNA will mark a 16 oz. Styrofoam cup with resident's name, room number, and date.
3. The CNA will fill the cup with water and ice chips (if the resident prefers to have no ice the CNA will omit the ice chips).
4. The CNA will place a lid on the cup. 5. The CNA will provide a straw to the resident. If the resident is unable to place the
straw in the lid, the CNA will do so.
6. The container will be placed on the resident's bedside table by the CNA. 7. The container will be refilled as needed.
8. If at any time, a new container is needed, it is to be replaced and the resident's name, room number and date is to be placed on the container.
12/95

icmm
PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING
MEAL DELIVERY SYSTEM
POLICY STATEMENT:
Meals arrive on the unit in meal tray carts and are delivered to each resident by the nursing staff. In order to maintain the safety of the resident, the meal tray is inspected by the licensed nurse and handed to the CNA for delivery to the individual resident
PROCEDURE:
1- The resident is seated at the appropriate table in the dining room (see the seating arrangement board present in the dining room).
2. At the breakfast meal, the resident is prepared for the meal in his/her room.
3. In the event that the resident prefers to eat lunch or'dinner in his/her room, the resident is prepared for the meal in that room.
4. Preparation for the meal shall include (as applicable):
A. Seating the resident in a chair. B. Raising the head of the bed. C. Providing a moist washcloth so the resident can freshen his/her hands and face. D. Providing a bib.
5. The licensed nurse will remove the tray from the cart.
6. The licensed nurse will inspect the tray for accuracy of food provided against the diet order as given by the physician.
7. When the licensed nurse is satisfied with the accuracy of the food provided, he/she will hand the tray to the CNA who will deliver the tray to the specific individual for whom the tray is intended. (The resident's name and room number is present on the diet slip which is a part of the resident's tray.)
8. The resident shall be assisted, as needed, in preparation of the tray (i.e. opening of the juice container, cutting of the meat, etc.)
9. When the resident requires feeding or assistance with feeding , the CNA will provide that service.
10. When the meal is consumed, the CNA will document on the Meal Consumption Record the percentage of the meal that has been consumed. (See Meal Consumption Record Policy and Procedure.)
10/95

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING

MEAL CONSUMPTION RECORD

POLICY STATEMENT:

In order to maintain an accurate record of the residents food intake, the Meal Consumption Record is maintained.

PROCEDURE:

1. The Meal Consumption Record is completed at the end of each meal.

2. The Meal Consumption Record is placed in the Meal Consumption Log Book at the

Beginning of each week and is made out to include:

A. The week of

__

B. The unit name

C. Each resident's name and room number (if the resident is on tube feedings

and is not taking nourishment by mouth, he/she does not become a part of

the Meal Consumption Record).

3. The Meal Consumption Record is placed in the Meal Consumption Log Book and is maintained at the Nurses Station.

4. When the meal is finished, the CNA will enter the percentage of the meal consumed in the appropriate space. For instance, if the resident has consumed half of his breakfast on Monday morning, the CNA will enter "50%"..in the block under the "B" for Monday. (See the pie chart Resident's Food Intake)

5. The pie chart, Residenf s Food Intake is kept in the front of each Meal Consumption Log Book and is used to carefully determine the percentage of food ingested. (See attached).

6. Licensed nurses will review the Meal Consumption Record in order to: A. Identify and report problems 1) Any identification of poor intake, for example 50% or less of meal

consumption in a 72 hour period, or very sporadic meal completions, are brought to the attention of the Oietidan or designee.
B. Document in the resident's chart, in the Nurses Notes and/or the Monthly
Summary, the amount of food consumed.

B.TC

10/95

MEAL CONSUMPTION RECORD

10

.

MON TUES

Stable Residents

WEDS THRUS FR1

SAT SUN

EPISCOPAL LONG TERM CARE PHILADELPHIA NURSING HOME
DEPARTMENT OF NURSING
RESIDENTS WEIGHT
POLICY: Resident weights are performed and recorded at least monthly. Resident weights are performed weekly when ordered by the physician or at the discretion of the dietician. Re-weights are performed when requested by the dietician. PURPOSE: In order to assess and track the physical and nutritional status of the resident. PROCEDURE: A. A weight is performed and recorded on each resident at least once per month. B. All monthly weights are completed by the 10th of the month. C. A weight is performed and recorded on a weekly basis when it is ordered by the
physician or requested by the dietician. 1. When a weekly weight is ordered by the physician or requested by the
dietitian, the name of the resident is entered in the weight book under "weekly weights". D. The CNA is assigned the task of weighing the resident by the Unit Manager or Charge Nurse. E. Weights should be performed on the same scale each month/week. F. Weekly weights should be performed on the same day of the week at approximately the same time of day.

