LONG-TERM CARE SURVEY MANUAL* - Nursing Home Help

LONG-TERM CARE * SURVEY MANUAL

Disclaimer: This manual was prepared by staff of the MU nursing home consultant program and funded by the Missouri Department of Health and Senior Services. This manual is advisory and does NOT represent the views of the Department of Health and Senior Services. The purpose of this manual is to aid and assist administrators and management teams of Missouri’s skilled nursing homes in preparing for their annual survey. All information contained in this manual is solely intended as a resource and a guide and assumes no responsibility for any error, omissions, or discrepancies. Refer to the official regulations listed below for the most current and accurate information. 1. The State Operations Manual (SOM), Appendix PP, Guidance to Surveyors for Long-Term Care Facilities http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R12SOM.pdf 2. The Division of Regulation and Licensure, Section for Long-Term Care Regulations, Licensure Regulations Manual - http://health.mo.gov/seniors/nursinghomes/pdf/Licensure_Manual.pdf

*If you find information in the manual that needs revision or if you have information you feel should be added to this manual, contact our staff by e-mail at [email protected]. Electronic files of this manual can be downloaded at http://www.nursinghomehelp.org. Your QIPMO nurse and the Long-Term Care Leadership Coach can also provide you with electronic copies during onsite visits.

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 1 - SURVEY PREPAREDNESS Survey Preparedness - The MU NHA Consultant recommends that your home maintain a SURVEY BOOK. The purpose of the book is to help your staff be survey ready every day. To be ready for the annual visit, the SURVEY BOOK should be reviewed weekly so that it is kept up-todate. Make sure that all your management staff knows where the book is located as surveyors might show up when the NHA and/or DON are not in the facility. This section provides you with several tools offered for you to consider. The key to a SURVEY BOOK is that it is organized, upto-date, and designed to meet the needs of your nursing home. SECTION Survey Readiness The Survey Book Items Needed for Your Survey Book Region 1, Springfield Region 2, Popular Bluff Region 3, Kansas City Region 4, Cameron Region 5, Macon Region 6, Jefferson City Region 7, St. Louis Pre-Survey Checklist Think Survey Preparedness Common Questions State Surveyors Ask CNAs Survey Preparedness Quiz Scavenger Hunt for Survey Preparedness Article: QI Helps Attain Survey Readiness Survey and Certification 101 Sample CMS Forms (CMS 671, 672, 802, 1513) Alzheimer’s Special Care Services Disclosure (MO 580-2637)

PAGE # 1.2 1.3 1.4-1.9 1.10 1.11-1.14 1.15 1.16-1.17 1.18 1.19 1.20 1.21-1.22 1.23 1.24-1.31 1.32 Appendix 1-A Appendix 1-B Appendix 1-C Appendix 1-D

SECTION 2 - LIFE SAFETY CODES Life Safety Codes - This section can be used as a reference for possible K-tag citations and includes checklists for self-assessment. SECTION K-Tags and Definitions Life Safety Code Check List Fire Safety Survey Worksheet for Rating Residents (Form CMS-2786M) Fire Safety Survey Report Medicare-Medicaid (Form CMS-2786R) Fire Safety Survey Report Short Form Medicare-Medicaid (Form CMS-2786S) Fire/Smoke Zone Evaluation Worksheet for Health Care Facilities (Form CMS-2786T) Fire Safety Survey Report - Intermediate Care Facilities for

PAGE # 2.2-2.3 2.4-2.6 Appendix 2-A Appendix 2-B Appendix 2-C Appendix 2-D Appendix 2-E i

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT the Mentally Retarded (Small) (Form CMS-2786V) Fire Safety Survey Report - Intermediate Care Facilities for the Mentally Retarded (Large) (Form CMS-2786W)

Appendix 2-F

SECTION 3 - CMS, CULTURE CHANGE, ARTIFACTS OF CULTURE CHANGE CMS and Culture Change and Artifacts of Culture Change - The traditional nursing home regulatory approach has created tensions between providers and surveyors. Culture change is movement to transform a facility to a home, a resident to a person, and a schedule to a choice. States and the federal government have worked over the years to examine regulations to evolve them into a more responsive regulatory system. Documents below are offered to home nursing homes to work with their regulators to change the environment of their homes while meeting the regulations. Missouri has set a 100% compliance goal for facilities filling out the on-line version of The Artifacts of Culture Change. (www.artifactsofculturechange.org)

SECTION CMS Nursing Home Culture Change Regulatory Compliance Questions and Answers Artifacts of Culture Change The First 24 Hours and Beyond New Dining Practice Standards The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to Furthering Innovation in Nursing Homes National Long-term Care Life Safety Task Force: Summary of Proposals Approved by NFPA

PAGE # 3.2-3.5 3.6-3.16 3.17-3.18 Appendix 3-A Appendix 3-B

Appendix 3-C

SECTION 4 - QUALITY OF CARE ROUNDS Quality of Care Rounds - In order to be survey ready, the MU NHA Consultant recommends that NH leadership, managers, and staff perform rounds of the nursing home on a scheduled basis. NH staff needs to be informed of the process to take when repairs are needed. New employees need to be oriented to the process also. The key to rounds is having a process in place that documents follow up when Federal standards are not met. SECTION Quality of Care Rounds Clinical Visits Assessments MDS/Care Plan Tracking Form Dietary Infection Control and Safety Checklist Infection Control and Safety Surveillance Housekeeping Dietary Rehabilitation Department Nursing Department Shower/Whirlpool Room Laundry

PAGE # 4.2-4.9 4.10-4.26 4.27 4.28-4.31 4.32-4.33 4.34-4.35 4.36 4.37-4.39 4.40 4.41-4.42 ii

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT Activities/Social Services Beautician/Barber Services Utility Room Pharmacy/Med Room/Medication Cart Central Supply Hazardous Waste Administrative Maintenance Administrators Daily Kitchen Rounds Environmental Services Tool Facility Inspection Facility Inspection Report Survey Tag Assignments

4.43 4.44 4.45 4.46 4.47 4.48 4.49 4.50-4.51 4.52-4.53 4.54-4.56 4.57-4.58 4.59-4.61 4.62-4.71

SECTION 5 - FACILITY SELF-ASSESSMENT (MOCK SURVEY TOOLS) Facility Self-Assessment - Mock surveys are an opportunity to look at systems, procedures and processes of care and to identify potential survey-risk areas. Mock surveys should be performed on a scheduled basis and shared with nursing home staff. The most important part of the survey process is what you do after it is over with the results. F-tags are used in this section. Be advised that CMS makes revisions to the F-tags on a regular basis. SECTION Article: Mock Survey: An Important Component Survey Preparation Self-Assessment/Mock Survey Guide to F-Tag Numbers “F” Tag Deficiencies Quality Indicator Report Results Process-Survey Tasks Meal Monitor Assignment and Times Mock Survey Assignments Survey Scope & Severity Grid Resident Review Worksheet General Observations of the Faculty First Impressions Checklist Surveyor Notes Worksheet Administration Checklist Contract Book Checklist Personnel File Checklist Environment Physical Plant Rounds-Initial Tour File Drill Grid QA Review: Surveyor Notes Worksheet Nursing Resident Review Worksheet Quality of Care MDS Audit Tool

PAGE # 5. 2 5.3 5.4-5.5 5.6-5.30 5.31 5.32-5.34 5.35 5.36 5.37-5.38 5.39-5.42 5.43-5.44 5.45 5.46 5.47 5.48 5.49 5.50 5.51-5.56 5.57 5.58-5.59 5.60 5.61-5.64 5.65 5.66 iii

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT Investigative Protocol Hydration Non-Sterile Dressing Change Discharge Records Review Chart Audit Tool Med Pass Technique CMS-677 Medication Pass Worksheet Dietary Dietary Observations Monthly Meal Quality Review Monthly Sanitation/Infection Control Review Meal Audit Tool Kitchen/Food Service Observation Social Services Social Services Audit Quality of Life Assessment Observation of Non-Interviewable Resident Quality of Life Assessment Resident Interview Resident Interview Quality of Life Assessment Family Interview Quality of Life Assessment Group Interview Resident Council Meeting Audit Activities Chart Audit Tool

5.67-5.72 5.73 5.74 5.75-5.76 5.77 5.78-5.80 5.81 5.82 5.83 5.84 5.85 5.86-5.87 5.88 5.89 5.90 5.91 5.92-5.94 5.95-5.97 5.98-5.101 5.102-5.103 5.104

SECTION 6 - DURING THE SURVEY During the Survey – During the days of the survey visit, it is natural for your staff to become nervous and forget their normal routines. The survey visit will be easier if you as the NH leader have worked with your staff for survey readiness throughout the year. The actual visit needs to be managed and the following tools are offered to assist you during the survey. SECTION Stand Down Survey Assignment Cards Best Practice DON/Nurse Managers Therapy Social Services Receptionist/Bookkeeper Maintenance Laundry Staff Housekeeping Staff Dietary Staff Medication Nurse/Treatment Nurse Activities Certified Nursing Assistant/Restorative Aide/ Rehabilitation Aide

PAGE # 6.2 6.3-6.8 6.9 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19

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LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 7 - AFTER THE SURVEY After the Survey - This section is designed to help you write an effective Plan of Correction and how to prepare the documentation needed to be ready for re-visit. You can find out how other licensed Missouri long-term care facilities did on their last inspection and how they wrote their plan at http://health.mo.gov/safety/showmelongtermcare/. SECTION Info Sheet: Reading a Nursing Home’s Survey/ Statement of Deficiencies State Operations Manual: Guidelines for Determining Immediate Jeopardy Violation Class Distinctions The Appeal Process: IDR and IIDR Informal Dispute Resolution: 4-Step Checklist Facility IDR Request Process Primaris Independent IDR Intake Form How to Write a Plan of Correction Putting Together a “Credible Allegations” Book Getting Ready for Re-Visit

PAGE # 7.2-7.5 7.6-7.41 7.42 7.43-7.54 7.55 7.56-7.57 7.58 7.59 7.60 7.61

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Survey Preparedness

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 1 - SURVEY PREPAREDNESS Survey Preparedness - The MU NHA Consultant recommends that your home maintain a SURVEY BOOK. The purpose of the book is to help your staff be survey ready every day. To be ready for the annual visit, the SURVEY BOOK should be reviewed weekly so that it is kept up-todate. Make sure that all your management staff knows where the book is located as surveyors might show up when the NHA and/or DON are not in the facility. This section provides you with several tools offered for you to consider. The key to a SURVEY BOOK is that it is organized, upto-date, and designed to meet the needs of your nursing home. SECTION Survey Readiness The Survey Book Items Needed for Your Survey Book Region 1, Springfield Region 2, Popular Bluff Region 3, Kansas City Region 4, Cameron Region 5, Macon Region 6, Jefferson City Region 7, St. Louis Pre-Survey Checklist Think Survey Preparedness Common Questions State Surveyors Ask CNAs Survey Preparedness Quiz Scavenger Hunt for Survey Preparedness Article: QI Helps Attain Survey Readiness Survey and Certification 101 Sample CMS Forms (CMS 671, 672, 802, 1513) Alzheimer’s Special Care Services Disclosure (MO 580-2637)

Updated May 2014

PAGE # 1.2 1.3 1.4-1.9 1.10 1.11-1.14 1.15 1.16-1.17 1.18 1.19 1.20 1.21-1.22 1.23 1.24-1.31 1.32 Appendix 1-A Appendix 1-B Appendix 1-C Appendix 1-D

SURVEY READINESS Be Prepared: 1. BE SURVEY READY EVERY DAY OF THE YEAR!! a. Continuous training with staff b. An effective QA program c. Active Resident Council d. An effective Customer Service Program e. An effective Grievance Program f. Daily and weekly rounds 2. Make sure you maintain a SURVEY BOOK and it is complete and updated weekly. See “ITEMS NEEDED FOR YOUR SURVEY BOOK” Pages 1.4 thru 1.11 3. Make sure that all staff knows their job functions as soon as the surveyors enter the facility. 4. Make an announcement on the intercom welcoming the survey team. 5. Have a plan for weekend, Holiday, and after hour surveys. 6. Train staff on what to expect during the survey. 7. Train staff on how to respond to surveyors when questions are asked. a. Review the list of questions surveyors could ask.

1.2

The Survey Book The goal of every nursing home administrator and facility should be to be survey ready every day. You should think about your survey all year and not wait until the State survey team shows up at your door. Best practice is to be prepared for the nursing home survey with a Survey Book—this book should contain everything that the surveyors will ask for when they enter your building. Please refer to the specific list of “Items Needed for Your Survey Book” for your region on pages 1.4 thru 1.11. This Survey Book should be: 1. available ,2. organized, and 3. kept current at least weekly. Make sure that other management people know where you keep this notebook—surveyors might show up when you’re not available. Some of these items are required within one hour, some within 24 hours, and some before the end of the survey. If you have these items available and current, you and your team will not be wasting time gathering this information. Each Region has their own specific list of things that they will ask for and these lists will change from time to time. Be sure you keep current on what your Region is asking for so you will be read for the next Survey. You can organize these items in any way you wish—I would suggest you keep them all in one notebook. Do NOT hand this entire notebook to the survey team. Only give them what they ask for. If you just hand over your information, it may lengthen your survey as it might trigger them to look in areas they had not planned on. Also, do not hand them your originals. Make them a copy, because there is a good chance you will not get it back.

1.3

ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist Region 1, Springfield Date: Facility:

CCN: Licensed Beds:

BY THE END OF TOUR: 1. Roster/Sample Matrix (Form CMS 802) 2. (Include all the residents on bed hold. You may provide this in a computer generated format. 3. You may make modifications for accuracy or add additional information within 24 hours.) 4. A copy of the current pay period schedule for RNs and LPNs and copy of the nursing schedule for the duration of the survey. 5. A list of residents with pressure sores. Stages and body part involved. 6. A list of residents currently on antibiotics. 7. List of all residents who are receiving or have received antipsychotic medications over the past 30 days. IN ONE HOUR: Items 1 through 8: May use your own forms for these items. 1. List of key facility personnel and their location (refer to page 3). 2. List of hospice residents (refer to page 4). 3. List of dialysis residents (refer to page 4). 4. List of residents age 55 and under (refer to page 4). 5. List of residents who communicate with non-oral communication devices, sign language, or speak a language other than the dominant language of the facility (refer to page 4). 6. List of admissions during the past month. 7. List of medication pass times by unit if variable(refer to page 4) 8. List of meal times (including the planned beginning of meal service for each dining room, unit and hall carts) (refer to page 4). 9. List of residents transferred or discharged during the past 3 months (including, if possible, the date and destination). 10. Evidence of routine monitoring of accidents and incidents, and system to prevent/minimize them in the future. 11. Copy of written information provided to residents regarding their rights. 12. Copy of the facility admission contract. 13. Copy of 2-3 alleged abuse violations and how the facility handled the violations, since the previous survey. 14. Copy of the facility layout including nursing station(s), resident rooms, and common areas. 15. Current activity calendar and previous month. 16. Copies of regular and therapeutic menus for today through __________ [date]. 17. List of all residents on therapeutic diets or special supplements. 18. Facility policies and procedures on abuse/neglect.

1.4

19. Nurses on site at the beginning of the survey. 20. Shift change times. (refer to page 4) 21. Emergency water supply. 22. List of current residents that were in the facility during the previous influenza season 10/1-3/31. WITHIN 24 HOURS: 1. Completed Resident Census and Conditions of Residents (CMS-672). 2. Completed Long-Term Care Facility Application for Medicare and Medicaid (CMS-671). 3. List of Medicare residents who requested a demand bill within the past six months. 4. List of employees with social security #’s/position/hire date. 5. List of all temporary staff with social security #’s (past month). TEAM COORDINATOR TEAM MEMBERS

KEY PERSONNEL: Administrator Director of Nursing (RN) Assistant DON (RN/LPN) Charge Nurse(s) (RN/LPN) Medical Director Q A Members Physical Therapist Restorative/Rehabilitation Occupational Therapist Speech Therapist Food Service Director Dietitian Social Services Director/Consultant

1.5

Activity Director Maintenance Supervisor Housekeeping Supervisor Laundry Supervisor Resident Funds/Bookkeeper Staff person responsible for coordinating and implementing the facility immunization program/infection control Pharmacy Consultant MDS/Care Plan Coordinator Person Responsible for QA 1. Hospice residents

2. Dialysis residents

3. Residents 55 & under

4. Residents with communication devices

1.

2.

3.

4.

5.

6.

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2.

3.

4.

1.

2.

3.

4.

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3.

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5.

6.

5. Medication Pass Times 6. Meal times 7. Shift change times

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8. Explanation of discrepancies between OSCAR and QM/QI Facility Characteristics: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 9. Description of special features of care and treatment programs, organization, and resident case-mix (Example: SCU for dementia or heavy care needs placed in a particular unit): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 10. Provide names of staff (including agency staff) who have successfully completed training for paid feeding assistants, and who are currently assisting selected residents with eating meals and/or snacks: _________________________________ _________________________________ _________________________________

_________________________________

_________________________________

_________________________________

11. If the facility utilizes paid feeding assistants, provide information regarding how and where these paid feeding assistants received their training pursuant to State law: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 12. Identify all rooms with less than required square footage: _____ _____ _____ _____ _____

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_____

1.7

13. Identify all rooms occupied by more than four residents: _____ _____ _____ _____

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14. Identify all rooms not having at least one window to the outside: _____ _____ _____ _____ _____

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15. Identify all bedrooms not at or above ground level: _____ _____ _____ _____

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16. Identify all bedrooms that do not have access to an exit corridor: _____ _____ _____ _____ _____

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17. Provide procedures to ensure water is available to essential areas during a loss of normal water supply: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________ LIFE SAFETY CODE: Photocopies of the following: 1. Documentation of Fire Alarm certification 2. Documentation of Automatic Sprinkler System certification 3. Electrical Wiring certification (DA-176) 4. Fire Safety Consultation (MO 580-2830) 5. Floor plan of the facility 6. Current evacuation plan, diagrams, and instructions. Documentation Review 1. Documentation that the automatic fire alarm system has been inspected, tested, and maintained in accordance with the NFPA 101, 2000 edition. Include smoke alarm sensitivity testing records. 2. Automatic sprinkler system inspection documentation - include facility check logs 3. Fire extinguisher testing and maintenance records 4. Maintenance/Certification of the Range Hood Suppression System 5. Logs of the checks on all battery powered smoke detectors. 6. Fire drill records for the past 12 months 7. Documentation that newly installed curtains, drapes, and blinds used in the facility are flame resistant and meet required specifications, including cubicle/privacy curtains. 8. Fire safety and emergency preparedness in-service records. 9. Documentation and logs that the emergency power is inspected and tested in accordance with NFPA 101, 2000 edition. ~For Battery Backup Emergency Lights a. Monthly 30-second check logs b. Annual 90-minute check logs ~For Generator 1. Weekly logs for automatic rollover 2. All inspection and testing records 10. Documentation of the inspection of elevators. 1.8

Policies and Procedures 11. Fire watch policy (used when fire alarm or sprinkler system is out of service) 12. Policies and procedures related to the facility’s “Building Maintenance Program” and “Building Inspection Programs” 13. Policies and Procedures related to the facility’s smoking prohibitions and use areas. 14. Policies and Procedures related to disaster planning. 15. Policies and Procedures related to water outages affecting the sprinkler system. Reference the 2000 edition of NFPA 101. 16. Maintenance records of any fusible link dampers (if any).

1.9

ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist Region 2, Poplar Bluff Information requested within 1 hour: 1. Roster/Sample Matrix (Changes may be made within 24 hours) 2. Resident Census and Condition, CMS 672 (Changes may be made within 24 hours). 3. List of key facility personnel (DON, SSD, etc.). 4. Staff person responsible for facility’s immunization program. 5. Residents who requested Medicare demand bills, by month for the last six months. 6. Facility building layout. 7. Policies and procedures to prevent and investigate allegations of abuse, neglect, and misappropriation of property and the name of the person to answer questions regarding these policies and investigations. 8. Copy of admission packet/contract(s) provided to all residents, including payment sources and resident rights information. 9. Meal times, dining locations, menus for survey week with serving sizes. 10. Medication pass times. 11. List of all admissions during the past month and a list of all transfers/discharges for the past three months with their destinations. 12. List of all residents receiving or have received antipsychotic medications over the past 30 days. 13. Application for Medicaid/Medicare (CMS 671). 14. List of residents age 55 and under. 15. Residents on hospice and dialysis. 16. Residents with discharge planned. 17. Residents who communicate with non-oral devices, sign language or do not speak English.

Information requested within 24 hours: 18. Current employees and SSN. 19. Hires since last survey with hire date and SSN. 20. Nursing staff schedule for survey week. 21. Evidence facility monitors accidents/incidents. 22. Current activity schedule. 23. Annual Fire Department Consultation form. 24. Certification of Electrical Wiring 25. Copy of Fire Alarm System Annual Inspection and current smoke detector sensitivity testing.. 26. Sprinkler System Annual Inspection. 27. Fire drill records for the past 12 months. 28. Resident evacuation plan. 29. Disaster plan for loss of water supply.

1.10

ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist Region 3, Kansas City Within 1 hour: Resident Roster (cms-802) of all Residents, including bed hold Please complete by the time the survey team completes tour (corrections can be made up to 24 hrs). Facility census for today (including bed holds) _______ List of residents (both alphabetical (include room # in alphabetical list) and by room) - 1 copy for each team member Layout of the facility - 2 copies List of key personnel and location - 1 for each team member Staff working today and location, including RN’s and LPN’s on duty (copy of staffing sheet) Med pass times (by unit, if variable) - 3 copies For the past 3 months: new admissions (with admission date); discharges & transfers (include dates & location) Meal times (1 copy for each team member), dining locations (1 copy for each team member, & extended menus today through end of survey), including all therapeutic diet menus List of Residents: who communicates with special devices, sign language or speak a foreign language; Age 55 and younger; with current infections (UTI, URI, Isolation); with special/therapeutic diets; with a ventilator; if survey conducted April 1 through September 30; all current residents who were in the facility during the previous influenza season Resident council minutes (and response forms if applicable) for the past 3 months Activity calendars for last 3 months (all units, if different) Copy of admission contract (for all payee types) and written information regarding resident’s rights P&P to prohibit and investigate allegations of abuse (include CBC/EDL screening information) and who is designated to answer questions about abuse prevention Evidence that the facility routinely monitors accidents and other incidents, records these in the clinical or other record; and has in place a system to prevent and/or minimize further accidents and incidents (include incident report form or similar records that the facility uses to monitor accidents)

1.11

Within 24 hours: Infection control Manual List of all personnel hired and volunteers acquired since last survey - include date of hire, job titles, whether currently employed (#of employees hired since last survey ______), ( # of current employees ____) List of current employees including job titles List of residents requesting demand bills in the past 6 months (if none, provide the facility policy on demand bills) List of residents who have been discharged from Medicare (A) benefits in the past 6 months (include dates and to where discharged) List of current residents with a resident trust fund A copy of contracts with any company that provides temporary/agency/contract/employees Application for Medicare and Medicaid (CMS-671) and the Residents Census and Condition (CMS-762) Last 6 months of MDS transmittal reports

1.12

ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist Region 3, Kansas City 1. Layout of the facility. 2. List of residents and room numbers, key personnel and location. 3. Waivers or variances 4. Weekly, monthly, and annual testing of fire pumps for the past 12 months (if applicable) 5. Policy on oxygen transfilling, power taps/strips, portable heaters, generator malfunction (if applicable) 6. Spec sheets for new flooring, window dressings, wall coverings, cubicle curtains, furniture and mattresses and for new and existing carpet used on wall (if any new fabric or materials either installed or using since last survey). 7. Spec sheets and policy for flame retardant mixtures (if any new fabric or materials either installed or using since last survey) 8. Annual inspection and consultation of the facility’s Fire and Evacuation Plan by the local fire jurisdiction. 9. Fire drills and evidence of activation of the fire alarm each month for the past 12 months 10. Fire alarm annual testing 11. Fire Extinguishers-monthly and annual inspection. 12. Smoke Detectors-sensitivity testing 13. Smoke Detectors-check batteries weekly; change batteries yearly, if un-sprinklered facility. 14. Sprinkler System-Annual and quarterly inspections and testing for system for the past 12 months Weekly and monthly testing (dry=weekly for valves (air/water pressure>alarms test yearly) (wet=monthly for valves (air/water-past 12 months). 15. Sprinkler Obstruction Test, required at least every 5 years 16. Location of Sprinkler Stock supply 17. Backflow inspection-Plumbing (annually). 18. Generator- weekly inspection and monthly testing for the past 12 months; any repair work in the last 12 months. 19. Emergency Lighting Monthly-monthly and yearly testing and inspection for the past 12 months Battery backup for emergency egress lighting/exit lights/”exit directional” lights (30 sec- month; 90 min annually [for generators=monthly under 30 min load]). 20. Elevator maintenance and testing for the past 12 months 21. Oxygen Medical Gas inspection and testing of piping and equipment (if applicable). 22. Water Heater and/or Boiler inspection (if container is with heating input of +200,000 btu annually) 23. Range Hood Suppression system (kitchen)-semi-annual inspection, testing and cleaning (past 2). 24. Electrical Inspection, required every two years. Please provide a copy of the following for DHSS files: 25. Policy regarding fire watch when fire alarm or sprinkler system is down. 26. Spec sheets and policy on alcohol gel. 27. Exercise and lubrication of fusible links in fire dampers every four years, if applicable. 28. Ceiling tile assembly rating, UL design number, spec sheets for replacement ceiling tiles 29. Policy on oxygen transfilling, power taps/strips, portable heaters, generator malfunction, if applicable. 30. Policy on admission of residents who require life support. 31. Policy on resident and staff smoking and resident evaluation to smoke (independently/supervised)

1.13

Please provide the facility Disaster Manual including: 32. 33. 34. 35. 36.

Policy on climate-control (if heating/air conditioning supply is disrupted) Policy on transporting/evacuating residents in case of an emergency to other nearby facilities Policy on hospital transfer agreement, if applicable Policy on the loss of water supply and contract with outside agency to provide water Policy on fire procedures and evacuation plan.

1.14

ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist for Region 4, Cameron INFORMATION NEEDED WITHIN ONE HOUR 1. Roster/Sample Matrix (HCFA Form 802). Please do not delay beyond the hour to correct, you have 24 hours to update/correct. 2. Completed CMS 672 (Resident Census & Conditions). 3. Facility Census including residents on bed hold (*may we have an alphabetical listing of residents with room numbers). 4. List all residents who have received antipsychotic meds in the last 30 days. 5. List of key personnel and their locations. 6. Copy of written information provided to residents regarding rights. 7. Meal times, dining locations, copies of menus including therapeutic menus for duration of survey and amounts to be served. 8. Dining rooms (s) seating diagram. 9. Med pass times. 10. List of admissions past month and transferred/discharged past 3 months with destination. 11. Copy of facility layout/floor plan. 12. Copy of all admissions contracts (if different for each payment source). 13. Copy of facility policies/procedures to prohibit/investigate allegation of abuse, including the name of the person designated to answer questions about what the facility does to prevent abuse. 14. Evidence that the facility monitors accidents/incidents, records them and has a system in place to prevent/minimize further accidents/incidents. 15. Names of residents age 55 and under. 16. Names of residents who communicate with non-oral communications devices or who speak a language other than dominant language of facility. 17. Actual working schedule of licensed nurses on duty for all shifts during the survey. 18. Disclosure form/brochure for special care unit (if applicable). (See Appendix 1-D in this manual.) INFORMATION NEEDED WITHIN ONE HOUR 1. Completed HCFA 671 (application for Medicare/Medicaid). 2. List of medicare residents requesting a demand bill in the last 6 months. 3. List of all current employees with SS#, date of hire and position from last payroll. Include employees hired since last payroll, temps who worked last month and regular volunteers (who provide a service paid staff would have to provide if that person were not a volunteer - van drive, regular activity help, etc.) 4. Do you have resident whose pay source is DMH? Yes No 5. Do provide a copy of the MO Guide to H&C Based Resources to residents at admission? Yes No 6. Staff person responsible for coordinating Immunization Program and List of all residents who were in the facility 10/1-5/31 (Only need this list for surveys conducted between 5/31-10-1). 7. Bed Classification form signed and dated if no changes. If you need a copy of the MO Guide to Home and Community Based Resources it can be found at: http://disability.mo.gov/gcd/pdf/HCBServices.pdf. Reminder: Please call Disaster phone (816) 632-9371 or R4 Office (816) 632-6541 M-F 8-5 for emergency events (loss of power, water, fire alarm, sprinkler) that affect residents.

1.15

ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist Region 5, Macon Please provide the following by the end of the Survey Team’s Initial Tour: __ Current and completed resident roster/matrix. (May be resubmitted within 24 hours) __ List of actual working schedules for LPNs and RNs during days of survey. __ List of residents with diagnosis of dementia who are receiving, have received, or who have orders, including PRN orders, for antipsychotic medications over the past 30 days. __ List of residents with falls in last 3 months __ List of residents with pressure ulcers (location and stage) __List of residents with weight loss in last 3 months Please provide the following information within 1 hour of conclusion of Entrance Conference: __ List of key personnel and their locations. __ Copy of written information that is provided to residents regarding their rights. __ Copy of meal times, dining locations, and all menus (including therapeutic menus) that will be served for the duration of the survey. __ Medication pass times. __ List of admissions during the past month and a list of residents transferred or discharged during the past 3 months, with destinations. __ Copy of facility admission contract for all residents: Medicare, Medicaid, Private Pay. __ Faculty policies and procedures to prohibit and to investigate allegations of abuse and the name of the person designated to answer questions about what facility does to prevent abuse. __ Evidence that the facility, on a routine basis monitors accidents and other incidents, records these in the clinical or other record, and has in place a system to prevent and/or minimize further accidents and incidents. __ Names of residents 55 years of age or under. __ Names of any residents who communicate with non-oral devices, sign language, or who speak a language other than the dominant language of the facility. Provide the following within 24 hours of Entrance Conference: __ Completed Long-Term Care Facility Application (CMS-671). __ Completed Resident Census and Conditions report (CMS-672). __ List of Medicare residents who requested demand billing in last 6 months. __ List of paid feeding assistants (if used). __ List of current residents who were in facility during flu season (October 1-March 31). Please provide this list only if the survey is conducted outside of the flu season __ List of residents who have a balance in the Resident Funds account, including current balance. Please ensure reconciled bank statements for the past 12 months are available for review __ Alphabetical list containing manes, social security number, dates of hire, and job titles of all individuals hired since the last full survey___. Please identify those who are currently employed. __ A list of any temporary workers or contract staff who have worked at the facility in the last month with each person’s social security number, date of hire, and job title, and a copy of the facility’s contract with the contracted agency. __ A list of the names and social security numbers of all volunteers who have direct contact with residents and volunteered in the last month. __ Complete Bed Classification form 1.16

Provide additional documents when requested Life safety information __ Resident list/room numbers and maintenance supervisor name. __ Approved floor plans with identified smoke compartments. __ Fire alarm certification. __ Electrical Wiring Certification (bi-annual). __ Sprinkler System Certification. __ Fire Department Consultation. __ Range Hood inspection (semi-annual) previous 2 inspection reports. __ Copies of any fire watches conducted in the past year (if any). __ Specification sheets: (ONLY IF NEWLY INSTALLED SINCE PREVIOUS SURVEY) flooring, window and wall coverings, cubicle curtains, furniture, mattresses, wall carpet, electric fireplace, flame retardants used in the facility. __ Routine maintenance log. __ Fire drills: previous 12 months. __ Fire alarm: monthly and annual inspection testing and maintenance. __ Smoke detectors: annual and sensitivity tests. __ Sprinkler: annual, quarterly, monthly, and weekly (ITM) (1 year), 5 year internal pipe obstruction test. __ Fire pumps: (if applicable) weekly, monthly, and annual testing. __ Generator: weekly inspection and monthly testing (12 months). __ Emergency lighting and/or exit signage: (if applicable) monthly and annual inspection and testing (12 months). __ Elevator: (if applicable) inspection (annual). __ Medical Gas: (if applicable) inspection and testing of piping and equipment. __ Boiler: most current inspection. __ Policies: (if applicable) oxygen trans-filling and training. __ Policies: fire watch, fire procedures, disaster plan, and evacuation plan. __ Policies: water outage. __ Policies: smoking and resident evaluation procedure.

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ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist Region 6, Jefferson City 1. 2. 3. 4. 5. 6. 7. 8.

Current and complete roster/sample matrix (HCFA Form 802). List of actual working schedules for licensed and registered nursing staff for survey time period. List of key personnel and their location (Administrator, DON, Medical Director, etc.) Copy of written information that is provided to the residents regarding their rights. Copy of meal times, dining locations, and all menus that will be served for the duration of the survey. Copy of therapeutic menus that will be served for the duration of the survey. Med pass times. List of admissions during the past month, and a list of residents transferred or discharged during the past 3 months with destination. 9. Copy of facility layout, indicating the location of nurse’s station, individual resident’s rooms, common areas. 10. Copy of the facility admissions contracts for all residents (Medicare, Medicaid, or their payment sources). 11. Facility policy and procedures to prohibit and investigate allegation of abuse and the name of the person the administrator designates to answer questions about what the facility does to prevent abuse. 12. Evidence that the facility on a routine basis monitors accidents and other incidents, records these in the clinical or other record and has a system in place to prevent and/or minimize further accidents and incidents. (Copy of last abuse and neglect investigation.) 13. The current resident activity schedule/calendar. 14. Names of any residents age 55 or under. 15. The names of any residents who communicate with non-oral communication devices, sign language, or who speak a language other than the dominant language of the facility. 16. List of all employees from last payroll, new staff hired since last payroll, and any temporary staff who worked in the last month (including volunteers) with their social security numbers. 17. A completed Long-Term Care Facility Application for Medicare and Medicaid (CMS-671). 18. A completed Resident Census and Condition of Residents (CMS-672). 19. A list of Medicare residents who request demand bills in the last 6 months (SNF or dually-participating SNF/NFs only). 20. Resident funds bank statements from last calendar year. 21. Resident funds current month bank statement. 22. Copy of surety bond. 23. Bed Classification Form (update, sign and date). 24. Nurse Aide Training Form.

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ITEMS NEEDED FOR YOUR SURVEY BOOK Survey Entrance Conference Checklist for Region 7, St. Louis Needed within 1 hour: 1. List of key personnel and locations. 2. Facility census at time of entrance. 3. Written information provided to residents regarding their rights. 4. Meal and medication pass times (serving times for each division, accucheck times, insulin times, etc.) 5. List of admissions/discharges during the past 3 months. 6. Facility layout with room numbers. 7. Current activity calendar and past 3 months. 8. Copies of menus for meals served during the survey (including spreadsheets). 9. Admission contracts for all payor types. 10. Pressure sore/wound report showing name, type of sore/wound, size, location, etc. (neither state nor federal regulations require a facility to keep/provide this report). 11. List of residents who receive hospice benefits. 12. List of residents who receive dialysis. 13. List of residents 55 and under. 14. List of residents who communicate with non-oral devices, sign language, or speak a language other than the dominant language of the facility. 15. List of all residents who are or have received antipsychotic medications over the past 30 days. 16. Evidence the facility monitors accidents/incidents (could be a record of accident incident reports) 17. Copy of policies and procedures to prevent and investigate allegations of abuse, neglect and misappropriation of resident’s property. 18. Copy of the current actual daily work schedules for licensed and registered nursing staff for all shifts during the survey. 19. List of paid feeding assistants 20. Complete Roster/ Matrix (CMS 802). (By end of tour) Needed within 24 hours: 21. Completed Long-Term Care Facility Application (CMS 671). 22. Completed Resident Care and Census (CMS 672). 23. List of residents who requested demand billing in the past 6 months and residents who received Medicare Part A services in the past 6 months. 24. Electrical certification (copy). 25. Fire Alarm certification (copy). 26. Sprinkler certification (copy). 27. Range hood inspection. 28. Fire drill records for the last four full quarters preceding the survey. 29. Generator log and inspection (if present). 30. Annual fire department consultation (copy). 31. Disaster policy. 32. Certification for any new floor/wall covering, drapes, etc., installed since the last survey AND certification for any upholstered furniture and mattresses purchased since last survey. 33. Resident fun records including ledger, current bond, and reconciled bank statements- prior 12 months. 34. Total number of facility employees. 35. List of all employees with title and social security number hired since the last survey. 36. List of facility employees hired since last payroll including title and social security number. 37. List of all temporary employees including title and social security number. 38. List of all volunteer names including title and social security number. 39. CLIA waiver. 1.19

PRE-SURVEY CHECKLIST Area Reviewed

Date

Action Needed

Previous survey results (focus areas) QM/QI (6 month history) Fall and Accident logs Care Plan for Falls/Accidents Abuse reporting immediate & investigated Grievance logs and follow up Care plan accurate (sample 5%) Pressure ulcer documentation Med administration review Med room storage (expired/labeled) Call lights answered and within reach Knocking on doors Speaking respectfully Hygiene and grooming Catheters with proper diagnosis Bladder incontinence assessments Toileting program Handwashing observation Dressing change observation Lab work reconciliation system 24 Hour report used MD/Family notification Observe peri care Observe meal assistance Check shower schedule Check splint schedules Turn and position program in place Review MD visits (timely?) Check pharmacists’ reports Review weight loss report and Care Planned Menu accuracy/served as listed Therapeutic diet service (consistency) Test tray, temp and palatability Kitchen sanitation Food storage practices Environment rounds Odors Dirty floors Trash storage Broken furniture Shower room condition Windows and doors Education records 12 hour CNA inservice CNA training (cognitive impair) Background/Reference checks complete Agency orientation conducted Staffing list posted Survey results posted Evidence of QA committee

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THINK SURVEY PREPAREDNESS  Identify your 4-month window for Annual Survey - Every nursing home is required to have at least an annual survey in the range of every 9 - 12 months. Of course, if you have complaints or are a focus facility, your survey will have a shortened span.  Read your last annual survey and plan of correction. Sustain the plan!  Make sure the last Annual Survey is posted.  Make sure “daily staffing” is posted, per federal requirements.  Make rounds daily using a variety of rounding tools or QA audit forms.  Review QA Committee minutes, Grievance Log and Incidents for trends to focus on.  Review facility Quality Measure/Indicator Report for anything ranked above the 90th percentile.  Schedule Medication Pass Audits with consultant pharmacist.  Monitor dining service and room trays. Ask for a test tray and monitor hot food and cold food temperatures.  All meals served timely.  Interventions for residents with weight loss and gain? Are they care planned?  Make sure your staff is not handling food with bare hands.  Accurate and complete meal monitoring with an alternative menu posted and offered.  Conduct frequent Infection Control rounds with nursing assistants. Work toward making improvements.  Check refrigerator temps and temps for resident room refrigerators. Are they clean, food items labeled and dated?  Check microwaves. Are they clean?  Are there unpleasant odors?  Conduct in-services, as needed. For example: one-on-one coaching at the bedside for proper pericare technique and pressure relief positioning.  In-service staff for comprehension of residents rights, abuse, neglect, etc.  Is your staff knocking on doors, waiting for permission to enter before entering a resident room?  Is your staff closing window curtains, privacy curtains, and room doors before providing care?  Are privacy curtains missing, soiled?  Is fresh water within reach for each resident?  Is there mold in shower rooms, cold and hot water temps, unsecured chemicals or sharps?  Is there linen, refuse, or devices on the floor?  Are personal items labeled?  Oral care separate from pericare supplies?  Wheelchairs and seat cushions clean and free from odor?  Is your staff answering call lights within 3-5 minutes?  Are call lights within reach?  Are noise levels low - excessive overhead paging, staff chatter, unnecessary noise?  Do your employees know how to respond to complaints, concerns, or grievances?  Are there background checks on all employees?  Are licenses/certifications current?  Are annual or new residents given a “two-step” TB skin check and are they up-to-date?  CNAs compliant with 12-hours education annually?  Care plans address resident needs? Current and updated? Staff is following care according to care plans?  No holes in documentation? Check random MARs.  No missed signatures.  Staff performs proper hand washing between glove changes or between moving from soiled to clean?  Ensure proper wheelchair and bed positioning. 1.21

 Are glucometers being properly calibrated each month? Disinfected correctly? Used for more than one resident?  Check for good resident grooming i.e., post-meal grooming, good oral care, no facial hair (men and woman - unless residents choice and care planned), dirty nails, long finger and toe nails, etc.  Check designated smoking area. Proper cigarette disposal system in place? Smoking aprons? Supervision? No burn holes in clothing or linen.  Foley catheter tubing not on floor? Leg straps used? Bag covered?  Disaster/Emergency Preparedness. Does your staff know what to do?  Med carts clean?  Disposed of all expired meds?  Oxygen cylinders properly stored and chained?  O2 tubing off floors?  All O2 concentrators have clean filters.  No ice scoops stored in ice chests.  Labs are tracked and timely.  Dumpsters closed.  24-hour report utilized.  Gait belts used. Fall prevention program in place.  Check restorative programs i.e. Walk-to-dine are functioning.  Fire drills done at varied times on different shifts.  Are generators tested and run under load weekly?  Is resident trust fund balanced and reconciled? Signed agreement in business file? Quarterly statements mailed and interest allocated to each account?  Activity calendar posted? Evening and weekend activities?  Is resident mail delivered when received including Saturdays?  Are residents able and encouraged to vote during elections?  Safety committee in place and evidence that accidents/incidents are monitored  Is your Resident Census and Conditions (CMS 672) and your Application for Medicaid/Medicare (CMS 671) current?  Annual Fire Department Consultation form complete and current?  Certification of Electrical Wiring compete and current?  Do you have a written resident evacuation plan?  Do you have a disaster plan for loss of water supply?  Are fire alarms inspected annually with recent smoke detector sensitivity test?  Are Sprinklers inspected annually? Quarterly flow test documentation? Weekly visual inspection documentation?

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COMMON QUESTIONS STATE SURVEYORS MIGHT ASK CNAs 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

Do you participate on a regular basis in resident care conferences? Name some of the topics presented at the past in-service education program you attended. If you saw someone hurt a resident, what would you do? If you discovered a fire in a resident’s room, name the first two things you would do. What type of orientation did you receive when you began working here? How often do you have staff meetings on your unit? What is the purpose of range of motion exercises, why are they done, and when do you do them? What is the difference between active and passive range of motion exercises? How do you know which residents to ambulate? In what situation would you suggest the social worker to see the resident? How often do you reposition residents who are confined to bed? Where on the body are pressure ulcers most likely to occur? Where do you place pillows or other forms of support when you are positioning a resident on their side? What do you do if you walk into a room and find a resident on the floor? Describe and demonstrate what you would do if someone was choking? At what times are between-meal nourishments provided to residents? Describe the proper place for dentures when they are not in the resident’s mouth? Where would you find information about what a resident is able to do for themselves? How many confused or disoriented residents do you have on your assignment today? When was the last fire drill you participated in? Have you ever attended training on abuse or neglect? How many residents on your assignment are incontinent? Describe mental abuse of a resident? Describe what you do if a resident refuses to eat? How and when do you report what a resident has eaten? How often do you check bedridden incontinent residents? Are gelatin desserts considered a liquid or solid on intake forms? Describe your role in a bladder management program. Do any of your residents use adaptive devices to eat? If so, describe them and their purpose. Under what circumstances is it necessary to have an incident/accident report filled out? At what time do you wash your hands? Name as many of the resident rights, as you can. What do you do if a resident refuses care, such as a bath? I’ve noticed you were helping Joe. Can you tell me what you do for him?

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Employee: ________________________________ Date: __________

SURVEY PREPAREDNESS QUIZ 1.

CNAs are not allowed to see a resident’s care plan; only nurses need to know the information there. True False

2. The resident’s current care plan is kept where? a. The DON’s office b. In a notebook at the nurses’ station c. In each resident’s chart d. In the computer e. b and c 3. Who can have input when a resident’s care plan is being completed? a. Any staff member who works with that resident b. Only licensed nurses c. The care plan team 4. QA&A meetings are a requirement under state and federal guidelines? True False 5. According to State and Federal Regulations, the QA&Q committee must meet at least: a. Quarterly b. Monthly c. Weekly d. Annually 6. Who attends the facility QA&A meeting? 17. The Medical Director, Administrator, DON and other staff members and professional consultants as designated 18. Only the facility department heads 19. The Medical Director and DON go out for lunch and call it QA&A 20. All of the above 7. The family and resident have the right to participate in their care plan process and have input into how the care is directed. True False 8. At a QA&A meeting, the committee discusses various aspects of resident care and facility practices such as falls, pressure ulcers, restraints, weight loss, environmental, resident and family grievances, injuries, pharmacy and other aspects of facility care. True False 9. Nursing Policy and Procedure Manual, as well as other pertinent policy and procedure manuals are kept ONLY in the Administrator and DON’s offices. True False 10. When a resident is on Hospice services, the facility staff is not required to do anything for them such as bathing, passing medications, turning, etc. That is what the hospice staff is for. True False 1.24

11. Associates who are told by a resident of abuse, neglect or other concerns, or associates who notice bruising or other injuries should: a. Not pay any attention because all residents are confused and bruise easily b. Report the situation to their charge nurse, the DON, Social Services Director, or the Administrator immediately so the incident can be investigated c. Tell all the other staff that someone abused the resident so the story can be fully embellished and circulated through the grapevine because that is the best way to make sure it doesn’t happen again 12. CNAs and other nursing staff should not do range of motion or use wheelchair seating devices, splints or other adaptive equipment because only therapists are allowed to do this. True False 13. It is not necessary for staff to wash their hands after doing patient care if they wear gloves, nor is it necessary to wash hands if you have used alcohol sanitizer gel. True False 14. The facility’s policy is to keep various logs for temperatures in facility and resident refrigerators, but it is up to the individual employee whether they complete the logs or not. True False 15. A facility can be cited a deficiency for NOT following a facility designated policy and procedure even if it doesn’t result in harm to a resident. True False 16. If a resident appears distressed, upset, crying or is having other unusual behaviors, all staff members, including environmental, nursing and dietary staff, should: a. Ignore it; it’s probably a full moon b. Leave the resident’s room and let them cry in peace c. Report the situation to the Social Services Director and/or Charge nurse so it can be appropriately addressed 17. The facility has an obligation to provide for not only the resident’s physical well-being, but also for the resident’s mental and psychosocial well-being. True False 18. Residents should be turned and repositioned per their plan of care, not every 2 hours. True False 19. If a staff member is assisting a resident with personal care, there is no need to shut the door, pull the privacy curtain or close the window curtains. True False 20. Before performing any care for a resident, staff members should: a. Tell the charge nurse and other staff what they are going to do so someone has a clue b. Explain to the resident what is being done during the care so the resident will be at ease and the resident does have the right to know what is being done for them c. Just get the care done because the resident is confused and wouldn’t understand what was happening to them anyway

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21. When feeding residents who must have assistance, staff should: a. Stand up and carry on a conversation with the other staff members in the room b. Sit down, focus attention on the residents at the table and ensure that the dining experience is pleasant for each resident c. Feed one resident at a time letting the food for the others get cold d. Start a food fight in the dining room so the residents can be entertained 22. There is never really a need to call residents by their preferred names because they are usually hard of hearing and wouldn’t understand anyway. True False 23. Staff should be familiar with resident’s rights because the residents are people too and deserve to be treated with dignity and respect which includes addressing their immediate needs, knocking on doors before entering and ensuring that their privacy is respected curing care. True False 24. It is acceptable to tell a surveyor that you don’t have the information they are requesting and go to your supervisor for assistance. Additionally, it is acceptable for a staff member to go to the facility policy and procedure manual at the nurse’s station and look up a policy if the surveyor asks if they know the information. True False 25. The term “MSDS” stand for: a. An assessment process, required by the government which is completed by nursing. b. Material Safety Data Sheets which outline precautionary measures for chemical handling. c. A lady who is unmarried and has a Doctorate Degree in Sociology. d. A computer operating system by Microsoft. 26. The first thing an employee should do upon discovering a fire in a resident’s room is to: a. Evacuate all residents from the facility b. Rescue the resident from the location of the fire c. Contain and extinguish the fire d. Activate the facility fire alarm 27. You observe another staff member remove a wig from a resident’s head stating, “You can have your hair back when you finish eating”. This would not be considered as a reportable incident to your supervisor, since the goal was positive in getting the resident to eat their meal. True False 28. Upon entering a resident’s room, you observe the resident lying on the floor next to the bed. Your first action would be to: a. Call the doctor b. Call the family c. Check the resident and if OK assist back up d. Check the resident and notify the nurse immediately before moving 29. The facility Evacuation Plan is found in the Safety and Loss Control Manual. True False

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30. When doing rounds on your assigned unit, you observe a Medication Cart outside a resident’s room with a med drawer standing open. You should: a. Go about your business since you are not skilled in passing meds. b. Look through the drawer and see if there is anything you could use. c. Access the facility intercom and announce “attention, the med cart is now open”. d. Close the drawer and stay with the cart to assure no unauthorized access occurs until the responsible person returns. 31. It is OK to call a resident pet names such as “honey” or “grandma” because you usually always call the resident this. True False Write your response: 1. Where are blood spill kits located in your facility and when would you use one?

2. You find medications in a residents room, what would you do?

3. A call light is not working in a resident’s room. What would you do?

4. During a meal time you are feeding a resident and another resident asks to be taken to the bathroom. What would you do?

5. While in the dining room you notice a resident not eating. What should you do?

6. While dressing a resident, he/she begins crying in pain. What should you do?

7. Where is the Disaster Manual kept?

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Answers

SURVEY PREPAREDNESS QUIZ 1.

CNAs are not allowed to see a resident’s care plan; only nurses need to know the information there. True False

2. The resident’s current care plan is kept where? a. The DON’s office b. In a notebook at the nurses’ station c. In each resident’s chart d. In the computer e. b and c 3. Who can have input when a resident’s care plan is being completed? a. Any staff member who works with that resident b. Only licensed nurses c. The care plan team 4. QA&A meetings are a requirement under state and federal guidelines? True False 5. According to State and Federal Regulations, the QA&Q committee must meet at least: a. Quarterly b. Monthly c. Weekly d. Annually 6. Who attends the facility QA&A meeting? a. The Medical Director, Administrator, DON and other staff members and professional consultants as designated b. Only the facility department heads c. The Medical Director and DON go out for lunch and call it QA&A d. All of the above 7. The family and resident have the right to participate in their care plan process and have input into how the care is directed. True False 8. At a QA&A meeting, the committee discusses various aspects of resident care and facility practices such as falls, pressure ulcers, restraints, weight loss, environmental, resident and family grievances, injuries, pharmacy and other aspects of facility care. True False 9. Nursing Policy and Procedure Manual, as well as other pertinent policy and procedure manuals are kept ONLY in the Administrator and DON’s offices. True False 10. When a resident is on Hospice services, the facility staff is not required to do anything for them such as bathing, passing medications, turning, etc. That is what the hospice staff is for. True False 1.28

11. Associates who are told by a resident of abuse, neglect or other concerns, or associates who notice bruising or other injuries should: a. Not pay any attention because all residents are confused and bruise easily b. Report the situation to their charge nurse, the DON, Social Services Director, or the Administrator immediately so the incident can be investigated c. Tell all the other staff that someone abused the resident so the story can be fully embellished and circulated through the grapevine because that is the best way to make sure it doesn’t happen again 12. CNAs and other nursing staff should not do range of motion or use wheelchair seating devices, splints or other adaptive equipment because only therapists are allowed to do this. True False 13. It is not necessary for staff to wash their hands after doing patient care if they wear gloves, nor is it necessary to wash hands if you have used alcohol sanitizer gel. True False 14. The facility’s policy is to keep various logs for temperatures in facility and resident refrigerators, but it is up to the individual employee whether they complete the logs or not. True False 15. A facility can be cited a deficiency for NOT following a facility designated policy and procedure even if it doesn’t result in harm to a resident. True False 16. If a resident appears distressed, upset, crying or is having other unusual behaviors, all staff members, including environmental, nursing and dietary staff, should: a. Ignore it; it’s probably a full moon b. Leave the resident’s room and let them cry in peace c. Report the situation to the Social Services Director and/or Charge nurse so it can be appropriately addressed 17. The facility has an obligation to provide for not only the resident’s physical well-being, but also for the resident’s mental and psychosocial well-being. True False 18. Residents should be turned and repositioned per their plan of care, not every 2 hours. True False 19. If a staff member is assisting a resident with personal care, there is no need to shut the door, pull the privacy curtain or close the window curtains. True False 20. Before performing any care for a resident, staff members should: a. Tell the charge nurse and other staff what they are going to do so someone has a clue b. Explain to the resident what is being done during the care so the resident will be at ease and the resident does have the right to know what is being done for them c. Just get the care done because the resident is confused and wouldn’t understand what was happening to them anyway

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21. When feeding residents who must have assistance, staff should: a. Stand up and carry on a conversation with the other staff members in the room b. Sit down, focus attention on the residents at the table and ensure that the dining experience is pleasant for each resident c. Feed one resident at a time letting the food for the others get cold d. Start a food fight in the dining room so the residents can be entertained 22. There is never really a need to call residents by their preferred names because they are usually hard of hearing and wouldn’t understand anyway. True False 23. Staff should be familiar with resident’s rights because the residents are people too and deserve to be treated with dignity and respect which includes addressing their immediate needs, knocking on doors before entering and ensuring that their privacy is respected curing care. True False 24. It is acceptable to tell a surveyor that you don’t have the information they are requesting and go to your supervisor for assistance. Additionally, it is acceptable for a staff member to go to the facility policy and procedure manual at the nurse’s station and look up a policy if the surveyor asks if they know the information. True False 25. The term “MSDS” stand for: a. An assessment process, required by the government which is completed by nursing b. Material Safety Data Sheets which outline precautionary measures for chemical handling c. A lady who is unmarried and has a Doctorate Degree in Sociology d. A computer operating system by Microsoft 26. The first thing an employee should do upon discovering a fire in a resident’s room is to: a. Evacuate all residents from the facility b. Rescue the resident from the location of the fire c. Contain and extinguish the fire d. Activate the facility fire alarm 27. You observe another staff member remove a wig from a resident’s head stating, “You can have your hair back when you finish eating”. This would not be considered as a reportable incident to your supervisor, since the goal was positive in getting the resident to eat their meal. True False 28. Upon entering a resident’s room, you observe the resident lying on the floor next to the bed. Your first action would be to: a. Call the doctor b. Call the family c. Check the resident and if OK assist back up d. Check the resident and notify the nurse immediately before moving 29. The facility Evacuation Plan is found in the Safety and Loss Control Manual. True False

1.30

30. When doing rounds on your assigned unit, you observe a Medication Cart outside a resident’s room with a med drawer standing open. You should: 1. Go about your business since you are not skilled in passing meds 2. Look through the drawer and see if there is anything you could use 3. Access the facility intercom and announce “attention, the med cart is now open” 4. Close the drawer and stay with the cart to assure no unauthorized access occurs until the responsible person returns 31. It is OK to call a resident pet names such as “honey” or “grandma” because you usually always call the resident this. True False

Write your response: 1. Where are blood spill kits located in your facility and when would you use one?

2. You find medications in a residents room, what would you do?

3. A call light is not working in a resident’s room. What would you do?

4. During a meal time you are feeding a resident and another resident asks to be taken to the bathroom. What would you do?

5. While in the dining room you notice a resident not eating. What should you do?

6. While dressing a resident, he/she begins crying in pain. What should you do?

7. Where is the Disaster Manual kept?

1.31

SCAVENGER HUNT FOR SURVEY PREPAREDNESS 1. Where are blood spill kits located? 2. Where is the Disaster Manual located? 3.

Where can you find an MSDS?

4.

Locate 4 fire extinguishers: 1.

2.

3.

4.

5.

Where are the State Survey results located?

6.

Where are Resident’s Care Plans located?

7.

Where is the nearest eye wash station?

8. Where are Medicaid/Medicare numbers posted? 9. Where is the Daily Staffing Schedule posted? 10. Name 3 members who participate on the QA&A Committee? 1.

2.

3.

11. Who is the Resident Council President? 12. Where are Resident Council Minutes located? 13. Where are meal alternate items posted? 14. Where are grievance forms located? 15. Where are Maintenance Request slips located? 16. Where are the “Wet Floor” signs stored? 17. Find Therapy’s Hydroculator. Is it locked or secured from residents?

1.32

Quality First

J E N N I F E R L . S C U L LY, R N , A N D BARBARA BAYLIS, RN

QI Helps Attain Survey Readiness By correcting deficient practices on an ongoing basis, facilities can solve most problems before survey.

W

HEN SKILLED NURSING

facilities find themselves scrambling to prepare for a periodic state survey, with staff members anxiously wondering if every last detail is in order, perhaps it’s time to consider an approach that targets maintaining full “survey readiness” at all times. The key can be found in the principles of quality improvement (QI), which rely on a proactive, rather than reactive, mind-set. Implementing a system that’s based on QI cannot work, however, unless every staff member is focused on the goal of providing a high standard of care and an ever-improving quality of services. Basic QI principles include identification of areas for improvement through thorough review and data collection, analysis of the information, development of corrective action plans, evaluation of the plans for effectiveness and outcomes, and routine reevaluation to ensure the systems implemented have been maintained and sustained. Knowing The Regulations Employing QI principles to regulatory compliance must begin with an understanding of the regulations and interpretative guidelines as outlined in the “State Operations Manual” (SOM). These regulations should be reviewed and thoroughly digested by all team members within a facility, since QI

principles dictate that everyone be held to these standards. Sharing and discussing the required information at a facility’s regularly held in-services or daily meetings is a good way to get people on board. Team leaders should review one or two requirements per meeting, explaining the rationale and how the requirements apply to themselves and to specific team members. In the context of survey performance, QI employs a step-by-step evaluation of all systems and practices in order to identify opportunities for improvement. Poor regulatory performance may stem from inadequate or “broken” systems or a lack of knowledge, skill, or understanding of the requirements. QI is dependent on how a facility team monitors systems, identifies opportunities for correction, analyzes the information, and develops action plans and interventions to correct the deficient practice or outcome. Identifying opportunities for improvement begins with data collection, which allows for an objective analysis of potential problems that may become serious issues if not addressed and corrected in a timely manner. Data may be concurrent or retrospective, depending on the particular system being reviewed. Concurrent data would be a review of care plans for current patients, whereas retrospective data may be a review of closed

charts to determine adherence to a bed-hold policy. Data collection and analysis may also reveal best practices that can be replicated for improvement in other systems. Each facility should implement QI reviews on a routine basis, not just in preparation for survey. In order to achieve and sustain compliance, the facility team must develop measurable, agreed-upon goals using a collaborative approach. Encouraging everyone’s participation creates a culture of success toward QI, which, in turn, encourages team members to identify and communicate additional corrective areas. The Process In Action Getting started on the road to survey readiness may well be the most timeintensive part of the process when applying QI principles. It generally requires the systematic collection of a significant body of data. However, all the necessary data should be available within the facility, and, once collected, it will not be necessary for staff to scurry around collecting documents at the time of the survey. It is helpful for providers to obtain a JENNIFER L. SCULLY, RN, CCM, CLNC, is executive vice president of clinical services for Sava Senior Care, Atlanta. BARBARA BAYLIS, RN, is senior vice president of clinical operations at Kindred Healthcare, Louisville, Ky. Provider • August 2005 51

Appendix 1-A

Quality First recent quality indicator profile to help analyze the facility for potential areas of concern. Providers should determine trends and patterns and—using the most current patient roster—identify specific individuals who may need additional assessment and follow-up. Once these tasks have been complet-

ed, the facility should conduct a thorough review of the most recent survey results. This will help determine areas that have been problematic in the past, so that the same mistakes are not repeated. Facilities should keep weekly updates in a readily accessible file so that pre-

cious time is not wasted during the actual survey. In addition, this information is valuable and can be used by the facility to determine areas for opportunity. For example, how many hospice patients are currently in the facility? Do they all have interdisciplinary care plans in conjunction with the hospice agency? Are they current and appropriate? Other Survey Tips Survey teams routinely conduct several interviews with individual patients, groups of patients, and family members. Facilities should complete these interviews on a routine basis and follow up on any concerns raised. Corrective actions should then be communicated to the patients, their families, and facility team members. When an actual survey is in progress, a thoroughly prepared facility will be able to maintain its usual routines. Required information should be current and readily available, allowing staff to remain relaxed. Team members should proactively respond to surveyors’ questions and concerns. They should be able to comfortably answer questions and provide clarification and explanations using accurate and informed objective responses. The facility team knows the patients and facility practices better than anyone, and if the facility has created an environment of continuous QI, the survey process will run smoothly. The final step in the QI process involves follow-up to the survey findings. This should begin as soon as the surveyors leave the premises, rather than waiting for the official results. Team members should begin with the information provided during the survey. For example, did the survey team identify deficient areas that need correction? Were specific concerns raised regarding individual patients? If so, this is the time to develop a plan of correction and set it in motion. There is no time to wait when addressing patient care. ■

52 Provider • August 2005

Appendix 1-A

Survey and Certification 101 For Direct-Care Nursing Home Staff AN OVERVIEW OF THE SURVEY / INSPECTION PROCESS IN MISSOURI PROVIDED BY THE SECTION FOR LONG-TERM CARE REGULATION

Missouri Department of Health & Senior Services

Appendix 1-B

Let’s Start at the Top:


Appendix 1-B

If CMS Is Supposed to Ensure Compliance, Why Does the State Do Our Survey?

Center for Medicaid and State Operations Family and Childrens Health Programs Groups

Northeastern Consortium

ROs 1 ,2, and 3

Disabled & Elderly Health Programs Group

Southern Consortium

ROs 4 and 6

Survey & Certification Group

Finance, Systems & Budget Group

Midwestern Consortium

Western Consortium

ROs 5 and 7

State agencies


Appendix 1-B

ROs 8, 9 and 10

Why is it So Important to be in Compliance with the Regulations? There are several reasons.  Most importantly, compliance is consistent with good care, and

nursing home residents deserve good care.

But speaking purely to the regulatory aspect:  A home has to be certified as compliant with regulations in order

to participate in the Medicare and/or Medicaid programs.

 If a home can’t stay in substantial compliance, it is de-certified.  Sometimes monetary penalties are also assessed because of non-

compliance.


Appendix 1-B

So Being Surveyed Is Just About Participating in Medicare and Medicaid?

Not quite.  A nursing home also has to be licensed by the state

in order to operate.  If a facility can’t maintain compliance with state and federal regulations, its license may be revoked or not renewed.  So the survey results also determine whether the state will allow the home to continue operations.  And again, the main point is to ensure good care. Missouri Department of Health & Senior Services

Appendix 1-B

Questions?

This is pretty much the end of the federal portion.


Appendix 1-B

So Missouri DHSS Visits Every Home in the State?

Yes, every year.  495 Skilled Nursing Facilities  35 Intermediate Care Facilities  471 Residential Care Facilities  145 Assisted Living Facilities  We also respond to approximately 7,000 hotline calls each

year.

Missouri Department of Health & Senior Services Appendix 1-B

Are All Types of Facilities Surveyed the Same Way?

Almost.  RCFs and ALFs (and a few SNFs and ICFs) are not

federally-certified, so they only have to follow Missouri’s state regulations.

 Missouri regulations are very similar to the federal

regulations, though.

 In these homes, the process is officially called an

“inspection” rather than a “survey.”


When Does DHSS Visit Facilities? We can’t let anyone know when we’re coming, but there are some guidelines.  Missouri law requires each home to be inspected

twice per fiscal year (July 1 – June 30).  CMS requires one survey every 9 – 15 months.


How Can DHSS Be In So Many Places At Once?


Appendix 1-B

Questions?

We’re about to start focusing on the survey process.


Appendix 1-B

Which Type of Survey Are We Talking About?  Many states have begun using a computerized survey

system in which surveyors carry tablet PCs. This is called the QIS survey process.  Eventually, CMS will require all states to conduct

this type of survey.  Missouri currently plans to begin implementing the

QIS survey in 2013.  The following slides only pertain to the current,

standard survey process. Missouri Department of Health & Senior Services Appendix 1-B

When Does A Survey Actually Begin? A day or two before surveyors visit your home.  At the regional office, members of the survey team review

your home’s Quality Indicator report (the exact same one your Administrator and DON can access from the home).  They also review recent complaint investigations and previous survey results.  They may visit with your Ombudsman.  This review helps the team identify a sample of residents that they will observe for the next few days.


Appendix 1-B

What Things Really Catch the Team’s Attention?

Things that might be dangerous. • Weight loss • Dehydration • Pressure ulcers • Fecal impaction • Quality indicators at or above 90% Missouri Department of Health & Senior Services

Appendix 1-B

So When Does The Real Surveying Begin? With the Entrance Conference.  Upon entering the building, the team leader should

introduce the team to the Administrator.  The team leader explains the process and requests some standard information.  The remainder of the team begins a tour of the home, with staff members if possible.


Appendix 1-B

What’s Going On During The Tour, Anyway? A few different things.  Surveyors are making sure their pre-selected residents

are still in the nursing home.  They’re confirming information collected during the offsite preparation.  They’re taking note of any potential new concerns that are immediately obvious.  And one of them is probably heading toward the kitchen. Missouri Department of Health & Senior Services

Appendix 1-B

What Are Surveyors Trying to Accomplish with A Tour?  To get a general look at the care and services offered.  To meet the residents (especially the pre-selected    

sample) and visit with them. To observe how residents and staff interact. To identify newly-admitted residents, or those awaiting transfer or discharge. Note which residents are interview-able, or not interview-able. Determine if any family members are available for interviews.


Appendix 1-B

What Happens After these First Minutes of the Tour? The surveyors start paying close attention to the quality of specific services.  Are the residents clean and groomed appropriately?  Are residents active, or sitting around and mainly

inactive?  Are caregivers available when needed?  What is the response of nursing home employees to residents with behavioral issues? Missouri Department of Health & Senior Services

Appendix 1-B

Other Evidence of Quality:

 Whether the environment is home-like.  Whether the home is clean (and smells clean).  Whether the staff seems to understand infection

control practices.  Whether residents seem to have the assistive devices they need.  Whether any residents are at risk of dehydration.


Appendix 1-B

What Happens After the Tour? Sample Selection.  The team gets together on-site and reviews its pre-

selected sample of residents.  They agree to select additional residents if necessary for a mixed sample.  Later, the team may have to select another sample of residents based on new concerns identified during the survey.


Appendix 1-B

What Happens After the Sample is Selected? The team begins gathering information.  Information about the environment (maintenance     

personnel). Information about the kitchen, meals and dietary staff. Information about the residents’ quality of life. Information about medication passes. Information about the Quality Assurance Committee. Information about abuse prevention.


Appendix 1-B

Why Might Surveyors Want to Speak with Maintenance Staff?

 The home should be free of accident hazards.  The resident call system and other equipment should    

be functioning properly. The building should be sanitary and comfortable. An effective pest control program should be in place. Housekeeping compounds should be stored safely. Things should appear home-like.


Appendix 1-B

Why Might They Speak with Dietary Staff?

 Food needs to be stored, prepared, distributed and     

served in ways that prevent food-borne illness. Potentially dangerous ingredients need to be cooked appropriately. Frozen items should be thawed properly. The equipment and environment should be clean. The food should taste good to the residents. The dining experience should be pleasant.


Appendix 1-B

What About the Nursing Staff, Specifically? The nursing staff tends to be observed the most.  Surveyors watch to see if residents are treated with     

dignity while interacting with nursing staff. They watch to see whether residents are offered choices when they are assisted. They notice whether the residents’ needs are met. They look to see if drugs are appropriate and effective. They verify the accuracy of the Resident Assessment Instrument (RAI) and the Minimum Data Set (MDS). They review residents’ care plans.


Appendix 1-B

What About the Medication Pass? Surveyors will check to determine that staff members safely store and administer meds.  The medication error rate has to be below 5%.  Surveyors initially view 20-25 opportunities for an

error.  If a rate of 5% or more is observed, then they have to observe 20-25 more opportunities for error.  After 40-50 opportunities, the rate has to be below 5%. Missouri Department of Health & Senior Services

Appendix 1-B

What Exactly is a Medication Error? Many things are counted as medication errors:  Medication given to wrong resident.  Wrong medication given.  Wrong dose of medication is given.  The medication is given in the wrong route.  Medication is given at the wrong time.  Documentation related to medications is inadequate.  Evaluation of medication effectiveness is inadequate. Missouri Department of Health & Senior Services Appendix 1-B

Do Surveyors Look for Evidence of Abuse? They ask aides how to report abuse, and they look for policies and procedures that prohibit the following:  Abuse  Neglect  Misappropriation of resident property  Involuntary seclusion  These documents should also outline prevention

measures (hiring practices, training, etc.)  Investigation protocol should ensure that residents are protected during any investigation period. Missouri Department of Health & Senior Services

Appendix 1-B

Questions?

We’re about to discuss deficiencies.


Appendix 1-B

What Happens After the Observations Are Done?

 Information and collected evidence is discussed to

determine if sufficient evidence exists to cite a deficiency or non compliance.  The team determines whether substandard care

exists (which may trigger an extended survey).  An exit conference is held, and preliminary

deficiency findings are shared with the Administrator and other staff members. Missouri Department of Health & Senior Services

Appendix 1-B

Why Are Deficiencies Written as a Combination of Letters and Numbers? Different letters and numbers mean different things.  Deficient practices are identified as F-Tags or K-Tags

in the State Operations Manual (SOM).  State regulations have different letters and numbers (they’re sometimes called A-Tags), but usually correspond to an F-Tag.  Federal deficiencies are also assigned a letter that establishes the scope and severity of the deficiency. Missouri Department of Health & Senior Services

Appendix 1-B

What is Meant By Scope and Severity? Severity Immediate Jeopardy

J

K

L

Actual harm

G

H

I

No harm, potential more than minimal

D

E

F

No harm, potential Less for minimal

A

B

C

Isolated

Pattern Scope


Appendix 1-B

Widespread

Does This Apply to All Types of Facilities?

    

No. It applies to Medicare- or Medicaid-Certified homes (or those undergoing their initial certification). For state-licensed-only homes, violations are classified as Class I, II, or III. Class I violations usually = a s/s of J or higher. Class II violations usually = a s/s of between D & I. Class III violations usually = a s/s of A, B or C.


Appendix 1-B

What is Substandard Care? Not exactly what you might think. In the survey process, this term has a specific meaning.  The tag number of the deficiency falls between F221 &

F225, between F240 & F258, or between F309 & F334.

 (These are tags related to restraints, pressure sores,

hydration, supervision, accidents, etc.)

AND  The scope and severity must be an F, H,I,J,K or L.  (Scope and severity of G is excluded.)


Appendix 1-B

Can A Home Receive A Deficiency & Still Be In Substantial Compliance?

Yes.  Any deficiency may be cited at a scope and severity of A, B or C, and the home is still considered to be in substantial compliance.  On the state side, a home may have up to 20

deficiencies, with none higher than a Class III, and it is still considered in substantial compliance.


Appendix 1-B

Questions?

If you have a question about a survey or investigation that you’ve experienced, get ready to ask it.


Appendix 1-B

What Does All of this Mean For Aides? It means (unfortunately) that they’re under the microscope.  The survey process is designed to evaluate the care

residents receive.  Since aides deliver almost all of the direct care,

surveyors spend a lot of time watching and interviewing aides.


Appendix 1-B

How Do Surveyors Decide Which Aides to Watch? They don’t.  The survey team samples residents, not employees.  Especially in homes with consistent staffing, it may

feel like surveyors are monitoring you.

 If you happen to be caring for more than one

sampled resident, you may really be getting a lot of attention from surveyors.


Appendix 1-B

What If You Get Nervous? You’re not the only one.  If you make a mistake because you’re nervous, and

you realize that you’ve done it, say something. That way, the surveyor knows it was just a one-time mistake, and not something you do all the time.  Try saying something like, “Sorry, I don’t normally

do it that way, but I’m nervous about being watched. I normally do it this way instead.”


Appendix 1-B

Why Do Surveyors Want to Ask Me Questions? Sometimes they have to.  As part of the “information-gathering” of the survey,

the team needs to conduct interviews with some staff members, some residents, and some family members.  Some homes do things differently than all other homes (especially with culture change, now). A surveyor really might not understand what you’re doing. Missouri Department of Health & Senior Services

Appendix 1-B

Why Else Might A Surveyor Want to Talk to Me? They might just be making polite conversation.

 Surveyors are in your building to do a job, but for the

most part, they’re more friendly and less sneaky than you probably think.


Appendix 1-B

Can You Have Your Supervisor With You When You Answer A Surveyor’s Questions?

Probably.  Nothing says you have to be alone when answering a

surveyor’s questions, and if you’d be more comfortable with someone else present, you can say so.  If an aide can’t answer even basic questions at the bedside without consulting a supervisor first, a surveyor might logically wonder if something is wrong. Missouri Department of Health & Senior Services

Appendix 1-B

Can You Ask A Co-Worker For Help When A Surveyor Is Watching?

Absolutely.  You should care for residents however you normally care

for them.  If you normally work alone, that’s fine.  If you normally ask for assistance with some things, ask for assistance.

 The point is, surveyors understand that they disrupt the

normal pattern of things when they’re surveying. Just take your time.


Appendix 1-B

What Kinds of Questions Might A Surveyor Ask?  “If you saw someone hurt a resident, what would you    

do?” “Have you ever attended training on abuse or neglect?” “If a fire started in the dining room, what would you do?” “Does this resident use any special assistive equipment?” “I noticed you were helping Mary. Can you tell me what you do for her?”


Appendix 1-B

Questions?

Last call for questions…


Appendix 1-B

Contact Information

Matt Younger, Administrator Section for Long-Term Care Regulation Missouri Dept. of Health and Senior Services [email protected] (573) 522-6228


Appendix 1-B

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

LONG TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID Standard Survey From: F1 ■■ ■■ ■■ To: F2 ■■ MM DD YY MM Name of Facility

Extended Survey From: F3 ■■ ■■ ■■ To: F4 ■■ MM DD YY MM Provider Number

■■ ■■ DD YY

■■ ■■

DD YY Fiscal Year Ending: F5

■■ ■■ ■■ MM

City

Street Address

County

State/County Code: F7

Telephone Number: F6

State

DD YY Zip Code

State/Region Code: F8

A. F9 ■■ 01 Skilled Nursing Facility (SNF) - Medicare Participation 02 Nursing Facility (NF) - Medicaid Participation 03 SNF/NF - Medicare/Medicaid B. Is this facility hospital based? F10 Yes

■

No

■

If yes, indicate Hospital Provider Number: F11 ■■■■■■■ Ownership: F12 ■■ For Profit 01 Individual 02 Partnership 03 Corporation

NonProfit 04 Church Related 05 Nonprofit Corporation 06 Other Nonprofit

Owned or leased by Multi-Facility Organization: F13 Yes

■

No

Government 07 State 10 City/County 08 County 11 Hospital District 09 City 12 Federal

■

Name of Multi-Facility Organization: F14

Dedicated Special Care Units (show number of beds for all that apply) F15 F17 F19 F21 F23

■■■ AIDS ■■■ Dialysis ■■■ Head Trauma ■■■ Huntington's Disease ■■■ Other Specialized Rehabilitation

F16 F18 F20 F22

■■■ Alzheimer's Disease ■■■ Disabled Children/Young Adults ■■■ Hospice ■■■ Ventilator/Respiratory Care

Does the facility currently have an organized residents group? Does the facility currently have an organized group of family members of residents? Does the facility conduct experimental research? Is the facility part of a continuing care retirement community (CCRC)?

F24 F25 F26 F27

Yes Yes Yes Yes

■ ■ ■ ■

No No No No

■ ■ ■ ■

If the facility currently has a staffing waiver, indicate the type(s) of waiver(s) by writing in the date(s) of last approval. Indicate the number of hours waived for each type of waiver granted. If the facility does not have a waiver, write NA in the blanks. Waiver of seven day RN requirement. Date: F28 ■■ ■■ ■■ Hours waived per week: F29________ Waiver of 24 hr licensed nursing requirement. Date: F30 ■■ ■■ ■■ Hours waived per week: F31________ MM DD YY Does the facility currently have an approved Nurse Aide Training and Competency Evaluation Program? Form CMS-671 (12/02) Appendix 1-C

F32

Yes

■

No

■

FACILITY STAFFING Tag Number

A Services Provided 1

Physician Services

F33 F34

Medical Director

F35

Other Physician Physician Extender

F36

Administration

Nursing Services

F39

Nurses with Admin. Duties Registered Nurses

F40

F42

Certified Nurse Aides

F43

Nurse Aides in Training Medication Aides/Technicians

F44

Food Service Workers Therapeutic Services Occupational Therapists Occupational Therapy Assistants Occupational Therapy Aides Physical Therapists Physical Therapists Assistants Physical Therapy Aides

3

F50 F51 F52 F53 F54 F55

F59

Other Activities Staff

F60

Qualified Social Workers

F61

Other Social Services Dentists

F62 F63

Podiatrists

F64

Mental Health Services

F65

Vocational Services

F66 F67 F68

Housekeeping Services Other

Contract (hours)

F48 F49

Qualified Activities Professional

Diagnostic X-ray Services Administration & Storage of Blood

Part-Time Staff (hours)

F46 F47

Therapeutic Recreation Specialist

Clinical Laboratory Services

Full-Time Staff (hours)

F45

F56 F57 F58

Speech/Language Pathologist

D

F41

Licensed Practical/ Licensed Vocational Nurses

Dietary Services Dietitian

C

F37 F38

RN Director of Nurses

Pharmacists

2

B

F69 F70 F71

Name of Person Completing Form

Time

Signature

Date

Form CMS-671 (12/02)

Appendix 1-C

GENERAL INSTRUCTIONS AND DEFINITIONS (use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid) This form is to be completed by the Facility For the purpose of this form “the facility” equals certified beds (i.e., Medicare and/or Medicaid certified beds). Standard Survey - LEAVE BLANK - Survey team will complete Extended Survey - LEAVE BLANK - Survey team will complete INSTRUCTIONS AND DEFINITIONS Name of Facility - Use the official name of the facility for business and mailing purposes. This includes components or units of a larger institution. Provider Number - Leave blank on initial certifications. On all recertifications, insert the facility's assigned six-digit provider code. Street Address - Street name and number refers to physical location, not mailing address, if two addresses differ. City - Rural addresses should include the city of the nearest post office. County - County refers to parish name in Louisiana and township name where appropriate in the New England States. State - For U.S. possessions and trust territories, name is included in lieu of the State. Zip Code - Zip Code refers to the "Zip-plus-four" code, if available, otherwise the standard Zip Code. Telephone Number - Include the area code. State/County Code - LEAVE BLANK - State Survey Office will complete. State/Region Code - LEAVE BLANK - State Survey Office will complete. Block F9 - Enter either 01 (SNF), 02 (NF), or 03 (SNF/NF). Block F10 - If the facility is under administrative control of a hospital, check "yes," otherwise check "no." Block F11 - The hospital provider number is the hospital's assigned six-digit Medicare provider number. Block F12 - Identify the type of organization that controls and operates the facility. Enter the code as identified for that organization (e.g., for a for profit facility owned by an individual, enter 01 in the F12 block; a facility owned by a city government would be entered as 09 in the F12 block).

Definitions to determine ownership are: FOR PROFIT - If operated under private commercial ownership, indicate whether owned by individual, partnership, or corporation. NONPROFIT - If operated under voluntary or other nonprofit auspices, indicate whether church related, nonprofit corporation or other nonprofit. GOVERNMENT - If operated by a governmental entity, indicate whether State, City, Hospital District, County, City/County, or Federal Government. Block F13 - Check "yes" if the facility is owned or leased by a multi-facility organization, otherwise check "no." A Multi-Facility Organization is an organization that owns two or more long term care facilities. The owner may be an individual or a corporation. Leasing of facilities by corporate chains is included in this definition. Block F14 - If applicable, enter the name of the multi-facility organization. Use the name of the corporate ownership of the multi-facility organization (e.g., if the name of the facility is Soft Breezes Home and the name of the multi-facility organization that owns Soft Breezes is XYZ Enterprises, enter XYZ Enterprises). Block F15 – F23 - Enter the number of beds in the facility's Dedicated Special Care Units. These are units with a specific number of beds, identified and dedicated by the facility for residents with specific needs/diagnoses. They need not be certified or recognized by regulatory authorities. For example, a SNF admits a large number of residents with head injuries. They have set aside 8 beds on the north wing, staffed with specifically trained personnel. Show "8" in F19. Block F24 - Check "yes" if the facility currently has an organized residents’ group, i.e., a group(s) that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; to support each other; to plan resident and family activities; to participate in educational activities or for any other purposes; otherwise check "no." Block F25 - Check "yes" if the facility currently has an organized group of family members of residents, i.e., a group(s) that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; to support each other, to plan resident and family activities; to participate in educational activities or for any other purpose; otherwise check "no.”

1 Appendix 1-C

GENERAL INSTRUCTIONS AND DEFINITIONS (use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid) Block F26 - Check "yes" if the facility conducts experimental research; otherwise check "no." Experimental research means using residents to develop and test clinical treatments, such as a new drug or therapy, that involves treatment and control groups. For example, a clinical trial of a new drug would be experimental research.

