Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Resident Rights
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F-157: Notification of changes- The facility immediately informs the resident; consults with the resident's physician; and if known, notifies the resident's legal representative or an interested family member when there is significant change in the resident's status?
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F-159 Protection of Resident Funds: Accounting and Records - The individual financial records are available through quarterly statements and on request to the resident or his or her legal representative?
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F-161 Protection of Resident Funds: Assurance of Financial Security - The facility purchases a surety bond, or otherwise provides assurance satisfactory to the Secretary, to assure the security of all personal funds of residents are deposited with the facility?
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F-164 Privacy and Confidentiality - The resident has the right to personal privacy and confidentiality of his or her personal and clinical records (including privacy during personal care)?
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F-176 Self Administration of Drugs - An individual resident may self-administer drugs if the interdisciplinary team has determined that this practice is safe?
Admission, Transfer, and Discharge Rights
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F-202 Documentation - When the facility transfers or discharges a resident under any of the circumstances specified in F201, the resident's clinical record is documented? This documentation is made by a physician when transfer or discharge is necessary?
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F-205 Notice of Bed Hold Policy and Readmission- At the time of transfer of a resident for hospitalization or therapeutic leave, the nursing facility provides to the resident and a family member, or legal representative, written notice which specifies the duration of the bed-hold policy under the State plan during which the resident is permitted to return and resume residence in the nursing faciity; and the nursing facilities policies regarding bed-hold periods, permitting a resident to return?
Resident Behavior and Facility Practice
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F-221 Restraints - The 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?
Quality of Life
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F-241 Dignity - The facility promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality?
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F-248 Activities - The facility provides for an ongoing program of activities designed to meet, in accordance with the the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident?
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F-253 Environment- The facility provides effective housekeeping and maintenance services?
Resident Assessment
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F-272 Comprehensive Assessment: Resident Assessment Instrument - The facility makes a comprehensive assessment of a resident's needs, using the RAI, and includes...documentation of summary information regarding the additional assessment performed through the resident assessment protocols (RAPS)?
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F-274 Comprehensive Assessment - A facility conducts a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition?
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F-279 Comprehensive Care Plans - The facility uses the results of the assessment to develop, review, and revise the resident's comprehensive plan of care?
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F-281 Professional Standards - The services provided or arranged by the facility meet professional standards of quality?
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F-282 Care Plans - The services provided or arranged by the facility are provided by qualified persons in accordance with each resident's written plan of care?
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F-283 Discharge Summary - When the facility anticipates discharge a resident has a discharge summary which includes: (1) a recapitulation of the resident's stay?
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F-284 Discharge Summary - When the facility anticipates discharge, a resident has a discharge summary that includes a post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment?
Quality of Care
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F-309 Quality of Care - Each resident receives and the facility provides 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?
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F-314 Pressure Sores - A resident that has a pressure sore receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing?
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F-315 Urinary Incontinence (d)(1) - A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization is necessary: and (d)(2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible?
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F-318 Range of Motion - Based on the comprehensive assessment of a resident, the facility ensures that a resident with a limited range of motion receibes appropriate treatment and services o increase range of motion and/or to prevent further decrease in range of motion?
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F-323 Accidents - The facility ensures that the resident environment remains as free from accident hazards as is possible; and each residnet receives adequate supervision and assistive devices to prevent accidents?
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F- 327 Hydration - The facility provides each resident with sufficient fluid intake to maintain proper hydration and health?
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F-328 Special Needs Respiratory Care - The facility ensures that residents receive proper treatment and care for respiratory care?
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F-329 Unnecessary Drugs- Each resident's drug regimen is free from unnecessary drugs? An unnecessary drug is any drug when used: (i) in excessive dose (including duplicate therapy); or (ii) for excessive duration; or (iii) without adequate monitoring; or (iv) without adequate indications for its use; or (v) in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) any combination of the above.
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F-332/333 Medication Errors - The facility ensures that (m)(1) it is free of medication error rates of 5% or greater; and (m)(2) residents are free from any significant medication error?
Dietary Services
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F- 363 Menus and Nutritional Adequacy - Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences?
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F-371 Sanitary Conditions - The facility stores, prepares, distributes, and serves food under sanitary conditions?
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F-373 Paid Feeding Assistants (2) Supervision - (ii) In an emergency, a feeding assistant calls a supervisory nurse for help on the resident call system?
Physician Services
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F-386 Physician Visits - The physician signs and dates all orders?
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F-387 Frequency of Physician Visits - The residents are seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter?
Pharmacy Services
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F-425 Procedures - A facility provides pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident?
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F-431 Storage of Drugs and Biologicals - (2) The facility provides separately locked, permanently affixed compartments for storage of controlled drugs listed as Schedule II and other drugs subject to abuse?
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F-432 Storage of Drugs and Biologicals - In accordance with state and federal laws, the facility stores all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to the keys?
Infection Control
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F-441 Infection Control - The facility establishes and maintains 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?
Administration
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F-498 Proficiency of Nurse Aides - The facility ensures that nurse aides are able to demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care?
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F-520 Quality Assessment and Assurance - The facility maintains a quality assessment and assurance committee consisting of the director of nursing services, a physician designated by the facility, and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly...and develops and implements appropriate plans of action to correct identified quality deficiencies?