6 . Re-weights will be completed within 24 hours of the request for re-weight. H. Resident weights are documented in the weight book. '. Resident weights are transcribed from the weight book to the chart by the Unit
Clerk. J. When a resident has a weight gain or weight loss of 5 pounds or more, or a
weight gain or loss of 5% of their previous body weight, the dietitian will notify the physician. The dietician will review the weight book weekly. K. When a resident has a weight gain or loss of 5% of his/her body weight, a new MDS is initiated by the Interdisdplianry Team and the care plan is revised to address the problem.
TIM

Title: POLICY: PROCEDURE:

PHILADELPHIA NURSING HOME Administrative Policy and Procedure
Nutritional Assessments

Eff. Date Rev. Date No. Paees

5/95 9/96
1 of 1

A comprehensive Nutritional Assessment will be completed for each resident within seven days of admission.

1)

The Clinical Dietitian or Dietetic Technician completes a nutritional assessment

utilizing the Initial Nutritional History/Assessment Data Collection Form.

2)

The assessment form is completed and placed in the residents medical record

(Dietary section) within seven days of admission.

3)' The completed assessment form remains is the resident's medical records until the records are closed.

4)

The assessment includes, but is not limited to the following:

a.

Nutritional Intake - current food/fluid intake determined from

observation of resident's intake and review of food intake records.

b.

Functional Capacity - review of feeding ability determined from

observation of resident's intake and review of food intake records.

c.

Resident's Eating Habits and Preferences - determined from interviewing

resident and/or family to determine need.

d.

Dietary Restrictions - obtained from written physician order.

e.

Physical Information - record height, weight, usual body weight, weight

six months and one month prior to admission.

f.

Laboratory Studies - record all which are relevant to nutrition and

hydration status.

g.

Clinical Observations - note any physician signs of malnutrition.

h.

Dental Status - ability to chew the ordered diet consistency.

i.

Medications - note all relevant routine medications and drug/nutrient

interactions,

j.

Skin integrity - note condition of skin and specify stage and site of all

open areas and presence of edema.

k.

Estimated Needs - calculate resident's estimated Calorie/Pro/Fluid needs,

evaluate if diet and/or rube feedings meet estimated needs.

1.

Nutrition Problems/Goals/Approaches - identify nutrition problems and

establish measurable foals and specific approaches to meet goals.

5)

A brief note is written in the Dietary Progress Notes indicating the completing

of the assessment and time frame for next nutrition note/follow-up (i.e., 30 days

or 90 days).

c:\policy\nutriti.on

-ti

Philadelphia Nursing Home Episcopal Long Term Care
Restorative Dining Program

Purpose
To increase and promote independence in resident eating through observation, direct assistance, verbal cueing, and staff training.

Goals
• Identify residents with chewing and swallowing problems and functional disabilities that interfere with their ability to get food to their mouths.
• Assist residents to acheive their highest level of function related to independent feeding.
• Assure safety during the dining process by implementation of specific therapuetic interventions outlined by ST/OT.
• Maintain adequate nutrition and hydration.
• Maintain a calming atmosphere in order to support the residents' dining efforts.

Admission Criteria

*

Residents must be able to assume a sitting position for AT LEAST

45 minutes and the ability to maintain attention with cueing.

*

Residents identified as high risk for aspiration by ST, OT, or

Nursing.

*

Residents in need of instruction and/or monitoring on usage of

adaptive equipment

•

Residents discharged from therapy who need further instruction,

reinforcement and continued training to improve their eating abilities.

•

Residents with an unexplained weight loss or refusal to eat (for pre-

determined observation period).

•

Residents in need of instruction in seff-feeding techniques.

Admissions Process

•

ST will place an order for RESTORATIVE DINING PROGRAM on the resident's

chart and complete the Restorative Dining Notification Form (attached).

Program Phase

• AH resident on program will be brought to the 6th floor dining room by the Restorative Certified Nursing Aide (RCNA). If the RCNA is unavailable, the regular floor staff will see that the resident is brought to the dining room.

•

Residents will be seated according to the seating plan devised by ST/OT which

is present in the Restorative Dining Documentation binder. This seating plan is

reviewed by ST/OT on a monthly and pm basis.

•

Unless otherwise indicated, residents will be transferred from their wheelchairs

and placed in dining room chairs to facilitate optimal seating for meal

consumption.

• All meals will be supervised by a licensed employee (SST, OT, and/or Nursing).

•

The RCNAs will assure that each resident has their specific cue card in place on

the table during meals. Cue cards are reviewed and updated by ST/OT on a bi-

weekly basis. RCNAs will be assigned to dining tables and will assure that cues

an resident observation and assistance are provided as ordered.

•

RCNAs will be present for ail meals unless otherwise indicated by the

Restorative Nursing Program Director.

C.\pQlicy\restor.din

* At the completion of the meal, the RCNA will complete the Restorative Dining Record and meal consumption record for each resident. These forms will be filed in the Restorative Dining binder for a 1 week period. Upon completion, each record is reviewed and signed by ST/OT and placed in the resident's chart.
Discharge Phase
Criteria
* Resident's ability to follow strategies independently are assessed as adequate by ST/OT.
* Resident has been determined by ST/OT to have reached optimal level of function

Philadelphia Nursing Home Episcopal Long Term Care
Restorative Dining Notification

Resident: Todays Date:

Room:

The following action for the above resident is requested:
(Place a CHECK mark in the appropriate box)
G Place on restorative dining program beginning
Diet ordered:

(date).