Column A-1 - Refers to those services provided onsite to residents, either by employees or contractors. Column A-2 - Refers to those services provided onsite to non-residents. Column A-3 - Refers to those services provided to residents offsite/or not routinely provided onsite.

Block F27 - Check "yes" if the facility is part of a continuing care retirement community (CCRC); otherwise check "no." A CCRC is any facility which operates under State regulation as a continuing care retirement community. Blocks F28 – F31 - If the facility has been granted a nurse staffing waiver by CMS or the State Agency in accordance with the provisions at 42CFR 483.30(c) or (d), enter the last approval date of the waiver(s) and report the number of hours being waived for each type of waiver approval. Block F32 - Check "yes" if the facility has a State approved Nurse Aide Training and Competency Evaluation Program; otherwise check "no."

Column B - Full-time staff, C - Part-time staff, and D - Contract - Record hours worked for each field of full-time staff, part-time staff, and contract staff (do not include meal breaks of a half an hour or more). Full-time is defined as 35 or more hours worked per week. Part-time is anything less than 35 hours per week. Contract includes individuals under contract (e.g., a physical therapist) as well as organizations under contract (e.g., an agency to provide nurses). If an organization is under contract, calculate hours worked for the individuals provided. Lines blocked out (e.g., Physician services, Clinical labs) do not have hours worked recorded. REMINDER - Use a 2-week period to calculate hours worked.

FACILITY STAFFING GENERAL INSTRUCTIONS

DEFINITION OF SERVICES

This form requires you to identify whether certain services are provided and to specify the number of hours worked providing those services. Column A requires you to enter "yes” or "no” about whether the services are provided onsite to residents, onsite to nonresidents, and offsite to residents. Columns B-D requires you to enter the specific number of hours worked providing the service. To complete this section, base your calculations on the staff hours worked in the most recent complete pay period. If the pay period is more than 2 weeks, use the last 14 days. For example, if this survey begins on a Tuesday, staff hours are counted for the previous complete pay period. Definition of Hours Worked - Hours are reported rounded to the nearest whole hour. Do not count hours paid for any type of leave or non-work related absence from the facility. If the service is provided, but has not been provided in the 2-week pay period, check the service in Column A, but leave B, C, or D blank. If an individual provides service in more than one capacity, separate out the hours in each service performed. For example, if a staff person has worked a total of 80 hours in the pay period but has worked as an activity aide and as a Certified Nurse Aide, separately count the hours worked as a CNA and hours worked as an activity aide to reflect but not to exceed the total hours worked within the pay period. Completion of Form Column A - Services Provided - Enter Y (yes), N (no) under each sub-column. For areas that are blocked out, do not provide the information.

Administration - The administrative staff responsible for facility management such as the administrator, assistant administrator, unit managers and other staff in the individual departments, such as: Health Information Specialists (RRA/ARTI), clerical, etc., who do not perform services described below. Do not include the food service supervisor, housekeeping services supervisor, or facility engineer. Physician Services - Any service performed by a physician at the facility, except services performed by a resident's personal physician. Medical Director - A physician designated as responsible for implementation of resident care policies and coordination of medical care in the facility. Other Physician - A salaried physician, other than the medical director, who supervises the care of residents when the attending physician is unavailable, and/or a physician(s) available to provide emergency services 24 hours a day. Physician Extender - A nurse practitioner, clinical nurse specialist, or physician assistant who performs physician delegated services. Nursing Services - Coordination, implementation, monitoring and management of resident care plans. Includes provision of personal care services, monitoring resident responsiveness to environment, range-of-motion exercises, application of sterile dressings, skin care, naso-gastric tubes, intravenous fluids, catheterization, administration of medications, etc.

2 Appendix 1-C

GENERAL INSTRUCTIONS AND DEFINITIONS (use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid) Director of Nursing - Professional registered nurse(s) administratively responsible for managing and supervising nursing services within the facility. Do not additionally reflect these hours in any other category. Nurses with Administrative Duties - Nurses (RN, LPN, LVN) who, as either a facility employee or contractor, perform the Resident Assessment Instrument function in the facility and do not perform direct care functions. Also include other nurses whose principal duties are spent conducting administrative functions. For example, the Assistant Director of Nursing is conducting educational/in-service, or other duties which are not considered to be direct care giving. Facilities with an RN waiver who do not have an RN as DON report all administrative nursing hours in this category. Registered Nurses - Those persons licensed to practice as registered nurses in the State where the facility is located. Includes geriatric nurse practitioners and clinical nurse specialists who primarily perform nursing, not physician-delegated tasks. Do not include Registered Nurses' hours reported elsewhere. Licensed Practical/Vocational Nurses - Those persons licensed to practice as licensed practical/vocational nurses in the State where the facility is located. Do not include those hours of LPN/LVNs reported elsewhere. Certified Nurse Aides - Individuals who have completed a State approved training and competency evaluation program, or competency evaluation program approved by the State, or have been determined competent as provided in 483.150(a) and (3) and who are providing nursing or nursing-related services to residents. Do not include volunteers. Nurse Aides in Training - Individuals who are in the first 4 months of employment and who are receiving training in a State approved Nurse Aide training and competency evaluation program and are providing nursing or nursing-related services for which they have been trained and are under the supervision of a licensed or registered nurse. Do not include volunteers. Medication Aides/Technicians - Individuals, other than a licensed professional, who fulfill the State requirement for approval to administer medications to residents. Pharmacists - The licensed pharmacist(s) who a facility is required to use for various purposes, including providing consultation on pharmacy services, establishing a system of records of controlled drugs, overseeing records and reconciling controlled drugs, and/or performing a monthly drug regimen review for each resident.

Dietary Services - All activities related to the provision of a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. Dietitian - A person(s), employed full, part-time or on a consultant basis, who is either registered by the Commission of Dietetic Registration of the American Dietetic Association, or is qualified to be a dietitian on the basis of experience in identification of dietary needs, planning and implementation of dietary programs. Food Service Workers - Persons (excluding the dietitian) who carry out the functions of the dietary service (e.g., prepare and cook food, serve food, wash dishes). Includes the food services supervisor. Therapeutic Services - Services, other than medical and nursing, provided by professionals or their assistants, to enhance the residents' functional abilities and/or quality of life. Occupational Therapists - Persons licensed/registered as occupational therapists according to State law in the State in which the facility is located. Include OTs who spend less than 50 percent of their time as activities therapists. Occupational Therapy Assistants - Person(s) who, in accord with State law, have licenses/certification and specialized training to assist a licensed/certified/registered Occupational Therapist (OT) to carry out the OT's comprehensive plan of care, without the direct supervision of the therapist. Include OT Assistants who spend less than 50 percent of their time as Activities Therapists. Occupational Therapy Aides - Person(s) who have specialized training to assist an OT to carry out the OT's comprehensive plan of care under the direct supervision of the therapist, in accord with State law. Physical Therapists - Persons licensed/registered as physical therapists, according to State law where the facility is located. Physical Therapy Assistants - Person(s) who, in accord with State law, have licenses/certification and specialized training to assist a licensed/certified/registered Physical Therapist (PT) to carry out the PT's comprehensive plan of care, without the direct supervision of the PT. Physical Therapy Aides - Person(s) who have specialized training to assist a PT to carry out the PT's comprehensive plan of care under the direct supervision of the therapist, in accord with State law. Speech-Language Pathologists - Persons licensed/registered, according to State law where the facility is located, to provide speech therapy and related services (e.g., teaching a resident to swallow).

3 Appendix 1-C

GENERAL INSTRUCTIONS AND DEFINITIONS (use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid) Therapeutic Recreation Specialist - Person(s) who, in accordance with State law, are licensed/registered and are eligible for certification as a therapeutic recreation specialist by a recognized accrediting body.

Mental Health Services - Staff (excluding those included under therapeutic services) who provide programs of services targeted to residents' mental, emotional, psychological, or psychiatric well-being and which are intended to: • Diagnose, describe, or evaluate a resident's mental or emotional status; • Prevent deviations from mental or emotional well-being from developing; or • Treat the resident according to a planned regimen to assist him/her in regaining, maintaining, or increasing emotional abilities to function.

Qualified Activities Professional - Person(s) who meet the definition of activities professional at 483.15(f)(2)(i)(A) and (B) or 483.15(f)(2)(ii) or (iii) or (iv) and who are providing an on-going program of activities designed to meet residents' interests and physical, mental or psychosocial needs. Do not include hours reported as Therapeutic Recreation Specialist, Occupational Therapist, OT Assistant, or other categories listed above.

Among the specific services included are psychotherapy and counseling, and administration and monitoring of psychotropic medications targeted to a psychiatric diagnosis.

Other Activities Staff - Persons providing an on-going program of activities designed to meet residents' needs and interests. Do not include volunteers or hours reported elsewhere.

Vocational Services - Evaluation and training aimed at assisting the resident to enter, re-enter, or maintain employment in the labor force, including training for jobs in integrated settings (i.e., those which have both disabled and nondisabled workers) as well as in special settings such as sheltered workshops.

Qualified Social Worker(s) - Person licensed to practice social work in the State where the facility is located, or if licensure is not required, persons with a bachelor's degree in social work, a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling and psychology, and one year of supervised social work experience in a health care setting working directly with elderly individuals.

Clinical Laboratory Services - Entities that provide laboratory services and are approved by Medicare as independent laboratories or hospitals. Diagnostic X-ray Services - Radiology services, ordered by a physician, for diagnosis of a disease or other medical condition.

Other Social Services Staff - Person(s) other than the qualified social worker who are involved in providing medical social services to residents. Do not include volunteers.

Administration and Storage of Blood Services - Blood bank and transfusion services.

Dentists - Persons licensed as dentists, according to State law where the facility is located, to provide routine and emergency dental services.

Housekeeping Services - Services, including those of the maintenance department, necessary to maintain the environment. Includes equipment kept in a clean, safe, functioning and sanitary condition. Includes housekeeping services supervisor and facility engineer.

Podiatrists - Persons licensed/registered as podiatrists, according to State law where the facility is located, to provide podiatric care.

Other - Record total hours worked for all personnel not already recorded, (e.g., if a librarian works 10 hours and a laundry worker works 10 hours, record 00020 in Column C).

4 Appendix 1-C


RESIDENT CENSUS AND CONDITIONS OF RESIDENTS Provider No.

Medicare

Medicaid

Other

F75

ADL

Total Residents

F76

Independent

F77

Assist of One or Two Staff

F78

Dependent

Bathing

F79

F80

F81

Dressing

F82

F83

F84

Transferring

F85

F86

F87

Toilet Use

F88

F89

F90

Eating

F91

F92

F93

A. Bowel/Bladder Status

B. Mobility

F94 ____ With indwelling or external catheter

F100____ Bedfast all or most of time F101____ In a chair all or most of time

F95 Of the total number of residents with catheters, how many were present on admission ____?

F102____ Independently ambulatory

F96 ____ Occasionally or frequently incontinent of bladder

F103____ Ambulation with assistance or assistive device F104____ Physically restrained

F97 ____ Occasionally or frequently incontinent of bowel

F105 Of the total number of residents with restraints, how many were admitted or readmitted with orders for restraints ____?

F98 ____ On urinary toileting program F99 ____ On bowel toileting program

F106____ With contractures F107 Of the total number of residents with contractures, how many had a contracture(s) on admission ____?

C. Mental Status

D. Skin Integrity

F108____ Intellectual and/or developmental disability

F115____ Pressure ulcers (exclude Stage 1)

F108-114 – indicate the number of residents with:

F115-118 – indicate the number of residents with:

F116 Of the total number of residents with pressure ulcers excluding Stage 1, how many residents had pressure ulcers on admission ____?

F109____ Documented signs and symptoms of depression F110____ Documented psychiatric diagnosis (exclude dementias and depression) F111____ Dementia: (e.g., Lewy-Body, vascular or Multi- infarct, mixed, frontotemporal such as Pick’s disease; and dementia related to Parkinson’s or Creutzfeldt- Jakob diseases), or Alzheimer’s Disease F112____ Behavioral healthcare needs F113 Of the total number of residents with behavioral healthcare needs, how many have an individualized care plan to support them ____?

F117____ Receiving preventive skin care F118____ Rashes

F114____ Receiving health rehabilitative services for MI and/or ID/DD

Form CMS-672 (05/12)

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Appendix 1-C

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

I certify that this information is accurate to the best of my knowledge.

E. Special Care F119-132 – indicate the number of residents receiving:

F127____ Suctioning

Fl19 ____ Hospice care

F128____ Injections (exclude vitamin B12 injections)

F120____ Radiation therapy

F129____ Tube feedings

F121____ Chemotherapy

Fl30____ Mechanically altered diets including pureed and all chopped food (not only meat)

F122____ Dialysis

F124____ Respiratory treatment

F131____ Rehabilitative services (Physical therapy, speech- language therapy, occupational therapy, etc.) Exclude health rehabilitation for MI and/or ID/DD

F125____ Tracheostomy care

F132____ Assistive devices with eating

F123____ Intravenous therapy, IV nutrition, and/or blood transfusion

F126____ Ostomy care

F. Medications

G. Other

F133-139 – indicate the number of residents receiving:

F140____ With unplanned significant weight loss/gain

F133____ Any psychoactive medication

F141____ Who do not communicate in the dominant language of the facility (include those who use American sign language)

F134____ Antipsychotic medications F135____ Antianxiety medications

F142____ Who use non-oral communication devices

F136____ Antidepressant medications

F143____ With advance directives

F137____ Hypnotic medications

F144____ Received influenza immunization

F138____ Antibiotics

F145____ Received pneumococcal vaccine

F139____ On pain management program

Signature of Person Completing the Form

Title

Date

TO BE COMPLETED BY SURVEY TEAM F146

Was ombudsman office notified prior to survey?

___ Yes

___ No

F147

Was ombudsman present during any portion of the survey?

___ Yes

___ No

F148

Medication error rate _______%

Form CMS-672 (05/12)

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Appendix 1-C

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (use with Form CMS-672)

GENERAL INSTRUCTIONS: THIS FORM IS TO BE COMPLETED BY THE FACILITY AND REPRESENTS THE CURRENT CONDITION OF RESIDENTS AT THE TIME OF COMPLETION There is no federal requirement to automate the 672 form. A facility may use its MDS data to assist in completing the entry fields for the 672 form, however, facilities should ensure that the MDS information is not simply counted and copied over into the form. All conditions noted on this form that are not identified on the MDS must be counted manually. This information is designed to be a representation of the facility during survey; it does not directly correspond to the MDS data in every field. The information entered on this form must be reflective of all residents as of the day of survey; therefore all information entered must be independently verified. Following certain entry fields, the related MDS 3.0 item(s) is noted. Remember, that although MDS items are noted for some fields, the field itself may need to be completed differently to reflect the current status of all residents as of the day of survey. The MDS items are provided only as a reference point, the form is to be completed using the time frames and other specific instructions as noted below. Where a field refers to the “admission assessment,” use only the counts from the first assessment since the most recent admission/entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident). For the purpose of completing this form the terms: “facility” means certified beds (i.e., Medicare and/or Medicaid certified beds) and “residents” means residents in certified beds regardless of payer source.

INSTRUCTIONS AND DEFINITIONS: Complete each field by specifying the number of residents in each category. If no residents fall into a category enter a “0”. Provider Number: Facility CMS certification provider number. A0100B; leave blank for initial certifications. Block F75: Residents whose primary payer is Medicare. Block F76: Residents whose primary payer is Medicaid. Block F77: Residents whose primary payer is neither Medicare nor Medicaid. Block F78: Residents for whom a bed is maintained on the day the survey begins, including those temporarily away in a hospital or on leave. This should be representative of residents in the nursing facility or those who have a bed-hold. ADLS (F79 – F93): To determine resident status, unless otherwise noted, consider the resident’s condition for the 7 days prior to the survey. Horizontal totals across the three columns (Independent, Assist of One or Two Staff, and Dependent) must equal the number in Block F78, Total Residents, for each of the ADL categories (Bathing, Dressing, Transferring, Toilet Use and Eating). Bathing (F79 – F81): This includes a full-body bath/shower, sponge bath, and transfer into and out of tub or shower. G0120A = 0 for F79, G0120A = 1, 2, OR 3 for F80. OR G0120A = 4 for F81. Facilities may provide “setup” assistance to residents such as drawing water for a tub bath or laying out clothes, bathing supplies/toiletries, etc. Also, a resident may only need assistance with washing their back or shampooing their hair. If either of these are the case, and the resident requires no other assistance, count the resident as independent.

Dressing (F82 – F84): How the resident puts on, and takes off all items of clothing, including donning/removing prostheses (e.g., braces and artificial limbs) or elastic stockings. G0110G1 = 0 for F82 OR G0110G1 = 1, 2, OR 3 for F83 OR G0110G1 = 4 for F84. Facilities may set out clothes for residents. If this is the case and this is the only assistance the resident receives, count the resident as independent. However, if a resident receives assistance, such as with dressing, donning a brace, elastic stocking, a prosthesis , or securing fasteners, etc. count the resident as needing the assistance of 1 or 2 staff, as appropriate. Transferring (F85 – F87): How the resident moves between surfaces, including, to or from bed, chair, wheelchair, or standing position. (EXCLUDES transfers to/from the bath/ toilet). G0110B1 = 0 for F85 OR G0110B1 = 1, 2, or 3 for F86 OR G0110B1 = 4 for F87. Facilities may provide “setup” assistance to residents, such as handing equipment (e.g., quad cane) to the resident. If this is the case and is the only assistance required, count the resident as independent. Toilet Use (F88 – F90): How the resident uses the toilet, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad(s); manages ostomy or catheter, and adjusts clothing. If all that is done for the resident is to open a package (e.g., a clean incontinence pad), count the resident as independent. G0110I1 = 0 for F88 OR G0110I1 = 1, 2, or 3 for F89 OR G0110I1 = 4 for F90. Eating (F91 – F93): How a resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, includes IV fluids administered for nutrition or hydration). Facilities may provide “setup” activities, such as opening containers, buttering bread, and organizing the tray; if this is the case and is the only assistance a resident needs, count this resident as independent. G0110H1 = 0 for F91 OR G0110H1 = 1, 2, or 3 for F92 OR G0110H1 = 4 for F93.

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Appendix 1-C


A. BOWEL/BLADDER STATUS (F94 – F99) RESIDENTS F94: With an indwelling or an external catheter: Whose urinary bladder is constantly drained by a catheter (e.g., an indwelling catheter, a suprapubic catheter or nephrostomy tube) or who wears an appliance that is applied over the penis and connected to a drainage bag to collect urine from the bladder (e.g., condom catheter or similar appliance). H0100A or B = checked. F95: Of the total number of residents with catheters: Who had a catheter present on admission/entry or reentry. H0100A or B = checked. To complete this field use only the counts from the first assessment since the most recent admission/ entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident). F96: Occasionally or frequently incontinent of bladder: Who have an incontinent episode two or more times per week. Do not include residents with an indwelling or external catheter. H0100A and B = not checked AND H0300 =1, 2, or 3. F97: Occasionally or frequently incontinent of bowel: Who have a loss of bowel control two or more times per week. H0400 = 2 or 3. F98: On urinary toileting program: With a systematically implemented, individualized urinary toileting program (i.e. bladder rehabilitation/retraining, prompted voiding, habit training/scheduled voiding) to decrease or prevent urinary incontinence or minimizing or avoiding the negative consequences of incontinence (e.g., pelvic floor exercises). Count all residents on urinary training programs including those who are incontinent. H0200A = 1 OR H200C = 1 OR H0300 = 1, 2 or 3. F99: On bowel toileting program: With a systematically implemented, individualized bowel toileting program to decrease or prevent bowel incontinence or minimizing or avoiding the negative consequences of incontinence (e.g., use of adequate fluid intake, fiber in the diet, exercise, and scheduled times to attempt bowel movement). Count all residents on toileting programs including those who are incontinent. H0400 = 2 or 3 OR H0500 OR H0600 = 1.

B. MOBILITY (F100 – F107) - RESIDENTS Total for F100 – F103 should = the number in Block F78, Total Residents. Algorithm to force mutual exclusivity: Test for each resident. If F100 = 1 then add 1 to F100, and go to the next resident; If F101 = 1 then add 1 to F101 and go to the next resident; If F103 = 1 then add 1 to F103 and go to the next resident; If F102 = 1 then add 1 and go to the next resident.

F100: Bedfast all or most of time: Who are bedfast all or most of the time (e.g., in bed or geriatric chair/recliner) includes bedfast with bathroom privileges. F101: In a chair all or most of time: Who depend on a chair for mobility includes those residents who can stand with assistance to pivot from bed to wheelchair or to otherwise transfer. The resident cannot take steps without extensive or constant weight-bearing support from others and is not bedfast all or most of the time. G0300A or E = 2 OR G0600C = checked. F102: Independently ambulatory: Who require no help or oversight; or help or oversight was provided only 1 or 2 times during the past 7 days. Do not include residents who use a cane, walker or crutch. G0110C1 or G0110D1 = 0 or 7 and G0110C2 or G0110D2 = 0 or 1 AND G0600A and G0600B = not checked. F103: Ambulation with assistance or assistive devices: Who require oversight, cueing, physical assistance or who use a cane, walker, or crutch. Count the use of lower leg splints, orthotics, and braces as assistive devices. G0110C1 or G0110D1 = 1, 2, or 3 AND G0110C2 or G0110D2 = 1, 2 or 3 OR G0600A and/or G0600B = checked. F104: Physically restrained: For whom restraints were used. Restraints include any manual or physical method or mechanical device, material or equipment attached or adjacent to the resident’s body in such a way that the individual cannot remove easily and it restricts freedom of movement or normal access to one’s body. Do not include devices such as braces which are used for medical/clinical reasons. P0100A through H = 1 or 2. F105: Of total number of restrained residents: On admission/ entry or reentry with an order for restraint(s). P0100A through H = 1 or 2. To complete this field use only the counts from the first assessment since the most recent admission/entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident). F106: With contractures: With a restriction of full passive range of motion of any joint due to deformity, disuse, pain, etc., includes loss of range of motion in neck, fingers, wrists, elbows, shoulders, hips, knees and ankles. G0400A and/or B = 1 or 2. F107: Of the total number with contractures, those who had a contracture(s) on admission: To complete this field use only the counts from the first assessment since the most recent admission/entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident). (neck contractures not included in MDS data).

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Appendix 1-C


C. MENTAL STATUS (F108 – F114) - RESIDENTS

D. SKIN INTEGRITY (F115 – F118) - RESIDENTS

F108: With Intellectual Disability (ID) (Mental retardation as defined at 483.45(a)) or Developmental Disability (DD): In all of the categories of intellectual or developmental disability regardless of severity, as determined by the State Mental Health or State Mental Retardation Authorities. A1550A, B through E = checked.

F115: With pressure ulcers: With localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/ or friction (exclude Stage I). M0300B1, M0300C1, M0300D1, M0300E1, M0300F1and/or M0300G1 > 0.

F109: With documented signs and symptoms of depression: With documented signs and symptoms of depression. D0200A1 through D1 = 1 for any indicator present OR D0200I1 = 1OR D0200A2 through D2 = 2 or 3 for symptom frequency OR D0300 = 05 - 27 OR D0500A1 through D1 = 1 for any indicator present OR D0500I1 = 1 OR D0500A2 through D2 = 2 or 3 for symptom frequency OR D0600 = 05 - 30.

F116: Of the total number of residents with pressure ulcers (excluding Stage 1), those who had pressure ulcers on admission/entry or reentry: M0300B2, M0300C2, M0300D2, M0300E2, M0300F2 and/or M0300G2 > 0. To complete this field, use only the counts from the first assessment since the most recent admission/entry or reentry. (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident.)

F110: With documented psychiatric diagnosis (exclude dementias and depression): With primary or secondary psychiatric diagnosis including: • Schizophrenia • Schizo-affective disorder • Schizophreniform disorder • Delusional disorder • Anxiety disorder • Psychotic mood disorders (including mania and depression with psychotic features, acute psychotic episodes, brief reactive psychosis and atypical psychosis). I5700, I5900, I5950, I6000 or I6100 = checked.

F117: Receiving preventive skin care: Receiving nonroutine skin care ordered by a physician, and/or included in the resident’s comprehensive plan of care (e.g., hydrocortisone ointment to areas of dermatitis three times a day, granulex sprays, etc.). M1200A through I = checked.

F111: Dementia: Non-Alzheimer’s Dementia (e.g., LewyBody, vascular or Multi-infarct, mixed, frontotemporal such as Pick’s disease; and dementia related to Parkinson’s or Creutzfeldt-Jakob diseases), or Alzheimer’s Disease: With a primary or secondary diagnosis of dementia or organic mental syndrome including, Non-Alzheimer’s Dementia (e.g., LewyBody, vascular or Multi-infarct, mixed, frontotemporal such as Pick’s disease; and dementia related to Parkinson’s or CreutzfeldtJakob diseases). I4200 or I4800 = checked

F119: Receiving hospice care: Who have elected or are currently receiving the hospice benefit. O0100K2 = checked.

F112: With behavioral health care needs: With one or more of the following indicator(s): wandering, verbally abusive, physically abusive, socially inappropriate/disruptive, and resistive to care. E0200A, B, or C = 1, 2, or 3 OR E0300 = 1 OR E0500A, B, or C = 1 OR E0600A, B, or C = 1 OR E0800 = 1, 2, or 3 OR E0900 = 1, 2, or 3 OR E1000A or B = 1. F113: Of the total number with behavioral healthcare needs, those having an individualized care plan to support them: With behavior symptoms who are receiving an individualized care plan/program designed to support and manage behavioral needs (as noted in F112). F114: Receiving health rehabilitative services for Mental Illness (MI) and/or ID/DD: Receiving health rehabilitative services for MI and/or ID/DD.

Fl18: With rashes: Who have rashes which may or may not be treated with any medication or special baths, etc. (e.g., may include but are not limited to antifungals, corticosteroids, emollients, diphenhydramines or scabicides).

E. SPECIAL CARE (F119 – F132) - RESIDENTS

F120: Receiving radiation therapy: Who are under a treatment plan involving radiation therapy. O0100B1 or O0100B2 = checked. F121: Receiving chemotherapy: Who are under a treatment plan involving chemotherapy. O0100A1 or O0100A2 = checked. F122: Receiving dialysis: Receiving hemodialysis or peritoneal dialysis either within the facility or offsite. O0100J1 or O0100J2 = checked. F123: Receiving intravenous therapy, IV nutrition and/ or blood transfusion: Receiving fluids, medications, all or most of their nutritional requirements and/or blood and blood products administered intravenously. K0510A2, O0100H2, or O0100I2 = checked. F124: Receiving respiratory treatment: Resceiving treatment by the use of respirators/ventilators, oxygen, IPPB or other inhalation therapy, pulmonary toilet, humidifiers, and other methods to treat conditions of the respiratory tract. This does not include residents receiving tracheostomy care or respiratory suctioning. O0100C2, O0100F2, or O0100G2 = checked.

Form CMS-672 (05/12)

5

Appendix 1-C


F125: Receiving tracheostomy care: Receiving care involved in maintenance of the airway, the stoma and surrounding skin, and dressings/coverings for the stoma. O0100E2 = checked. F126: Receiving ostomy care: Receiving care for a colostomy, ileostomy, uretrostomy, or other ostomy of the intestinal and/or urinary tract. DO NOT include tracheostomy. H0100C = checked. F127: Receiving suctioning: That require use of a mechanical device which provides suction to remove secretions from the respiratory tract via the oral cavity, nasal passage, or tracheostomy. O0100D2 = checked. (Note: O0100D2 does not include oral suctioning, so residents who receive oral suctioning will have to be counted separately.) F128: Receiving injections: That have received one or more injections within the past 7 days. (Exclude injections of Vitamin B 12.) Review residents where N0300 > 0. Omit from the count any resident whose only injection currently is B12. F129: Receiving tube feeding: Who receive all or most of their nutritional requirements via a feeding tube that delivers food/nutritional substances directly into the GI system (e.g., nasogastric tube, gastrostomy tube). K0510B2 = checked. F130: Receiving mechanically altered diets: Receiving a mechanically altered diet including pureed and/or chopped foods (not only meat). K0510C2 = checked. F131: Receiving rehabilitative services: Receiving care designed to improve functional ability provided by, or under the direction of a rehabilitation professional (physical therapist, occupational therapist, speech-language pathologist). Exclude health rehabilitation for MI and/or ID/DD. Any minutes > 0 entered in O0400. F132: Assistive devices with eating: Who are using devices to maintain independence and to provide comfort when eating (i.e., plates with guards, large handled flatware, large handle mugs, extend hand flatware, etc.). O0500C or H > 0.

F. MEDICATIONS (F133 – F139) - RESIDENTS F133: Receiving psychoactive medications: That receive medications classified as antipsychotics, anxiolytics, antidepressants, and/or hypnotics. Days entered > 0 for N0410A, B, C or D. Use the following lists to assist you in determining the number of residents receiving psychoactive medications. These lists are not meant to be all inclusive; therefore, a resident receiving a psychoactive medication not on this list, should be counted under F133 and any other medication category that applies: F134, F135, F136, and/or F137.

F134: Antipsychotic medications: Days entered for N0410A > 0 • Clozapine • Haloperidol • Haloperiodal Deconate • Droperidol • Loxapine • Thioridazine • Molindone • Theothixene • Zyprexa • Pimozide • Fluphenazine Deconate • Fluphenazine • Quetiapine • Risperidone • Mesoridazine • Promazine • Trifluoperazine • Chlorprothixene • Chlorpromazine • Acetophenazine • Perphenazine F135: Antianxiety medications (anxiolytics): Days entered for N0410B > 0 • Lorazepam • Oxazepam • Prazepam • Diazepam • Clonazepam • Hydroxyzine • Chlordiazepoxide • Halazepam • Alprazolam F136: Antidepressant medications: Days entered for N0410C > 0 • Aripiprazole • Amoxapine • Nortriptyline • Wellbutrin • Trazodone • Venlafaxine • Amtriptyline • Lithium • Maprotiline • Isocarboxazid • Phenelzine • Serzone • Desipramine • Tranylcypromine Paroxetine • Fluoxetine • Sertraline • Doxepin • Imipramine • Protriptyline

Form CMS-672 (05/12)

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Appendix 1-C


F137: Hypnotic medications: Days entered for N0410D > 0 • Flurazepam • Quazepam • Estazolam • Temazepam • Triazolam • Zolpidem F138: Receiving antibiotics: Receiving antibacterial sulfonamides, antibiotics, etc., either for prophylaxis or treatment. Days entered for N0410F > 0. F139: On a pain management program: With a specific plan for control of difficult to manage or intractable pain, which may include self medication pumps or regularly scheduled administration of medication alone or in combination with nonmedication interventions (e.g., massages heat/cold, biofeedback, etc.). J0100A, B, or C = 1.

F142: Who use non-oral communication: Who communicate via non-oral methods, including, picture boards, computers, etc. A1100B, Preferred Language (e.g. American Sign Language). F143: Who have advance directives: Who have advance directives, such as Physician’s Orders for Life-Sustaining Treatment (POLST), a living will or durable power of attorney for health care, recognized under state law and relating to the provisions of care when the individual is incapacitated. F144: Received influenza immunization: Who received the influenza immunization within the last 12 months. O0250A = 1. F145: Received pneumococcal vaccine: Who received the pneumococcal vaccine. O0300A = 1. LEAVE BLANK (F146-F148) – To Be Completed By Survey Team

G. OTHER RESIDENT CHARACTERISTICS (F140 – F145)

F146: Ombudsman notice: Indicate whether or not the State Ombudsman was notified prior to the survey.

F140: With unplanned significant weight loss/gain: Who have experienced unplanned weight loss/gain of > 5% in one month or > 10% over six months. K0300 or K0310 = 2.

F147: Ombudsman presence: Indicate whether or not the State Ombudsman was present at any time during the survey.

F141: Who do not communicate in the dominant language at the facility: Who do not speak or understand the dominant language spoken in the facility and need or want an interpreter to communicate. A1100A = 1.

F148: Medication error rate: Calculate and enter the medication error percentage of the facility.

Form CMS-672 (05/12)

7

Appendix 1-C

surveyor assigned

Resident Room

Resident Number

Phase 1 ____________________

Phase 2 ____________________ Individual Interview (I) ______ Family Interview (F) ________

Closed Record (CL) _________

Comprehensive (C) __________ total sample:_______________

Form CMS-802 (04/12)

Abuse/Neglect Clean/Comfort/Homelike moderate/severe pain (Constant or Frequent) Hi-Risk pressure Ulcer (stage 2-4) New/Worsened pressure Ulcers (stage 2-4) physical Restraints

2 3 4 5 6 7 8 9

Behavior symptoms affecting others/Self Depressive symptoms

Admittance/Transfer/Discharge MI (Non-Dementia) or ID/DD Language/Communication Vision/Hearing/Other Assistive Devices

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

Appendix 1-C

Specialized Rehab Services (OT, PT, Speech, etc.)

Infections

Hydration/Swallowing/Oral Health

Specialty Care (Tube Feeding, Central Lines, Ventilators, O2)

ROM/Contractures/Positioning

Dialysis

Hospice

Need for increased aDl Help

excessive Weight loss/Gain

lo-Risk Resident lose Bowel/Bladder Control

indwelling Urinary Catheter

Urinary tract infection

psychoactive meds with absence of Condition antianxiety/Hypnotic medication Use

Falls including Falls with major injury

Social Services

1

Self-Determination/Accommodation of Needs

Privacy/Dignity Issues

Resident Name

Closed Record/Comprehensive/Focused

Focused Review (FO) ________

Interview: Individual/Family

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Offsite _____ Phase I _____ Phase 2 _____ Provider # __________________

RosteR/sample matRix


ROSTER/SAMPLE MATRIX INSTRUCTIONS FOR PROVIDERS (use with Form CMS-802)

The Roster/Sample Matrix form (CMS-802 ) is used to list all current residents (including residents on bed-hold) and to note pertinent care categories. The facility completes the resident name, resident room, and columns 6–30, which are described below. Columns 1–5 and blank columns 31–34 are for Surveyor Use Only. For the purpose of completing this form the terms: “facility” means certified beds (i.e., Medicare and/or Medicaid certified beds) and “residents” means residents in certified beds regardless of payer source. There is no federal requirement to automate the CMS-802 form. A facility may use its MDS data to assist in completing the fields; however, all conditions noted on this form that are not identified on the MDS must be entered manually. Facilities should ensure that MDS information is not simply copied over into the form. All information entered by computer should be verified by a staff member knowledgeable about the resident population. Information must be reflective of all residents as of the day of survey. Following the definition of certain fields, related MDS item(s) are noted. Although the MDS item(s) are noted for some fields, the field itself may need to be completed differently or manually to reflect the current status of all residents as of the day of survey. The MDS items are provided only as a reference point. The form is to be completed using the time frames and other specific instructions noted below.

For each resident mark all columns that are pertinent.

1. – 5. Surveyor Use Only 6. Moderate/Severe Pain (constant or frequent): Needs pain medication, comfort measures or is on a pain management program. J0100A, B, or C = 1 OR J0300 = 1 or 9 OR J0400 = 1, 2, or 3 OR J0500A, B = 1 OR J0600A = 01–10 OR J0600B = 1, 2, 3, or 4 OR J0700 =1 OR J0800A, B, C, or D = checked OR J0850 = 1, 2, or 3. 7. Hi-Risk Pressure Ulcers (Stage 2-4): Has stage 2, 3 or 4 pressure ulcer(s) and/or unstageable pressure ulcer(s); M0300B1, M0300C1, M0300D1, M0300E1, M0300F1, or M0300G1 > 0. 8. New/Worsened Pressure Ulcers (Stage 2-4): Has stage 2, 3 or 4 pressure ulcer(s) that are new or worsened. M0800A > 0 and M0800A ≤ M0300B1 OR M0800B > 0 and M0800B ≤ M0300C1 OR M0800C > 0 and M0800C ≤ M0300D1. 9. Physical Restraints: Has a physical restraint. Enter N for non-side rail devices and S for side rails. Enter the appropriate letter for all possible responses. P0100A = 1 or 2, enter S; P0100B, C, D, E, F, G, or H = 1 or 2, enter N. 10. Falls and/or Falls with Major Injury: Has fallen within the past 30 days and/or has fallen within the past 180 days and incurred a major injury. Enter F if fall without injury or fracture; Enter Fx if resident has had a fall with major injury (including fracture). Enter the appropriate letter for all possible responses. I3900 or I4000 = checked, enter Fx. J1700A or B = 1, enter F. J1700C = 1, enter Fx. J1800 = 1, enter F. J1900A and/or J1900B = 1 or 2, enter F. J1900C = 1 or 2, enter Fx. 11. Psychoactive Medications with Absence of Condition: Receives any psychoactive medications but has no psychiatric condition. If N0410A through D = ≥ 1 AND I5700 – I6100 = not checked, and/or I8000 = no psychiatric/mood diagnoses (i.e., no ICD-9 codes between 295-299 inclusive).

12. Antianxiety/Hypnotic Medications: Receives anxiolytics and/or hypnotics. Enter A for anti-anxiety and H for hypnotic. Enter the appropriate letter for all possible responses. N04010B = ≥ 1, enter A. N0410D = ≥ 1, enter H. 13. Behavioral Symptoms Affecting Others or Self: Has behavioral health care needs. E0200A, B, or C = 1, 2 or 3 OR E0500A, B, or C = 1 OR E0600A, B, or C = 1 OR E0800 = 1, 2, or 3 OR E0900 = 1, 2, or 3 OR E1000A and/or B = 1. 14. Depressive Symptoms: Has symptoms of depression. I5800 or I5900 = checked OR D0300 = 05 – 27 OR D0600 = 05 – 30 OR D0350 or D0650 = 1. 15. Urinary Tract Infection: I2300 = checked. 16. Indwelling Urinary Catheter: H0100A = checked. 17. Lo-risk Residents Who Lose Bowel/Bladder Control– Incontinence/Toileting Programs: Incontinent of bladder/ bowel, enter I. If the resident is on a bladder/bowel toileting program, enter T. Enter the appropriate letter for all possible responses. H0200A = 1 or H0200C = 1, enter T. H0300 = 1, 2, or 3, enter I. H0400 = 2 or 3, enter I. H0500 = 1, enter T. 18. Excessive Weight Loss/Gain: Has had an unintended weight loss/gain of >5% in one month or >10% in six months, or is at nutritional risk. K0300 or K0310 = 2. 19. Need for Increased ADL Help: Has shown a decline in ADL areas. 20. Hospice: Has elected or is currently receiving hospice care. O0100K2 = checked. 21. Dialysis: Is receiving hemo- or peritoneal dialysis either within the facility or offsite. O0100J1 or O0100J2 = checked.

Form CMS-802P (04/12)

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Appendix 1-C

22. Admission/Transfer/Discharge: Enter the appropriate letter in this column if the resident was admitted within the past 30 days or is scheduled to be transferred or discharged within the next 30 days. Enter A for an initial admission or for the first assessment after initial admission/entry or reentry after discharge without expectation of return. Enter T for a transfer. Enter D for a discharge. Enter the appropriate letter for all possible responses. A0310E = 1, enter A. A0310F = 11, enter T. A0310F = 10 or 12, enter D. If today’s date minus A1600, (Entry Date), is less than or equal to 30 days, enter A. 23. Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental retardation as defined at 42 CFR 483.45(a)): Resident has a diagnosis of MI or ID/DD. Enter MI for mental illness not classified as dementia, ID for intellectual disability or DD for developmental disability. A1500 =1 and A1510A = checked, enter MI. A1510B = checked, enter ID. A1550A, B, C, D, or E = checked, manually enter ID and/or DD as appropriate. I5700, I5800, I5900, I5950, I6000, I16100 = checked, enter MI. I8000 psychiatric/ mood disorder diagnosis listed, enter MI. 24. Language/Communication: Does not speak or understand the dominant language spoken in the facility and needs or wants an interpreter to communicate, or exhibits difficulty communicating his/her needs. A1100A = 1, enter L. If a resident uses American Sign Language, consider this an alternate language and enter L. If B0600 = 1 or 2 OR B0700 = 2 or 3 OR B0800 = 2 or 3, enter C.

impairment, and D for use of devices (glasses or hearing aids). B0200 = 2 or 3, enter H and/or B0300 = 1, enter D. B1000 = 2, 3, or 4, enter V and/or B1200 = 1, enter D.

Other Assistive Devices: Uses special devices to assist with eating or mobility (e.g., tables, utensils, hand splints, canes, crutches, etc.) and other assistive devices. O0500C = > 1 OR G0600A through D = checked, enter D.

26. ROM/Contractures/Positioning: Has functional limitations in range of motion. G0400A and/or B = 1 or 2 OR M1200C = checked. 27. Special Care (Tube Feeding, Central Lines, Ventilators, O2 ): Has special treatments. K0510B2 = checked OR O0100C2 or F2 = checked. 28. Hydration/Swallowing/Oral Health: Has nutrition, hydration or oral health issues. K0510A2, C2, D2 = checked, enter H for hydration. K0100A-D = checked, enter S for swallowing. L0200A-F = checked, enter O for oral health. 29. Infections: Has infections or infectious disease. I1700 – I2500 = checked OR I8000 = infection diagnosis (i.e. ICD-9 codes between 001-139 inclusive) OR M1040A = checked OR O0100M2 = checked. 30. Specialized Rehabilitation (PT, OT, recreational, respiratory, psychological, speech, restorative nursing) or other Services: O0400A, B, C, D, E, F = minutes > 0 OR O0500 A-J = > 1.

25. Vision/Hearing/Other Assistive Devices: Has significant impairment of vision or hearing, or uses devices to aid vision or hearing. Enter V for visual impairment, H for hearing

Form CMS-802P (04/12)

2

Appendix 1-C


ROSTER/SAMPLE MATRIX INSTRUCTIONS FOR SURVEYORS (use with Form CMS-802)

The Roster/Sample Matrix form (CMS-802) is used to list all current residents (including residents on bed-hold) and to note pertinent care categories. The facility completes the resident name, resident room, and columns 6–30, all remaining columns are for Surveyor Use Only. For the purpose of completing this form the terms: “facility” means certified beds (i.e., Medicare and/or Medicaid certified beds) and “residents” means residents in certified beds regardless of payer source. The Roster/Sample Matrix is a tool for selecting the resident sample and may be used for recording information acquired during the tour. When using the form to identify the resident sample, indicate by a check whether this CMS-802 is being used for the sample from Offsite, Phase 1 or Phase 2. The horizontal rows list residents chosen for review (or residents encountered during the tour) and indicate the characteristics/concerns identified for each resident. Use the resident sample selection table in Appendix P of the State Operations Manual (SOM) to identify the number of residents required in the sample. Mark the Interview: Individual/Family column with ‘I’ for each resident receiving an interview or with ‘F’ for any non-interviewable resident receiving a family interview and/or staff observation. Mark the Closed Record/Comprehensive/Focused Review column with ‘CL’ for a closed record review, ‘C’ for a resident chosen for a comprehensive review or ‘FO’ for a resident chosen for a focused review. Use the vertical columns numbered 1 through 30 for each resident, as appropriate. During each portion of the survey (Offsite, Phase 1, Phase 2) highlight the vertical columns for each resident potential concern identified.

Resident Number: Number each line sequentially down the rows continuing the numbering sequence for any additional pages needed. These numbers may be used as resident identifiers for the sample. Resident Name: List the name of the resident.

Surveyor Assigned: List initials or surveyor number of surveyor assigned to review each resident. Resident Room: Identify room # for the resident.

Highlight each column that is an area of concern. For each resident entered on the roster/sample matrix, check all columns that pertain to the resident according to the Offsite and Sample Selection Tasks of the Survey. 1. Privacy/Dignity: resident’s right to privacy, (accommodations, written and telephone communication, visitation, personal care, etc.) or concerns that the facility does not maintain or enhance resident’s dignity. 2. Social Services: medically related or other social services; e.g., interpersonal relationships, grief, clothing, etc. 3. Self-Determination/Accommodation of Needs: resident’s ability to exercise their rights as citizens; freedom from coercion, discrimination or reprisal; self-determination and participation; choice of care and schedule, etc. 4. Abuse/Neglect: resident abuse, neglect or misappropriation of resident property or how the facility responds to allegations of abuse, neglect or misappropriation of resident property. 5. Clean/Comfortable/Homelike: facility’s environment including cleanliness, lighting levels, temperature, comfortable sound levels, or homelike environment and the resident’s ability to use their personal belongings and individualize their room to the extent possible. 6. Moderate/Severe Pain (constant or frequent): timely assessment and intervention with residents needing pain medications or measures to provide comfort, including nonmedication interventions, or who are on a pain management program.

7. Hi-Risk Pressure Ulcers (Stage 2-4): risk assessment, clinical assessment, treatment, monitoring, evaluation, and prevention of pressure ulcers; or other necessary skin care. Concerns regarding residents identified as having stage 2, 3, or 4 pressure ulcers or unstageable pressure ulcers. 8. New/Worsened Pressure Ulcers (Stage 2-4): risk assessment, clinical assessment, treatment, monitoring, evaluation, and prevention of pressure ulcers; or other necessary skin care. Concerns regarding residents identified as having new or worsened stage 2, 3, or 4 pressure ulcers. 9. Physical Restraints: residents identified as physically restrained, including side rails. 10. Falls and/or Falls with Major Injury: residents that have fallen within the past 30 days and/or have fallen within the past 180 days and incurred a major injury. 11. Psychoactive Medications with Absence of Condition: residents receiving any psychoactive medications in the absence of a psychiatric or mood related diagnoses or conditions. 12. Antianxiety/Hypnotic Medications: residents receiving anxiolytics and/or hypnotics. 13. Behavioral Symptoms Affecting Others or Self: residents with behavioral health care needs; e.g., verbal or physical outbursts, withdrawing/isolation, etc.

Form CMS-802S (04/12)

1

Appendix 1-C

14. Depressive Symptoms: residents with symptoms of depression with or without antidepressant therapy. 15. Urinary Tract Infections (UTl): residents having a UTI. 16. Indwelling Urinary Catheter: residents with an indwelling urinary catheter. 17. Lo-Risk Residents Who Lose Bowel/Bladder Control– Incontinence/Toileting Programs: residents with bowel and/or bladder incontinence and/or on a toileting program. 18. Excessive Weight Loss/Gain: residents with an unintended weight loss/gain of >5% in one month or >10% in six months, or is at nutritional risk. 19. Need for Increased ADL Help: concerns about residents identified as having ADL decline. 20. Hospice: residents who have elected or are receiving hospice care. 21. Dialysis: care and coordination of services for residents receiving hemo- or peritoneal dialysis either within the facility or offsite. 22. Admission/Transfer/Discharge: care/treatment for residents admitted within the past 30 days or is scheduled to be transferred or discharged within the next 30 days. Including but not limited to, resident preparation and procedures for transfer or discharge, such as:

•

•

25. Vision/Hearing/Other Assistive Devices: residents with visual or hearing impairments to function at their highest practicable level, including those residents who have glasses or hearing aids. Include residents needing other special devices to assist with eating or mobility. 26. ROM/Contractures/Positioning: occurrence, prevention or treatment of contractures, staff provision or lack of provision of appropriate application/use of splints, ROM exercises, or positioning. Concerns about residents identified as having a decline in ROM. 27. Special Care (Tube Feeding, Central Lines, Ventilators, O2 , etc.): residents receiving nutrition via a feeding tube; residents with tracheostomies or ventilators; residents needing suctioning, and/or residents receiving oxygen, IPPB or other inhalation therapy, pulmonary toilet, humidifiers, etc., or have special care areas, (e.g., prosthesis, ostomy, injection, IV’s, including total parenteral nutrition, etc.). 28. Hydration/Swallowing/Oral Health: residents, who show signs or symptoms or have risk factors for dehydration. Residents with chewing or swallowing problems. Provision or lack of provision for oral health care for residents. 29. Infections: residents receiving antibiotics or have an infectious disease or residents under strict isolation precautions.

30. Specialized Rehabilitation: provision or lack of provision of specialized rehabilitative services including, but not Relevant clinical and psychosocial information provided limited to: to next care providers, (i.e., Home Health, Hospital, Primary Care Provider, etc.) and, • Physical therapy

Appropriate arrangements for necessary services to meet • Speech/language pathology resident needs upon transfer and/or discharge. • Occupational therapy 23. Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) and/or Developmental Disability (DD). • Nursing restorative programs (Mental retardation as defined at 42 CFR 483.45(a)): • Health rehabilitative services for MI and/or ID/DD care and treatment of residents with a diagnosis of MI, ID and/or DD. 31–34. Note any other concerns; e.g., residents who are 24. Language/Communication: residents with communication comatose, have delirium, have special skin care needs other challenges to communicate at their highest practicable level, than pressure ulcers, fecal impaction or observed to spend or residents identified as speaking and/or understanding most of their time in bed or a chair, such as a geriatric chair, other than the dominant language of the facility, or using recliner, etc. If during offsite preparation, concerns arise non-oral communication such as, picture boards, computers, about the accuracy of the MDS information, enter MDS American Sign Language, etc. accuracy as a concern.

Form CMS-802S (04/12)

2

Appendix 1-C

Form Approved OMB No. 0938-0086


INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (CMS-1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by titles V, XVIII, XIX, and XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the Secretary of appropriate State agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the Secretary or appropriate State agency to enter into an agreement or contract with any such institution or in termination of existing agreements.

SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All title XX providers must complete part II (a) and (b) of this form. Only those title XX providers rendering medical, remedial, or health related homemaker services must complete parts II and III. Title V providers must complete parts II and Ill.

General Instructions For definitions, procedures and requirements, refer to the appropriate Regulations: Title V – Title XVIII – Title XIX – Title XX –

42CFR 42CFR 42CFR 45CFR

51a.144 420.200 – 206 455.100 – 106 228.72 – 73

Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet. Return the original and second and third copies to the State agency; retain the first copy for your files. This form is to be completed annually. Any substantial delay in completing the form should be reported to the State survey agency.

Controlling interest is defined as the operational direction or management of a disclosing entity which may be maintained by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e., joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV – VII - Changes in Provider Status

DETAILED INSTRUCTIONS These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT.

Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the owning partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 percent or more financial interest in the facility or in an owning corporation, or any change of ownership. For Items IV – VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued.

Item I (a) Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. (b) For Regional Office Use Only. If the yes box is checked for item VII, the Regional Office will enter the 5-digit number assigned by CMS to chain organizations. Item II - Self-explanatory. Item III - List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related services under the social services program. Indirect ownership interest is defined as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A's interest equates to an 8 percent indirect ownership and must be reported.

Item IV - (a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in the appropriate space. Item V - If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VI - If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate. Item VII - A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health agencies, are not considered to be chain affiliates. Item VIII - If yes, list the actual number of beds in the facility now and the previous number.

Appendix 1-C


Form Approved OMB NO. 0938-0086

DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT I. Identifying Information (a) Name of Entity

Provider No.

D/B/A

Vendor No.

City, County, State

Street Address

Telephone No.

Zip Code

■■■■■ LB1 II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and addresses of individuals or corporations under Remarks on page 2. Identify each item number to be continued. (b) (To be completed by CMS Regional Office)

Chain Affiliate No.

(a) Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by titles XVIII, XIX, or XX? ■ Yes ■ No LB2 (b) Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by titles XVIII, XIX, or XX?

■ Yes

■ No

LB3

(c) Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)

■ Yes

■ No

LB4

Ill. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks.

Address

Name

EIN LB5

(b) Type of Entity:

■ Sole Proprietorship ■ Unincorporated Associations

■ Partnership ■ Other (Specify)

■ Corporation

LB6

(c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks. Check appropriate box for each of the following questions: (d) Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership or members of Board of Directors.) If yes, list names, addresses of individuals and provider numbers. ■ Yes ■ No LB7 Name

Address

CMS-1513 (5/86)

Provider Number

Page 1

Appendix 1-C

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES IV. (a) Has there been a change in ownership or control within the last year? If yes, give date _____________

Form Approved OMB NO. 0938-0086

■ Yes

■ No

LB8

(b) Do you anticipate any change of ownership or control within the year? If yes, when? _______________

■ Yes

■ No

LB9

(c) Do you anticipate filing for bankruptcy within the year? If yes, when? _______________

■ Yes

■ No

LB10

■ Yes

■ No

LB11

■ Yes

■ No

LB12

■ Yes

■ No

LB13

V. Is this facility operated by a management company, or leased in whole or part by another organization? If yes, give date of change in operations ____________ VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year? VII. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN) Name EIN #

Address LB14

VII. (b) If the answer to Question VII.a. is No, was the facility ever affiliated with a chain? (If yes, list Name, Address of Corporation, and EIN) Name EIN #

■ Yes

■ No

LB18

Address LB19 VIII. Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater, within the last 2 years?

■ Yes If yes, give year of change ____________ Current beds _____________ LB16

■ No

LB15

Prior beds _____________ LB17

WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. Name of Authorized Representative (Typed)

Title

Signature

Date

Remarks

CMS-1513 (5/86)

Page 2

Appendix 1-C

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0086. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.

Appendix 1-C

Appendix 1-D

Appendix 1-D

Appendix 1-D

Appendix 1-D

[THIS PAGE INTENTIONALLY LEFT BLANK]

Life Safety Codes

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 2 - LIFE SAFETY CODES Life Safety Codes - This section can be used as a reference for possible K-tag citations and includes checklists for self-assessment. SECTION K-Tags and Definitions Life Safety Code Check List Fire Safety Survey Worksheet for Rating Residents (Form CMS-2786M) Fire Safety Survey Report Medicare-Medicaid (Form CMS-2786R) Fire Safety Survey Report Short Form Medicare-Medicaid (Form CMS-2786S) Fire/Smoke Zone Evaluation Worksheet for Health Care Facilities (Form CMS-2786T) Fire Safety Survey Report - Intermediate Care Facilities for the Mentally Retarded (Small) (Form CMS-2786V) Fire Safety Survey Report - Intermediate Care Facilities for the Mentally Retarded (Large) (Form CMS-2786W)

Updated March 2015

PAGE # 2.2-2.3 2.4-2.6 Appendix 2-A Appendix 2-B Appendix 2-C Appendix 2-D Appendix 2-E Appendix 2-F

K-TAGS AND DEFINITIONS K011 K012 K014 K015 K016 K017 K018 K019 K020 K021 K022 K023 K024 K025 K027 K028 K029 K031 K032 K033 K034 K036 K037 K038 K039 K040 K041 K042 K043 K044 K045 K046 K047 K048 K049 K050 K051 K052 K053 K054 K055 K056 K059 K060 K061

Common Wall Construction Type Interior Finish for Corridors Interior Finish for Rooms Newly Installed Floor Finish Corridors Separated with Fire Walls Construction of Doors Vision Panels in Corridor Walls Vertical Openings - Fire Walls Doors in Fire Separation Walls Enclosure Doors Serving Exits Smoke Barriers (at least 2 Smoke compartments) Smoke Compartments Smoke Barriers (1/2 Hr Fire Resistance Rating) Doors in Smoke Barriers (20 Min Fire Protection) Doors in Smoke Barriers (34 Inches Wide) Hazardous Areas Separated by Construction Laboratories Employing Flammable Materials Two Acceptable Exits Provided on Each Floor Exit Components - Fire Walls Stairways and Smoke proof Towers Travel Distances to Exits Exit does not have Dead End Exceeding 30 feet Exit Accessible at all Times Width of Aisles or Corridors Exit Access Doors are Swinging Type Sleeping Rooms have Access to Exits At Least Two Exits Keyless Egress Horizontal Exits Illumination of Means of Egress Emergency Lighting One Hour Duration Exit Signs Display Continuous Illumination Written Plan - Fire Drill Evacuation Plan Posted Fire Drills Held at Unexpected Times Fire Alarm Sys to Provide Effective Warning Fire Alarm Tested Monthly Automatic Smoke Detection Sys All Smoke Detectors Inspected and Tested Patient Sleeping Rooms - Outside Windows Auto Sprinkle System of Standard Approved Type Automatic Sprinkler - Water Flow Devices Automatic Sprinkler - Central Fire Alarm Automatic Sprinkler - Main Control Valve 2.2

K062 K063 K064 K065 K066 K067 K068 K069 K070 K071 K072 K073 K074 K075 K076 K077 K078 K080 K081 K082 K083 K103 K104 K105 K106 K107 K108 K109 K118 K144 K147

Automatic Sprinkler - Maintenance Automatic Sprinkler - Water Supply Portable Fire Extinguishers Maintenance of Fire Extinguishers Smoking Regulations are Adopted Air Conditioning and Ventilating Equipment Combustion and Ventilation Air Commercial Cooking Equip. Meets Requirements Fuel Burning Space Heaters Linen and Trash Chutes No Objects Placed to Obstruct Exits or Visibility Nothing of Explosive or Flammable Character Used Flame Retardant Curtains Wastebaskets in Patients rooms are Non-Combustible Nonflammable Medical Gas Systems Medical Gas Systems Anesthetizing Areas and Rooms for Storage Hazardous Areas - Sprinklers Automatic Fire Detection Devices Installed Patients Rooms Separated by Construction Fire Resist Fire Department Response Time is Adequate Interior Walls of Non-Combustible Materials Penetrations of Smoke Barriers Life Support Systems - Egress Life Support Systems - Electrical Require Alarm and Detection Systems Alarms, Emergency Communications Systems Automatic Smoke Detector Elevators and Conveyors Generator Inspection & Load Testing Electrical Wiring & Equipment

2.3

LIFE SAFETY CODE CHECK LIST Mechanical Rooms

1. High/low ventilation and combustion ductwork. 2. All ceiling and wall penetration sealed with fire rated caulking. 3. Doors - Self-closing and latch automatically. 4. Not used for storage. 5. Ceiling installed completely. 6. Fire dampers installed at duct penetrations of walls. 7. No grills or vents in doors. 8. Separated with one-hour fire rated construction to roof deck.

Kitchen

1. Doors - Self-closing and latch automatically. 2. Fusible links - On all doors held open.

Laundry

1. Dryers enclosed. 2. High/low ventilation and combustion ductwork behind dryers. 3. Doors - Self-closing and latch automatically.

Soiled Linen Rooms

1. Doors - Self-closing and latch automatically. 2. Soiled linen receptacle capacity greater than 32 gallons - room shall be separated by one-hour fire rated construction, self-closing automaticallylatching door, and sprinklered.

Oxygen Storage

1. Vented to outside. 2. Storage greater than 3000 cu.ft. - Room separated by one-hour fire rated construction and self-closing automatically-latching door.

Storage Rooms

1. 50 to 100 sq.ft. - Separated by one-hour fire rated construction and selfclosing automatically-latching door. 2. Greater than 100 sq.ft. - Separated by one-hour fire rated construction, selfclosing automatically-latching door, and sprinklered.

Patient Rooms

1. Window or outside door. 2. Window and cubicle curtains flame retardant. 3. No furnishings and decorations of highly-flammable character. 4. Corridor door closes and latches without impediment, gaps, and against jamb. 5. No portable space heaters. 6. Class A or B flame spread rating.

Corridors and Exitways

1. Class A or B rating - Walls and ceiling. 2. Continuously maintained free of all obstructions or impediments. 3. Handrails secure and without damage. 4. No items on wall extending out beyond the handrail below seven feet.

Stairways

1. One hour fire rated construction - Up to three stories. Four stories or more - Two hour fire rated construction. 2. All penetrations sealed. 3. Self-closing automatically-latching doors. 4. No storage.

Exit Lights

1. Illuminated. 2. Signs located to show direction to exit from any point in a corridor - Two directions.

2.4

3. Illuminated by emergency power within ten seconds of loss of normal power. Alcohol-based Hand Rub

1. The corridor is at least six feet wide. 2. The maximum individual fluid dispenser capacity shall be1.2 liters (2 liters in suites of rooms). 3. The dispensers shall have a minimum spacing of four feet from each other. 4. Not more than ten gallons are used in a single smoke compartment outside a storage cabinet. 5. Dispensers are not installed over or adjacent to an ignition source. 6. If the floor is carpeted, the building is fully sprinklered.

Smoking Regulations

1. Smoking shall be prohibited in any room, ward or compartment where flammable liquids, combustible gases or oxygen is used or stored in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. 2. Smoking by patients classified as not responsible shall be prohibited, except when under direct supervision. 3. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. 4. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be available to all areas where smoking is permitted.

Electrical

1. All switch and outlet covers installed. None damaged. 2. Panels installed on all electrical equipment. 3. Three foot clearance on all four sides of main electrical panels. 4. Circuit breaker panels labeled. 5. Ground Fault Circuit Interrupters installed in all outlets - Within six feet of any sink, bathrooms, garages, electrical vehicle charging systems, elevators, wet areas (utility rooms-outlets serving counter tops, janitor closets, dish washing rooms), kitchen (outlets serving counter tops), roof tops, and outdoor outlets.

Kitchen Range Hood Fire Suppression System

1. Inspected monthly - Grease buildup on nozzles and ductwork. 2. Inspected annually - Licensed individual. 3. Eight inch shield installed between fryer and stove - on tallest appliance not required if fryer is sixteen inches from stove.

Fire Extinguishers

1. Inspect monthly - Proper location, not obstructed, operating instructions on nameplate facing outward, safety seal not broken, unit is full, obvious physical damage, pressure gauge reading in operable range - Document inspections. 2. Annual inspection by licensed individual.

Fire Alarm System

1. Annual inspection by licensed individual - Report available. 2. Semi-annually - Visual inspection of fire alarm components.

Single Station Smoke Detectors

1. Inspect and test according to manufacturer's instructions; at least monthly. 2. Replace batteries according to manufacturer' instructions; 3. Document testing and maintenance;

Sprinkler System

1. Annual inspection by a Licensed individual - Report available. 2. Test tamper and flow switches quarterly - Document. 3. Storage eighteen inches below sprinkler head deflector.

2.5

4. Sprinkler heads free of lint and corrosion, pipes not used for clothes hangers. 5. Sprinkler heads not obstructed. Emergency Generator

1. Annual inspection by licensed individual - Report available. 2. Maintenance scheduled per manufacturer's requirement - Keep log. 3. Monthly recordings of battery electrolyte specific gravity - lead acid batteries- all others weekly recording of battery voltage. 4. Monthly load test (30%) for thirty minutes - Record time and voltage. 5. Switch to emergency power within ten seconds. 6. Outlets connected to emergency power identified by distinctive color unless total building on generator.

Fire Drills

1. A drill for each shift during each quarter. 2. At unannounced times, not during shift change, not all on same day, 90% attendance. 3. Do not mix drills and inservices. 4. Document each drill with time, date, shift, procedures used, reactions of staff, and signatures of staff participating.

Corridor, Fire, and Smoke Barrier walls Exits

All penetrations sealed with fire rated caulking or foam. Check behind service personnel. Maximum half-inch gap around penetrations. 1. Doors open without impediment. 2. Discharge path smooth hard surface. Maximum half-inch elevation between surfaces. If higher, 20:1 ramp. 3. Dual bulb outside light fixture.

In General

Facility shall be maintained according to all applicable codes. Any renovations or alterations to the facility shall be submitted to OLTC for approval. rev. 05/22/09

2.6



FIRE SAFETY SURVEY — 2000 LIFE SAFETY CODE

F-1

Worksheet for Rating Residents

SIDE 1

Complete one Worksheet for each resident. Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance.

Resident’s Name

Rater

Facility

Date

Write any explanatory remarks you may wish to make here:

Surveyor (Signature)

Title

Date

Title

Date

Surveyor ID Fire Authority Official (Signature)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-2786M (03/04) Previous Versions Obsolete

Appendix 2-A

Page 1



F-1

COMPLETE OTHER SIDE FIRST Worksheet for Rating Residents

SIDE 2

Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance.

F-1A Rating the Resident on the Risk Factors Rating the resident on each of the factors below by checking the one circle in each risk factor that best describes the resident. For the first six factors, write the scores for the circles you checked in the appropriate score boxes in the far right column. For "response to fire drills," write the three checked scores in the large circles. Write the sum of the 3 scores in the large box on the right.

SCORE BOXES I. Risk of Resistance

(Check only one) II. Impaired Mobility

(Check only one)

Minimal Risk

score = 0 SelfStarting

IV. Need for Extra Help

(Check only one) V. Response to Instructions

(Check only one) VI. Waking Response to Alarm (Check only one) VII. Response to Fire Drills

(Without Guidance or Advice from Staff)

Slow

score = 3

Needs Limited Assistance from 2 Staff

score = 1 Response Probable

score = 20

score = 20 Needs Full Assistance from 2 Staff score = 40 Requires Considerable Attention/May Not Respond

score = 3

score = 10

Response Not Probable

score = 0 Initiates and Completes Evacuation Promptly

score = 6

score = 30 Requires Supervision

Needs Full Assistance or Very Slow

Totally Impaired

score = 6

score = 0 Follows Instructions

score = 20 Needs Limited Assistance

Partially Impaired

score = 0 Needs at Most One Staff

Risk of Strong Resistance

score = 6

score = 0

No Significant III. Impaired Consciousness Risk

(Check only one)

Risk of Mild Resistance

score = 6 Yes

No

score = 0 Chooses and Completes Back-up Strategy

Yes

Stays at Designated Location

Yes

score = 8 No

score = 0

+ score = 4

No

score = 0

+ score = 6

F-1B Finding the ResIdent’s Overall Need For AssIstance Compare the numbers in the 7 score boxes you have filled in. Take the one highest score from the score boxes and write it in this box: Form CMS-2786M (03/04) Previous Versions Obsolete

SUM OF THESE THREE ITEMS

EVACUATION ASSISTANCE SCORE Page 2

Appendix 2-A

FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) PROVIDER NUMBER

FACILITY NAME

SURVEY DATE

K1

K6

* K4

K3

DATE OF PLAN APPROVAL

MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________ NUMBER OF THIS BUILDING

LSC FORM INDICATOR

____________

12 13

14 15

ASC Form 2000 EXISTING 2000 NEW

SMALL

(16 BEDS OR LESS)

K8:

1 PROMPT 2 SLOW 3 IMPRACTICAL

LARGE

K8:

ICF/MR Form 2786V, W, X 2000 EXISTING 2786V, W, X 2000 NEW

16 17

SELECT NUMBER OF FORM USED FROM ABOVE

*K9:


ENTER E – SCORE HERE

(Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.) K29:


APARTMENT HOUSE

K8: * K7

BUILDING WING FLOOR APARTMENT UNIT

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

Health Care Form 2786R 2000 EXISTING 2786R 2000 NEW

2786U 2786U

A B C D

K5:

K56:

e.g. 2.5

FACILITY MEETS LSC BASED ON (Check all that apply) A1. (COMP. WITH ALL PROVISIONS)

A2.

A3.

(ACCEPTABLE POC)

FACILITY DOES NOT MEET LSC B.

A4.

(WAIVERS)

A5. (FSES)

(PERFORMANCE BASED DESIGN)

K0180

A. FULLY SPRINKLERED

B. PARTIALLY SPRINKLERED

(All required areas are sprinklered) (Not all required areas are sprinklered)

C. NONE (No sprinkler system)

* MANDATORY

Form CMS-2786M (03/04) Previous Versions Obsolete

Page 3

Appendix 2-A

2000 CODE


FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE Medicare – Medicaid

1. (A) PROVIDER NUMBER

1. (B) MEDICAID I.D. NO.

K1

K2

Form Approved OMB Exempt

PART I — Life Safety Code, New and Existing PART IV — Waiver Recommendation Form Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (A) MULTIPLE CONSTRUCTION (BLDGS)

2. NAME OF FACILITY

2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A.

(All required areas are sprinklered)

A. BUILDING ________________ B. WING

________________

C. FLOOR

________________

MEDICARE

MEDICAID

Partially Sprinklered

B.

(Not all required areas are sprinklered)

None

C.

K3

3. SURVEY FOR

Fully Sprinklered

(No sprinkler system)

K0180

4. DATE OF SURVEY


K4

K6

SURVEY UNDER 5.

2000 EXISTING

6.

2000 NEW

K7

5. SURVEY FOR CERTIFICATION OF 1.

HOSPITAL

2.

SKILLED/NURSING FACILITY

4.

ICF/MR UNDER HEALTH CARE

IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 1.

ENTIRE FACILITY 2.

6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY ______ 7. A.

B.

IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED? a.

c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE _____

HOSPICE

YES

b.

NO

d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID ______

e. NUMBER OF NF or ICF/MR BEDS CERTIFIED FOR MEDICAID_______

THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES) 1.

K9

3.

DISTINCT PART OF (SPECIFY) __________________________________

b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE ____

5.

COMPLIANCE WITH ALL PROVISIONS

2.

ACCEPTANCE OF A PLAN OF CORRECTION

3.

RECOMMENDED WAIVERS

4.

FSES

5.

PERFORMANCE BASED DESIGN

THE FACILITY DOES NOT MEET THE STANDARD

SURVEYOR (Signature)

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

SURVEYOR ID K10

FIRE AUTHORITY OFFICIAL (Signature)

Form CMS-2786R (02/2013)

Appendix 2-B

Page 1

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

PART I - LSC REQUIREMENTS - Items in italics relate to the FSES

BUILDING CONSTRUCTION K11

If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and shall be protected by approved self-closing fire doors with at least 1½ hour fire resistance rating 18.1.1.4.1, 18.1.1.4.2, 18.2.3.2, 19.1.1.4.1, 19.1.1.4.2

K12

2000 EXISTING Building construction type and height meets one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1 1

I (443), I (332), II (222)

Any Height

2

II (111)

One story only (non-sprinklered).

3

II (111)

Not over three stories with complete automatic sprinkler system.

4

III (211)

5

V (111)

6

IV (2HH)

7

II (000)

8

III (200)

9

V (000)

Not over two stories with complete automatic sprinkler system.

Not over one story with complete automatic sprinkler system.

Building contains fire treated wood. Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. Form CMS-2786R (02/2013)

Appendix 2-B

Page 2

Name of Facility

2000 CODE

ID PREFIX

K12

MET NOT MET

N/A

REMARKS

2000 NEW Building construction type and height meets one of the following: 18.1.6.2, 18.1.6.3, 18.3.5.1.

1

I (443), I (332), II (222)

Any height with complete automatic sprinkler system

2

II (111)

Not over three stories with complete automatic sprinkler system

3

III (211)

4

V (111)

5

IV (2HH)

6

II (000)

7

III (200)

8

V (000)

Not over one story with complete automatic sprinkler system.

Not Permitted

Building contains fire treated wood. Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. K103 Interior walls and partitions in buildings of Type I or Type II construction shall be noncombustible or limited-combustible materials. 18.1.6.3, 19.1.6.3 (Indicate N/A for existing buildings using listed fire retardant treated wood studs within non-load bearing one-hour rated partitions.) Form CMS-2786R (02/2013)

Appendix 2-B

Page 3

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

INTERIOR FINISH K14

2000 EXISTING Interior finish for means of egress, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. Interior finishes existing before December 17, 2010 that are applied directly to wall and ceilings with a thickness of less than ½8 inch shall be permitted to remain in use without flame spread rating documentation. 10.2, 19.3.3.1, 19.3.3.2, NFPA TIA 00-2 Indicate flame spread rating/s _________ 2000 NEW Interior finish for means of egress, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. Lower half of corridor walls, not exceeding 4ft in height, may have a Class C flame spread rating. 10.2, 18.3.3.1, 18.3.3.2, NFPA TIA 00-2 Indicate flame spread rating/s_________

K15

2000 EXISTING Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully-sprinklered buildings, flame spread rating of Class C may be continued in use within rooms separated in accordance with 19.3.6 from the exit access corridors.) 19.3.3.1, 19.3.3.2 Indicate flame spread rating/s_________ 2000 NEW Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (Rooms not over 4 persons in capacity may have a flame spread rating of Class A, Class B, or Class C). 18.3.3.1, 18.3.3.2. Indicate flame spread rating/s_________

Form CMS-2786R (02/2013)

Appendix 2-B

Page 4

Name of Facility

2000 CODE

ID PREFIX

K16

MET NOT MET

N/A

REMARKS

2000 EXISTING Newly installed interior floor finish complying with 10.2.7 shall be permitted in corridors and exits if Class I. 19.3.3.3 In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, no interior floor finish requirements shall apply. CORRIDOR WALLS AND DOORS

K17

2000 EXISTING Corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5 If the walls have a fire resistance rating, give rating _________ if the walls terminate at the underside of a ceiling, give a brief description in REMARKS, of the ceiling, describing the ceiling throughout the floor area. 2000 NEW Corridor walls shall form a barrier to limit the transfer of smoke. Such walls shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. No fire resistance rating is required for the corridor walls. 18.3.6.1, 18.3.6.2, 18.3.6.4, 18.3.6.5

Form CMS-2786R (02/2013)

Appendix 2-B

Page 5

Name of Facility ID PREFIX

K18

2000 CODE MET NOT MET

N/A

REMARKS

2000 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Clearance between bottom of door and floor covering is not exceeding 1 inch. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.2.3.2.1. Roller latches are prohibited by CMS regulations in all health care facilities. 19.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. 2000 NEW Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between bottom of door and floor covering is not exceeding 1 inch. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches shall be prohibited. 18.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc.

K19

Vision panels in corridor walls or doors shall be fixed window assemblies in approved frames. (In fully sprinklered smoke compartments, there are no restrictions in the area and fire resistance of glass and frames.) In other than smoke compartments containing patient bedrooms, miscellaneous opening are permitted in vision panels or doors provided the aggregate area of the opening per room does not exceed 20 in.2 and the opening is installed in bottom half of the wall (80 in.2 in fully sprinklered buildings). 18.3.6.5, 19.3.6.2.3, 19.3.6.3.8, 19.3.6.5

Form CMS-2786R (02/2013)

Appendix 2-B

Page 6

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

VERTICAL OPENINGS K20

2000 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5, 8.2.5.6, 19.3.1.1 If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. If enclosures are less than required, give a brief description and specific location in REMARKS. 2000 NEW Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and buildings up to three stories in height.) An atrium may be used in accordance with 8.2.5.6, 8.2.5, 18.3.1.1. If enclosures are less than required, give a brief description and specific location in REMARKS.

K21

Doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure are self-closing and kept in the closed position, unless held open by as release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: (a) The required manual fire alarm system and (b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and (c) The automatic sprinkler system, if installed 18.2.2.2.6, 18.3.1.2, 19.2.2.2.6, 19.3.1.2, 7.2.1.8.2 Door assemblies in vertical openings are of an approved type with appropriate fire protection rating. 8.2.3.2.3.1 Boiler rooms, heater rooms, and mechanical equipment rooms doors are kept closed.

Form CMS-2786R (02/2013)

Appendix 2-B

Page 7



N/A

REMARKS

Describe method used in REMARKS SMOKE COMPARTMENTATION AND CONTROL K23

2000 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2 2000 NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on floors that are usable, but unoccupied. 18.3.7.1, 18.3.7.2

K24

The smoke compartments shall not exceed 22,500 square feet and the travel distance to and from any point to reach a door in the required smoke barrier shall not exceed 200 feet. 18.3.7.1, 19.3.7.1 Detail in REMARKS zone dimensions including length of zones and dead end corridors.

K25

2000 EXISTING Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5 2000 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels in approved frames. 8.3, 18.3.7.3, 18.3.7.5

K26

Space shall be provided on each side of smoke barriers to adequately accommodate the total number of occupants in adjoining compartments. 18.3.7.4, 19.3.7.4

Form CMS-2786R (02/2013)

Appendix 2-B

Page 8

Name of Facility

2000 CODE

ID PREFIX

K27

MET NOT MET

N/A

REMARKS

2000 EXISTING Doors in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Doors shall be self-closing or automaticclosing in accordance with 19.2.2.2.6. Swinging doors are not required to swing with egress and positive latching is not required. 19.3.7.5, 19.3.7.6, 19.3.7.7 2000 NEW Doors in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Nonrated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8

K28

2000 EXISTING Door openings in smoke barriers shall provide a minimum clear width of 32 inches (81 cm) for swinging or horizontal doors. 19.3.7.7 2000 NEW Door openings in smoke barriers are installed as swinging or horizontal doors shall provide a minimum clear width as follows: Provider Type

Swinging Doors

Horizontal Sliding Doors

Hospitals and Nursing Facilities

41.5 inches (105 cm)

83 inches (211 cm)

Psychiatric Hospitals and Limited Care Facilities

32 inches (81 cm)

64 inches (163 cm)

18.3.7.7

Form CMS-2786R (02/2013)

Appendix 2-B

Page 9

Name of Facility

2000 CODE

ID PREFIX

K104

MET NOT MET

N/A

REMARKS

Penetrations of smoke barriers by ducts are protected in accordance with 8.3.5. Dampers are not required in duct penetrations of smoke barriers in fully ducted HVAC systems where a sprinkler system in accordance with 18/19.3.5 is provided for adjacent smoke compartments. 18.3.7.3, 19.3.7.3. Hospitals may apply a 6-year damper testing interval conforming to NFPA 80 & NFPA 105. All other health care facilities must maintain a 4-year damper maintenance interval. 8.3.5 Describe any mechanical smoke control system in REMARKS. HAZARDOUS AREAS

K29

2000 EXISTING One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Area a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair Shops and Paint Shops e. Laboratories (if classified a Severe Hazard - see K31) f. Combustible Storage Rooms/Spaces (over 50 sq feet) g. Trash Collection Rooms i. Soiled Linen Rooms

Automatic Sprinkler

Separation

N/A

Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.

Form CMS-2786R (02/2013)

Appendix 2-B

Page 10

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

Area a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair, Maintenance and Paint Shops e. Laboratories (if classified a Severe Hazard - see K31) f. Combustible Storage Rooms/Spaces (over 50 and less than 100 sq feet) g. Trash Collection Rooms i. Soiled Linen Rooms m. Combustible Storage Rooms/Spaces (over 100 sq feet)

Area L. Gift Shop storing hazardous quantities of combustibles

Form CMS-2786R (02/2013)

Automatic Sprinkler

Separation

N/A

Automatic Sprinkler Separation N/A

Appendix 2-B

Page 11

Name of Facility

2000 CODE

ID PREFIX

K211

MET NOT MET

N/A

REMARKS

Where Alcohol Based Hand Rub (ABHR) dispensers are installed: The corridor is at least 6 feet wide The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) The dispensers shall have a minimum spacing of 4 ft from each other Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. Dispensers are not installed over or adjacent to an ignition source. If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623 EXITS AND EGRESS

K22

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating “No Exit”. 7.10, 18.2.10.1, 19.2.10.1

K32

Not less than two exits, remote from each other, are provided for each floor or fire section of the building. Not less than one exit from each floor or fire section shall be a door leading outside, stair, smoke-proof enclosure, ramp, or exit passageway. Only one of these two exits may be a horizontal exit. Egress shall not return through the zone of fire origin. 18.2.4.1, 18.2.4.2, 19.2.4.1, 19.2.4.2

K33

2000 EXISTING Exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1 If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. If enclosures are less than required, give a brief description and specific location in REMARKS.

Form CMS-2786R (02/2013)

Appendix 2-B

Page 12



N/A

REMARKS

2000 NEW Exit enclosures (such as stairways) in buildings four stories or more are enclosed with construction having a fire resistance rating of at least two hours, are arranged to provide a continuous path of escape, and provide a protection against fire and smoke from other parts of the building. In all buildings less than four stories, the enclosure is at least one hour. 7.1.3.2, 8.2.5.2, 8.2.5.4, 18.3.1.1, 18.2.2.3 If enclosures are less than required, give a brief description and specific location in REMARKS. K34

Stairways and smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4

K35

The capacity of required mean of egress is based on its width, in accordance with 7.3.

K36

Travel distance (exit access) to exits are measured in accordance with 7.6. • Room door to exit ≤ 100 ft (≤ 150 ft sprinklered) • Point in room or suite to exit ≤ 150 ft (≤ 200 ft sprinklered) • Point in room to room door ≤ 50 ft • Point in suite to suite door ≤ 100 ft 18.2.6, 19.2.6

K37

2000 EXISTING Existing dead-end corridors shall be permitted to be continued to be used if it is impractical and unfeasible to alter them so that exists are accessible in not less than two different directions from all points in aisles, passageways, and corridors. 19.2.5.10 2000 NEW Every exit and exit access shall be arranged so that no corridor, aisle or passageway has a pocket or dead-end exceeding 30 feet. 18.2.5.10

K38

Exit access is so arranged that exits are readily accessible at all times in accordance with 7.1. 18.2.1, 19.2.1

K39

2000 EXISTING Width of aisles or corridors (clear and unobstructed) serving as exit access shall be at least 4 feet. 19.2.3.3

Form CMS-2786R (02/2013)

Appendix 2-B

Page 13



N/A

REMARKS

2000 NEW Width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes shall be at least 8 feet. In limited care facility and psychiatric hospitals, width of aisles or corridors shall be at least 6 feet. 18.2.3.3, 18.2.3.4 K40

2000 EXISTING Exit access doors and exit doors used by health care occupants are of the swinging type and are at least 32 inches in clear width. An exception is provided for existing 34-inch doors in existing occupancies. 19.2.3.5 2000 NEW Exit access doors and exit doors used by health care occupants are of the swinging type and are at least 41.5 inches in clear width. Doors in exit stairway enclosures shall be no less than 32 inches in clear width. In psychiatric hospitals or limited care facilities (e.g.,ICF/MD providing medical treatment) doors are at least 32 inches wide. 18.2.3.5

K41

All sleeping rooms have a door leading to a corridor providing access to an exit or have a door leading directly to grade. One room may intervene in accordance with 18.2.5.1, 19.2.5.1 If doors lead directly to grade from each room, check this box.