D Discharge resident from restorative dining program on

(date).

Comments:

cc: D Dietary Director G Nursing Unit
9/97fs

D Restorative Nursing Director

Resident

Restorative Dining Evaluation Record

Room .

Diet

Awak« or Chawing

Lethargic

Monday
SL0
GGG

PPP

Looting food from Y Y Y

mouth

NNN

Drooling/Increased Y Y Y

accretions

NNN

Pocketing

YYY

NNN

Coughing

YYY

NNN

Choking

YYY

NNN

Refusing food

YYY

NNN

Avoiding certain

YYY

foods 4*1 voica

N NN YYY

NNN

Increased feeding time Selffaading

YYY N NN YYY

N NN

Using adaptive

YYY

• aulomant

N NN

Unable to pick up food

YYY NNN

Abie to ait upright Y Y Y

Requires back.'

N NN YYy

head suooort

N NN

Correct diat sent

Adaet.aauio.as ord. Initials

Tuesday W e d n e s d a y T h u r s d a y Friday S a t u r d a y Sundav
8 L 0 B L 0 8.L 0 a L 0 8 L 0 a L 0

GGG G G G

G GG F

GGG

G GG

GG G

Y YY NNN YYY N NN YYY NNN YYY NNN YYY NNN YYY NNN YYY N NN YYY NNN Y YY NNN YYy NNN YYY N NN YYY N NN YYY NNN YYY NNN

YY Y NN N YYY NN N YY Y NN N YYY NN N YY Y NN N YY Y NN N YY Y NNN YY Y NN N YY Y NN N YY Y NNN YY Y NNN YY Y NNN YYY NN N YY Y NNN

YYY NNN YYY NNN YY Y NNN YYY NHN YYY NN N y YY NNN YYY NNN YYY NNN YYY NNN y YY NNN YYY NNS YYY NNN Yy Y NNN YYY NN N

YY Y NN N YY Y NNN YY Y NN N
NNN YY Y NN N YY Y NN N YY Y NN N YY Y NN N YY Y NNN yYY HNN YY Y NN N YY Y NN N YY Y NNN YYY NNN

YY Y NNN YY Y NN YYY NN N
Y NNN YYY N N >4 YYV NNN YYV NNN YYY N NN YYy NNN Y YV N NN Y YV MNN Y Yy N NN
N NN YYy NNN

Y YY NNN YYY N NN YYY NNN YYY NNN YYY NNN YYY NNN YYY NNN YYY NNN Y YY NNN YYY N NN YYY NNN YYY NNN
NN N YYy NN

Initials

Full Name

Reuletued by ST/QT

Z'\ '.I*)'

C5-/7
Philadelphia Nursing Home Episcopal Long Term Care
Dysphagia Team Purpose To identify those residents who demonstrate dysphagic symptomatology, physical limitations effecting independent feeding, and those at high risk for weight loss as related to tolerance of diet consistency.
Goals • Continue to promote strategies addressed during skilled speech therapy and
ooccupational therapy through restorative nursing • Identify residents that may require skilled speech therapy or occupational
therapy as it relates to PO intake.
Criteria
• Dysphagia rounds will occur in each dining room once a month throughout the facility. Participants of dysphagia team will include the following: Speech Language Pathologist Occupational Therapist Charge Nurse Licensed Dietician Restorative CNA Schedule for rounds will be developed and distributed by SLP. Resident list for monitoring during rounds is to be generated 48 hours prior to rounds by the charge nurse on the unit, using the attached form.
rosed 9«7 Is

ot

PHILADELPHIA NURSING HOME EPISCOPAL LONG TERM CARE

DEPARTMENT OF NURSING

POLICY: Gastrostomy (Peg) Tube Feeding

PURPOSE: To assure the accurate administration of enteral nutrition or medication as

"

prescribed by the physician through an artificial opening in the abdominal

walL

PROCEDURE:

1. Explain procedure to the resident.

2. Wash hands prior to hanging the feeding bag to prevent the introduction of bacteria into feeding solution.

3. Position the resident in a semi-fowler's position (30-45° angle). Maintain the elevation of the head of the bed to prevent regurgkation and aspiration of the feeding solution.

4. Document on assignment sheet "ELEVATE HEAD OF BED AT ALL TIMES" to remind persons in contact with resident to keep HOB elevated.

5. Attach syringe to peg tube to check for residual. This monitors the degree of motility and prevents over feeding.

6. Adjust controller clamp for prescribed rate and verify the correct setting of the controls on the flexiflow pump. This will prevent a too rapid infusion of feeding solution which can lead to gastric distention.

7. Terminate the feeding if signsof obstruction (vomiting, marked distention) are present or if the resident feels nauseated. Report the condition to the physician.

8. After the feeding, instill lOOcc of water to promote potency of the tubing, unless the resident is on fluid restriction.