K42

Any patient sleeping room or suite of rooms of more than 1,000 sq. ft. has at least 2 exit access doors remote from each other. 18.2.5.2, 19.2.5.2

K43

Patient room doors are arranged such that the patients can open the door from inside without using a key. Special door locking arrangements are permitted in facilities. 18.2.2.2.4, 18.2.2.2.5, 19.2.2.2.4, 19.2.2.2.5 If door locking arrangement without delay egress is used indicate in REMARKS 18.2.2.2.2, 19.2.2.2.2

K44

Horizontal exits, if used, are in accordance with 7.2.4. 18.2.2.5, 19.2.2.5

K47

Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 18.2.10.1, 19.2.10.1 (Indicate N/A in one story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Form CMS-2786R (02/2013)

Appendix 2-B

Page 14

Name of Facility

2000 CODE

ID PREFIX

K72

MET NOT MET

N/A

REMARKS

Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10. 18.2.1, 19.2.1 ILLUMINATION

K45

Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture will not leave the area in darkness. Lighting system shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8, 7.8

K46

Emergency lighting of at least 1½ hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1.

K105

2000 NEW (INDICATE N/A FOR EXISTING) Buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the Life Safety Branch of the electrical system described in NFPA 99. 18.2.9.2., 18.2.10.2 (Indicate N/A if life support equipment is for emergency purposes only). EMERGENCY PLAN AND FIRE DRILLS

K48

There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. 18.7.1.1, 19.7.1.1

K50

Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. 18.7.1.2, 19.7.1.2

Form CMS-2786R (02/2013)

Appendix 2-B

Page 15

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

FIRE ALARM SYSTEMS K51

A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Fire alarm system wiring or other transmission paths are monitored for integrity. Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations. Occupant notification is provided by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of fire. The fire alarm automatically activates required control functions. System records are maintained and readily available. 18.3.4, 19.3.4, 9.6

K52

A fire alarm system required for life safety shall be, tested, and maintained in accordance with NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code and records kept readily available. The system shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and 72. 9.6.1.4, 9.6.1.7,

K155

Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8

K53

2000 EXISTING (INDICATE N/A FOR HOSPITAL AND FULLY SPRINKLERED NURSING HOMES) In an existing nursing home, not fully sprinklered, the resident sleeping rooms and public areas (dining rooms, activity rooms, resident meeting rooms, etc) are to be equipped with single station battery-operated smoke detectors. There will be a testing, maintenance and battery replacement program to ensure proper operation. CFR 483.70

Form CMS-2786R (02/2013)

Appendix 2-B

Page 16



N/A

REMARKS

2000 NEW (NURSING HOME AND EXISTING LIMITED CARE FACILITIES) An automatic smoke detection system is installed in all corridors. (As an alternative to the corridor smoke detection system on patient sleeping room floors, smoke detectors may be installed in each patient sleeping room and at smoke barrier or horizontal exit doors in the corridor.) Such detectors are electrically interconnected to the fire alarm system. 18.3.4.5.3 K109

2000 EXISTING LIMITED CARE FACILITIES (INDICATE N/A FOR HOSPITALS OR NURSING HOMES) An automatic smoke detection system is installed in all corridors with detector spacing no further apart than 30 ft on center in accordance with NFPA 72. (As an alternative to the corridor smoke detection system on patient sleeping room floors, smoke detectors may be installed in each patient sleeping room and at smoke barrier or horizontal exit doors in the corridors.) Such detectors are electrically interconnected to the fire alarm system. 19.3.4.5.1 Smoke Detection System Corridors Rooms Bath

K54

All required smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance with the manufacturer’s specifications. 9.6.1.3 Give a brief description, in REMARKS of any smoke detection system which may be installed.

K55

2000 EXISTING Every patient sleeping room shall have an outside window or outside door. Except for newborn nurseries and rooms intended for occupancy for less than 24 hours. 19.3.8 2000 NEW Every patient sleeping room shall have an outside window or outside door. The allowable sill height shall not exceed 36 inches (91 cm) above the floor. Windows are not required for recovery rooms, newborn nurseries, emergency rooms, and similar rooms

Form CMS-2786R (02/2013)

Appendix 2-B

Page 17

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

intended for occupancy for less than 24 hours. Window sill height for limited care facilities shall not exceed 44 inches (112 cm) above the floor. 18.3.8 K60

Initiation of the required fire alarm systems shall be by manual fire alarm initiation, automatic detection, or extinguishing system operation. 18.3.4.2, 19.3.4.2, 9.6.2.1 AUTOMATIC SPRINKLER SYSTEMS

K56

2000 EXISTING Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13 2000 NEW There is an automatic sprinkler system installed in accordance with NFPA13, Standard for the Installation of Sprinkler Systems, with approved components, device and equipment, to provide complete coverage of all portions of the facility. Systems are equipped with waterflow and tamper switches, which are connected to the fire alarm system. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 18.3.5, 18.3.5.1.

K154

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1. A. Date sprinkler system last checked and necessary maintenance provided. _______________________________

Form CMS-2786R (02/2013)

Appendix 2-B

Page 18

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

B. Show who provided the service. _______________________ C. Note the source of water supply for the automatic sprinkler system. ___________________________________ (Provide, in REMARKS, information on coverage for any non-required or partial automatic sprinkler system.) K61

Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

K62

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

K63

Required automatic sprinkler systems have an adequate and reliable water supply which provides continuous and automatic pressure. 9.7.1.1, NFPA 13

K64

Portable fire extinguishers shall be installed, inspected, and maintained in all health care occupancies in accordance with 9.7.4.1, NFPA 10. 18.3.5.6, 19.3.5.6 SMOKING REGULATIONS

K66

Smoking regulations shall be adopted and shall include not less than the following provisions: 18.7.4, 19.7.4, 8-6.4.2 (NFPA 99) (1)

Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Exception: In facilities where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs that prohibit smoking in use areas are not required. (Note: This exception is not applicable to medical gas storage areas.) 8-3.1.11.3 (NFPA 99) Form CMS-2786R (02/2013)

Appendix 2-B

Page 19



N/A

REMARKS

Form CMS-2786R (02/2013)

Appendix 2-B

Page 20


MET NOT MET

(4) K160

2000 CODE N/A

REMARKS

Existing flue-fed incinerators shall be sealed by fire resistive construction to prevent further use.

2000 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in A17.1, Safety Code for Elevators and Escalators. Fire Fighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators & Escalators. All existing elevators, having a travel distance of 25 ft or more above or below the level that best serves the needs of emergency personnel for fire fighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. 9.4.2, 9.4.3, 19.5.3 (Includes firefighters service phase I key recall and smoke detector automatic recall, firefighters service phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 2000 NEW Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in A17.1, Safety Code for Elevators and Escalators. Fire Fighter’s Service is operated monthly with a written record. New elevators conform to ASME/ANSI A17.1, Safety Code for Elevators and Escalators, including Fire Fighter’s Service Requirements. 9.4.2, 9.4.3, 18.5.3 (Includes firefighters service phase I key recall and smoke detector automatic recall, firefighters service phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.)

K161

2000 EXISTING Escalators, dumbwaiters, and moving walks comply with the provisions of 9.4. All existing escalators, dumbwaiters, and moving walks conform to the requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. 19.5.3, 9.4.2.2

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Appendix 2-B

Page 21



N/A

REMARKS

Newly introduced upholstered furniture shall meet the char length and heat release criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.3, 18.7.5.2, 19.7.5.2. Newly introduced mattresses shall meet the char length and heat release criteria specified when tested in accordance with the method cited in 10.3.2 (3) and 10.3.4. 18.7.5.3, 19.7.5.3 Newly introduced upholstered furniture and mattresses means purchased since March, 2003. K75

Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed .5 gal/ft2 (20.4 L/m2). A

Form CMS-2786R (02/2013)

Appendix 2-B

Page 22

Name of Facility

2000 CODE

ID PREFIX

MET NOT MET

N/A

REMARKS

capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. 18.7.5.5, 19.7.5.5 LABORATORIES K31

Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard shall be protected in accordance with NFPA 99. (Laboratories that are not considered to be severe hazard shall meet the provision of K29.) 18.3.2.2, 19.3.2.2, Chapter 10 (NFPA 99)

K136

Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department in accordance with 10-2.1.3.1 (NFPA 99), 18.3.2.2., 19.3.2.1

K131

Emergency procedures shall be established for controlling chemical spills in accordance with 10-2.1.3.2 (NFPA 99)

K132

Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures reviewed annually shall be in accordance with 10-2.1.4.2 (NFPA 99).

K133

Fume hoods shall be in accordance with 5-4.3, 5-6.2 (NFPA 99).

K134

Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths designed and installed to avoid injurious water pressure shall be in accordance with 10-6 (NFPA 99).

K135

Flammable and combustible liquids shall be used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals.

Form CMS-2786R (02/2013)

Appendix 2-B

Page 23



N/A

REMARKS

Storage cabinets for flammable and combustible liquids shall be constructed in accordance with NFPA 30, Flammable and Combustible liquids Code, 4-3 (NFPA 99), 10-7.2.1 (NFPA 99) MEDICAL GASES AND ANESTHETIZING AREAS K76

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. 4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4

K77

Piped in medical gas, vacuum and waste anesthetic gas disposal systems comply with NFPA 99, Chapter 4.

K78

Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Shutoff valves are located outside each anesthetizing location and arranged so that shutting off one room or location will not affect others. (b) Relative humidity is maintained equal to or great than 35% 4-3.1.2.3(n) and 5-4.1.1 (NFPA 99), 18.3.2.3, 19.3.2.3 Medical gas warning systems shall be in accordance with NFPA 99, Standard for Health Care Facilities. (a) Master alarm panels are in two separate locations and have audible and visible signals. (b) There are high/low alarms for +/- 20% operating pressure. This section shall be in accordance with NFPA 99, 4-3.1.2.2 (c) Where a level 2 gas system is used, one alarm panel that complies with 4-3.1.2.2(b)3a,b,c,d and with 4-3.1.2.2(c)2,5 shall be permitted. 4-4.1 (NFPA 99) exception No. 4.

K140

4-3.1.2.2 (NFPA 99) K141

Medical gas storage areas shall have a precautionary sign, readable from a distance of 5 ft, that is conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUSION, OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. 18.3.2.4, 19.3.2.4, 8-3.1.11.3 (NFPA 99)

Form CMS-2786R (02/2013)

Appendix 2-B

Page 24



K142

All occupancies containing hyperbaric facilities shall comply with NFPA 99, Standard for Health Care Facilities, Chapter 19.

K143

Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:: (a) separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) the area that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring; and (c) in an area that is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted in accordance with NFPA 99 and Compressed Gas Association. 8-6.2.5.2 (NFPA 99)

N/A

REMARKS

ELECTRICAL AND EMERGENCY POWER K106

Hospitals and inpatient hospices with life support equipment have an Type I Essential Electric System, and nursing homes have a Type II ESS that are powered by a generator with a transfer switch and separate power supply in accordance with NFPA 99. 12-3.3.2, 13-3.3.2.1, 16-3.3.2 (NFPA 99)

K107

Required alarm and detection systems are provided with an alternative power supply in accordance with NFPA 72. 9.6.1.4, 18.3.4.1, 19.3.4.1

K108

2000 NEW (INDICATE N/A FOR EXISTING) Power for Alarms, emergency communication systems, and illumination of generator set locations are in accordance with essential electrical system of NFPA 99. 18.5.1.2

K144

Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 and NFPA 110. 3-4.4.1 and 8-4.2 (NFPA 99), Chapter 6 (NFPA 110)

K145

The Type I EES is divided into the critical branch, life safety branch and the emergency system and Type II EES is divided into the emergency and critical systems in accordance with 3-4.2.2.2, 3-5.2.2 (NFPA 99)

Form CMS-2786R (02/2013)

Appendix 2-B

Page 25



K146

The nursing home/hospice with no life support equipment shall have an alternate source of power separate and independent from the normal source that will be effective for minimum of 11/2 hour after loss of the normal source 3-6. (NFPA 99)

K147

Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

K130

Miscellaneous List in the REMARKS sections, any items that are not listed previously, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Form CMS-2786R (02/2013)

N/A

Appendix 2-B

REMARKS

Page 26

Name of Facility

2000 CODE PART IV RECOMMENDATION FOR WAIVER OF SPECIFIC LIFE SAFETY CODE PROVISIONS

For each item of the Life Safety code recommended for waiver, list the survey report form item number and state the reason for the conclusion that: (a) the specific provisions of the code, if rigidly applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet provisions will not adversely affect the health and safety of the patients. If additional space is required, attach additional sheet(s). PROVISION NUMBER(S)

JUSTIFICATION

Appendix 2-B

K84

Surveyor (Signature)

Title

Office

Date

Fire Authority Official (Signature)

Title

Office

Date

Form CMS-2786R (02/2013)

Appendix 2-B

Page 27

FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) FACILITY NAME

PROVIDER NUMBER

SURVEY DATE

K1

K6

* K4

K3




LSC FORM INDICATOR

____________

12 13


14 15

2786U 2786U


16 17


SMALL

(16 BEDS OR LESS)

K8:


LARGE

K8:



(Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.)

*K9:


APARTMENT HOUSE


K29:



K8: * K7

A B C D

K5:

K56:

e.g. 2.5


A2. (ACCEPTABLE POC)


A3.

A4.

(WAIVERS) K0180

A.

FULLY SPRINKLERED

A5. (FSES)





* MANDATORY

Form CMS-2786R (02/2013)

Page 28

Appendix 2-B

2000 CODE


FIRE SAFETY SURVEY REPORT SHORT FORM Medicare – Medicaid


1. (A) PROVIDER NUMBER


K1

K2

Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. NAME OF FACILITY

2. (A) MULTIPLE CONSTRUCTION (BLDGS)

2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A.

A. BUILDING ________________ B. WING

________________

C. FLOOR

________________

B.



MEDICARE

C.

 None (No sprinkler system)

K0180

4. DATE OF SURVEY



 Partially Sprinklered


K3

3. SURVEY FOR

Sprinklered  Fully (All required areas are sprinklered)

SHORT FORM CHECK HERE

MEDICAID K4

SURVEY UNDER



5.

 2000 EXISTING

 2000 NEW

K5

5. SURVEY FOR CERTIFICATION OF 1. K8



HOSPITAL

2.



SKILLED/NURSING FACILITY

IF “2” OR “3” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 1.

 ENTIRE FACILITY

2.

3.

 DISTINCT PART OF (SPECIFY)_____________________________



IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED BY JCAHO/AOA? a. YES b. NO





6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY

b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE

c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE

d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID K9: FOR STATE AGENCY USE ONLY A. The facility MEETS based upon:

I HAVE CONDUCTED A FIRE SAFETY SCREENING USING THE SHORT FORM:



 The facility meets all of the items on the form. B.  The facility does not meet all of the items on the form. C.  A complete fire safety survey is recommended. A.

 Compliance with all provisions  Acceptance of a Plan of Correction 3.  Recommended waivers. 1.

2. B.

K9


e. NUMBER OF ICF BEDS CERTIFIED FOR MEDICAID

 The facility DOES NOT MEET THE STANDARD.

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

8. SURVEYOR I.D. NO K10

REVIEW AUTHORITY OFFICIAL (Signature)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 1

Name of Facility

2000 CODE

ID PREFIX

MET

NOT MET

N/A

REMARKS

CORRIDOR WALLS AND DOORS K18

2000 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. 2000 New Doors protecting corridor openings shall be constructed to resist the passage of smoke. Doors shall be provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches shall be prohibited. 18.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc.

K22

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4 VERTICAL OPENINGS

K20

2000 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5.6, 19.3.1.1. If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. 

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 2


2000 CODE MET

NOT MET

N/A

REMARKS

If enclosures are less than required, give a brief description and specific location in REMARKS. 2000 NEW Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.) 18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5. If enclosures are less than required, give a brief description and specific location in REMARKS. SMOKE COMPARTMENTATION AND CONTROL K23

2000 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2 2000 NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on floors that are usable, but unoccupied. 18.3.7.1, 18.3.7.2

K28

2000 EXISTING Door openings in smoke barriers shall provide a minimum clear width of 32 inches (81 cm) for swinging or horizontal doors. Vision panels are of fire-rated glazing or wired glass panels and steel frames. 19.3.7.5, 19.3.7.7

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 3

Name of Facility

2000 CODE

ID PREFIX

MET

NO MET

N/A

REMARKS

2000 NEW Door openings in smoke barriers are installed as swinging or horizontal doors shall provide a minimum clear width as follows: Provider Type

Swinging Doors

Horizontal Sliding Doors

Hospitals and Nursing Facilities

41.5 inches (105 cm)

83 inches (211 cm)

Psychiatric Hospitals and Limited Care Facilities

32 inches (81 cm)

64 inches (163 cm)

Vision panels of fire-rated glazing or wired panels in approved frames are provided for each door. 18.3.7.5, 18.3.7.7 HAZARDOUS AREA K29

2000 EXISTING One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Area Automatic Sprinkler a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair Shops and Paint Shops e. Laboratories (if classified a Severe Hazard - see K31) f. Combustible Storage Rooms/Spaces (over 50 sq feet) g. Trash Collection Rooms i. Soiled Linen Rooms

Separation

N/A

Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 4

Name of Facility

2000 CODE

ID PREFIX

MET

NO MET

N/A

REMARKS

2000 NEW Hazardous areas are protected in accordance with 8.4. The areas shall be enclosed with a one hour fire-rated barrier, with a 3 /4 hour fire-rated door, without windows (in accordance with 8.4). Doors shall be self-closing or automatic closing in accordance with 7.2.1.8. 18.3.2.1 Area Automatic Sprinkler a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair, Maintenance and Paint Shops e. Laboratories (if classified a Severe Hazard - see K31) f. Combustible Storage Rooms/Spaces (over 50 and less than 100 sq feet) g. Trash Collection Rooms i. Soiled Linen Rooms m.Combustible Storage Rooms/Spaces (over 100 sq feet)

Separation

N/A

Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. K30

Gift shops shall be protected as hazardous areas when used for storage or display of combustibles in quantities considered hazardous. Non-rated walls may separate gift shops that are not considered hazardous, have separate protected storage and that are completely sprinkled. Gift shops may be open to the corridor if they are not considered hazardous, have separate protected storage, are completely sprinklered and do not exceed 500 square ºfeet. 18.3.2.5, 19.3.2.5 Area L. Gift Shop storing hazardous quantities of combustibles

Automatic Sprinkler

Separation

N/A

18.2.6, 19.2.6 K211

2000 EXISTING Where Alcohol Based Hand Rub (ABHR) dispensers are installed:  The corridor is at least 6 feet wide  The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)  The dispensers shall have a minimum spacing of 4 ft from each other  Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.  Dispensers are not installed over or adjacent to an ignition source.  If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 482.41, 483.70, 483.623

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 5

Name of Facility

2000 CODE

ID PREFIX

K211

MET

NO MET

N/A

REMARKS

2000 NEW Where Alcohol Based Hand Rub (ABHR) dispensers are installed:  The corridor is at least 6 feet wide  The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)  The dispensers shall have a minimum spacing of 4 ft from each other  Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.  Dispensers are not installed over or adjacent to an ignition source.  If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 482.41, 483.70, 483.623 EXISTS AND EGRESS

K38

Exit access is so arranged that exits are readily accessible at all times in accordance with 7.1. 18.2.1, 19.2.1

K39

2000 EXISTING Width of aisles or corridors (clear and unobstructed) serving as exit access shall be at least 4 feet. 19.2.3.3 2000 NEW Width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes shall be at least 8 feet. In limited care facility and psychiatric hospitals, width of aisles or corridors shall be at least 6 feet. 18.2.3.3, 18.2.3.4

K40

2000 EXISTING Exit access doors and exit doors used by health care occupants are of the swinging type and are at least 32 inches in clear width. 19.2.3.5 2000 NEW Exit access doors and exit doors used by health care occupants are of the swinging type, with openings of at least 41.5 inches wide. Doors in exit stairway enclosures shall be no less than 32 inches in clear width. In ICFs/MR, doors are at least 32 inches wide. 18.2.3.5

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 6

Name of Facility

2000 CODE

ID PREFIX

K43

MET

NO MET

N/A

REMARKS

Patient room doors are arranged such that the patients can open the door from inside without using a key. Special door locking arrangements are permitted in health facilities. 18.2.2.2.4, 18.2.2.2.5 If door locking arrangement without delay egress is used indicate in REMARKS 18.2.2.2.2, 19.2.2.2.2 ILLUMINATION AND EMERGENCY POWER

K45

Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. 18.2.8, 19.2.8, 7.8

K47

2000 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one story buildings with less than 30 occupants where the line of exit travel is obvious.) 2000 NEW Exit and directional signs are displayed with continuous illumination also served by the emergency lighting, system in accordance with 7.10. 18.2.10.1

K105

2000 NEW (INDICATE N/A FOR EXISTING) Buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the Life Safety Branch of the electrical system described in NFPA 99. 18.2.9.2., 18.2.10.2, 18.5.1.1, 18.5.1.2 (Indicate N/A if life support equipment is for emergency purposes only).

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 7

Name of Facility

2000 CODE

ID PREFIX

MET

NO MET

N/A

REMARKS

EMERGENCY PLAN AND FIRE DRILLS K48

There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. 18.7.1.1, 19.7.1.1

K50

Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. 18.7.1.2, 19.7.1.2 FIRE ALARM SYSTEMS

K51

2000 EXISTING A fire alarm system with approved component, devices or equipment installed according to NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system shall be by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas, may be omitted provided that manual pull stations are within 200 ft of nurse’s stations. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be in accordance with NFPA 72, and records of maintenance kept readily available. There shall be annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6 2000 NEW A fire alarm system with approved component, devices or equipment installed according to NFPA 72, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system shall be by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be maintained in accordance with NFPA72, and records of maintenance kept readily available. There shall be remote annunciation of the fire alarm system to an approved central station. 18.3.4, 9.6

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 8


2000 CODE MET

K52

A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and 72. 9.6.1.4

K155

Where a required fires alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8

K53

2000 EXISTING (INDICATE N/A FOR HOSPITALS AND FULLY SPRINKLERED NURSING HOMES) In an existing nursing home, not fully sprinklered, the resident sleeping rooms and public areas (dining rooms, activity rooms, resident meeting rooms, etc) are to be equipped with single station battery-operated smoke detectors. There will be a testing, maintenance and battery replacement program to ensure proper operation. CFR 483.70

NO MET

N/A

REMARKS

2000 NEW (NURSING HOME AND EXISTING LIMITED CARE FACILITIES) An automatic smoke detection system is installed in all corridors. (As an alternative to the corridor smoke detection system on patient sleeping room floors, smoke detectors may be installed in each patient sleeping room and at smoke barrier or horizontal exit doors in the corridor.) Such detectors are electrically interconnected to the fire alarm system. 18.3.4.5.3

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 9

Name of Facility

2000 CODE

ID PREFIX

K109

MET

NO MET

N/A

REMARKS

2000 EXISTING LIMITED CARE FACILITIES (INDICATE N/A FOR HOSPITALS OR NURSING HOMES) An automatic smoke detection system is installed in all corridors, with detector spacing no further apart than 30 ft on center in accordance with NFPA 72. (As an alternative to the corridor smoke detection system on patient sleeping room floors, smoke detectors may be installed in each patient sleeping room and at smoke barrier or horizontal exit doors in the corridors.) Such detectors are electrically interconnected to the fire alarm system. 19.3.4.5.1 Smoke Detection System  Corridors  Rooms  Bath AUTOMATIC SPRINKLER SYSTEMS

K56

2000 EXISTING Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. 19.3.5, NPFA 13 2000 NEW When required by construction type, there is an automatic sprinkler system installed in accordance with NFPA13, Standard for the Installation of Sprinkler Systems, with approved components, device and equipment, to provide complete coverage of all portions of the facility. Systems are equipped with waterflow and tamper switches, which are connected to the fire alarm system. 18.3.5. A. Date sprinkler system last checked and necessary maintenance provided. _______________________________ B. Show who provided the service. _______________________

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 10

Name of Facility

2000 CODE

ID PREFIX

MET

K154

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

K62

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

K64

Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1, NFPA 10. 18.3.5.6, 19.3.5.6

NO MET

N/A

REMARKS

SMOKING REGULATIONS K66

Smoking regulations shall be adopted and shall include not less than the following provisions: 18.7.4, 19.7.4  (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.  (2) Smoking by patients classified as not responsible shall be prohibited, except when under direct supervision.  (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.  (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 11

Name of Facility

2000 CODE

ID PREFIX

MET

NO MET

N/A

REMARKS

BUILDING SERVICE EQUIPMENT K70

Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212oF (100oC). 18.7.8, 19.7.8 FURNISHINGS AND DECORATIONS

K72

Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10

K74

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with provisions of 10.3.1 and NFPA 13 Standard for the Installation of Sprinkler Systems. Except shower curtains shall be in accordance with NFPA 701.  Newly introduced upholstered furniture shall meet the criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.1. 18.3.5.3 and NFPA 13 LABORATORIES

K31

Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard shall be protected in accordance with NFPA 99. (Laboratories that are not considered to be severe hazard shall meet the provision of K29.) Laboratories in Health Care occupancies and medical and dental offices shall be in accordance with NFPA 99, Standard for Health Care Facilities 10.5.1.

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 12


2000 CODE MET

K134

Emergency Shower: Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths designed and installed to avoid injurious water pressure shall be in accordance with NFPA 99, 10.6.

K135

Flammable and combustible liquids shall be used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Storage cabinets for flammable and combustible liquids shall be constructed in accordance with NFPA 30, Flammable and Combustible liquids Code NFPA 99, 4.3, 10.7.2.1.

NO MET

N/A

REMARKS

MEDICAL GASES AND ANESTHETIZING AREAS K76

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99, 4.3.1.1.2, 18.3.2.4, 19.3.2.4

K141

Non-smoking and no smoking signs in areas where oxygen is used or stored shall be in accordance with 18.3.2.4, 19.3.2.4, NFPA 99, 8.6.4.2

K143

Transferring of oxygen shall be: (a) separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) the area that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring; and (c) in an area that is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted in accordance with NFPA 99 and Compressed Gas Association. 8.6.2.5.2

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 13

Name of Facility

2000 CODE

ID PREFIX

MET

NO MET

N/A

REMARKS

ELECTRICAL K144

Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3.4.4.1, NFPA 110, 8.4.2.

K146

The nursing home/hospice with no life support equipment shall have an alternate source of power separate and independent from the normal source that will be effective for minimum of 11/2 hour after loss of the normal source NFPA 99, 3.6

K130

Miscellaneous List in the REMARKS sections, any items that are not listed previously, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Form CMS-2786S (06/07) EF 06/2007

Appendix 2-C

Page 14


FACILITY NAME

SURVEY DATE

* K4

* K4 MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________

NUMBER OF THIS BUILDING

____________

LSC FORM INDICATOR 1 2 3 4 5 6 7 8 9

*K7



2786 A-67 EXISTING A-67 NEW B-73 EXISTING B-73 NEW F-81 EXISTING F-81 NEW C-SHORT H-ASC J, K, L 85-CHAPTER 21 (ICFs/MR ONLY) P-85 EXISTING P-85 NEW

10 11

A B C D

SMALL

(16 BEDS OR LESS)

K8:


LARGE

K8:


APARTMENT HOUSE 7 PROMPT

SELECT NUMBER OF FORM USED FROM ABOVE K8:

8 SLOW 9 IMPRACTICAL

(Check if not applicable)

ENTER E – SCORE HERE K29:

K56: K5:

e.g. 2.5

*K9: FACILITY MEETS LSC BASED ON: (Check all that apply) A1. (COMP. WITH ALL PROVISIONS)

FACILITY DOES NOT MEET LSC: B.

A2.

A3.

(ACCEPTABLE POC)

A4.

(WAIVERS)

(FSES)

K0180





* MANDATORY

Form CMS-2786S (06/07) EF 06/2007

Page 14

Appendix 2-C



ZONE __________ OF __________ ZONES

FIRE/SMOKE ZONE* EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES 2000 LIFE SAFETY CODE FACILITY

BUILDING

ZONE(S) EVALUATED PROVIDER/VENDOR NO.

DATE OF SURVEY

COMPLETE THIS WORKSHEET FOR EACH ZONE. WHERE CONDITIONS ARE THE SAME IN SEVERAL ZONES, ONE WORKSHEET CAN BE USED FOR THOSE ZONES. Step 1: Determine Occupancy Risk Parameter Factors - Use Table 1. A. For each Risk Parameter in Table 1, select and circle the appropriate risk factor value. Choose only one for each of the five Risk Parameters. TABLE 1. OCCUPANCY RISK PARAMETER FACTORS Risk Parameters

Risk Factors Values

1. Patient Mobility (M)

Mobility Status

Mobile

Limited Mobility

Not Mobile

Not Movable

Risk Factor

1.0

1.6

3.2

4.5

2. Patient Density (D)

No. of Patients

1–5

6–10

11–30

>30

Risk Factor

1.0

1.2

1.5

2.0

3. Zone Location (L)

4. Ratio of Patients to Attendants (T) 5. Patient Average Age (A)

Floor

1st

2nd or 3rd

4th to 6th

7th and Above

Basements

Risk Factor

1.1

1.2

1.4

1.6

1.6

Patients Attendant

1–2 1

3–5 1

6–10 1

>10 1

One or More None

Risk Factor

1.0

1.1

1.2

1.5

4.0

Age

Under 65 Years and Over 1 year

65 Years and Over 1 Year and Younger

Risk Factor

1.0

1.2

Step 2: Compute Occupancy Risk Factor (F) - Use Table 2. A. Transfer the circled risk factor values from Table 1 to the corresponding blocks in Table 2. B. Compute F by multiplying the risk factor values as indicated in Table 2. TABLE 2. OCCUPANCY RISK FACTOR CALCULATION M

OCCUPANCY RISK Step 3: A. B. C.

D

L

T

A

F

xxxx =

Compute Adjusted Building Status (R) - Use Table 2. If building is classified as “NEW” use Table 3A. If building is classified as “Existing” use Table 3B. Transfer the value of F from Table 2 to Table 3A or Table 3B as appropriate. Calculate R. Transfer R to the block labeled R in Table 7 on page 4 of the work sheet. TABLE 3A. (NEW BUILDINGS) F

1.0

x

TABLE 3B. (EXISTING BUILDINGS)

R

F

=

0.6

x

R

=

* FIRE/SMOKE ZONE is a space separated from all other spaces by floors, horizontal exIts, or smoke barrIers.

SURVEYOR SIGNATURE

TITLE

DATE

FIRE AUTHORITY SIGNATURE

TITLE

DATE

Form CMS-2786T (06/07) EF 06/2007

Appendix 2-D

Page 1

Step 4: Determine Safety Parameter Values - Use Table 4. A. Select and circle the safety value for each safety parameter in Table 4 that best describes the conditions in the zone. Choose only one value for each of the 13 parameters. If two or more appear to apply, choose the one with the lowest point value. TABLE 4. Safety Parameters

Safety Parameters Values

1. Construction Floor or Zone First Second Third 4th and Above

Combustible Types III, IV, and V 000 -2 -7 -9 -13

NonCombustible Types I and II

111 0 -2 -7 -7

200 -2 -4 -9 -13

211 + 2HH 0 -2 -7 -7

000 0 -2 -7 -9

111 2 2 2 -7

2. Interior Finish (Corridors and Exits)

Class C -5(0)f

Class B 0(3)f

Class A 3

3. Interior Finish (Rooms)

Class C -3(1)f

Class B 1(3)f

Class A 3

None or Incomplete -10(0)a

1/2 to 1 hour 2(0)a

No Door

20 min FPR

>20 min FPR and Auto Clos.

-10

0

1(0)d

2(0)d

4. Corridor Partitions/Walls 5. Doors to Corridor

6. Zone Dimensions

7. Vertical Openings

>100 ft

Dead End >50 ft to 100 ft

30 ft to 50 ft

-6(0)b

-4(0)b

-2(0)b

Open 4 or More Floors

Open 2 or 3 Floors

-14

-10

8. Hazardous Areas

9. Smoke Control

10. Emergency Movement Routes

No Control

Smoke Barrier Serves Zone

-5(0)c

0

13. Automatic Sprinklers

NOTE:

2(0)e

3(0)e

0

No Manual Fire Alarm

No Deficiencies 0

1

Direct Exit(s) 5

Manual Fire Alarm W/O F.D. Conn. W/F.D. Conn 1 2

None

Corridor Only

Rooms Only

Corridor and Habit. Spaces

Total Spaces In Zone

0(3)g

2(3)g

3(3)g

4

5

None

Corridor and Habit. Space

Entire Building

0

8

10

Use (0) where parameter 5 is -10.

b


c

Use (0) on floor with fewer than 31 patients (existing buildings only)

d


Form CMS-2786T (06/07) EF 06/2007

>2 hr

0

3

-2

a

For SI units: 1 ft = 0.3048 m

1 hr to 150 ft 100 ft to 150 ft 1.5 ≤ 5.0

6.

 2000 NEW

5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATION DIFFICULTY (Check one)

Slow

> 5.0

 2000 EXISTING

K7

1.

 Prompt

2.



Slow

3.



Impractical

Impractical

K5

K8

6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY

e. NUMBER OF ICF/MR BEDS CERTIFIED FOR MEDICAID

 THE FACILITY MEETS, BASED UPON (check all appropriate boxes): 1.  COMPLIANCE WITH ALL PROVISIONS 2.  ACCEPTANCE OF A PLAN OF CORRECTION B.  THE FACILITY DOES NOT MEET THE STANDARD K9 7. A.


4.



FSES

5.




TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

SURVEYOR ID K10

FIRE AUTHORITY OFFICIAL (Signature)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 1

INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786V) SMALL FACILITIES —16 BEDS OR LESS 1. Complete a Worksheet for Rating Residents (CMS-2786M) for each resident in the facility. 2. Complete the first few pages of this form, a Worksheet for Calculating Evacuation Difficulty Score (Chapter 6 NFPA 101A, 2001 Edition). Note: This is the ONLY method permitted to determine Level of Evacuation Difficulty in SMALL facilities. 3. Transfer the E-Score obtained in Scoresheet F2 C (Page 5) to the E-SCORE block on Page 1 of this form. 4. Complete either Chapter 31 or 32 Requirements or the FSES/BC Appendix G - Rating the Building. A. If completing Chapter 31 or 32 Requirements: 1. PROMPT - Complete ONLY the PROMPT section of this form. 2. SLOW - Complete both PROMPT and SLOW sections of this form. 3. IMPRACTICAL - Complete all three sections of this form PROMPT, SLOW and IMPRACTICAL. B. If completing the FSES/BC - Appendix G - Rating The Building 1. You must also complete the Chapter 31 or 32 requirements. An FSES building evaluation cannot be done without completing the usual survey form pages for these Chapters. 2. You may use the FSES Health Care to evaluate the building (Form CMS-2786T), but if you choose to do so, you must also use the LSC Survey Report for Health Care Form CMS-2786R.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 2

Worksheet for Calculating Evacuation Difficulty Score (E-Score)

F-2 BEFORE FILLING OUT THIS WORKSHEET: • Please read the Instruction Manual. • Make sure you have the completed “Worksheets for Rating Residents” (CMS-2786M) for each resident. • Determine whether the requirements for using the Evacuation Difficulty Index have been satisfied by checking the one box to the left of each question below that shows whether the answer to the question is “YES” or “NO.”  Yes

 No

1. Has a protection plan been developed and written and have all staff members counted in the calculation of E-Scores been trained in its implementation?

 Yes

 No

2. Is the total available staff at any given time able to handle the individual evacuation needs of each resident who may be in the residence?

 Yes

 No

3. Can every staff member counted in the calculation of E-Scores meaningfully participate in the evacuation of every resident?

 Yes

 No

4. Are all staff members counted in the calculation of E-Scores required to remain in the residence with only the exceptions listed in the Instruction Manual?

 Yes

 No

5. Were at least twelve fire drills conducted during the year?

This worksheet is filled out for the staff “Shift” From ______________________________________ To ______________________________________ (You must fill out this worksheet for the time of day, week, etc., when the ratings for the combination of staff and residents yields the highest E-Score. This period of time will usually be late at night. When it is not obvious which time period has the highest E-Score, complete a separate worksheet for all candidate time periods and use the one having the highest E-Score.)

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 3

F-2A

Finding the Total Resident Score

1. List each resident's name in the scoresheet below. (Scoresheet F-2A) 2. For each resident, transfer the Evacuation Assistance Score (Part F-1B) from his/her Worksheet for Rating Residents (Step 1). 3. Add the Evacuation Assistance Score for all the residents and write the answer in the appropriate space at the bottom of Scoresheet F-2A.

Scoresheet F-2A

RESIDENT SCORES Evacuation Resident’s Name Assistance Score

Resident's Name

Evacuation Assistance Score


Resident's Name

Evacuation Assistance TOTAL

F-2B

Finding the Staff Shift Score

1. In Scoresheet F-2B (below), list the names of staff members who are required to remain in the group home during the time period (shift) specified on the front page of this worksheet. 2. Determine whether the effectiveness of the alarm system is rated as "assured" or "not assured" as explained in the Instruction Manual. 3. Using the appropriate “assured” or “not assured” column in the table below, find each staff member's Promptness of Response Score for the time period specified. Write each staff member's score in the appropriate space in Scoresheet F-2B. 4. Add the staff members’ Promptness of Response Scores and write the total in the appropriate space in Scoresheet F-2B.

Scoresheet F-2B

STAFF SCORES

Staff’s Name

Promptness of Response Score

Staff's Name


PROMPTNESS OF RESPONSE SCORES Alarm Effectiveness Staff Availability Assured Not Assured Standby or asleep

16

2

Immediately available

20

2

Immediately available & close by

20

10

Staff Shift TOTAL NOTE: If the facility is a large residential facility, staff members may be responsible for assisting the residents in a fire/smoke zone, but may also have responsibilities for residents in other fire/smoke zones. See the glossary for Step 2 for the special procedure for assigning Promptness of Response Scores. Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 4

F-2C

Finding the Home's Evacuation Difficulty Score

1. Rate the home on the factor below by checking the circle that best describes the home. Vertical Distance From Bedrooms to Exits

Small Facility

All BR on floor with direct exits

Any BR one floor from exit

Any BR two or more floors from exit

 score = 0.8

 score = 1.0

 score = 1.2

Large Facility or Apartment

 score = 1.0

2. Write the score for the category you checked in the appropriate box in Scoresheet F-2C below. 3. Compute the E-Score as show in Scoresheet F-2C: a. Multiply the Resident Score Total by the score for Vertical Distance from Bedrooms to Exits. b. Divide the answer by the Staff Shift Score Total to find the Evacuation Difficulty Score (E-Score).

CALCULATION OF E-SCORE

Scoresheet F-2C

Vertical Distance from Bedrooms to Exits

Resident Score Total

x Staff Shift Score Total

ENTER THIS SCORE on COVER of THIS FORM E-SCORE

=

4. Determine and record Level of Evacuation Difficulty appropriate to the Calculated E-Score; use Scoresheet F-2D. Scoresheet F-2D E-Score

Level of Evacuation Difficulty

≤ 1.5

Prompt

> 1.5 ≤ 5.0

Slow

> 5.0

Impractical

Form CMS-2786V (06/07) EF 06/2007


Appendix 2-E

Page 5

ID PREFIX

SMALL FACILITY PROMPT EVACUATION

NO MET MET

N/A

REMARKS

BUILDING CONSTRUCTION No Requirements HAZARDOUS AREAS K29

2000 EXISTING Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means. (a) Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour. (b) Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.2.4, located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8. 33.2.3.2.2. 2000 NEW Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means: (a) Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.18 that has a fire protection rating of not less than 3/4 hour. The enclosure shall be protected by an automatic fire detection system connected to the fire alarm system provided in 32.2.3.4.1. (b) Protection shall be automatic sprinkler protection, in accordance with 32.2.3.5, and a smoke partition, in accordance with 8.2.4, located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8, 32.2.3.2.2.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 6

ID PREFIX

K211

NO MET MET

N/A

REMARKS

2000 EXISTING Where Alcohol Based Hand Rub (ABHR) dispensers are installed:  The corridor is at least 6 feet wide  The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)  The dispensers shall have a minimum spacing of 4 ft from each other  Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.  Dispensers are not installed over or adjacent to an ignition source.  If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 483.70 2000 NEW Where Alcohol Based Hand Rub (ABHR) dispensers are installed:  The corridor is at least 6 feet wide  The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)  The dispensers shall have a minimum spacing of 4 ft from each other  Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.  Dispensers are not installed over or adjacent to an ignition source.  If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 483.470

K119

2000 EXISTING Other hazardous areas shall be protected in accordance with 33.2.3.2.3 by one of the following: (1) An enclosure having a fire resistance rating of not less than 1 /2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction. (2) Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 7

ID PREFIX

NO MET MET

N/A

REMARKS

2000 NEW Other hazardous areas shall be protected in accordance with 32.2.3.2.3 by one of the following: (1) An enclosure having a fire resistance rating of not less than 1 /2 hour, with a self-closing or automatic closing door in accordance with 7.2.1.8 that is equivalent of not less than 13/4 inch (4.4 cm) thick, solid-bonded wood core construction and is protected by an automatic fire detection system connected to the fire alarm system provided in 32.2.3.1. (2) Automatic sprinkler protection in accordance with 32.2.3.5, regardless of enclosure. FIRE ALARM SYSTEMS K51

2000 EXISTING A manual fire alarm system shall be provided in accordance with Section 9.6, 33.2.3.4.1.  Exception No 1: Where there are interconnected smoke detectors meeting the requirements of 33.2.3.4.3 and there is not less than one manual fire alarm box per floor arranged to continuously sound the smoke detector alarms.  Exception No. 2: Other manually activated continuously sounding alarms acceptable to the authority having jurisdiction. 2000 NEW A manual fire alarm system shall be provided in accordance with Section 9.6, 32.2.3.4.1.

K155


Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 8

ID PREFIX

NO MET MET

N/A

REMARKS

SMOKE SYSTEMS K53

2000 EXISTING Approved smoke alarms shall be provided in accordance with 9.6.2.10. These alarms shall be powered from the building electrical system and when activated, shall initiate an alarm that is audible in all sleeping areas. Smoke alarms shall be installed on all levels, including basement but excluding crawl spaces and unfinished attics. Additional smoke alarms shall be installed for living rooms, dens, day rooms, and similar spaces. 33.2.3.4.3.  Exception No 1: Buildings protected throughout by an approved automatic sprinkler system, in accordance with 33.2.3.5, that uses quick response or residential sprinklers, and protected with approved smoke alarms installed in each sleeping room in accordance with 9.6.2.10, that are powered by the building electrical system.  Exception No. 2: Where buildings are protected throughout by an approved automatic sprinkler system, in accordance with 33.3.2.5, that uses quick-response or residential sprinklers, with existing battery-powered smoke alarms in each sleeping room, and where, in the opinion of the authority having jurisdiction, the facility has demonstrated that testing, maintenance, and a battery replacement program ensure the reliability of power to smoke alarms. 2000 NEW Approved smoke alarms shall be provided in accordance with 9.6.2.10, 32.2.3.4.3.1. Smoke alarms shall be installed on all levels, including basements but excluding crawl spaces and unfinished attics. Additional smoke alarms shall be installed for all living areas as defined in 3.3.119.  Exception: Smoke alarms shall not be required in buildings protected throughout by an approved automatic sprinkler system in accordance with 32.2.3.5.

K56

2000 EXISTING Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7, 33.2.3.5.2 and shall activate the fire alarm system in accordance with 33.2.3.4.1. The adequacy of the water supply shall be documented to the authority having jurisdiction.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 9

ID PREFIX

NO MET MET

N/A

REMARKS

 Exception No. 1: In prompt evacuation facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One and two Family Dwellings and Manufactured Homes, shall be permitted. Automatic sprinklers shall not be required in closets not exceeding 24 sq. ft. and in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or materials providing a 15 minute thermal barrier.  Exception No. 2: Not applicable  Exception No. 3: In prompt and slow evacuation capability facilities where an automatic sprinkler system is in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, automatic sprinklers shall not be required in closets not exceeding 24 sq. ft and in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or material providing a 15 minute thermal barrier.  Exception No. 4: In prompt and slow evacuation capability facilities up to and including four stories in height, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted.  Exception No. 5: Not applicable  Exception No. 6: Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.2.3.5.5. 2000 NEW Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall initiate the fire alarm system in accordance with 32.2.3.4.1, 32.2.3.5.2. The adequacy of the water supply shall be documented to the authority having jurisdiction.  Exception No. 1: In prompt evacuation facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One and Two Family Dwellings and Manufactured Homes, shall be permitted. Facilities with more than eight residents shall be permitted. Facilities with more than eight residents shall be treated as two-family dwellings with regard to water supply. Additionally entrance foyers shall be sprinklered.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 10

ID PREFIX

NO MET MET

N/A

REMARKS

 Exception No. 2: Not applicable  Exception No. 3: In prompt and slow evacuation capability facilities where an automatic sprinkler system is in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, automatic sprinklers shall not be required in closets not exceeding 24 sq. ft and in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or material providing a 15 minute thermal barrier.  Exception No. 4: In prompt and slow evacuation capability facilities up to and including four stories in height, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted.  Exception No. 5: Not applicable  Exception No. 6: Initiation of the fire alarm system shall not be required for existing installations in accordance with 32.2.3.5.5. K154

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1 A. Date sprinkler system last checked and necessary maintenance provided. _____________________________________________ B. Show who provided the service. __________________________ C. Note the source of the water supply for the automatic sprinkler system._______________________________________________ (Provide, in REMARKS, information on coverage for any non-required or partial automatic sprinkler system.)

K144

2000 NEW All facilities shall be protected throughout by an approved automatic sprinkler system in accordance with 32.2.3.5.2, 32.2.3.5.1. Quick response or residential sprinklers shall be provided.  Exception No. 1: In conversions, sprinklers shall not be required in small board and care homes with a rating of prompt evacuation capability and serving eight or fewer residents.  Exception No. 2: Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 32.2.3.2.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 11

ID PREFIX

NO MET MET

N/A

REMARKS

INTERIOR FINISH K14

2000 EXISTING Interior wall and ceiling finish shall be Class A or Class B in accordance with section 10.2, 33.2.3.3. There shall be no requirements for interior floor finish.  Exception: Class C interior wall and ceiling finish shall be permitted in prompt evacuation capability facilities. 2000 NEW Interior wall and ceiling finish materials complying with 10.2.3 shall be Class A or Class B. 32.2.3.3.2.  Exception: Class C interior wall and ceiling finish shall be permitted in prompt evacuation capability facilities. SEPARATION OF SLEEPING ROOMS

K17

2000 EXISTING The separation walls of sleeping rooms shall be capable of resisting fire for not less than 1/2 hour, which is considered to be achieved if the partitioning is finished on both sides with lath and plaster or materials providing a 15 minute thermal barrier. Sleeping room doors shall be substantial doors, such as those of 13/4 inch thick, solid-bonded wood core construction or other construction of equal or greater stability and fire integrity. Any vision panels shall be fixed fire window assemblies in accordance with 8.2.3.2.2 or shall be wired glass not exceeding 1296 sq. in. each in area and installed in approved frames. 33.2.3.6.1, 33.2.3.6.2.  Exception No. 1: In prompt evacuation facilities, all sleeping rooms shall be separated from the escape route by smoke partitions in accordance with 8.2.4. Door closing shall be regulated by 33.2.3.6.4.  Exception No. 2: This requirement shall not apply to corridor walls that are smoke partitions in accordance with 8.2.4 and that are protected by automatic sprinklers in accordance with 33.2.3.5 on both sides of the wall and door. In such instances, there shall be no limitation on the type or size of glass panels. Door closing shall be regulated by 33.2.3.6.4.  Exception No. 3: Sleeping arrangements that are not located in sleeping rooms shall be permitted for nonresident staff members, provided that the audibility of the alarm in the sleeping area is sufficient to awaken staff that might be sleeping.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 12

ID PREFIX

NO MET MET

N/A

REMARKS

 Exception No. 4: In previously approved facilities, where the group achieves an E-score of three or less using the board and care methodology of NFPA 101A. Guide on Alternative Approaches to Life Safety, sleeping rooms shall be separated from escape routes by walls and doors that are smoke resistant. No louvers or operable transoms or other air passages shall penetrate the wall, except properly installed heating and utility installations other than transfer grilles. Transfer grilles shall be prohibited. 2000 NEW The separation walls of sleeping rooms shall be capable of resisting fire for not less than 1/2 hour, which is considered to be achieved if the partitioning is finished on both sides with lath and plaster or materials providing a 15 minute thermal barrier. Sleeping room doors shall be substantial doors, such as those of 13/4 inch thick, solid-bonded wood core construction or other construction of equal or greater stability and fire integrity. Any vision panels shall be fixed fire window assemblies in accordance with 8.2.3.2.2. or shall be wired glass not exceeding 1296 sq. in. each in area and installed in approved frames. 32.2.3.6.1 and 32.2.3.6.2.  Exception No. 1: In prompt evacuation capability facilities, all sleeping rooms shall be separated from the escape route by smoke partitions in accordance with 8.2.4. Door closing shall be regulated by 32.2.3.6.4.  Exception No. 2: This requirement shall not apply to corridor walls that are smoke partitions in accordance with 8.2.4 and that are protected by automatic sprinklers in accordance with 32.2.3.5 on both sides of the wall and door. In such instances, there shall be no limitation on the type or size of glass panels. Door closing shall be regulated by 32.2.3.6.4.  Exception No. 3: Sleeping arrangements that are not located in sleeping rooms shall be permitted for nonresident staff members, provided that the audibility of the alarm in the sleeping area is sufficient to awaken staff that might be sleeping. No louvers or operable transoms or other air passages shall penetrate the wall, except properly installed heating and utility installations other than transfer grilles. Transfer grilles shall be prohibited.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 13

ID PREFIX

K18

NO MET MET

N/A

REMARKS

Doors shall be provided with latches or other mechanisms suitable for keeping the doors closed. No doors shall be arranged to prevent the occupant from closing the door. 32.2.3.6.3, 32.2.3.6.4, 33.2.3.6.3, 33.2.3.6.4 Doors shall be self-closing or automatic closing in accordance with 7.2.1.8  Exception: Door closing devices shall not be required in buildings protected throughout by an approved automatic sprinkler system in accordance with 32.2.3.5.1 and 33.2.3.5.2. EGRESS

K41

Every sleeping room and living area shall have access to a primary means of escape located to provide a safe path of travel to the outside. 33.2.2.2.1. Where sleeping rooms or living areas are above or below the level of exit discharge, the primary means of escape shall be an interior stair in accordance with 32.2.2.4 and 33.2.2.4, an exterior stair, a horizontal exit, or a fire escape stair. 32.2.2.2.

K120

2000 EXISTING In addition to the primary route, each sleeping room shall have a second means of escape that consists of one of the following: (a) It shall be a door, stairway, passage, or hall providing a way of unobstructed travel to the outside of the dwelling at street or ground level that is independent of and remotely located from the primary means of escape. (b) It shall be a passage through an adjacent nonlockable space, independent of and remotely located from the primary means of escape, to approved means of escape. (c) It shall be an outside window or door operable from the inside without the use of tools, keys, or special effort that provides a clear opening of not less than 5.7 sq. ft. The width shall be not less than 20 inches. The height shall be not less than 24 inches. The bottom of the opening shall be not more than 44 inches above the floor. Such means of escape shall be acceptable where one of the following criteria are met:

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 14

ID PREFIX

NO MET MET

N/A

REMARKS

(1) The window shall be within 20 ft of grade. (2) The window shall be directly accessible to fire department rescue apparatus as approved by the authority having jurisdiction. (3) The window or door shall open onto an exterior balcony. 33.2.2.3  Exception No. 1: If the sleeping room has a door leading directly to the outside of the building with access to grade or to a stairway that meets the requirements of exterior stairs in 33.2.3.1.2, that means of escape shall be considered as meeting all the escape requirements for the sleeping room.  Exception No. 2: A second means of escape from each sleeping room shall not be required where the facility is protected throughout by approved automatic sprinkler system in accordance with 33.2.3.5.  Exception No. 3: Existing approved means of escape shall be permitted to continue to be used. 2000 NEW In addition to the primary route, each sleeping room in facilities that use Exception No. 1 to 32.2.3.5.1 shall have a second means of escape that consists of one of the following: (d) It shall be a door, stairway, passage, or hall providing a way of unobstructed travel to the outside of the dwelling at street or ground level that is independent of and remotely located from the primary means of escape. (e) It shall be a passage through an adjacent nonlockable space, independent of and remotely located from the primary means of escape, to approved means of escape. (f) It shall be an outside window or door operable from the inside without the use of tools, keys, or special effort that provides a clear opening of not less than 5.7 sq. ft. The width shall be not less than 20 inches. The height shall be not less than 24 inches. The bottom of the opening shall be not more than 44 inches above the floor. Such means of escape shall be acceptable where one of the following criteria are met: (1) The window shall be within 20 ft of grade. (2) The window shall be directly accessible to fire department rescue apparatus as approved by the authority having jurisdiction. Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 15

ID PREFIX

NO MET MET

N/A

REMARKS

(3) The window or door shall open onto an exterior balcony. 33.2.2.3  Exception: If the sleeping room has a door leading directly to the outside of the building with access to grade or to a stairway that meets the requirements of exterior stairs in 32.2.3.1.2, that means of escape shall be considered as meeting all the escape requirements for the sleeping room. K20

2000 EXISTING Interior stairs used as a primary means or escape shall be enclosed with 1/2 hour fire barriers, with all openings equipped with smokeactuated automatic closing or self-closing doors having a fire protection rating comparable to that required for the enclosure. Stairs shall comply with 7.2.2.5.3. The entire primary means of escape shall be arranged so that it is not necessary for the occupants to pass through a portion of a lower story unless that route is separated from all spaces on that story by construction having not less than a 1/2 hour fire resistance rating. In buildings of construction other than Type II (000), Type III (200), or Type V (000), the supporting construction shall be protected to afford the required fire resistance rating of the supported wall. 33.2.2.4.  Exception No. 1: Stairs that connect a story at street level to only one other story shall be permitted to be open to the story that is not at street level.  Exception No. 2: Stair enclosures shall not be required in buildings of three or fewer stories that house prompt or slow evacuation capability facilities protected through out by an approved automatic sprinkler system in accordance with 33.2.3.5 that uses quick response or residential sprinklers. This exception shall be permitted only if a primary means of escape from each sleeping area still exists that does not pass through a portion of a lower floor, unless that route is separated from all spaces on that floor by construction having a 1/2 hour fire resistance rating.  Exception No. 3: Stair enclosures shall not be required in buildings of two or fewer stories that house prompt evacuation capability facilities with not more than eight residents and are protected by an approved automatic sprinkler system in accordance with 33.2.3.5 that uses quick-response or residential sprinklers. Exception No. 2 to 33.2.2.3 shall not be used in conjunction with this exception. The exceptions to 33.2.3.4.3 shall not be used in conjunction with this exception.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 16

ID PREFIX

NO MET MET

N/A

REMARKS

 Exception No. 4: In buildings of three or fewer stories that house prompt or slow evacuation capability facilities protected by an approved automatic sprinkler system in accordance with 33.2.3.5 stairs shall be permitted to be open at the topmost story only. The entire primary means of escape of which the stairs are a part shall be separated from all portions of lower stories. 2000 NEW 32.2.2.4 Interior stairs shall be enclosed with 1/2 hour fire barriers, with all openings equipped with smoke-actuated automatic closing or self-closing doors having a fire protection rating comparable to that required for the enclosure. Stairs shall comply with 7.2.2.5.3. The entire primary means of escape shall be arranged so that it is not necessary for the occupants to pass from all spaces on that story by construction having not less than a 1/2 hour fire resistance rating. In buildings of construction other than Type II (000), Type III (200), or Type V (000), the supporting construction shall be protected to afford the required fire resistance rating of the supported wall.  Exception No. 1: Stairs that connect a story at street level to only one other story shall be permitted to be open to the story that is not at street level.  Exception No. 2: Stair enclosures shall not be required for prompt and slow evacuation capability facilities in buildings of three or fewer stories that are protected with an approved automatic sprinkler system in accordance with 32.2.3.5. This exception shall be permitted only if a primary means of escape from each sleeping area still exists that does not pass through a portion of a lower floor, unless that route is separate from all spaces on that floor by construction having a 1/2 hour fire resistance rating.  Exception No. 3: Stair enclosures shall not be required in buildings of two or fewer stories that house prompt evacuation capability facilities with not more than eight residents. The exception to 32.2.3.4.3.1 shall not be used in conjunction with this exception. Exception No. 1 to 32.2.3.5.1 shall not be used in conjunction with this exception.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 17

ID PREFIX

K21

NO MET MET

N/A

REMARKS

32.2.3.1.1, 33.2.3.1.1 Vertical openings shall be protected so as not to expose a primary means of escape. Vertical openings shall be considered protected if separated by smoke partitions in accordance with 8.2.4 that prevent the passage of smoke from one story to any primary means of escape on another story. Smoke partitions shall have a fire resistance rating on not less than 1/2 hour. Any doors or openings to the vertical opening shall be capable of resisting fire for not less than 20 minutes.  Exception: Stairs shall be permitted to be open where complying with Exception no. 2 or Exception No. 3 to 32.2.2.4, 33.2.2.4.

K40

2000 EXISTING 33.2.2.5.1 Doors or paths of travel to a means of escape shall not be less than 28 inches.  Exception: Bathroom doors shall not be less than 24 inches. 2000 NEW 32.2.2.5.1 Doors or paths of travel to means of escape shall be not less than 32 inches.  Exception No. 1: Bathroom doors shall be not less than 24 inches.  Exception No. 2: In conversions (see 32.1.1.3), 28 inch doors shall be permitted to continue in use.

K121

Winders complying with 7.2.2.2.4 shall be permitted 32.2.2.6.2., 33.2.2.6.2

K122

Every closet door latch shall be readily opened from the inside in case of an emergency. 32.2.2.5, 33.2.2.5.3

K123

Every bathroom door shall be designed to allow opening from the outside during an emergency when locked. 32.2.2.5.4, 33.2.2.5.4

K43

No door in any means of escape shall be locked against egress when the building is occupied.  Exception: Delayed egress locks complying with 7.2.1.6.1 shall be permitted on exterior doors. 32.2.2.5.5, 33.2.2.5.5.

If the level of evacuation difficulty is PROMPT, stop here.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 18

ID PREFIX

NO MET MET

N/A

REMARKS

SMALL FACILITY – SLOW EVACUATION BUILDING CONSTRUCTION K11

2000 EXISTING 33.2.1.3.2 The facility shall be housed in a building where the interior is fully sheathed with lath and plaster or other material providing a 15 minute thermal barrier, including all portions of bearing walls, bearing partitions, floor construction, and roofs. All columns, beams, girders, and trusses shall be similarly encased or otherwise shall provide not less than a 1/2 hour fire resistance rating. 33.2.1.3.2.  Exception No. 1: Exposed steel or wood columns, girders, and beams (but not joists) located in the basement.  Exception No. 2: Buildings of Type I, Type II (2,2,2), Type II (1,1,1), Type III (2,1,1), Type IV, Type V (1,1,1) construction (See 8.2.1)  Exception No. 3: Areas protected by approved automatic sprinkler systems in accordance with 33.2.3.5.  Exception No. 4: Unfinished, unused, and essentially inaccessible loft, attic, or crawl space.  Exception No. 5: Where the facility achieves an E-score of three or less using the board and care occupancies evacuation capability determination methodology of NFPA 101A, Guide on Alternative Approaches to Life Safety. Note: No requirement for New - Chapter 32 INTERIOR FINISH

K16

Interior wall and ceiling finish materials in accordance with 10.2 and 10.2.3 shall be Class A or Class B. 32.2.3.3.2, 33.2.3.3

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 19

ID PREFIX

NO MET MET

N/A

REMARKS

AUTOMATIC SPRINKLER SYSTEM K145

2000 NEW 32.2.3.5.1 All facilities shall be protected throughout by an approved automatic sprinkler system in accordance with 32.2.3.5.2. Quick response or residential sprinklers shall be provided.  Exception No. 1: In conversions, sprinklers shall not be required in small board and care homes with a rating of prompt evacuation capability and serving eight or fewer residents.  Exception No. 2: Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 32.2.3.2.

K56

2000 EXISTING 33.2.3.5.2 Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall activate the fire alarm system in accordance with 33.2.3.4.1. The adequacy of the water supply shall be documented to the authority having jurisdiction.  Exception No. 1: Not Applicable  Exception No. 2: In slow and impractical evacuation capability facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in one-andtwo-Family Dwellings and Manufactured Homes, with a 30 minute water supply, shall be permitted. All habitable areas and closets shall be sprinklered. Automatic Sprinklers shall not be required in bathrooms not exceeding 55 ft2 (5.1 m2), provided that such spaces are finished with bath and plaster or materials provided a 15 minute thermal barrier.  Exception No. 3: In prompt and slow evacuation capability facilities where an automatic sprinkler system is in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, automatic sprinklers shall not be required in closets not exceeding 24 sq. ft. and in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or material providing a 15 minute thermal barrier.  Exception No. 4: In prompt and slow evacuation capability facilities up to and including four stories in height, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted.  Exception No. 5: Not Applicable

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 20

ID PREFIX

NO MET MET

N/A

REMARKS

 Exception No. 6: Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.2.3.5.5. 2000 NEW 32.2.3.5.2 Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall initiate the fire alarm system in accordance with 32.2.3.4.1. The adequacy of the water supply shall be documented to the authority having jurisdiction.  Exception No. 2: In slow and impractical evacuation capability facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in one-andtwo Family Dwellings and Manufactured Homes, with a 30 minute water supply, shall be permitted. All habitable areas and closets shall be sprinklered. Facilities with more than eight residents shall be treated as two family dwellings with regard to water supply.  Exception No. 3: In prompt and slow evacuation capability facilities where an automatic sprinkler system is in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, automatic sprinklers shall not be required in closets not exceeding 24 sq. ft. and in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or material providing a 15 minute thermal barrier.  Exception No. 4: In prompt and slow evacuation capability facilities up to and including four stories in height, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted.  Exception No. 5: Not Applicable  Exception No. 6: Initiation of the fire alarm system shall not be required for existing installations in accordance with 32.2.3.5.5. EGRESS K32

2000 EXISTING (Only) 33.2.2.2.2 In slow and impractical evacuation capability facilities, the primary means of escape for each sleeping room shall not be exposed to living areas and kitchens.  Exception: Buildings equipped with quick-response or residential sprinklers throughout. Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2.

If the level or evacuation capability is SLOW, stop here. Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 21

ID PREFIX

NO MET MET

N/A

REMARKS

SMALL FACILITY IMPRACTICAL EVACUATION CAPABILITY BUILDING CONSTRUCTION K12

2000 EXISTING Buildings shall be of any construction type in accordance with 8.2.1 other than Type II (000), Type III (200), or Type V (000) construction. 33.2.1.3.3.  Exception: Buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with 33.2.3.5 shall be permitted to be of any type of construction. AUTOMATIC SPRINKLER SYSTEM

K56

2000 EXISTING Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall activate the fire alarm system in accordance with 33.2.3.4.1. The adequacy of the water supply shall be documented to the authority having jurisdiction. 33.2.3.5.2.  Exception No. 1: Not Applicable.  Exception No. 2: In slow and impractical evacuation capability facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One and Two Family Dwellings and Manufactured Homes, with a 30 minute water supply, shall be permitted. All habitable areas and closets shall be sprinklered. Automatic sprinklers shall not be required in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or materials providing a 15 minute thermal barrier.  Exception No. 3: Not Applicable.  Exception No. 4: Not Applicable.  Exception No. 5: In impractical evacuation capability facilities up to and including four stories in height, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted. All habitable areas and closets shall be sprinklered. Automatic sprinklers shall not be required in bathrooms not exceeding 55 sq. ft., provided that such spaces are finished with lath and plaster or materials providing a 15 minute thermal barrier.  Exception No. 6: Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.2.3.5.5.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 22

ID PREFIX

NO MET MET

N/A

REMARKS

2000 NEW Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall initiate the fire alarm system in accordance with 32.2.3.4.1. The adequacy of the water supply shall be documented to the authority having jurisdiction. 32.2.3.5.2.  Exception No. 1: Not Applicable.  Exception No. 2: In slow and impractical evacuation capability facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One and Two Family Dwellings and Manufactured Homes, with a 30 minute water supply, shall be permitted. All habitable areas and closets shall be sprinklered. Facilities with more than eight residents shall be treated as two family dwellings with regard to water supply.  Exception No. 3: Not Applicable.  Exception No. 4: Not Applicable.  Exception No. 5: In impractical evacuation capability facilities up to and including four stores in height, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stores in Height, shall be permitted. All habitable areas and closets shall be sprinklered.  Exception No. 6: Initiation of the fire alarm system shall not be required for existing installations in accordance with 32.2.3.5.5. VERTICAL OPENINGS K20

Vertical openings shall be protected so as not to expose a primary means of escape. Vertical openings shall be considered protected if separated by smoke partitions in accordance with 8.2.4 that prevent the passage of smoke from one story to any primary means of escape on another story. Smoke partitions shall have a fire resistance rating of not less than a 1/2 hour. Any doors or openings to the vertical opening shall be capable of resisting fire for not less than 20 minutes. 32.2.3.1.1, 33.2.3.1.1  Exception: Stairs shall be permitted to be open where complying with Exception No. 2 or Exception No. 3 to 32.2.2.4 and 33.2.2.4.

Note: Make sure you have completed PROMPT and SLOW as well as this section. Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 23

ID PREFIX

NO MET MET

N/A

REMARKS

OPERATING FEATURES FOR ALL FACILITIES K46

Utilities shall comply with Section 9.1. 32.2.5.1, 33.2.5.1

K147

The administration of every resident board and care facility shall have in effect and available to all supervisory personnel written copies of a plan for protecting all persons in the event of fire, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating person from the building when necessary. The plan shall include special staff response, including fire protection procedures needed to ensure the safety of any resident, and shall be amended or revised whenever any resident with unusual needs is admitted to the home. All employees shall be periodically instructed and kept informed with respect to their duties and responsibilities under the plan. Such instruction shall be reviewed by the staff not less than every 2 months. A copy of the plan shall be readily available at all times within the facility. 32.7.1, 33.7.1

K148

Smoking regulations shall be adopted by the administration of board and care occupancies. 32.7.4.1, 33.7.4.1

K149

Where smoking is permitted, noncombustible safety type ashtrays or receptacles shall be provided in convenient locations. 32.7.4.2, 33.7.4.2

K150

New draperies, curtains, and other similar loosely hanging furnishings and decorations in board and care facilities shall be in accordance with provisions of 10.3.1. 32.7.5.1, 33.7.5.1

K151

New upholstered furniture within board and care facilities shall be tested in accordance with the provisions of 10.3.2(1) and 10.3.3.  Exception: Upholstered furniture belonging to the resident in sleeping rooms, provided that a smoke alarm is installed in such rooms. Battery-powered single-station smoke alarms shall be permitted. 32.7.5.2, 33.7.5.2

K152

CFR-42-483.470(i) Evacuation Drills (1) The facility must hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to –  (i) Ensure that all personnel on all shifts are trained to per form assigned tasks:  (ii) Ensure that all personnel on all shifts are familiar with the use of the facility’s emergency and disaster plans and procedures.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 24

ID PREFIX

NO MET MET

N/A

REMARKS

(2) The facility must –  (i) Actually evacuate clients during at least one drill each year on each shift;  (ii) Make special provisions for the evacuation of clients with physical disabilities:  (iii) File a report and evaluation on each drill:  (iv) Investigate all problems with evacuation drills, including accidents and take corrective action: and  (v) During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code. (3) Facilities must meet the requirements of paragraphs (i) (1) and (2) of this section for any live-in and relief staff that they utilize.

Form CMS-2786V (06/07) EF 06/2007

Appendix 2-E

Page 25


FACILITY NAME

SURVEY DATE

K1

K6

* K4

K3




LSC FORM INDICATOR

____________

12 13

14 15


SMALL

(16 BEDS OR LESS)

K8:


LARGE

K8:


16 17


*K9:





APARTMENT HOUSE

K8: * K7




2786U 2786U

A B C D

K5:

K56:

e.g. 2.5




A3.

A4.

(WAIVERS)

A5. (FSES)


K0180





* MANDATORY

Form CMS-2786V (06/07) EF 06/2007

Page 26

Appendix 2-E


2000 CODE ICFs/MR

FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded

1. (A) PROVIDER NO.

LARGE



K1

K2

PART I — Figure 6.8 — A Procedure for Determining Evacuation Capability PART II — Chapters 32 & 33 — Residential Board & Care Occupancies — Requirements PART III — Figure 7.5 — Fire Safety Evaluation System for Board & Care (Optional) — CMS-2786T Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE A.

2. (A) MULTIPLE CONSTRUCTION

2. NAME OF FACILITY

 Fully Sprinklered

(All required areas are sprinklered)

A. BUILDING

B. C.

C. FLOOR 4. DATE OF SURVEY


SURVEY UNDER:

K4

K6

K7

9.

E–Score


< 1.5 > 1.5 < 5.0 > 5.0

Prompt Slow Impractical

 2000

 Chapter 32 New

 Chapter 33 Existing

5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY LEVEL OF EVACUATION DIFFICULTY (check one)

4. Prompt

6. Impractical

5. Slow

K8

K5

6. BED COMPOSITION A. TOTAL NO. OF BEDS IN THE FACILITY

7.

 None (No sprinkler system)

K0180

K3

E–Score

 Partially Sprinklered


B. WING

E. NUMBER OF BEDS CERTIFIED FOR MEDICAID

A. THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES) 1.



COMPLIANCE WITH ALL PROVISIONS

2.



ACCEPTANCE OF A PLAN OF CORRECTION

4.



FSES

5.




B. THE FACILITY DOES NOT MEET THE STANDARDS K9

SURVEYOR (SIGNATURE)

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

SURVEYOR ID K10

FIRE AUTHORITY OFFICIAL (SIGNATURE)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242.The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-2786W (06/07) EF 06/2007

Page 1

Appendix 2-F

INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786K) LARGE FACILITIES — 17 BEDS OR MORE 1. DetermIne the Level of Evacuation Capability of the facility. 2. Transfer the E-Score obtained in Fig. 6.8 of page 1 of this form. 3. Complete either LSC Chapter 32 for (new) or LSC Chapter 33 for (existing) requirements of this form, or Fig. 7.5 — Rating the Building. A. If completing Chapter 32 or 33 Requirements: 1. PROMPT OR SLOW - Complete sections for PROMPT and SLOW 2. Impractical - Complete a CMS-2786R (Health Care) or FSES/Health Care (Optional) — see page 13. B. If completIng the FSES/BC — Chapter 32 or 33 — Rating the Building 1. You MUST also complete the Chapter 32 or 33 requirements. An FSES building evacuation cannot be done without completing the usual survey form pages for Chapter 32 or 33 2. You may use the FSES/Health Care to evaluate the building (Form CMS-2786T Chapter 4 & Fig. 4.7), but if you choose to do so, you must use the LSC Survey Report for Health Care (CMS-2786R)

*Figures for FSES/HC are taken from NFPA 101 A 2001 Edition

Form CMS-2786W (06/07) EF 06/2007

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Appendix 2-F

Worksheet for Calculating Evacuation Difficulty Score (E-Score)

F-2 BEFORE FILLING OUT THIS WORKSHEET: • • •

Please read the Instruction Manual. Make sure you have the completed “Worksheets for Rating Residents” (figure 6.8) for each resident. Determine whether the requirements for using the Evacuation Difficulty Index have been satisfied by checking the one box to the left of each question below that shows whether the answer to the question is “YES” or “NO.”

 YES

 NO 1. Has a protection plan been developed and written and have all staff members counted in the calculation of E-Scores been trained in its implementation?

 YES

 NO 2. Is the total available staff at any given time able to handle the individual evacuation needs of each resident who may be in the residence?

 YES

 NO 3. Can every staff member counted in the calculation of E-Scores meaningfully participate in the evacuation of every resident?

 YES

 NO 4. Are all staff members counted in the calculation of E-Scores required to remain in the residence with only the exceptions listed in the Instruction Manual?

 YES

 NO 5. Were at least twelve fire drills conducted during the year?

This worksheet is filled out for the staff “Shift” From

To

(You must fill out this worksheet for the time of day, week, etc. when the ratings for the combination of staff and residents yields the highest E-Score. This period of time will usually be late at night. When it is not obvious which time period has the highest E-Score, complete a separate worksheet for all candidate time periods and use the one having the highest E-Score.) EVALUATOR’S NAME (if other than Fire Authority Surveyor)

DATE

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Appendix 2-F

Worksheet 6.8.1 Cover Sheet Resident’s name___________________________________________________________________________________ Evaluator___________________________________________________________________________________ Facility __________________________________________________________________________________________ Date ______________________________________________________________________________________ Zone ______________________________________________________________________________________ Write any explanatory remarks here:

Worksheet 6.8.2 Rating the Resident on the Risk Factors Rate the resident on each of the factors below by checking the one circle for each risk factor that best describes the resident. For the first six factors, write the scores for the circles checked in the appropriate score boxes in the far right column. For “Response to Fire Drills,” write the three checked scores in the large circles. Write the sum of the three scores in the large box on the right. I. Risk of Resistance

Minimal Risk

(Check only one)

II. Impaired Mobility

IV. Need for Extra Help

No Significant Risk

Follows Instructions

Response Probable

Needs Full Assistance from 2 Staff

score = 40

score = 30

Requires Supervision

Requires Considerable Attention/Might Not Respond score = 3

score = 10

Response Not Probable

score = 0

(Check only one)

score = 20

score = 6

score = 1

(Check only one)

VI. Waking Response to Alarm

score = 20

Totally Impaired

Needs Limited Assistance from 2 Staff

score = 0

Needs Full Assistance or Very Slow

score = 6

score = 3

Partially Impaired

score = 0

Needs at Most One Staff

score = 6

VII. Response to Fire Drills

Initiates and Completes Evacuation Promptly

Yes

(Without guidance or advice from staff)

Chooses and Completes Back-up Strategy

Yes

No score = 0

score = 8

No score = 0

Yes

Remains at Designated Location

Appendix 2-F

score = 4

No score = 0

Form CMS-2786W (06/07) EF 06/2007

Score Boxes

score = 20

Needs Limited Assistance

score = 0

(Check only one)

V. Response to Instructions

Slow

Self-Starting

(Check only one)

Risk of Strong Resistance

score = 6

score = 0

(Check only one)

III. Impaired Consciousness

Risk of Mild Resistance

score = 6

Sum of These Three Scores Page 4

Worksheet 6.8.3 Determining the Resident’s Overall Need for Assistance Compare the numbers in the seven score boxes filled in. Take the highest score from the score boxes (Worksheet 6.8.2.) and write it in the box at the right. Evacuation Assistance Score

Notes:

Worksheet 6.8.4 Resident Scores Evac. Assist. Score

Resident’s Name


Form CMS-2786W (06/07) EF 06/2007

Total

Evac. Assist. Score

Resident’s Name


Appendix 2-F

Total

Page 5

Worksheet 6.8.5 Cover Sheet Staff Shift Score Facility ________________________________________

Zone __________________________________________

Evaluator ______________________________________

Date ___________________________________________

Staff Shift: From_________________________________

To_____________________________________________

Worksheet 6.8.6 Staff Response and Training YES

NO

A protection plan has been promulgated and all staff members considered in this rating have been trained in its implementation. (See 6.5.2.1) The total available staff at any given time is able to handle the individual evacuation needs of each resident who is in the facility. (See 6.5.2.2. and Exception) Every staff member considered in this rating can meaningfully participate in the evacuation of each resident. (See 6.5.2.3) All staff members considered in this rating are required to be in the facility when on duty, except as permitted. (See 6.5.2.4 and Exceptions) At least 12 fire drills were conducted during the previous year. (See 6.5.2.5 and Exception) All items must score “Yes” before proceeding.

Worksheet 6.8.7 Promptness of Response Scores Alarm Effectiveness Staff Availability Standby or asleep Immediately available Immediately available and close by

Assured 16 20 20

Not Assured 2 2 10

Worksheet 6.8.8 Staff Scores Promptness of Response Score

Resident’s Name

Staff Shift Score

Form CMS-2786W (06/07) EF 06/2007

Total


Resident’s Name

Staff Shift Score

Appendix 2-F

Total

Page 6

Worksheet 6.8.9 Rating the Facility Vertical Distance from Sleeping Rooms to Exits All SR on Floors with Direct Exit Small Facility

Any SR One Floor from Exit

Score 0.8

Any SR Two or More Floors from Exit

Score 1.0

Large Facility or Apartment

Score 1.2

Score 1.0

NOTE: Small facilities have 16 or fewer residents. See 6.6.6 for apartments.

Worksheet 6.8.10 Calculation of Evacuation Capability Score Total Resident Evacuation Assistance Score (Worksheet 6.8.4)

Vertical Distance from Sleeping Room to Exit (Worksheet 6.8.9)

X = Evacuation Capability Score (Go to Worksheet 6.8.11) Staff Shift Score (Worksheet 6.8.8)

Worksheet 6.8.11 Evacuation Capability Score Evacuation Capability Score

Level of Evacuation Capability

1. to 5.0

Impractical

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Appendix 2-F

Evacuation Capability for this Facility or Zone

Page 7

ID PREFIX

MET NOT N/A MET

LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES

REMARKS

LARGE PROMPT & SLOW

BUILDING CONSTRUCTION (NEW & EXISTING) K12

Minimum Construction Requirements: Based on highest story normally used by residents One and Two Story  Any construction type of one-hour or greater fire rating, or  Type IV (2HH), or  Fully sheathed, or  With automatic sprinkler system throughout, in accordance with 32.3.3.5, 33.3.3.5.  Exception: One story any construction type and no more than 30 residents capable of prompt evacuation. Three to Six Stories  Type I, II or Ill construction of one-hour or greater fire resistance rating, or  Type IV construction with automatic sprinkler system throughout in accordance with 32.3.3.5 or 33.3.3.5.  Exception: Three or four story facilities of Type V (000), sheathed and with automatic sprinkler system throughout, in accordance with 32.3.3.5, 33.3.3.5. More than Six Stories  Type I or II (222) construction, or  Type II (111) construction, or  Type III (211) construction, or  Type IV (2HH) with automatic sprinkler system throughout in accordance with 32.3.3.5, 33.3.3.5. 32.3.1.3, 33.1.3.1 OCCUPANT LOAD  Not less than two exits shall be accessible from every floor and in at least two different directions. The occupant load, in number of persons for who means of egress and other provisions are required, shall be determined on the basis of the occupant load factors or Table 7.3.1.2 that are characteristic of the use of the space or shall be determined as the maximum probable population of the space under consideration, whichever is greater. 33.3.1.4, 32.3.1.4

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Appendix 2-F

ID PREFIX

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REMARKS

LARGE PROMPT & SLOW

HAZARDOUS AREAS K124

Any room containing high-pressure boilers, refrigerating machinery, transformers, or other service equipment subject to possible explosion shall not be located under or adjacent to exits. All such rooms shall be effectively separated from other parts of the building as specified in section 8.4.

K29

32.3.3.2.1, 33.3.2.1 All hazardous areas shall be separated with construction of a minimum of one-hour fire resistance or automatic extinguishment system with openings protected with self-closing fire doors.  Exception: Existing buildings may have hazardous areas separated from other parts of the building by a smoke partition in accordance with section 8.2.4. Hazardous areas shall include but not be limited to the following: boiler or heating rooms, laundries, repair shop, spaces storing combustibles in quantities deemed hazardous by the authority having jurisdiction. 32.3.3.2.2, 33.3.3.2.2

K211

2000 EXISTING Where Alcohol Based Hand Rub (ABHR) dispensers are installed:  The corridor is at least 6 feet wide  The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)  The dispensers shall have a minimum spacing of 4 ft from each other  Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.  Dispensers are not installed over or adjacent to an ignition source.  If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 483.470

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Appendix 2-F

ID PREFIX

K211

MET NOT N/A MET


REMARKS

LARGE PROMPT & SLOW

2000 NEW Where Alcohol Based Hand Rub (ABHR) dispensers are installed:  The corridor is at least 6 feet wide  The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)  The dispensers shall have a minimum spacing of 4 ft from each other  Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.  Dispensers are not installed over or adjacent to an ignition source.  If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 483.470

DETECTION ALARM & COMMUNICATIONS SYSTEMS K51

A manual fire alarm system with approved component devices or equipment, shall be installed in accordance with section 9.6.  Exception: Where each bedroom has an exterior exit access in accordance with 7.5.3 and the building is not greater than three stories. INITIATION The required fire alarm system shall be initiated by the following means: (1) Manual means in accordance with 9.6.2  Exception: A manual means, as specified in 9.6.2, in excess of the manual fire alarm box at a constantly attended location per 33.3.3.4.2(2) below shall not be required where there are other effective means (such as a complete automatic sprinkler or automatic detection system) for notification of fire as required. (2) A manual fire alarm box located at a convenient central control point under continuous supervision of responsible employees. (3) The automatic sprinkler system.