9. Verify the integrity of the skin around the site and document accordingly.

10. In an emergency situation, aspirate tube and connect tube to low Gomco Suction to prevent aspiration.

Pace 2
11. Charting:
(A) In the Nurses Notes:
Amount and content of feeding. Amount and content of residual. Amount of water used in flushing the tube. Any comment made by resident. General observation of the resident Problems encountered.
(B) On the Intake and Output Sheet:
* Note time and amount of feeding.

pg. 2 of 2

10/95

Title:

PHILADELPHIA NURSING HOME Administrative Policy and Procedure
Enteral Feedings

Eff. Date Rev. Date No. Pases

5/95 2/96
1 of 1

POLICY: PROCEDURE:

Enteral feedings via Naso-Gastric or PEG tubes are not used unless the resident's clinical condition that requires the use of the tube feedings as unavoidable. Clinical conditions which may indicate a need for enteral feedings include inability to swallow without chocking or aspiration, comatose or malnutrition resulting form inadequate oral intake.

1)

The physician orders all enteral feedings; orders for tube feedings must include

the following:

a.

The brand name of the product

b.

The rate to be infused each hour

c.

The total number of hours and time to infuse the feeding

d.

Bolus or gravity feedings need to specify die volume and frequency of

feedings need to specify die volume and frequency of feedings per 24

hours

e.

The volume of water flush per shift or after each feeding

2)

Only commercially prepared formulas are utilized, The current formulary is

provided by Sandoz Nutrition and supplemented by a limited number of

specialized formulas from ROSS products.

3)

The Nursing Staff is responsible for all feeding equipment, formulas and the

administration of the tube feeding.

4)

The volume of water flush for all tube feedings should be based on a resident's

estimated water needs; standard water flushes are not recommended.

5)

The Clinical Dietitian will complete an initial assessment and a monthly follow-

up progress note to include the following:

a.

The nutritional composition of the tube feedings order and its nutritional

adequacy in meeting the resident's estimated needs for calories, protein,

water and all vitamins and minerals (RDAs).

b.

Any problems or limitations as a result of tube feeding; resident's

tolerance to the tube feeding.

The Registered Dietitian will utilize the calendar or resident assessment form to keep an ongoing documentation schedule for all residents. See policy for periodic review of nutritional status.

c:\policytawriLcm

Tide:

PHILADELPHIA NURSING HOME Administrative Policy and Procedure
Weaning From Enteral Feedings

Eff. Date Rev. Date No. Pazes

5/95 2/96
1 of I

POLICY: PROCEDURE:

Any resident on enteral feeding will be weaned from tube feedings unless it is nutritionally or medically contraindications.

1)

All residents receiving enteral feedings will be monitored for nutritional status.

2)

If indicated, the resident will be slowly weaned from enteral feedings to improve

oral nutrition intake.

3)

The Ginical Dietitian will monitor oral intake and recommend adjustments to

enteral feedings to improve oral nutritional intake

4)

When the resident demonstrates the ability to consume enough food to meet their

nutritional needs, the Clinical Dietitian will recommend discontinuing enteral

feedings.

5)

The Clinical Dietitian will document the resident's progression in the medical

record.

6)

The Ginical Dietitian will complete an initial assessment and a monthly follow-

up progress note to include the following:

a.

The nutritional composition of the tube feedings order and its nutritional

adequacy in meeting the resident's estimated needs for calories, protein,

water and all vitamins and minerals (RDAs).

b.

Any problems or limitations as a result of tube feeding; resident's

tolerance to the tube feeding.

7)

The Registered Dietitian will utilize the calendar or resident assessment form to

keep an ongoing documentation schedule for all residents. See policy for

periodic review of nutritional status.

e:\policy\nunit. wea

Title:

PHILADELPHIA NURSING HOME Administrative Policy and Procedure
Tuberculosis Skin Testing Program

Eff. Date. Pages Rev.

7/95 1 of 1 7/1/98

Purpose:
To ensure administration of tuberculosis skin testing consistent with Center for Disease Control guidelines.
Policy:
Employee Skin Testing:
All employees will be skin tested at the time of initial employment and annually thereafter. Employees with positive skin testing results will be given chest x-rays and treatment as determined to be necessary by employee health and infectious disease.
Resident Skin Testing:
All residents will have a two step PPD administered on admission. Residents will subsequently have an annual PPD administered thereafter.
Procedure:
All residents of Philadelphia Nursing Home will have a repeat PPD completed by December 29, 1998.
The Mantoux test will be administered and read by the Infection Control Coordinator.
Test results will be documented on each residents' immunization record which remains in the medical record.
Effective January 1999 annual repeat PPD will be administered, interpreted and documented on each resident by specifically training Department of Nursing staff.
The Infection Control Coordinator will monitor the process, maintain a master log, administer and read PPDs on all new admissions.

rule:

PHILADELPHIA NURSING HOME Administrative Policy

FfF. Due Pages

2/97 1 of 1

PURPOSE:
POLICIES AND RESPONSIBILITIES:

To ensure the provisioii of comprehensive rehabilitation services by qualified physical, occupational and speech therapists in accordance with accepted professional standards to anain or maintain the highest practicable level of function.
Residents will be screened withia forty eight (48) working hours of admission or rcadmission or through mining referrals by therapy staff to determine if functional declines are present: skilled services ars required; or for maintenance of qpnrml levels of function; or quarterly in conjunction with resident interdisciplinary care conferences.
Residents will be screened on a quarterly basis for changes in swallowing function and ability to Tn"int*ir adequate nutrition and hydration on prescribed diet.
Initial resident evaluation will be completed within forty eight (48) working hours of a physician order and placed in the medical record.

a.