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Appendix 2-F

ID PREFIX

MET NOT N/A MET


REMARKS

LARGE PROMPT & SLOW

 Exception: Automatic sprinkler systems that are not required by another section of this Code shall not be required to initiate the fire alarm system. (4) Any required detection system.  Exception: Sleeping room smoke alarms shall not be required to initiate the building fire alarm system. 32.3.3.4, 33.3.3.4 ANNUNCIATOR PANEL  An annunciator panel connected with the fire alarm system shall be provided. The location of the annunciator shall be approved by the authority having jurisdiction.  Exception: Buildings not more than two stories in height and with not more than 50 sleeping rooms. 32.3.3.4.3 OCCUPANT NOTIFICATION 2000 EXISTING  Occupant notification shall be provided automatically, without delay, by internal audible alarm in accordance with 9.6.3. 33.3.3.4.4 2000 NEW  Occupant notification shall be provided automatically, without delay, in accordance with 9.6.3. 32.3.3.4.4 FIRE DEPARTMENT NOTIFICATION  In case of a fire, provisions shall be made for the immediate notification of the public fire department by either telephone or other means. Where there is no public fire department, this notification shall be made to the private fire brigade. 32.3.3.4.6, 33.3.3.4.6 K155


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Appendix 2-F

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REMARKS

LARGE PROMPT & SLOW

SMOKE DETECTION AND ALARM K109

SMOKE DETECTION 2000 EXISTING Each sleeping room shall be provided with an approved smoke alarm in accordance with 9.6.2.10 that is powered from the building electrical system.  Exception No.1: Existing battery-powered smoke alarms, rather than building electrical service-powered smoke alarms, shall be accepted where, in the opinion of the authority having jurisdiction, the facility has demonstrated that testing, maintenance, and battery replacement programs ensure the reliability of power to the smoke alarms.  Exception No. 2: Facilities having an existing corridor smoke detection system in accordance with Section 9.6 that is connected to the building fire alarm system. 33.3.3.4.7 2000 NEW Each sleeping room shall be provided with an approved smoke alarm in accordance with 9.6.2.10 that is powered from the building electrical system. 32.3.3.4.7  All living areas as defined in 3.3.119 and corridors shall be provided with smoke detectors in accordance NFPA 72, National Fire Alarm Code, that are arranged to initiate an alarm that is audible in all sleeping areas.  Exception No. 1: Detectors shall not be required in living areas and kitchens in facilities protected throughout by an approved automatic sprinkler system installed in accordance with 33.3.3.5.  Exception No. 2: Unenclosed corridors, passageways, balconies, colonnades, or other arrangements with one or more sides along the long dimension fully or extensively open to the exterior at all times. 32.3.3.4.8, 33.3.3.4.8

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Appendix 2-F

ID PREFIX


MET

NOT N/A MET

REMARKS

LARGE PROMPT & SLOW

AUTOMATIC SPRINKLERS K56

2000 EXISTING Where an automatic sprinkler system is installed for total or partial building coverage, the system shall be in accordance with Section 9.7.  Exception No. 1: In buildings not more than four stories in height, a sprinkler system complying with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted.  Exception No. 2: Automatic sprinklers shall not be required in small clothes closets where the smallest dimension does not exceed 3 ft (0.9m), the area does not exceed 24f 2 (2.2m 2), and the walls and ceilings are finished with noncombustible or limited-combustible material.  Exception No. 3: Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.3.3.5.4. Automatic sprinkler systems shall be supervised in accordance with Section 9.7. Waterflow alarms shall not be required to be transmitted off-site. Sprinkler piping serving not more than six sprinklers for any isolated hazardous area in accordance with 9.7.1.2 shall be permitted. In new installations where more than two sprinklers are installed in a single area, waterflow detection shall be provided to initiate the fire alarm system required by 33.3.3.4.1. 33.3.3.5.1, 33.3.3.5.2, 33.3.3.5.3, 33.3.3.5.4 2000 NEW All buildings shall be protected throughout by an approved automatic sprinkler system in accordance with Section 9.7. Quick-response or residential sprinklers shall be provided throughout.  Exception No. 1: In buildings not more than four stories in height, a sprinkler system complying with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted

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Appendix 2-F

ID PREFIX


MET

NOT N/A MET

REMARKS

LARGE PROMPT & SLOW

 Exception No. 2: Automatic sprinklers shall not be required in small clothes closets where the smallest dimension does not exceed 24 ft2 (2.2m2), and the walls and ceilings are finished with noncombustible or limited-combustible materials.  Exception No. 3: Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 32.3.3.2. Automatic sprinkler systems shall be supervised in accordance with Section 9.7. 32.3.3.5.1, 32.3.3.5.3 K154

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1 A. Date sprinkler system last checked and necessary maintenance provided. ______________________________ B. Show who provided the service._______________________ C. Note the source of the water supply for the automatic sprinkler system. ___________________________________ (Provide, in REMARKS, information on coverage for any non-required or partial automatic sprinkler system.)

PORTABLE FIRE EXTINGUISHERS K64

Portable fire extinguishers shall be provided near hazardous areas in accordance with 9.7.4.1. 33.3.3.5.5, 32.3.3.5.5

SEPARATION OF SLEEPING ROOMS FROM EXIT ACCESS K17

2000 EXISTING Access shall be provided from every resident use area to not less than one means of egress that is separated from all other rooms or spaces by walls complying with 33.3.3.6.3 through 33.3.3.6.6.

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Appendix 2-F

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REMARKS

LARGE PROMPT & SLOW

 Exception No. 1: Rooms or spaces, other than sleeping rooms, protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5.  Exception No. 2: Prompt evacuation capability facilities in buildings not over two stories in height where not less than one required means of egress from each sleeping room provides a path of travel to the outside without traversing any corridor or other spaces exposed to unprotected vertical openings, living areas, and kitchens.  Exception No. 3: Rooms or spaces, other than sleeping rooms, provided with a smoke detection and alarm system connected to activate the building evacuation alarm. Furnishings, finishes, and furniture, in combination with all other combustibles within the spaces, shall be of minimum quantity and arranged so that a fully developed fire is unlikely to occur. Sleeping rooms shall be separated from corridors, living areas, and kitchens by walls complying with 33.3.3.6.3 through 33.3.3.6.6. Walls required by 33.3.3.6.1 or 33.3.3.6.2 shall have a fire resistance rating of not less than 1/2 hour.  Exception No. 1: In buildings protected throughout by an approved automatic sprinkler system in accordance with 33.3.35, walls shall be smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply.  Exception No. 2: In buildings not more than two stories in height that are classified as prompt evacuation capability and that house not more than 30 residents, walls shall be smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. Doors in walls required by 33.3.3.6.1 or 33.3.3.6.2 shall have a fire protection rating of not less than 20 minutes.  Exception No. 1: Solid-bonded wood core doors of not less than 13/4 in. (4.4cm) thickness shall be permitted to continue to be used.  Exception No. 2: In buildings protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5, doors that are nonrated shall be permitted to continue to be used. Form CMS-2786W (06/07) EF 06/2007

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Appendix 2-F

ID PREFIX

MET NOT N/A MET


REMARKS

LARGE PROMPT & SLOW

 Exception No. 3: Where automatic sprinkler protection is provided in the corridor with 31.3.5.2 through 31.3.5.4, doors shall not be required to have a fire protection rating but shall be in accordance with 8.2.4.3. The provisions of 8.2.4.3.5 shall not apply. Doors shall be equipped with latches for keeping the doors tightly closed. Walls and doors required by 33.3.3.6.1 and 33.3.3.6.2 shall be constructed as smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. No louvers, transfer grilles, operable transoms, or other air passages shall penetrate such walls or doors, except properly installed heating and utility installations. Doors in walls required by 33.3.3.6.1 and 33.3.3.6.2 shall be self-closing or automatic-closing in accordance with 7.2.1.8. Doors in walls separating sleeping rooms from corridors shall be automatic-closing in accordance with 7.2.1.8.  Exception No. 1: Doors to sleeping rooms that have occupantcontrol locks such that access is normally restricted to the occupants or staff personnel shall be permitted to be self-closing.  Exception No. 2: In buildings protected throughout by an approved automatic sprinkler system installed in accordance with 33.3.3.5, doors, other than doors to hazardous areas, vertical openings, and exit enclosures, shall not be required to be self-closing or automatic-closing. 33.3.3.6.6 2000 NEW Access shall be provided from every resident use area to not less than one means of egress that is separated from all sleeping rooms by walls complying with 32.3.3.6.3 through 32.3.3.6.6. Sleeping rooms shall be separated from corridors, living areas, and kitchens by walls complying with 32.3.3.6.3 through 32.3.3.6.6. Walls required by 32.3.3.6.1 or 32.3.3.6.2 shall have a fire resistance rating of not less than 1/2 hour.  Exception: In conversions (see 32.1.1.3), no fire resistance rating shall be required, but the wall shall be a smoke partition in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. Form CMS-2786W (06/07) EF 06/2007

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Appendix 2-F

ID PREFIX


MET

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REMARKS

LARGE PROMPT & SLOW

Doors in walls required by 32.3.3.6.1 or 32.3.3.6.2 shall have a fire protection rating of not less than 20 minutes.  Exception: Doors in renovations and conversions (see 32.1.1.3) that are nonrated doors that resist the passage of smoke shall be permitted to continue to be used. Doors to hazardous areas, vertical openings, exits, and exit passageways shall be self-closing or automatic-closing. 32.3.3.6.6 K18

Doors in walls separating sleeping rooms from corridors shall have a fire protection rating of not less than 20 minutes. Doors shall be equipped with latches for keeping the doors tightly closed.  Exception No. 1: Existing 13/4 inch solid bonded wood core doors shall be permitted.  Exception No. 2: Where walls are only required to resist the passage of smoke, doors without fire rating and which resist the passage of smoke are permitted.  Exception No. 3: Where automatic sprinkler protection is provided in the corridor in accordance with 31.3.5.3 through 31.3.5.4, doors shall not be required to have a fire protection rating but shall be in accordance with 8.2.4.3. The provisions of 8.2.4.3.5 shall not apply. Doors shall be equipped with latches for keeping the doors tightly closed. 32.3.3.6.4, 33.3.3.6.4 Walls and doors required by 32.3.3.6.1 and 32.3.3.6.2. shall be constructed as smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. No louvers, transfer grilles, operable transoms, or other air passages shall penetrate such walls or doors, except properly installed heating and utility installations. 32.3.3.6.5, 33.3.3.6.5

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Appendix 2-F

ID PREFIX


MET

NOT N/A MET

REMARKS

LARGE PROMPT & SLOW

EXIT SYSTEM K34

Exits or exit components, arranged in accordance with Chapter 7, shall be of types in accordance with 32.3.2 or 33.3.2.

K35

Capacity of means of egress shall be in accordance with 7.3.

K38

Access to all required exits shall be in accordance with 7.3. 32.3.2.5.1, 33.3.2.5.1

K43

DOORS 2000 Existing Doors in means of egress shall be as follows: (1) Doors complying with 7.2.1 shall be permitted. (2) Doors within individual rooms and suites of rooms shall be permitted to be swinging or sliding. (3) No door in any means of egress shall be locked against egress when the building is occupied.  Exception No. 1: The requirement of 33.3.2.2.2(3) shall not apply to delayed-egress locks in accordance with 7.2.1.6.1, provided that not more than one device exists in a means of egress.  Exception No. 2: The requirement of 33.3.2.2.2(3) shall not apply to access-controlled egress doors in accordance with 7.2.1.6.2. (4) Revolving doors complying with 7.2.1.10 shall be permitted. 33.3.2.2.2, 32.3.2.2.2 2000 NEW (5) Every bathroom door shall be designed to allow opening from the outside during an emergency when locked. 32.3.2.2.2

K32

Not less than two exits shall be accessible from every story, including floors below the level of exit discharge and floors occupied from public purposes. 33.3.2.4, 32.3.2.4

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Appendix 2-F

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MET

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REMARKS

LARGE PROMPT & SLOW

The width of corridors shall be sufficient for the occupant load served but shall be not less than 44 in. (112cm).  Exception: Corridors serving an occupant load fewer than 50 shall be not less than 36 in. (91cm) wide. 33.3.2.3.3, 32.3.2.3.3 Stairs complying with 7.2.2 shall be permitted. 33.3.2.2.3, 32.3.2.2.3

ARRANGEMENT OF MEANS OF EGRESS K40

2000 EXISTING Common paths of travel shall not exceed 110 ft (33.5m)  Exception: In buildings protected throughout by automatic sprinkler systems in accordance with 33.3.3.5, common path of travel shall not exceed 160ft (48.8m). Dead-end corridors shall not exceed 50 ft (15m). 33.3.2.5 2000 NEW Common paths of travel shall not exceed 125ft (38.1m). Dead end corridor shall not exceed 50ft (15m). 32.3.2.5.2

SUBDIVISION OF BUILDING SPACES K120

Every sleeping room floor shall be divided into not less than two smoke compartments of approximately the same size, with smoke barriers in accordance with 8.3. Smoke dampers shall not be required. Additional smoke barriers shall be provided such that the travel distance from a sleeping room corridor door to a smoke barrier shall not exceed 150 ft (45m).  Exception No. 1: Buildings protected throughout by an approved automatic sprinkler system installed in accordance with 33.3.3.5.  Exception No. 2: Where each sleeping room is provided with exterior ways of exit access arranged in accordance with 7.5.3.

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Appendix 2-F

ID PREFIX

LARGE FACILITY IMPRACTICAL EVACUATION

MET

NOT N/A MET

REMARKS

LARGE IMPRACTICAL

 Exception No. 3: Smoke barriers shall to be required where the aggregate corridor length on each floor is not more than 150 ft (45m). 33.3.3.7 K36

2000 EXISTING Travel distance from the corridor door of any room to nearest exit shall be a maximum of 100 feet. 33.3.2.6.2 2000 NEW Travel distance from the corridor door of any room to the nearest exit, measured in accordance with 7.6, shall not exceed 200 feet (60m). 32.3.2.6.2 2000 EXISTING Travel distance from the door or most remote room in a suite or apartment to the corridor shall not exceed 75 feet (23m).  Exception: Travel distance may be 125ft (48m) in building protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5. 33.3.2.6.1 2000 NEW Travel distance within a room, suite, or living unit to a corridor door shall not exceed 125 ft (38.1m) 32.3.2.6.1.

INTERIOR FINISH K14

2000 EXISTING Interior wall and ceiling finish shall be Class A or Class B in accordance with Section 10.2. Interior floor finish in accordance with 10.2.7 shall be Class I or Class II in corridors and exits.  Exception: Previously installed floor coverings, subject to the approval of the authority having jurisdiction. 33.3.3.3

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Appendix 2-F

ID PREFIX


MET

NOT N/A MET

REMARKS

LARGE IMPRACTICAL

2000 NEW Interior finish shall be in accordance with 10.2. 10.2, 32.3.3.3.1. K15

Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows: (1) Exit enclosures - Class A (2) Lobbies and corridors - Class A or Class B (3) Other spaces - Class A or Class B 32.3.3.3.2

K16

Interior floor finish in corridors and exits shall be class I or II in accordance with 10.2.7, 32.3.3.3.3.

K20

2000 EXISTING Any vertical opening shall be enclosed or protected in accordance with 8.2.5.  Exception No. 1: Unprotected vertical openings not part of required egress shall be permitted to be waived by the authority having jurisdiction where such openings do not endanger required means of egress. This exception shall apply only in buildings protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5.1 and in which exits and required ways of travel thereto are adequately safeguarded against fire and smoke within the building, or in which every individual room has direct access to an exterior exit without passing through a public corridor.  Exception No. 2: In buildings not more than two stories in height, unprotected vertical openings shall be permitted by the authority having jurisdiction if the building is protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5.1 No floor below the level of exit discharge used only for storage, heating equipment, or purposes other than residential occupancy shall have unprotected openings to floors used for residential occupancy. 32.3.3.1.1, 32.3.3.1.2, 33.3.3.1.1, 33.3.3.1.2

Form CMS-2786W (06/07) EF 06/2007

Page 21

Appendix 2-F

ID PREFIX

K21


MET

NOT N/A MET

REMARKS

LARGE IMPRACTICAL

Building Services 2000 EXISTING Utilities shall comply with the provisions of 9.1. Heating, ventilating, and air conditioning equipment shall comply with the provisions of 9.2. No stove or combustion heater shall be located to block escape in case of fire caused by the malfunction of the stove or heater. Unvented fuel-fired heaters shall not be used in any board and care occupancy. Elevators, dumbwaiters, and vertical conveyors shall comply with the provisions of 9.4. Rubbish chutes, incinerators, and laundry chutes shall comply with the provisions of 9.5. 33.3.6.1, 33.3.6.2, 33.3.6.2.1, 33.3.6.2.2, 33.3.6.2.3. 33.3.6.3, 33.3.6.4 2000 NEW In high-rise buildings, one elevator shall be provided with a protected power supply and shall be available for use by the fire department in case of emergency. 32.3.6.1, 32.3.6.2, 32.3.6.2.1, 32.3.6.2.2, 32.3.6.2.3, 32.3.6.3.1, 32.3.6.3.2, 32.3.6.4 Facilities housing groups of persons classed as IMPRACTICAL TO EVACUATE shall meet the requirements for custodial care facilities, Chapter 18 or 19 as appropriate.  Exception: Facilities found to have equivalent safety. Example 7.5 Using the applicable mandatory safety requirement. 32.3.1.2.2 See CMS-2786R

Form CMS-2786W (06/07) EF 06/2007

Page 22

Appendix 2-F

Fire Safety Evaluation Worksheet for a Large Facility

Fig. 7.5 Facility Identification ______________________________________________________________________________________________________________ Evaluator______________________________________________________________________Date _____________________________________________ (Complete one worksheet for each large facility. This normally means a capacity for more than 16 residents.) First complete Fig. 7.5.1. Continue with Fig. 7.5.2, 7.5.3, 7.5.4A, 7.5.4B, 7.5.5. Then return to this page to obtain the Equivalency Conclusions.

TURN TO NEXT PAGE Part 2E. Equivalency Conclusions Complete Fig. 7.5.1 through 7.5.5 before doing this part. 1. All of the checks in Fig. 7.5.5 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed for large residentail facilities.* 2. One or more of the checks in Fig. 7.5.5 is in the “NO” column. The level of fire safety is not shown by this system to be equivalent to that prescribed by the Life Safety Code for large residential facilities. *The equivalency covered by this worksheet includes the majority of consideratons covered by the Life Safety Code. There are a few consideratons that are not evaluated by this method. These must be considered separately. These additional considerations are covered in the “Facility Fire Safety Requirements Worksheet.” One copy of this separate worksheet is to be completed for each facility.

Facility Fire Safety Requirements Worksheet Considerations

Met

Not Met

Not Applicable

A. Utilities comply with provisions of 9.1. B. Heating, ventilating, and air conditioning equipment comply with provisions of 9.2. C. Elevators, dumbwaiters, and vertical conveyors comply with the provisions of 9.4. D. Rubbish chutes, incineratiors, and laundry chutes comply with the provisions of 9.5. E. Complies with the applicable requirements of Sections 32.7 and/or 33.7. Form CMS-2786W (06/07) EF 06/2007

Page 23

Appendix 2-F


FACILITY NAME

SURVEY DATE

K1

K6

* K4

K3




LSC FORM INDICATOR

____________

12 13

14 15


SMALL

(16 BEDS OR LESS)

K8:


LARGE

K8:


16 17


*K9:





APARTMENT HOUSE

K8: * K7




2786U 2786U

A B C D

K5:

K56:

e.g. 2.5




A3.

A4.

(WAIVERS)

A5. (FSES)


K0180





* MANDATORY

Form CMS-2786W (06/07) EF 06/2007

Page 24

Appendix 2-F


CMS and Culture Change & Artifacts of Culture Change

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 3 - CMS, CULTURE CHANGE, ARTIFACTS OF CULTURE CHANGE CMS and Culture Change and Artifacts of Culture Change - The traditional nursing home regulatory approach has created tensions between providers and surveyors. Culture change is movement to transform a facility to a home, a resident to a person, and a schedule to a choice. States and the federal government have worked over the years to examine regulations to evolve them into a more responsive regulatory system. Documents below are offered to home nursing homes to work with their regulators to change the environment of their homes while meeting the regulations. Missouri has set a 100% compliance goal for facilities filling out the on-line version of The Artifacts of Culture Change. (www.artifactsofculturechange.org)

SECTION CMS Nursing Home Culture Change Regulatory Compliance Questions and Answers Artifacts of Culture Change The First 24 Hours and Beyond New Dining Practice Standards The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to Furthering Innovation in Nursing Homes National Long-term Care Life Safety Task Force: Summary of Proposals Approved by NFPA

Updated January 2015

PAGE # 3.2-3.5 3.6-3.16 3.17-3.18 Appendix 3-A Appendix 3-B

Appendix 3-C

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-12-25 Baltimore, Maryland 21244-1850

Center for Medicaid and State Operations/Survey and Certification Group DATE:

December 21, 2006

TO:

State Survey Agency Directors

FROM:

Director Survey and Certification Group

SUBJECT:

Ref: S&C-07-07

Nursing Home Culture Change Regulatory Compliance Questions and Answers

Memorandum Summary This memorandum provides the State Survey Agencies and CMS regional offices with: 1. Responses we have made to inquiries concerning compliance with the long-term care health and life safety code requirements in nursing homes that are changing their cultures and adopting new practices; 2. Summarizes questions and answers from a June, 2006 CMS Pic-Tel conference with leaders of the Green House Project (Attachment A); and 3. Provides information about an upcoming series of 4 CMS culture change satellite webcasts (Attachment B). Following are regulatory questions that have been sent from culture change organizations from 2004 to date, along with our answers: Question 1: Tag F368 (Frequency of Meals): You request a clarification that the regulation language at this Tag that “each resident receives and the facility provides at least three meals daily” does not require the resident to actually eat the food for the facility to be in compliance. You also ask for clarification about the regulatory language specifying that there must be no more than 14 hours between supper and breakfast (or 16 hours if a resident group agrees and a nourishing snack is provided). You state that some believe this language means all of the residents must actually eat promptly by the 14th hour, which makes it difficult for the facility to honor a specific resident’s request to refuse a night snack and then sleep late. Response 1: The regulation language is in place to prevent facilities from offering less than 3 meals per day and to prevent facilities from serving supper so early in the afternoon that a significant period of time elapses until residents receive their next meal. The language was not intended to diminish the right of any resident to refuse any particular meal or snack, nor to diminish the right of a resident over their sleeping and waking time. These rights are described at Tag F242, Self-determination and Participation. You are correct in assuming that the regulation language at F368 means that the facility must be offering meals and snacks as specified, but that each resident maintains the right to refuse the food offered. If surveyors encounter a situation in which a resident or residents are refusing snacks routinely, they would ask the resident(s) the reason for their customary refusal and would continue to investigate this issue only if the resident(s) complains about the food items provided. If a resident is sleeping late and misses breakfast, surveyors would want to know if the facility has anything for the resident to eat when they awaken (such as continental breakfast items) if they desire any food before lunch time begins. 3.2

Question 2: F370 (Approved Food Sources): You ask if the regulatory language at this Tag that the facility must procure food from approved sources prohibits residents from any of the following: 1) growing their own garden produce and eating it; 2) eating fish they have caught on a fishing trip; or 3) eating food brought to them by their own family or friends. Response 2: The regulatory language at this Tag is in place to prohibit a facility from procuring their food supply from questionable sources, in order to keep residents safe. It would be problematic if the facility is serving food to all residents from the sources you list, since the facility would not be able to verify that the food they are providing is safe. The regulation is not intended to diminish the rights of specific residents to eat food in any of the circumstances you mention. In those cases, the facility is not procuring food. The residents are making their own choices to eat what they desire to eat. This would also be the case if a resident ordered a pizza, attended a ball game and bought a hot dog, or any similar circumstance. The right to make these choices is also part of the regulatory language at F242, that the resident has the right to, “make choices about aspects of his or her life in the facility that are important to the resident.” This is a key right that we believe is also an important contributing factor to a resident’s quality of life. Question 3: Tag F354 (Registered Nurse): “Can the traditional DON role be shared with several registered nurses with each nurse responsible for one or more households or clusters?” Response 3: The interpretive guidelines (i.e., Guidance to Surveyors) already contain this language: “The facility is required to designate an RN to serve as DON on a full time basis. This requirement can be met when RNs share the position. If RNs share the DON position, the total hours per week must equal 40. Facility staff must understand the shared responsibilities.” Thus, the position can be shared; however, a comprehensive set of duties and responsibilities of a DON is not specified in the regulations or interpretive guidelines. We interpret this role to encompass not only general supervision of nursing care for the facility, but oversight of nursing policies and procedures, overall responsibility for hiring/firing of nursing staff, ensuring sufficient nursing staff (F353), ensuring proficiency of nurse aides (F498), active participation in the quality assurance committee (see Tag F520), and responsibility to receive and act on communications from the pharmacy consultant about medication problems (Tags F429 and F430). A facility that desires to have various people share the DON position would need to consider how these DON duties will be fulfilled in a shared position. As long as these duties are fulfilled, we would consider the facility in compliance with F354, whether or not the position is being shared. Question 4: Tag F521 (Quality Assessment and Assurance): You ask whether the regulatory responsibility for this committee to “meet” can be fulfilled if the physician member is not physically present, but is participating through alternate means, “such as conference calls or reading minutes/issues and giving input.” Response 4: Yes, participation can be achieved through means of telephone conferencing, however, we do not accept the alternative of the physician merely reading documents before or after the meeting. We believe the purpose of these meetings is to provide a forum for discussion of issues and plans, which cannot be adequately fulfilled if the physician is merely reading and commenting on documents, since this does not allow for the interchange of ideas. Question 5: (HIPAA and Principles of Documentation): You express concern that the Statement of Deficiencies that surveyors write, which is a publicly posted document, may violate a resident’s right to privacy, since the details may identify a specific resident to the public. Response 5: We have received other comments on this issue, and have provided guidance to our State Survey Agencies and CMS regional offices on our interpretation of this issue in our Survey and Certification (S&C) 3.3

memorandum #04-18. All our S&C memoranda are stored on the CMS website for public access at http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp Question 6 (Handrails): Could the interpretive guidelines explain that handrails are not necessary at the very ends of the hallways on the very small sides of the door? This would allow for filling these unused areas with live plants, for instance, without obstructing egress and handrails would still be available up to the end of each hallway. Response 6: The purpose of the handrail requirements at Tag F468 is to assist residents with ambulation and/or wheelchair navigation. They are a safety device as well as a mobility enhancer for those residents who need assistance. The survey team onsite would need to observe the responses of residents to the placement of objects that block the portion of the handrails that is at the end of a hallway. They would also interview residents to gain their opinion as to whether the objects in question are interfering with their independence in navigating to the places they wish to go. Question 7 (Resident Call system): Could the resident call system (F463) regulation that requires calls to be able to be received at the nurses’ station be changed to also include nurses’ work areas and direct care workers, as well as the nurses’ stations? Many homes moving away from the institutional model are replacing nurses’ stations with normal kitchens, living room and dining room areas, and using systems whereby resident calls connect directly to caregivers’ radio/pagers. Because it is harder to change the text of regulation, could the phrase “at the nurses’ station” be removed from the following sentence in the Interpretive Guidelines: “The intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means to directly contact staff at the nurses’ station.” Response 7: We agree that it is desirable for residents and/or their caregivers or visitors to be able to quickly contact nursing staff when they need help. To meet the intent of the requirement at F463, it is acceptable to use a modern pager/telephone system which routes resident calls to caregivers in a specified order in an organized communication system that fulfills the intent and communication functions of a nurse’s station. We will make a change in the Interpretive Guideline to reflect this position. Question 8 (Posting of Survey Results): Would CMS consider adding to the posting requirements at Tag F156 [42 CFR 483.10(b)(10)], text similar to that stated in Tag F167 about posting of survey results, “...or a notice of their availability?” Although this may just be trading one posting for several, some homes really want to create a homey environment without so many postings and many homes are placing postings into a photo album or binder to minimize the institutional look of so many postings. Response 8: The purpose of the posting requirements at both F156 and F167 is for residents and any other interested parties to be able to know the information exists, and to easily locate and read the information without needing to ask for it. What you request above, namely one posting that advises the public of what information is available to meet requirements of both Tags, is acceptable, as long as the information itself is in public and easily accessible, such as in a lobby area in a marked (titled) notebook or album. This includes the following information: •

“A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit;.” (F156)

•

“Written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits;” (F156) and 3.4

•

The facility, “must make the results available for examination in a place readily accessible to residents and must post a notice of their availability.” (F167)

Question 9 (Hallway Width): Does the 8 feet requirement (at LSC Tag K39) continue to be necessary since evacuations are no longer done via wheeling a person out of the building in a bed? Could 6 feet meet the requirement? If 6 feet sufficed, this would again refer back to our question regarding the requirement for handrails when something else such as a bench might take up the other 2 feet. Response 9: The 8 foot corridor width is a requirement of the Life Safety Code (LSC). Corridors remain a route to use in internal movement of residents in an emergency situation to areas of safety in different parts of the facility. This movement may be by beds, gurney or other methods which may require the full width of the corridor. We do not believe it would be in the best interests of the residents to reduce the level of safety in a facility. Question 10 (Tag K72 and Exits): In regard to LSC Tag K72 (no furnishings, decorations, or other objects are placed to obstruct exits or visibility of exits), can secured unit doors be disguised or masked with murals, etc.? Staff typically will be the ones to use these doors in the case of emergency and will know where they are. By disguising exit doors, resident anxiety of wanting to go out them may decrease. Response 10: The life safety code allows some coverings on doors, but not concealment. The code also specifically forbids the use of mirrors on a door. It is a judgment call by the survey team as to what would be considered concealment of the door, but in general the door must still be recognizable by a non-impaired person (such as a visitor). The code does not allow the removal or concealment of exit signs, door handles, or door opening hardware. Question 11 (Dining Together): Is it permissible for staff and residents to dine together? Response 11: There is no federal requirement that prohibits this. We applaud efforts of facilities to make the dining experience less institutional and more like home. Our concern would be for the facility to make sure that residents who need assistance receive it in a timely fashion (not making residents wait to be assisted until staff finish their meals). Question 14 (Candles): Can candles be used in nursing homes under supervision, in sprinklered facilities. Response 14: Regarding the request to use candles in sprinklered facilities under staff supervision, National Fire Protection Association data shows candles to be the number one cause of fires in dwellings. Candles cannot be used in resident rooms, but may be used in other locations where they are placed in a substantial candle holder and supervised at all times while they are lighted. Lighted candles are not to be handled by residents due to the risk of fire and burns. If you would like to discuss this issue, you may contact James Merrill at 410-786-6998, or via email at [email protected]. Question 15 (Tablecloths): Are cloth tablecloths and napkins permissible in nursing homes? Response 15: There is no regulation that prohibits it and, in fact, the use of these items is greatly preferable to the use of bibs, as bibs can detract from the homelike attractiveness of the dining room setting.

3.5

Artifacts of Culture Change - Online Version (www.artifactsofculturechange.org) Pioneer Network is host to this web-based version of the Artifacts of Culture Change. By registering and completing the Artifacts of Culture Change, providers are able to input, score and store their data online. Providers will be able to access current and historical data and are encouraged to: 

 

Complete the tool at a minimum of twice a year. Quarterly updating is recommended, because for many homes, organizational reporting occurs quarterly. Adding Artifacts to a quarterly reporting schedule can also help to better analyze incremental changes in benchmark reporting; Create high involvement of staff, family and residents in completing the tool and solicit feedback from varying perspectives (see below); Although assessments of responses can be approximates (e.g. responders do not need to count every adaptive handle), providers are encouraged to provide close approximate estimates to ensure the best possible measurements of longitudinal change. Tips for High Involvement (By Peggy Bargmann, R.N., B.S.N)

Start by gathering the Culture Change Leadership Team. This team should consist of the administrator, the director of nursing, and representatives from each department in the organization. In order to have complete representation of the home, it is important that there be representatives from all levels of the organization. Be sure to include direct care staff members, and at least one family member and one resident. The team is usually comprised of 15 – 20 people. Once the team is gathered, have them divide up into groups of 3 – 4 and ask each group to complete the tool ensuring that everyone has input. Once all the groups have completed the tool, a facilitator can bring the large group back together and start down through the tool enlisting input from all groups to form a final consensus score. For some questions, there will be common agreement on the score. For other questions, there will be a wide variance and the resulting discussion will be lively. By listening, there is much that can be learned during these discussions. The facilitator will need to be sure that all voices in the room have equal input – be sure to be listening to the input from direct care staff, residents, and families. As an example, question # 11 states, "Residents can get a bath/shower as often as they would like." The staff may feel that all residents have choice in their bathing times, until a resident informs them that when she moved in she was told what days she was "scheduled" for her shower, and didn't realize that she could ask for other days. This could lead to a discussion of how residents are informed and how choice is encouraged and what impact that has on the day-to-day operations. The process for completing the tool and facilitating the robust discussion can take up to three hours. It is a great way for the Culture Change Leadership Team to assess where the home is on its culture change journey, celebrate their accomplishments and, as a result of the group discussion, generate goals and action plans for their culture change journey. The Team can decide how often they want to repeat this process (e.g., every 6 months or annually) in order to assess their progress, celebrate their successes and revise their goals and action plans, as necessary, to continue on their culture change journey.

3.6

Artifacts of Culture Change - PLEASE complete the Online Version (http://www.artifactsofculturechange.org/) Home name ________________________________ Date ______________ City ______________________ State ________ Current number of residents ________

Care Practice Artifacts 1. Percentage of residents who are offered any of the following styles of dining:  Restaurant style where staff take residents’ orders;  Buffet style where residents help themselves or tell staff what they want;  Family style where food is served in bowls on dining tables where residents help themselves or staff assist them;  Open dining where meal is available for at least 2 hours time period and residents can come when they choose;  24 hour dining where residents can order food from the kitchen 24 hours a day. 2. Snacks/drinks available at all times to all residents at no additional cost, i.e., in a stocked pantry, refrigerator or snack bar.

_____________Enter the actual percentage % in your home

3. Baked goods are baked on resident living areas.

____________Enter the actual number of days in your home

4. Home celebrates residents’ individual birthdays rather than, or in addition to, celebrating resident birthdays in a group each month. 5. Home offers aromatherapy to residents by staff or volunteers. 6. Home offers massage to residents by staff or volunteers.

Convert your home's figure based on the below scale: 100-81 % (5 points) 80-61 % (4 points) 60-41 % (3 points) 40-21 % (2 points) 20-1 % (1 point) 0% (0 points)

_____ All residents (5 points) _____ Some residents (3 points) _____ Not a current practice (0 points)

Convert your home's figure based on the below scale: All days of the week (5 points) 2-6 days/week (3 points) < 2 days/week (0 points) ____ All residents (5 pts) ____ Some residents (3 pts) ____ Not a current practice (0 pts) ____ All residents (5 pts) ____ Some residents (3 pts) ____ Not a current practice (0 pts) ____ All residents (5 pts) ____ Some residents (3 pts) ____ Not a current practice (0 pts)

3.7

Care Practice Artifacts (cont.) 7. Home has dog(s) and/or cats(s).

8. Home permits residents to bring own dog and/or cat to live with them in the home. 9. Waking time/bedtimes chosen by residents. 10. Bathing Without a Battle techniques are used with residents. 11. Residents can get a bath/shower as often as they would like. 12. Home arranges for someone to be with a dying resident at all times (unless they prefer to be alone) – family, friends, volunteers or staff. 13. Memorials/remembrances are held for individual residents upon death. 14. “I” format care plans, in the voice of the resident and in the first person, are used.

_____ At least one dog or one cat lives on premises (5 pts) _____ The only animals in the building are when staff bring them during work hours (3 pts) _____ The only animals in the building are those brought in for special activities or by families (1 pt) _____ None (0 pts) _____ Yes (5 pts) _____ No (0 pts) _____ All residents (5 pts) _____ Some residents (3 pts) _____ Not a current practice (0 pts) _____ All residents (5 pts) _____ Some residents (3 pts) _____ Not a current pratice (0 pts) _____ All residents (5 pts) _____ Some residents (3 pts) _____ Not a current practice (0 pts) ____ All residents (5 pts) ____ Some residents (3 pts) ____ Not a current practice (0 pts) ____ All residents (5 pts) ____ Some residents (3 pts) ____ Not a current practice (0 pts) ____ All care plans (5 pts) ____ Some (3 pts) ____ Not a current practice (0 pts)

Care Practice Artifacts Total (Out of 70 possible points)

Environment Artifacts

15. Percent of residents who live in households that are self-contained with full kitchen, living room and dining room.

______Enter the actual percentage % in your home Convert your home's figure based on the below scale: 100-81 % (100 points) 80-61 % (80 points) 60-41 % (60 points) 40-21 % (40 points) 20-1 % (20 points) 0 % (0 points)

3.8

Environment Artifacts (cont.) 16. Percent of residents in private rooms.

______Enter the actual percentage % in your home Convert your home's figure based on the below scale:

17. Percent of residents in privacy enhanced shared rooms where residents can access their own space without trespassing through the other resident’s space. (This does not include the traditional privacy curtain.)

18. No traditional nurses’ stations or traditional nurses’ stations have been removed. 19. Percent of residents who have a direct window view not past another resident’s bed.

100-81 % (50 points) 80-61 % (40 points) 60-41 % (30 points) 40-21 % (20 points) 20-1 % (10 points) 0 % (0 points) ______Enter the actual percentage % in your home Convert your home's figure based on the below scale: 100-81 % (25 points) 80-61 % (20 points) 60-41 % (15 points) 40-21 % (10 points) 20-1 % (5 points) 0 % (0 points) _____ No traditional nurses’ stations (25 pts) _____ Some traditional nurses’ stations have been removed (15 pts) ____ Traditional nurses’ stations remain in place (0 pts) _____Enter the actual percentage % in your home Convert your home's figure based on the below scale: _____ 100 – 68% (5 pts) _____ 67 – 34% (3 pts) _____ 33 – 0 % (0 pts)

20. Resident bathroom mirrors are wheelchair accessible and/or adjustable in order to be visible to a seated or standing resident. 21. Sinks in resident bathrooms are wheelchair accessible with clearance below sink for wheelchair.

_____ All resident bathroom mirrors (5 pts) _____ Some (3 pts) _____ None (0 pts)

22. Sinks used by residents have adaptive/easy-to-use lever or paddle handles.

_____ All sinks (5 pts) _____ Some (3 pts) _____ None (0 pts)

23. Adaptive handles, enhanced for easy use, for doors used by residents (rooms, bathrooms and public areas).

_____ All resident-used doors (5 pts) _____ Some (3 pts) _____ None (0 pts)

24. Closets have moveable rods that can be set to different heights.

_____ All closets (5 pts) _____ Some (3 pts) _____ None (0 pts)

_____ All resident bathroom sinks (5 pts) _____ Some (3 pts) _____ None (0 pts)

3.9

Environment Artifacts (cont.) 25. Home has no rule prohibiting, and residents are welcome, to decorate their rooms any way they wish including using nails, tape, screws, etc. 26. Home makes available extra lighting source in resident room if requested by resident such as floor lamps, reading lamps. 27. Heat/air conditioning controls can be adjusted in resident rooms.

_____ Yes (5 pts) _____ No (0 pts) _____ Yes (5 pts) _____ No (0 pts) _____ All resident rooms (5 pts) _____ Some (3 pts) _____ None (0 pts)

28. Home provides or invites residents to have their own refrigerators.

_____ Yes (5 pts) _____ No (0 pts)

29. Chairs and sofas in public areas have seat heights that vary to comfortably accommodate people of different heights.

_____ Chair seat heights vary by 3” or more (5 pts) _____ Chair seat heights vary by less than 3”(3 pts) _____ Chair seat heights do not vary (0 pts)

30. Gliders which lock into place when person rises are available inside the home and/or outside. 31. Home has store/gift shop/cart available where residents and visitors can purchase gifts, toiletries, snacks, etc. 32. Residents have regular access to computer/Internet and adaptations are available for independent computer use such as large keyboard or touch screen.

_____ Yes (5 pts) _____ No (0 pts)

33. Workout room available to residents.

_____ Yes (5 pts) _____ No (0 pts)

34. Bathing rooms have functional and properly installed heat lamps, radiant heat panels or equivalent.

_____ All bathing rooms (5 pts) _____ Some (3 pts) _____ None (0 pts)

35. Home warms towels for resident bathing.

_____ All residents (5 pts) _____ Some residents (3 pts) _____ Not a current practice (0 pts)

36. Accessible, protected outdoor garden/patio provided for independent use by residents. Residents can go in and out independently, including those who use wheelchairs, e.g. residents do not need assistance from staff to open doors or overcome obstacles in traveling to patio. 37. Home has outdoor, raised gardens available for resident use.

____ Available to all residents (5 pts) ____ Available for some residents (3 pts) ____ Not available (0 pts)

_____ Yes (5 pts) _____ No (0 pts) _____ Both Internet access & adaptations (10 pts) _____ Access without adaptations (5 pts) _____ Neither (0 pts)

____ Available to all residents (5 pts) ____ Available for some residents (3 pts) ____ Not available (0 pts)

3.10

Environment Artifacts (cont.) 38. Home has outdoor walking/wheeling path which is not a city sidewalk or path. 39. Pager/radio/telephone call system is used where resident calls register on staff’s pagers/radios/telephones and staff can use it to communicate with fellow staff. 40. Overhead paging system has been turned off or is only used in case of emergency. 41. Personal clothing is laundered on resident household/neighborhood/unit instead of in a general all-home laundry, and residents/families have access to washer and dryer for own use. Environment Artifacts Total (Out of 320 possible points)

____ Available to all residents (5 pts) ____ Available for some residents (3 pts) ____ Not available (0 pts) _____ Yes (5 pts) _____ No (0 pts)

_____ Yes (5 pts) _____ No (0 pts)

_____ Available to all residents (5 pts)

_____ Available to some residents (3 pts) _____ None (0 pts)

Family & Community Artifacts 42. Regularly scheduled intergenerational program in which children customarily interact with residents.

_____ Weekly (5 pts) _____ Monthly or less frequently (3 pts) _____ No (0 pts)

43. Home makes space available for community groups to meet in home with residents welcome to attend. 44. Private guestroom available for visitors at no, or minimal cost for overnight stays. 45. Home has café/restaurant/ tavern/canteen available to residents, families and visitors at which residents and family can purchase food and drinks daily. 46. Home has special dining room available for family use/gatherings which excludes regular dining areas. 47. Kitchenette or kitchen area with at least a refrigerator and stove is available to families, residents, and staff where cooling and baking are welcomed.

_____ Yes (5 pts) _____ Not a current practice (0 pts) _____ Yes (5 pts) _____ Not a current practice (0 pts) _____ Yes (5 pts) _____ No (0 pts)

_____ Yes (5 pts) _____ Not a current practice (0 pts) _____ Yes (5 pts) _____ Not a current practice (0 pts)

Family and Community Artifacts Total (Out of 30 possible points)

3.11

Leadership Artifacts 48. CNAs attend resident care conferences.

_____ All care conferences (5 pts) _____ Some (3 pts) _____ Not a current practice (0 pts)

49. Residents or family members serve on home quality assessment and assurance (QAA, QI, CQI, QA) committee.

_____ Yes (5 pts) _____ Not a current practice (0 pts)

50. Residents have an assigned staff member who serves as a “buddy”, case coordinator, Guardian Angel, etc. to check with the resident regularly and follow up on any concerns. (This is in addition to an assigned social service staff.) 51. Learning Circles or equivalent are used regularly in staff and resident meetings in order to give each person the opportunity to share their opinion/ideas. 52. Community Meetings are held on a regular basis bringing staff, residents and families together as a community.

_____ All new residents (5 pts) _____ Some (3 pts) _____ Not a current practice (0 pts)

_____ Yes (5 pts) _____ Not a current practice (0 pts) _____ Yes (5 pts) _____ Not a current practice (0 pts)

Leadership Artifacts Total (Out of 25 possible points)

Workplace Practice Artifacts 53. RNs consistently work with the residents of the same neighborhood/household/unit (with no rotation). 54. LPNs consistently work with the residents of the same neighborhood/household/unit (with no rotation). 55. CNAs consistently work with the residents of the same neighborhood/household/unit (with no rotation). 56. Self-scheduling of work shifts. CNAs develop their own schedule and fill in for absent CNAs. CNAs independently handle the task of scheduling, trading shifts/days, and covering for each other instead of a staffing coordinator.

_____ All RNs (5 pts) _____ Some (3 pts) _____ Not a current practice (0 pts) _____ All LPNs (5 pts) _____ Some (3 pts) _____ Not a current practice (0 pts) _____ All CNAs (5 pts) _____ Some (3 pts) _____ Not a current practice (0 pts) _____ All CNAs (5 pts) _____ Some (3 pts) _____ Not a current practice (0 pts)

3.12

Workplace Practice Artifacts (cont.) 57. Home pays expenses for nonmanagerial staff to attend outside conferences/workshops, e.g. CNAs, direct care nurses. Check yes if at least one nonmanagerial staff member attended an outside conference or workshop paid by home in past year. 58. Staff is not required to wear uniforms or “scrubs”.


59. Percent of other staff cross-trained and certified as CNAs in addition to CNAs in the nursing department.

_____Enter the actual percentage % in your home

60. Activities, informal or formal, are led by staff in other departments such as nursing, housekeeping or any departments. 61. Awards given to staff to recognize commitment to person-directed care, e.g. Culture Change award, Champion of Change award. This does not include Employee of the Month. 62. Career ladder positions for CNAs, e.g. CNA II, CNA III, team leader, etc. There is a career ladder for CNAs to hold a position higher than base level.


63. Job development programs, e.g. CNA to LPN to RN to NP.


64. Day care onsite available to staff

_____ Yes (5 points) _____ Not a current practice (0 points)

65. Home has on staff a paid volunteer coordinator in addition to activity director.

_____ Full time (30 hours/week or more) (5 pts) _____ Part time (15-30 hrs/week) (3 pts) _____ No paid volunteer coordinator (0 pts)

66. Employee evaluations include observable measures of employee support of individual resident choices, control and preferred routines in all aspects of daily living.

_____ All employee evaluations (5 points) _____ Some (3 points) _____ Not a current practice (0 points)


Convert your home's figure based on the below scale: _____100–81 % (5 pts) _____ 80 – 61% (4 pts) _____ 60 – 41% (3 pts) _____ 40 – 21% (2 pts) _____ 20 – 1% (1 point) _____ 0 (0 pts)



Workplace Practice Artifacts Total (Out of 70 possible points)

3.13

Staffing Outcomes and Occupancy 67. Average longevity of CNAs (in any position). Add length of employment in years of permanent CNAs and divide by number of CNA staff.

Convert your home's figure based on the below scale: Above 5 years (5 points) 3-5 years (3 points) Below 3 years (0 points)

_______ Enter your home's average years. 68. Average longevity of LPNs (in any position). Add length of employment in years of permanent staff LPNs and divide by the number of LPN staff.


_______ Enter your home's average years. 69. Average longevity of RN/GNs (in any position). Add length of employment in years of permanent staff RNs/GNs and divide by the number of RN/GN staff. _______ Enter your home's average years. 70. Longevity of the Director of Nursing (in any position). _______ Enter your home's figure in years. 71. Longevity of the Administrator (in any position). _______ Enter your home's figure in years. 72. Turnover rate for CNAs. Number of CNAs who left, voluntary or involuntary, in previous 12 months divided by the total number of CNA's employed in the previous 12 months. _______ Enter your home's percentage.


Convert your home's figure based on the below scale: Above 5 years (5 points) 3-5 years (3 points) Below 3 years (0 points) Convert your home's figure based on the below scale: Above 5 years (5 points) 3-5 years (3 points) Below 3 years (0 points) Convert your home's figure based on the below scale: 0-19 % (5 points) 20-39 % (4 points) 40-59 % (3 points) 60-79 % (2 points) 80-99 % (1 point) 100% and above (0 points)

3.14

Staffing Outcomes and Occupancy (cont.) 73. Turnover rate for LPNs.

Convert your home's figure based on the below scale:

Number of LPNs who left, voluntary or involuntary, in previous 12 months divided by the total number of LPNs employed in the previous 12 months. _______ Enter your home's percentage.

0-12 % (5 points) 13-25 % (4 points) 26-38 % (3 points) 39-51 % (2 points) 52-65 % (1 point) 66 % and above (0 points)

74. Turnover rate for RNs.


Number of RNs who left, voluntary or involuntary, in previous 12 months divided by the total number of RNs employed in the previous 12 months. _______ Enter your home's percentage.

0-12 % (5 points) 13-25 % (4 points) 26-38 % (3 points) 39-51 % (2 points) 52-65 % (1 point) 66 % and above (0 points)

75. Turnover rate for DONs.


_______ Enter number of DONs in the last 12 months

1 (5 points) 2 (3 points) 3 or more (0 points) Convert your home's figure based on the below scale:

76. Turnover rate for Administrators. _______ Enter number of NHAs in the last 12 months

1 (5 points) 2 (3 points) 3 or more (0 points)

77. Percent of CNA shifts covered by agency staff over the last month. Total number of CNA shifts (all shifts regardless of hours in a shift) in a 24 hour period; Multiplied by the number of days in the last full month; Of this number, number of shifts covered by an agency CNA

Convert your home's figure based on the below scale: 0 % (5 points) 1-5% (3 points) Over 5% (0 points)

_______Enter your percentage (agency shifts divided by total number multiplied by days multiplied by 100)

3.15

Staffing Outcomes and Occupancy (cont.) 78. Percent of nurse shifts covered by agency staff over the last month. Total number of nurse shifts (all shifts regardless of hours in a shift) in a 24 hour period; Multiplied by the number of days in the last full month; Of this number, number of shifts covered by an agency nurse.

Convert your home's figure based on the below scale: 0 % (5 points) 1-5% (3 points) Over 5% (0 points)

_______Enter your percentage (agency shifts divided by total number multiplied by days multiplied by 100) 79. Current occupancy rate.


_______ Enter your home’s occupancy rate

Above average 86-100 % (5 points) Average 83-85 % (3 points) Below average 0-82 % (0 points)

Staffing Outcomes and Occupancy Total (Out of 65 possible points)

Artifacts Sections Care Practices Environment Family and Community Leadership Workplace Practice Staffing Outcomes and Occupancy Artifacts of Culture Change

Potential Points

Score

70 320 30 25 70 65 580

Developed by the Centers for Medicare and Medicare Services and Edu-Catering, LLP. ACC-FL adapted with permission.

3.16

The First 24 Hours and Beyond My name is: ______________________________ Preferred time to arise: Prior to 6:00am Between 6:00am and 7:00am Between 7:00am and 8:00am Between 8:00am and 9:00am Between 9:00am and 10:00am Between 10:00am and 11:00am Between 11:00am and 12:00pm Afternoon Specific Time: ___________

I prefer to be called: ___________________________________

Wake up preference: I wake up on my own Have staff wake me up I use an alarm clock

Nap preference: I prefer a nap at ____________ I don’t take naps My nap lasts for _____________

Whenever I awake but not past _____

Sleeping aids: Television on Radio on Extra pillows Blankets on Blankets off No pillows Snack prior to bed Room lights on Night light on Lamp on All lights off Other: _____________________

Bathing preference:

Bathing day(s) preferred:

Bathing time(s) preferred:

Shower Bath Sponge Bath Shower or bath

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Before breakfast at __________ After breakfast at ___________ Before lunch at _____________ After lunch at ______________ Before dinner at ____________ After dinner at _____________ Before bed at ______________

When do you normally take your medications? Before breakfast at __________ After breakfast at ___________ Before lunch at _____________ After lunch at ______________ Before dinner at ____________ After dinner at _____________ Before bed at ______________

Do you normally eat three meals a day?

Bedtime or morning routine you are comfortable with: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Food/Special diet preferences:

Foods I dislike:

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

_____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

Breakfast yes or no Lunch yes or no Dinner yes or no Other: _____________

3.17

Group size preference:

Please remember:

I don’t like:

Things that comfort me:

Large groups Small groups Individual Independent Community programs Other: _____________________

I am hard of hearing in R/L/both I wear a hearing aid in R/L/both I wear glasses I wear dentures I use a wheelchair/walker/cane Other: ______________________

Noise Being cold Being hot Being touched Being with people Bright lights Dim lights Loud noise / music Talking about: _________________ Activities such as: ______________ _____________________________ Other: _______________________

Being in my room Being touched Being with people Calling family/friends Humor Music Religion Sports TV Reading Talking about: ________________ Comfort food: ________________ Other: ______________________

Snacks preferred:

Important events you typically celebrate throughout the year?

Drinks: ______________________ ____________________________ Snacks: _____________________ ____________________________ Favorite dessert: ______________ Time you prefer snack: _________ (please give brand name as well)

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

Other things you need to know:

3.18

Appendix 3-A

Introduction   Food and dining requirements are core components of quality of life and quality of care in  nursing homes.  Research also shows that:  50%‐70% of residents leave 25% or more of their food uneaten at most meals and both  chart documentation of percent eaten and the MDS are notoriously inaccurate, consistently  representing a gross under‐estimate of low intake. 1, 2 60%‐80% of residents have a physician or dietitian order to receive dietary supplements.3  25% of residents experienced weight loss when research staff conducted standardized  weighing procedures over time. 4, 5 The American Dietetic Association (ADA) reports that under‐nutrition adversely affects  the quality and length of life, and therefore, has aroused the concern of geriatric health  professionals.  The prevalence of protein energy under‐nutrition for residents ranges from  23% to 85%, making malnutrition one of the most serious problems facing health  professionals in long term care.  Malnutrition is associated with poor outcomes and is an  indicator of risk for increased mortality.  It has been found that most residents with  evidence of malnutrition were on restricted diets that might discourage nutrient intake.6  CMS notes that the most frequent questions and concerns received by their staff focus on  the physicalenvironment and dining/food policies in nursing homes.  Therefore, in 2010  the Pioneer Network and CMS held their second co‐sponsored national symposium  Creating Home II National Symposium on Culture Change and the Food and Dining  Requirements , sponsored by the Hulda B. & Maurice L. Rothschild Foundation.  The  Symposium brought together a wide diversity of stakeholders, including nursing home  staff, regulators, provider leadership, researchers,  registered dietitians, vendors, and  advocates for culture change.   1 Simmons SF & Reuben D.  (2000). Nutritional intake monitoring for nursing home residents: A comparison 

of staff documentation, direct observation, and photography methods.  Journal of the American Geriatrics  Society, 48(2):209‐213. 2 Simmons SF, Lim B & Schnelle JF.  (2002). Accuracy of Minimum Data Set in identifying residents at risk for  undernutrition:  Oral intake and food complaints.  Journal of the American Medical Directors’ Association,  3(May/June):140‐145. 3 Simmons SF & Patel AV.  (2006). Nursing home staff delivery of oral liquid nutritional supplements to  residents at risk for unintentional weight loss. Journal of the American Geriatrics Society, 54(9):1372‐1376. 4 Simmons SF, Garcia ET, Cadogan MP, Al‐Samarrai NR, Levy‐Storms LF, Osterweil D & Schnelle JF.  (2003).  The Minimum Data Set weight loss quality indicator: Does it reflect differences in care processes related to  weight loss? Journal of the American Geriatrics Society 51(10):1410‐1418. 5 Simmons SF, Peterson E & You C.  (2009).The accuracy of monthly weight assessments in nursing homes:  Implications for the identification of weight loss.  Journal of Nutrition, Health & Aging, 13(3):284‐288. 6 ADA Position Paper Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long‐ Term Care 2005.

2 Appendix 3-A

The Pioneer Network is a growing coalition of organizations and individuals from across  the nation, changing the culture of aging and long term care.  Pioneer Network is dedicated  to making fundamental changes in values and practices to create a culture of aging that is  life‐affirming, satisfying, humane and meaningful. It advocates for public policy change,  creates communication, networking and learning opportunities; builds and supports  relationships and community; identifies and promotes transformation in practice, services,  public policy and research; develops and provides access to resources and leadership; and  hosts a national conference to bring together interested parties with a desire to propel this  important work.   The Hulda B. & Maurice L. Rothschild Foundation is the only national philanthropy  exclusively focused on improving the quality of life for elders in nursing homes throughout  the United States.  One of its key strategies is to work together with significant stakeholders  in order to modify existing regulations, such that they better support new models of aging  in long term care.  Currently, the Foundation has initiated and is supporting a number of  such efforts:  • The National Life Safety Task Force convened by Pioneer Network that has revisions  pending to the National Life Safety Code.   • The Center for Health Design expert panel that is developing recommendations for  the guidelines which govern the Design and Construction of Healthcare Facilities.  • The American Intitute of Architects Design for Aging Community that is drafting a  Proposal for Changes to Accessibility Standards for Nursing Home & Assisted Living  Residents in Toileting and Bathing under the Americans with Disabilities Act.   • At the specific request of the regulatory community, the Foundation has supported  the University of Minnesota in building a free website, NHRegsPlus, which provides  a cross‐indexed compendium of all state nursing home regulations.  Food and dining are an integral part of individualized care and self‐directed living for  several reasons, including: (1) the complexity of food and dining requirements when  advancing models of culture change; (2) the importance of food and dining as a significant  element of daily living, and (3) the most frequent questions and concerns CMS receives  from regulators and providers consistently focus on dining and food policies in nursing  homes. Therefore, we believe this area is one most in need of national dialogue if we are to  improve quality of life for persons living in nursing homes while maintaining safety and  quality of care.  In order to gather input from the many key stakeholders, the Creating Home II National  Symposium on the Food and Dining Requirements and Culture Change was co‐sponsored  by Pioneer Network and CMS, in collaboration with the American Health Care Association.  A set of research papers were commissioned with a wide variety of experts as well as a  3 Appendix 3-A

series of webinars, hosted by Carmen Bowman under contract with CMS, and all were  posted online. This process allowed many members of interested organizations,  associations, regulatory departments, and others to participate. The Hulda B. & Maurice L.  Rothschild Foundation supported a Stakeholder Workshop on May 14, 2010 that was  attended by 83 national leaders, which reviewed the feedback from all stakeholders, expert  speakers and individual participants.  Two of the numerous recommendations at the  Creating Home II symposium for future consideration were:  National stakeholder workgroup develop guidelines for clinical best practice for  individualization in long term care living to provide regulatory overview and  interpretive protocol and investigative guidance, and prepare related education  materials to facilitate implementation.    Each profession serving elders in long‐term care develop and disseminate standards  of practice for their professional accountability that addresses proper training,  competency assessment, and their role as an active advocate for resident rights and  resident quality of life from a wellness perspective in addition to quality of care  from a medical perspective. 

  These recommendations were acted upon at least in part thanks to the generous funding of  the Hulda B. and Maurice L. Rothschild Foundation to the Pioneer Network in 2011 by  forming the Food and Dining Clinical Standards Task Force.  The Food and Dining Clinical  Standards Task Force is comprised of symposium experts, representatives from Centers for  Medicare and Medicaid Services Division of Nursing Homes, the US Food and Drug  Administration and the Centers for Disease Control and Prevention as well as national  standard setting groups.   The Food and Dining Clinical Standards Task Force made a significant effort to obtain  evidence and thus the New Dining Practice Standards document reflects evidence‐based  research available to‐date. The document also reflects current thinking and consensus  which are in advance of research.  Therefore the Current Thinking portions of each section  of the New Dining Practice Standards document represent a list of recommended future  research.   

4 Appendix 3-A

GOAL STATEMENT:  Establish nationally agreed upon new standards of practice  supporting individualized care and self‐directed living versus traditional diagnosis‐focused  treatment.    Organizations Agreeing to the New Dining Practice Standards  • American Association for Long Term Care Nursing (AALTCN)  • American Association of Nurse Assessment Coordination (AANAC)  • American Dietetic Association (ADA)  • American Medical Directors Association (AMDA)  • American Occupational Therapy Association (AOTA)  • American Society of Consultant Pharmacists (ASCP)  • American Speech‐Language‐Hearing Association (ASHA)  • Dietary Managers Association (DMA)  • Gerontological Advanced Practice Nurses Association (GAPNA)  • Hartford Institute for Geriatric Nursing (HIGN)   • National Association of Directors of Nursing Administration   in Long Term Care (NADONA/LTC)  • National Gerontological Nursing Association (NGNA)                                                        Note to reader:  5 Appendix 3-A

  Regular diet is referred to often in this document. Regular diet is defined as what should be  prepared and offered to meet nutritional needs in accordance with the current  recommended dietary allowances of the Food and Nutrition Board of the National Research  Council, National Academy of Sciences, used as a standard meal planning guide while  residents have the right to make choices.    Whenever physician is referred to in this document, it is recognized that medical care may  be delivered by a physician, or a nurse practitioner, or a physician assistant under the  direction of a physician in accordance with state licensure law.    Borrowing from CMS interpretive guidance and probe language at Tag F280 and Tag F281:    Tag F280:    “Interdisciplinary” means that professional disciplines, as appropriate, will work  together to provide the greatest benefit to the resident.      The physician must participate as part of the interdisciplinary team, and may  arrange with the facility alternate methods other than attendance at care planning  conferences, of providing his/her input, such as one‐on‐one discussions and  conference calls.    Some interdisciplinary professional disciplines include the occupational therapist, dietitian  and speech therapist as the Probes at Tag F280 indicate:    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? 

6 Appendix 3-A

 

b. Do the dietitian and 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 oropharyngeal  capabilities of the resident?   c. Is there evidence of physician involvement in development of the care  plan (e.g., presence at care plan meetings, conversations with team  members concerning the care plan, conference calls)? 

   

Tag F281:  “Professional standards of quality” means services that are provided according to  accepted standards of clinical practice. Standards may apply to care provided by a  particular clinical discipline or in a specific clinical situation or setting. Standards  regarding quality care practices may be published by a professional organization,  licensing board, accreditation body or other regulatory agency. Recommended  practices to achieve desired resident outcomes may also be found in clinical  literature. Possible reference sources for standards of practice include:     • Current manuals or textbooks on nursing, social work, physical therapy, etc.     • Standards published by professional organizations such as the American  Dietetic Association, American Medical Association, American Medical  Directors Association, American Nurses Association, National Association of  Activity Professionals, National Association of Social Work, etc.     • Clinical practice guidelines published by the Agency of Health Care Policy  and Research.     • Current professional journal articles.    

  Similarly, whenever “interdisciplinary team” is referred to in this document, it can and is  recommended that it include extended technical, support , and administrative team  members such as Certified Nursing Assistants, (CNAs), Patient Care Technicians (PCTs),  directors of food service (including Certified Dietary Managers (CDMs) & Dietetic  Technicians, Registered (DTRs), cooks, housekeepers, and cross trained/blended workers.  This document comprises numerous quotations from many professional organizations,  thus a variety of nomenclature is used. There has been no effort to edit or standardize the  nomenclature referring to people who live in long term care settings, e.g. elders, residents,  clients, patients or to describe where they live, e.g. facilities, nursing homes, homes and  communities.  

7 Appendix 3-A

Contents  Standard of Practice regarding Individualized Nutrition   Approaches/Diet Liberalization          

 

      

 

     8 

Standard of Practice for Individualized Diabetic/Calorie Controlled Diet  

    

   12 

Standard of Practice for Individualized Low Sodium Diet  

 

 

    

   15 

Standard of Practice for Individualized Cardiac Diet        Standard of Practice for Individualized Altered Consistency Diet 

 

  

   18 

 

  

   20 

Standard of Practice for Individualized Tube Feeding      Standard of Practice for Individualized Real Food First      Standard of Practice for Individualized Honoring Choices  

 

    

 

   25 

 

       

    

   29 

 

 

   

   33 

Standard of Practice for Shifting Traditional   Professional Control to Individualized Support of Self Directed Living   

    

   42 

New Negative Outcome                    Patient Rights and Informed Consent/Refusal across the Healthcare Continuum   Mayo Clinic Proceedings 2005    References                              

8 Appendix 3-A

   45     51     58 

Standard of Practice for Individualized Nutrition Approaches/Diet Liberalization    Basis in Current Thinking and Research    American Medical Directors Association (AMDA):  Weight loss is common in the nursing home and associated with poor clinical outcomes  such as the development of pressure ulcers, increased risk of infection, functional decline,  cognitive decline and increased risk of death. One of the frequent causes of weight loss in  the long‐term care setting is therapeutic diets.  Therapeutic diets are often unpalatable and  poorly tolerated by older persons and may lead to weight loss.  The use of therapeutic  diets, including low‐salt, low‐fat, and sugar‐restricted diets, should be minimized in the LTC  setting.7    Attending physicians are encouraged to consider liberalizing dietary restrictions (e.g.,  calorie limitation, salt restrictions) that are not essential to the resident’s well being, and  that may impair quality of life or acceptance of diet.8     Patients and families who have become accustomed to dietary restrictions while at home  or in the acute care setting may need to be educated about this change in thinking.   Swallowing abnormalities are common but do not necessarily require modified diet and  fluid textures, especially if these restrictions adversely affect food and fluid intake.9    American Dietetic Association (ADA):  It is the position of the American Dietetic Association that the quality of life and nutritional  status of older residents in long‐term care facilities may be enhanced by liberalization of  the diet prescription.  Medical nutrition therapy must balance medical needs and individual  desires and maintain quality of life.  The recent paradigm shift from restrictive institutions  to vibrant communities for older adults requires dietetics professionals to be open‐minded  when assessing risks versus benefits of therapeutic diets, especially for frail older adults.   Food is an essential component of quality of life; an unacceptable or unpalatable diet can  lead to poor food and fluid intake, resulting in weight loss and undernutrition and a spiral  of negative health effects.10    Although limited evidence supporting a medicalized diet in select older adults does exist, it  is also important to note that these diets are often less palatable and poorly tolerated and  can lead to weight loss.  Weight loss is a far greater concern to the often frail nursing home 

American Medical Directors Association Clinical Practice Guideline:  Altered Nutritional Status. 2009.  AMDA Synopsis of Federal Regulations in the Nursing Home: Implication for Attending Physicians and  Medical Directors 2009. 9 AMDA Clinical Practice Guideline: Diabetes Management in the Long‐Term Care Setting 2008. 10 ADA Position Paper Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in  Long‐Term Care 2005. 7 8

9 Appendix 3-A

resident and easily outweighs the potential modest benefits a medicalized diet can only  sometimes offer.11    It is the position of the American Dietetic Association that the quality of life and nutritional  status of older adults residing in health care communities can be enhanced by  individualization to less‐restrictive diets.  Although therapeutic diets are designed to  improve health, they can negatively affect the variety and flavor of the food offered.   Individuals may find restrictive diets unpalatable, resulting in reducing the pleasure of  eating, decreased food intake, unintended weight loss, and undernutrition – the very  maladies health care practitioners are trying to prevent.  In contrast, more liberal diets are  associated with increased food and beverage intake.  For many older adults residing in  health care communities, the benefits of less‐restrictive diets outweigh the risks.12    Centers for Medicare and Medicaid Services (CMS):  Liberalized diets should be the norm, restricted diets should be the exception.  Generally  weight stabilization and adequate nutrition are promoted by serving residents regular or  minimally restricted diets.13    Research suggests that a liberalized diet can enhance the quality of life and nutritional  status of older adults in long‐term care facilities.  Thus, it is often beneficial to minimize  restrictions, consistent with a resident’s condition, prognosis, and choices before using  supplementation. It may also be helpful to provide the residents their food preferences,  before using supplementation.  This pertains to newly developed meal plans as well as to  the review of existing diets.  Dietary restrictions, therapeutic (e.g., low fat or sodium  restricted) diets, and mechanically altered diets may help in select situations.  At other  times, they may impair adequate nutrition and lead to further decline in nutritional status,  especially in already undernourished or at‐risk individuals.  When a resident is not eating  well or is losing weight, the interdisciplinary team may temporarily abate dietary  restrictions and liberalize the diet to improve the resident’s food intake to try to stabilize  their weight.  Sometimes, a resident or resident’s representative decides to decline  medically relevant dietary restrictions.  In such circumstances, the resident, facility and  practitioner collaborate to identify pertinent alternatives (CMS Tag F 325 Nutrition).14   

Current Thinking    Given that most nursing home residents are at risk for malnutrition and may in fact have  different, therapeutic targets for blood pressure, blood sugar and cholesterol, a regular or  liberalized diet which allows for resident choice is most often the preferred initial choice. 

11 Gardner CD, Coulston A, Chatterjee L, Rigby A, Spiller G, Farquhar JW, The effect of a plant‐based diet on 

plasma lipids in hypercholesterolemic adults: a randomized trial. Intern Med. 2005;142 (9):725. 12 ADA Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long‐Term Care  2005. 13 CMS Satellite Broadcast From Institutional to Individualized Care: Case Studies in Culture Change, Part III,  2007 available from the Pioneer Network www.pioneernetwork.net.  14 State Operations Manual for LTC Facilities, Appendix PP, 483.25(i) F 325 Nutrition, 2008 Guidance.

10 Appendix 3-A

As with any medical issue, residents should be monitored for desired outcomes as well as  for potential adverse effects.15     Some homes have actually made the “regular” diet with ranges of consistency  modifications such as "puree to mechanical soft" their only available option, then honored  the resident's choice to eliminate "not recommended" foods from his/her diet by choice,  then monitored his/her clinical outcomes and made changes as necessary.  That being said,  homes with transitional care units or that serve younger disabled people may choose to  offer the more restrictive diets as an option for long term health.16    All persons moving into a nursing home receive a regular diet unless there is a strong  medical historical reason to initiate/continue a restricted diet.  Those who require  medicalized diets can be assessed by the dietitian, physician, and if necessary the speech  therapist for appropriate individualized modification.  There needs to be continuous  monitoring of the usage of all medicalized diets to ensure that they continue to be  medically indicated, much the same way the usage of urinary catheters or other medical  devices are monitored.  When potential interventions have the ability to both help and  harm, such as medicalized diets and thickened liquids, the interventions should be  reviewed by the interdisciplinary team in a holistic fashion and discussed with the resident  and/or their family/POA prior to their implementation.  Residents and/or their  families/POA should be educated regarding these interventions and the care plan  monitored for both safety and effectiveness.  The physician and interdisciplinary team  should treat asymptomatic disease PROVIDED it is consistent with the resident’s goals for  care, is SUPPORTED by the literature and DOES NOT DECREASE QUALITY OF LIFE.17  Relevant Research Trends  See below for relevant research to each specific diet. 

15 Leible and Wayne, The Role of the Physician’s Order, paper written for CHII 2010.  16 Bump, Linda. Clinical Standards Task Force communication, 2011. 17

Leible and Wayne, The Role of the Physician’s Order, paper written for CHII 2010. 

11 Appendix 3-A

Recommended Course of Practice  • Diet is to be determined with the person and in accordance with his/her informed  choices, goals and preferences, rather than exclusively by diagnosis.  • Assess the condition of the person. Include quality of life markers such as  satisfaction with food, meal time service, level of control and independence.  • Assess the condition of the person. Assess and provide the person's preferred  context and environment for meals, in other words the person's preferences,  patterns and routines for socialization (i.e. eating alone or with others), physical  support (i.e. adapted eating utensils, assistance with cartons/cutting or adapted w/c  positioning), timing of meals (i.e. typical community or unique meal times) and  personal meaning/value of the dining experience (i.e. for one who does not eat  breakfast, breakfast is not important but perhaps an early lunch is).  Include quality  of life markers such as satisfaction with food, service received during meals, level of  control and independence.  • Unless a medical condition warrants a restricted diet, consider beginning with a  regular diet and monitoring how the person does eating it.  • Empower and honor the person first, and the whole interdisciplinary team second,  to look at concerns and create effective solutions.  • Support self‐direction and individualize the plan of care.  • Ensure that the physician and consultant pharmacist are aware of resident food and  dining preferences so that medication issues can be addressed and coordinated i.e.  medication timing and impact on appetite.  • Monitor the person and his/her condition related to their goals regarding  nutritional status and their physical, mental and psychosocial well‐being.  • Although a person may have not been able to make decisions about certain aspects  of their life, that does not mean they cannot make choices in dining.    • When a person makes “risky” decisions, the plan of care will be adjusted to honor  informed choice and provide supports available to mitigate the risks.   • Most professional codes of ethics require the professional to support the  person/client in making their own decisions, being an active, not passive,  participant in their care.  • When caring for frail elders there is often no clear right answer.  Possible  interventions often have the potential to both help and harm the elder.  This is why  the physician must explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family. The resident then has the right to make his/her informed choice  even if it is not to follow recommended medical advice and the team supports the  person and his/her decision, mitigating risks by offering support, i.e. offering foods  of natural pureed consistency when one refuses recommended tube feeding.  It is  when the team makes decisions for the person without acknowledgement by all that  problems arise.  The agreed upon plan of care should then be monitored to make  sure the community is best meeting the resident's needs.  • All decisions default to the person. 

12 Appendix 3-A

 Standard of Practice for Individualized Diabetic/Calorie Controlled Diet    Basis in Current Thinking and Research    AMDA:   “…intensive treatment of diabetes may not be appropriate for all individuals in the LTC  setting.  To improve quality of life, diagnostic and therapeutic decisions should take into  account the patient’s cognitive and functional status, severity of disease, expressed  preferences, and life expectancy.”18    An individualized regular diet that is well balanced and contains a variety of foods and a  consistent amount of carbohydrates has been shown to be more effective than the typical  treatment of diabetes.19     ADA:   There is no evidence to support prescribing diets such as no concentrated sweets or no  sugar added for older adults in living in health care communities, and these restricted diets  are no longer considered appropriate.  Most experts agree that using medication rather  than dietary changes to control blood glucose, blood lipid levels, and blood pressure can  enhance the joy of eating and reduce the risk of malnutrition in older adults in health care  communities.20    CMS:   Nothing specific to diabetes was found, however, CMS has stated much about liberalizing  diets, see Diet Liberalization section as well as each specific diet section.      Current Thinking    If a person with diabetes chooses not to eat breakfast, for example, that decision should be  made and communicated before a dose of regular insulin is administered in the morning.  While we agree that people should be given as much freedom as possible in choice of diets  and foods, it may be more appropriate in many cases to liberalize the treatment goals or  targets (such as hemoglobin A1C or cholesterol) rather than add more medication.21     The only benefit to sliding scale insulin is with a new diagnosis where the clinician is  attempting to estimate daily dosage of insulin.  For this reason, insulin sliding scale should  be used sparingly if at all, and glucose monitoring should be done no more than once daily  in stable diabetics, more frequently, albeit temporary, if actively adjusting the regimen.22   More than once daily blood sugars in stable diabetic patients should be discouraged (Ibid).  18 AMDA Clinical Practice Guidelines: Diabetes Management in the Long‐Term Care Setting 2008. 19 AMDA Clinical Practice Guideline:  Diabetes Management in the Long‐Term Care Setting 2008.  20 ADA Position Paper Individualized Nutrition Approaches for Older Adults in Health Care Communities 

2010. 21 Food and Dining Clinical Standards response, 3/23/11 American Society of Consultant Pharmacists. 22 Leible and Wayne, The Role of the Physician’s Order, paper written for CHII 2010. 

13 Appendix 3-A

Elderly nursing home residents with diabetes can receive a regular diet that is consistent in  the amount and timing of carbohydrates, along with proper medication to control blood  glucose levels (Ibid).    Relevant Research Trends    The traditional treatment of diabetes of a “no concentrated sweets” and a liberal diabetic  diet have not been shown to improve glycemic control in nursing home residents.23     Recent studies have failed to show that tight glycemic control prevents heart attacks and  strokes in diabetics and may in fact worsen outcome. 24 Tighter glycemic control may  prevent long term complications of diabetes such as retinopathy, neuropathy and  nephropathy in newly diagnosed diabetics however these conditions take years to develop  and few, if any, older adults would benefit from this approach.25     Given the lack of clear evidence to guide treatment in the older adult population, AMDA  recommends individualizing the treatment plan based on a resident’s underlying medical  condition and associated co‐morbidities and has stated a target hemoglobin AIC between 7  and 8 is reasonable.26     Little evidence supports the use of sliding scale insulin as it is reactive in nature and fails to  meet the physiologic needs of the person (Ibid).       Recommended Course of Practice  • Diet is to be determined with the person and in accordance with his/her informed  choices, goals and preferences, rather than exclusively by diagnosis.  • Assess the condition of the person. Assess and provide the person's preferred  context and environment for meals, in other words the person's preferences,  patterns and routines for socialization (i.e. eating alone or with others), physical  support (i.e. adapted eating utensils, assistance with cartons/cutting or adapted w/c  positioning), timing of meals (i.e. typical community or unique meal times) and  personal meaning/value of the dining experience (i.e. for one who does not eat  breakfast, breakfast is not important but perhaps an early lunch is).  Include quality  of life markers such as satisfaction with food, service received during meals, level of  control and independence.  • Unless a medical condition warrants a restricted diet, consider beginning with a  regular diet and monitoring how the person does eating it. 

23 Tariq SH, Karcic E, Thomas DR, et al. The use of no‐concentrated sweets diet in the management of type 2 

diabetes in nursing homes. J Am Dietetic Assoc 2001; 101(12):1463‐1466. 24 Tariq SH, Karcic E, Thomas DR, et al. The use of no‐concentrated sweets diet in the management of type 2  diabetes in nursing homes. J Am Dietetic Assoc 2001; 101(12):1463‐1466 25 Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358(24):2545‐255 26 AMDA Clinical Practice Guideline: Diabetes Management in the Long‐Term Care Setting 2008. 

14 Appendix 3-A

 

• Empower and honor the person first, and the whole interdisciplinary team second,  to look at concerns and create effective solutions.  • Support self‐direction and individualize the plan of care.  • Ensure that the physician and consultant pharmacist are aware of resident food and  dining preferences so that medication issues can be addressed and coordinated i.e.  medication timing and impact on appetite.  • Monitor the person and his/her condition related to their goals regarding  nutritional status and their physical, mental and psychosocial well‐being.  • Although a person may have not be able to make decisions about certain aspects of  their life, that does not mean they cannot make choices in dining.    • When a person makes “risky” decisions, the plan of care will be adjusted to honor  informed choice and provide supports available to mitigate the risks.   • Most professional codes of ethics require the professional to support the  person/client in making their own decisions, being an active, not passive,  participant in their care.  • When caring for frail elders there is often no clear right answer.  Possible  interventions often have the potential to both help and harm the elder.  This is why  the physician must explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family. The resident then has the right to make his/her informed choice  even if it is not to follow recommended medical advice and the team supports the  person and his/her decision, mitigating risks by offering support, i.e. offering foods  of natural pureed consistency when one refuses recommended tube feeding.  It is  when the team makes decisions for the person without acknowledgement by all that  problems arise.  The agreed upon plan of care should then be monitored to make  sure the community is best meeting the resident's needs.  • All decisions default to the person. 

15 Appendix 3-A

Standard of Practice for Individualized Low Sodium Diet    Basis in Current Thinking and Research    AMDA:  Such dietary restrictions may benefit some individuals, but more lenient blood pressure  and blood sugar goals in the frail elderly may be desirable while a less palatable restricted  diet may lead to weight loss and its associated complications.27    ADA:  The relationship between congestive heart failure, blood pressure, and sodium intake in  the elderly population has not been well studied.  The American Heart Association  recommends that older adults attempt to control blood pressure through diet and lifestyle  changes and recommends a sodium intake of 2 to 3 g/day for patients with congestive  heart failure. However, a randomized trial of adults aged 55 to 83 years found that a  normal‐sodium diet improved congestive heart failure outcomes.  A liberal approach to  sodium in diets may be needed to maintain adequate nutritional status, especially in frail  older adults.28    CMS:  Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically  altered diets may help in select situations.  At other times, they may impair adequate  nutrition and lead to further decline in nutritional status, especially in already  undernourished or at‐risk individuals.  When a resident is not eating well or is losing  weight, the interdisciplinary team may temporarily abate dietary restrictions and liberalize  the diet to improve the resident’s food intake to try to stabilize their weight.29    Relevant Research Trends    The typical two gram sodium diet that is often recommended for individuals with  hypertension, has been shown to reduce systolic blood pressures, on average, by only 5  mmHg, and diastolic blood pressures by only 2.5 mmHg making this diet’s effect on blood  pressure modest at best and has not actually been shown to improve cardiovascular  outcomes in the nursing home resident30.    Guidelines for blood pressure targets for older adults differ from those for younger people.   For older adults, current literature supports intervention, with medication and/or diet,  only for systolic blood pressures over 160 mmHg and targets a systolic blood pressure of  less than 150mmHg.31  AMDA The Role of the Medical Director in Person‐Directed Care White Paper, Mar. 2010, 3. ADA Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in LTC 2005. 29 CMS State Operations Manual Appendix P, Tag 325 Nutrition 30 Dickinson, HO, Mason, JM, Nicolson, DJ, et al. Lifestyle interventions to reduce raised blood pressure: a  systematic review of randomized controlled trials. J Hypertens 2006; 24:215. 31 Beckett, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N  Engl J Med 2008; 358:1887. 27 28

16 Appendix 3-A

  Lowering systolic blood pressures below 120 to 130mmHg and diastolic pressures below  65mmHg may increase mortality in the elderly.32     Limiting salt intake in individuals with congestive heart failure is felt to be of benefit by  limiting fluid retention, but the clinical experience of two medical directors of numerous  nursing homes shows that this is necessary in only a minority of nursing home patients,  usually those who are salt sensitive and often have advanced disease.33    Older people have the same taste preferences as they have had all of their life, and thus low  sodium, low fat meals are not always as appetizing as the normal version of a food with  naturally high fat and sodium content.34      Recommended Course of Practice    Low sodium diets are not shown to be effective in the long term care population of elders  for reducing blood pressure or exacerbations of CHF and therefore should only be used  when benefit to the individual resident has been documented.    Recommended Course of Practice  • Diet is to be determined with the person and in accordance with his/her informed  choices, goals and preferences, rather than exclusively by diagnosis.  • Assess the condition of the person. Assess and provide the person's preferred  context and environment for meals, in other words the person's preferences,  patterns and routines for socialization (i.e. eating alone or with others), physical  support (i.e. adapted eating utensils, assistance with cartons/cutting or adapted w/c  positioning), timing of meals (i.e. typical community or unique meal times) and  personal meaning/value of the dining experience (i.e. for one who does not eat  breakfast, breakfast is not important but perhaps an early lunch is).  Include quality  of life markers such as satisfaction with food, service received during meals, level of  control and independence.  • Unless a medical condition warrants a restricted diet, consider beginning with a  regular diet and monitoring how the person does eating it.  • Empower and honor the person first, and the whole interdisciplinary team second,  to look at concerns and create effective solutions.  • Support self‐direction and individualize the plan of care.  • Ensure that the physician and consultant pharmacist are aware of resident food and  dining preferences so that medication issues can be addressed and coordinated i.e.  medication timing and impact on appetite.  32 Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest 

old. J Am Geriatr Soc 2007; 55(3):383‐8. 33 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010. 34 Calverley, D.  “The Food Fighters.” Nursing Standard, Vol. 22, 2007, 20‐21. 