Progress notes will be written for each resident receiving

therapy services on a weekly basis.

b.

A monthly summary will be written at month's end for each

resident receiving therapy services.

Tie interdisciplinary team win be informed of a resident's impending discharge from therapy services to ensure proper education has been provided and to allow for continuity of care by the team.

a.

A discharge summary will be completed for all residents

discharged from skilled rehabilitation services within five (5)

days of discharge.

Rehabilitation Staff will -participate in the Department of Nursing Restorative PTII^JHH to facilitate the residents return and/or maintenance of their highest practical level of function and well being.

a.

Assist facility staff in the development or general restorative

programs related to the needs of facility residents

Title:

PHILADELPHIA NURSING HOME
Ariminiili IIITI* Ptrlirr and Procadurs
Rahihifitnfton Services

No. EfT. Dan
Pifes

J/9J 2 of 2

1.

Restorative Dining

2.

Positioning

3.

Splinting

4.

Range of Motion

3.

Ambulation

b.

Provide education/training and establishment of competence for

all levels of Nursing.

7.

Therapy staff will participate m M.D.S. completion for residents

receiving therapy services.

8.

Residents win receive therapy services at the bedside when they are

unable to participate in services provided in the gym.

9.

Therapy staff wiU present therapy-related information at interdisciplinary

care conferences fur residents receiving therapy services.

10. All therapy staff will adhere to all facility policies including but not limited to die following:

a.

Universal Pr>fM>nfi'7r'*^TTif'*<*tiOiT> Control

b.

Equipment Maintenance

e.

Resident rights

d.

Reporting of Incidents/Accidents

e.

Fire/Safety

Title:

PHILADELPHIA NURSING HOME
Administrative Policy 2nd Procedure
Medical Records

No.
Effective: 6/95 Page l o f 3

POLICY:

The Philadelphia Noising Home shall ensure that a Medical Records Service is established which shall be responsible for filing, auditing, receiving, maintaining and appropriately disposing of ail clinical resident records consistent with standards established by professional Medical Records Associations and by state and federal statute. A dirrical/medical record shall be established ibr every resident upon admission to the Philadelphia Noising Home. This record shall include clinical, medical and psychosociai information on every resident.

PROCEDURE:

1.

A complete clinical record will be maintained for each resident in accordance with state

and federal laws and regulations. All entries shall be made on a "current" basis, signed

and dated. The resident record will serve as a basis for documenting, planning and

recording all resident care and for providing a means of communication among all

members of the resident cars team.

2.

All information contained in resident records shall be considered and treated as

"confidential" information. Accordingly, information from the resident record shall be

disclosed to authorized persons only and shall be released in a manner which is

consistent with procedures and policies identified herein and in the policy -which

addresses "Confidentiality".

3.

All resident/clinical records shall be maintained for a period of seven (7) years after the

last date of service In the event that the resident is a minor, records should be

maintained for at least three (3) years after the minor comes of age under state law.

4.

In the case of a disaster in Philadelphia Nursing Home, it will be the responsibility of

the Medical Records Department to assure that a "master file" is stored in a secure

location. In the event that evacuation of residents from Philadelphia Nursing Home to

another location is required/initiated, it will be the responsibility of the Medical Records

Department to assure that current records of current residents are retained and sent with

the residents. If time permits, closed records should also be removed from Philadelphia

Nursing Home or from danger in the event of disaster.

The Medical Records Department shall function under the direction of a full time records coordinator. la addition to the responsibilities already identified herein, it shall be the responsibility of the Medical Records Director and Department to:

a.

Ensure orderly control of all records, provide for the systematic filing of

resident records.

b.

Compile records for authorized outside agencies who require medical/

statistical information:

Participate in gathering medical and statistical data.

Title:

PHILADELPHIA NURSING HOME
Administrative Policy and Procedure
Medical Records

No. Effective: 6793 Page 2 of 3

*

Provide medical record information requested by third-party payon

and others upon appropriate written request.

Prepare and oversee resident disdiarge records.

Safeguard proper use of and confidentiality of resident records, iociudiag r* for HC*M »nrf a release system.

•

Make resident records available to professionals and other staff

directly involved in care, as well as representatives of the Department

of Aging - Ombudsmen.

Provide residents with ready access to all thdr medical records within three (3) working days of an oral or written request (if not adjudicated incompetent by state laws). Reasonable fee may be charged for copies.

•

Mate available, after a death of a resident, the resident's medical

record to the deceased resident's executor or administrator of

decedent's estate or person,responsiblefor disposition of the body

(reasonable fee may be charged).

Ensure completion of discharge iccords within thirty (30) days of discharge.

Clinical infonnatioa pertaining to resided shall be centralized on resident's medical record.

Records shall be easily retrieved within one (1) business day.

Maintain a master book with copies of forms used by each department. Records should include:

Physicians orders and progress notes, nurses notes, medical history and physical examination reports and nursing and assessment.

•

identification information, admission data, documented evidence of

informed Advance Directives, documented evidence of assessment of

resident's (MDS). established treatment plan, and plans of care and

services.

•

Hospital diagnoses authentication, discharge summary, reports from

attending physicians or transfer form, and therapeutic orders, reports

of treatment, clinical findings, medication records, and discharge

summaries including final diagnosis, progress or cause of death,

autopsy reports and de«th certificates.

• Each professional discipline - history and progress notes completedin
a timely fashion and addressing the individual needs of the residents.

Tide:

PHILADELPHIA NURSING BOMS Administrative Policy

Ma. Effective 6/22 Page 3 of 3

Medical Records

Symptoms and other iodlcaxiofls of illness or tnjm y) actioo takes onisi be included.
Conduct medical record and resident care audits.
Review and analyze quarterly sample of records to determine accuracy,

•

Reports monthly to the Associate Adminstrator, Patient Care Services

regarding Medical Record services.

Maintain record fer seven (7) years (long-term care) after the last date of service.

 
 ROUTING AND TRANSMITTAL SLIP
TO: (Name, office symbol, room number, building, Agency/Post)
1.
2.
3.
4.

Date Initials Date

ui

Action Approval As Requested Circulate Comment Coordination REMARKS

File For Clearance For Correction For Your Information Investigate Justify

Note and Return Per Conversation Prepare Reply See Me Signature

-35
DEPARTMENT GF JUSTICE
JL;L 2 5 \995 •

DO NOT use this form as a RECORD of approvals, concurrences, disposals, clearances, and similar actions

FROM: (Name, org. symbol, Agency/Post)

Room No.—Bldg.

5041-102 GPO : 1987 0 - 196-409

Phone No.
OPTIONAL FORM 41 (Rev. 7-76) Prucribtd by GSA FPMR (41 CFR) 101-11.206

CRIPA Investigation

H

VI IHH

H I B B » • • • QBaHa

NH-PA-004-001

U.S. Department of Justice United States Attorney Eastern District of Pennsylvania

DRH:kjh (215) 451-5337

615 Chestnut Street Suite 1250

Philadelphia, Pennsylvania 19106

(215) 451-5200
July 20, 1995
Via Federal Express Richard J. Farano Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 10th & Pennsylvania Avenue, N.W.
Washington, DC 20530
RE: Philadelphia Nursing Home
Dear Mr. Farano: Enclosed please find the Memo to Deval L. Patrick
regarding Philadelphia Nursing Home. If you need anything further, please feel free to contact me.
Very truly yours,
MICHAEL tf. STILES United sftates Attorney

Enclosure

DXVlD R. HOFFMAN Assistant Unite

tes Attorney

&

V - ^ •:-'&';^r"i~'v->-'i'\\^i.^^^

<•.'••<;

U.S. Department of Justice United States Attorney Eastern District of Pennsylvania

615 Chestnut Street Suite 1250 Philadelphia, Pennsylvania 19106-4476 (215) 451-5200

July 20, 1995

MEMO TO: DEVAL L. PATRICK ASSISTANT ATTORNEY GENERAL CIVIL RIGHTS DIVISION

FROM: RE:

JAMES G. SHEEHAN ASSISTANT UNITED STATES ATTORNEY CHIEF, CIVIL DIVISION
DAVID R. HOFFMAN ASSISTANT UNITED STATES ATTORNEY
PHILADELPHIA NURSING HOME

I am writing to request the immediate intervention of the Department of Justice in the Philadelphia Nursing Home (PNH), Girard and Corinthian Streets, Philadelphia, Pennsylvania. An investigation by the Department into the conditions at PNH, pursuant to its authority under the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997 et seq. . is necessitated by recent findings at the facility as well as concerns raised by advocates of those residing in the facility. PNH is a city-owned facility which has delegated managerial functions to Episcopal Long Term Care, a subsidiary of Episcopal Hospital. There are approximately 3 60 individuals currently residing at PNH.

BACKGROUND

PNH is the only city-owned nursing facility in the City

of Philadelphia. PNH has a population mix of elderly,

developmentally disabled, HIV/AIDS patients, accident victims and

those suffering from mental impairments. The residents range in

ages from .21 to over 90 years of age.

.. .