17 Appendix 3-A

   

• Monitor the person and his/her condition related to their goals regarding  nutritional status and their physical, mental and psychosocial well‐being.  • Although a person may have not be able to make decisions about certain aspects of  their life, that does not mean they cannot make choices in dining.    • When a person makes “risky” decisions, the plan of care will be adjusted to honor  informed choice and provide supports available to mitigate the risks.   • Most professional codes of ethics require the professional to support the  person/client in making their own decisions, being an active, not passive,  participant in their care.  • When caring for frail elders there is often no clear right answer.  Possible  interventions often have the potential to both help and harm the elder.  This is why  the physician must explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family. The resident then has the right to make his/her informed choice  even if it is not to follow recommended medical advice and the team supports the  person and his/her decision, mitigating risks by offering support, i.e. offering foods  of natural pureed consistency when one refuses recommended tube feeding.  It is  when the team makes decisions for the person without acknowledgement by all that  problems arise.  The agreed upon plan of care should then be monitored to make  sure the community is best meeting the resident's needs.  • All decisions default to the person. 

18 Appendix 3-A

 Standard of Practice for Individualized Cardiac Diet    Basis in Current Thinking and Research    AMDA:  Routine dietary restrictions are usually unnecessary and can be counterproductive in the  LTC setting.  Special diets for diabetes, hypertension and heart failure, and  hypercholesterolemia have not been shown to improve control or affect symptoms.  When  a patient is at risk or has unintended weight loss, the presence of one of diagnoses alone is  insufficient justification for continuing dietary restrictions.  The reasons for any dietary  restrictions that are ordered should be clearly stated in the patient’s record.35    ADA:  The Dietary Approaches to Stop Hypertension (DASH) eating pattern is known to reduce  blood pressure and may also reduce rates of heart failure.  The DASH diet is low in sodium  and saturated fat but also high in calcium, magnesium, and potassium.  The nutrition care  plan for older adults with cardiac disease should focus on maintaining blood pressure and  blood lipid levels while preserving eating pleasure and quality of life.  Using menus that  work toward the objectives of the Dietary Guidelines for Americans and/or the DASH diet  can help achieve those goals.36    CMS:  Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically  altered diets may help in select situations.  At other times, they may impair adequate  nutrition and lead to further decline in nutritional status, especially in already  undernourished or at‐risk individuals.  When a resident is not eating well or is losing  weight, the interdisciplinary team may temporarily abate dietary restrictions and liberalize  the diet to improve the resident’s food intake to try to stabilize their weight.37    Relevant Research Trends    The effects of the traditional low cholesterol and low fat diets typically used to treat  elevated cholesterol vary greatly and, at most, will decrease lipids by only 10‐15%. If  aggressive lipid reduction is appropriate for the nursing home resident it can be more  effectively achieved through the use of medication that provides average reductions of  between 30 and 40% while still allowing the individual to enjoy personal food choices.38, 39 

35

AMDA Clinical Practice Guideline for Alteration in Nutritional Status, 2010, 20.

36 ADA Position Paper Individualized Nutrition Approaches for Older Adults in Health Care Commun. 2010.

CMS State Operations Manual Appendix P, Tag 325 Nutrition Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian  Simvastatin Survival Study (4S), The Lancet. 1994;344(8934):1383. 39 LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd  J, Wenger NK, Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in  patients with stable coronary disease.  N Engl J Med. 2005;352(14):1425. 37 38

19 Appendix 3-A

Recommended Course of Practice    Low saturated fat (low cholesterol) diets have only a modest effect on reducing blood  cholesterol in the long term care elder population and therefore should only be used when  benefit has been documented.    Recommended Course of Practice  • Diet is to be determined with the person and in accordance with his/her informed  choices, goals and preferences, rather than exclusively by diagnosis.  • Assess the condition of the person. Assess and provide the person's preferred  context and environment for meals, in other words the person's preferences,  patterns and routines for socialization (i.e. eating alone or with others), physical  support (i.e. adapted eating utensils, assistance with cartons/cutting or adapted w/c  positioning), timing of meals (i.e. typical community or unique meal times) and  personal meaning/value of the dining experience (i.e. for one who does not eat  breakfast, breakfast is not important but perhaps an early lunch is).  Include quality  of life markers such as satisfaction with food, service received during meals, level of  control and independence.  • Unless a medical condition warrants a restricted diet, consider beginning with a  regular diet and monitoring how the person does eating it.  • Empower and honor the person first, and the whole interdisciplinary team second,  to look at concerns and create effective solutions.  • Support self‐direction and individualize the plan of care.  • Ensure that the physician and consultant pharmacist are aware of resident food and  dining preferences so that medication issues can be addressed and coordinated i.e.  medication timing and impact on appetite.  • Monitor the person and his/her condition related to their goals regarding  nutritional status and their physical, mental and psychosocial well‐being.  • Although a person may have not be able to make decisions about certain aspects of  their life, that does not mean they cannot make choices in dining.    • When a person makes “risky” decisions, the plan of care will be adjusted to honor  informed choice and provide supports available to mitigate the risks.   • Most professional codes of ethics require the professional to support the  person/client in making their own decisions, being an active, not passive,  participant in their care.  • When caring for frail elders there is often no clear right answer.  Possible  interventions often have the potential to both help and harm the elder.  This is why  the physician must explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family. The resident then has the right to make his/her informed choice  even if it is not to follow recommended medical advice and the team supports the  person and his/her decision, mitigating risks by offering support, i.e. offering foods  of natural pureed consistency when one refuses recommended tube feeding.  It is  when the team makes decisions for the person without acknowledgement by all that 

20 Appendix 3-A

problems arise.  The agreed upon plan of care should then be monitored to make  sure the community is best meeting the resident's needs.  • All decisions default to the person. 

21 Appendix 3-A

 Standard of Practice for Individualized Altered Consistency Diet  An altered consistency diet is usually prescribed due to swallowing difficulties, or  dysphagia, which is not a diagnosis but rather a symptom commonly associated with  conditions such as stroke, dementia or Parkinson’s disease.      Basis in Current Thinking and Research    AMDA:  Swallowing abnormalities are common but do not necessarily require modified diet and  fluid textures, especially if these restrictions adversely affect food and fluid intake.40    Provide foods of a consistency and texture that allow comfortable chewing and swallowing.   A resident who has difficulty swallowing may reject pureed or artificially thickened foods  but may eat foods that are naturally of a pureed consistency, such as…. mashed potatoes,  ….puddings, ….and yogurt, finely chopped foods may retain their flavor and be equally  well handled (Ibid).  ADA:  The registered dietitian should collaborate with the speech‐language pathologist and other  healthcare professionals [such as the occupational therapist] to ensure that older adults  with dysphagia receive appropriate and individualized modified texture diets.  Older adults  consuming modified texture diets report an increased need for assistance with eating,  dissatisfaction with foods, and decreased enjoyment of eating, resulting in reduced food  intake and weight loss.41     CMS:  In deciding whether and how to intervene for chewing and swallowing abnormalities, it is  essential to take a holistic approach and look beyond the symptoms to the underlying  causes.  Excessive modification of food and fluid consistency may unnecessarily decrease  quality of life and impair nutritional status by affecting appetite and reducing intake.  Many  factors influence whether a swallowing abnormality eventually results in clinically  significant complications such as aspiration pneumonia.  Identification of a swallowing  abnormality alone does not necessarily warrant dietary restrictions or food texture  modifications.  No interventions consistently prevent aspiration and no tests consistently  predict who will develop aspiration pneumonia.42      

40 AMDA

Clinical Practice Guideline for Alteration in Nutritional Status 2010, 20. ADA Unintended Weight Loss Guideline 2009.  42 CMS State Operations Manual Appendix PP, 483.25 Tag F325 Nutrition. 41

22 Appendix 3-A

Relevant Research Trends    Disease states which affect muscle strength and coordination alter the ability for one to  successfully complete a swallow and/or protect the airway resulting in: 1) choking, where  food partially or fully obstructs a resident’s airway; or 2) aspiration or inhalation of  food/liquids, oral secretions or gastric secretions into the airway and lungs which may  result in pneumonia or pneumonitis.43 In addition, problems with swallowing efficiency  (weakness/fatigue/limited endurance) may lead to residue in the oral tract, incomplete  swallowing and reduced intake.44, 45    The anticipated outcome of solid foods ground or pureed and liquids thickened to nectar or  honey thickness is improvement in oral intake and a reduced risk of choking and/or  aspiration.  However, data on their effectiveness is inconsistent; not all residents with  dysphagia aspirate or choke and not all aspiration results in pneumonia.46, 47, 48  While a modified barium swallow may show that thickened liquids reduce the risk of  aspiration acutely, there is little to no long term evidence that this intervention prevents  aspiration pneumonia49, 50, 51.       There is evidence that improved oral care can reduce the risk of developing aspiration  pneumonia in the elderly. 52, 53 In addition, oral care can impact clinical issues such as  dehydration. For example, residents with swallowing problems may be able to have water 

Marik PE. Aspiration Pneumonitis and Aspiration Pneumonia. N Eng J Med 2001; 344; 9: 665‐671. Kays, S. & Robbins, J. 2009. The application of tongue endurance measures to functional dining.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18, 61‐67.  45 Kays, S.A., Hind, J.A., Gangnon, R.E., & Robbins, J. 2010. Effects of dining on tongue endurance and  swallowing‐related outcomes. Journal of Speech, Language, and Hearing Research, 53, 898‐907. 46 Logeman JA, Gensler G, Robbins, et al.  Design, Procedures, Findings, and Issues from the Largest NIH  Funded Dysphagia Clinical Trial entitled Randomized Study of Two Interventions for Liquid Aspiration; Short  and Long‐term Effects. (Protocol 201) Presented at ASHA Annual Conference, November 16‐18, 2006.   Available at http://www.dysphagassist.com/major_randomized_studies.  Accessed Dec 20, 2009. 47 Robbins J, et al.  Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence.  Ann Int Med  2008; 148:509‐518. 48 Messinger‐Rapport B, et al.  Clinical Update on Nursing Home Medicine:  2009.  J Amer Med Dir Assoc 2009;  10: 530‐553. 49 Logeman JA, Gensler G, Robbins, et al.  Design, Procedures, Findings, and Issues from the Largest NIH  Funded Dysphagia Clinical Trial entitled Randomized Study of Two Interventions for Liquid Aspiration; Short  and Long‐term Effects. (Protocol 201) Presented at ASHA Annual Conference, Nov. 16‐18, 2006.  Available at  http://www.dysphagassist.com/major_randomized_studies.  Accessed Dec 20, 2009. 50 Robbins J, et al.  Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence.  Ann Int Med  2008; 148:509‐518. 51 Messinger‐Rapport B, et al.  Clinical Update on Nursing Home Medicine.  J Amer Med Dir Assoc 2009; 10:  530‐553. 52 Sarin J, Balasubramaniam R, Corcoran AM, et al. Reducing the risk of aspiration pneumonia among elderly  patients in long‐term care facilities through oral health interventions. J Am Med Dir Assoc. 2008;9:128–135 53 Yoon, M.N. & Steele, C.M. (2007). The oral care imperative: The link between oral hygiene and aspiration  pneumonia. Topics in Geriatric Rehabilitation, 23, 280‐288. 43 44

23 Appendix 3-A

throughout the day (i.e. the Frazier free water protocol), as long as good oral care is  provided. 54  Recent information also raises the concern that these at risk residents become more at risk  for dehydration and malnutrition caused by the unpalatable and visually unappealing  modified dysphagia diets.55      Management of all geriatric conditions involves some risks.  No known evaluations or  interventions can guarantee that someone will not aspirate.  It is important to note that  many elderly individuals with swallowing abnormalities and aspiration risk do not get  aspiration pneumonia.  In fact, there is evidence that altered consistency diets may increase  the risk of nutrition and hydration deficits.  Thickened liquids and pureed foods are often  poorly tolerated.56   While there are currently no published studies that show that tube feeding prevents  aspiration, one study found that orally fed patients with dysphagic disorders had  significantly less aspiration than tube‐fed patients.57   Current Thinking    Given the complexity of the swallow mechanism and the multitude of problems that can  arise, it is essential that the physician is involved in the evaluation of swallowing disorders.   A thorough history and physical examination is required to determine potential causes of  the swallowing dysfunction.   While the most common processes causing dysphagia in long  term care are related to identified, co‐morbid conditions, it is important to consider other  disease states or pathology such as previously undiagnosed mass lesions, gastroesphogeal  reflux, or cancer.58   ...the interdisciplinary team should assess dysphagia in the context of the whole individual.   It is essential to understand who the resident is, and how he/she is doing medically,  functionally and psychosocially.59   If a medical evaluation identifies oral‐pharyngeal dysphagia as a concern, a bedside  swallow evaluation should be performed. This evaluation may provide valuable  information regarding the resident’s swallowing function and efficiency. Results of this  Panther, K. 2005. The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders  (Dysphagia), 14, 4‐9.  55 Steele C.  Food for Thought:  Primum Non Nocere:  The Potential for Harm in Dysphagia Intervention.   Perspectives on Swallowing and Swallowing Disorders (Dysphagia).  2006: 15: 19‐23. 56 Levenson, Steven. “Changing Perspectives on LTC Nutrition & Hydration.” Caring for the Ages. September  2002, Vol. 3, No. 9, pp. 10‐14. www.amda.com/publications/caring/september2002/nutrition.cfm 57 Feinbert MJ, Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly population followed over  three years. Dysphagia 1996; 11; 104‐109. 58 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010. 59 Levenson, S. The Basis for Improving and Reforming Long‐Term Care, Part 3: Essential Elements for  Quality Care, J Amer Med Dir Assoc, 2009: 10: 597‐606.   54

24 Appendix 3-A

evaluation should be considered by the interdisciplinary team and recommendations  regarding swallowing management, including diet modifications, should be made based  upon concerns that have been raised and discussion with the resident and/or their  family/POA regarding risks and benefits.60     The use of videofluoroscopy or other instrumental swallowing assessments in long term  care should be used only when clinically indicated. When used appropriately, these  assessments can provide useful information about where problems are arising and  potential modifications that may be of assistance to the resident.  The results of these tests  should be used in assisting the interdisciplinary team in discussing further options with the  resident and or their family/Power of Attorney (POA).  If the testing will not add new  information or aid in adjusting the resident’s plan of care then the value of the additional  test needs to be reconsidered (Ibid).     Interdisciplinary team members, including health care practitioners, should be involved in  balancing the risks of aspiration against the potential benefits of more liberal diets and  food consistency, and deciding whether there are viable alternatives.  There should be a  discussion of the patient’s progress, goals and objectives.  Often, aspiration risks must be  tolerated because of other, more immediate or probable risks such as nutrition or  hydration deficits.61  (For this purpose of this document, healthcare practitioners refers to  advanced practice nurses, physician assistants and physicians.)    Some physicians are writing orders for modified consistencies in ranges that accommodate  each resident’s differing acceptance/tolerance at different times of day, to different food  groups such as "puree to mechanical soft" or "mechanical soft to soft."62    A comprehensive and thorough assessment of the resident includes everything from  medication side effects that reduce appetite to depression and beyond to ensure that the  standard of care related to nutrition is provided.  When all is ruled out and documented  and the resident or family persists in refusal‐‐‐this becomes the standard of care for that  person.  Ensuring thorough ongoing reassessment is of utmost importance in order to  continually challenge the highest practicable level of functioning repeatedly over time,  especially in the months following the original diagnosis as well as capturing that what a  person wants can and does change over time (Ibid).  The risk of choking needs to be compared and weighed to the slow process of wasting  away.  We need to stop letting the risk‐benefits default to the special diet.  We’re weighted  on that side and not looking at that the person might waste away (CHII Recommendation).    Recommended Course of Practice  60 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010.

61 Levenson, Steven. “Changing Perspectives in LTC Nutrition and Hydration.” Caring for the Ages. 9.3 2002 

10‐14. 62 Bump, Linda. Clinical Standards Task Force communication, 2011.

25 Appendix 3-A

• Diet is to be determined with the person and in accordance with his/her informed  choices, goals and preferences, rather than exclusively by diagnosis.  • Assess the condition of the person. Assess and provide the person's preferred  context and environment for meals, in other words the person's preferences,  patterns and routines for socialization (i.e. eating alone or with others), physical  support (i.e. adapted eating utensils, assistance with cartons/cutting or adapted w/c  positioning), timing of meals (i.e. typical community or unique meal times) and  personal meaning/value of the dining experience (i.e. for one who does not eat  breakfast, breakfast is not important but perhaps an early lunch is).  Include quality  of life markers such as satisfaction with food, service received during meals, level of  control and independence.  • Unless a medical condition warrants a restricted diet, consider beginning with a  regular diet and monitoring how the person does eating it.  • Empower and honor the person first, and the whole interdisciplinary team second,  to look at concerns and create effective solutions.  • Support self‐direction and individualize the plan of care.  • Ensure that the physician and consultant pharmacist are aware of resident food and  dining preferences so that medication issues can be addressed and coordinated i.e.  medication timing and impact on appetite.  • Monitor the person and his/her condition related to their goals regarding  nutritional status and their physical, mental and psychosocial well‐being.  • Although a person may have not be able to make decisions about certain aspects of  their life, that does not mean they cannot make choices in dining.    • When a person makes “risky” decisions, the plan of care will be adjusted to honor  informed choice and provide supports available to mitigate the risks.   • Most professional codes of ethics require the professional to support the  person/client in making their own decisions, being an active, not passive,  participant in their care.  • When caring for frail elders there is often no clear right answer.  Possible  interventions often have the potential to both help and harm the elder.  This is why  the physician must explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family. The resident then has the right to make his/her informed choice  even if it is not to follow recommended medical advice and the team supports the  person and his/her decision, mitigating risks by offering support, i.e. offering foods  of natural pureed consistency when one refuses recommended tube feeding.  It is  when the team makes decisions for the person without acknowledgement by all that  problems arise.  The agreed upon plan of care should then be monitored to make  sure the community is best meeting the resident's needs.  • All decisions default to the person. 

Standard of Practice for Individualized Tube Feeding    Basis in Current Thinking and Research  26 Appendix 3-A

  AMDA:   Tube feeding may be clinically appropriate in certain circumstances, but it should not be an  automatic next step when other feeding strategies have failed.  Before deciding to initiate  tube feeding, the interdisciplinary care team should meet with the patient and family to  carefully consider the risks and benefits of tube feeding and the patient’s preferences.     Contrary to what many people think, tube feeding does not ensure the patient’s comfort or  reduce suffering; it may cause diarrhea, abdominal pain, and local complications and may  increase the risk of aspiration.63    ADA:  Enteral nutrition may not be appropriate for terminally ill older adults with advanced  disease states, such as terminal dementia, and should be in accordance with advanced  directives.  The development of clinical and ethical criteria for the nutrition and hydration  of persons throughout the life span should be established by members of the health care  team, including the registered dietitian.64    CMS:  In deciding whether and how to intervene for chewing and swallowing abnormalities, it is  essential to take a holistic approach and look beyond the symptoms to the underlying  causes.  Excessive modification of food and fluid consistency may unnecessarily decrease  quality of life and impair nutritional status by affecting appetite and reducing intake.  Many  factors influence whether a swallowing abnormality eventually results in clinically  significant complications such as aspiration pneumonia.  Identification of a swallowing  abnormality alone does not necessarily warrant dietary restrictions or food texture  modifications.  No interventions consistently prevent aspiration and no tests consistently  predict who will develop aspiration pneumonia.  For example, tube feeding may be  associated with aspiration, and is not necessarily a desirable alternative to allowing oral  intake, even if some swallowing abnormalities are present.65    Relevant Research Trends    Feeding tubes have not been shown to reduce the risk of aspiration or prolong survival in  residents with end stage dementia.66       Oral secretions and/or gastric content are often the source of aspiration pneumonia or  pneumonitis and thus will not be resolved with the placement of a tube.67    

63

AMDA Clinical Practice Guideline for Alteration in Nutritional Status, 2010, 22.

64 ADA Unintended Weight Loss Guideline, 2009. 

CMS State Operations Manual Appendix PP, 483.25 Tag F325 Nutrition Casarett D, Kapo J, Kaplan A.  Appropriate Use of Artificial Nutrition and Hydration‐Fundamental Principles  and Recommendations.  N Eng J Med 2005; 353;24: 2607‐2612. 67 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010. 65 66

27 Appendix 3-A

Arguments for placing a tube for feeding include improving nutritional status.  Studies in  the elderly with dementia have shown little to no improvement in weight.  In situations  when there was improvement in weight, there was no improvement in clinical outcome for  the residents.  Enteral feeding is also considered for wound care as a means to improve  wound healing.  Data over a 6 month follow up has shown no impact on pressure ulcers or  on infections such as cellulitis associated with wounds68, 69.      Percutaneous endoscopic gastrostomy (PEG) and Percutaneous Endoscopic Jejunostomy   (PEJ)  tubes do not improve a resident’s quality of life.  There are associated physical and  psychosocial discomforts related to the feedings themselves such as abdominal distension,  diarrhea, and restriction of free movement if attached to an infusion device.  Additionally,  the resident is deprived of the social experience of mealtime that is valued by many.   Placing a PEG tube in residents with advanced dementia should be strongly discouraged,  and placement in other individuals should take goals of care into account.70   A systematic literature search of 13 controlled trials on the use of supplements with people  with dementia and 12 controlled trials testing assisted feeding showed high calorie  supplements and other oral feeding options can help people with dementia to gain weight  as an alternative to tube feeding.71    Due to a focus on food and their aromas “half a dozen residents have traded in their g‐tubes  for a place at the table” at Idylwood Care Center in Sunnyvale, California.72      Methicillin‐resistant Staphylococcus aureus (MRSA) colonization is more likely to be  identified in residents with pressure ulcers or fecal incontinence or who are bed bound or  require feeding tubes or urinary catheters.73    Issues related to tube feeding are captured in this story from a family member: Rose had a  stroke when she was 82 leaving her immobile, unable to speak clearly or feed herself.  It  was found that she was aspirating upon swallowing and of course her physician strongly  recommended a permanent feeding tube.  Despite her losses, Rose was very mentally clear  and strongly indicated she wanted no tubes!  Her sister/power of attorney defended her  choices and the physician reluctantly discharged her to skilled care with no tubes.  Rose  was hand fed pureed food and she did die of aspiration … 7 years later.74    68 Sampson EL, Candy B, Jones L.  Enteral tube feeding for older people with dementia.  Cochrane Database 

2009 April 15; (2): CD007209. 69 Finucane T, Christmas C, Travis K.  Tube Feedings in Patients with Advanced Dementia: A Review of the  Evidence.  JAMA, Oct 1999; 1365‐1370. 70 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010. 71 Hanson, L.C., Ersek, M., Gilliam, R., and Carey, T. S. Oral Feeding Options for People with Dementia: A  Systematic Review, JAGS 59: 463‐472, 2011. 72 Schaeffer, Keith. Nourish the Body and Soul, Action Pact Publishing, 2008.  73 Bradley S. Issues in the management of resistant bacteria in long‐term care facilities. Infect Control Hosp  Epidemiol 1999;20:362‐6.   74 Anna Ortigara, anecdotal family story, 4‐2011.

28 Appendix 3-A

Recommended Course of Practice  When there is weight loss and functional decline in an elder with multiple comorbidities or  with end stage disease the default should not be to place a g‐tube for nutrition and  hydration.  The interdisciplinary team including the elder’s primary care physician should  meet to address the elder’s and or POA goals for care and develop a care plan that meets  the changing needs of the elder.  This may include a discussion regarding palliative care or  hospice with the elder and the family.  • Diet is to be determined with the person and in accordance with his/her informed  choices, goals and preferences, rather than exclusively by diagnosis.  • Assess the condition of the person. Assess and provide the person's preferred  context and environment for meals, in other words the person's preferences,  patterns and routines for socialization (i.e. eating alone or with others), physical  support (i.e. adapted eating utensils, assistance with cartons/cutting or adapted w/c  positioning), timing of meals (i.e. typical community or unique meal times) and  personal meaning/value of the dining experience (i.e. for one who does not eat  breakfast, breakfast is not important but perhaps an early lunch is).  Include quality  of life markers such as satisfaction with food, service received during meals, level of  control and independence.  • Unless a medical condition warrants a restricted diet, consider beginning with a  regular diet and monitoring how the person does eating it.  • Empower and honor the person first, and the whole interdisciplinary team second,  to look at concerns and create effective solutions.  • Support self‐direction and individualize the plan of care.  • Ensure that the physician and consultant pharmacist are aware of resident food and  dining preferences so that medication issues can be addressed and coordinated i.e.  medication timing and impact on appetite.  • Monitor the person and his/her condition related to their goals regarding  nutritional status and their physical, mental and psychosocial well‐being.  • Although a person may have not be able to make decisions about certain aspects of  their life, that does not mean they cannot make choices in dining.    • When a person makes “risky” decisions, the plan of care will be adjusted to honor  informed choice and provide supports available to mitigate the risks.   • Most professional codes of ethics require the professional to support the  person/client in making their own decisions, being an active, not passive,  participant in their care.  • When caring for frail elders there is often no clear right answer.  Possible  interventions often have the potential to both help and harm the elder.  This is why  the physician must explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family. The resident then has the right to make his/her informed choice  even if it is not to follow recommended medical advice and the team supports the  person and his/her decision, mitigating risks by offering support, i.e. offering foods  of natural pureed consistency when one refuses recommended tube feeding.  It is  when the team makes decisions for the person without acknowledgement by all that  29 Appendix 3-A

 

problems arise.  The agreed upon plan of care should then be monitored to make  sure the community is best meeting the resident's needs.  • All decisions default to the person. 

Please see the appendix as it includes an ethical case study involving tube feeding  and a superb document regarding informed choice and who ultimately decides. 

30 Appendix 3-A

 Standard of Practice for Individualized Real Food First    Basis in Current Thinking and Research    AMDA:  Provide foods of a consistency and texture that allow comfortable chewing and swallowing.   A resident who has difficulty swallowing may reject pureed or artificially thickened foods  but may eat foods that are naturally of a pureed consistency, such as … mashed potatoes,   ...puddings, … and yogurt, finely chopped foods may retain their flavor and be equally well  handled.75  ADA:  Research suggests that the goal of food service should be to create a meal situation as  natural and independent as possible, comparable with eating at home; making choices from  a wide range of menu items tailored to the resident’s wants; and seeking input from  residents, family and staff.  Stringent diet restrictions limiting familiar foods and  eliminating or modifying seasonings may contribute to poor appetite; decreased food  intake; and increased risk of illness, infection and weight loss.76 CMS:  With any nutrition program, improving intake via wholesome foods is generally preferable  to adding nutritional supplements.77    CMS answers regarding choice to eat food out of a garden in the Survey and Certification  memo S&C ‐07‐07 December 21, 2006:    Question 2: (370) Approved Food Sources:  You ask if the regulatory language at this  Tag that the facility must procure food from approved food sources prohibits  residents from any of the following:  1) growing their own garden produce and  eating it; 2) eating fish they have caught o a fishing trip; or 3) eating food brought to  them by their own family or friends.    Response 2: The regulatory language at this Tag is in place to prohibit a facility from  procuring their food supply from questionable food sources, in order to keep  residents safe.  It would be problematic if the facility is serving food to all residents  from the sources you list, since the facility would not be able to verify that the food  they are providing is safe.  The regulation is not intended to diminish the rights of  specific residents to eat food in any of the circumstances you mention.  In those  cases, the facility is not procuring food.  The residents are making their own choices  to eat what they desire to eat.  This would also be the case if a resident ordered a  pizza, attended a ball game and bought a hot dog, or any similar circumstance.  The  right to make these choices is also part of the regulatory language at F242, that the  75

AMDA Clinical Practice Guideline for Alteration in Nutrition, 2010. ADA Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in LTC, 2005. 77 CMS State Operations Manual Appendix PP 483.25(i) Tag F325 Nutrition 2008 Revised Guidance. 76

31 Appendix 3-A

resident has the right to, “make choices about aspects of his or her life that are  important to the resident.”  This is a key right that we believe is also an important  contributing factor to a resident’s quality of life.      Relevant Research Trends    An expectation of OBRA since 1987, choosing food before supplements, and food before  medication is a natural decision in culture change.  With choice, accessibility and  individualization, our residents eat foods of choice throughout the day, and even during the  night if need be, eliminating the need for costly, and often refused, commercial  supplements.  Similarly, the need for laxatives is reduced and often eliminated with  increased fluid intake and increased opportunities for fiber rich, bowel stimulating foods of  choice.  Even the need for medication for behavioral management can be reduced when  foods of choice are available at times of choice and places of choice.78     Homes eliminating commercial supplements have found a significant increase in food  consumption and reduced incidence of weight loss (Ibid).      Oral supplements…… often go wasted or conflict with medications.   Improving taste is  one of the best and simplest ways of improving nutrition.79    An 11 week randomized controlled intervention study with 121 people living in nursing  homes found improved nutrition and function with a multifaceted intervention of  chocolate, homemade supplements, group exercise and oral care.80    Oral liquid nutrition supplements have been shown to be only moderately successful in  increasing energy intake, which has also been shown to be related to the limited time staff  can devote to getting the supplements delivered and giving verbal encouragement to  consume them.81    A randomized, controlled trial in three nursing homes with sixty three residents found  offering residents a choice among a variety of foods and fluids twice per day may be a more  effective nutrition intervention than oral liquid nutrition supplementation.  Also found was  that snack options are a more cost‐effective nutrition intervention relative to supplements  based on staff time, resident refusal rates, caloric intake and waste.82   

Bump, Linda. Food for Thought. Action Pact Publishing. 2004‐2005. Webster, Clint. Preventing Malnutrition in the Elderly. Final Research Papers, Winter 2008, March 4, 2008. 80 Beck, A. M., Damkajaer, K. and Beyer, N. Multifaceted nutritional intervention among nursing home  residents has a positive influence on nutrition and function. Nutrition, 24, 2008,1073‐1080. 81 Schlettwein‐Gsell, D. “Nutrition and the quality of life: A measure for the outcome of nutritional  intervention?” American Journal of Clinical Nutrition, Vol. 556, 1992, pp. 12635‐12665. 82 Simmons, Sandra F., Zhuo, X., Keeler, E. Cost‐effectiveness of Nutrition Interventions in Nursing Home  Residents: a pilot intervention. The Jour of Nut, Health and Aging Vol. 14 No. 5 2010 367‐372. 78 79

32 Appendix 3-A

Historically, it has been shown that giving people foods they like to eat minimizes the use of  supplements and can reduce costs. For example, Eric and Margie Haider, administrator and  director of nursing at Crestview Nursing Home in Missouri in 2001, espoused that by giving  people foods they like to eat, you can minimize the use of supplements and calculated a  savings of $1,164.00 per month by serving real foods residents wanted to eat.83   Supplements at Crestview went from 72 in 1998 to only 14 by July 2000.84    One study revealed that among 100 frail nursing home residents, oral protein supplements  did not produce improvement in measures of strength or function unless it was combined  with resistance strength training.85    Reducing the number of medications that a resident takes can also impact appetite.  Residents that must take numerous pills or large volumes of liquid at each med‐pass, with  bulk laxatives, for example, can have reduced appetite at meal time.86    Elderly people who have one or more medical conditions and are taking an average of three  medications show greater losses of taste sensitivity than healthy, older adults.87   Flavor  enhancement of nutrient dense food may compensate for taste losses and improve food  intake. Flavor enhancers are mixtures of odorous molecules that are extracted from natural  products or synthesized, such as monosodium glutamate. Flavor enhancement differs from  adding spices, herbs, and salt because flavor enhancement intensifies the flavor of food  while spices and herbs increase odor and taste sensation. Studies involving frail elderly  have shown that adding flavor enhancers to food improved intake and immune function by  increasing the total number of lymphocytes, resulting in improved functional status.88      Current Thinking  Before any nutritional supplement is offered let alone “ordered,” providers and surveyors  ensure that real foods were offered first (CHII Recommendation).    

Some homes are finding alternatives to dietary supplementation by engaging the elders in  growing their own garden.  The elders choose what will be grown, help with the planting,  tending and harvesting.  Then they help prepare and eat the harvest.  Besides the  83 Bowman, Carmen S. The Environmental Side of the Culture Change Movement: Identifying Barriers and 

Potential Solutions to furthering Innovation in Nursing Homes. Background Paper to the April 3rd, 2008  Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environment  Requirements. Report of CMS Contract HHSM‐500‐2005‐00076P. 84 Rantz, Marilyn J., and Marcia K. Flesner.  Person Centered Care: A Model for Nursing Homes.  American  Nurses Association: Washington D.C., 2004, pp. 23, 25. 85 Fiatarone MA, O’Neill MF, Ryan ND, et al. Exercise training and nutritional supplementation for physical  frailty in very elderly people. N Engl J Med, 1994; 330; 1769‐1775. 86 Martin, McHenry Caren. The Consultant Pharmacist’s Expanded Role in Nutrition Management. The  Consultant Pharmacist. June 2009. Vol. 24. No. 6. 87 Shiffman SS, Graham BG, Taste and smell perception affect appetite and immunity in the elderly. Euro Clin  Nutr2000; 54, 3: 54‐63.  88 Shiffmann SS, Intensification of sensory properties of foods for the elderly. J Nutr 2000; 130 Suppl 4; 927‐ 930.

33 Appendix 3-A

nutritional benefit, the elders also have the benefit of accomplishment and contribution  which affects their mood and self‐esteem.89    Recommended Course of Practice  Advocate the use of real food before the addition of dietary supplements.  Recommend using real food before any modified foods including laxative mixtures or single  source nutrient powders/liquids.      Instead of artificial supplements, extra protein, vitamin and fiber powders can be added to  smoothies, shakes, malts and other real foods people like to eat.     Use of fresh produce is encouraged, an example would be produce from resident gardens.    The dining experience should be as natural as possible comparable to eating at home.    Resident satisfaction with the quality of the food and the dining experience should be a  home’s priority. 

89

Hyde, Denise. The Role of the Pharmacist. Paper for CHII. 

34 Appendix 3-A

Standard of Practice for Individualized Honoring Choices     Many homes are offering the people who live there more dining choices based on the  individual’s life patterns, history and current preferences.  Including but not limited to  open dining times, choice from menus, buffets, family dining style with food at the table and  snack bars/accessible pantries.  Honoring choice is a complex issue including variables  such as balancing risk with benefit, individual decision making capacity, and inclusion of  resident advocates.   Honoring choice is born out of relationship, consistent resident staff  relationships are essential to identifying and honoring individual choice.      Basis in Current Thinking and Research    AMDA:  Most residents will appreciate having these choices and the team can weigh the benefits  against the risks and work with the resident and/or family/POA to establish an effective  individualized plan of care.90    Identifying the proper balance between medical complexity, which may require  medications, modifications and restrictions, and allowing for personal choice, is the  essence of good medicine.  However, a blanket or rote approach to these issues (for  example, easing restrictions on everyone without regard to impact) is inconsistent with  sound approaches.  Individualized care should seek to understand the entire person, to  focus attention on the medical, functional and psychosocial aspects of the resident.  The  interdisciplinary team should consider the potential effects of proposed interventions on  the resident, rather than simply the treatment or protocol’s effect on a disease.  For  example, some residents who remain in bed until they awake on their own may develop  pressure ulcers or lose weight, although most will not.  Most residents will appreciate  having these choices and the team can weigh the benefits against the risks and work with  the resident and/or family/POA to establish an effective individualized plan of care.  This  approach is especially helpful in situations where the benefits of the intervention are  modest and the risks significant.91    ADA:  Involving individuals in choices about food and dining such as food selections, dining  locations, and meal times can help them maintain a sense of dignity, control, and  autonomy.92  Including older individuals in decisions about food can increase the desire to eat and  improve quality of life (Ibid).     CMS:  AMDA The Role of the Medical Director in Person‐Directed Care White Paper, Mar. 2010, 3. AMDA The Role of the Medical Director in Person‐Directed Care White Paper, Mar. 2010, 3. 92 ADA Position Paper Individualized Nutrition Approaches for Older Adults in Health Care Communities,  2010. 90 91

35 Appendix 3-A

Tag F242 Self‐Determination and participation ‐ The resident has the right to:  1) Choose activities, schedules, and health care consistent with his/her interests,  assessments and plans of care;  2) Interact with members of the community both inside and outside the facility; and   3) Make choices about aspects of his or her life that are significant to the resident.  Providers are to be actively seeking preferences, choice over schedules important to the  resident i.e. waking, eating, bathing, retiring and states if resident is unaware of the right to  make such choices determine if home has actively sought resident preference information  shared with caregivers.93  Tag F280 Participation planning care and treatment – The resident has the right to ‐ unless  adjudged incompetent or otherwise found to be incapacitated under the laws of the State,  participate in planning of care and treatment or changes in care and treatment.     Sometimes, a resident or resident’s representative decides to decline medically relevant  dietary restrictions.  In such circumstances, the resident, facility and practitioner  collaborate to identify pertinent alternatives.  [The resident or representative] has the right  to make informed choices about accepting or declining care and treatment.94  The right to make informed decisions means that the patient or patient’s representative is  given the information needed in order to make “informed” decisions regarding his/her  care.95  Relevant Research Trends  Nursing home residents value control and choice on aspects of their daily lives including  food.96, 97, 98  Residents consumed a greater proportion of food when they were fed by CNAs who had  less need for power and allowed the resident to control the interaction.99    Autonomy in relation to food such as access to food between meals and having foods  brought in by family and friends has a positive association with quality of life for  residents.100 

93 CMS State Operations Manual Appendix PP, 483.15(b) Tag 242 Self‐determination and participation.

CMS State Operations Manual Appendix PP 483.25(i) Tag F325 Nutrition. CMS State Operations Manual Appendix A Hospitals Survey Protocol, Regulations and Interpretive  Guidelines for Hospitals, A‐0049 482.13(b)(2). 96 Kane, R.A. et al. “Everyday Matters in the Lives of Nursing Home Residents: Wish for and Perception of  Choice and Control,” Journal of the American Geriatrics Society, 45, No. 9, 1997, 1086‐1093. 97 Evans BC and Crogan NL. Using the FoodEx‐LTCto assess institutional food service practices through  nursing home residents’ perspectives on nutrition care. J Gerontol Med Sci, 2005, 60A, 125‐128. 98 West GE, Oullet D & Oulette S. Resident and staff ratings of foodservices in long‐term care: implications for  autonomy and quality of life. J Appl Gerontol 2003; 22 (1), 57‐75. 99 Mezey M, Fulmer T, Amella, E. Factors Influencing the Proportion of Food Consumed by Nursing Home  Residents with Dementia. Journal of the American Geriatrics Society, Volume 47, Issue 7, Nov. 1999. 94 95

36 Appendix 3-A

  When residents were asked to make a list of those aspects of their lives that were most  important to their quality of life, they identified choice of dining companions and where to  eat their meals as their top priorities.101    Bulk food service (steam table/buffet) and a home‐like environment optimize energy  intake in individuals at high risk for malnutrition, particularly those with low body mass  index and cognitive impairment.102    Snacking is an important dietary behavior among older adults… (and) may ensure older  adults consume diets adequate in energy.  Snacks provide over 25% of resident energy  intake and 14% of protein intake.103    Making food available 24 hours a day is recommended in the 2000 Malnutrition and  Dehydration in Nursing Homes:  Key Issues in Prevention and Treatment research study as  one approach to the prevention and treatment of malnutrition and dehydration in nursing  home residents.104    Persons with mild to moderate cognitive impairment (i.e. Mini Mental State Exam scores  13‐26) are able to respond consistently to questions about preferences, choices and their  own involvement in decisions about daily living, and to provide accurate and reliable  responses to questions about demographics.105            There is no way of knowing whether family surrogates, formal or informal, accurately  represent the wishes of the older person with dementia.106 Family members’ and older 

100 Carrier N, West GE, Ouellet D. Dining experience, foodservices and staffing are associated with quality of 

life in elderly nursing home residents. The Journal of Nutrition, Health and Aging, Vol. 13, No. 6, 2009. 565‐ 570. 101 Cohn J & Sugar JA. Determinants of quality of life in institutions: perceptions of frail older residents, staff  and families. In: Burren JF, Lubben JF, Rowe JC & Deutschman DE, The concept and measurement of quality of  life in the frail elderly. Academic Press, Inc. Chapter 2. 102 Desai et al, Changes in Types of Foodservice and Dining Room Environment Preferentially Benefit  Institutionalized Seniors with Low Body Mass Index, 2007. 103 Zizza, C.A., F.A. Tayie, and M. Lino.  “Benefits of Snacking in Older Americans.”  Journal of the American  Dietetic Association, Vol. 107, 2007, 800‐806. 104 Burger, S.G. J Kayser‐Jones and J. P. Bell Malnutrition and Dehydration in Nursing Homes: Key Issues in  Prevention and Treatment The Commonwealth Fund 2000. 105 Feinberg, Lynn Friss and Carol J Whitlatch, Are Persons with Cognitive Impairment able to State Consistent  Choices? The Gerontologist, Vol. 41, No. 3, 374‐382. 106 Kane, R.L. and R.A. Kane, “What Older People Want from Long‐Term Care And How They Can Get It.”  Health Affairs Nov./Dec. 2001

37 Appendix 3-A

residents’ ratings of the services of both nursing homes and assisted living facilities reveal  little congruence. 107, 108    Current Thinking    Choice of food has a tremendous impact on quality of life.  Some might say it defines quality  of life.109    Foods of choice are available whenever residents are hungry, not just at scheduled meal  times.  And when they long for a specific food, it is available.  Foods of choice are available  24/7 and someone is available 24/7 to prepare them.110    Simply speaking, it is all about choice.  It is as simple as asking, “What does the resident  want?  How did they do it at home?  How can we do it here?”  Choice of what to eat, when to  eat, where to eat, whom to eat with, how leisurely to eat.  True choice, not token choice.   Not the win‐lose choice between a hot breakfast and sleeping to the rhythm of your day.   Not simply the choice of hot or cold cereal, but also the raisins and brown sugar that make  oatmeal a daily pleasure.  For dining, true choice is exemplified in point‐of‐service choice...  (Ibid).    Develop approaches to dining that reflect a view of elders as capable of making choices and  deciding what, when, and with whom to dine as a mental wellness activity because it  “exercises” the decision making circuitry of the brain, enhances pleasure, and strengthens  memory encoding and retrieval.111    There needs to be a new “red flag” or “assumption” for both surveyors and providers that a  tray line or set/limited meal times are now viewed as an obvious contradiction of choice  and if this lack of choice leads to failure to thrive it would be considered harm during the  survey process (CH recommendation).    There needs to be another new “red flag” whereby any notation in a resident record or care  plan of a resident as “non‐compliant” with physician orders is viewed as an obvious  contradiction to resident choice with a shift to facility non‐compliance with requirements  to offer choice at tag 242, right to refuse treatment at tag 155 and right to same rights as  any citizen of the United States at Tag 151 (CHII Recommendation).  Everyone, provider community, all disciplines, MDS Coordinators identify in assessment  and on care plans a person’s preferences more so than problems, distinguishing between  true medical problems and personal preferences using the new guidance at Tag 242  107 Kane, R.A. et al, First Findings from Wave 1 Data Collection: Measures, Indicators and Improvement of 

Quality of Life in Nursing Homes (Minneapolis: Division of Health Services Research and Policy, School of  Public Health, University of Minnesota, 2000.. 108 Levin, C.A. Resident and Family Perspectives on Assisted Living. Doctoral Thesis, Univ. of Minnesota, 2001. 109 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010. 110 Bump, Linda. The Deep Seated Issue of Choice, paper for CHII 2010. 111 Ronch, Judah. Food for Thought paper for CHII 2010.

38 Appendix 3-A

“actively seeking preferences” to guide all of us.  Create a new standard of practice that  care plans identify familiar and meaningful foods preferred (CHII Recommendation).    The majority of nursing home residents are able to reliably answer questions about their  satisfaction with the food service, regardless of cognitive status, and the presence of  complaints is related to poor meal intake and depressive symptoms.112  Informed choice implies that someone informed the person, this is the facility’s  responsibility: risks of certain choices, benefits of certain choices, education.  However, it  now sounds like what we’ve been teaching to be the risks of choosing not following a  certain restricted diet may not be true after all.  If there is no evidence that restricted diets  actually bring about the outcomes we thought they did, then we really do not know.  Better  yet would be basing probability on what the individual’s baseline and history shows risk  for that person to be.113    The medical director should work closely with the registered dietitian, director of nursing  and the director of food services to develop a system promoting resident choice while  maintaining quality of care.  This system should include policies that promote routine use  of a regular diet while maintaining opportunities for discussion of the risks and benefits of  diet choices that are felt, by convention, to place the resident at risk.  The facility must  provide evidence of the education that was offered to the resident and the family as well as  documentation of the discussion of the risks.  A periodic review of the risks associated with  the resident’s choices should be conducted with the resident and his/her family.  It is  imperative the resident’s physician be involved in these discussions.114     The facility should attempt to offer less risky alternatives to food choices the resident may  request.  Offering ice cream instead of a cookie may satisfy the desire for a dessert while  maintaining a safer consistency.  The facility must plan for the resident’s choice, noting  ways to monitor and provide for safety, such as offering to cut meat into small pieces at  meals, recognizing the resident’s ability to decline the offer.  An informed consent by the  resident does not mitigate the facility’s responsibility to keep the resident as safe as the  resident and his/her family allow based on informed choice (Ibid).    Defining Health‐Related Quality of Life  Subjective  Measured from the patient’s perspective after informed education about illness and  therapy (emphasis added)  Multidimensional sense of well‐being (commonly agreed on by authors)  Functional well‐being:  energy level and ability to participate in activities of daily  living, including work and leisure  112 Simmons, Sandra F., Patrick Cleeton, and Tracey Porchak.  “Resident Complaints about the Nursing Home 

Food Service: Relationship to Cognitive Status.”  Journal of Gerontology: Psychological Sciences, Vol. 10, 2009. 113 Bowman, Carmen. The Food and Dining Side of the Culture Change Movement: Identifying Barriers and  Potential Solutions to furthering Innovation in Nursing Homes Background Paper for the Feb.  2010 CHII.  Report of CMS Contract HHSM‐500‐2009‐00057P. 114 Leible and Wayne, The Role of the Physician Order, paper written for CHII 2010.

39 Appendix 3-A

Emotional:  comprises both positive (peace of mind, happiness) and negative  (depression, anxiety) moods  Physical well‐being:  body symptoms of pain, dyspnea, dysphagia, nausea, fatigue  Treatment satisfaction (emphasis added):  includes financial costs  Social functioning:  the ability to engage in social activities  Intimacy:  concerns of body image and sexuality  Family well‐being: ability to maintain communication and family relationships.115 

  The elder’s right to have a liberalized diet or even the elimination of caloric and other  dietary restrictions has slowly been embraced to enhance quality of life.  But many …   interdisciplinary team[s] resist the elder’s right to have an informed refusal of an ordered  diet (texture modified or tube feeding) that might put them at aspirative and choking risk.   Often this is based upon the long held, preconceived notion that federal regulatory  requirements (and possibility of a deficiency finding) are for safety first, and quality of life  decisions take a second seat after that.  It is also based upon years of NOT informing the  resident that these choices were his/her rights and NOT including the resident’s voice or  preference in the dietary planning and decision making.  Yet, the F tag 151 federal  requirement states its intent regarding the facility’s responsibilities toward rights:   “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.”  This includes  the right of refusal of an ordered medical therapy or diet.  The surveyor is to “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.”  Each facility must answer  the questions:  How is the resident informed about dietary/dining rights?  Does the  resident have a voice or is it limited?  Is there educating and informing the resident about  alternatives and consequences of choices?  Is there a mutually agreed upon plan  recognizing the resident’s choice?  Is there adequate resident support and monitoring once  that informed refusal is made?  Remember the challenges when there were federal  mandates of removing physical and chemical restraints for a resident’s quality of life?   There will always be safety issues and concerns.  We are facing some of the same  challenges in supporting a resident’s informed refusal and right of choice.116    Put resident choice before regulations and guidelines such as Recommended Daily  Allowances which are generic estimated nutritional needs and non‐individualized (CHII  Recommendation).    Residents who have capacity to decide should not be denied the choice to eat hot dogs or  grapes whole which many homes and companies are imposing to minimize the potential  choking risk (CHII Recommendation).    McMahon, MM, Hurley, DL, Kamath, PS, Mueller, PS.  Medical and Ethical Aspects of Long‐term Enteral  Tube Feeding. Mayo Clin Proc Nov. 2005;80(11):1470  mayoclinicproceedings.com/content/80/11/1461.full.pdf 116 Handy, Linda. Culture Change in Dining and Regulatory Compliance, www.handydietaryconsulting.com   2011. 115

40 Appendix 3-A

“I’m a firm believer in the rights of elders to do whatever the hell they want.  If you only  have the right to make the ‘good, wise’ decisions that your grown daughter agrees with,  then you’re not running your own life anymore.  I’ve taken care of lots of people who didn’t  even know their own children.  Sure, they probably shouldn’t be making decisions about  their 401(k) plans, but they can decide what to wear and what to eat and whether to go  outside on a daily basis.  People think that if old people cannot make the big decisions, they  cannot make any decisions—and that is just wrong.  They have the right to folly.”117      Provide education to the whole clinical team on how to negotiate risk with the Elder when  their life goals are contrary to best medical practices.  Health care professionals need  education in determining nutritional risk, conducting comprehensive nutritional  assessments, developing and executing nutritional interventions, and evaluating nutritional  outcomes.  We need to make sure that the risks and the benefits are being discussed with  residents at the same time that we’re asking for their choices and preferences (CHII  Recommendation).    When caring for frail elders there is often no clear right answer.  Possible interventions  often have the potential to both help and harm the elder.  This is why the physician must …  explain the risks and benefits to both the resident and interdisciplinary team.  The  information should be discussed amongst the team and resident/family and only then  should an agreed upon choice be made.  It is when the team makes decisions for the person  without agreement by all that problems arise.  The agreed upon plan of care should then be  monitored to make sure the community is best meeting the resident's needs.118     Recommended Course of Action    Choices with meaningful options in accordance with the person’s preferences are offered to  each resident numerous times daily, i.e. when to awaken, when to eat, what to eat, where to  eat, what to do, when to bathe, when to retire, what to wear, etc.    A variety and increased number of staff present in the dining room enables both physical  and psychosocial needs to be met.  Additionally, staff can enhance and honor the individual  choices for all residents reflective of preferences.   There needs to be a new “red flag” or “assumption” for both surveyors and providers that a  tray line or set/limited meal times are now viewed as an obvious contradiction of choice  and if this lack of choice leads to failure to thrive it would be considered harm during the  survey process (CHII recommendation).  Residents’ individual choices are actively sought after, care planned and honored, as Tag F  242 requires, based on life patterns, history and current preferences.  117 Dr. William Thomas as reported by Brown, Nell Porter. “At Home with Old Age Reimagining Nursing 

Homes” Harvard Magazine November – December 2008 The Alumni,  http://harvardmagazine.com/2008/11/at‐home‐with‐old‐age.html. Accessed 10/15/09. 118 Wayne, Matthew. Clinical Standards Task Force communication, 2011.

41 Appendix 3-A

  Team members of all disciplines and MDS Coordinators identify in assessment and on care  plans a person’s preferences more so than problems, distinguishing between true medical  problems and personal preferences using the new guidance at Tag 242 “actively seeking  preferences” to guide all team members.  Create a new standard of practice that care plans  identify familiar and meaningful foods preferred (CHII Recommendation).  There needs to be another new “red flag” whereby any notation in a resident record or care  plan of a resident as “non‐compliant” with physician orders is viewed as an obvious  contradiction to resident choice with a shift to facility non‐compliance with requirements  to offer choice at Tag 242, right to refuse treatment at Tag 155 and right to same rights as  any citizen of the United States at Tag 151 (CHII Recommendation).  Instead of labeling one as “non‐compliant,” nurses work with physicians to eliminate  “orders” for restrictive diets residents don’t eat and instead create plans with the person  that work for the person (see standards for various diets in Diet Liberalization section).    When caring for frail elders there is often no clear right answer.  Possible interventions  often have the potential to both help and harm the elder.  This is why the physician must be  present [involved] in order to explain the risks and benefits to both the resident and  interdisciplinary team.  The information should be discussed amongst the team and  resident/family and only then should an agreed upon choice be made.  It is when the team  makes decisions for the person without agreement by all that problems arise.  The agreed  upon plan of care should then be monitored to make sure the community is best meeting  the resident's needs.119     Provide education and support to anyone speaking on behalf of the resident, including  health care professionals, families, friends, and legal representative on their obligation in  advocating for the resident’s/the person’s individual life patterns, history, current  preferences, opinions and wishes (not necessarily their own).  Education should be  inclusive so that the representatives clearly see their role as an advocate for the  individual’s choice (not necessarily their own).  We do not assume that just because a resident may not be able to make decisions in some  parts of their life they cannot make choices related to their dining preferences.  Education,  good observational skills, strong advocacy and consistent relationships with caregivers  enables a person with impaired decision making capacity to make choices.    When making dining decisions that can be viewed as a risk to the individual’s physical  health, the plan of care will be adjusted to honor choice and provide the supports available  to mitigate the risks based upon the individual’s life goals.    

119 Wayne, Matthew. Clinical Standards Task Force communication, 2011.

42 Appendix 3-A

Put resident choice before regulations and guidelines such as Recommended Daily  Allowances which are generic estimated nutritional needs and non‐individualized (CHII  Recommendation).   Resident preferences in dining will be communicated to the entire interdisciplinary team  so that medications and treatments, schedules and food offered at activities are consistent  with choices honoring personal preferences.    Resident dining profiles (tray tickets) should be limited to adapted equipment, allergies,  consistency modification and unique dietary needs.  Preferences should be sought after as  choices are offered (not just once and then recorded on a tray ticket indefinitely).  

43 Appendix 3-A

Standard of Practice for Shifting Traditional Professional Control to Individualized  Support of Self Directed Living  Basis in Current Thinking and Research    AMDA:  Person‐directed care promotes resident choice and self‐determination in ways that are  meaningful to the resident.  It has been a key component of geriatric medicine for decades.   The interdisciplinary team and the medical director have essential roles both in facilitating  this process as well as in monitoring it for desired outcomes.  Medical directors and  clinicians should help nursing home administration and staff understand how to provide  person‐directed care while maintaining clinical excellence.  To ensure success, nursing  home leadership must support these efforts.120    ADA:  Despite the growing body of evidence discouraging the use of therapeutic diets in older  adults, these diets are still regularly prescribed.  Research has not demonstrated benefits of  restricting sodium, cholesterol, fat, and/or carbohydrate in older adults.121    CMS:  Residents have the right to refuse treatment, CMS Tag F151.  Residents have the right to informed choice, CMS Tag F325.  Residents have the right to choice, CMS Tag F242.    Pioneer Network/Hartford Institute for Geriatric Nursing:  Nurse Competencies for Nursing Home Culture Change –   #2 – Creates systems and adapts daily routines and “person‐directed” care practices to  accommodate resident preferences.  #4 – Evaluates the degree to which person‐directed care practices exist in the care team  and identify and addresses barriers to person‐directed care.  #9 – Problem‐solves complex medical/psychosocial situations related to resident choice  and risk.  #10 – Facilitates team members, including residents and families, in shared problem‐ solving, decision making and planning.  Related Research Trends    As we know that residents have their very individual biography of nutrition and are  experts in preparing meals, the cook meets every week with small groups of residents  discussing a variety of food‐ and meal‐ related topics. The idea is the cook gets to know  each individual resident and learns about their wishes, their expectations, their skills, and  their expertise…. What we observe in these settings is that life becomes normal, livelier,  AMDA The Role of the Medical Director in Person‐Directed Care White Paper, Mar. 2010, 5. ADA Position Paper Individualized Nutrition Approaches for Older Adults in Health Care Communities  2010. 120 121

44 Appendix 3-A

that residents eat much better and that loneliness, helplessness and monotony are reduced.  Residents need less medicine and sleep much better.122    Current Thinking  … the people with the power remain the biggest barrier to meaningful culture change in  long‐term care.  They are too easily satisfied.  Even as they gravitate toward this new way,  their old way of thinking is so strong it keeps leaders from truly changing the organization  and empowering teams.  The old mindset makes us way too satisfied with the low‐hanging  fruit – those positive outcomes that inevitably result from even modest changes.  Because  even small improvements are so much better than the old way, it is easy to become  complacent and avoid the really difficult work necessary to create true home for elders.123     Unfortunately, these evidence based guidelines are not yet widely accepted as standards of  practice, and even more unfortunately, standards of traditional best practice developed for  individuals at earlier stages of the life cycle are currently applied to elders, often limiting  their choices, limiting their quality of life, while well‐meaning practitioners practice a  medical model of care (Ibid).    Life extension with medically advanced treatments or imposed chronic condition  management at an advanced age negating choice or satisfaction often leads to negative  outcomes that are then managed with more liberal approaches that should have been the  approach from the beginning (Ibid).    Establish guidelines that define an elder’s right to make an unpopular or ill‐advised  decision in view of all available information about the impact of the decision on his/her  future self (“the right to folly”) versus cognitive, emotional or other conditions that render  him/her vulnerable to exploitation, abuse or neglect.  This should be based on imagining  future scenarios that result from the decision and how the elder appreciates and plans for  the impact on his/her well being.124    We all need to shift to agreeing that care givers will offer to do what is clinically best for a  person and if the person refuses, that’s okay.  Along with liability comes responsibility to  the person we’re serving – if an elder decides to not eat what is clinically best we work with  them but never force them – caring for someone doesn’t mean you have to make the  choices for them (CHII Recommendation).    Another level of education is needed for clinicians and care givers to be able to shift  traditional professional control over to the resident since it feels like we’re going against  what we have believed to be our obligation or even a nursing license of what “good care” is  122 Hoffmann, AT. Quality of Life, Food Choice and Meal Patterns – Field Report of a Practitioner. Ann, Nutr 

Metab 2008; 52 (suppl 1): 20‐24. 123 Bump, Linda. The Deep Seated Issue of Choice paper for CHII Feb. 2010. 124 Ronch, Judah. Food for Thought: The Missing Link between Dining and Positive Outcomes, paper for CHII  2010.

45 Appendix 3-A

which we now realize has been making decisions for residents and not honoring their  decisions (CHII Recommendation).    Self‐directed living includes honoring the resident's choice even in the face of family  disagreement.  Power of Attorney does not give the right to demand restricted diets or  altered consistencies.  Even with a guardianship, a family member should work closely with  the physician to assess all risks including the risk of more restrictive choice, or in other  words, of not honoring the resident's choice (CHII Recommendation).    At times the life goals should supersede medical best practices.  Recommendations should  be based on what each elder wants, not what we would want for ourselves or what we  think the elder wants.125  While alcohol is not a medical treatment it may present certain risks.  It is for some elders a  lifestyle choice.  Due to potential for interactions with medications and certain clinical  conditions the elder’s physician should be consulted regarding the elder’s choice to enjoy  an alcoholic beverage.   If there are concerns regarding medications or effects on illness  there is a opportunity to provide information to the elder or his/her family about the  potential risks.   The clinician may choose to make changes in the medication regimen to  address potential concerns.  There is an opportunity to offer non‐alcoholic drinks when the  risks are considered to be higher than the potential benefit.  It the elder and his or her  family’s right to make an informed choice.126    If the patient is sufficiently informed about the risks and benefits of acceptance (informed  consent) or refusal (informed refusal) of a proposed intervention or treatment and refuses,  the clinician should respect the patient’s decision (Mayo Clinic Proceedings 2005).127    Recommended Course of Action  All decisions default to the person.   

125 Hyde, Denise. The Role of the Pharmacist paper written for the CHII 2010.  126 Power, Al. The Physician and Person‐Directed Dining, unpublished, April 2011. 127 McMahon, MM, Hurley, DL, Kamath, PS, Mueller, PS.  Medical and Ethical Aspects of Long‐term Enteral 

Tube Feeding. Mayo Clinic Proceedings Nov. 2005; 80(11): 1461‐1476.

46 Appendix 3-A

New Negative Outcome    Basis in Current Thinking and Research    AMDA:  “Person‐directed care” is a philosophy that encourages both older adults and their  caregivers to express choice and practice self‐determination in meaningful ways at every  level of daily life.  Values that are essential to this philosophy include choice, dignity,  respect, self‐determination and purposeful living.  These values also are at the core of  desirable medical care and are embraced by many medical providers.  Yet practices that  conflict with these principles are common in the long term care setting.  Examples include  awaking residents at times that are determined by staff convenience, modifying residents’  diets without discussion, and inflexible meal times and medication pass times.  In addition,  care plans may be created without truly understanding a resident, their history or previous  occupation, their recreational and personal preferences, wishes regarding life‐sustaining  treatment, and other likes and dislikes.  Geriatrics is a discipline that emphasizes medical  care in the proper context, including its impact on function, quality of life, and personal  preferences.128    ADA:  For many older adults residing in health care communities, the benefits of less‐restrictive  diets outweigh the risks.  When considering a therapeutic diet prescription, a health care  practitioner should ask:  Is a restrictive therapeutic diet necessary?  Will it offer enough  benefits to justify its use?129    CMS:  Tag F325 Nutrition, Deficiency Categorization    Severity Level 4 ‐ Immediate Jeopardy:  Substantial and ongoing decline in food intake resulting in significant unplanned  weight loss due to dietary restrictions or downgraded diet textures (e.g., mechanic  soft, pureed) provided by the facility against the resident’s expressed preferences.     Severity Level 3 ‐ Actual Harm:  Unplanned weight change and declining food and/or fluid intake due to the facility’s  failure to assess the relative benefits and risks of restricting or downgrading diet  and food consistency or to obtain or accommodate resident preferences in accepting  related risks;           AMDA The Role of the Medical Director in Person‐Directed Care White Paper, Mar. 2010, 1. ADA Position Paper: Individualized Nutrition Approaches for Older Adults in Health Care Communities,  2010. 128 129

47 Appendix 3-A

Current Thinking    Professional standards direct nurses to act to prevent unsafe, illegal, and unethical practices  and protect patients who may be at risk.130  Nurses are educated to look for errors in  medication and treatment orders, and to look for adverse outcomes related to medication  and treatments.  When a resident refuses a medication or treatment, the physician is  promptly notified.  Sometimes this standard does not translate into other aspects of care,  such as acting on evidence that nutrition practices are not achieving intended outcomes.   When a resident refuses a meal food or is observed consuming minimal amounts of food,  prompt action is needed.  Using current practice standards, physician notification may not  occur until the resident looses weight.  A proactive approach, which employs the nursing  process, for all aspects of care, including nutrition, should be the practice standard.  The  nursing process, which involves assessment, diagnosis of need, planning of resident’s care,  implementation, and evaluation of success of implemented care, supports honoring  resident preferences and implementing dining practices that support choice.131, 132     Relevant Research Trends    Caregivers often fear that residents’ mealtime choices will result in negative outcomes.   Mealtime dining studies provide evidence that enabling residents to choose what they want  to eat at mealtime does not result in negative nutritional outcomes.  Enabling choice can  increase nutritional intake and increase resident, family and caregiver satisfaction.133, 134,  135, 136 Moreover, these studies demonstrate that usual care, which does not provide for  resident choice, when compared to dining practices that enable choice, can result in  negative outcomes such as worsening of nutritional markers and quality of life indicators.    Ongoing discussions of where residents are on the health illness/trajectory and  modifications of care goals are essential to providing person‐directed care. The health care  team needs to recognize when the goal of nutritional care is no longer prevention or  130

American Association of Colleges of Nursing 2008. The Essentials of Baccalaureate Education for  Professional Nursing Practice. Washington, DC: American Association of Colleges of Nursing.   131  Remsburg, Robin.  Home‐style Dining Interventions in Nursing Homes: Implications for Practice. Paper for  CH II 2010. 132 Pioneer Network/Hartford Institute Nurse Competencies for Nursing Home Culture Change  http://www.pioneernetwork.net/Data/Documents/TenCompetenciesReport0510.pdf. 133 Remsburg, R.E., Luking, A., Baran, P., Radu, C., Pineda, D., Bennett, R.G., Tayback, M. 2001. Impact of a  buffet‐style dining program on weight and biochemical indicators of nutritional status in nursing home  residents: a pilot study. J Am Diet Assoc, 101(12), 1460‐3. 134 Nijis, K.A.N.D., de Graff, C., Siebelink, E., Blauw, Y.H., Vanneste, V., Kok, F.J., van Staveren, W.A. 2006. Effect of  family‐style meals on energy intake and risk of malnutrition in Dutch nursing home residents: A randomized  control trial.  J Gerontol A Biol Sci Med Sci, 61(9), 935‐42. 135 Nijis, K.A.N.D., de Graff, C., Kok, F.J., van Staveren, W.A. 2006. Effect of family style mealtimes on quality of  life, physical performance, and body weight of nursing home residents: Cluster randomized controlled trial.  BMJ, 10, 1‐5.  136 Ruigrok, J. & Sheridan, L. 2006.  Life enrichment programme: Enhanced dining experience, a pilot project.  Internat J of Health Care, 19(5), 420‐429.

48 Appendix 3-A

restoration, but rather comfort and palliation.  Identifying when to shift practices to  support palliative nutrition will ensure the resident receives quality care at the end of life.   Continuing to provide active restorative nutritional care when it is likely to have limited, if  any effect on the well‐being of the resident, can create great distress for the resident, family  and caregivers.137    From researcher psychologists Ellen Langer and Judith Rodin:    I had recently completed research on the illusion of control, which showed me how  important it was for people to control their own lives.  It was so important that even  in chance‐determined situations, people would not relinquish their control.   Therefore, with the slightest provocation, they engaged in illusory control behavior.   Around this same time, I was visiting my grandmother in a nursing home.  I was  struck by how little control she and the other residents were permitted.  I thought  this was outrageous.  How could ‘they’ be so sure they know better than these  people?  I thought all facts were probabilistic statements so their certainty bothered  me.      Let me give you an example to make this clearer.  Should an elderly diabetic be  allowed to have ice cream?  The relationship between diabetes and sugar is  probabilistic even though it is treated by many people as absolute.  Whether or not  that ice cream will hurt the person depends on what else was eaten that day, how  much ice cream is consumed, whether or not the person has exercised, and so on.   Recent evidence, in fact, suggests that no sugar is more dangerous than a small  amount of sugar.  Regardless of the findings, however, I think nursing‐home staff  should make recommendations, but leave the final decision up to the resident.  One  cannot know today what “facts” will turn up tomorrow.      I approached Judy Rodin at Yale, who was also working in the area of control at this  time.  She too felt that this population was characteristically denied the opportunity  to exercise control.  Together we visited local nursing homes.… The experiment we  conducted was successful.  Psychologically, control proved to be a potent variable.   The follow‐up showed us that control was also important physiologically.  Half as  many people given our control intervention had died 18 months later than those  given a comparison treatment.  Because the longevity findings were so dramatic, I’ve  spent a good deal of time trying to understand how such a simple treatment (a pep  talk encouraging decision making, a few decisions, and a plant to take care of) could  have such a profound effect on people.     The experimental group also showed “a significant improvement over the control  group in alertness, active participation, and general sense of well‐being.”138  Remsburg, Robin.  Home‐style Dining Interventions in Nursing Homes: Implications for Practice. Paper for  CH II 2010. 138 Langer, Ellen J.  This Week’s Citation Classic: Sept. 20, 1985.  Current Contents/Number 44, November 4,  1985, 14. 137

49 Appendix 3-A

    Current Thinking    The Eden Alternative® recognizes helplessness as one of the three plagues of  institutionalization.   In the institutional setting staff learn that if residents cooperate with their ability to help  them, it is a more efficient use of their time.  The price paid is for the resident to learn to  wait to be helped.  This squelches autonomy, skills atrophy, residents become even more  dependent on care givers, and have even less control over their lives.  Staff’s style of speech  encourages learned dependency.  Intonation is often similar to what is used with children  which causes an adult to feel devalued.  Research shows the person loses faith in their  ability to affect outcomes in their own world.139    Not supporting individualized care and a person’s choice, not supporting “the right to  folly,” causes learned helplessness, depression, learned dependency, even bringing death  earlier.  We have not intended harm with our good intentions, but we are creating it.  The  Hippocratic Oath is known as “Do no Harm.”140    It is as difficult as staring straight at the sun, but if we as a profession are to initiate radical  change, then we must be conscious of and focus on the harm that we do.  Harm – not just to  the body, but to the very person – is systematically embedded in bureaucratic institutions  that strip elders of their personhood.141     The harm, the potential harm, we overly identify and worry about is to the body.  When a  person will not follow recommended medical advice, aka the physician’s order, we worry  about the physical harm it might cause their body.  Notice too how it is called “against  medical advice” as if the person is somehow wrong to go against the physician’s advice,  again a bad person, “non‐compliant.”  We haven’t contemplated much the harm to the  person that results from denying them this right, the right to go against medical advice, the  right to their personhood, their life, their schedule, their wishes.  No one should have to  fight for, cry for or be told ever again, “You can’t come in the dining room until the doors  are open” or “You can’t have this because it’s not on your diet.”  We decide for people they  will only drink decaf coffee.  We decide for people they can only eat this food and not eat  that food.  If you were denied your rights to this extent, would it feel like abuse, neglect?   Part of the culture change movement is to call things as they are and not longer sugar  coat.142    Ronch, Judah 2006 CMS satellite broadcast Psychosocial Severity Outcome Guide  www.pioneernetwork.net. 140 Bowman, The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential  Solutions to furthering Innovation in Nursing Homes Background paper for CHII 2010. 141 Frank, Barbara, Sarah Forbes‐Thompson and Stephen Shields.  “The Why and How of Radical Change.”   Nursing Homes/Long Term Care Management, May 2004, 44‐47. 142 Bowman, Background paper for CHII 2010. 139

50 Appendix 3-A

The Reasonable Person Concept is defined as when a resident’s reaction to a deficient  practice is markedly incongruent with the level of reaction the reasonable person would  have to the deficient practice (CMS).143    Even if a resident’s reaction is that it is “fine” for her/his choice not to be honored this is  “markedly incongruent” with a reasonable person like you and I living in the community at  large.  If someone gave us decaf coffee when we wanted caffeinated or woke us up  according to when they thought we should get up, we would not be happy about it … to say  the least.  I ask people all over the country how many of them do not even eat breakfast.   Inevitably half the crowd raises their hands whether there are 8 or 800.  Half of us do not  eat breakfast.  What is the number one driving force in every nursing home every day for  getting people up?  Breakfast.  Why do we even wake people up at all?  Breakfast.  I ask my  half a crowd how they would feel about being awakened from sleep to eat a meal they  didn’t want.  They say “mad” and “angry.”  Someone inevitably says they would be “non‐ compliant” and administered a psychotropic drug in order to be compliant.  Unfortunately,  this is the norm, according to my audiences.  This is Unnecessary Drugs.  This is restraining  a person for the convenience of staff, for honoring what a CNA once called the “almighty  schedule” not the person.  This is non‐compliance with the federal requirements.  It is the  dawning of a new day to realize there are negative outcomes we are not considering and  people’s health and well‐being are in the balance (Ibid).     Develop approaches to dining that reflect a view of elders as capable of making choices and  deciding what, when, and with whom to dine as a mental wellness activity because it  “exercises” the decision making circuitry of the brain, enhances pleasure, and strengthens  memory encoding and retrieval.144     Residents who receive good personalized care and opportunities for choice have higher  morale, greater life satisfaction, and better adjustment (Institute of Medicine).145 

143 CMS Psychosocial Severity Outcome Guide, State Operations Manual, Appendix P, 2006. 144

Ronch, Food for Thought:  The Missing Link between Dining and Positive Outcomes paper for CHII 2010.

145 Improving the Quality of Care in Nursing Homes.  Institute of Medicine.  Committee on Nursing Home 

Regulation.  National Academy Press; Washington, D.C., 1986. 

51 Appendix 3-A

Recommended Course of Practice  All health care practitioners and care giving team members offer choice in every  interaction even with persons with cognitive impairment in order to ensure control  remains with the person, higher satisfaction with life, improved brain health and to prevent  any harm from not honoring choice which has been proven to bring about earlier mortality.  

52 Appendix 3-A

Patient Rights and Informed Consent/Refusal across the Healthcare Continuum    One of the most thorough resources found on this subject pertaining to any person’s rights  in any healthcare setting is the following from the 2005 Mayo Clinic Proceedings.  McMahon, MM, Hurley, DL, Kamath, PS, Mueller, PS.  Medical and Ethical Aspects of Long‐ term Enteral Tube Feeding. Mayo Clinic Proc. Nov. 2005; 80(11): 1461‐1476  http://www.mayoclinicproceedings.com/content/80/11/1461.full.pdf.    FREQUENTLY ENCOUNTERED CLINICAL AND ETHICAL ISSUES    The following case examples illustrate frequently encountered clinical and ethical  questions related to long‐term tube feeding.    Illustrative Case 1.  A 95‐year‐old woman with mild dementia was hospitalized with  progressive neuromuscular disease and dysphagia. She experienced a 10% unintentional  weight loss during the prior 3 months and dehydration due to the inability to take food and  water by mouth for 1 week.  Videofluoroscopic swallow evaluation revealed aspiration of  all consistencies of food and liquid.  Tube feeding was recommended because permanent  tube feeding was anticipated.  The patient was alert and oriented to person, place, and time,  could articulate the risks, benefits, and alternatives to tube feeding discussed with her, and  wished to proceed with percutaneous endoscopic gastrostomy (PEG).  After the procedure,  she expressed a desire to eat small amounts of food in addition to receiving tube feeding.  Again, she could articulate the risks (e.g., aspiration), benefits, and alternatives to eating  small amounts of food and remained steadfast in her desire to eat.    ‐‐The word autonomy is derived from the Greek words autos (“self”) and nomos (“rule”).   The principle of respect for patient autonomy is the basis of informed consent.  The  elements of informed consent include information (e.g., the illness, the proposed  intervention, and the risks and benefits of and alternatives to the proposed intervention  including doing nothing), understanding of the information, decision‐making capacity, and  voluntary agreement to the intervention.    ‐‐Society and law assume that all adults are competent.    ‐‐Competence is a legal term, and only a court can declare a person incompetent.  In  contrast, clinicians determine whether a patient has intact medical decision‐making  capacity, which patients must have to be fully autonomous and participate in the informed  consent process.  Although no universally accepted tool for determining decision‐making  capacity exists, numerous groups, including the American Psychiatric Association, provide  useful guidelines.  Decision‐making capacity includes the ability to evidence a choice (i.e., to  reach a decision and effectively communicate the decision), the ability to understand the  nature of the decision, the ability to understand and appreciate the risks and consequences  of the decision, and the ability to manipulate information rationally.  Clinicians are  obligated to protect patients with impaired decision making capacity from inappropriate  53 Appendix 3-A

health care decisions.  The patient in the case example had mild dementia but had sufficient  decision‐making capacity for consenting to PEG tube placement and tube feeding.  She  understood and could articulate the indications, risks, and benefits of the procedure and  voluntarily consented to it.  Patients with impaired cognition may have sufficient decision‐ making capacity for specific health care decisions.     ALGORITHM FOR DECISION MAKING 

Figure 1. Decision algorithm for long‐term tube feeding.     

54 Appendix 3-A

 

  Figure 2. Decision algorithm for long‐term enteral tube feeding.    The level of decision‐making capacity should be in accordance with the risks and benefits  of the decision to be made.  For example, one should be absolutely certain that a patient  who refuses a low‐risk yet life‐saving intervention has adequate decision‐making capacity.   The patient in the case example expressed a desire to eat small amounts of food  despite the risk of aspiration.  It is ethically and legally permissible for patients with  decision making capacity to refuse unwanted medical interventions and to ignore  recommendations of the clinician.  A patient’s choice not to adhere to a clinician’s  recommendations may be at odds with a clinician’s desire to “do good” or avoid  harm.  If the patient is sufficiently informed about the risks and benefits of  acceptance (informed consent) or refusal (informed refusal) of a proposed  intervention or treatment and refuses, the clinician should respect the patient’s  decision.  In the case example, the patient placed a high value on the experience of  tasting even small amounts of food and on the social aspects of eating with others.   The Nutrition Support Services discussed potential risks of eating with the patient,  documented the discussion, and supported her decision by asking a dietitian and  occupational therapist to work with her to develop the safest approach to eating  small amounts of food.  Regardless of the decisions made, clinicians should not  abandon their patients.  If the clinician conscientiously objects to a patient’s  decision, the clinician should arrange to transfer care of the patient to another  clinician.    ‐‐‐The durable power of attorney for health care identifies a surrogate decision maker who  can make health care decisions if the patient no longer has decision‐making capacity.   Persons also may identify an alternate surrogate in case the first person designated 

55 Appendix 3-A

is unavailable.  Some states have a health care directive that combines the features of a  living will and durable power of attorney….    Surrogates must be fully informed of the risks, benefits, and alternatives to a proposed  procedure or treatment.  Surrogates should base their decisions on the patient’s previously  expressed values and goals (substituted judgment).  However, as with the case example,  patients often do not discuss their health care values and goals with their surrogate.  In  these situations, surrogates must make decisions based on what they regard as most  appropriate for the patient’s clinical condition, quality of life, and other factors (best  interest of the patient).  Notably, patients may regard designating a trusted surrogate as  more important than trying to predetermine all the possible future medical issues and  circumstances that may require a decision.    PREVENTING AND ADDRESSING ETHICAL DILEMMAS  The prima facie principles that characterize the ethical aspects of clinical medicine are  respect for patient autonomy, beneficence, nonmaleficence, and justice.  ‐‐ Respect for patient autonomy refers to the duty to respect persons and their rights of  self‐determination.   ‐‐Beneficence refers to the clinician’s duty to act for the good of the patient, whereas  nonmaleficence refers to the duty to avoid harming the patient.   ‐‐Justice refers to the duty to treat patients fairly.   When caring for patients for whom longterm tube feeding is being considered,  clinicians may find these ethical principles at odds with each other.  For example,  respect for patient autonomy may conflict with the clinician’s desires to be  beneficent and to avoid harm.  Effective communication among clinicians, patients,  and surrogate decision makers may help prevent ethical dilemmas.  Clinicians  should take time to learn about the patient and the patient’s values, goals, and  beliefs.  The patient should be provided ample time to discuss and provide his or her  concerns related to nutrition and hydration.  When conveying medical information  concerning benefits and risks of longterm tube feeding, clinicians should avoid  using complex medical language and frequently should assess the patient’s  comprehension.  Conversely, ineffective communication among clinicians, patients,  and surrogate decision makers may result in ethical dilemmas.  Lack of training,  perceived lack of time, fear of the patient’s emotional response, and general  discomfort with these topics may result in clinicians avoiding these discussions.  In  fact, discussions about lifesustaining treatments between clinicians and patients are  reportedly uncommon.     Despite good communication, clinicians may face ethical dilemmas related to long‐term  tube feeding that they cannot resolve.  In these situations, an ethics consultation may be  valuable.  The Ethics Consultation Service at our institution uses the 4‐topic case‐based  approach described by Jonsen et al.  This approach (below) reviews medical indications,  patient preferences, quality of life, and contextual (e.g., financial, religious, cultural, and  allocation of resources) issues of a given case and facilitates the exposition, organization,  and analysis of the ethically relevant facts (i.e., the facts related to the prima facie ethical  principles).  Answering the questions is a convenient approach to the 4 topics, and,  56 Appendix 3-A

reviewed together, the answers to the questions not only define the ethical problem but  often suggest a solution.    CONCLUSIONS  The use of long‐term tube feeding has increased substantially.  Review of the literature  highlights the need for improved education for physicians, patients, and surrogate decision  makers about use of long‐term tube feeding and its ethical implications.  Clinicians should  take an active role in recommending advanced directives to their patients.  Patients should  be encouraged to identify a surrogate decision maker and to make intentions clear to this  person about use of long‐term tube feeding.  Although outcome data from prospective,  randomized, controlled studies are limited, information from observational studies is  useful.  In general, PEG or percutaneous endoscopic jejunostomy (PEJ) feeding tube  placement should not be considered unless the anticipated duration of tube feeding is at  least 1 month.  The technical procedures to secure enteral tube access are generally safe,  but they are not risk free.  A simple guideline to outline the appropriate use of long‐term  tube feeding does not exist because each person has a unique perspective about their  quality of life.  As with other forms of medical interventions and treatments, the approach  should be individualized.  However, as discussed earlier, a systematic approach (Figures 1  and 2) can facilitate the decision‐making process.     Physicians [and the interdisciplinary team] should first determine whether the patient’s  treatment goals are potentially curative, rehabilitative, or palliative.  Next, to allow  informed decision making, clinicians should clearly communicate with patients and  surrogate decision makers about the patient’s diagnosis, prognosis, and potential outcomes  from providing or withholding long‐term tube feeding.  For patients in the terminal stages  of dementia, cancer, or other illnesses, current studies do not document improved outcome  from long‐term tube feeding use.  It is unrealistic to expect artificial nutrition to favorably  improve medical outcomes in these conditions; however, it is important to recognize that,  in certain situations, patients and surrogate decision makers will choose long‐term tube  feeding to achieve personal goals, independent of medical outcome.  If the potential  medical outcome is curative or rehabilitative, the decision should rest on the patient’s  wishes.  Patients and surrogate decision makers should be given sufficient time and  support for making informed decisions regarding long‐term tube feeding use, and their  decisions should be honored.  Research is needed to improve the clinician’s ability to  estimate the needed duration of artificial nutrition in order to select short‐term vs. long‐ term enteral access for feeding and to assess the effect of long‐term tube feeding on quality  of life and medical outcome for differing medical conditions.   

57 Appendix 3-A

Four‐Topic Approach to Identify Ethically Relevant Facts    [The PEG/PEJ placement and long‐term tube feeding is underlined indicating that any  course of treatment could be inserted into this four‐topic approach to decision making.]    Medical indications  The principles of beneficence and nonmaleficence  1. What is the patient’s medical problem that is prompting consideration of PEG/PEJ  placement and long‐term tube feeding? Prognosis?  2. Is the problem acute?  Chronic?  Critical?  Emergent?  Reversible?  3. What are the goals of PEG/PEJ placement and long‐term tube feeding?  4. What are the probabilities of success?  5. What are the plans in case of therapeutic failure?  6. In sum, how can this patient benefit from medical and nursing care, and how can harm  be avoided?    Patient preferences  The principle of respect for patient autonomy  1. Does the patient have decision‐making capacity?  2. If the patient has decision‐making capacity, what are his or her preferences for  treatment?  3. Has the patient been informed of the benefits and risks of PEG/PEJ placement and long‐ term tube feeding, understood this information, and given consent?  4. If the patient lacks decision‐making capacity, who is the appropriate surrogate?  5. Has the patient expressed preferences about PEG/PEJ placement and long‐term tube  feeding previously (e.g., advance directive)?  6. Is the patient unwilling or unable to cooperate with treatment? If so, why?  7. In sum, is the patient’s right to choose being respected to the extent possible in ethics  and law?    Quality of life  The principles of beneficence, nonmaleficence, and respect for patient autonomy  1. What are the prospects, with or without PEG/PEJ placement and long‐term tube feeding,  for a return to normal life?  2. What physical, mental, and social deficits is the patient likely to experience if treatment  succeeds?  3. Are there biases that might prejudice the clinician’s evaluation of the patient’s quality of  life?  4. Is the patient’s present or future condition such that his or her continued life might be  judged undesirable?  5. Is there any plan and rationale to forgo treatment?  6. Are there plans for comfort and palliative care?     

58 Appendix 3-A

Contextual features  The principles of loyalty and fairness (justice)  1. Are there family issues that may influence decisions related to PEG/PEJ placement and  long‐term tube feeding?  2. Are there clinician issues that may influence treatment decisions?  3. Are there financial and economic factors?  4. Are there religious or cultural factors?  5. Are there limits on confidentiality?  6. Are there problems of allocation of resources?  7. How does the law affect treatment decisions for PEG/PEJ placement and long‐term tube  feeding?  8. Is clinical research or teaching involved?  9. Is there any conflict of interest on the part of clinicians or the institution?    Adapted from Jonsen et al, 111 with permission from McGraw‐Hill.  Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions  in Clinical Medicine. 5th ed. New York, NY: McGraw Hill; 2002.  (Permission to use has been requested from Mayo Clinic Proceedings as of 1/31/11.)   

59 Appendix 3-A

References  AMDA – www.amda.com  • AMDA Synopsis of Federal Regulations in the Nursing Home:  Implication for  Attending Physicians and Medical Directors 2009.  Available for a fee.  • AMDA Clinical Practice Guideline:  Altered Nutritional Status.  2009.  Available for a  fee.  • AMDA Clinical Practice Guideline:  Diabetes Management in the Long‐Term Care  Setting 2008.  Available for a fee. • AMDA: The Role of the Medical Director in Person Directed Care, 2010  http://www.amda.com/governance/whitepapers/G10.cfm    ADA – www.eatright.org/HealthProfessionals  • ADA Position Paper Individualized Nutrition Approaches for Older Adults in Health  Care Communities 2010.  • ADA Position Paper Liberalization of the Diet Prescription Improves Quality of Life  for Older Adults in Long‐Term Care 2005.   • ADA Evidence Analysis Library.  ADA Unintended Weight Loss Nutrition Practice  Guideline 2009.  • Roberts, L, Cryst Suzanne C, Robinson, G, Elliott, C, Moore L C, Rybicki M, Carlson, M.  American Dietetic Association: Standards of Practice and Standards of Professional  Performance for Registered Dietitians (Competent, Proficient and Expert) in  Extended Care Settings. J Am Diet Assoc. 2011; 111:617‐624; 624.e1‐e27.  www.eatright.org/HealthProfessionals/content.aspx?id=6867    DMA – www.DMAonline.org    • DMA Position Paper The Role of the Certified Dietary Manager in Person‐Directed  Dining 2011.  Handy, Linda, Dietary Manager’s Association:”The Role of the Certified  Dietary Manager in PersonDirected Dining," DMA Magazine, April 2011, page 13.  http://www.DMAonline.org/Members/Articles/2011_04_positionPaper.pdf  • Handy, Linda, Dietary Manager’s Association: “Your Role in Ensuring Culture Change in Dining and Regulatory Compliance, DMA Magazine, June 2010, page 14. http://www.DMAonline.org/Members/Articles/2010_06_cultureChange.pdf     CMS – www.cms.gov  • Psychosocial Severity Outcome Guide, State Operations Manual, Appendix P, 2006.  • State Operations Manual for LTC Facilities Appendix PP 1/2011 update      Pioneer Network – www.pioneernetwork.net • Nurse Competencies for Nursing Home Culture Change, May 27, 2010.  Pioneer  Network/Hartford Institute for Geriatric Nursing.   60 Appendix 3-A

 

• The following papers and accompanying webinars can be accessed at  www.pioneernetwork.net >>Conferences>>Creating Home II: Food and Dining. This  National Symposium on Culture Change and the Food and Dining Requirements  were sponsored by CMS and Pioneer Network, February 2010: 

  Bump, Linda.  The Deep Seated Issue of Choice.    Leible, Karyn and Wayne, Matthew. The Role of the Physician’s Order.    Handy, Linda.  Survey Interpretation of Regulations.    Hyde, Denise.  The Role of the Pharmacist.     Remsburg, Robin.  Home‐style Dining Interventions in Nursing Homes: Implications  for Practice.     

 

 

Ronch, Judah.  Food for Thought:  The Missing Link between Dining and Positive  Outcomes.    Simmons, Sandra F., Bertrand, Rosanna M.  Enhancing the Quality of Nursing Home  Dining Assistance:  New Regulations and Practice Implications.    Bowman, Carmen.  The Food and Dining Side of the Culture Change Movement:   Identifying Barriers and Potential Solutions to furthering Innovation in Nursing  Homes Background Paper for the Feb. 2010 CHII. Report of CMS Contract HHSM‐ 500‐2009‐00057P.    • The following papers some of which address the dining environment, were written  for the Creating Home (I) Creating Home in the Nursing Home:  A National  Symposium on Culture Change and the Environment Requirements sponsored by  CMS and the Pioneer Network, April 2008:  Calkins, Margaret.  Private vs. Shared Bedrooms in Nursing Homes.     Nelson, Gaius.  Household Models for Nursing Home Environment    Brawley, Elizabeth.  Lighting: Partner in Quality Care Environments.    Cutler, Lois.  Nothing is Traditional about Environments in Traditional Nursing  Homes.    Calkins, Margaret.  Creating Home in the Nursing Home: Fantasy or Reality? 

61 Appendix 3-A

Bowman, Carmen.  The Environmental Side of the Culture Change Movement:  Identifying Barriers and Potential Solutions to furthering Innovation in Nursing  Homes.  Background Paper to the April 3rd, 2008 Creating Home in the Nursing  Home:  A National Symposium on Culture Change and the Environment  Requirements.  Report of CMS Contract HHSM‐500‐2005‐00076P.    Free Water Protocols  Panther, K. (2005). The Frazier Free Water Protocol. Perspectives on Swallowing and  Swallowing Disorders (Dysphagia), 14 (1), 4‐9.    Planetree Long Term Care Improvement Guide    http://www.planetree.org/LTC%20Improvement%20Guide%20For%20Download.pdf 

62 Appendix 3-A

The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to furthering Innovation in Nursing Homes

Pre-symposium Paper: to the February 11, 2010 Symposium Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements

January 28, 2010 Prepared by Carmen S. Bowman, MHS

This pre-symposium paper is intended to provide a context and a detailed background for the presentations and discussions at the February 11, 2010 symposium.

Appendix 3-B

Table of Contents

Introduction

2

Chapter 1

The Importance of Food and the Dining Experience to Creating Home

5

Chapter 2

Progression of the Food and Dining Side of the Culture Change Movement 9

Chapter 3

Food and Dining Research and Outcomes Realized by Pioneering Homes

16

Chapter 4

CMS – A Partner in the Culture Change Movement

20

Chapter 5

The Issues and the Regs: Food and Dining Issues and the CMS Food and Dining Regulations

22

Chapter 6

Current Survey Processes as they Pertain to Food and Dining

40

Chapter 7

Other Food and Dining Standards

43

Chapter 8

Tools and Resources

45

Chapter 9

Moving into New Territory

46

Bibliography

47

Appendix A: CMS Survey & Certification letter SC 09_39 (5/29/09) re: F371 clarification

54

Appendix B: CMS Survey & Certification letter SC 07_07 (12/21/06) re: culture change questions

56

1 Appendix 3-B

Introduction Robinson and Gallagher have stated that the future long term care “…customer, savvy and well educated, will re-formulate long term care by demanding fine dining, and concierge services, and healthy fast foods from a food court with ‘brand’ named franchises open 24 hours per day” (Robinson and Gallagher, 2008). So let’s imagine the New Nursing Home. No one wakes you up. You sleep until you naturally rouse. You decide if you want a cup of coffee, tea or your drink of choice now or later. Maybe you have a coffee pot in your room. If you live in a neighborhood or household, coffee is brewing in the kitchenette or kitchen. You drink out of your own ceramic coffee cup. There is a coffee cart available, or better yet a coffee bar that is open early and open late. When you’re ready, someone asks you what you’re hungry for. Whether you eat breakfast early, late or not at all, but are hungry for lunch a little earlier than most, open dining times make it possible to eat when you are ready. You can order room service if you don’t feel like getting up or wander down to the continental breakfast to see what’s available today. Not only are you asked what you want every meal, you are also involved in deciding the menus, even making up the grocery list. You are welcome to cook what you’re famous for. Or you contribute by setting the table and washing dishes, no one’s offer is turned away. Some of the food comes from the garden in the backyard, presenting the opportunity to eat fresh healthy foods you yourself may have tended to and harvested. In the New Nursing Home, there are home-living environments called Households with a full kitchen, living room, dining room, and, usually, all private rooms led by self-directed work teams and a Town Center where residents gather for large events, often a coffee shop and sometimes a general store. Nurses and other clinicians circulate among several colocated houses to provide needed care, where residents enjoy private rooms, a large dining room table where they can dine together and a hearth, often with a cozy fireplace. Many homes focused on providing individualized and personalized dining services are trading in the traditional tray line meal service for a variety of dining styles such as buffet, restaurant, family-style and others with increased choice and direct resident access to refrigerators and the kitchen throughout the day. These alternative dining arrangements, although common in society at large, are new to the nursing home setting and have sometimes led to difficulties with nursing home surveyor interpretation of the federal requirements as applied to these innovations. In April of 2008, the Pioneer Network and the Centers for Medicare and Medicaid Services (CMS) co-sponsored Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environment Requirements. Almost 700 people attended, experts gave presentations, and everyone was invited to give public comment. This was followed by an invitational workshop of culture change experts and stakeholders who were formed into workgroups to study and further develop the options discussed. All options regarding the nursing home environment were collected and many were acted upon. All speakers’ 2 Appendix 3-B

papers and presentations, the transcript from the entire symposium, and the background paper written for it are available at: www.pioneernetwork.net. Due to the many questions arising around food and dining, the Pioneer Network and CMS decided to co-sponsor a second symposium inviting another national dialogue to discuss them. The purpose of this paper is to provide background and context for the upcoming February 11, 2010 symposium: Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements. Welcome to the table. Bon appétit.

3 Appendix 3-B

Note to readers: In this paper, italics are used for CMS regulations and interpretive guidance. Lighting, use of color, contrasting plate and table color, music, and other environmental factors affect the dining environment. However, because the physical environment was the focus of the 2008 symposium, many issues of the physical setting for the dining environment came to light then and will not be revisited in this paper. Instead, the symposium planning team has set an agenda that focuses on some of the clinical and quality of life issues regarding food and dining. It should be stressed that, when referring to nursing home residents, we mean all residents including those with dementia. The content of this paper is applicable to all residents, and in particular each person’s right to make their own choices and to receive superb individualized care. Persons with dementia “tell” us everyday their preferences, sometimes with words, sometimes not. We must only observe and, as Naomi Feil, the founder of Validation Therapy, says “exquisitely listen” (2003).

4 Appendix 3-B

Chapter One The Importance of Food and the Dining Experience in Creating Home Food and the experience of dining happen every day, and are so important and unique to each of us. In fact, very often food and dining are spoken of, not separately, but together: “We should look for someone to eat and drink with before looking for something to eat and drink....” Epicurus “Good food ends with good talk.” Geoffrey Neighor “One cannot think well, love well, sleep well, if one has not dined well.” Virginia Woolf “Food is the most primitive form of comfort.” Sheila Graham “When I walk into my kitchen today; I am not alone. Whether we know it or not, none of us is. We bring fathers and mothers and kitchen tables, and every meal we have ever eaten. Food is never just food. It’s also a way of getting at something else; who we are, who we have been, and who we want to be.” Molly Wizenburg, from A Home Made Life “Food is the heart of the home and most often one of our life’s daily pleasures.” LaVrene Norton, from Nourish the Body and Soul Food. Dining. Eating. “What’s for dinner?” “Let’s eat.” “Let’s go out for dinner.” Favorite foods. Comfort foods. Potlucks. Cookie exchange. Out for coffee. Over for tea. “Come on over for a beer.” Grilled. Sauted. Steamed. Carmelized. Cookies baking. Soup simmering. Tea steeping. Coffee brewing. Bread baking. Dishes clinking. Setting the table. Washing the dishes. Fresh fruit. Just picked veggies. Shucking corn. Snapping peas. Appetizers. Soup and salad. Chips and dip. Bread sticks and dipping oils. The main entree. Dessert. “I’m full.” “That was sooo good.” So what should food and dining look like, even in a nursing home? “Like Mom’s chicken noodle soup, the focus on food seems to hold an answer for just about every ailment of institutionalized living.” Keith Schaeffer, from Nourish the Body and Soul “Comfort foods – those familiar foods that evoke a caring, pleasant feeling even before (emphasis added) they are tasted.” Frampton, Gilpin and Charmel, from Putting Patients First “Providing nourishment is more than just providing the right number of calories; it is taking care that the appearance, presentation, aromas, flavors, delivery and setting are optimal as well.” Ibid 5 Appendix 3-B

“We know that uneaten food provides no nourishment.” Ibid “The feeding of persons in health is of great importance, but when (one) succumbs to disease, then feeding becomes a question of extreme moment.” Fannie Farmer, from Food and Cookery for the Sick and Convalescent. “Food for the sick should be carefully prepared and attractively served at regular intervals. The person who is ill is frequently more difficult to please than when he is well. Individual tastes of the patient must be considered, as well as the suitability of foods to be served.” Gorrell, McKay and Zuill, from Food and Family Living “Let food be your medicine.” Hippocrates There may be four different causes, any one of which will produce the same result, viz., the patient slowly starving to death, from want of nutrition: 1. Defect in cooking; 2. Defect in choice of diet; 3. Defect in choice of hours for taking diet; 4. Defect of appetite in patient. “Yet all these are generally comprehended in the one sweeping assertion that the patient has 'no appetite.'” Florence Nightingale “Our goals are always two: increase our residents’ intake and increase quality of life through celebrations around food.” Linda Bump, from Nourish the Body and Soul Food is the Heart of Home Linda Bump, a leader in the culture change movement, dietitian, and licensed nursing home administrator has written one of the only books on changing the culture of dining. It is called Life Happens in the Kitchen…How to make the kitchen the heart of your home. She says: Food is the heart of our home…and most often one of our life’s daily pleasures. When we enhance the dining experience of our elders, we nourish their souls, as well as their bodies. As caregivers committed to maximizing the quality of life and quality of care for the elders residing in our long term care facilities, we are called to best serve our elders’ nutritional needs while best serving their psychological and psychosocial needs. When we honor our elders’ preferences in dining, we honor their past and best serve their future (Bump, 2004-2005). Bump says so much here - home and daily pleasure, nutritional and psychological and psychosocial needs, quality of life and quality of care. All of that is precisely our focus for this paper, as well as Creating Home II. Moving away from institution and toward home. Using food to nourish both body and soul. Using food to honor past and serve future. Food is one of the main mediums to reflect and build upon our past, and as psychologist Dr. 6 Appendix 3-B

Judah Ronch teaches: when our choices and preferences are not honored we have no “future self” (2009). Nothing to look forward to, nothing to decide, nothing to affect in our lives. And lastly the time has come to stop viewing quality of life and quality of care as separate. The Institute of Medicine study and precursor to OBRA ’87 said the same thing in different words in 1986: For the very sick and disabled, the quality of the care and the way it is provided are probably the most significant contributors to well-being…..Many aspects of nursing home life that affect a resident’s perceptions of quality of life – and therefore, sense of well-being – are intimately intertwined with quality of care (Improving the Quality of Care in Nursing Homes, 1986). Pioneer and culture change leader Linda Bump encourages “excellence in individualization” and says in order to do that we must provide: Choice – the choice of what to eat, when to eat, where to eat, who to eat with, and how leisurely to eat. True choice, not token choice. Choice of beverages, breads, desserts. Choice of service style, whether waited, self-selected, buffet or family style. Accessibility – foods of choice available when hungry, or when just longing for a specific food. Food available 24 hours a day/7days a week, and someone available 24/7 to help prepare it. Refrigerator rights, perhaps even a refrigerator in their own room, and perhaps a microwave too! Individualization – the elder’s favorite foods, comfort foods, ethnic foods, foods prepared from their own favorite recipes, foods they choose to eat in their own home, foods that make them look forward to the day, foods that warm their heart and soul, as well as nourish their bodies. Liberalized diets – The elder’s right to choice in following a restrictive diet. Food First – An expectation of OBRA since 1987, choosing food before supplements, and food before medication is a natural decision in culture change. With choice, accessibility and individualization, our residents eat foods of choice throughout the day, and even during the night if need be, eliminating the need for costly, and often refused, commercial supplements. Similarly, the need for laxatives is reduced and often eliminated with increased fluid intake and increased opportunities for fiberrich, bowel-stimulating foods of choice. Even the need for medication for behavioral management can be reduced when foods of choice are available at times of choice and places of choice.

7 Appendix 3-B

Quality Service - Relationships are the key to quality care giving, and relationships are the key to quality service in dining. Knowing the elder, their choices, their preferences, and their daily pleasures in dining, results in service that encourages optimal intake. Relationship-based service is caregiving from the heart. Knowing what an elder ate, knowing what they need to eat, knowing what to tempt them with, all can make the difference between joy in dining and failure to thrive. Responsiveness - Relationship-based service, refrigerator rights, 24/7 accessibility…the common theme is responsiveness, and just the right amount of attention – not hovering, just quiet attention to every need (2004-2005).

Quiet attention. Responsiveness. Quality of care and quality of life together. Individualized care. “Excellence in individualization.” Good food. A warm and inviting dining experience. All contribute to a person’s well-being.

8 Appendix 3-B

Chapter Two Progression of the Food and Dining Side of the Culture Change Movement Moving from Traditional to Transformational Transformation begins when there is an awareness of the need for change and residentcentered care, consistent staff, engaging direct care givers and residents in decisions and increasing choices at meal times. In the Nourish the Body and Soul DVD, Linda Bump advises us to “Think about the opportunities to have the coffee pot on all day, smell fresh cookies baking and enjoy a warm treat in the evenings. Even if we can’t cook the hot food there, we can start simple hosting, offering choice of beverage, choice of white or wheat bread, a simple salad bar cart with just a few choices or a dessert cart” (2008). It can all start with toast: Transformational design can be as simple as - we brought our toasters to the table. We actually physically set the toasters in the middle of the dining room. When the core team met, they said, “We always cook it in the kitchen, stack it up, bring it out and by the time it gets to the dining room its cold and hard. And that’s just the way we’ve always done it. Now a resident asks for a piece of toast, we put the bread in, butter it and we give it to them right there. Now, it was just an experiment and the whole building was talking about it for days afterwards, over toast. It was probably the very best thing we did, to start with that because everybody got excited about all the other things we could do.” (Nourish the Body and Soul DVD, 2008) Thus, it is within the transformational model where steam tables, open dining times, buffet style, waited table service and family style start to become possible. Early Pioneers do Dining Differently Sister Pauline Brecanier is considered a pioneer in the culture change movement, leading transformation at Teresian House in Albany, New York as administrator since 1970. Sister Pauline’s pioneering spirit began before then however. She tells of when she was at St. Joseph’s nursing home in Connecticut in the 1960’s and sent two men to Culinary Arts school - two brothers, who came back to serve residents as chefs. She explains that in order to provide good cooked food for the residents, Mother Bernadette, Teresian’s administrator from 1964 to 1970, always had a chef and “never apologized for the cost of food as food was the most important part of a resident’s day.” She advises you’re “going to pay a little bit more [for a chef] but you’re going to get better quality. Pre-prepared foods, anyone can put those together.” In her matter of fact way, she says, “we’ve always had a chef” (2009). At Teresian House there is a cocktail lounge that serves drinks and food with hours of operation and a menu. What is most striking about it, as Sister Pauline explained, is it gives residents the opportunity to “treat their guests,” something most nursing home residents no longer have. 9 Appendix 3-B

Planetree is a patient-centered model of care begun in hospitals by Angelica Thieriot. Planetree affiliates focus on providing comfort foods, creating kitchens in patient care areas for families to prepare their relative’s favorite foods, and never turning down a request for food any time day or night (Frampton et al, 2003). The first nursing home to adopt the Planetree model was Wesley Village in Shelton, Connecticut under the leadership of Heidi Gil. One of the Planetree Continuing Care Components is Recognizing the Nutritional and Nurturing Aspects of Food (Frampton and Charmel, 2009). Restaurant Style Dining As reported in the book Person Centered Care: A Model for Nursing Homes, Eric Haider, as administrator of a nursing home in Kansas in1989, implemented a restaurant style dining service with waiters taking orders from a menu and longer/open dining times. He realized, looking at a restaurant one day, that a nursing home has everything a restaurant has – food, a kitchen and a dining room. In 1992 at Crestview nursing home in Missouri he added buffet style dining, and by 1995 food was available upon request 24 hours a day (2003). Although nursing homes have food, kitchens, and dining rooms just like a restaurant, restaurants are able to offer a large menu, instead of only one or two choices typical of traditional nursing homes. Restaurants are able to serve each customer what that person wants from their menu, at the time the customer arrives. This has functioned “backwards” in the nursing home where traditionally the “customers” are made to be ready when the food is ready. Buffet Style Dining Although it began as a research study by Robin Remsburg and others, due to its success buffet-style meal service was adopted by Johns Hopkins Geriatric Center in Baltimore for all meals (2001). Dr. Remsburg reports that buffet style dining advantages include the opportunity to bring tantalizing smells into the dining room to increase resident’s appetites, and staff doesn’t get “overtaxed” when there are typically just two main items and several side dishes (Roloff, 2006). And who doesn’t like getting to pick exactly what they want? Neighborhood Dining From the Norton/Grant Stage Model, Stage III is the Neighborhood. Here is where self-led interdepartmental teams start to make greater changes to dining practices. Dining becomes decentralized, residents eat in smaller dining rooms on their neighborhoods, are supported to sleep until they wake and eat when they want. Med pass, housekeeping and activity schedules all must change, therefore it must be done as Bump says, “in team.” The need for kitchenettes and even full kitchens with shared decentralized production kitchens placed between two neighborhoods begins to be realized (Bump, 2008). In 1991 Teresian House remodeled into smaller neighborhoods of 40 residents from 60 (Ronch and Weiner, 2003). Each neighborhood has its own country kitchen and pantry. 10 Appendix 3-B

Meals are made in the main kitchen and brought to the steam tables in the neighborhood, bringing the point of service closer to the residents. A new staff position of neighborhood coordinator was developed to administer these small settings within the larger nursing home. Neighborhood coordinators were chosen for their leadership skills, and applicants were not restricted to nurses. Interestingly enough, Providence Mount St. Vincent also began its journey of neighborhoods with food served from steam tables in each neighborhood’s kitchen in 1991, after hiring Charlene Boyd as administrator in 1990. Charlene brought experience from the Mary Conrad Center in Anchorage, Alaska where she had been administrator from 1986- 1990. At Mary Conrad Center, the “neighborhood concept” gave residents access to a kitchen and snacks at all times (Ronch and Weiner, 2003). Family Style Dining Another familiar dining style being implemented is family style, which affords one the opportunity to serve themselves what they want and as much as they want just like at the table at home. “From bowls and baskets on their table, residents are able to serve themselves as much as they want of the foods they enjoy and none of the foods they dislike” (Roloff, 2006). Apple Health Care, a small for-profit nursing home chain, implemented family style dining in 1997 beginning at Watrous Nursing Center in Madison, Connecticut under the leadership of dietitian Karen Morton. Sue Misiorski, former Apple nurse consultant shares that “family style dining was very successful. Food temperatures were great because the food came straight from the kitchen to the table and was served immediately. Plate waste decreased dramatically because residents took what they want. They also took lots of smaller first portions and then second helpings of things they particularly liked” (Misiorski, personal communication, 2009). Choice Menus, Full Service Restaurant and Room Service The Providence Benedictine Nursing Center in Marion County, Oregon underwent major dining transformations in the autumn of 2009 because of low resident satisfaction scores, an overly clinical atmosphere, and an outdated dining environment. Choice Menus are offered within the long-term care units, with staff assisting residents in choosing what they want to order for the following day. Room Service with 19 meal options and 12 sides is offered on the skilled unit, where there are phones in each room. A grant and donations helped the facility to acquire the computerized menu system, which tracks preferences and allergies for each resident. Whereas most residents used to eat on their units making the main dining room underutilized, the full-service, updated restaurant is now filled to capacity, residents encourage and help each other get to the restaurant, and many are “dressing for dinner.” Through all three options residents are now “self-directing their lives” (Havens, 2009).

11 Appendix 3-B

Household Dining From the Stage Model, Stage IV is the Household Model, and also includes the Green Houses®, small houses, and the Scandinavian Service Houses. Home has been established again, living in houses with self-contained fully functioning kitchens, cross-trained staff reporting into the house and not to departments. Elders run their lives, get up when they want, eat what and when they want, choose snacks, have friends over for dinner or coffee, and plan their lives (Nourish the Body and Soul, 2008). In some households there is a new staff role, homemaker, responsible for cooking meals and other homemaking duties. Many households designate a food budget for the household for true resident choice. On a weekly basis, residents make their grocery list. They decide what kind of ice cream they would like or cereal - Captain Crunch anyone? LaVrene Norton, Executive Leader of Action Pact, often speaks of residents’ “refrigerator rights.” When one lives where there is a kitchen, they have the same “refrigerator rights” as any one of us has in our own home. That right to open up the fridge and ponder, “Hmm, what do I want to eat….” We might as well take it one step further and call them “kitchen rights.” This is something the Household Model affords. It also affords limitless opportunities for hosting. Residents have hosted others in their homes all their lives, the household/house also makes this possible again. According to Linda Bump, “The systems that have held us back in the other stages are now transformed, and the entire household team can focus on resident preferences, their rhythm of the day and their choices” (2008). Homes that have not progressed to the Household Model yet have, nonetheless, come up with various ways of honoring “refrigerator rights” such as pantries, snack and beverage bars, coffee bars, the “general store” where residents can choose food items without paying extra, ice cream parlors and loaded snack carts taken to resident living areas. Eden Alternative® and Green House Project® The Eden Alternative® was born in the mid 1990’s with the idea that is it better to live in a garden than an institution. The theme of the garden describes the Eden Alternative® in many ways. Eden has helped remind us that residents should flourish and thrive in their home. In addition, staff members, or “care partners” as Eden refers to them, also deserve to grow as individuals. As Nancy Fox, first Executive Director of the Eden Alternative says, “we’ve been managing for the worst in people instead of for the best” (2007). Dr. Bill Thomas, founder with his wife Jude of the Eden Alternative®, was one of the first to talk about giving back to residents the opportunity to till the garden and enjoy the bounty of fresh foods from it. After ten years of the Eden Alternative’s existence, Dr. Thomas decided it was taking too long to transform nursing homes. He preaches that nursing homes shouldn’t be changed, they should be abolished - calling himself a nursing home abolitionist (Baker, 2007). This led to the next level of creating home he called the Green House. Green House® communities have Culinary Arts, not dietary departments. In fact, the root word “diet” of Dietary has a negative connotation for most, and is treated by many as a four letter word. 12 Appendix 3-B

All the more reason to move away from the medical model and offer dining and culinary services instead (McKorkell Worth, 2009). Ten to twelve elders live in a Green House® and lead their lives in a home where they can access the kitchen, dine together at the dining table, and enjoy “convivium.” Convivium Dr. Bill Thomas has resurrected the concept of “convivium,” an old Roman word that describes the pleasure that accompanies the sharing of good food with people we know well. Instead of fast food, instant food or, for instance, soup from large cans warmed up as in most institutional nursing homes, soup is made from scratch and cooked slowly. It simmers on the stovetop all day for all to experience, from the preparation if they so choose, to the aromas, to enjoying it for the evening meal. Dr. Thomas says this about food: At its best food nourishes us – body and soul. A meal can embody powerful symbols of love and acceptance. The bond between comfort and food, which begins at the breast, is fortified throughout childhood and gains renewed strength in the late decades of life. Properly prepared, the meals we cook and serve to our elders should be drenched in memory, ritual and culture. … Fresh, local ingredients prepared according to authentic regional recipes are served to people eager to share. They use smell, taste and texture as a springboard to good conversation and vital relationships (2008). Staff Dining with Residents – Convivium and Building Relationships Staff dining with residents is a culture change practice that has been implemented to build relationships between staff and residents. It opens up the opportunity for friendships to form and grow between those living in a nursing home and those caring for them. Of course, residents still need to receive any assistance they need, and good infection control needs to be practiced, and staff should interact with residents and not only with each other. Dining Together Equalizes Everyone “The extra socialization and encouragement, plus ready offers to get an alternate or to pour an extra cup of coffee makes all the difference between institutional food service and enhancing the residents dining experience” (Bump, 2004-2005). An example of “socialization in action” comes to mind. Beth Irtz, then the administrator of Clear Creek Care Center in Colorado and now Quality of Life Lead for Sava Senior Care Colorado region and President of the Colorado Culture Change Coalition, implemented a Wednesday Buffet where staff were invited to eat (free of charge) with residents. The buzz of conversation was almost deafening and thrilling to see and hear. When people dine together, they are just people, no longer separated as “residents and staff.” All people eat. Dining together serves as a well known experience that “equalizes everyone” a practice which serves to soften the “us-versus-them” atmosphere that may occur in institutional living (Krugh and Bowman, 2009). 13 Appendix 3-B

What Residents Really Hunger For Richard Taylor, retired psychologist and outspoken person diagnosed with dementia, was interviewed as part of a “Leaders in Eldercare” series. He said these powerful words about dining based on an experience of his own in an institution: The staff would come in, and they were cheery-deary and loveable and wellintended human beings who really loved what they did, and they’d come in and start everybody eating, and then they would leave, and everybody would just sit there silently, eating. Not saying anything, not talking to each other. Eating wasn’t an activity, it was barely an event. It was just something that they came and got me at five o’clock to do. And so I started talking to people. Now, it took me five minutes to get about half the room talking. It’s not that I got everybody to talk or everybody wanted to talk or even could talk, but people who hadn’t talked in a long time started to talk because I took the time to sit and listen to them. And I don’t know if they were telling me the truth or not. They were telling me their version of it. And I found them to be very interesting and bright people (InsideElderCare.com, 2009). The staff of one nursing home reported, after deciding to dine with residents, that residents didn’t eat. That sounds bad at first, but it turns out the residents just wanted to talk. Residents now “fight over” which staff members they want to eat with them. They’re showing they are hungry for companionship. Culture change leader and administrator of Rowan Community in Denver, Colorado, Maxine Roby eats with her residents every day, moving from table to table. Maxine often jokingly says, “I know what’s going on in my building” - an added bonus perhaps. Psychologist Dr. Susan Wehry on Part II of the CMS From Institutionalized to Individualized Care DVD series, relays the power of dining together in a story about a resident that staff were worried about. Staff identified signs of depression including not eating, although the resident, Helen, had always seemed to enjoy meals. Helen had Alzheimer’s disease and agnosia, meaning she didn't know what to do with her meal. When Dr. Wehry put Helen’s fork in her hand, pointed to her potatoes and said, "This looks good- do you want to try some?” Helen would smile, nod her head yes, but take no action. “When I demonstrated what I wanted her to do, she mimed me very well. She wanted to eat. She had the physical capability to eat. My intervention was then to have lunch with her. I asked staff to bring me a tray. I would say, "That looks good," take a bite, and she would do the same. She ate the whole meal independently by watching to see what I would do next. I suggested to the CNA that she do the same” (2007). Probably every staff member in a nursing home has been asked by a resident somewhere along the way to “Sit and eat with me.” Yet staff members admit they have been programmed to reply with something like “Oh no, I can’t” even though they say they would love to. In a nursing home in Colorado after discussing this, the administrator said, “I’m 14 Appendix 3-B

embarrassed to say this, but I was invited by residents to eat with them the other day, and I went and asked the dining supervisor if I could, and I still didn’t eat with my residents.” That is a bold and brave administrator to admit what to him was embarrassing. Culture change pioneer Eric Haider has said over the years that the culture change movement could be called the common sense movement. Dr. Thomas and his focus on convivium and experiences such as these are making the case that dining together makes good common sense. Staff Members Get to Know Residents’ Preferences On Part II of the CMS From Institutional to Individualized Care series, staff from featured home Salmon Family Services of Westborough and Northbridge, Massachusetts reported that residents eat better when staff look residents in the eye to connect and get a response directly from them. “One of the big things in my opinion is the Dietary staff. The people who were always on the serving line, always making up trays, now get into the dining room and actually meet people. Some of them don’t speak English very well. It’s amazing that they can communicate. They figure out exactly what the residents want, and they have come to know the resident” said Mike Salmon, Food Service Director (2007). Many homes have experimented with all sorts of ways to serve residents with great results. At Littleton Manor in Littleton, Colorado, department managers have taken turns serving residents at mealtimes since 2003. The former director of nursing always remarked that when it came time for quarterly re-assessment, she knew firsthand what each resident ate or didn’t eat. Brookside Inn in Castle Rock, Colorado, had all department managers become trained dining assistants. They rotate serving as the dining room host or hostess, and are available to assist residents to eat if needed. Many homes have brought the kitchen staff out of the kitchen, with many stories of relationships forming and staff members realizing things like, “Why would we serve that to Mary? She doesn’t like it; never has.” Other Welcomed Dining Practices As part of a dignified dining experience, forward-thinking pioneers questioned, and then simply stopped using bibs, serving food on trays, and got rid of what used to be called “feeder tables” - tables designed in a horseshoe shape in order to feed four residents at a time. What is also becoming a former long term care practice is referring to those needing assistance or to be fed as “feeders.” Harm was not meant by these ideas, but they have contributed to putting the task, and the goal of efficiency before the person. Many have replaced the language “feed,” “fed,” and “feeder” with “dining,” “dine,” “assist with dining,” and even more personal, some encourage the normal practice of using the person’s name instead of any sort of label. Lastly, some homes have had fun shopping with residents for real glassware and real coffee cups, no longer serving coffee in plastic mugs. Plate, glass and silverware that came from places like Pier 1 Imports and other dinnerware stores fits what Rose Marie Fagan, founding executive director of the Pioneer Network, teaches wherever she goes that the goal of the culture change movement is “rampant normalcy.” 15 Appendix 3-B

Chapter Three Food and Dining Research and Outcomes Realized by Pioneering Homes According to a 2005 American Dietetic Association Report of the Task Force on Aging, as many as 65% of long term care residents experience unintended weight loss and undernutrition, and there is concern that the incidence of malnutrition is underreported. Many causes of weight loss may be amenable to intervention. Formal research studies and anecdotal evidence coming from homes focusing on individualizing food and dining services show some promising results. In a Scandinavian study, food was served family style, and residents helped themselves. Residents experienced a 25% increase in protein and energy intake (Elmstahl et al, 1987). In a study of thirty Veteran’s Administration homes where choice was increased, dining environment improved and restricted diets liberalized, 50% of the residents gained weight (Abassi and Rudman, 1994). One family-style dining study that also focused on staff giving encouragement and praise to persons with dementia resulted in higher participation in eating and even improvement in appropriate communication (Altus et al, 2002). A family style dining study including persons without cognitive impairment resulted in improvements in quality of life measures, fine motor functioning and body weight (Nijs et al, 2006). A study done in Canada found that “bulk” or steam table/buffet food service and a homelike dining environment optimized energy intake in individuals at high risk for malnutrition, particularly those with low body mass index and cognitive impairment (Desai et al, 2007). Rolling Fields of Conneautville, Pennsylvania, an Eden registered home and winner of the OPTIMA Long Term Living 2009 Award, offers 24 hour dining. Residents can choose food they want to eat around the clock. As a result, pressure ulcers have healed, many residents at risk for weight loss have gained weight, supplements have decreased and even pain and behavioral issues have improved. Staff attributes this to being able to serve actual meals [rather than minimal snacks] for those who are awake and hungry, especially at night. Additionally, resident satisfaction has improved, care plan meetings and Resident Council meetings no longer revolve around food issues but instead are filled with compliments. During the last State surveys, not only were there no resident complaints about food, there were instead “many glowing reviews about the food service not only from our Elders but also from the state surveyors, who ordered lunch each day of the survey” (Ltlmagazine.com, 2009). After being reminded personally of the feelings that foods like soup and bread evoke for him, Franco Diamond, administrator of Idylwood Care Center in Sunnyvale, California, embarked on a journey focusing on foods and their aromas. A Soup of the Day contest led his whole community into forty-plus food activities and events. Schaeffer writes, “Anyone could participate in that experience by merely inhaling, and letting memories arise with the aroma. For people with advanced dementia, food may be the last thing they lose interest in” (2008). One resident, Mrs. C, was not “so easily enticed,” still complained about the 16 Appendix 3-B

“lousy” food, and her eating habits declined. Staff decided to use food as an ice-breaker when they discovered her love for cooking Italian food with fava beans. Caregivers planted some, but because they “didn’t know beans” about fava beans, they got her to show them how to pick, shell and cook the gourmet bean which ultimately led to Mrs. C leading a cooking class. Not only did she flourish socially, but nutritionally as well. “Mrs. C’s magical transformation confirmed for Diamond that residents would become involved if offered familiar and meaningful activities. It also fed staff’s gastronomical approach to culture change: If Mrs. C could change so dramatically, maybe they should put more stock into how meals were presented and the ingredients in them” (Schaeffer, 2009). Perhaps Ildylwood’s experience makes the case for care planning “familiar and meaningful food and aromas” for each resident. Dietitian Sharon Leppert makes a great case for creating “a social atmosphere and culture for resident dining” that is participatory with choice and independence as well as socially rich “as a treatment modality” (2007). Although the term “treatment modality” sounds a bit medical, Leppert is onto something. She invites us to consider how the dining atmosphere contributes or takes away from an individual’s health by asking: When residents are given the opportunity to express preferences on food selection and portion size at the time of service, are they not also provided with an opportunity to contribute to their sense of self-esteem by exercising control over their environment in a small yet positive way? Adequate energy intake to prevent weight loss is an important factor in managing the health risk in populations with advancing age, but the value of food may impact more than nutrition when mealtime contributes to social interaction, self-esteem, and enjoyment for the aging individual (2007).

After Initial Increases, Budget Neutrality and Cost Savings Linda Bump explains that initial food costs may increase with new enhancements, but as staff learn resident preferences and plan for them, those costs “reestablish within budget” (2004-2005). Eric Haider similarly says that staff learn what residents prefer and how much of each item to prepare, minimizing waste. He attributed a savings of $20,000 per year to this process (Rantz and Flesner, 2004). This is also the experience of the facility identified in Linda Handy’s book Surveyor M.O. for Nutritional Care (F325) that there are “budget increases at first until you figure out who is going where,” “less prep,” residents “usually eat what they take which means we are not feeding the garbage can as much as we used to” and budget is now “actually more efficient and more effective” (2009). Also by avoiding the pre-plating of food, unused food may be used as leftovers following guidelines at Tag 371 or even as “planned overs,” both of which reduce costs according to Linda Bump (2004-2005). There may be initial costs for a steam table and other equipment as it is added, but there can be a coinciding decrease in main kitchen equipment replacement and repair according to Bump. She also teaches that labor costs can be held budget-neutral following the initial 17 Appendix 3-B

confusion of transitioning to new serving styles. She encourages teams to be creative, to tap underutilized staff minutes and to “take the plunge many homes have without increasing staff” (2004-2005).

Real Food instead of Commercial Supplements Margie Haider, director of nursing at Crestview in 2001, espoused that by giving people foods they like to eat, you can minimize the use of supplements. Margie and Eric shared that Crestview saved $1,164.00 per month by serving real foods residents wanted to eat . In Person Centered Care it is recorded that supplements went from 72 in 1998 to only 14 by July 2000 (2004). Bump explains that having foods of choice available 24/7 virtually eliminates the need for supplements. She adds, “There are not many residents who will choose a canned commercial supplement over real food or personal preference.” Bump points out that snack and “hydration” carts can also be eliminated with the addition of pantries and snack bars (2004-2005). Eliminating carts is also what many homes have done to lessen the institutional feel and to create home. In his article on malnutrition in the older individual, Webster states that “Oral supplements are also not very beneficial and often go wasted or conflict with medications” (2008). Oral liquid nutrition supplements have been shown to be only moderately successful in increasing energy intake, which has also been shown to be related to the limited time staff can devote to getting the supplements delivered and giving verbal encouragement to consume them (Schlettwein-Gsell, 1992). Webster says that, “Improving taste is one of the best and simplest ways of improving nutrition” (2008). The “elderly have the same taste preferences as they have had all of their life, and thus low sodium, low fat meals are not always as appetizing as the normal version of a food with naturally high fat and sodium content” (Calverley, 2007).

Real Foods, Less Meds and Cost Savings When nutrients are offered in the form of yummy foods, medication usage will decline especially for laxatives, appetite stimulants and even multivitamins. Neighborhood and household kitchens virtually eliminate laxatives, using food instead to support normal bowel function (Bump, 2004-2005). Charlene Boyd of Providence Mount St. Vincent reports that “the number of special diets is reduced to a few, as homes learn it is more important for elders to eat appetizing food than to have meals medicalized into inedible ordeals,” leading to less food waste and reduced use of dietary supplements, all while residents gain weight (Baker, 2007).

18 Appendix 3-B

Common Sense Ideas and Results Debi Majo the director of nursing at the Northwood Health Care Center in Marble Falls, Texas shared some common sense ideas that more homes are trying in Part III of the CMS From Insitutional to Individualized Care series: We work diligently on reducing sugar in all of our menus because in reality, no one needs a lot of sugar in their diet. We sweeten our cakes with applesauce and sometimes add carrot juice or even prune puree to chocolate cupcake batter instead of sugar. So our reduced concentrated sweet diet is actually closer to sugar free. For all diets we do not add salt to any item that we cook. Some of the ‘pre-made’ breads contain salt so we call our reduced sodium diet ‘no added salt’ and I can tell you that corn bread tastes a little flat without salt, but you get used to it. And mechanically altered diets, these are just regular food that has been blended in the blender or hand chopped (2007).

19 Appendix 3-B

Chapter Four CMS – A Partner in the Culture Change Movement The brochure for the upcoming Creating Home in the Nursing Home II Symposium, cosponsored by CMS and the Pioneer Network states: “CMS has become a partner in the culture change movement, and wishes to encourage meaningful changes in food and dining service that provide greater quality of life for residents”. CMS has a history of support for culture change. In 2002, CMS developed a satellite webcast for state survey agencies called “Innovations in Quality of Life: The Pioneer Network”. Surveyors were exposed to background information on culture change, its positive outcomes, and how facilities can make culture changes and remain compliant with nursing home regulations. Culture change became the basis fora pilot project that included twenty-one states during the 8th Scope of Work for the CMS Quality Improvement Organizations (QIOs) between August 2004 and October 2005. CMS also took part in the St. Louis Accord in 2005. This was a gathering of long term care stakeholders interested in culture change. The more than 400 participants included ombudsmen, advocate groups, regulators, providers, state and national trade associations, culture change experts, and QIO representatives. All 50 States were represented and State teams created action plans to promote transformation of institutional culture in their respective States (www.qualitypartnersriqio.org/cfmodules/objmgr.cfm accessed 1-1110). In April 2006, CMS let a contract for development of the “Artifacts of Culture Change” measurement tool. The tool is designed to capture tangible evidence of changes that come from a changed culture and includes several dining items under the domain of Care Practices. In 2009 the Pioneer Network developed a data base that automates the completion of the tool. The site, which is in the test stage at this writing, will enable a nursing home to fill out the Artifacts tool and receive a report comparing them to others in the data base. In December of 2006, CMS issued a Survey and Certification letter with answers to culture change questions from the culture change community which is available at http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCletter07-07.pdf. For convenience, the letter is also included in Appendix B. In April of 2008 CMS and the Pioneer Network co-sponsored Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environment. Subsequent to the symposium, the Hulda B. and Maurice L. Rothschild Foundation funded the Pioneer Network to convene the National Long Term Care Life Safety Task Force. The Task Force was composed of volunteer architectural and Life Safety Code experts. They submitted five proposals to the National Fire Protection Association regarding the Life Safety Code® in August of 2009 for the 2012 Edition. CMS issued new interpretive guidance effective 20 Appendix 3-B

July 12, 2009 for ten regulations regarding the environment and quality of life, directly stemming from the symposium discussions. CMS funded the writing of the background paper for the first symposium, as well as this background paper in preparation for the second symposium. In addition, the 2009 version of the CMS “Guide to Choosing a Nursing Home,” contains a section describing culture change and person-directed practices for the first time. The Pioneer Network has asked AHFSA – the Association of Health Facility Survey Agencies – and AHFSA in turn has invited each State survey agency, to name a culture change contact person within their survey agency. In addition, the leadership of AHFSA has created an Individualized Care Committee, essentially its own culture change committee.

21 Appendix 3-B

Chapter Five

Food and Dining Issues and the CMS Food and Dining Regulations CMS has identified many culture change practices regarding food and dining in newer interpretive guidance. However, the issues surrounding new and innovative ways of serving food in the nursing home are not always completely addressed. 483.35(i) F325 Nutrition Based on a resident’s comprehensive assessment, the facility must ensure that a resident – 483.35(i)(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 483.35(i)(2) Receives a therapeutic diet when there is a nutritional problem. Receives a Therapeutic Diet Therapeutic diet refers to two kinds of diets: restricted diets (such as no concentrated sweets and low or no salt) and altered texture diets (such as mechanical soft or pureed). As might be expected, residents would often prefer not to follow a restricted diet. Residents on a modified texture diet would also sometimes prefer a regular diet, which might put them at risk for choking. The Intent statement in the interpretive guidance for this requirement currently states that care and services be consistent with the resident’s comprehensive assessment and that the therapeutic diet takes into account the resident’s clinical condition and preferences. The resident’s personal wishes are acknowledged with the following: Goals and prognosis refer to a resident’s projected personal and clinical outcomes. These are influenced by the resident’s preferences (e.g., willingness to participate in weight management interventions or desire for nutritional support at end-of-life)…. Tag F325 Nutrition guidance identifies that a person has dislikes, preferences and preferred portion sizes. Resident Goals CMS Interpretive Guidance also identifies that resident goals and resident specific interventions should be care planned. The culture change community has begun “I-format” care planning which redirects staff to the person. I-format care planning is the resident’s care plan in their own voice such as “I have diabetes and my goal is for my blood sugars to be stable.” Approaches are also in the voice of the person stating to care givers what works best for them. Providers who have committed to I-format care planning state that it is “powerful” and helps staff see the resident as a person.

22 Appendix 3-B

Resident Choice The Interpretive Guidance includes a section on Resident Choice at F325 Nutrition. It states the following: The resident or resident representative has the right to make informed choices about accepting or declining care and treatment. The facility can help the resident exercise those rights effectively by discussion with the resident (or the resident’s representative) the resident’s condition, treatment options (including related risks and benefits, and expected outcomes), personal preferences, and any potential consequences of accepting or refusing treatment. If the resident declines specific interventions, the facility must address the resident’s concerns and offer relevant alternatives. This section evidences real recognition of the right to informed choice, about the fact that one may decline care and treatment, and that the facility can even help the resident exercise those rights. The Resident Choice section of Tag F325 follows: The facility’s care reflects a resident’s choices, either as offered by the resident directly or via a valid advance directive, or based on a decision based on a resident’s surrogate or representative in accordance with state law. The presence of care instructions, such as an advance directive declining some interventions does not necessarily imply that other support and care was declined or is not pertinent. When preferences are not specified beforehand, decisions related to the possible provision of supplemental or artificial nutrition should be made in conjunction with the resident or resident’s representative in accordance with State law, taking into account relevant considerations such as condition, prognosis, and a resident’s known values and choices. Diet Liberalization The CMS Interpretive Guidance contains a section at F325 Nutrition on Diet Liberalization: Research suggests that a liberalized diet can enhance the quality of life and nutritional status of older adults in long-term care facilities. Thus, it is often beneficial to minimize restrictions, consistent with a resident’s condition, prognosis and choices before using supplementation. It may also be helpful to provide the residents their food preferences, before using supplementation. This pertains to newly developed meal plans as well as to the review of existing diets. Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically altered diets may help in select situations. At other times, they may impair adequate nutrition and lead to further decline in nutritional status, especially in already undernourished or at-risk individuals. When a resident is not eating well or is losing weight, the interdisciplinary team may temporarily abate dietary restrictions and liberalize the diet to improve the resident’s food intake to try to stabilize their weight. Sometimes, a resident or 23 Appendix 3-B

resident’s representative decides to decline medically relevant dietary restrictions. In such circumstances, the resident, facility and practitioner collaborate to identify pertinent alternatives. Diet Liberalization – A New Standard of Practice The American Dietetic Association (ADA) in 2002 released a position paper on diet liberalization called “Liberalized Diets for Older Adults in Long-term Care.” In it, the ADA stated, “It is the position of the ADA that the quality of life and the nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet.” The paper further states that nutrition in long term care settings must meet two goals: maintenance of health through medical care and maintenance of quality of life. The ADA has gone beyond just looking at quality of care to consider quality of life as well: “To meet the needs of every resident, dietetic professionals must consider each person holistically, including personal goals, overall prognoses, benefits and risks of treatment, and perhaps most important, quality of life” (2002). CMS Supports Culture Change The following is excerted from the Environmental Factors section of the F325 guidelines: Appetite is often enhanced by the appealing aroma, flavor, form and appearance of food. Resident-specific facility practices that may help improve intake include providing a pleasant dining experience (e.g., flexible dining environments, styles and schedules), providing meals that are palatable, attractive and nutritious (e.g., prepare food with seasonings, serve food at proper temperatures, etc.), and making sure that the environment where residents eat (e.g., dining room and/or resident’s room) is conducive to dining. Flexible dining environments, styles and schedules help to improve dietary intake. Research shows that socializing with others improves appetite (Simmons et al 2001, Simmons and Schnelle, 2004). It is accepted that certain aromas such as chocolate improve appetite. Music, lighting, ambiance, basically a pleasant dining experience improves everything. Real Food over Supplements CMS guidance states that most people prefer real food to supplements: With any nutrition program, improving intake via wholesome foods is generally preferable to adding nutritional supplements. Avoidable and Unavoidable A definition of “unavoidable” in regards to nutrition is provided at F325: 24 Appendix 3-B

“Unavoidable” means that the resident did not maintain acceptable parameters of nutritional status even though the facility had evaluated the resident’s clinical condition and nutritional risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Thus, weight loss is not automatically considered a deficiency. Surveyors will investigate whether it was avoidable in light of poor care practice or unavoidable in light of good care practices. Only the avoidable weight loss will become a deficiency. When investigating whether any sort of nutritional decline was unavoidable, the guidance advises that the resident’s needs and goals be taken into account, as well as considering recognized standards of practice. That is part of providing good care, and is now a part of the guidance for Tag F242 Self-determination and Participation. Investigative Protocol Review of Facility Practices, If the interventions defined, or the care provided, appear to be inconsistent with recognized standards of practice, interview one or more health care practitioners as necessary (e.g., physician, hospice nurse, dietitian, charge nurse, director of nursing or medical director). The CMS guidance supports person-centered, self-directed living ideas by stating under Observations in the Investigative Protocol for Tag F325 Nutrition: During observations, surveyors may see non-traditional or alternate approaches to dining services such as buffet, restaurant style of or family style dining. These alternate dining approaches may include more choices in meal options, preparations, dining areas and meal times. Such alternate dining approaches are acceptable and encouraged. Heavy Hitters CMS has made a strong statement regarding the importance of resident choice and preferences at F325 Deficiency Categorization: The first instance is an example of Severity Level 4 - Immediate Jeopardy: Substantial and ongoing decline in food intake resulting in significant unplanned weight loss due to dietary restrictions or downgraded diet textures (e.g., mechanic soft, pureed) provided by the facility against the resident’s expressed preferences. The following are examples given at Severity Level 3 - Actual Harm: Unplanned weight change and declining food and/or fluid intake due to the facility’s failure to assess the relative benefits and risks of restricting or downgrading diet and 25 Appendix 3-B

food consistency or to obtain or accommodate resident preferences in accepting related risks; Decline in function related to poor food/fluid intake due to the facility’s failure to accommodate documented resident food dislikes and provide appropriate substitutes. And under the section Potential Tags for Additional Investigation, the very first tag mentioned is Tag 150 Resident Rights and stated is, “Determine if the resident’s preferences related to nutrition and food intake were considered.” F360 483.35 Dietary Services The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. F361 483.35(a) Staffing, Qualified Dietician CMS at Tag F325 Nutrition identifies that qualified dieticians help identify nutritional risk factors and recommend nutritional interventions, based on each resident’s medical condition, needs, desires and goals. Linda Roberts, RD and consultant in long term care, shares some insight into the role of the dietitian. She says the dietitian “has been trained to treat certain diseases with food” citing the extensive education an RD receives in chemistry, biochemistry, microbiology and anatomy. The dietitian understands the body's workings at the cellular level and how the components of food (carbohydrates, fats, proteins, vitamins, minerals, phytochemicals) affect the health and wellness of the individual. And dietitians want to help people. However, the other part of the equation, Roberts advises, is the patient's lifelong habits. She cites the example of 80 year olds. There will be some that are very interested in prolonging their life and others will say: “who cares if I live another 2 months or not - I'm 80 years old.” The goal should always be to individualize according to what each person wants, needs, will put up with, will concede to. To truly individualize means to figure out what works best for a person, remembering that we’re all different. Staffing to Complement the Dietitian In order to focus on resident needs, desires and goals, some nursing homes are hiring chefs and restaurant managers to complement the role of the required qualified dietician. Because chefs, restaurant managers and wait staff are used to serving people what they want when they want it, they have a real commitment to service. Solid training in the facility’s practice of encouraging and reminding residents of any food related recommendations is needed by all staff. 26 Appendix 3-B

“Healthcare: Chefs Needed” Ryan Krebs is Executive Chef/Director of Dietary Services at Victoria Special Care Center in El Cajon, California. A former executive chef from the restaurant world, Krebs is passionate about inviting executive chefs into the meaningful business of long term care. According to Krebs, a culinary education focus is service plus a passion and enthusiasm for food. What many suppose is that chefs cost more. Krebs says this is true initially but to “keep in mind that many chefs are also held to the highest of standards, especially from larger corporations and privately owned restaurants. They manage money, large staffs, and control costs and are held accountable to numbers in so many ways. And, their management experience could immediately impact overhead labor and purchasing costs, possibly allowing their salary requirements to be met. Having an executive chef is also a great marketing tool for organizations, stating that your business has made an investment in bringing in the best the industry has to offer….” (2009). Johnson & Wales University, Krebs’ alma mater in Providence, Rhode Island, offers a degree in Culinary Nutrition, the first of its kind, blending the healthcare focus of nutrition with the culinary arts. Krebs says that as our economy suffers and restaurants and hotels are closing or making cut-backs, there are eager chefs awaiting the chance to enter the field of healthcare (2009). F362 483.35(b) Sufficient Staff This guidance points out that an assessment of whether residents are receiving sufficient assistance for meals should be included in an assessment of the adequacy of staffing.

F363 483.35(c) Menus and Nutritional Adequacy Menus must: 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. 483.35 (c) (2) Be prepared in advance 483.35 (c) (3) Be followed. The Intent section of the guidance for this regulation states: This regulation also assures that there is a prepared menu by which nutritionally adequate meals have been planned for the resident and followed. In 2008 the Colorado Department of Healthcare Policy and Finance developed the Colorado Nursing Facilities Pay for Performance (P4P) Medicaid reimbursement program which also includes resident participation in menu planning. One of the minimum requirements is: Menus that include numerous options, menus developed with resident input. Menu options must be more than the entree and alternate selection. These options should include input from a resident/family advisory group such as resident 27 Appendix 3-B

council or a dining advisory committee. The residents have input into the appearance of the dining atmosphere. 483.35 (c) (3) Be followed The Procedures section of the interpretive guidelines for tag, F363 states: For sampled residents…observe if meals served are consistent with the planned menu and care plan in the amounts, types and consistency of foods served. 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 dietician to support reason(s) for deviation from the written menu. The guidance does not state that deviation from the menu is automatically assumed to be a deficient practice, but ratherthat surveyors should to investigate the reasons for the deviation. CMS guides the surveyor to conduct a record review. If the facility has explained the reasons in assessments and the plan of care, it should be taken into account. 483.35 (d) F364 Food 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; 483.35 (d) (3) F365 Food prepared in a form and designed to meet individual needs. 483.35 (d) (4) F366 Substitutes offered of similar nutritive value to residents who refuse food served. F367 483.35(e) Therapeutic diets Therapeutic diets must be prescribed by the attending physician. In the California Dining Project, CMS Region IX encourages thinking about “partnership:” Nursing facilities need to establish a partnership among the health care practitioners including consistently assigned direct care staff, the long term and short stay residents and his/her families (when appropriate) to ensure that food and fluid decisions respect all these residents’ wants, needs and preferences and that the capable residents, care givers and involved families are satisfied with their care, as well as their clinical outcomes. Coordination and integration of the nutrition and hydration services should involve and include clinical, ancillary, and support services staff. Capable residents should be encouraged to give on-going input about the program (2008).

28 Appendix 3-B

F368 483.35(f) Frequency of Meals – “The 14 Hour Rule” 1) Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. 2) There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in (4) below. 3) The facility must offer snacks at bedtime daily. 4) When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served. CMS has given guidance in the S&C-07-07 letter (Appendix B) answering questions including “the 14 hour rule” and the resident right to choice: Question 1: Tag F368 (Frequency of Meals): You request a clarification that the regulation language at this Tag that “each resident receives and the facility provides at least three meals daily” does not require the resident to actually eat the food for the facility to be in compliance. You also ask for clarification about the regulatory language specifying that there must be no more than 14 hours between supper and breakfast (or 16 hours if a resident group agrees and a nourishing snack is provided). You state that some believe this language means all of the residents must actually eat promptly by the 14th hour, which makes it difficult for the facility to honor a specific resident’s request to refuse a night snack and then sleep late. Response 1: The regulation language is in place to prevent facilities from offering less than 3 meals per day and to prevent facilities from serving supper so early in the afternoon that a significant period of time elapses until residents receive their next meal. The language was not intended to diminish the right of any resident to refuse any particular meal or snack, nor to diminish the right of a resident over their sleeping and waking time. These rights are described at Tag F242, Selfdetermination and participation. You are correct in assuming that the regulation language at F368 means that the facility must be offering meals and snacks as specified, but that each resident maintains the right to refuse the food offered. If surveyors encounter a situation in which a resident or residents are refusing snacks routinely, they would ask the resident(s) the reason for their customary refusal and would continue to investigate this issue only if the resident(s) complain about the food items provided. If a resident is sleeping late and misses breakfast, surveyors would want to know if the facility has anything for the resident to eat when they awaken (such as continental breakfast items) if they desire any food before lunch time begins. F369 483.35(g) Assistive devices Assistive devices are very helpful to certain individuals needing them, contributing greatly to independence. This tag plays an important role in helping residents reach their highest practicable level of well-being. 29 Appendix 3-B

F371 483.35(i) Sanitary conditions The facility must: 1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities: and 2) Store, prepare, distribute and serve food under sanitary conditions. The revised guidance for this Tag F371 was issued on June 20, 2008 with an effective date of September 1, 2008. The guidance recognizes new approaches: Approaches to create a homelike environment or to provide accessible nourishments may include a variety of unconventional and non-institutional food services. Meals or snacks may be served at times other than scheduled meal times and convenience foods, ready-to-eat foods, and pre-packaged foods may be stored and microwave heated on the nursing units. Whatever the approach, it is important that staff follow safe food handling practices. Unsafe Food Sources Unsafe food sources are not approved or considered satisfactory by Federal, State or local authorities. Nursing homes are not permitted to use home-prepared or home preserved (e.g., canned, pickled) foods for service to residents. This guidance was clarified with the following addition on May, 29 2009: NOTE: The food procurement requirements for facilities are not intended to restrict resident choice. All residents have the right to accept food brought to the facility by any visitor(s) for any resident. In a June 12, 2009 CMS Survey and Certification letter (SC 09-39 included in Appendix A) CMS also indicated to facilities: The facility does have a responsibility under the food and safety regulatory language at F371 to help visitors understand safe food handling practices (such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees F) and to ensure that if they are assisting visitors with reheating or other preparation activities, that facility staff use safe food handling practices and encourage visitors and residents who are contributing to food preparation in the facility to use these safe practices as well. So, food can be brought in, but the facility has responsibilities to keep it safe once it’s there and to try to have it come in as safe a condition as possible. A facility can decide on their own policies and practices to uphold resident rights as well as keep food safe. CMS gave guidance on this issue in the Survey and Certification S&C -07-07 December 21, 2006 answering culture change questions (Appendix B): 30 Appendix 3-B

Question 2: (370) Approved Food Sources: You ask if the regulatory language at this Tag that the facility must procure food from approved food sources prohibits residents from any of the following: 1) growing their own garden produce and eating it; 2) eating fish they have caught o a fishing trip; or 3) eating food brought to them by their own family or friends. Response 2: The regulatory language at this Tag is in place to prohibit a facility from procuring their food supply from questionable food sources, in order to keep residents safe. It would be problematic if the facility is serving food to all residents from the sources you list, since the facility would not be able to verify that the food they are providing is safe. The regulation is not intended to diminish the rights of specific residents to eat food in any of the circumstances you mention. In those cases, the facility is not procuring food. The residents are making their own choices to eat what they desire to eat. This would also be the case if a resident ordered a pizza, attended a ball game and bought a hot dog, or any similar circumstance. The right to make these choices is also part of the regulatory language at F242, that the resident has the right to, “make choices about aspects of his or her life that are important to the resident.” This is a key right that we believe is also an important contributing factor to a resident’s quality of life. CMS articulates in this memo the difference between the facility procuring food from approved sources and the right of residents to make choice, an important distinction. Gardens In 2006, in the S&C -07-07 letter (Appendix B), CMS honored the resident’s right to choose to eat foods they grew in a garden under the umbrella of involvement in activities, not food procured by the facility for all residents. Since that time CMS has received many questions as to whether food from gardens planted by the facility to serve the whole population is acceptable. CMS is working with the FDA on this issue, and Glenda Lewis from the FDA will address it at the Creating Home II symposium. No bare hand contact In the Employee Health section of this guidance it is stated: Bare hand contact with foods is prohibited. This requirement stems from the Food and Drug Administration’s (FDA) Food Code. The Food Code’s Intent at 1-102.10 is stated as, “The purpose of this Code is to safeguard public health and provide to consumers food that is safe, unadulterated, and honestly presented.” Chapter 3 of the Food Code at 3-301.11 states: (B) “….Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, tongs, single use gloves or dispensing equipment.”

31 Appendix 3-B

(D) “Food employees not serving a highly susceptible population may contact exposed, ready-to-eat food with their bare hands if…” (many points follow). At 3-801.11 (D) Special requirements for Highly Susceptible Populations it is stated, “Food employees may not contact ready-to-eat food” and “’Food employee’ means an individual working with unpackaged food, food equipment or utensils, or food-contact surfaces” according to Chapter 1 – Purpose and Definitions. “Highly susceptible population” means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool aged children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney dialysis center, hospital or nursing home, or nutritional or socialization services such as a senior center. The FDA Food Code can be accessed at http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/u cm186464.htm (as of Dec. 2009). Gloves CMS has given tighter guidance regarding gloves at F371: Gloved hands are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can contribute to crosscontamination….. NOTE: The use of disposable gloves is not a substitute for proper hand washing with soap and water. Resident Refrigerators The Environment task in the QIS survey directs surveyors to look at “snack/nourishment refrigerators on the units.” Nursing home residents sometimes have their own refrigerators, although there is some lack of clarity as to whether the resident or the facility has the responsibility of maintaining them. Take-out and Delivered Foods Based on the new CMS clarification, take-out and home delivery foods are the right of residents. And per the 5/29/09 Survey and Certification letter (Appendix B), the facility has the responsibility to keep foods safe. Alcohol-based Hand Rubs In the section Hand Washing, Gloves and Antimicrobial Gel, CMS has stated: Antimicrobial gel cannot be used in place of proper hand washing techniques in a food service setting. 32 Appendix 3-B

Eggs Guidance calls for any unpasteurized eggs to be cooked to a 145 degrees Fahrenheit internal temperature, and under the section called Pooled Eggs, CMS has made the statement: Waivers to allow undercooked unpasteurized eggs for resident preference are not acceptable. Pasteurized shell eggs are available and allow for safe consumption of undercooked eggs. Hairnets CMS only requires hair restraints of dietary staff at F371: Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent their hair from contacting exposed food. The guidance is written with the assumption of the roles and duties of staff by department. In innovative homes with households or little houses, there is no departmental division of labor, and there is no large, main preparation kitchen that is off limits to residents. Instead, roles become blended. A person who is a certified nursing assistant may be cooking, a person who is a social worker may be dishing out food from large bowls at a table, the administrator or family member or resident may be taking cookies out of the oven, washing dishes, etc. There is a need for clarity on what duties and situations, not what positions or departments, need hair restraints. Buffets and Steam Tables There are standards of good infection control practice that are obviously required with buffets such as sneeze guards, serving utensils, tongs, tissues and ensuring proper food temperatures. Food Holding Times “Danger Zone” refers to temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause foodborne illness outbreak if consumed. CMS specifically mentions the time frame food can be on a steam table following this 4 hour rule: The maximum length of time that foods can be held on a steam table is a total of 4 hours. Family Style Dining Good infection control practice becomes especially important when foods are served in serving bowls, as they would be in our homes. Proper food temperature is also especially important in this instance. 33 Appendix 3-B

Staff Dining with Residents CMS addressed this issue in 2006 in the S&C-07-07 letter (Appendix B): Question 11 (Dining Together): Is it permissible for staff and residents to dine together? Answer 11: There is no federal requirement that prohibits this. We applaud efforts of facilities to make the dining experience less institutional and more like home. Our concern would be for the facility to make sure that residents who need assistance receive it in a timely fashion (not making residents wait to be assisted until staff finish their meals). So dining together is welcome as long as residents always receive assistance needed. Does a Nurse have to be in the Dining Room for Meals? At Tag F373, regarding paid feeding/dining assistants CMS has stated: Adequate supervision by a supervising nurse does not necessarily mean constant visual contact or being physically present during the meal/snack time, especially if a feeding assistant is assisting a resident to eat in his or her room. However, whatever the location, the feeding assistant must be aware of and know how to access the supervisory nurse immediately in the event that an emergency should occur. Should an emergency arise, a paid feeding assistant must immediately call a supervisory nurse for help on the resident call system. F373 483.35(h) Paid Feeding Assistants – Dining Assistants CMS published a Federal Register rule in September of 2003 creating the regulatory language that was then placed at Tag F373, making it possible for long-term care facilities to use Paid Feeding Assistants to help residents eat who have no complicated eating problems. Paid Feeding Assistant/Dining Assistant Research Now that dining assistants (DA) have been in existence for six years, several studies, cosponsored by CMS and the Agency for Healthcare Research and Quality (AHRQ), have been completed to investigate the impact of DA programs. The primary researchers for these studies, Drs. Sandra Simmons of Vanderbilt University and Rosanna Bertrand of Abt Associates will share their findings as featured speakers at the upcoming Creating Home II symposium.

34 Appendix 3-B

A Manual for Dining Assistant Programs in Nursing Homes: Guidelines for Implementation has been developed by Abt Associates and Vanderbilt University with funding and input from both CMS and AHRQ. It is available at www.VanderbiltCQA.org. Dining Assistants play a large part in the 24-hour dining that is offered by Rolling Fields of Conneautville, Pennsylvania. Rolling Fields explains that in order to “pull off” 24 hour dining, staff roles had to be changed, every staff member stepped out of their traditional role and became a caregiver including, “all Staff in our home are certified feeding assistants; therefore, anyone can sit down and assist an Elder with his/her meal” (ltlmagazine.com 9/11/09). Dining Assistants Enhance Quality of Care and Quality of Life Rolling Fields says that because of their increased selection of food available and because there is more time for one-on-one interaction with dining, partly due to the DAs, they only have seven residents remaining on a pureed diet from the 20 to 30 they used to have. They also state, “quality of life for our Elders has been improved greatly because they now may choose exactly what and when they want to eat” (2009). F240 483.15 Quality of Life It is fitting for our discussion about food, dining, and self-directed living to think about the requirements of this Tag that states: A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life. Quality of life is personal to each person, as are food preferences. Facilities are required by CMS to maintain quality of life, or even better, enhance it for each resident. The facilities’ requirement to promote quality of life begins at this Tag which leads the regulatory section of Quality of Life and continues throughout the entire section, 483.15 (a) – (h). Depression and Weight Loss The results of the study conducted by Simmons et al: “Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of Feeding Assistance” found that residents with a diagnosis of depression lost more weight than those without the depression diagnosis. In fact, studies by Morley and Kraenzle, Morley and Silver and Simmons, Cadogen and Carbonnera have shown that depression is a major cause of unintentional weight loss.. In 2006 CMS released the Psychosocial Outcome Severity Guide, which guides surveyors on how to select the level of severity for any deficiency with a psychosocial outcome or potential outcome to residents (State Operations Manual, Appendix P). This has helped bring attention to the severity of psychosocial outcomes that could occur as a result of any deficient practice.

35 Appendix 3-B

F241 483.15(a) Dignity The facility must promote 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 or her individuality. CMS issued new guidance to ten tags in July of 2009, Dignity being one of them. These identified many institutional practices including several dining practices, and asked facilities to now avoid them. Food served on trays has been identified as institutional, a remnant of the old hospital-type institution. Staff standing while assisting residents to eat has been earmarked as undignified as well. Surveyors are now guided to watch for staff conversing with residents rather than only with each other and to provide any needed bathroom assistance during meals. And bibs have been identified as undignfied: Promoting dignity in dining by eliminating such practices as: bibs (also known as clothing protectors) and instead offering cloth napkins. Bibs were addressed by CMS in the early 1990’s in the guidance to this Tag F241 Dignity. The new guidance again places emphasis on bibs being undignified. F242 483.15(b) Self-determination and participation The resident has the right to: 1) Choose activities, schedules, and health care consistent with his/her interests, assessments and plans of care; 2) Interact with members of the community both inside and outside the facility; and 3) Make choices about aspects of his or her life that are significant to the resident. Facilities must be actively seeking preferences, choice over schedules important to the resident, i.e., waking, eating, bathing, and retiring per CMS’ new guidance. Even if a person can’t tell us their preferences, caregivers can still actively seek them. Pertaining to preference, CMS has stated: If resident is unaware of the right to make such choices determine if the home has actively sought resident preference info and if shared with caregivers. CMS’ requirement is that the facility go deeper in finding out resident preferences even if a resident did not tell staff, even if a resident does not realize they have this right to choice and their preferences should be honored. Informed Consent A facility cannot just let people eat what they want and when they want with no oversight or care about it. Tag F325 addresses the right to make informed choice: Sometimes, a resident or resident’s representative decides to decline medically relevant dietary restrictions. In such circumstances, the resident, facility and practitioner collaborate to identify pertinent alternatives. And stated is that the resident or representative has the right to make informed choices about accepting or declining care and treatment.

36 Appendix 3-B

F279 483.20(d) Comprehensive Care Plans including Highest Practicable Well-being The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, physical, mental and psychosocial needs that are identified in the comprehensive assessment. CMS calls for care plans to be comprehensive. This would include details of food preferences and choice, food passions and pet peeves, what someone loves to eat and hates to eat. Highest Practicable Well-being F279 continued - The care plan must describe the following: The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being. Highest practicable means innate capability, based solely on the individual’s abilities, limitations, and potential, independent of external limitations (CMS Individualized Care series, 2006). If someone is capable of feeding him or herself, a facility is to do all it can to assist the person in maintaining this highest practicable level of well-being. F280 483.10(d)(3) Participate in Planning Care and Treatment The resident has the right to –- 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. F441 483.65 Infection Control CMS released new guidance for this requirement, effective July 17, 2009. Many infection control guidelines having to do with food and dining are included in Tags F325, F371, and F441: Note: It is important that all infection prevention and control practices reflect current Centers for Disease Control and Prevention (CDC) guidelines. Residents can be exposed to potentially pathogenic organisms in different ways, including but not limited to the following: • Improper hand hygiene • Improper glove use (e.g. utilizing a single pair of gloves for multiple tasks or multiple residents) and • Improper food handling.

37 Appendix 3-B

Under Hand Hygiene the following are examples relating most to food and dining: Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: • Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); • Before and after eating or handling food (hand washing with soap and water); • Before and after assisting a resident with meals (hand washing with soap and water): • After removing gloves or aprons. 483.15(h) Environment: Safe, Clean, Comfortable and Homelike – The Short Stay Experience and Food and Dining In a facility in which most residents come for a short-term stay, the “good practices” listed in this section are just as important as in a facility with a majority of long-term care residents. CMS also states in a Note, under Procedures: Many residents who are residing in the facility for a short-term stay may not wish to personalize their rooms nor bring in many belongings Persons needing a short rehab stay in a nursing home often do not want to be called residents, they are not moving in and they do expect a medical treatment atmosphere. However, the “good practices”/institutional features to eliminate listed in the new guidance are still important. Additionally, all people appreciate choice and the clientele for a short stays are quite accustomed to exerting choice. Choice in foods and meal times, choice in whether to go to a dining area or stay and eat in the room, all are choices most people want to make and are used to making every day. The Role of the Consultant Pharmacist Much could be said about medications: how they can alter taste, cause dry mouth, lethargy, nausea, confusion, etc. which can all affect a person’s eating patterns. Pharmacists enter into a resident’s food and dining experience in several ways besides their typical role of reviewing medications and identifying side effects. Pharmacists can affect appetite stimulation with medications and timing of medications, as well as identify contraindications of foods with medications. They are charged with reducing number of medications wherever possible. They affect whether a nutritional supplement might be used or real food. Tag 155 483.10 (b)(4) Refusal of treatment The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive.

38 Appendix 3-B

“Treatment” is defined as care provided for purposes of maintaining /restoring health, improving functional level, or relieving symptoms. From the interpretive guidelines: The facility should determine 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 to 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 the refusal, offer alternative treatments, and continue to provide all other services. If a resident’s refusal of treatment brings about 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 psychosocial well-being in the context of making that refusal. Tag 151 483.10 (a)(1) Exercise of Rights The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. From the interpretive guidelines: The facility must not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights.

39 Appendix 3-B

Chapter Six Current Survey Processes as they Pertain to Food and Dining Traditional Survey The nationwide implementation of the Quality Indicator Survey (QIS) will ultimately make the traditional survey process obsolete. However, both survey processes are being used during the transition, which will take several additional years. New surveyor guidance issued at this time is operative for both survey processes. CMS’ has issued new guidance at Tag 242 (Self-determination and Participation) regarding actively seeking resident preferences. This would include resident preferences regarding what they eat and when they eat. In addition, there is new guidance at Tags F325 (Nutrition) and F371 (Kitchen Sanitation). QIS Within the new QIS process a number of the Pathways, Critical Elements and Interviews touch on food and dining. The QIS Dining Observation Pathway (20053 9/09), #9 asks: 9. Are resident’s desires considered when using clothing protectors? The new revised Dining Observation Pathway (20053 revised 7/31/09) slated to be released June 2010 does bring up the use of napkins but also still clothing protectors: Provide napkins and non-disposable cutlery and dishware (including cups and glasses). Consider resident’s desires when using clothing protectors. The Nutrition-Hydration-Tube Feeding Critical Element (20075 6/07) under the Resident/Representative Interview on page 7 guides surveyors to ask “Whether there are any concerns regarding…” many things. However, resident food preferences are not inquired about, although they are under Care Planning. The Resident Interview and Resident Observation (20050 6/07) includes this question at B Choices: Are you able to participate in making decisions regarding food choices/preferences? Time to go to bed, get up and bathing schedule are reflected. There is no inquiry regarding preferred times to eat. The Family Interview (20049 9/08) includes these questions at B Choices: 40 Appendix 3-B

Does the facility honor [resident’s] preferences and previous life routines, such as when to get up, and go to sleep or when to take a bath? Does the facility honor [resident’s name] preferences on what he/she eats or drinks? Again, there is no question regarding preferred times to eat. On both the current (20053 9/09) and newly revised (20053 revised 7/31/09) Dining Observation Pathway, the following question is asked: 16. Does the facility provide meals with no greater than a 14 hour lapse between the evening meal and breakfast (or 16 hours) with approval of a resident group and provision of a substantial evening snack? The new Dining Observation Pathway (20053 revised 7/13/09) slated to be issued June 2010 identifies and recognizes neighborhoods, households and expanded meal hours: Meal times and dining room locations should be identified while the team coordinator is conducting the entrance conference. Some nursing homes have “households” or “neighborhoods” that contain a kitchen and dining room and provide expanded meal service hours, such as 7-10 a.m. for breakfast, or food services on a 24-hour basis, seven days a week. Meals may be prepared in the household/neighborhood or catered in, such as occasionally ordering pizza or takeout food. The purpose of meal services in these settings is to provide the residents choices for times to eat and sleep, to offer food choices/preferences, and to provide a more home-like setting. MDS 2.0 Within the federally required Minimum Data Set assessment in its current 2.0 version, food and dining are mostly reflected in Section K. Oral/Nutritional Status. One item in that section states: K.4.c. Resident leaves 25% or More of Food Uneaten at Most Meals Recording food intake is technically not required by regulation. Recording food intake is mentioned by CMS in the guidance for Tag F325 Nutrition, in regards to when there is insidious or sudden weight loss, in particular by “intensifying observation of intake and eating patterns.” The MDS requires a 7 day look back period. According to the MDS Active Resident Information Report: Third Quarter 2009, 34.5% of all residents nationally leave 25% or more of their food uneaten (http://www.cms.hhs.gov/MDSPubQIandResRep/04_activeresreport.asp?isSubmitted=res 3&var=K4c&date=28). With so many residents leaving that much food uneaten, questions 41 Appendix 3-B

about the palatability of the food arise. On the other hand, the data also support that it is not every resident that has this problem. Facilities need to have good systems and policies in place to ensure recording intake is completed when needed. When intake is recorded, a good practice identified by Handy is to use printed menus first to mark resident choice and then to record percentage intake for each item eaten (2009). MDS 2.0 items can be tracked at MDS Active Resident Information Report at: http://www.cms.hhs.gov/MDSPubQIandResRep/04_activeresreport.asp. MDS 3.0 The new version of MDS (MDS 3.0) is scheduled to be implemented in October 2010. The K.4.c. item is not included in MDS 3.0. In MDS 3.0, the only question about food posed to the resident is: “While you are at this facility how important to you is…have snacks available between meals?” Although bedtime preference is asked about, preferences regarding times to eat and what to eat are not.