From July 1994 until December 1994, the census increased by 150 residents, to over 480. There are, however, only 2 attending physicians to care for the entire resident population with the exception of one other physicians who is treating only one resident.
A survey of the facility was performed on the following dates; June 1-2, 5-16. On June 13, 1995, the Commonwealth of Pennsylvania Department of Health found that there is a "serious and immediate threat to residents." On July 14, 1995, the Health Care Financing Administration, based upon a revisit by the state's Department of Health found that the immediate threat to resident health and safety had been removed but that 9 level A deficiencies remained. These deficiencies involved Quality of Care, Quality of Life, Nursing Services, Dietary Services, Infection Control, Resident Behavior and Facility Practices of the nursing home.
As a result of the survey, the census at PNH dropped to approximately 360 residents from over 480. Based upon information supplied by the Long-Term Care Ombudsman Program, it is estimated that approximately 100 residents of PNH were transferred to local hospitals from PNH based upon their medical condition as discovered by the Department of Health surveyors.
THE JUNE SURVEY RESULTS
The nursing home survey conducted in June found multiple serious deficiencies including, but not limited to:
Resident to Resident Abuse:
(a) The rape of a 89 year old resident; (b) The infliction of cigarette burns on two residents; (c) An elderly diabetic resident was hit in the face and
eye.
Even more disturbing was the fact that there were no reports filed by the facility nor was there any intervention by the facility in any of these cases.
Quality of Care:
(a) Residents with decubitus ulcers were not identified by staff, i.e., 14 out of 29 targeted residents had Stage II decubitus ulcers found by the surveyors that were never noted by the facility;
(b) One resident, who was critically ill, was observed lying in bed on his right side without being turned and repositioned

for almost three hours. Additionally, pressure relieving devices between the resident's knees and legs were not provided. The resident was also incontinent of bowel, had not been bathed and a strong body odor was present. Within a two week period, the resident had developed four Stage II decubitus ulcers;
(c) Reports of pressure sores were incomplete or inaccurate so proper tracking and cause of pressure sores advancing from the Stage II to the Stage IV level was impossible;
(d) One resident had abnormal laboratory values evidencing acute renal failure that was never communicated to physician. Upon learning of the lab values, the resident was immediately hospitalized;
(e) Residents are at nutritional risk. One resident had an unexplained loss of weight of over thirty (3 0) pounds in less than three months while another resident lost over 21 pounds in 2 months. Additionally, one resident did not have food served even though the resident was in the restorative feeding program. This resident has bilateral gangrene of the lower extremities, at least 5 decubitus ulcers on both legs, including 4 Stage IV pressure sores. Protein and food consumption, critical elements in good wound healing, were unable to be reviewed since the documents were inaccurate and missing information;
(f) The nursing staff failed to turn and reposition residents, provide incontinence care, and release residents from restraints in a timely fashion.
Quality of Life:
Residents throughout the facility were observed with genitals, buttocks, thighs and backs exposed to other residents, staff and visitors.
Residents wore soiled and torn clothing.
Residents were not regularly bathed.
CONTINUING NATURE OP DEFICIENCIES:
The survey noted that "all deficiencies cited during the July 18, 1994, Medicare, Medicaid and State Licensure Survey remained in noncompliance on this survey."
Additionally, as of July 14, 1994, all Level A deficiencies remained after the facility was re-surveyed in July.

JULY MEETING WITH ADVOCATES On July 18, 1995, a meeting was held at the U.S. Attorney's Office in Philadelphia, Pennsylvania that included representatives from advocacy groups for the elderly (Long-Term Care Ombudsman Program), developmentally disabled, and AIDS patients. The meeting was convened to gather information as to the day-to-day occurrences at PNH and the attempts made by the advocacy community to rectify the conditions at PNH. All of the representatives found the conditions at PNH to be inadequate, appalling and also emphasized that staff at PNH was overwhelmed. In addition to the survey findings, a summary of the information supplied at the meeting evidenced the fact that: (a) residents are being discharged to the community in a septic condition and that their discharge planning "almost killed a few people"; (b) residents are not receiving physical or occupational therapy and physician consultations are simply not occurring thereby jeopardizing residents1 health;
(c) staff was unaware of psychiatric and/or psychological histories of residents thereby offering no proper treatment and endangering other residents;
(d) the vast majority of staff was temporary in nature thereby creating a lack of familiarity with resident needs and conditions;
(e) the nursing home administrator was extremely difficult to reach with complaints and was, in fact, non-responsive;
(f) the physicians responsible for the provisions of care do not know what is going on with the residents' medical conditions and therefore, proper medical care is not being provided;
(g) the food at PNH is inedible based on taste, preparation and delivery and as such, residents are at nutritional risk as evidenced by the survey results.
SEl

CONCLUSION
Based upon the information compiled to date, it is apparent that the inadequate provision of quality care to the residents of PNH necessitates an investigation by the Office of Civil Rights pursuant to the authority under CRIPA. I offer my continued assistance in attempting to rectify the intolerable conditions at PNH. The United States Attorney for the Eastern District of Pennsylvania has been apprised of the circumstances surrounding this request.