42 Appendix 3-B

Chapter Seven Other Food and Dining Standards Food and Drug Administration (FDA) The U.S. Public Health Service (PHS) began its food protection activities at the turn of the 20th century with studies of the role of milk in the spread of disease. These studies found that effective disease prevention called for comprehensive food sanitation measures from production to consumption. Model codes began to be developed, the first of which was the Grade A Pasteurized Milk Ordinance – Recommendations of the PHS/FDA published in 1924. A new edition of the Food code is developed every 4 years by the FDA. During each 4 year cycle the FDA may issue supplements to the code if necessary, and those supplements are incorporated into the next edition. The FDA accepts recommendations for Food Code modification from any individual or organization, with specific forms and time frames for submission. The Conference for Food Protection covers retail food issues while there are conferences specific to milk and shellfish production. The 2005 edition of the Food Code reflects recommendations made at the 2002 and 2004 Conference for Food Protection. The FDA has an open and democratic process of state by state delegate votes. And the FDA “encourages interested individuals to consider raising issues and suggesting solutions involving the federal-state cooperative programs based on FDA’s model food codes through these organizations.” The FDA has 75 state and territorial agencies and more than 3,000 local departments whose primary responsibility is prevention of foodborne illness and licensure and inspections of retail food establishments. Information and history about the FDA were found at the following website: http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/Food Code2005/ucm123930.pdf. The Food Code itself can be found at: http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2005/d efault.htm. The CMS guidance at Tags F371 Kitchen Sanitation and F441 Infection Control are not in conflict with the FDA model food code. Centers for Disease Control and Prevention (CDC) Originally, CDC was named the Communicable Disease Center when it was established in 1946. Descending from the wartime agency “Malaria Control in War Areas,” the CDC initially focused on fighting malaria by killing mosquitoes. At its beginning, there were fewer than 400 employees, with the majority being entomologists and engineers. There were only seven medical officers on staff. The CDC, now called the Centers for Disease Control and Prevention, celebrated its 60th anniversary in 2006. 43 Appendix 3-B

Today, the CDC is a global leader in public health and leads our nation in health promotion, prevention, and preparedness. Its public health efforts include prevention and control of infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats. The CDC is globally recognized for conducting research and investigations and for an action-oriented approach. It works with states and other partners to provide a health surveillance system to monitor and prevent disease outbreaks including bioterrorism, implement disease prevention strategies, and maintain national health statistics. The CDC also guards against international disease transmission with personnel stationed in more than 25 foreign countries. CDC is one of the 13 agencies of the U.S. Department of Health and Human Services (DHHS). CDC guidelines are developed with the help of federal advisory committees. The Federal Advisory Committee Act (Public Law 92-463) provides a mechanism for experts and stakeholders to participate in the decision-making process by offering advice and recommendations to the Federal government as members of advisory committees. Twenty-four federal advisory committees provide advice and recommendations on a broad range of public health issues including an advisory committee on healthcare infection control. That federal advisory committee is called the Healthcare Infection Control Practices Advisory Committee (HICPAC) and its function is described as follows: “The Committee shall advise the Centers for Disease Control and Prevention on periodic updating of existing guidelines, development of new guidelines, guideline evaluation; and other policy statements regarding the prevention of healthcare-associated infections and healthcare-related conditions” (www.cdc.gov/hicpac). The Guideline for Hand Hygiene in Healthcare Settings – 2002, was developed by the CDC's HICPAC, in collaboration with the Society for Healthcare Epidemiology of America (SHEA), the Association of Professionals in Infection Control and Epidemiology (APIC), and the Infectious Disease Society of America (IDSA). Guidelines currently being developed are: Guidelines for Infection Prevention and Control in Healthcare Personnel; Guidelines for the Prevention of Intravascular Catheter-Related Infections; Guideline for the Prevention and Management of Norovirus Gastroenteritis Outbreaks in Healthcare Settings; and Pediatric Infection Prevention: Gap Summary. More information regarding the posting of guidelines in development open public comment periods will be discussed at the HICPAC meetings and posted on the website. And as is with the FDA Food Code, CMS’ guidance at F371 and F441 also does not conflict with CDC guidelines.

44 Appendix 3-B

Chapter Eight Tools and Resources The Stage Model The Stages Tool developed by Les Grant and LaVrene Norton is a stage model of culture change in nursing facilities. This tool assesses the degree of culture change from an organizational development perspective in four stages: Stage I - Institutional model, Stage II - Transformational model, Stage III - Neighborhood model and Stage IV - Household model. It describes the organizational status of Decision Making, Staff Roles, Physical Environment, Organizational Design and Leadership Practices in each. The tool speaks to the respective dining practices in each stage (also explained in Chapter Two). The tool is available at culturechangenow.com. The Culture Change Staging Tool is a web-based questionnaire that assesses 12 key culture change domains. It determines for a facility, based on the facility’s responses, what its highest model stage is of the four stages identified in the Grant and Norton Stages Tool. This tool is available at myinnerview.com. Artifacts of Culture Change The Artifacts of Culture Change is a tool designed to capture the concrete changes homes make that reflect a changed culture, changes in attitude, policies and practices to be more resident-directed. A full report called Development of the Artifacts of Culture Change Tool explains the rationale for developing the tool, the point scale, and includes a large Source Information table. The Source Information gives background for each item, where it exists around the country, as well as any research found which supports it. The Development report and the Artifacts tool itself are both available at pioneernetwork.net. NHRegsPlus The Hulda B. and Maurice L. Rothschild Foundation provides funding for the NHRegsPlus searchable website, which contains a repository of State nursing home regulations for each of the 50 States. It allows the user to search through all 50 States’ requirements per sections such as dietary services. Most States’ licensure regulations and waiver/variance process (if there is one), can be accessed directly from the site. The website, housed at the University of Minnesota, contains a wealth of information and can be accessed at: http://www.hpm.umn.edu/NHRegsPlus.

45 Appendix 3-B

Chapter Nine Moving into New Territory The nursing home setting presents many issues in the areas of food and dining and serving the individual. The table has now been set for the Creating Home II national symposium February 11, 2010. We invite you to join us and share what you think. Experts have been invited to share their experiences. Everyone is invited to come and share their own wisdom on these subjects at this event. Together we will create a welcomed and needed national dialogue about what needs to happen next. As Linda Roberts, registered dietitian and long term care consultant said at her 2009 Pioneer Network session on dining, “we are in new territory.” We invite you to pull up a chair to the table. This is the “menu item” of most interest to all of us: transforming our thinking and our systems to where the person and her/his individualized preferences are in the forefront. What will your role be in cutting the paths in this new territory? What will you stand for? What are you willing to “take on?” Will it be volunteering to speak at a nursing course in your community? Will it be developing a research study? Will it be taking it on personally to educate just one physician? Will it be leading a committee in your facility? Thank you for what you have done, for what you are doing and what you will do. And let this be what we stand for: “The life of a nursing home resident…should be as similar as possible to the life he or she would choose to lead at home” (Pearson, Hocking, Mott and Riggs, from Journal of Advanced Nursing, 1993).

46 Appendix 3-B

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Kahn R. “Weight loss and depression in a community nursing home.” Journal of the American Geriatric Society, Vol. 43, 1995, p. 83. Kayser-Jones J. “Mealtime in nursing homes; the importance of individualized care.” Journal of Gerontological Nursing, Vol. 3, 1996, pp. 26-31. Krebs, Ryan. “Innovations in Long-term Care – Dining as Recreation. RTC News. January 2010 issue and “Healthcare: Chefs Needed” article written and shared via email on 12/5/2009. Krugh, Christine, and Carmen Bowman. Changing the Culture of Care Planning: a persondirected approach. Action Pact Press: Milwaukee, Wisconsin, 2008. Krugh, Christine, and Bowman, Carmen. SOFTEN the Assessment Process. Action Pact Press: Milwaukee, Wisconsin, 2009. Langer, Ellen J. This Week’s Citation Classic: Sept. 20, 1985. Current Contents/Number 44, November 4, 1985, p. 14. Laport, Meg. “Providers Upgrade Buildings, Expand Services.” Provider, November 2006, pp. 19-33. Leppert, Sharon. “Bulk Foodservice: A Nutrition Care Strategy for High-Risk Dementia Residents.” Journal of the American Dietetics Association. Vol. 107, No. 5, May 2007. Levenson, S.A. Medical Direction in Long-Term Care. A Guidebook for the Future. 2nd ed. Carolina Academic Press; Durham, North Carolina, 1993, p. 135. Levenson, Steven. “Changing Perspectives on LTC Nutrition & Hydration.” Caring for the Ages. September 2002, Vol. 3, No. 9, pp. 10-14. www.amda.com/publications/caring/september2002/nutrition.cfm McCorkell Worth, Susan. “Continuing Down the Highway for Cultural Change- Words Do Make a Difference.” Connections: Dietetics in Health Care Communities a dietary practice group of the ADA. Vol. 34, Issue 2, Fall 2009. McDonald, Kelly A. Alternative Treatment Consents and Behavior Agreements: When and How to Use Them. Presentation at AAHSA conference November 2009. Morley, J.E. and D. Kraenzle. “Causes of weight loss in a community nursing home.” Journal of the American Geriatric Society, Vol. 42, 1994, pp. 583-585. Morley, J.E., and A.J. Silver. “Nutritional issues in nursing home care.” Annals of Internal Medicine, Vol. 123, 1995, pp. 850-859.

50 Appendix 3-B

Nijs, K.A., C. de Graaf, F.J. Kok, and W.W. van Straveren. “Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: Cluster randomized controlled trial.” BMJ, Vol. 332, 2006, pp. 1180-1184. Norton, LaVrene and Steve Shields. In Pursuit of the Sunbeam: A Practical Guide to Transformation from Institution to Household. Action Pact Press: Milwaukee, Wisconsin, 2006, p. ix. Pearson, A., S. Hocking, S. Mott, and A. Riggs. “Quality care in nursing homes: From the resident’s perspective.” Journal of Advanced Nursing, Vol. 18, No. 1, 1993, pp. 20-24. Pioneer Network. The New Quality of Life Revisions to LTC Surveyor Guidance. June 10 and 11, 2009 www.pioneernetwork.net. Public Consulting Group. Nursing Facility Pay-for-Performance Application Review. Presented to Diane Taylor of Health Care Policy and Finance, June 30, 2009. Puckett, Ruby. A Look at Modified and Liberalized Diets. Dietary Manager, March 2005, pp. 29-30. Rantz, Marilyn J., and Marcia K. Flesner. Person Centered Care: A Model for Nursing Homes. American Nurses Association: Washington D.C., 2004, pp. 23, 25. Remsburg, Robin, Amy Luking, Patricia Baran, Charlotte Radu, Deborah Pineda, Richard G. Bennett, and Matthew Tayback. “Impact of a Buffet Style Dining on weight and biochemical indicators of nutritional status in nursing home residents: a pilot study.” Journal of the American Dietetic Association, Vol. 101, No. 12, December 2001, pp. 1460-1462. Robinson, Gretchen E. and Ann Gallagher. “Culture Change Impacts Quality of Life for Nursing Home Residents.” Topics in Clinical Nutrition, Vol. 23, No. 2, April-June 2008, pp. 120-130. Ronch, Judah and Audrey Weiner. Culture Change in Long-term Care. Co-published as Journal of Social Work in Long-term Care, Volume 2, Numbers 1/2 and 3/4, 2003. Rolling Fields of Conneautville, Pennsylvania article about winning the 2009 Long Term Living OPTIMA Award, ltlmagazine.com, 9/11/09. Roloff, Shellee. “Rethinking the Dining Experience in Long-Term Care.” Dietary Manager, October 2006. Schaeffer, Keith. “Soup’s On,” Nourish the Body and Soul. Action Pact Press: Milwaukee Wisconsin, 2008.

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Schlettwein-Gsell, D. “Nutrition and the quality of life: A measure for the outcome of nutritional intervention?” American Journal of Clinical Nutrition, Vol. 556, 1992, pp. 1263512665. Shatenstein, B., B. Ska, and G. Ferland. “Employee reactions to the introduction of a bulk food distribution system in a nursing home.” Canadian Journal of Dietary Practice Research, Vol. 62, 2001, pp. 18-25. Simmons, S.F., D. Osterweil, and J.F. Schnelle. “Improving food intake in nursing home residents with feeding assistance: A staffing analysis.” Journal of Gerontology: Medical Sciences, Vol. 56A, No. 12, 2001, pp. M790-M794. Simmons, S.F. and J.F. Schnelle. “Individualized feeding assistance care for nursing home residents: Staffing requirements to implement two interventions.” Journal of Gerontology: Medical Sciences, Vol. 59A, No. 9, 2004, pp. 966-973. Simmons, Sandra F., Rosanna Bertrand, Victoria Sheir, Rebecca Sweetland, Therese J. Moore, Donna T. Hurd, and John F. Schnelle. “A Preliminary Evaluation of the Paid Feeding Assistant Regulation: Impact on Feeding Assistance Care Process Quality in Nursing Homes.” The Gerontologist, Vol. 47, No. 2, 2007, pp. 184-192. Simmons, Sandra F., Patrick Cleeton, and Tracey Porchak. “Resident Complaints about the Nursing Home Food Service: Relationship to Cognitive Status.” Journal of Gerontology: Psychological Sciences, Vol. 10, 2009. Simmons, Sandra F., Keeler, Emmet, Zhou, Xiaohui, Hickey, Kelly, Sato, Hui-wen, and Schnelle, John. “Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of Feeding Assistance.” Journal of the American Geriatric Society, Vol. 56, 2008, pp. 1466-1473. Simmons, S.F., M.P. Cadogan, and G. Carbonera. “The minimum data set depression quality indicator: Does is reflect differences in care processes?” Gerontology, Vol. 44, 2004, pp. 554-564. Simmons, S.F., Garcia E.F., Cadogan M.P., Al-Samarrai N.R., Levy-Storms L.F., Osterweil D., and Schnelle J.F. “The Minimum Data Set weight loss quality indicator: Does it reflect differences in care processes related to weight loss?” Journal of the American Geriatrics Society, Vol. 51, No. 10, 2003, pp. 1410-1418. Simmons S.F., S. Babineau, F. Garcia, and J.F. Schnelle. “Quality assessment in nursing homes by systematic direct observations: Feeding assistance.” Journal of Gerontology: Medical Sciences, Vol. 57A, 2002, pp. M1-M7. Tarnove, Lorraine. “LTC’s Secret Clincal Weapon.” Provider, September 2003, pp. 59-63. Taylor, Richard. Interview by Ryan Malone, Leaders in Eldercare series, August 19, 2009. 52 Appendix 3-B

http://www.insideeldercare.com/leaders-in-eldercare/podcast-leaders-in-elder-care-drrichard-taylor-on-alzheimers-the-farthest-thing-from-the-long-goodbye/ Tjia, Jennifer, K.M. Maxor, T. Field, V. Meterko, A. Spenard, and J.H. Gurwitz. “NursePhysician Communication in the Long-Term Care Setting: Perceived Barriers and Impact on Patient Safety” Journal of Patient Safety, Vol. 5, Number 3, September 2009, pp 145-152. The Green House Project® Guide Book, 2009. thegreenhouseproject.org Thomas, William H. Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home. Vanderwyk & Burnham: Action, Massachusetts, 1996. Thomas, William H. “Thoughts by Dr. Bill: Convivium.” The Green House Project Quarterly, Fall-Winter, 2008. Walen, Heather R. Control, Perceived. Encyclopedia of Aging, 2002. http://www.encyclopedia.com/doc/1G2-3402200083.html, accessed 10/15/09. Webster, Clint. Preventing Malnutrition in the Elderly. Final Research Papers, Winter 2008, March 4, 2008. Zizza, C.A., F.A. Tayie, and M. Lino. “Benefits of Snacking in Older Americans.” Journal of the American Dietetic Association, Vol. 107, 2007, pp. 800-806.

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Appendix A DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-12-25 Baltimore, Maryland 21244-1850


May 29, 2009

TO:


FROM:

Director, Survey and Certification Group

SUBJECT:

Food Procurement at 42 CFR 483.35(i)(1)(2), Tag F 371, and Self Determination and Participation at 42 CFR 483.15, Tag F 242 Memorandum Summary

This memorandum clarifies that: •

• •

The language at 42 CFR 483.35(i), Tag F 371 “Procure food from sources approved or considered satisfactory by Federal, State or local authorities” is intended solely for the foods procured by the facility. A revision has been made to the interpretive guidelines at F371 to further clarify this intent; Foods accepted by residents from visitors, family, friends, or other guests are not subject to the regulatory requirement at F 371; and Residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices at §483.15, F 242, Self Determination and Participation.

The Centers for Medicare & Medicaid Services (CMS) regulation at 42 CFR 483.35, Tag F 371, states that foods procured by the facility must come from sources approved or considered satisfactory by Federal, State, or local authorities. The surveyors should use the regulation and interpretive guidelines at F 371 when determining how the facility acquired food for resident consumption. This regulatory requirement does not expand beyond the scope of the intent to monitor how the facility procures food for the nursing home resident population. The surveyor(s) should not use the food procurement regulatory language at F 371 to monitor any food(s) provided by visitors, friends, family members, or resident guests which the resident has chosen to accept. The facility does have a responsibility under the food safety regulatory language at F371 to help visitors to understand safe food handling practices (such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees F.) and to ensure that if they are assisting visitors with reheating or other preparation activities, that facility staff use safe food handling practices and encourage visitors and residents who are contributing to food preparation in the facility to use these safe practices as well. 54 Appendix 3-B

Page 2 –State Survey Agency Directors A clarification has been added to F371, which CMS has released as an advance copy along with revisions to several quality of life and environment tags, with an issuance date of June 17, 2009. The CMS regulation at §483.15, F242 protects the resident(s) right to choose to accept food from visitors, family, friends, or other guests (e.g., facility-sponsored activities such as a community pot luck). This regulation states, “the resident has the right to make choices about his or her life in the facility that are significant to the resident.” When the survey team determines that a facility has not allowed a resident or residents to choose to accept food from any friends, family, visitors or other guests, the team should consult the regulation and guidance at F 242 to determine if the resident(s) rights have been violated. For questions regarding this memorandum, please contact Debra Swinton-Spears at (410) 7867506 or e-mail at [email protected]. Effective Date: This clarification is effective immediately. Please ensure that all appropriate staff are fully informed within 30 days of the date of this memorandum. Training: This information should be shared with all appropriate survey and certification staff, surveyors, their managers, and applicable staff. /s/ Thomas E. Hamilton cc: Survey and Certification Regional Office Management

55 Appendix 3-B

Appendix B DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-12-25 Baltimore, Maryland 21244-1850


December 21, 2006

TO:


FROM:

Director, Survey and Certification Group

SUBJECT:

Nursing Home Culture Change Regulatory Compliance Questions and Answers

Memorandum Summary This memorandum provides the State Survey Agencies and CMS regional offices with: 1. Responses we have made to inquiries concerning compliance with the long-term care health and life safety code requirements in nursing homes that are changing their cultures and adopting new practices; 2. Summarizes questions and answers from a June, 2006 CMS Pic-Tel conference with leaders of the Green House Project (Attachment A); and 3. Provides information about an upcoming series of 4 CMS culture change satellite webcasts (Attachment B). Following are regulatory questions that have been sent from culture change organizations from 2004 to date, along with our answers: Question 1: Tag F368 (Frequency of Meals): You request a clarification that the regulation language at this Tag that “each resident receives and the facility provides at least three meals daily” does not require the resident to actually eat the food for the facility to be in compliance. You also ask for clarification about the regulatory language specifying that there must be no more than 14 hours between supper and breakfast (or 16 hours if a resident group agrees and a nourishing snack is provided). You state that some believe this language means all of the residents must actually eat promptly by the 14th hour, which makes it difficult for the facility to honor a specific resident’s request to refuse a night snack and then sleep late. Response 1: The regulation language is in place to prevent facilities from offering less than 3 meals per day and to prevent facilities from serving supper so early in the afternoon that a significant period of time elapses until residents receive their next meal. The language was not intended to diminish the right of any resident to refuse any particular meal or snack, nor to diminish the right of a resident over their sleeping and waking time. These rights are described at Tag F242, Self-determination and Participation. You are correct in assuming that the regulation language at F368 means that the facility must be offering meals and snacks as specified, but that each resident maintains the right to refuse the food offered. If surveyors encounter a situation in which a resident or residents are refusing snacks routinely, they would ask the resident(s) the reason for their customary refusal and would continue to investigate this issue only if the resident(s) complains about the food items provided. If a resident is

56 Appendix 3-B

Page 2 - State Survey Agency Directors sleeping late and misses breakfast, surveyors would want to know if the facility has anything for the resident to eat when they awaken (such as continental breakfast items) if they desire any food before lunch time begins. Question 2: F370 (Approved Food Sources): You ask if the regulatory language at this Tag that the facility must procure food from approved sources prohibits residents from any of the following: 1) growing their own garden produce and eating it; 2) eating fish they have caught on a fishing trip; or 3) eating food brought to them by their own family or friends. Response 2: The regulatory language at this Tag is in place to prohibit a facility from procuring their food supply from questionable sources, in order to keep residents safe. It would be problematic if the facility is serving food to all residents from the sources you list, since the facility would not be able to verify that the food they are providing is safe. The regulation is not intended to diminish the rights of specific residents to eat food in any of the circumstances you mention. In those cases, the facility is not procuring food. The residents are making their own choices to eat what they desire to eat. This would also be the case if a resident ordered a pizza, attended a ball game and bought a hot dog, or any similar circumstance. The right to make these choices is also part of the regulatory language at F242, that the resident has the right to, “make choices about aspects of his or her life in the facility that are important to the resident.” This is a key right that we believe is also an important contributing factor to a resident’s quality of life. Question 3: Tag F354 (Registered Nurse): “Can the traditional DON role be shared with several registered nurses with each nurse responsible for one or more households or clusters?” Response 3: The interpretive guidelines (i.e., Guidance to Surveyors) already contain this language: “The facility is required to designate an RN to serve as DON on a full time basis. This requirement can be met when RNs share the position. If RNs share the DON position, the total hours per week must equal 40. Facility staff must understand the shared responsibilities.” Thus, the position can be shared; however, a comprehensive set of duties and responsibilities of a DON is not specified in the regulations or interpretive guidelines. We interpret this role to encompass not only general supervision of nursing care for the facility, but oversight of nursing policies and procedures, overall responsibility for hiring/firing of nursing staff, ensuring sufficient nursing staff (F353), ensuring proficiency of nurse aides (F498), active participation in the quality assurance committee (see Tag F520), and responsibility to receive and act on communications from the pharmacy consultant about medication problems (Tags F429 and F430). A facility that desires to have various people share the DON position would need to consider how these DON duties will be fulfilled in a shared position. As long as these duties are fulfilled, we would consider the facility in compliance with F354, whether or not the position is being shared. Question 4: Tag F521 (Quality Assessment and Assurance): You ask whether the regulatory responsibility for this committee to “meet” can be fulfilled if the physician member is not physically present, but is participating through alternate means, “such as conference calls or reading minutes/issues and giving input.” Response 4: Yes, participation can be achieved through means of telephone conferencing, however, we do not accept the alternative of the physician merely reading documents before or after the meeting. We believe the purpose of these meetings is to provide a forum for discussion of issues and

57 Appendix 3-B

Page 3 – State Survey Agency Directors plans, which cannot be adequately fulfilled if the physician is merely reading and commenting on documents, since this does not allow for the interchange of ideas. Question 5: (HIPAA and Principles of Documentation): You express concern that the Statement of Deficiencies that surveyors write, which is a publicly posted document, may violate a resident’s right to privacy, since the details may identify a specific resident to the public. Response 5: We have received other comments on this issue, and have provided guidance to our State Survey Agencies and CMS regional offices on our interpretation of this issue in our Survey and Certification (S&C) memorandum #04-18. All our S&C memoranda are stored on the CMS website for public access at http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp Question 6 (Handrails): Could the interpretive guidelines explain that handrails are not necessary at the very ends of the hallways on the very small sides of the door? This would allow for filling these unused areas with live plants, for instance, without obstructing egress and handrails would still be available up to the end of each hallway. Answer 6: The purpose of the handrail requirements at Tag F468 is to assist residents with ambulation and/or wheelchair navigation. They are a safety device as well as a mobility enhancer for those residents who need assistance. The survey team onsite would need to observe the responses of residents to the placement of objects that block the portion of the handrails that is at the end of a hallway. They would also interview residents to gain their opinion as to whether the objects in question are interfering with their independence in navigating to the places they wish to go. Question 7 (Resident Call system): Could the resident call system (F463) regulation that requires calls to be able to be received at the nurses’ station be changed to also include nurses’ work areas and direct care workers, as well as the nurses’ stations? Many homes moving away from the institutional model are replacing nurses’ stations with normal kitchens, living room and dining room areas, and using systems whereby resident calls connect directly to caregivers’ radio/pagers. Because it is harder to change the text of regulation, could the phrase “at the nurses’ station” be removed from the following sentence in the Interpretive Guidelines: “The intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means to directly contact staff at the nurses’ station.” Answer 7: We agree that it is desirable for residents and/or their caregivers or visitors to be able to quickly contact nursing staff when they need help. To meet the intent of the requirement at F463, it is acceptable to use a modern pager/telephone system which routes resident calls to caregivers in a specified order in an organized communication system that fulfills the intent and communication functions of a nurse’s station. We will make a change in the Interpretive Guideline to reflect this position. Question 8 (Posting of Survey Results): Would CMS consider adding to the posting requirements at Tag F156 [42 CFR 483.10(b)(10)], text similar to that stated in Tag F167 about posting of survey results, “...or a notice of their availability?” Although this may just be trading one posting for several, some homes really want to create a homey environment without so many postings and many homes are placing postings into a photo album or binder to minimize the institutional look of so many postings.

58 Appendix 3-B

Page 4 – State Survey Agency Directors Answer 8: The purpose of the posting requirements at both F156 and F167 is for residents and any other interested parties to be able to know the information exists, and to easily locate and read the information without needing to ask for it. What you request above, namely one posting that advises the public of what information is available to meet requirements of both Tags, is acceptable, as long as the information itself is in public and easily accessible, such as in a lobby area in a marked (titled) notebook or album. This includes the following information: •

“A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit;.” (F156)

•

“Written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits;” (F156) and

•

The facility, “must make the results available for examination in a place readily accessible to residents and must post a notice of their availability.” (F167)

Question 9 (Hallway Width): Does the 8 feet requirement (at LSC Tag K39) continue to be necessary since evacuations are no longer done via wheeling a person out of the building in a bed? Could 6 feet meet the requirement? If 6 feet sufficed, this would again refer back to our question regarding the requirement for handrails when something else such as a bench might take up the other 2 feet. Answer 9: The 8 foot corridor width is a requirement of the Life Safety Code (LSC). Corridors remain a route to use in internal movement of residents in an emergency situation to areas of safety in different parts of the facility. This movement may be by beds, gurney or other methods which may require the full width of the corridor. We do not believe it would be in the best interests of the residents to reduce the level of safety in a facility. Question 10 (Tag K72 and Exits): In regard to LSC Tag K72 (no furnishings, decorations, or other objects are placed to obstruct exits or visibility of exits), can secured unit doors be disguised or masked with murals, etc.? Staff typically will be the ones to use these doors in the case of emergency and will know where they are. By disguising exit doors, resident anxiety of wanting to go out them may decrease. Answer 10: The life safety code allows some coverings on doors, but not concealment. The code also specifically forbids the use of mirrors on a door. It is a judgment call by the survey team as to what would be considered concealment of the door, but in general the door must still be recognizable by a non-impaired person (such as a visitor). The code does not allow the removal or concealment of exit signs, door handles, or door opening hardware. Question 11 (Dining Together): Is it permissible for staff and residents to dine together? Answer 11: There is no federal requirement that prohibits this. We applaud efforts of facilities to make the dining experience less institutional and more like home. Our concern would be for the facility to make sure that residents who need assistance receive it in a timely fashion (not making residents wait to be assisted until staff finish their meals).

59 Appendix 3-B

Page 5 – State Survey Agency Directors Question 14 (Candles): Can candles be used in nursing homes under supervision, in sprinklered facilities. Answer 14: Regarding the request to use candles in sprinklered facilities under staff supervision, National Fire Protection Association data shows candles to be the number one cause of fires in dwellings. Candles cannot be used in resident rooms, but may be used in other locations where they are placed in a substantial candle holder and supervised at all times while they are lighted. Lighted candles are not to be handled by residents due to the risk of fire and burns. If you would like to discuss this issue, you may contact James Merrill at 410-786-6998, or via email at [email protected]. Question 15 (Tablecloths): Are cloth tablecloths and napkins permissible in nursing homes? Answer 15: There is no regulation that prohibits it and, in fact, the use of these items is greatly preferable to the use of bibs, as bibs can detract from the homelike attractiveness of the dining room setting. Beginning November 3, 2006, (see attached) CMS is broadcasting a 4-part series on culture change through fiscal year 2007. Three of the broadcasts, produced by the Quality Improvement Organizations (QIOs), will highlight culture change principles and outcomes from the QIO scope of work. The other broadcast, produced by CMS, will explore changes being made to medical and nursing care practices and policies in terms of compliance and the survey process. We are including information on the series for your convenience. We believe this broadcast series will be of interest to providers and other stakeholders, as well as State Survey Agencies. We encourage States, CMS regional offices, and QIOs to consider setting up joint viewing opportunities for survey personnel, stakeholders, and nursing home staff when possible. As with all CMS broadcasts, these broadcasts may be viewed either live via satellite or internet, or via internet for a year after each broadcast. For questions concerning this memorandum, please contact Karen Schoeneman at (410) 786-6855 or via e-mail at [email protected]. Effective Date: Immediately. Please ensure that all appropriate staff are fully informed within 30 days of the date of this memorandum, and disseminate the information to affected providers. Training: The information contained in this announcement should be shared with all nursing home surveyors and supervisors. /s/ Thomas E. Hamilton

Attachment cc: Survey and Certification Regional Office Management (G-5)

60 Appendix 3-B

National Long-term Care Life Safety Task Force Summary of Proposals Approved by NFPA Prepared by Amy Carpenter, Task Force Member Cooking: Kitchens will be permitted to be open to other spaces, and the corridor, as long as they meet all of the following criteria: May use either residential or commercial stoves or cooktops The kitchen cannot serve more than 30 residents The kitchen must be within a smoke compartment and must only serve residents in that smoke compartment. However, if you have a building that has multiple smoke compartments, each one may have an open kitchen. The smoke compartment where the kitchen is located, whether new or existing building, must be fully sprinkled. A range hood must be provided with a fire suppression system, grease clean-out capability and a 500 cfm fan. You can get all of this in a hood manufactured by “Cooksafe”, or combine a higher end residential hood with a UL 300a fire suppression system. Hoods may be vented to the exterior or re-circulating but do not need to meet full commercial hood requirements. Local smoke alarms that are not tied into the fire alarm system may be provided in the area of the open kitchen.

Seating in corridors: Furniture may be provided in corridors when they meet all of the following criteria:

Appendix 3-C

Furniture must be attached to the wall or floor to prevent it from migrating into the required hallway clearance or moving from its intended location. This can be achieved with a simple metal bracket that is screwed to the legs of the chair and to the floor. The bracket could be easily removed for cleaning and maintenance purposes. Furniture in the corridor may not reduce the clear width of the corridor to less than 6 feet. That means if you have an 8ft corridor, you can have a maximum chair depth of 2 ft. If you have a 12 ft corridor, you could have up to 6 ft of furniture depth. Furniture must be located only on one side of the corridor. This will allow residents to navigate the hallway continuously without having to weave back and forth across the hallway to get around seating areas. This also helps emergency responders. There are limits to how long a seating area can be and how far apart they must be spaced but these are all very generous. The building must be sprinkled and must have smoke detectors in the corridors. Decorations: Combustible decorations will be permitted in resident rooms, corridors, on doors, and in common space. There are limitations on the percentage of coverage depending on whether the building is sprinklered and where located. Fireplaces: This proposal will allow gas or electric fireplaces to be used in smoke compartments that contain sleeping rooms, but not within individual sleeping rooms. Some of the restrictions are that the controls must be locked and a sealed glass front must be provided to prevent anyone from throwing object into the flames.

Appendix 3-C

Quality of Care Rounds Unlike the Mock Survey/Self-Assessment section which is usually used once or twice a year, the following forms can be used on a daily, weekly, or monthly basis. To ensure quality you’ve got to monitor current systems and take corrective action as needed. Be sure that your corrective action includes documentation in your Quality Assurance Committee Meetings with plans to correct and monitor for continued compliance. Assign different tasks to employees that normally wouldn’t take care of that area - seeing things from a “fresh” perspective will help you improve your outcomes. The following pages include a variety of tools - use all or some of them. Remember, if you find any deficient practices be sure you bring it to your Quality Assurance Meetings, document your findings, and come up with a workable plan to correct the problem.

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 4 - QUALITY OF CARE ROUNDS Quality of Care Rounds - In order to be survey ready, the MU NHA Consultant recommends that NH leadership, managers, and staff perform rounds of the nursing home on a scheduled basis. NH staff needs to be informed of the process to take when repairs are needed. New employees need to be oriented to the process also. The key to rounds is having a process in place that documents follow up when Federal standards are not met. SECTION Quality of Care Rounds Clinical Visits Assessments MDS/Care Plan Tracking Form Dietary Infection Control and Safety Checklist Infection Control and Safety Surveillance Housekeeping Dietary Rehabilitation Department Nursing Department Shower/Whirlpool Room Laundry Activities/Social Services Beautician/Barber Services Utility Room Pharmacy/Med Room/Medication Cart Central Supply Hazardous Waste Administrative Maintenance Administrators Daily Kitchen Rounds Environmental Services Tool Facility Inspection Facility Inspection Report Survey Tag Assignments

Updated May 2014

PAGE # 4.2-4.9 4.10-4.26 4.27 4.28-4.31 4.32-4.33 4.34-4.35 4.36 4.37-4.39 4.40 4.41-4.42 4.43 4.44 4.45 4.46 4.47 4.48 4.49 4.50-4.51 4.52-4.53 4.54-4.56 4.57-4.58 4.59-4.61 4.62-4.71

QUALITY OF CARE ROUNDS

Directions: Place a check (√) in the corresponding unshaded column if the standard is met. If not place an (x) in the unshaded column and enter comment. Enter “NA” if no observation is made. RR = Resident Rights RR

SS

PE

SS = Safety and Security IC

EP

PE = Physical Environment F-Tag

IC = Infection Control

EP = Employee Practice

Observations

Standards/Comments

NURSING STATION F260

Nursing station is clean and orderly

1.

F176

Confidential resident information is not in view of visitors (i.e., charts, care plans)

2.

F502

A system in place to assure that each CNA receives a specific resident care assignment

3.

Unit meeting held at least monthly and documented with signed attendance; minutes are available for staff not attending

4.

Staff dressed in clean uniforms per facility dress code

5.

Nursing staff are wearing name tag with current title

6.

System established to provide regular or emergency care when the attending physician is unavailable; posted at the station or in the resident’s record

7.

Weekend/evening call list is posted

8.

Emergency phone list is present at nursing station, which includes list of current management staff

9.

Resident Roster is current and accurate (utilize during resident/room visit)

10.

F387

4.2

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

The following manuals (current and approved by the Resident Care Committee) are present at each nursing unit: F509

1. Nursing Policy and Procedure Manual

11.

F509

2. Infection Control Manual

12.

F509

3. Pharmacy Manual

13.

F492

4. Exposure Control Plan Manual

14.

F492

5. Fire and Disaster Plan/Manual

15.

F509

6. Diet Manual

16.

The following references are available on each nursing unit: 1. Current Drug Reference; i.e., PDR

17.

2. Current Care Plan Manual

18.

3. Restorative Manual

19.

F265

Noise level is acceptable

20.

F260

Clean Utility Room is safe, sanitary, orderly, nothing stored under sink

21.

F433

Nourishment refrigerator is clean, thermometer present at 35°-45°, food covered, labeled, dated

22.

F333

Portable ice chest is sanitized daily, and stored clean and dry, when not in continuous use

23.

F333

Resident water pitchers are sanitized at least 2x/week per Infection Control Manual

24.

F339

Emergency resuscitator and airway is accessible, covered and ready for use

25.

F338

Suction machine is accessible. covered and ready for use

26.

CLEAN UTILITY

4.3

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

F339

Emergency Oxygen is accessible, covered and ready for use with gauge and mask/cannula attached

27.

F339

Oxygen tanks are secured by stands, carts or chains

28.

F260

Soiled Utility Room is safe and orderly with nothing stored under sink. Only soiled items stored in room

29.

F260

Hoppers are clean and orderly; rinsed hoses are hung properly

30.

F492

Gloves/goggles/aprons (PPE) available and accessible to staff on units

31.

F447

Infectious waste is handled appropriately, and is covered and marked biohazardous waste receptacle

32.

F492

Hazardous Products are locked when not in use and under constant direct visual supervision when being used

33.

F492

“Right to Know” information present on nursing units; MSDS accessible to employees

34.

F433

Medication keys to med room and med cart are in possession of authorized personnel at all times

35.

F433

Medication room is locked at all times

36.

F433

Medication room is clean and orderly; and free of staff personal belongings

37.

F433

Refrigerator is clean, thermometer present at 350 - 450, food covered, labeled, dated

38.

F433

Medication carts are locked when out of view or unattended

39.

F433

Medication carts are clean and orderly

40.

SOILED UTILITY

MEDICATION/TREATMENT

4.4

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

F334

Needles and syringes are disposed of in suitable punctureresistant container which is firmly attached to a surface and out of resident’s reach

41.

F334

Used needles are not broken or recapped by hand

42.

F433

Treatment carts are locked when not in use or unattended

43.

F433

Treatment carts are clean and orderly

44.

F433

Supplies in treatment carts are stored individually for each resident requiring treatment (plastic bag may be used)

45.

F441

Open pour bottles of sterile solution (e.g., normal saline, sterile water) are dated, timed and initialed when opened; and discarded at least 72 hours after opening

46.

F260 F329

Shower/tub room is clean and free of cracked or missing tiles

47.

F329

Grab bars for tub, showers and toilet are present and secure

48.

F260

Room is odor free

49.

F260

Shower chairs available and clean

50.

F241

Privacy is provided to residents (i.e., shower curtain available)

51.

F260

Free of resident care items unless in locked cabinet

52.

F260

Free of clutter, i.e., improperly stored items, furniture

53.

F447

Clean linen is covered or in a cabinet. Soiled linen is in a covered container; stored in an appropriate container

54.

SHOWER/TUB ROOM

4.5

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

HALL/CORRIDOR F532

Fire Evacuation Plan on nursing unit indicating evacuation route, location of fire extinguisher, manual alarm stations, and “You Are Here”

55.

F260

Halls uncluttered, all items on one side of the hall

56.

F260 F329

Hand rails on both sides of the halls are clean, secure

57.

F260 F329

Floors are clean, buffed or vacuumed and in good repair

58.

F260 F329

Walls are clean and in good repair

59.

F260 F329

Ceiling/tiles intact, stain free

60.

F260

Areas are free of unpleasant odors, i.e., urine, feces

61.

Name tag on resident’s door is present and legible for all residents

62.

F339

“Oxygen, No Smoking” signs are visible to all personnel, and posted on appropriate doors of rooms where oxygen tanks or concentrators are present or in use

63.

F176

All staff knock or announce entry prior to entering room

64.

F354

Call lights are answered between 3-5 minutes. Emergency call lights are answered immediately

65.

F241

Staff to resident interactions are appropriate, i.e., residents are treated with respect

66.

F317

Residents are dressed appropriately for location

67.

Staff to staff interaction is appropriate. Prompt action taken when needed

68.

Hands washed between direct resident care

69.

F446

4.6

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

F447

Soiled linen is handled correctly; carried away from body; transported in a covered container, not found on floor, separated from clean linen by at least 3 feet, and bagged before placed in chute

70.

F447

Clean linen Is carried away from body; clean linen carts are covered

71.

F333

Ice distribution – ice passing technique is conducted in a sanitary manner, ice scoop is covered when not in use

72.

Gait belts present and used by staff upon transferring residents

73.

F354

Residents are readied for meal (i.e., toileted, positioned, protectors, if appropriate are in place)

74.

F354

Nursing staff present while residents are eating, provide assistance to residents

75.

F377

Door to food cart remains closed when unattended

76.

F377

Uncovered food trays are not carried more than two doorways from the food cart

77.

F377

Clean trays on food cart are not cross-contaminated

78.

F176

Resident is afforded privacy, i.e., curtain closed during care, staff knocks on door prior to entering room, only authorized staff present during care and treatments

79.

F176

Privacy curtain present (except in private room), clean and in good repair

80.

F472

Call light is operative, visible and accessible to resident, staff and others

81.

F477

Room is adequately furnished; allows resident to engage in activities (chair, dresser, closet present

82.

ROOM/MEAL SERVICE

RESIDENT ROOM

4.7

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

F478

Sufficient space to accommodate resident’s needs; can move about room, access space safety, does not appear crowded

83.

F260 F329

Walls and ceilings are clean, free of satins and in good repair

84.

F260 F329

Floors are clean, buffed or vacuumed

85.

F260 F329

Furniture is dust free and in good repair

86.

F483

No evidence of pest infestation observed; unit, rooms are pest- free

87.

F260

Bathroom is clean and free of persistent odors

88.

F260 F329

Bathroom fixtures are clean and in good repair

89.

F329

Grab bars are present and secure

90.

F441

Shared bathrooms are free of personal care items and bar soaps

91.

F446

Liquid soap, paper towels available for hand washing

92.

No flammable products observed

93.

F260

Rooms are individualized, homelike with presence of personal articles to encourage link with past

94.

F253

Physical environment adapted to residents’ needs, i.e., reorienting devices such as clocks, calendars, commode seat elevated

95.

F468

Mattress is correct size for the resident; clean, comfortable, in good condition

96.

F262

Bed linen is in good condition (i.e., in good repair), clean and stain free

97.

F454A

4.8

RR

SS

PE

IC

EP

F-Tag

Observations

Standards/Comments

F261

Personal care items available, clean, stored properly, i.e., comb/brush clean, toothbrush stored separately and covered. Night stand, dresser, closet are clean and orderly

98.

F261

Resident equipment is clean and in good repair, i.e., suction machine, feeding pumps, oxygen equipment, IV stands, WC, geri-chairs, etc.

99.

F261

Bedpans, urinals, graduates for measuring output are clean, and stored appropriately

100.

F260

Piston/bulb syringes are clean, washed after each use, sanitized (per facility policy – at least every 24 hours), and are stored covered in a clean and sanitary manner. May be stored in a barrel

101.

F260

Food items in resident’s room are stored properly, in sealed containers

102.

F333

Fresh water, covered container and drinking utensil available at all times to resident

103.

F333

Medications stored at bedsides have Physician’s Order and are labeled appropriately

104.

F317

Resident is well groomed and appropriately dresses for location

105.

F351

Identification band is on resident’s person; contains at least resident’s name and admission number

106.

F319

Resident (in or out of bed) is positioned in good body alignment to prevent skin breakdown/contractures

107.

F319

For “Resident at Risk” preventative measures are used (i.e., mattress overlay, wheelchair cushion, heel cuffs, foot supports)

108.

F221

Restraints are applied correctly and released every two (2) hours

109.

F322

Foley catheter/tubing positioned correctly for straight drainage, bag is below level of bladder, tubing and bag not touching the floor, catheter is secure to body

110.

RESIDENT

TOTAL FOR EACH CATEGORY

4.9

CLINICAL VISIT ASSESSMENTS Facility: Circle type of evaluation:

Date: 30 day

60 day

90 day

Other

Name of Evaluator:

PHYSICAL PLANT & ENVIRONMENT ENTRANCE/LOBBY

“U” = Unsatisfactory

Ratings

“S” = Satisfactory

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Parking lot in good repair/free of liter Landscape maintained/free of liter Exterior/trim of building maintained Sign is maintained in good repair No “odor” is noted upon entering building Lobby is neat/maintained-free of clutter Office area neat/maintained-free of clutter CORRIDORS/COMMON AREAS Floors are maintained/clean/no tiles missing Corners clean/no build up Walls/ceiling are clean/stain free Light fixtures covered/working/clean Furniture in good repair & adequate Corridors are free of obstruction Free of pests

4.10

Exit lights RESIDENT ROOMS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Drapes/blinds are clean and maintained/fire retardant Cubicle curtain provides full privacy & clean Resident chairs maintained/adequate # Other furniture in good repair/adequate Bathrooms are clean, in good repair Soap & towels available, free of clutter Bathroom ventilation adequate/vent clean Toilet anchored, set in good repair/clean Sink secure, fixtures clean, no leaks Walls/ceilings in good repair Bed is dust free and in good repair Call light in reach, working properly A/C and heating unit operable and clean Adequate lighting Waste basket, fire retardant, available GENERAL BATH AREAS Ventilation is adequate, vents clean Curtains adequate length, stain free Tile in good repair, walls/ceiling clean

4.11

Toilet area with adequate privacy curtain Toilet, sink, tub, showers in good repair Lighting adequate/covered and working Free of soiled linen, clutter & personal items Supplies/chemicals stored properly Soap, towels available Grab bars securely mounted Shower heads clean and free of lime build up Heating unit operable and clean Thermometer available & used Sanitizing procedure posted DINING ROOM

“U”

“S”

COMMENTS

Tables are proper height for wheelchairs Tables are in good repair and clean Adequate # of chairs available and clean Chairs are in good repair Floor in good repair and clean. No stains Room is free of clutter, dishes Napkins available instead of clothing protectors Pre-post meal grooming materials available Residents can choose where to sit

4.12

OTHER AREAS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Laundry machinery is clean and operating Housekeeping carts are clean Mechanical room is kept locked Chemicals are properly stored Generator tested weekly. Records indicate routine testing/maintenance Water temperature logs are maintained (check for accuracy) Separate clean and soiled linen SAFETY Review OSHA 300 log, 5 years on file with signature Check for MSDS in each department Records indicate employees are trained on use of chemicals/documentation on file Complete book of MSDS’s on file in ED office All chemicals used are labeled properly Chemicals are stored correctly/all departments Employees are informed on Hepatitis B (check personnel files for documentation Exposure Control plan written and inserviced Alarm system in good repair/staff inserviced Housekeeping carts are in view of worker Wet floor/caution signs being used

4.13

Hazardous waste stored correctly/door to room marked appropriately Gait belt policy enforced Proper use of protective material in laundry OSHA sharps container in appropriate places Designated eye wash stations per OSHA policy PERSONNEL RECORDS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Yearly physical, PPD/chest x-ray on file Health records kept for 30 years + length of employment. In separate file Hepatitis B consent/decline form filed Job description categorized per OSHA rules Orientation check list signed 1-9 immigration form in separate file Verification of CNA training/certificate Verification of current license (proof) Reference checks completed on all applicants DIETARY Refrigerator, freezer temps checked & documented Dish machine temp checked/documented daily Food/steam table checked/recorded in each meal Foods in refrigerator covered/labeled/dated

4.14

Thawing foods put in refrigerator correctly Menus posted and followed each meal Substitutes posted in dining room Substitutes freely offered by staff/all meals Therapeutic diets served per M.D.’s order Stock stored correctly/rotated Disaster stock labeled/adequate Cleaning procedures adequate/followed 3 compartment sink used correctly/written policy Dishes/pots dried correctly. No cloths Garbage stored/removed properly Dumpster area clean/doors closed Consultant reports on file Follow-up documentation available Yearly hood inspection available LAUNDRY/HOUSEKEEPING

“U”

“S”

COMMENTS

Linen in good repair/adequate amount Linen available on 11-7 shift System to “rag” out linen Check par level/if linen appears low Soiled linen handled properly by staff

4.15

Clean linen stored properly/covered Residents’ satisfied with laundry service Check closets for storage/neatness Appropriate number of workers available Cleaning schedules posted and followed Chemicals used and stored correctly Carts have locked boxes for chemicals Infection control procedures followed Caution signs used when buffing floors Check electric cords in hallways Wet floor signs clean/used correctly Personnel folders complete/accurate Personal clothing and bibs washed separately SOCIAL SERVICES

“U”

“S”

COMMENTS

Progress notes current/adequate (quarterly) Psycho-social needs are being met (resident interviews) Resident Council active with documentation Check written responses/minutes Interview Resident Council President Active Family Council (if applicable) Admission packet reviewed and signed by resident

4.16

SS follows upon discharge needs of resident Documentation on anticipated discharge form and care plan Advance directive orders in compliance with State Self Determination Act policies in place Current list of living wills and durable POAs’ on health care maintained Grievance procedure in place/used ACTIVITIES

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Progress notes current/adequate (quarterly) Program has variety and meets the needs of all types of residents. Evening activities available Out of facility events being offered All staff support attendance at programs A volunteer program is provided Room visits/one on one visits documented Calendar is current in resident’s room Community & Family involvement encouraged INSERVICE/NURSE AIDE TRAINING Review CNA training program Mandatory inservices posted/offered (calendar) Attendance is documented/sign in sheets Required training hours documented

4.17

Disaster drills scheduled and completed Question staff on “procedures” Fire drills held quarterly/each shift Question staff on “procedure” Inservices content available NURSING ADMINISTRATION

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Full time designated Nurse Manager (DON) in building QA stats being maintained Review current stats Staffing is appropriate for level of care Full time RN staffed minimum one shift per day on certified unit High-risk residents identified appropriately/staff aware of high- risk residents DON has regular staff meetings Procedure to review consultants reports in place Nursing P/P’s reviewed yearly Daily rounds by DON completed Adequate supplies available to staff Central Supply charge system in place/used appropriately RESTORATIVE PROGRAMS Rehab potential assessed on all residents Appropriate programs in place

4.18

- re-feeding/walk and dine - bowel/bladder retraining - ambulation - range of motion - turning/positioning - grooming Therapy providers screening all residents, recommendation noted

Restorative program includes use of handrolls, positioning devices, adaptive eating equipment CARE PLANS AND MDS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Resident assessment schedule in place & current Meetings are scheduled and attended/all disciplines MDS’s current and signed by all departments Quarterly reviews being handled correctly Significant changes identified and addressed through new MDS Resident and/or family invited to care plans and documented Problems and goals realistic and measurable Nurses notes address status of care plan goals CNA’s aware of care plan goals PRESSURE ULCERS Skin assessments done weekly and documented

4.19

Documentation in nurses notes describes ulcers All pressure ulcers are care planned (size, stage, etc.) High-risk residents identified and monitored Preventative methods being used/available Wound care protocols in place Weekly & Monthly stats monitored RESTRAINTS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Evaluation for least restrictive device completed MD order, type, reason, duration & consent completed Therapy involved in determining type Restraint release schedule in place/used Restraints are maintained/adequate Restraint reduction program in place/effective TUBE FEEDING MD order = nutrient, type of tube, amt/24 hour total (caloric total), cc’s/24 hours, cc’s to flush Hydration needs being met RD consultant has assessed all tube feeders & recommendations on chart and addressed Bags labeled as order is written Procedure to change bags daily in place Nutritional needs being met (weight stable)

4.20

Pumps/poles and equipment clean WEIGHT VARIANCE

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Weight variance being addressed Active “Nutrition at Risk” committee/weekly Weight loss/gain addressed on care plan Current height/weight recorded on chart RD recommends interventions as needed Notification of MD & Family per policy/timely MEDICARE Nurses notes address need for skilled care Notes are written daily Certifications are current and signed Staffing meets needs of residents (2:1 ratio) Procedure in place to review stay/coverage Therapy notified of orders promptly Therapy notes current and on chart Medicare sign-in sheets being used Assignments reflect certified rooms for sign-in sheets INFECTION CONTROL Policy and Procedures current & reviewed annually Surveillance log current and updated on an ongoing basis during the month

4.21

Clusters identified and appropriate measures taken Monthly stats of nosocomial infection rate Protocol in place for MRSA residents Abnormal cultures addressed timely LABORATORY SERVICES

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Policy and procedures current/reviewed Lab waiver on file for simple tests – CLIA Blood Glucose log in place and used Lab protocol adequate for facility Current lab on chart Abnormal labs addressed promptly MEDICATIONS Medication pass audit conducted on 10% of residents with less than 5% error rate Medications have reason Psychoactive flow records used/accurate Pharmacy consultant reviews flow sheets Consultant reports reviewed and addressed Med carts clean, in good repair and locked Applesauce is in covered container, dated Water pitcher is clean, covered Medication rooms neat, orderly, locked

4.22

No expired medications on hand Sharps disposed of correctly Med destruction handled appropriately Opening dates on all bottles Narcotic records maintained/accurate Stock meds rotated/adequate Medication refrigeration used appropriately All stock meds labeled when applicable MEDICAL RECORDS

“U”

“S”

COMMENTS

Face sheet current and legible Physician’s orders reviewed and signed Physician’s progress notes current Alternate visit schedule documented Nurses notes current and adequate Cumulative weight sheet on chart Current level of care documented Intake/Output sheets totaled and accurate Adequate documentation left on chart Labeling of charts accurate, legible Medical records provide ongoing audits

4.23

DELIVERY OF DIRECT CARE

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Residents able to be out of bed at times/adequate length of time

Residents appear neat, well groomed Bedfast residents are neat, well groomed All residents are encouraged to go to D.R. Dignity/privacy is promoted, provided Residents are provided autonomy At least 10% of residents interviewed to determine satisfaction of delivery of care Staff aware of needs of assigned residents ACCOMMODATION OF NEEDS Wheelchairs in good repair, available in adequate number/geri- chairs

Over bed tables available to any resident being fed in bed. Clean/in good repair Adaptive feeding equipment available/used Private use of phone available to residents Residents aware of smoking policies/areas Equipment appropriate for individual resident ACCIDENTS/INCIDENTS Safety program promoted by staff Incident reports reviewed daily and logged with appropriate follow-up and investigation as needed

4.24

Medical Director review of all report/signature Analysis report being completed/reviewed monthly Interview staff for awareness of safety rules Safety inservices current/attended Accidents causing injury to residents reported to appropriate state agencies Employee injuries reviewed. Appropriate action taken if injury caused by failure to follow safety procedures CLOSED CHART/MEDICAL RECORDS

“U”

“S”

COMMENTS

“U”

“S”

COMMENTS

Designated medical records person Work area uncluttered & organized Sufficient storage space Records are audited and organized timely Necessary dates and signatures are available Discharge & post discharge plans are available Discharge order written Final nurses notes Disposition of personal effects and medication Discharge summary with final diagnosis INCONTINENCE/FOLEY CATHETER Residents have been assessed Appropriate residents are on B&B program

4.25

There is an incontinence management program There is a medical reason for all catheters There are MD orders with size, frequency of change, and catheter care available State of continence, catheters, etc., is on the MDS and Care Plan OTHER

“U”

“S”

COMMENTS

IV Therapy Policy and Procedures in place Staff trained MD order – type, cc’s/hour, duration Proper documentation Acceptable technique Specialty Services (Vents, Shunts, TPN, etc.) Policy and Procedures in place Staff trained Applicable MD orders Proper documentation Acceptable technique

4.26

MDS/CARE PLAN TRACKING FORM Name:

Room #: Done

MR#: To be done by

Fall Risk Assessment Form Braden Score Assessment AIMS test Medication Restraint Consents (quarterly) Physical Restraint Consents (quarterly) Activity Note Dietary Note Social Services Note Physical Therapy Note – OT-PT Notes Care Plan CAAS Care Planned Raps Done Measurable Goals Old Goals Resolved/Updated Changes Made On MDS to_ to_ to_ to_ to_ to_ Significant Change: _ Date to Re-Evaluate:

4.27

DIETARY INFECTION CONTROL AND SAFETY CHECKLIST Facility

Month / Yr.:

PLACE A CHECK UNDER THE YES OR NO COLUMN APPROPRIATELY WRITE “N/A” IF A QUESTION DOES NOT APPLY TO YOUR FACILITY PERSONAL HYGIENE Employees wear clean and proper uniform including shoes and no excessive jewelry. Effective hair restraints are properly worn and all wear hair nets. Fingernails are short, unpolished and clean. Hands are washed properly, frequently at appropriate times and gloves are worn at all times when serving food.

YES

NO

Burns, wounds, sores, scabs, splints and water-proof bandages on hands are bandaged and completely covered with a foodservice glove while handling food. Eating, drinking, chewing gum, smoking or using tobacco are allowed only in designated areas away from preparation, service, storage and ware washing areas. Employees use disposable tissues when coughing or sneezing and then immediately wash hands. Hand sinks are unobstructed, operational and clean. Hand sinks are stocked with soap, disposable towels and warm water. A hand washing reminder sign is posted. Employee restrooms are operational and clean. FOOD PREPARATION All food stored or prepared in facility is from approved sources. Food equipment, utensils and food contact surfaces are properly washed, rinsed and sanitized before every use. Frozen food is thawed under refrigeration, cooked to proper temperature from frozen state, or in cold running water. Thawed food is not refrozen. Preparation is planned so ingredients are kept out of the temperature danger zone to the extent possible. Food is tasted using the proper procedure. Procedures are in place to prevent cross-contamination. Food is handled with suitable utensils such as single use gloves or tongs. Food is prepared in small batches to limit the time it is in the temperature danger zone. Clean reusable towels are used only for sanitizing equipment and surfaces and not for drying hands, utensils or floor. Food is cooked to the required safe internal temperature for the appropriate time. The temperature is tested with a calibrated food thermometer. The internal temperature of food being cooked is monitored and documented. Handles of pans are turned toward the back of the range. Flames are tuned off when removing pans from the range. Dry potholders are available and used routinely. Fellow workers are warned when pans are hot. Steam equipment is in proper working order. Hot water is regulated to prevent scalding. Lids are lifted cautiously to avoid steam burns. Venting is adequate, hoods, filters and vent ducts are clean. Grease traps are clean with satisfactory waste grease disposal. Ovens and ranges are clean and free of food and grease. Hood works, free of grease, lights work, extinguisher nozzles free of grease/dust and filters are clean.

4.28

HOT HOLDING Hot holding unit / steam table is clean. Food is heated to the required safe internal temperature before placing in hot holding. Hot holding unites are not used to reheat potentially hazardous foods. Hot holding unit is pre-heated before hot food is placed in unit. Temperature of hot food being held is at or above 135°F. Food is protected from contamination. COLD HOLDING Refrigerators are kept clean and organized. Temperature of cold food being held is at or below 41°F. Food is protected from contamination. REFRIGERATOR, FREEZER AND MILK COOLER Thermometers are available and accurate. Freezer temperature reads . (Should be 0° F or below) Refrigerator thermometer reads _. (Should be 40° F or below) Food is stored 6 inches off floor in walk-in cooling equipment, floors dry, fans clean and lighting is covered Refrigerator and freezer units are clean and neat. Proper chilling procedures are used. Only pasteurized eggs are served “soft cooked”. Raw meat and eggs are stored on bottom shelf of refrigerator to prevent juices dripping on other foods. All food is properly wrapped, labeled and dated. All opened food is labeled/dated, in-date, wrapped completely with plastic film (not foil). There are no smudges, fingerprints, dried food particles on refrig/freezer outside surfaces. The FIFO (First In, First Out) method of inventory management is used. Ambient air temperature of all refrigerators and freezers is monitored and documented at the beginning of each shift. FOOD STORAGE AND DRY STORAGE Temperature of dry storage area is between 50°F and 70°F or State public health department requirement. All food and paper supplies are stored 6 – 8 inches off the floor on sanitizable shelves and 12” from the ceiling, All food is labeled with name and received date. Open bags of food are stored in containers with tight fitting lids and labeled with common name. The FIFO (First In, First Out) method of inventory management is used. There are no bulging or leaking canned goods. Food is protected from contamination. All food surfaces are clean. Chemicals are clearly labeled and stored away from food and food-related supplies. There is a regular cleaning schedule for all food surfaces. Food is stored in original container or a food grade container. CLEANING AND SANITIZING 3-compartment sink is properly set up for ware washing. Dish machine is working properly (such as gauges and chemicals are at recommended levels. Water is clean and free of grease and food particles. Water temperatures are correct for wash water (150° or state reg) and rinse (water is 180°). If heat sanitizing, the utensils are allowed to remain immersed in 171°F water for 30 seconds.

4.29

If using a chemical sanitizer, it is mixed correctly and a sanitizer strip is used to test chemical concentrations. ("WASH" temp is 120 degrees F) ("RINSE" 50ppm Chlorine) Smallware and utensils are allowed to air dry. Wiping cloths are stored in sanitizing solution while in use. UTENSILS AND EQUIPMENT All small equipment and utensils, including cutting boards and knives, are cleaned and sanitized between uses. Small equipment and utensils are washed, sanitized and air-dried. Broken dishes are promptly disposed of properly. Knives are stored in the slotted case provided for them. Knives are not put into the sink when soiled. Work surfaces and utensils are clean. Work surfaces are cleaned and sanitized between uses. Thermometers are cleaned and sanitized after each use. Thermometers are calibrated on a routine basis. Can opener is clean and blade not badly worn. Drawers and racks are clean. Clean utensils are handled in a manner to prevent contamination of areas that will be in direct contact with food or a person’s mouth. Employees are instructed in proper use of pressurized cookers. LARGE EQUIPMENT Food slicer is clean. Food slicer is broken down, cleaned and sanitized before and after every use. A safety hood is over the slicer after use/cleaning. Safety devices are provided on slicers and choppers. Slicer and mixer bowl are covered when not in use. Exhaust hood and filters are clean. GARBAGE STORAGE AND DISPOSAL Kitchen garbage cans are clean and kept covered. Garbage cans are emptied as necessary. Boxes, containers and recyclables are removed from the site. Loading dock and area around dumpsters are clean and odor-free. Dumpsters are clean. Loading docks, ramps and stairways are in good repair. There are separate waste receptacles for garbage, trash and glass. PEST CONTROL Outside doors have screens, are well-sealed and are equipped with a self-closing device. No evidence of pests is present. There is a regular schedule of pest control by a licensed pest control operator. SAFETY MISCELLANEOUS All electrical cords are in proper repair with sufficient outlets for equipment in use. Corridors and aisles are free of debris and adequate for personnel and materials. All work surfaces and shelving is in good repair and not rusting or splintered. Articles on shelves are placed securely.

4.30

Step ladders are sturdy and in good repair. Mops are hung-up; brooms, etc. are stored properly. Lighting is adequate to facilitate work. Fire extinguishers are adequate and routinely checked. Gas pipes are free of leads and are routinely checked. Eyewash area is clearly marked and equipment is adequate. Floor surfaces are clear of trash/food particles, clean, dry and free of cracks or holes and grates over the floor drains. Walls are free of splatters, damage, chips and/or peeling paint. Papers are all in covers on clean bulletin board. Ceiling is in good repair and appears clean, with clean, unbroken light fixtures – bulbs working/bulbs covered. Food carts are clean (including wheels) and disinfected, in good working order and easily moved. Food is covered or wrapped during transport. Dietary employees understand and follow Standard Precautions/Infection Control and Safety Rules and are inserviced annually. Dietary employees can locate blood spill kit and verbalize correct usage of kit. Dietary employees have been instructed and follow proper lifting techniques. All machines are securely anchored and properly guarded. Dietary employees are trained in use of fire extinguishers. MSDS and Safety Manuals are available in the dietary department. Floors do not have any slip, trip or fall hazards. Sharp tools are correctly handled and safely stored. Lighting is adequate in all work and storage areas. Worktables are substantial and sufficient in size. Hand trucks and dollies are properly used, maintained and stored. Employees report unsafe conditions to their supervisor. Sewage and plumbing meet state or local law. Manager’s office is free of clutter/organized. If a deficiency is indicated, list action to correct:

Completed by

Date

4.31

INFECTION CONTROL AND SAFETY SURVEILLANCE:

HOUSEKEEPING

Responsible Person:

Date:

Yes

No

Floor is clean and free of debris and does not have any slip, trip or fall hazards.

Yes

No

Wall, ceilings and vents are clean.

Yes

No

Soap and paper towel dispensers are full.

Yes

No

Wastebaskets are lined with a plastic bag emptied daily and are non-combustible.

Yes

No

All doorknobs are disinfected daily.

Yes

No

All bathrooms are cleaned daily according to housekeeping’s policy.

Yes

No

Hallways and hallway handrails are cleaned and disinfected.

Yes

No

Mop water and mop heads are changed every 4 rooms or as needed.

Yes

No

Regulated waste is handled per facility policy.

Yes

No

Garbage receptacles have covers and are cleaned and emptied daily in the dining room, utility rooms and medication rooms.

Yes

No

The smoking area is clean and free of debris.

Yes

No

Ash trays and ash cans are noncombustible and free of paper and plastic.

Yes

No

Carpets appear clean and spot free.

Yes

No

Utility gloves are worn and washed with soap and water

Yes

No

_

Personal protective equipment such as gloves, goggles and gowns are used when handling potentially hazardous chemicals, acids, detergents

Yes

No

Housekeeping employees are in-serviced annually and understand and follows Standard Precautions / Infection Control and Safety Rules.

Yes

No

Housekeeping carts are locked when not in sight.

Yes

No

Cleaning supplies are not easily accessible to cognitively impaired residents.

Yes

No

Chemicals are properly labeled, safely arranged and stored in a closed, locked area and staff is properly trained in their use.

Yes

No

Housekeeping employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No

Employees have been instructed on proper lifting and handling techniques.

Yes

No

Handles of tools are free of splinters and rough surfaces.

4.32

Yes

No

Buckets, tubs and pans are in good repair.

Yes

No

Vacuum cleaners, buffers and scrubbers are in good repair.

Yes

No

Electric tools are properly grounded.

Yes

No

Broken glass is properly and safely handled and disposed.

Yes

No

Tools, carts and mop handles are placed to prevent interference with normal operations or tripping hazards.

Yes

No

Spillages are wiped up immediately.

Yes

No

“Wet Floor” caution signs are used when appropriate.

Yes

No

A dry passage is maintained when mopping.

Yes

No

Equipment room is clean and orderly.

Yes

No

MSDS & Safety Manuals are available in each department.

Yes

No

Floors do not have any slip, trip or fall hazards.

Yes

No

Employees are trained in the use of fire extinguishers.

Corrective action and/or follow-up required:

4.33


DIETARY

Responsible Person:

Date:

Yes

No

Refrigerator is clean and food within is dated and covered.

Yes

No

Refrigerator thermometer reads

Yes

No

Only pasteurized eggs are served “soft cooked”.

Yes

No

Raw meat and eggs are stored on bottom shelf of refrigerator to prevent juices

. (should be 40 degrees F or below)

dripping on other foods. Yes

No

Bulk storage areas are clean, orderly and well arranged.

Yes

No

Food containers are stored off of the floor.

Yes

No

Shelving is in good repair and not rusting or splintered.

Yes

No

Ovens and ranges are clean and free of food and grease.

Yes

No

Freezer temperature reads

Yes

No

Food in steam table reads

Yes

No

Hood filters are clean.

Yes

No

Food slicer is clean and free of food particles.

Yes

No

Floor surfaces are clean, dry and free of cracks or holes and grates over floor drains.

Yes

No

Walls and ceiling are free of chipped and/or peeling paint.

Yes

No

Food carts are clean and disinfected, in good working order and easily moved.

Yes

No

Food is covered or wrapped during transport.

Yes

No

All tables and chairs in the dining rooms are clean and free

. (should be 0 degrees F or below) .

of food particles. Dish washing machine “wash” water is 150-165 degrees.

Yes

No

Yes

No

Yes

No

Dish machine “rinse” water is 180 degrees. For chemical sanitizer "wash" temp is 120. Final "rinse" 50ppm hypochlorite (chlorine)

Yes

No

Logs are completed every shift for chemical titration.

Yes

No

Dishwasher chemical readings recorded per policy.

Yes

No

All chemicals properly labeled and stored away from food.

4.34

Yes

No

Cleaning schedules posted and followed.

Yes

No

Dietary Personnel wash hands appropriately and wear gloves when serving food.

Yes

No

All hand washing facilities are properly stocked with soap and paper towels.

Yes

No

Hair nets are worn by all dietary employees and uniforms are clean.

Yes

No

Food temps are taken daily and logged and are within acceptable range: Hot foods > 140 degrees; Cold foods = or < 41 degrees

Yes

No

All garbage containers and dumpsters in good condition with no leaking and waste is contained with lids closed.

Yes

No

Kitchen and dining area are pest free.

Yes

No

Dietary employees are in-serviced annually and understand and follow Standard Precautions / Infection Control and Safety Rules.

Yes

No

Dietary employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No


Yes

No

All machines are securely anchored and properly guarded.

Yes

No

Sharp tools are correctly handled, cleaned and stored

Yes

No

Loading docks, ramps and stairways are in good repair.

Yes

No

There are separate waste receptacles for garbage, trash and glass.

Yes

No

Employees are trained in use of fire extinguishers.

Yes

No


Yes

No



4.35


Responsible Person:

REHABILITATION DEPARTMENT

Date:

Yes

No

All work areas are cleaned and disinfected after each resident’s use.

Yes

No

Service area is clean and free of peeling paint, chips, and cracked equipment/.

Yes

No

All equipment is cleaned and disinfected after each resident’s use.

Yes

No

Linens or towels are cleaned and stored in a cupboard when not in use.

Yes

No

Sink is cleaned and disinfected after each resident’s use.

Yes

No

Chemicals are properly labeled and stored in a closed, locked area.

Yes

No

Proper hand washing is performed after each procedure.

Yes

No

Rehab employees are in-serviced annually and understand and follow Standard Precautions/Infection Control and Safety Rules.

Yes

No

Gloves, gowns and eye protection are used appropriately.

Yes

No

Rehab employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No


Yes

No



4.36


NURSING DEPARTMENT

Responsible Person:

Date:

Yes

No

Hand washing is followed per policy.

Yes

No

Isolation precautions are followed per policy.

Yes

No

Treatment cart is clean, stocked and well organized and disinfected as needed and locked when not in sight of nurse.

Yes

No

Top of cart is free of equipment, i.e. BP cuff, stethoscope.

Yes

No

Gloves and/or gowns are used appropriately. Hands are washed after removal of gloves.

Yes

No

Gloves are available and disposed of in resident’s room or plastic bag on dirty linen barrel.

Yes

No

Nurses dispose of contaminated dressings in biohazard containers.

Yes

No

Catheter care observed and completed correctly according to policy and procedure.

Yes

No

Tracheotomy care observed and completed according to policy and procedure.

Yes

No

Medication pass observed and completed correctly.

Yes

No

Medication cart is clean and locked when not in sight of nurse.

Yes

No

Tube feeding procedure observed and completed correctly. Tube feeding equipment changed per protocol.

Yes

No

Oxygen tubing changed per protocol.

Yes

No

Policy and procedure for handling oxygen equipment is followed correctly.

Yes

No

Cultures are obtained according to policy and procedure.

Yes

No

Work areas are kept free of food and drink.

Yes

No


Yes

No

Nursing employees are in-serviced annually and understand and follow Standard Precautions / Infection Control and Safety Rules.

Yes

No

Nursing employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No

Items in bedside table drawer are separated and bagged.

4.37

Yes

No

Bedpans, urinals and wash basins present, clean and bagged if not stored in resident’s bedside table.

Yes

No

No perishable food is present in bedside tables.

Yes

No

Resident’s personal refrigerator clean and temp is = or < 40 degrees.

Yes

No

No medication in bedside table (except for self-medicate with proper assessment and documentation).

Yes

No

Wheelchairs clean.

Yes

No

Bedside commodes clean.

Yes

No

IV poles clean.

Yes

No

Tube feeding pump and pole clean, bottles dated, tubing changed every 24 hours.

Yes

No

Nursing employees are in-serviced annually and understand and follow Standard Precautions / Infection Control, Safety Rules and Fire and Evacuation Plan.

Yes

No

Nursing staff understands and uses standard precautions appropriately.

Yes

No

Nursing employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No

Gloves, goggles and masks are used appropriately.

Yes

No

Hallways are unobstructed.

Yes

No

Exits are not locked or blocked.

Yes

No

Employees wear proper clothing and footwear.

Yes

No

Employees have been instructed on proper lifting and transferring techniques including mechanical and electrical lifts.

Yes

No

Gait belts are available and used.

Yes

No

There is a method of identifying residents requiring 2 or 3 person transfer or mechanical lift.

Yes

No

Proper lifting equipment is utilized.

Yes

No

Combative residents are identified.

Yes

No

Proper footwear is worn.

Yes

No

All maintenance problems are reported for repair.

4.38

Yes

No

Electric cords for lights, radio, TV, etc. are safely placed.

Yes

No

No electrical extension cards are in use.

Yes

No

Bed adjustment handles are kept turned inward.

Yes

No

Chemicals are safely stored and handled.

Yes

No

Contaminated needles/sharps are disposed of in a puncture proof container.

Yes

No

Proper instructions are given and applied when handling or using oxygen and other flammable gases.

Yes

No

“No Smoking” is enforced in rooms where oxygen is being administered.

Yes

No

Oxygen tanks are secured at all times.

Yes

No

Smoking is only allowed with proper supervision in designated areas.

Yes

No


Yes

No


Yes

No

Employees are trained in the use of fire extinguishers.

Yes

No_

All wandering alarm bracelets are checked for placement and functioning daily and documented.

Yes

No

All door alarms are checked for functioning and documented weekly.


4.39


Responsible Person:

SHOWER / WHIRLPOOL ROOM

Date:

Yes

No

Shower chairs are disinfected after each resident’s use.

Yes

No

Tubs and whirlpool are disinfected and cleaned according to facility policy. Policy is posted in Shower room.

Yes

No


Yes

No

Resident’s personal items are labeled.

Yes

No

Privacy curtains are in place and used.

Yes

No

Room is well ventilated.

Yes

No

Shower room is clean, odor free and no dust is present.

Yes

No

Sharps container readily available, capped when ¾ full and NOT accessible to residents.

Yes

No

Shower floor is free of hazards and grates over floor drains.

Yes

No


Yes

No


Yes

No

Bathing facilities have non-slip surfaces.

Yes

No

Water temps are taken weekly and logged and within acceptable range. (NOT to exceed 110 degrees).


4.40


LAUNDRY

Responsible Person:

Date:

Yes

No

Clean linen is covered during transport.

Yes

No

All clean linen is kept separate from soiled linen.

Yes

No

All soiled linen is stored in a designated area.

Yes

No

Contaminated linen (blood soaked) is adequately marked, kept separate from soiled linen and washed separately.

Yes

No

Laundry appliances are cleaned according to Laundry’s Cleaning Policy.

Yes

No

Rubber gloves and water resistant gowns are worn during sorting of soiled laundry.

Yes

No

Washing machine wash temperature is maintained at

degrees (may vary with

concept program). Yes

No

Dryer temperature is maintained at 160 degrees (may vary with concept program). Lint is removed as needed.

Yes

No

Soiled linen containers are lined with plastic bags.

Yes

No

Soiled lined barrels are cleaned per schedule.

Yes

No

Laundry employees are in-serviced annually and understand and follow Standard Precautions / Infection Control and Safety Rules and safe handling techniques of contaminated laundry.

Yes

No


Yes

No

Laundry employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No

Linen is NOT stained, torn or thread bare and there is a system in place to remove this type of linen.

Yes

No


Yes

No

Proper sorting and loading techniques are used, monitored and reinforced.

Yes

No

All V-belts, chain drives, gears or sprockets are guarded.

Yes

No

All electrical wiring is in conduit and safely fused with no evidence of corrosion.

Yes

No

Laundry carts are free of jagged edges.

4.41

Yes

No

All castered or wheeled equipment is in good repair.

Yes

No

Laundry floors are free of cracks and foreign matter and grates over floor drains.

Yes

No

Pilot light areas on dryers are kept free of combustible build up.

Yes

No

Eye and hand protection is used when using acids, bleaches, soaps and detergent.

Yes

No

Chemical feed tubes are cleaned and maintained properly.

Yes

No

Laundry area has adequate ventilation.

Yes

No

Portable air fans safely arranged and guarded.

Yes

No

Fire emergency instructions are posted.

Yes

No

Laundry employees are trained in use of fire extinguishers.

Yes

No


Yes

No



4.42

INFECTION CONTROL AND SAFETY SURVEILLANCE: Responsible Person:

ACTIVITIES / SOCIAL SERVICES Date:

Yes

No


Yes

No

All reusable equipment/supplies are cleaned and disinfected after resident’s use.

Yes

No

Area is clean and free of peeling paint, chips, cracked furniture or equipment.

Yes

No

Activities/Social Services employees are in-serviced annually and understand and follow Standard Precautions/Infection Control.

Yes

No

Volunteers have been in-serviced on prevention and potential sources of infection.

Yes

No


Yes

No

Activities/Social Services employees can locate blood spill kit and verbalize correct usage of kit.

Yes

No

Gloves and/or gowns are used appropriately.

Yes

No


Yes

No


Yes

No

Activity employees are trained in use of fire extinguishers.


4.43


BEAUTICIAN / BARBER SERVICES

Responsible Person:

Date:

Yes

No


Yes

No

Service area is clean and free of peeling paint, chips, and cracked equipment.

Yes

No

All reusable equipment (brushes, combs, clips, curlers) are cleaned and disinfected after each resident’s use.

Yes

No

Capes and towels are cleaned and stored in a cupboard when not in use.

Yes

No

Sink is cleaned and disinfected after each resident’s use.

Yes

No

Hair is removed from the floor after each resident’s haircut.

Yes

No

Chemicals are properly labeled and stored in a closed locked area.

Yes

No

Proper hand washing is performed after each procedure.

Yes

No

Beautician and barber are in-serviced annually and understand and follow Standard Precautions/ Infection Control.

Yes

No

Beautician and barber can locate blood spill kit and verbalize correct usage of kit.

Yes

No

Gloves and/or gowns are used appropriately.

Yes

No


Yes

No



4.44


Responsible Person:

UTILITY ROOM

Date:

Yes

No

Dirty utility hopper sink is clean and in working order.

Yes

No

Dirty linen barrels remain covered and emptied when necessary.

Yes

No

No linen barrels on floor at mealtime.

Yes

No

Barrels cleaned per facility schedule and policy.

Yes

No

Utility room clean and neat at end of each shift.

Yes

No

Dirty utility room is odor free.

Yes

No

Gloves, gowns and face protection available in the dirty utility room and used appropriately.

Yes

No

Disinfectant is stocked and available.

Yes

No


Yes

No

Potential sources of infection are appropriately reported to Infection Control Officer / QA Committee.

Yes

No


Yes

No



4.45


PHARMACY / MED ROOM / MEDICATION CART

Responsible Person:

Date:

Yes

No

All work areas are cleaned and disinfected as needed.

Yes

No

Sink is cleaned and disinfected.

Yes

No

Floor is clean and free of debris.

Yes

No

Garbage receptacles have covers, are lined with a plastic bag and emptied daily or as needed.

Yes

No

Medicine receptacles (i.e. soufflé cups, plastic med cups) and water cups are stored in a clean and dry area.

Yes

No

Outside and inside of medication cart is clean.

Yes

No

Stock meds are stored in cabinets free from dust.

Yes

No

Med carts do not enter resident rooms.

Yes

No

Top of med cart is free of medication.

Yes

No

Oral and topical medications are separated in med cart.

Yes

No

Refrigerator clean and organized with a thermometer.

Yes

No

Refrigerator temps are taken and documented daily and are between 36 - 45 degrees. Refrigerator temp is

Yes

No

.

Sharps containers are readily available, capped when ¾ full and not accessible to residents.

Yes

No


Yes

No



4.46


CENTRAL SUPPLY

Responsible Person:

Date:

Yes

No

All work areas are cleaned and disinfected as needed.

Yes

No

Sink is cleaned and disinfected.

Yes

No

Floor is clean and free of debris.

Yes

No

Garbage receptacles have covers, are lined with plastic bag and emptied daily.

Yes

No

All reusable equipment is cleaned, disinfected and properly stored after each resident’s use.

Yes

No

All supplies are stored in an organized and neat manner.

Yes

No

Storage area is clean and free of peeling paint, chips, and cracked equipment.