 
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CLOSED, STANDARD
United States District Court Eastern District of Pennsylvania (Philadelphia) CIVIL DOCKET FOR CASE #: 2:98-cv-04253-SD

UNITED STATES v. THE CITY OF PHILA, et al Assigned to: JUDGE STEWART DALZELL Demand: $0 Cause: 31:3729 False Claims Act

Date Filed: 08/13/1998 Jury Demand: None Nature of Suit: 890 Other Statutory Actions Jurisdiction: U.S. Government Plaintiff

Plaintiff UNITED STATES OF AMERICA

represented by BILL LANN LEE U.S. DEPARTMENT OF JUSTICE P.O. BOX 66400 WASHINGTON, DC 20035-6400 LEAD ATTORNEY ATTORNEY TO BE NOTICED

DAVID R. HOFFMAN U.S. ATTORNEY'S OFFICE 615 CHESTNUT ST. SUITE 1250 PHILADELPHIA, PA 19106-4476 215-861-8337 Fax: 215-861-8594 Email: david.hoffman@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

JAMES G. SHEEHAN U.S. ATTORNEY'S OFFICE 615 CHESTNUT ST SUITE 1250 PHILADELPHIA, PA 19106-4476 215-861-8301 Fax: 215-861-8647 Email: james.sheehan@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

JANET RENO U.S. ATTORNEY GENERAL 320 FIRST STREET, NW WASHINGTON, DC 20530 LEAD ATTORNEY ATTORNEY TO BE NOTICED

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V. Defendant THE CITY OF PHILADELPHIA
Defendant EDWARD G. RENDELL MAYOR OF THE CITY OF PHILADELPHIA Defendant

MICHAEL R. STILES UNITED STATES ATTORNEY 615 CHESTNUT STREET SUITE 1250 PHILADELPHIA, PA 19106 TEL 215-861-8501 Fax: FAX 215-861-8618 LEAD ATTORNEY ATTORNEY TO BE NOTICED
RICHARD J. FARANO U.S. DEPARTMENT OF JUSTICE P.O. BOX 66400 WASHINGTON, DC 20035-6400 LEAD ATTORNEY ATTORNEY TO BE NOTICED
ROBINSUE FROHBOESE U.S. DEPARTMENT OF JUSTICE P.O. BOX 66400 WASHINGTON, DC 20035-6400 LEAD ATTORNEY ATTORNEY TO BE NOTICED
STEVEN H. ROSENBAUM U.S. DEPARTMENT OF JUSTICE P.O. BOX 66400 WASHINGTON, DC 20035-6400 LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by WILLIAM R. THOMPSON AMERICAN BUSINESS FINANCIAL SERVICES, INC. THE WANAMAKER BUILDING 100 PENN SQUARE EAST PHILADELPHIA, PA 19107 LEAD ATTORNEY ATTORNEY TO BE NOTICED

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ESTELLE B. RICHMAN COMMISSIONER, HEALTH DEPARTMENT
Defendant
EPISCOPAL LONG TERM CARE AS OPERATORS OF THE PHILADELPHIA NURSING HOME

represented by MARK H. GALLANT COZEN O'CONNOR 1900 MARKET ST PHILA, PA 19103 215-665-4136 Fax: 215-701-2436 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Date Filed 08/13/1998 08/13/1998 08/13/1998 08/14/1998
08/14/1998
08/14/1998 08/14/1998 11/02/2001
11/07/2001

#

Docket Text

1 Complaint. (tj) (Entered: 08/14/1998)

2 UNCONTESTED MOTION by PLAINTIFF UNITED STATES TO ENTER SETTLEMENT AGREEMENT , CERTIFICATE OF SERVICE. (tj) (Entered: 08/14/1998)

Standard Case Management Track. (tj) (Entered: 08/14/1998)

3 ORDER THAT THE CLERK SHALL CLOSE THIS CASE STATISTICALLY. ( SIGNED BY JUDGE STEWART DALZELL ) 8/14/98 ENTERED AND COPIES MAILED AND FAXED 8/14/98. (sc) (Entered: 08/14/1998)

4 ORDER GRANTING THE UNITED STATES UNCONTESTED MOTION TO ENTER THE SETTLEMENT AGREEMENT; THE SETTLEMENT AGREEMENT IS APPROVED; AND THE SETTLEMENT AGREEMENT IS ENTERED AS A JUDGMENT AND DECREE OF THIS COURT. ( SIGNED BY JUDGE STEWART DALZELL ) 8/14/98 ENTERED AND COPIES MAILED AND FAXED 8/14/98. (sc) (Entered: 08/14/1998)

Case closed (kv) (Entered: 08/17/1998)

5 Praecipe by PLAINTIFF UNITED STATES to substitute signature page of Lewis Morris which was filed with the Settlement Agreement on 08/13/98, Certificate of Service. (fe) (Entered: 08/17/1998)

6 JOINT MOTION by DEFENDANT EPISCOPAL LONG, DEFENDANT THE CITY OF PHILA, PLAINTIFF UNITED STATES TO DISMISS ACTION , MEMORANDUM, CERTIFICATE OF SERVICE. (jl) (Entered: 11/05/2001)

7 ORDER THAT THE JOINT MOTION TO DISMISS ACTION, IS GRANTED AND THE ACTION IS HEREBY DISMISSED WITH PREJUDICE. (SIGNED BY JUDGE STEWART DALZELL) 11/8/01 ENTERED AND COPIES MAILED AND FAXED BY CHAMBERS.

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(fh) (Entered: 11/08/2001)

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