Yes

No

Yes

No

Personal Protective Equipment (gloves, gowns, masks) is readily available and easy to locate. Safety sharps devices (retractable syringes and lancets, and needleless IV supplies) are only used and are readily available and easy to locate.

Yes

No

No supplies are stored directly on the floor.

Yes

No


Yes

No



4.47


HAZARDOUS WASTE

Responsible Person:

Date:

Yes

No

Sharps containers are readily available, capped when ¾ full and are NOT accessible to residents.

Yes

No

Soiled utility rooms have biohazard signage.

Yes

No

Regulated waste containers are closable, leak proof, clearly marked and located in the soiled utility room.

Yes

No

Nurses dispose of contaminated dressings by double bagging.

Yes

No

Trash / garbage (non-contaminated) is not placed in the biohazard container.

Yes

No

Only safety sharps devices, such as retractable syringes and lancets, and needleless IV supplies are used.

Yes

No

Biohazard waste is picked up and disposed of by an outside source in a timely manner.

Yes

No

Disposal log is up to date and accurate.

Yes

No


Yes

No



4.48


ADMINISTRATIVE

Responsible Person:

Date:

Yes

No

TB records and logs of residents and employees are to date.

Yes

No

Flu vaccines and Pneumovax are offered annually with proper consent obtained.

Yes

No

Sharps injury log is up to date.

Yes

No

Employee physicals are up to date, if applicable.

Yes

No

Hepatitis B declination and/or vaccinations are complete and documented in the employee’s personnel file.

Yes

No_

Annual in-services on Infection Control and Standard Precautions and Safety have been held, are on file and have employee signatures indicating attendance.

Yes

No

Policies and procedures regarding Occupational Exposure are reviewed annually and updated to reflect new or modified tasks or procedures.

Yes

No

Exposure Control plan, Safety Manual and MSDS Sheets are accessible to employees.

Yes

No

Facility has an up to date disaster plan which is available to all departments.

Yes

No

Facility has a written protocol that defines the source of water for the facility to ensure water is available when there is a loss of normal water supply.

Yes

No


Yes

No

Employee files have documentation of infection control and safety orientation.

Yes

No

Handrails provided and are securely fastened.

Yes

No

Furniture and fixtures are free of splinters or sharp edges.

Yes

No

Desk and file drawers easily operated and anchored to prevent tipping.

Yes

No

All electric cords, plugs, switches are in good repair.

Yes

No

Smoking is allowed only in the designated areas which are posted.

Yes

No

Storage areas are kept clean and orderly.

Yes

No_

All machines and heating elements are turned off at the end of office hours, or when not in use.

Yes

No

All door alarms are checked weekly for functioning and logged.

Corrective action and/or follow-up required: 4.49


Responsible Person:

MAINTENANCE

Date:

Yes

No


Yes

No

Work areas are clean, orderly, and safely arranged.

Yes

No

Hand rails are securely fixed to the wall and have no sharp edges or splinters.

Yes

No

All hand tools are in good repair, properly stored.

Yes

No

No electrical appliances have frayed wires.

Yes

No

All electric and gasoline powered equipment are well maintained.

Yes

No

Point of operation guards are provided and used.

Yes

No

Eye protection is provided and used where required.

Yes

No

Elevated platforms, step ladders and extension ladders are well constructed and in good repair.

Yes

No

All ladders are provided with non-slip base.

Yes

No

Work areas are isolated or barricaded to prevent outside interference.

Yes

No

Electrical switch lockouts / tagouts are used when making repairs on machinery.

Yes

No

Warning signs or barricades are placed when work creates a hazard to others.

Yes

No

Loose tools and materials are located so tripping hazards are not created.

Yes

No

Safety lines are used when working above ground level.

Yes

No

All ropes, cables, chains, etc. are inspected and adequate for the job.

Yes

No

Safe methods are used when replacing burned out lights and tubes

Yes

No

All electrical motors, machines, etc. on a preventive maintenance schedule.

Yes

No

All electrical plugs, switches, cords in good repair.

4.50

Yes

No

All wandering bracelets are checked daily for functioning and logged on MAR.

Yes

No

Proper type and number of fire extinguishers are available.

Yes

No

Employees are trained to use extinguisher.

Yes

No

Employees are instructed in fire reporting and emergency duties.

Yes

No

Departmental surveys are being reviewed and prompt action initiated on any safety hazards.

Yes

No

Annual Safety Objectives are on timetable for completion.

Yes

No

Workers’ Compensation claims are reviewed.

Yes

No

Resident incidents are reviewed in safety meetings.

Yes

No

Discipline procedures are being followed if employee violates safety rules.

Yes

No

List of residents who require 2-3 person or Hoyer lift is posted on assignment sheet and care plan.

Yes

No

Areas non-accessible to residents (mechanical rooms, oxygen storage, janitor’s closets, etc.) properly marked and locked to prevent sight impaired or confused residents from entering.

Yes

No


Yes

No



4.51

Administrator’s Daily Kitchen Rounds Area

In Compliance

Out of Compliance

Corrective Action

Milk, Eggs, Poultry, Fish, Meat stored and Handled properly Containers stored off of the floors Daily and Weekly Cleaning Schedules are Posted and Followed Temperature Logs for Freezers and Coolers Posted and Documentation is Complete All Food is covered, Labeled, and dated No personal items in Coolers or Freezers Dish Machines reach appropriate temp: Low Temp at 140 degrees or High Temp at 180 degrees with rinse Menu’s are followed with Menu changes documented with RD signature Meal temp’s are recorded on the Menu Meal Looks appealing with appropriate garnish Exhaust Hood clean with appropriate documentation Chemicals are stored away from food prep area Hair Nets

4.52

Extended menus available Dumpster lid closed When not in use, Garbage pails are closed and stored away from food prep area Ceiling is in good repair and appears clean with clean, unbroken light fixtures, all bulbs working and all bulbs covered Hood is free of grease, operational lights work, extinguisher nozzles free of grease and dust and the filters are clean Walk-in floors dry, fans clean, covered lighting Food transport prevents contamination Frozen foods are thawed properly Slicer and mixer bowl are covered when unused All refuse containers are covered, clean and adequate There is no sign of pest infestation Non-food and chemicals are stored away from food

4.53

Environmental Services Tool Cleaning Procedures for Residents Rooms Policy: The resident rooms will be cleaned on a daily basis. 1. Are housekeepers using gloves and safety glasses when needed /as well removing gloves as appropriate? YES/NO. If NO – EXPLAIN: 2. Are housekeepers knocking before entering resident’s room? YES/NO. If NO – EXPLAIN: 3. Are employees cleaning all horizontal surfaces of bed side tables, over-bed tables, foot and headboards, side rails, desk, chairs, and resident’s personal belongings, TV, telephones, picture frames, etc. and all other furniture in the room? YES/NO. If NO – EXPLAIN: 4. Is housekeeping dust mopping and wet mopping the entire floor? YES/NO. If NO – EXPLAIN: 5. Are housekeepers using wet floor signs at appropriate times? YES/NO. If NO – EXPLAIN: 6. How often is mop water being changed/per procedure every three rooms or more often as needed? YES/NO. If NO – EXPLAIN: 7. Do housekeepers know the procedures when cleaning a transferred or discharged resident's room? YES/NO. If NO – EXPLAIN:

Cleaning Procedures for Restrooms Policy: Restrooms are to be cleaned daily and as needed 1. Are the housekeepers cleaning from high to low areas within the restroom? YES/NO. If NO – EXPLAIN: 2. Are housekeepers cleaning the following areas daily/using proper disinfectant/cleaner: walls, wall hangers, shelves, lights, mirror doors and frames, kick-plates, switch-plates, sink and faucet, any exposed pipes; toilet should be the last item in the restroom cleaned? YES/NO. If NO – EXPLAIN: 3. Replenish supplies - paper towels, toilet paper, and hand soap when needed? YES/NO. If NO – EXPLAIN: 4. Sweep and wet mop restroom floor; place wet floor sign down until floor is dry? YES/NO. If NO – EXPLAIN:

4.54

Housekeeping Carts, Equipment, and Housekeeping Closets Policy: The materials and supplies used by the custodians are to be maintained on a daily basis and appropriate equipment shall be placed on a preventative maintenance schedule. 1. Housekeeping carts and equipment are cleaned at the end of shift? YES/NO. If NO – EXPLAIN: 2. Cart and all shelves on the cart? YES/NO. If NO – EXPLAIN: 3. Mop bucket, mop wringer, mop handle and all wet floor signs? YES/NO. If NO – EXPLAIN: 4. Scrubbers and buffers are disinfected? YES/NO. If NO – EXPLAIN: 5. Pads removed and cleaned and allowed to air dry? YES/NO. If NO – EXPLAIN: 6. Plungers are disinfected and put inside of a clean trash bag? YES/NO. If NO – EXPLAIN: 7. All equipment checked for any damages? YES/NO. If NO – EXPLAIN: 8. No food or drinks are kept on housekeeping carts or equipment? YES/NO. If NO – EXPLAIN: 9. Are housekeeping carts locked when unattended for any period of time? YES/NO. If NO – EXPLAIN: 10. Are housekeeping carts being stored in a safe area throughout the day? YES/NO. If NO – EXPLAIN: 11. Are chemicals stored and locked inside of housekeeping carts and not on top of carts? YES/NO. If NO – EXPLAIN: 12. Are janitor closets kept locked? YES/NO. If NO – EXPLAIN: 13. Are all chemical bottles labeled clearly and stored properly? YES/NO. If NO – EXPLAIN: 14. Are all aerosol cans that are not being used by housekeeping staff, stored in a fireproof cabinet? YES/NO. If NO – EXPLAIN: 15. Are there MSDS sheets for all chemicals used within the facility? YES/NO. If NO – EXPLAIN: 16. Does staff know where to locate the MSDS sheets? YES/NO. If NO – EXPLAIN:

4.55

Laundry Procedures -Personal Protective Equipment 1. Are PPE available to laundry staff? YES/NO. If NO – EXPLAIN: 2. Are laundry staff using PPE while handling soiled linen and residents’ personals and loading washers? YES/NO. If NO – EXPLAIN: 3. Is staff removing their Fluid Resistant Gown after handling soil linen and using a new one each time they sort linen? YES/NO. If NO – EXPLAIN: 4. Is staff washing their hands before leaving the soiled area? YES/NO. If NO – EXPLAIN:

Cleaning of Laundry Equipment Policy: The laundry department staff shall ensure that all laundry equipment/areas are properly cleaned and disinfected on a regularly schedule basis. 1. Are the washers and dryers fronts cleaned daily? YES/NO. If NO – EXPLAIN: 2. Are the folding tables and area cleaned daily? YES/NO. If NO – EXPLAIN: 3. All sinks and sink areas cleaned daily? YES/NO. If NO – EXPLAIN: 4. Soiled linen holding carts and cover-up containers cleaned daily or as needed? YES/NO. If NO – EXPLAIN: 5. Housekeeping, dietary and PT soiled containers cleaned daily or as necessary? YES/NO. If NO – EXPLAIN: 6. Are the washer and dry filters cleaned daily? YES/NO. If NO – EXPLAIN: 7. Is the soiled linen room cleaned daily? YES/NO. If NO – EXPLAIN:  Carts  Floor  Scales 8. Are following items/areas being cleaned and disinfected on a weekly basis? YES/NO. If NO – EXPLAIN:  Clean linen carts  Clean linen room racks  Shelves  Clothing delivery carts

Resident Clothing Delivery Policy: residents Clothing shall be delivered to residents on a daily basis. 1. Is the laundry staff delivering residents clothes on a daily basis? YES/NO. If NO – EXPLAIN: 4.56

Facility Inspection Facility ________________________________

A. Entrance/Lobby/Sitting Room

Possible Score

Walkway free of litter?

6

Cigarette urns clean and free of trash? Walkway free of cigarette butts? Walk off mats clean and in proper location? Entrance glass free of finger prints? Lobby is odor free? Corners clean?

Inspection Date __________________________ Administrator ___________________________

SCORE

B. Corridors and Walls

Possible Score

SCORE

C. Equipment

Possible Score

30

Buffer clean?

3

6 6 6

Corridors clean, waxed, polished and/or corridor carpets clean, free of spots? All decoration on walls free of dust? Baseboards clean and polished? Ceiling lights clean and clear?

3 3 3

Vacuums clean? All equipment in running order? Mop buckets clean?

3 3 3

6 6 6

Ceiling vents clean? Corners neat and clean? Fire extinguishers clean?

3 3 3

3 3 3

Floors (Carpets) clean of dirt, dust, litter?

6

3

Floors clean, waxed, polished and/or carpet clean, fresh where applicable? Lights clean and clear? Baseboards clean? Furniture clean and arranged neatly? Visible ledges free of dust?

25

Floor is free of marks left by wheelchairs, etc.? Corridors free of odors?

Chemicals stored appropriately? Correct labels in use? No food or drink on Housekeeping cart? Housekeeping carts clean and orderly?

3

Closet free of all unnecessary items?

3

3 3 3 3

5

Floor sink and drain clean? Janitor closet clean and orderly Mops clean and stored appropriately? Material Safety Data Sheets (MSDS) available? Maintenance Room clean and orderly?

3 3 3 3

Plants and ornaments clean?

Handrails clean and free of debris? Kick plates shined? Walls clean and free of smudges? Wet floor sigs in place when mopping floor? Walls painted/papered and free or damage?

Vents clean? Public rest rooms clean, free of trash? Total

5 4 108

Total

66

5 5 5 6

3

SCORE

3

3

42

Projects __________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

4.57

Possible Score

Resident Rooms Is room odor free? Is toilet bowel clean? Mirrors shined? Pipes clean and free of dust and dirt? Sink free of soap buildup (top & bottom)? Bathroom floor clean? Cubicle curtains, drapery, valances, clean? Floor clean or dirt, dust and litter? Floor finished with wax? Baseboards clean? Furniture clean? Ledges free of dust? Lights free of dust? Vents clean? Walls clean and free of spots? Waste basket clean and free of litter? Windows clean and free of finger prints? Total

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82

Possible Score

Room #

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82 Possible Score

Departments/Offices Baseboards clean? Cabinet & Counters clean? Ceiling lights clean and clear? Corners neat and clean? Floor clean of dirt, dust and litter? Floor waxed or carpet clean? Furniture cleaned? Ledges free of dust? Nothing stored on floor? Vents and registers clean? Walls clean and free of smudges? Waste baskets clean and freshly lined? Window blinds free of dust? Windows clean and free of smudges? Waste basket clean and free of litter? Windows clean and free of finger prints? Total

Room #

Room/ Office

Possible Score

Possible Score

Room #

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82 Room/ Office

Possible Score

Possible Score

Room #

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82 Room/ Office

Possible Score

Possible Score

Room #

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82 Room/ Office

Possible Score

2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2

31

31

31

31

31

Room/ Office

4.58

Facility Inspection Report Possible Score

A. Entrance/Lobby/Sitting Room Walkway free of litter?

6

Cigarette urns clean and free of trash? Walkway free of cigarette butts? Walk off mats clean and in proper location? Entrance glass free of finger prints? Lobby is odor free? Corners clean? Floors (carpets) clean of dirt, dust, litter?

6 6 6

Floors clean, waxed, polished and/or carpet clean, fresh where applicable? Lights clean and clear? Baseboards clean? Furniture clean and arranged neatly? Visible ledges free of dust? Plants and ornaments clean? Vents clean? Public rest rooms clean, free of trash? Total

25

C. Equipment Buffer clean? Vacuums clean? All equipment in running order? Mop buckets clean? Chemicals stored appropriately? Correct labels in use? No food or drink on Housekeeping cart? Housekeeping carts clean and orderly? Closet free of all unnecessary items? Floor sink and drain clean? Janitor closet clean and orderly Mops clean and stored appropriately? Material Safety Data Sheets (MSDS) available? Maintenance Room clean and orderly? Total

SCORE

6 6 6 6

5 5 5 6 5 5 4 108

Possible Score

SCORE

Possible Score

B. Corridors and Walls Corridors clean, waxed, polished and/or corridor carpets clean, free of spots? All decoration on walls free of dust? Baseboards clean and polished? Ceiling lights clean and clear?

30

Ceiling vents clean? Corners neat and clean? Fire extinguishers clean? Floor is free of marks left by wheelchairs, etc.? Corridors free of odors?

3 3 3 3

Handrails clean and free of debris? Kick plates shined? Walls clean and free of smudges? Wet floor sigs in place when mopping floor? Walls painted/papered and free or damage?

3 3 3 3 3

Total

66

D. Dietary

SCORE

3 3 3

3

Possible Score

3 3 3 3 3 3 3 3 3 3 3 3 3

Appliances clean & in running order? Range hood clean & in running order? Counters & Cabinets clean? Floors/Mats clean? Walls and backsplash clean? Food labeled correctly? Barrels empty clean & lined appropriately? Pantry clean and orderly? Storage free of all unnecessary items? Floor sink and drain clean? Coolers clean and orderly? Freezers clean and orderly? Chemicals stored appropriately?

3 3 3 3 3 3 3 3 3 3 3 3 3

3 42

Dishwasher water temp adequate?

3 42

SCORE

Notes ____________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

4.59

Facility Inspection Report

E. Resident Rooms Is room odor free? Is toilet bowel clean? Mirrors shined? Pipes clean and free of dust and dirt? Sink free of soap buildup (top & bottom)? Bathroom floor clean? Cubicle curtains, drapery, valances, clean? Floor clean or dirt, dust and litter? Floor finished with wax? Baseboards clean? Furniture clean? Ledges free of dust? Lights free of dust? Vents clean? Walls clean and free of spots? Waste basket clean and free of litter? Windows clean and free of finger prints? Total

F. Departments/Offices Baseboards clean? Cabinet and counters clean? Ceiling lights clean and clear? Corners neat and clean? Floor clean of dirt, dust and litter? Floor waxed or carpet clean? Furniture cleaned? Ledges free of dust? Nothing stored on floor? Vents and registers clean? Walls clean and free of smudges? Waste baskets clean and freshly lined? Window blinds free of dust? Windows clean and free of smudges? Waste basket clean and free of litter? Windows clean and free of finger prints? Total

Possible Score

Room #

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82

Possible Score

Possible Score

Room#

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82

Room/ Office

Possible Score

Possible Score

Room #

6 4 4 4 4 4 4 10 10 4 4 4 4 4 4 4 4 82

Room/ Office

Possible Score

2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2

31

31

31

Room/ Office

Notes ____________________________________________________________________________________ __________________________________________________________________________________________

4.60

Facility Inspection Report

AREA A. Entrance/Lobby/Sitting Room B. Corridors and Walls C. Equipment D. Dietary E. Resident Rooms F. Departments/Offices Totals

Score Available 108 66 42 42 82 31

Facility Score

Percent

Projects: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

Signature of Administrator: ________________________________ Date: ____________________ Signature of Inspector: _____________________________________ Date/Time Started: _______________________ Date/Time Completed: ____________________ 4.61

Figure A.7

Survey tag assignment

Tag description

Departmental responsibility

Team member name

Comments

F 150 Facility meets skilled nursing facility requirements F 151-156 Resident rights • Informed of changes • Informed of rights and responsibilities • Privacy • Personal funds • Exercise rights F 152 Resident rights • Legal surrogate • Review resident deemed incompetent • Legal representative appointed F 157 Notification of changes • Inform the resident • Inform the physician • Inform family or legal representative • Accidents • Condition change • Change in roommate • Transfer F 157-162 Protection of resident funds • Funds of $50.00 interest bearing account • Management of resident accounts • Conveyance upon death • Surety bond F 163 Choice of physician F 164-170 Privacy • Full visual • Auditory • Resident records • Grievances • Resolution to grievances • Survey results • Work • Mail

4.62

Figure A.7

Survey tag assignment (cont.)

Tag description


Team member name

Comments

F 172-177 Access and visitation • Immediate access • Ombudsman system • Telephone • Personal property • Self administration of drugs • Refusal of transfer • Admission/transfer/discharge F 201-208 Transfer and discharge • Notification of family/physician • Documentation • Advance notice • Bed hold • Equal access to care • Medicare/Medicaid rights F 221-222 Restraints • Physical restraints • Chemical restraints • Use for discipline or convenience F 223 Abuse • Free from physical, sexual, verbal, and mental abuse • Free from corporal punishment • Free from involuntary seclusion F 224-226 Staff treatment of resident • Mistreatment, neglect, or misappropriation of property • Facility’s implementation and development of policies and procedures • Employment of those convicted of abuse, neglect, and mistreatment F 240-241 Quality of life and dignity • Dress and groom according to wishes • Activities of resident’s choosing • Respect privacy and individuality • Promote independence in dining

4.63

Figure A.7


Tag description


Team member name

Comments

F 242 Self-determination and participation • Activities, schedule, and healthcare consistent with resident’s wishes • Interact with the community • Make significant decisions F 243-245 Participation in resident and family groups and other activities • Resident’s right to organize and participate • Family’s right to private meetings • Staff member provided • Participation in social, religious, other activities F 246-247 Accommodation of needs • Spaces large enough to meet needs • Functional bed and furniture • Notification of roommate change F 248-249 Activities • Room-bound residents provided with activities • Qualified activities director F 250-251 Social services • Medically related social services • Qualified social worker F 252-258 Personal property and environment • Retain and use personal property • Home-like environment • Housekeeping and cleanliness • Closet space • Lighting • Comfortable temperature and sound level F 271 Admission orders • Physician orders for immediate care F 272-275 Resident assessment • Initial and periodic assessments • Use of RAI F 276-286 Quality review assessment • State’s quarterly review requirements • Maintain active record

4.64

Figure A.7


Tag description


Team member name

Comments

F 287 Automated data processing requirement • Transmittal • Data format F 278 Accuracy of the assessment • Coordination and participation of appropriate parties • Certification F 279-282 Comprehensive care plans • Status in RAP areas • Rationale for decisions • Resident participation • Services meet standards of quality F 283-284 Discharge summary • Post-discharge plan of care F 285 Preadmission screening • Assessment for mental illness and mental retardation F 309 Quality of care • Highest practicable level of care • Care of skin ulcers and wounds F 310-312 Activities of daily living • Bathing, dressing, and grooming • Ambulation and transfer • Toileting • Eating • Functional communication systems F 313 Vision and hearing • Treatment and assistive devices F 314 Pressure sores • Prevent development of pressure sores • Treatment to promote healing • Assessment • Monitoring

4.65

Figure A.7


Tag description


Team member name

Comments

F 315 Urinary incontinence • Necessity of catheterization • UTI prevention • Bladder function improvement or maintenance F 317-318 Range of motion • Prevent reduction in range of motion F 319-320 Mental and psychosocial functioning • Appropriate treatment for adjustment difficulties • Clinical conditions • Unavoidability of development F 321-322 Naso-gastric tubes • Maintain ability to eat without NG tube • Necessity of treatment • Minimize potential for complications F 323-324 Accidents • Resident area free of accident hazard • Supervision and assistive devices F 325-326 Nutrition • Body weight and protein levels • Therapeutic diet F 327 Hydration • Sufficient fluid F 328 Special needs • Injections • Parenteral and enteral fluids • Colostomy, Ureterostomy, or Ileostomy care • Tracheostomy care • Foot care • Prostheses F 329-331 Unnecessary drugs • Monitor specific drugs • Avoid excessive dosage, duration • Usage of antipsychotics F 332 Medication errors • Rate of 5% or less • No significant errors

4.66

Figure A.7


Tag description


Team member name

Comments

F 353-354 Nursing services • RN at least 8 hours, 7 days • Full-time DON F 360-363 Dietary services • Dietician and/or food services director • Sufficient support personnel • Meet the nutritional needs of residents • Preplanned menus F 363-367 Food • Palatability • Attractiveness • Individualized meal plans • Substitutes • Appropriate therapeutic diets F 368 Frequency of meals • 3x a day • Substantial evening meal • Nourishing snack before bed F 369 Assistive devices • Devices to assist in independent eating F 370-372 Sanitary conditions • Procure food from approved sources • Storage, preparation, distribution, and serving • Disposal F 385-389 Physician services • Supervision of medical care of residents • Review residents total plan of care • Sign and date progress notes and orders • Frequency of visits • Availability for emergency care F 390 Physician delegation of tasks • Within scope of state law • Delegates to PA, NP, CNS

4.67

Figure A.7


Tag description


Team member name

Comments

F 406 Specialized rehab services • Provide required service • Medical necessity/prescribed by a physician F 411 Dental services • Routine and emergency services • Provide assistance to residents in scheduling/getting to appointments F 425-430 Pharmacy services • Timeliness • Pharmacuetical services must meet needs of residents • Consultation by pharmacist • Records and receipts • Drug regime reviewed 1x month by pharmacist • Pharmacist reports irregularities to physician and DON • Report acted upon F 431-432 Drugs and biologicals • Properly labeled • Locked, temperature controlled storage • Schedule II drugs stored separately F 441-444 Infection control • Establish plan to investigate, control, and prevent infection • Maintain records • Observe staff practicing infection control • Isolate to prevent spread of infection • Prohibit employees with communicable disease from contact with residents • Handwashing F 445 Linens • Handle, store, process, transport to prevent infection

4.68

Figure A.7


Tag description


Team member name

Comments

F 454-456 Physical environment • Life safety code requirements • Emergency power system • Emergency generator for life support system • Equipment in safe operating condition F 457-461 Resident rooms • No more than 4 residents per room • 80 square feet per resident in multiples rooms, 100 square feet per resident in singles • Direct access to exit corridor • Adequate privacy • Window, floor above grade F 462 Toilet facilities • Room contains or is near toilet facilities F 463 Resident call system • Nursing station is equipped for calls from rooms and bathrooms F 464-469 Dining and resident activities • Rooms are well-lighted, well ventilated; adequate outside ventilation • Non-smoking areas identified • Adequately furnished • Sufficient space • Corridors have secure handrails • Effective pest-control F 490 Administration • Effectively administered F 491 Licensure • Under applicable state and local laws F 492 Compliance with federal, state, and local laws and professional standards • Includes compliance with other HHS regulations F 493 Governing body • Licensed by state • Responsible for management

4.69

Figure A.7


Tag description


Team member name

Comments

F 494-498 Training of nursing aides • Employee of more than 4 months has completed training • Apply same rules to temps • Meet competency requirements • Registry verification • 12 hours of inservice/year F 499-507 Staff qualifications • Professional staff must be licensed, certified, or registered in accordance with applicable state laws • Outside professional used for services that can’t be met with facility staff • Medical director • Timely laboratory service • Resident transportation provided F 508-513 Radiology and other diagnostic services • Meet the needs of residents • Meet applicable conditions of participation • Obtain services according to physician orders, notify physician of finds • Provide transportation • File in clinical record F 514-516 Clinical record • Complete, accurate, readily accessible, systematically organized • Contains sufficient information to identify the resident • Contains record of assessments and care plans, services • Contains preadmission screening if required by state • Retained for specified period of time • Information protected from public, loss, destruction, unauthorized use

4.70

Figure A.7


Tag description


Team member name

Comments

F 517-518 Disaster and emergency preparedness • Detailed, written plans for disasters and emergencies • Trained employees F 519 Transfer agreement • Transfer agreement with hospital F 520-521 Quality assessment and assurance • Committee includes DON, physician, and 3 other staff • Meets at least quarterly • Corrective plans of action F 522 Disclosure of ownership • Notify state of changes

4.71


Facility Self-Assessment (Mock Survey) Tool

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 5 - FACILITY SELF-ASSESSMENT (MOCK SURVEY TOOLS) Facility Self-Assessment - Mock surveys are an opportunity to look at systems, procedures and processes of care and to identify potential survey-risk areas. Mock surveys should be performed on a scheduled basis and shared with nursing home staff. The most important part of the survey process is what you do after it is over with the results. F-tags are used in this section. Be advised that CMS makes revisions to the F-tags on a regular basis. SECTION Article: Mock Survey: An Important Component Survey Preparation Self-Assessment/Mock Survey Guide to F-Tag Numbers “F” Tag Deficiencies Quality Indicator Report Results Process-Survey Tasks Meal Monitor Assignment and Times Mock Survey Assignments Survey Scope & Severity Grid Resident Review Worksheet General Observations of the Faculty First Impressions Checklist Surveyor Notes Worksheet Administration Checklist Contract Book Checklist Personnel File Checklist Environment Physical Plant Rounds-Initial Tour File Drill Grid QA Review: Surveyor Notes Worksheet Nursing Resident Review Worksheet Quality of Care MDS Audit Tool Investigative Protocol Hydration Non-Sterile Dressing Change Discharge Records Review Chart Audit Tool Med Pass Technique CMS-677 Medication Pass Worksheet Dietary Dietary Observations Monthly Meal Quality Review Monthly Sanitation/Infection Control Review Meal Audit Tool Kitchen/Food Service Observation

Updated March 2013

PAGE # 5. 2 5.3 5.4-5.5 5.6-5.30 5.31 5.32-5.34 5.35 5.36 5.37-5.38 5.39-5.42 5.43-5.44 5.45 5.46 5.47 5.48 5.49 5.50 5.51-5.56 5.57 5.58-5.59 5.60 5.61-5.64 5.65 5.66 5.67-5.72 5.73 5.74 5.75-5.76 5.77 5.78-5.80 5.81 5.82 5.83 5.84 5.85 5.86-5.87

LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT Social Services Social Services Audit Quality of Life Assessment Observation of Non-Interviewable Resident Quality of Life Assessment Resident Interview Resident Interview Quality of Life Assessment Family Interview Quality of Life Assessment Group Interview Resident Council Meeting Audit Activities Chart Audit Tool

Updated March 2013

5.88 5.89 5.90 5.91 5.92-5.94 5.95-5.97 5.98-5.101 5.102-5.103 5.104

Mock Survey An Important Component of Survey Preparation Many long-term care providers strive to be ‘survey-ready’ all year round. But just like many of us schedule the big spring cleaning some time in advance of company arriving for their annual summer visit; some LTC providers opt to conduct a Mock Survey in anticipation of their annual licensure/certification visit. Mock Surveys can serve several purposes:  

A Mock Survey can be an opportunity to take a fresh look at systems, procedures and processes of care, and identify potential survey-risk areas. And survey-risk can translate into litigation-risk. A Mock Survey also can reveal how staff will function under stressful circumstances.

Taking that fresh and objective look is essential in order to reap the maximum benefit from the Mock Survey process. LTC providers are discovering the hard way that the procedures, protocols and monitoring/QA systems that served them well enough in the past are no longer sufficient to avoid survey deficiencies. ‘But we’ve always done it this way; the surveyors never cited us on this in the past; we thought we were doing this correctly; we’ve always done well on our surveys before – how could this be happening?’ It is hard to stay current with new standards and the more stringent application of existing standards like F314 Pressure Ulcers, F315 Continence/Catheters, F323 Accidents, etc. It is hard to look at one’s own organization and see its shortcomings. One way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. This ‘someone’ could be a consultant or an experienced and well informed professional from a neighboring LTC community. If, however, you elect to manage the process using your own personnel, incorporating the following approaches can facilitate objectivity: 





Assign department heads to ‘survey’ departments other than their own. In nursing, have charge nurses/unit managers, supervisors, etc., assigned to audit other units and/or aspects of care for which they are not usually responsible. It is often hard to see your own forest for the trees. Although obviously the internal ‘surveyors’ will know that a Mock Survey will be taking place at some point, it could be more beneficial if direct care staff and other workers were not informed. This maximizes the surprise and stress factor. Even though the internal ‘surveyors’ know that the process is planned, the Mock Survey should be unannounced. The Administrator walks in one morning and proclaims it to be Mock Survey Day. This simulates ‘real life’ conditions...

The most important part of the Mock Survey process is what you do after it’s over. If you have about three months between the Mock Survey and the earliest likely date of the next survey, then I recommend the ‘Systems’ approach. The Systems approach includes a broader review and analysis of organizational policies, procedures, protocols and practices that may be contributing to Quality Indicator Report flags and/or to the ‘findings’ of the Mock Survey ‘survey team.’ If you have one month or less between the Mock Survey and the earliest likely date of the next survey, then I recommend you go into ‘Manage the Damage Mode.’ What are your high-risk areas, which residents have experienced negative outcomes, how can the risk be lessened and/or the negative outcome be explained and/or otherwise addressed? In either scenario, “Systems” or “Manage the Damage Mode” develop a Corrective Action Roadmap that assigns responsibility, targets timeframes and breaks down the plan into operational steps. Pre-survey preparation and risk management are the two most effective tools we have to weather today’s regulatory climate. Most LTC providers, if they haven’t endured it already themselves, know of a provider in their area- good reputation, well respected in their community, satisfactory survey history – that has been blown out of the water during their last survey. Wouldn’t you rather have a ‘friendly outsider’ or your own team discovers the dust-bunnies before the surveyors do? Reprint from The Edge, April 29, 2009 The Edge is provided to members of the Kansas Association of Homes and Services for the Aging in partnership with Life Services Network, the Illinois AAHSA affiliate. Authored by Dorrie J. Seyfried, Vice President of Method Management, Risk Management & LTC Consultants based in St. Charles, Illinois.

5.2

Self-Assessment/Mock Survey Today, more than ever, nursing facilities must be prepared to demonstrate compliance with federal regulations not only at survey time, but all year long. Survey teams can arrive at facilities as soon as nine months after the last annual survey. They can appear at any time to conduct complaint investigation surveys. And, these days, they are likely to begin surveys at nontraditional times and on weekends. These changes in the frequencies, times and types of surveys make it imperative that facilities be prepared at all times. Nevertheless, with rapidly increasing turnover rates for nursing staff and managers, facility staff might not be familiar with surveyors' procedures, care observations, interviews, and record reviews and could be unprepared to meet these challenges. To adequately prepare staff to succeed at survey time, and to ensure that the facility complies with regulations at all times, periodic self-assessments or mock surveys can be an important feature of a facility's quality assurance process. A mock survey can be performed by facility staff, by corporate advisors or by outside consultants. In whatever manner your facility chooses to provide these services, there are a few guidelines to bear in mind. 1. Enlist "fresh eyes" to see existing problems clearly. Be sure to include new employees, an "outsider" or other mock surveyors who are not overly familiar with the facility's staff and residents. If using facility staff, ask them to review areas outside their direct span of control. 2. Replicate "real" survey procedures as faithfully as possible. Use precise observation methods, select a sample of residents according to survey guidelines and interview the same staff that real surveyors are likely to interview.

The following pages include a variety of tools for you to use for your own self-assessment—use all or some of them. Remember, if you find any deficient practices be sure you bring it to your Quality Assurance Meetings, document your findings, and come up with a workable plan to correct the problem.

5.3

GUIDE TO “F” TAG NUMBERS 483.10 RESIDENT RIGHTS F-151Exercise of Rights F-152Resident Competency F-153Access to Records F-154Informed of Health Status or Care F-155Refusal of Treatment F-156 Medicaid Services and Charges F-157 Notification of Changes F-158 Protection of Resident Funds F-159 Personal Fund Management F-160 Conveyance Upon Death F-161 Assurance of Financial Security F-162 Limitation on Charges to Personal Funds F-163 Free Choice on Physician Informed re: Care (refer to F-154) Planning care (refer to F-280) F-164 Privacy and Confidentiality F-165 Voice Grievances F-166 Resolution of Grievances F-167 Examination of Survey Results F-168 Agencies Acting as Advocates F169 Work F-170 Mail F-171 Access to Stationary F-172 Access & Visitation Rights F-173 Ombudsman Access to Records F-174 Telephone Personal Property (refer to F-252) F-175 Married Couples F-176 Self Administration of Drugs F-177 Refused of Certain Transfers 483.12 ADMISSION, TRANSFER & DISCHARGE F-201 Transfer & Discharge Requirements F-202 Documentation of Transfer & Discharge F-203Notice before transfer F-204 Orient re Transfer & Discharge F-205 Bed-hold Policy and Readmission F-206 Return to the Facility F-207 Equal Access to Quality Care F-208 Admissions Policy 483.13 RESIDENT BEHAVIOR & FACILITY PRACTICE F-221 Restraints (physical) F-222 Restraints (chemical) F-223 Abuse F-224 Treatment of Residents & their Property F-225 Employ Individuals Guilty of Abuse F-226 Policy & Procedure on Abuse

483.15 QUALITY OF LIFE F-240 Quality of Life F-241 Dignity F-242 Self-determination/Participation F-243 Participate in Resident/Family Groups F-244 Resident/Family Recommendation F-245 Participation in other Activities F-246 Accommodations of Needs F-247 Notification of Room Changes F-248 Activities F-249 Qualified Activity Professional F-250 Social Services F-251 Full Time Social Worker Qualifications of Social Worker F-252 Environment F-253 Housekeeping & Maintenance F-254 Linens Clean and in Good Condition F-256 Lighting Levels F-257 Comfortable Temperature F-258 Comfortable Sound Levels 483.20 RESIDENT ASSESSMENT F-271 Admission Orders F-272 Comprehensive Assessments F-273 Frequency of Assessments F-274 Significant Change F-275 Annual Assessments F-276 Quarterly Review Assessments (Refer to F-279) F-278 Accuracy/Coordination, RN Cert. F-279 Comprehensive Care Plans F-280 Care Plan Development F-281 Services Meets Professional Standards F-282 Services by Qualified Persons F-283 Discharge Summary F-284 Post-Discharge Plan of Care F-285 Preadmission Screening for MI F-286 MDS Data Storage & Maintenance F-287 Encoding & Transmitting 483.25 QUALITY OF CARE F-309 Quality of Care F-310 ADL Abilities F-311 Appropriate Treatment & Services F-312 Care for ADL Dependent Residents F-313 Vision & Hearing F-314 Pressure Sores F-315 Urinary Incontinence F-317 Range of Motion Diminished F-318 Range of Motion Treatment & Services F-319 Mental & Psychosocial Functioning F-320 Adjustment Difficulty F-321 Naso-gastric Tubes F-322 Services to Prevent Aspiration

F-323 Accidents F-325 Nutrition F-327 Hydration

QUALITY OF CARE (Continued) F-328 Special Needs F-329 Unnecessary Drugs F-332 Medication Errors 5% or Greater F-333 Significant/Non-Significant Med. Errors F-334 Influenza & Pneumococcal Immunizations 483.30 NURSING SERVICES F-353 Nursing Services/Sufficient Staff F-354 Registered Nurse Hours F-355 SNF Waiver for Licensed Nurse F-356 Posting Nursing Staff 483.35 DIETARY SERVICES F-360 Dietary Services F-361 Staffing F-362 Sufficient Staff F-363 Menus and Nutritional Adequacy F-364 Food F-365 Food Meets Individual Needs F-366 Substitutes Offered F-367 Therapeutic Diets F-368 Frequency of Meals F-369 Assistive Devices F-371 Sanitary Conditions F-372 Dispose of Garbage & Refuse Properly F-373 Paid Feeding Assistants (Michigan does not have this program) 483.40 PHYSICIAN SERVICES F-385 Physician Services/Supervision F-386 Physician Visits F-387 Frequency of Physician Visits F-388 Visits by Physician Exception F-389 Physician Available for Emergency Use F-390 Dr. Delegation of Tasks Performed in SNF/NF 483.45 SPECIALIZED REHABILITATION SERVICES F-406 Provision of Services F-407 Qualifications 483.55 DENTAL F-411 Skilled Nursing Facilities Dental Services F-412 Nursing Facilities Dental Services

5.4

483.60 PHARMACY F-425 Pharmacy Services/Procedures F-428 Drug Regimen Review F-431 Control, Labeling & Storage of Drugs 483.65 INFECTION CONTROL F-441 Infection Control

483.70 PHYSICAL ENVIRONMENT F-454Physical Environment F-455Emergency Power Space & Equipment (Refer to F246) F-456 Patient Care Equipment is Safe Resident Rooms (Refer to F-252) F-457Bedroom Accommodations F-458Square Footage/Room F-459Direct Access to Exit F-460Full Visual Privacy F-461Room with Window/Floor at Grade F-462Toilet Facilities F-463Resident Call System F-464Dining & Resident Activities F-465Other Environmental Conditions F-466Available Water Supply F-467Outside Ventilation F-468 handrails F-469Pest Control Program 483.75 ADMINISTRATION F-490 Administration F-491 licensure F-492 Federal, State, & Local Laws F-493Governing Body F-494 Required Training NA F-495 Competency F-496Registry Verification/Retraining F-497Regular In-Service Education F-498Proficiency of Nurse Aides F-499Staff Qualifications F-500Use of Outside Resources F-501Medical Doctor F-502Laboratory Services F-503Laboratory Requirements F-504 Physician Ordered Lab Services F-505 Promptly Notify Dr. of Findings F-506 Transportation To/From F-507Lab Reports in Resident File F-508Radiology & Diagnostic Services Meets Resident Needs F-509Radiology & Diagnostic Requirements F-510MD Ordered Radiology Services F-511 Promptly Notify Dr. of Findings F-512 Transportation To/From F-513 X-ray Reports in Resident File F-514Clinical Records F-515Retention of Clinical Records F-516Safeguard Clinical Records F-517Disaster & Emergency F-518Training for Emergency F-519 Transfer Agreement F-520 Quality Assessment & Assurance F-522 Disclosure of Ownership

5.5

“F” TAG DEFICIENCIES Facility Name: ID PREFIX TAG

Dates of Quality Review: SUMMARY STATEMENT OF FINDINGS

Reviewer: FINDINGS

PLAN OF CORRECTION

DATE OF COMPLETION

RESIDENT RIGHTS F-151

F-152

F-153

F-154

Exercise of Rights. 1. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 2. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. Resident Competency. 1. 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. 2. In the case of a resident who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the resident’s rights to the extent provided by State law. Access to Records. The resident or his or her legal representative has the right: 1. 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 2. After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard, photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility. Informed of Health Status or Care. 1. The resident has the right to be fully informed in a language that he or she can understands, of his or her total health status, including but not limited to, his or her medical condition. 2. The resident has the right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident’s well-being.

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5.6

F-155

F-156

F-157

F-158

F-159

F-160

F-161

F-162

Refusal of Treatment. The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive. Medicaid Services and Charges. The facility must 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. Such notification must be made prior to or upon admission and during the resident’s stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. Notification of Changes. A facility must immediately inform the resident; consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is: 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention; 2. A significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either lifethreatening conditions or clinical complications). Protection of Resident Funds. The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility. Personal Fund Management. 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. 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. 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 resident deposited with the facility. Limitation on Charges to Personal Funds. 1. The facility may not impose a charge against the

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5.7

F-163

F-164

F-165

F-166

F-167

F-168

F-169 F-170

F-171

F-172

personal funds of a resident for any item(s) or services for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts). 2. The facility may charge to resident’s funds, any item(s) or services requested by a resident, if the facility informs the resident there will be a charge and if payment is not made by Medicaid or Medicare. Free Choice/Physician. The resident has the right to choose a personal attending physician regarding: Care (refer to F-154) Planning Care (refer to F-280). Privacy and Confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Voice Grievances. The resident has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished. Resolution of Grievances. The resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. Examination of Survey Results. The facility must make the results of the most recent survey (Federal or State) available for examination in a place readily accessible to residents and must post a notice of their availability. Agencies Acting as Advocates. The resident has the right to receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. Work. The resident has the right to refuse to perform services for the facility. Mail. The resident has the right to privacy in written communications, including the right to send and promptly receive mail that is unopened. Access to Stationary. The resident has the right to have access to stationery, postage, and writing implements at the resident’s own expense. Access & Visitation Rights. The facility must provide reasonable access to any resident by an entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to

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5.8

F-173

F-174

F-175

F-176

F-177

deny or withdraw consent at any time. Ombudsman Access to Records. The facility must allow representatives of the State Ombudsman to examine a resident’s clinical records with the permission of the resident or the resident’s legal representative, and consistent with State law. Telephone. The resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. Personal Property (refer to F-252) 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. Self Administration of Drugs. The resident has the right to self-administer drugs if the interdisciplinary team has determined that this practice is safe. Refused of Certain Transfers. The resident has the right to refuse a transfer to another room within the facility if it does not affect the resident’s eligibility or entitlement to Medicare or Medicaid benefits.

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ADMISSION, TRANSFER AND DISCHARGE F-201

Transfer & Discharge Requirements. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless: 1. The transfer or discharge is necessary for the resident’s welfare; 2. The transfer or discharge is appropriate because the resident’s health has improved; 3. The safety of individuals in the facility is endangered; 4. The resident (or Medicare or Medicaid) has failed to pay for a stay at the facility. 5. The facility ceases to operate.

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F-202

Documentation of Transfer & Discharge. The resident’s clinical record must be documented when the facility transfers or discharges a resident

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5.9

F-203

Notice Before Transfer. Before a facility transfers or discharges a resident, the facility must notify the resident and a family member 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.

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F-204

Orient Regarding Transfer & Discharge. The facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.

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F-205

Bed-Hold Policy and Readmission. The facility must provide written information that specifies the duration of the bed-hold policy, to the resident and a family member or legal representative, before transfer of a resident to a hospital or allowing a resident to go on therapeutic leave.

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F-206

Return to the Facility. The facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bedhold period is readmitted to the facility.

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F-207

Equal Access to Quality Care. The facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services for all individuals regardless of source of payment.

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F-208

Admissions Policy. The facility must not require residents or potential resident to waive their rights to Medicare or Medicaid, nor require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.

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RESIDENT BEHAVIOR & FACILITY PRACTICE F-221

Restraints (physical). The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.

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F-222

Restraints (chemical). The resident has the right to be free from any chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.

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5.10

F-223

Abuse. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

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F-224

Treatment of Residents & Their Property. The facility must identify residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.

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F-225

Employ Individuals Guilty of Abuse. The facility must not employ individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law.

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F-226

Policy & Procedure on Abuse. The facility must develop and implement policies and procedures that include screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment and misappropriation of property.

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F-240

Quality of Life. The facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life.

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F-241

Dignity. The facility must promote 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 or her individuality.

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F-242

Self-Determination/Participation. The resident has the right to: 1. Choose activities, schedules, and health care consistent with his/her interests, assessments and plans of care; 2. Interact with members of the community both inside and outside the facility; 3. Make choices about aspects of his/her life in the facility that are significant to the resident.

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F-243

Participate in Resident/Family Groups. The resident has the right to organize and participate in resident groups and/or meet with the families of other residents.

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QUALITY OF LIFE

5.11

F-244

Resident/Family Recommendation. The facility must listen to the views and act upon the grievances and recommendations of resident and families concerning proposed policy and operational decisions affecting resident care and life in the facility.

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F-245

Participation in Other Activities. The resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility.

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F-246

Accommodations of Needs. The resident has the right to 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.

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F-247

Notification of Room Changes. A resident has the right to receive notice before the resident’s room or roommate in the facility is changed.

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F248

Activities. The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

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F-249

Qualified Activity Professional. The activities program must be directed by a qualified therapeutic recreation specialist or an activities professional who is licensed, registered or certified, if applicable, in the State where practicing.

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F-250

Social Services. The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident.

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F-251

Full Time Social Worker. A facility with more than 120 beds will employ a qualified social worker on a full time basis. Qualifications of Social Worker: a bachelor’s degree in social work or in a human services field, and one year of supervised social work experience working directly with individuals.

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5.12

F-252

Environment. The facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings, 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.

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F-253

Housekeeping and Maintenance. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

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F-254

Linens Clean and in Good Condition. The facility must provide clean bed and bath linens that are in good condition.

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F-256

Lighting Levels. The facility must provide adequate and comfortable lighting levels in all areas.

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F-257

Comfortable Temperature. The facility must provide comfortable and safe temperature levels maintaining a temperature range of 71-81°F.

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F-258

Comfortable Sound Levels. The facility must provide for the maintenance of comfortable sound levels.

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RESIDENT ASSESSMENT F-271

Admission Orders. At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care.

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F-272

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

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F-273

Frequency of Assessments. The facility must conduct a comprehensive assessment of a resident within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition.

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F-274

Significant Change. The facility should determine if there has been a significant change (major decline or improvement) in a resident’s status which requires intervention, interdisciplinary review or revision of the care plan.

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5.13

F-275

Annual Assessments. The facility shall conduct a resident assessment not less than once every 12 months.

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F-276

Quarterly Review Assessments. The facility must assess a resident not less frequently than once every 3 months. (refer to F-279)

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F-278

Accuracy/Coordination, RN Cert. 1. The facility must ensure that each resident receive an assessment that accurately reflects the resident’s status. 2. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

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F-279

Comprehensive Care Plans. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing and mental and psychosocial needs that are identified.

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F-280

Care Plan Development. The resident has the right to participate in planning his/her care and treatment or changes in his/her care and treatment, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State.

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F-281

Services Meet Professional Standards. The facility must assure that services being provided meet professional standards of quality and are provided by appropriate qualified persons.

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F-282

Services by Qualified Persons. The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident’s written plan of care.

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F-283

Discharge Summary. The facility must have a discharge summary that includes a recapitulation of the resident’s stay, a final summary of the resident’s status at the time of discharge to ensure appropriate planning and communication of necessary information to the continuing care provider.

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F-284

Post-Discharge Plan of Care. The facility will develop a post-discharge plan of care, with the participation of the resident and his/her family, which will assist the resident in adjusting to his/her new living environment.

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5.14

F-285

Pre-Admission Screening for Mental Illness. The facility must coordinate assessments with the preadmission screening and resident review program to ensure that individuals with mental illness and mental retardation receive the care and services they need in the most appropriate setting.

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F-286

MDS Data Storage & Maintenance. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record.

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F-287

Encoding & Transmitting. Within 7 days after a facility completes a resident’s assessment, the facility must encode and be capable of transmitting the appropriate information for each resident in the facility, in the specified format to the appropriate agency.

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QUALITY OF CARE F-309

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.

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F-310

ADL Abilities. The facility must ensure that a resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to: 1. Bathe, dress, groom; 2. Transfer and ambulate; 3. Toilet; 4. Eat; and 5. Use speech, language, or other functional systems.

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F-311

Appropriate Treatment & Services. The facility must ensure that a resident is given appropriate treatment and services to maintain or improve his or her ADL abilities listed in F-310.

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F-312

Care for ADL Dependent Residents. The facility must ensure that a resident who is unable to carry out ADL receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

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5.15

F-313

Vision & Hearing. The facility must ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities by making appointments and arranging transportation to the offices of the appropriate professionals.

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F-314

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

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F-315

Urinary Incontinence. The facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary and a resident that is incontinent of bladder receives appropriate treatment and services to prevent UTI’s and to restore as much bladder function as much as possible.

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F-317

Range of Motion Diminished. The facility must ensure that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable.

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F-318

Range of Motion Treatment and Services. The facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

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F-319

Mental & Psychosocial Functioning. The facility must ensure that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem and/or assist him/her in reaching and maintaining the highest level of mental and psychosocial functioning.

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5.16

F-320

Adjustment Difficulty. The facility must ensure that a resident whose assessment did not reveal a mental or 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 is unavoidable.

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F-321

Naso-Gastric Tubes. The facility must ensure that a resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident’s clinical condition demonstrates that the use of a naso-gastric tube was unavoidable.

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F-322

Services to Present Aspiration. The facility must ensure that a resident who is fed by an N/G or G/T receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasalpharyngeal ulcers and to restore, if possible, normal eating skills.

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F-323

Accidents. The facility must ensure that the resident’s environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents.

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F-325

Nutrition. The facility must ensure that: 1. A resident 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. 2. A resident receives a therapeutic diet when there is a nutritional problem.

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F-327

Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

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5.17

F-328

Special Needs. The facility must ensure that residents receive proper treatment and care for the following special services: 1. Injections; 2. Parental and enteral fluids; 3. Colostomy, ureterostomy or ileostomy care; 4. Tracheostomy care; 5. Tracheal suctioning; 6. Respiratory care; 7. Foot care; and 8. Prostheses.

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F-329

Unnecessary Drugs. Each resident’s drug regime must be free from unnecessary drugs. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

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F-332

Medication Errors 5% or Greater. The facility must ensure that it is free of medication error rates of five percent or greater.

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F-333

Significant/Non-Significant Med. Errors. The facility must ensure that residents are free of any significant medication errors.

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F-334

Influenza & Pneumococcal Immunizations. The facility must develop policies and procedures that ensure the following: 1. Before offering the immunization, each resident or the resident’s legal representative receives education regarding the benefits and potential side effects of the immunization; 2. Each resident is offered an immunization, unless the immunization is medically contraindicated or the resident has already been immunized; 3. The resident or the resident’s legal representative has the opportunity to refuse immunization; 4. The resident’s medical record includes documentation that indicates, at the minimum, the following: a. that the resident or resident’s legal representative was provided education regarding the benefits and potential side effects of the immunization; and b. that the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal.

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5.18

NURSING SERVICES F-353

Nursing Services/Sufficient Staff. The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care.

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F-354

Registered Nurse Hours. 1. The facility must use the services of a registered nurse (except when waived) for at least 8 consecutive hours a day, 7 days a week; 2. The facility must designate a registered nurse (except when waived) to serve as the director of nursing on a full time basis; 3. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

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F-355

SNF Waiver for Licensed Nurse. The State may waive certain requirements with respect to the facility if: 1. The facility demonstrates that despite diligent efforts, the facility has been unable to recruit appropriate personnel; 2. The State determines a waiver will not endanger the health or safety of individuals staying in the facility; 3. The State finds, 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 term care ombudsman, and the protection and advocacy system in the State for the mentally ill and

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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 members of their immediate families of the waiver.

5.19

F-356

Posting Nursing Staff. 1. Data requirements: The facility must post the following information on a daily basis: a. Facility name; b. Current date; c. Total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: - Registered nurses, - Licensed practical nurses or licensed vocational nurses. - Certified nurse aides, d. Resident census; 2. Posting requirements: a. Facility must post the nurse staffing date specified in paragraph (e)(1) of this section on a daily basis at the beginning of each shift. b. data must be posted as follows: - Clear and readable format, - In a prominent place readily accessible to residents and visitors. 3. Public access to posted nurse staffing data. 4. Facility data retention requirements.

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DIETARY SERVICES F-360

Dietary Services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.

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F-361

Staffing. The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis.

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F-362

Sufficient Staff. The facility must employ sufficient support personnel competent to carry out the functions of the dietary service.

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F-363

Menus and Nutritional Adequacy. 1. Meet the nutritional needs of resident in accordance with the recommended dietary allowances of the Food and Nutritional Board of the National Research Council, National Academy of Sciences; 2. Be prepared in advance; and 3. Be followed.

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5.20

F-364

Food. 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.

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F-365

Food Meets Individual Needs. Each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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F-366

Substitutes Offered. Each resident receives and the facility provides substitutes offered of similar nutritive value to residents who refuse food served.

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F-367

Therapeutic Diets. Therapeutic diets must be prescribed by the attending physician.

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F-368

Frequency of Meals. 1. Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. 2. There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in (4) below. 3. The facility must offer snacks at bedtime daily. 4. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served.

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F-369

Assistive Devices. The facility must provide special eating equipment and utensils for residents who need them.

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F-371

Sanitary Conditions. The facility must store, prepare, distribute, and serve food under sanitary conditions.

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F-372

Dispose of Garbage & Refuse Properly. The facility must dispose of garbage and refuse properly.

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5.21

F-373

Paid Feeding Assistants. (Michigan does not have this program) 1. A facility may use a paid feeding assistant if the assistant has successfully completed a State-approved training course. 2. The feeding assistant must work under the supervision of a registered nurse. 3. A facility must ensure the feeding assistant feeds only residents who have no complicated feeding problems.

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PHYSICIAN SERVICES F-385

Physician Services/Supervision. A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician.

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F-386

Physician Visits. The physician must: 1. Review the resident’s total program of care, including medications and treatments at each visit. 2. Write, sign, and date progress notes at each visit. 3. Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

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F-387

Frequency of Physician Visits. 1. The residents must be seen by a physician at least once very 30 days for the first 90 days after admission, and at least once every 60 thereafter. 2. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

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F-388

Visits by Physician Exception. 1. All required physician visits must be made by the physician personally. 2. At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist.

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F-389

Physician Available for Emergency Use. The facility must provide or arrange for the provision of physician services 24 hours a day, in case of emergency.

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5.22

F-390

Doctor Delegation of Tasks Performed in SNF/NF. 1. A physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist. 2. A physician may not delegate a task when the regulations specify that the physician must perform it personally or when the delegation is prohibited under State law or by the facility’s own policies.

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F-406

Provision of Services. The facility must provide or obtain the required services from an outside source if specialized rehab services, such as but not limited to, PT, ST, OT or mental health rehab for mental illness or mental retardation are required in the resident’s comprehensive care plan.

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F-407

Qualifications. Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.

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SPECIALIZED REHABILITATION SERVICES

DENTAL F-411

Skilled Nursing Facilities Dental Services. The facility must provide or obtain from an outside resource, routine and emergency dental services to meet the needs of each resident.

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F-412

Nursing Facilities Dental Services. The facility must: 1. Provide or obtain from an outside resource the following dental services to meet the needs of each resident: a. Routine dental services b. Emergency dental services 2. If necessary, assist the resident with making appointments and/or arranging transportation. 3. Must promptly refer residents with lost or damaged dentures to a dentist.

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5.23

PHARMACY F-425

Pharmacy Services/Procedures. The facility must provide 1. Routine and emergency drugs and biologicals to its residents, or obtain them under an agreement. 2. Permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. 3. Provide 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. 4. Must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility.

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F-428

Drug Regimen Review. 1. The drug regimen must be reviewed at least once a month by a licensed pharmacist. 2. The pharmacist must report any irregularities to the attending physician, and the director of nursing and these reports must be acted upon.

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F-431

Control, Labeling and Storage of Drugs. The facility must: 1. Employ or obtain services of a licensed pharmacist who establishes a system of records in order to maintain and reconcile the disposition of all controlled drugs. 2. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, include the appropriate accessory and cautionary instructions and expiration date when applicable, and be stored in accordance with State and Federal laws.

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INFECTION CONTROL F-441

Infection Control. The facility must establish and maintain 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.

5.24

PHYSICAL ENVIRONMENT F-454

Physical Environment. The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

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F-455

Emergency Power, Space & Equipment. The facility must have: 1. An emergency electrical power system adequate for lighting, maintaining the fire, alarm, extinguishing systems and life support systems. 2. Provide sufficient space and equipment to enable staff to provide residents with needed services as required and identified in each resident’s plan of care. (refer to F-246)

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F-456

Patient Care Equipment is Safe/Resident Rooms. The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. (refer to F-252)

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F-457

Bedroom Accommodations. Resident rooms must be designed and equipped for adequate nursing care, comfort and privacy of residents.

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F-458

Square Footage/Room. Rooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms.

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F-459

Direct Access to Exit. Resident rooms must have direct access to an exit corridor.

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F-460

Full Visual Privacy. Bedrooms must be designed or equipped to assure full visual privacy for each resident.

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F-461

Room with Window/Floor at Grade Level. Resident rooms must have at least one window to the outside and have a floor at or above grade level.

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F-462

Toilet Facilities. Each resident room must be equipped with or located near toilet facilities.

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F-463

Resident Call System. The nurses’ station must be equipped to receive resident calls through a communication system from resident rooms and toilet and bathing facilities.

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5.25

F-464

Dining & Resident Activities. The facility must provide one or more rooms designated for resident dining and activities that are well lighted, well ventilated, adequately furnished and have sufficient space to accommodate all activities.

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F-465

Other Environmental Conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

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F-466

Available Water Supply. The facility must establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply.

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F-467

Outside Ventilation. The facility must ensure there is adequate outside ventilation by means of windows, mechanical ventilation, or a combination of the two.

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F-468

Handrails. The facility must ensure corridors are equipped with firmly secured handrails on each side.

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F-469

Pest Control Program. The facility must maintain an effective pest control program so that the facility is free of pests and rodents.

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ADMINISTRATION F-490

Administration. The facility must 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 wellbeing of each resident.

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F-491

Licensure. The facility must be licensed under applicable State and local law.

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F-492

Federal, State & Local Laws. 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.

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F-493

Governing Body. The facility must have a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and appointing the administrator who is licensed by the State (where required) and responsible for the management of the facility.

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5.26

F-494

Required Training NA. The facility must not use any individual working in a facility as a nurse aide for more than 4 months, on a full-time basis, unless that individual has completed a training and competency evaluation program or is deemed competent.

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F-495

Competency. The facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual: 1. Is a full-time employee in a State-approved training and competency evaluation program; 2. Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program or competency evaluation program; or 3. Has been deemed competent.

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F-496

Registry Verification/Retraining. 1. The facility must receive registry verification that the individual has met competency evaluation requirements before allowing an individual to serve as a nurse aide. 2. If 24 months have passed since an individual’s most recent completion of a training and competency evaluation program and paid nursing or nursing-related services, the individual must complete a new training and competency evaluation program.

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F-497

Regular In-Service Education. The facility must complete a performance review on every nurse aide at least once every 12 months and provide regular inservice education based on the outcome of these reviews.

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F-498

Nurse Aide Proficiency. The facility must 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.

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F-499

Staff Qualifications. The facility must employ on a full-time, part time or consultant basis , professionals who are licensed, certified, or registered in accordance with applicable State laws, and necessary to carry out all requirements.

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5.27

F-500

Use of Outside Resources. The facility must provide services to residents by a person or agency outside the facility if the facility does not employ a qualified professional person to furnish a specific service.

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F-501

Medical Doctor. The facility must designate a physician to serve as medical director.

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F-502

Laboratory Services. The facility must provide or obtain lab services to meet the needs of its residents. The facility is responsible for quality and timeliness of the lab services.

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F-503

Laboratory Requirements. If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories.

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F-504

Physician Ordered Lab Services. The facility must provide or obtain laboratory services only when ordered by the attending physician.

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F-505

Promptly Notify Doctor of Findings. The facility must promptly notify the attending physician of the findings.

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F-506

Transportation To/From. The facility must assist the resident in making transportation arrangements to and from the source of service, if needed.

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F-507

Lab Reports in Resident File. The facility will file in the resident’s clinical record, laboratory reports that are dated and contain the name and address of the testing laboratory.

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F-508

Radiology & Diagnostic Services Meets Resident Needs. The facility must 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.

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F-509

Radiology & Diagnostic Requirements. If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals.

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F-510

MD Ordered Radiology Services. The facility must provide or obtain radiology and other diagnostic services only when ordered by the attending physician.

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F-511

Promptly Notify Doctor of Findings. The facility must promptly notify the attending physician of the findings.

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5.28

F-512

Transportation To/From. The facility must assist the resident in making transportation arrangements to and from the source of service, if needed.

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F-513

X-Ray Reports in Resident File. The facility will file in the resident’s clinical record, signed and dated reports of x-rays and other diagnostic services.

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F-514

Clinical Records. The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are: 1. Complete; 2. Accurately documented; 3. Readily accessible; and 4. Systematically organized.

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F-515

Retention of Clinical Records. The facility must retain clinical records for: 1. The period of time required by State law; or 2. Five years from the date of discharge when there is no requirement in State law; or 3. For a minor, three years after a resident reaches legal age under State law.

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F-516

Safeguard Clinical Records. The facility must safeguard clinical record information against loss, destruction, or unauthorized use.

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F-517

Disaster & Emergency. The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

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F-518

Training for Emergency. The facility must train all employees in emergency procedures when they begin to work in the facility and periodically review the procedures with existing staff.

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F-519

Transfer Agreement. The facility must have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs, that reasonably assures timely admission to the hospital when transfer is medically appropriate.

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5.29

F-520

Quality Assessment & Assurance. The facility must maintain a quality assessment and assurance committee consisting of designated key members that identify quality deficiencies, develops and implements plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans.

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F-522

Disclosure of Ownership. The facility must comply with disclosure requirements by providing written notice to the State agency responsible for licensing the facility at the time of change, if a changes occurs in: 1. Persons with an ownership or control interest. 2. The officers, directors, agents, or managing employees. 3. The corporation, association, or other company responsible for the management of the facility. 4. The facility’s administrator or director of nursing. 5. Notice must include the identity of each new individual or company.

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5.30

QUALITY INDICATOR REPORT RESULTS QI/QM PROFILE RESULTS A. SENTINEL EVENT Fecal Impaction Dehydration Pressure Ulcers, Low Risk B. Flagged 90th percentile

SPECIFIC QI/QM

RESIDENTS APPLIED TO

1. Prevalence of Fecal Impaction: 2. Prevalence of Dehydration: 3. Prevalence of Pressure Ulcers, Low Risk 1. 2. 3. 4.

th

C. Unflagged 75 percentile

5. 1. 2. 3. 4. 5.

D. Concerns

1. 2. 3. 4. 5.

Pre-select residents for the Phase 1 sample to represent the concerns that have been selected, including selecting residents who have sentinel event QI conditions (if multiple residents have a sentinel event QI condition it is not necessary to select them all).

5.31

Process – Survey Tasks Survey Task One: Survey Preparation

Responsible

Team

Action Item Review QI Profile, Facility Characteristics Report, OSCAR Data, Survey History of facility

Reference Survey Manual: Appendix P Pages P-5 to P-11

Phase One – Sample selection from 6 month QI Profile and Resident Level QI Summary. Select one half of sample size that Table 1 (p-23) would indicate.

Before FQR

Pre-identify any possible focus areas (flagged indicators, sentinel events, above th 75 ) Make copies of all Exhibit Worksheets Two: Entrance Conference

Team

Conduct entrance conference with Administrator and Department Heads. Request materials (Survey Readiness Book). Identify facility personnel to assist with tour.

Day One

Survey Manual: Appendix P Pages P-11 to P-15 CMS-805 Resident Review Worksheet CMS-803 General Observation of Facility First Impressions Checklist

Three: Initial Tour

Team

possible other residents to add to the Phase One sample.

Day One Four: Sample Selection

Validate that residents pre-selected in Task One are still present. Identify

Survey Manual: Appendix P Pages P17 to P-23

Identify other issues that may require investigation (i.e. restraint use, hydration, grooming, elopements, reportable events, falls) Team

Finalize Phase One sample. Pull records and begin comprehensive/focused reviews.

Survey Manual: Appendix P Pages P-17 to P-23

Team

Discuss focused areas based on results of comprehensive reviews and day one observations.

Survey Manual, Pages P-7 to P-21 CMS-805 Resident Review Worksheet

Day One Day Two Morning

Select Phase Two Sample. Conduct focused reviews. Complete focused reviews (if not completed on day one)

5.32

Process – Survey Tasks Survey Task Four: (continued) Day Two Morning

Responsible Nursing Team

Action Item Observe Medication Pass

Observe Treatments

Reference Task 5-E Medication Pass, Pages P-59 to P60 CMS-677 Medication Pass Worksheet Treatment Observation Sheet

Adm

Review Facility quality Assurance Program

Task 5-F LTC Manual

Determine if committee has method to identify, respond and evaluate identified problems.

Wandering and At Risk for Elopement Policies

Review 3 months minutes/Actions Plans and Follow-Up. Interview 1 CNA, 1 Nurse and 1 Department Head regarding QA Program knowledge Adm

Conduct Resident Group Interviews. Review

Safety Committee Meeting Minutes CMS-806B Group Interview

Activity and Grievance programs. Adm

Resident Trust Fund – Internal Audit Criteria Facility Petty Cash – Internal Audit Criteria

Five: Information Gathering

Team

Conduct comprehensive reviews. Record any concerns on Exhibit Worksheets. Begin focused reviews. Record any concerns on Exhibit Worksheet

Survey Manual, Exhibit 93, Pages 1-4 Survey Manual, Exhibit 95

Day One All Day

Team

Kitchen Observation

CMS-804 Kitchen/Food Observation

12:00 noon Team lunch to review morning findings

Meal Observation Focused Review: Weight Loss/Hydration

5.33

Process – Survey Tasks Survey Task Five: (continued) End of Day Team conference to review findings to plan Day Two

Responsible Team

Action Item Conduct Individual resident Interviews x 2

Reference

CMS-806A Resident Interview

Observe non-interviewable resident x 2 Mean Observation

CMS-806A Observation of noninterviewable resident

Environment Review Abuse Prevention Review smokers for Smoking Standard Compliance Review the criteria in the RCC Addendum, if applicable

CMS-806C Family Interview CMS-803 General Observations of facility Smoking Policy

Six: Determine Deficiencies Day Two Afternoon Seven: Exit Conference

Team

Decide which F-Tags and Standards are not in place.

Team

Review Findings with facility team.

Day Two Afternoon

5.34

MEAL MONITOR ASSIGNMENT AND TIMES

Date:

Breakfast: Person assigned to Main Dining Room: Person assigned to Hall Trays: Person assigned to Other Dining Room Specify exactly where: Person assigned to Other Dining Room Specify exactly where: Person assigned to Other Dining Room Specify exactly where:

Time:_____________ _

Time:_____________ Time: Time: Time:

Lunch: Person assigned to Main Dining Room:

Time:_____________

Person assigned to Hall Trays:

Time:_____________

Person assigned to Other Dining Room Specify exactly where: Person assigned to Other Dining Room Specify exactly where: Person assigned to Other Dining Room Specify exactly where:

Time: Time: Time:

Dinner: Person assigned to Main Dining Room:

Time:_____________

Person assigned to Hall Trays:

Time:_____________

Person assigned to Other Dining Room Specify exactly where: Person assigned to Other Dining Room Specify exactly where: Person assigned to Other Dining Room Specify exactly where:

Time: Time: Time:

5.35

MOCK SURVEY ASSIGNMENTS Prior to Mock: Complete Survey History (OSCAR): Ready upon entrance: Complete and gather all survey preparation documentation: Within 1 hour of entrance: Complete CMS 802 form (Roster Sample Matrix) Within 24 hours of entrance: Complete CMS 672 form (Resident Census & Condition) Upon arrival of Mock Team: Print out QI/QM for last 6 months: First 4 hours of survey: Review the Quality Indicators and choose a sample group. Team Leader: Entrance Conference: Exit Conference: Activities: Date & Time of Resident Council: Administration: Environment: Nursing: Med Pass: Treatments: Dietary: Social Services; Mock Summary Form Completion: 5.36

SURVEY SCOPE & SEVERITY GRID Appendix B Table 1: Deficiency and CMS Remedy Table Scope of the Deficiency Severity of the Deficiency

Isolated

Pattern

Widespread

Immediate jeopardy to resident health or safety

J PoC Required: Cat. 3 Optional: Cat. 1 Optional: Cat. 2

K poC Required: Cat. 3 Optional: Cat. 1 Optional: Cat. 2

L PoC Required: Cat. 3 Optional: Cat. 2 Optional: Cat. 1

Actual harm that is not immediate

G PoC Required* Cat. 2 Optional: Cat. 1

H PoC Required* Cat. 2 Optional: Cat. 1

I PoC Required* Cat. 2 Optional: Cat. 1 Optional: Temporary Mgmt.

No actual harm with potential for more than minimal harm that is not immediate jeopardy

D PoC Required* Cat. 1 Optional: Cat. 2

E PoC Required* Cat. 1 Optional: Cat. 2

F PoC Required* Cat. 2 Optional: Cat. 1

No actual harm with potential for minimal harm

A No PoC No remedies Commitment to Correct

B PoC

C PoC

Source: State Operations Manual. February 25, 2004. http://www.cms.hhs.gov/manuals/pub07pdf/pub07pdf.asp

Table Notes: *Required only when a decision is made to impose alternate remedies instead of or in addition to termination. Deficiencies in F, H, I, J, K and L categories are considered substandard quality of care (darker shade). Deficiencies in A, B and C are considered substantial compliance (lighter shade). PoC refers to a plan of correction (a plan by the facility for correcting the deficiency).

5.37

There are three remedy categories referred to on the table (Cat. 1, Cat. 2, Cat. 3). These categories as associated with the following penalties:

Category 1 (Cat.1)

Category 2 (Cat.2)

Category 3 (Cat.3)

Directed Plan of Correction State Monitor; and/or Directed In-Service Training

Denial of Payment for New Admissions Denial of Payment for All Individuals Imposed by CMS; and/or Civil Money Penalties: Up to $3,000 per day $1,000 - $10,000 per instance

Temp. Mgmt. Termination Optional: Civil Money Penalties 3,050-$10,000 per day $1,000 - $10,000 per instance

Denial of payment for new admissions must be imposed when a facility is not in substantial compliance within 3 months after being found out of compliance. Denial of payment and State monitoring must be imposed when a facility has been found to have provided substandard quality of care on three consecutive standard surveys. NOTE: Termination may be imposed by the State or CMS at any time.

5.38


RESIDENT REVIEW WORKSHEET Facility Name:

Provider Resident Number: Name: Resident Identifier:

Surveyor Name: Surveyor Number:

Birthdate: Discipline:

Unit:

Orig. Admission Date:

Rm #: Readmission

Date: Survey Date: Payment Source: Admission: Current: Interviewable: Yes No Type of Review: Comprehensive Focused Selected for Individual Interview: Yes No Selected for Family Interview and Observation of Non-Interviewable Resident: Yes Focus/Care Areas:

Closed Record No __ __

Instructions: Any regulatory areas related to the sampled resident’s needs are to be included in this review. • Initial that each section was reviewed if there are no concerns. • If there are concerns, document your investigation. • Document all pertinent resident observations and information from resident, staff, family interviews and record reviews for every resident in the sample. SECTION A: RESIDENT ROOM REVIEW: Evaluate if appropriate requirements are met in each of the following areas, including the accommodation of needs: •

Adequate accommodations are made for resident privacy, including bed curtains.

•

Call bells are functioning and accessible to residents

•

Resident is able to use his/her bathroom without difficulty.

•

Adequate space exists for providing care to residents.

• Resident with physical limitations (e.g., walker, wheelchair) is able to move around his/her room.

•

Environment is homelike, comfortable and attractive; accommodations are made for resident personal items and his/her modifications.

•

Bedding, bath linens and closet space is adequate for resident needs.

•

Resident care equipment is clean and in good repair.

•

Room is safe and comfortable in the following areas: temperature, water temperature, sound level and lighting.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on Surveyor Notes sheet page 4. SECTION B: RESIDENT DAILY LIFE REVIEW: Evaluate if appropriate requirements are met in each of the following areas: • Resident appears well groomed and reasonably attractive (e.g., clean clothes, neat hair, free from facial hair). •

Staff treats residents respectfully and listens to resident requests. Note staff interaction with both communicative and non-communicative residents.

•

Staff is responsive to resident requests and call bells.

•

Residents are free from unexplained physical injuries and there are no signs of resident abuse. (e.g. residents do not appear frightened around certain staff members.)

•

Facility activities program meets resident’s individually assessed needs and preferences.

•

Medically related social services are identified and provided when appropriate.

•

Restraints are used only when medically necessary. (see 483.13(a))

•

Resident is assisted with dining when necessary.

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on Surveyor Notes sheet page 4. Form CMS-805 (07/95)

5.39

RESIDENT REVIEW WORKSHEET (continued) SECTION C: ASSESSMENT OF DRUG THERAPIES Review all the over-the-counter and prescribed medications taken by the resident during the last 7 days. •

Evaluate drug therapy for indications/reason, side effects, dose, review of therapy/monitoring, and evidence of unnecessary medications including antipsychotic drugs.

•

If you note concerns with drug therapy, review the pharmacist’s report. See if the physician or facility has responded to recommendations or concerns.

• Correlate drug therapy with resident’s clinical condition. THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Medications/Dose/Schedule

Medications/Dose/Schedule

Medications/Dose/Schedule

Document concerns and follow-up on page 4. SECTION D: RAI/CARE REVIEW SHEET (Includes both MDS and use of RAPS): Reason for the most current RAI: Date of Most Recent RAI

Annual

Initial

Significant Change

Date of Comparison/Quarterly RAI

•

For a comprehensive review complete a review of all care areas specific to the resident, all ADL functional areas, cognitive status, and MDS categories triggering a RAP.

•

For a focused review: Phase I: Complete a review of those requirements appropriate to focus and care areas specific to the resident. Phase II: Complete a review of requirements appropriate to focus areas.

•

For both comprehensive and focused reviews record only the applicable sections and relevant factors about the clinical status indicating an impairment or changes between reviews.

•

If the current RAI is less than 9 months old, scan and compare with the previous RAI and most recent quarterly review.

•

If the RAI is 9 months or older, compare the current RAI with the most recent quarterly review.

•

Note any differences for the applicable areas being reviewed.

•

Review the RAP summary and care planning.

•

Look for implementation of the care plan as appropriate to the comprehensive or focused review.

•

Note specifically the effects of care or lack of care.

•

If the resident declined or failed to improve relative to expectations, determine if this was avoidable or unavoidable.

•

For closed records, complete a review of the applicable areas of concern.

•

Use the additional MDS item blocks on page 3 to document other sections or additional concerns.

•

Dining observation; If there are concerns with weight loss or other nutritional issues, observe resident dining and review adequacy of meals served and menus..

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on page 4.

5.40

RESIDENT REVIEW WORKSHEET (continued) Care

MDS Items

RAI Status/Comparison

Plan Y/N

Notes/Dates/Times/Source and Tag: Observations and Interview for resident and implementation of care plan and TX, including accuracy, completeness, and how information from use of RAPs is incorporated into the resident's care. Outcome: improve/failure to improve/same/decline. If a decline or failure to improve occurred, was it avoidable or unavoidable?

Cognitive/ Decisionmaking Mood/Behavior/ Psychosocial Transfer

Ambulation

Dressing

Eating

Hygiene/ Bathing

ROM Limits

Bowel

Bladder

Activities

5.41

RESIDENT REVIEW WORKSHEET (continued) Tag/Concerns

Source*

Surveyor Notes (including date/time)

*Source: O=Observat1on, RR=Record Rev1ew, l=lnterv1ew

5.42


GENERAL OBSERVATIONS OF THE FACILITY Facility Name:

Surveyor Name:

Provider Number:

Surveyor Number:

Observation Dates: From

Discipline:

To

Instructions: Use the questions below to focus your observations of the facility. Include all locations used by residents (units, hallways, dining rooms, lounges, activity and therapy rooms, bathing areas, and resident smoking areas). Also check other areas that affect the residents, such as storage and utility areas. Initial that there are no concerns or note concerns and your follow-up in the space provided. Begin your observations as soon as possible after entering the facility and continue throughout the survey. Note, these tags are not all inclusive. LIST ANY POTENTIAL CONCERNS FROM OFFSITE SURVEY PREPARATION. 1. HANDRAILS: Do corridors have handrails? Are handrails affixed to walls, intact, and free of splinters? (F468) 2. ODORS: Is the facility free of objectionable odors? Are resident areas well ventilated? Especially observe activity areas and the dining room during activities and lunch, when the residents are using them. Are nonsmoking areas smoke free? Do smoking areas provide good quality of life for residents who smoke? (F252) 3. CLEANLINESS: How clean is the environment (walls, floors, drapes, furniture)? (F252) 4. PESTS: Is the facility pest free? (F469) 5. LINEN: Is the linen processed, transported, stored and handled properly to prevent the spread of infection? (F445) 6. HAZARDS: Is the facility as free of accident hazards as possible? Are water temperatures safe and comfortable? Are housekeeping/hazards, compounds, and other chemicals stored to prevent resident access? (F252, 323) 7. CALL SYSTEM: Is there a functioning call system in bathing areas and resident toilets in common areas? (F463) 8. SPACE: Do the space and furnishings in dining and activity areas appear sufficient to accommodate all activities? (F464) 9. FURNISHINGS: Are dining and activity rooms adequately furnished? (F464) 10. DRUG STORAGE: Are drugs and biologicals stored properly (locked and at appropriate temperatures)? (F432) 11. EQUIPMENT: Is the resident equipment in common areas sanitary, orderly, and in good repair? (Equipment in therapy rooms, bathing rooms, activity areas, etc.) Are equipment and supplies appropriately stored and handled in clean and dirty utility areas (sterile supplies, thermometer, etc.)? (F253) 12. EQUIPMENT CONDITION: [Excluding the kitchen] Is essential equipment in safe and effective operating condition (e.g. boiler room equipment, nursing unit/medication room equipment, unit refrigerators, laundry equipment, therapy equipment)? (F456) 13. SURVEY POSTED: Are survey results readily accessible to residents? Are the survey results or a notice concerning survey results posted? (F167) 14. INFORMATION POSTED: Is information about Medicare, Medicaid and contacting advocacy agencies posted? (Fl56) 15. POSlTlONING: Is correct posture and comfortable positioning and assistance being provided to residents who need assistance — especially check residents who are dining or participating in activities? (F246, 311, 318) 16. EMERGENCY: Are staff prepared for an emergency or disaster? Ask two staff and a charge nurse to describe what they do in emergencies (include staff from different shifts). Evaluate the responses to determine their correctness and preparedness. (F518) 17. EMERGENCY POWER: Is there emergency power? Are staff aware of outlets, if any, powered by emergency source? (F455) 18. WASTE: Is waste contained in properly maintained (no breaks) cans, dumpsters or compactors with covers? (F454, 371) THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.) Document concerns and follow-up on back of page: Form CMS-803 (7-95)

5.43

GENERAL OBSERVATIONS OF THE FACILITY Tag I Concerns

Source *

Surveyor Notes (including date/time)

*Source. 0= Observation, RR=Record Review, I=- Interv1ew Form C::\IS-803 (7-95)

5.44

FIRST IMPRESSIONS CHECKLIST Item to be Inspected

Met

Not met

Corrective Action

Date corrected

Facility signage visible, well lit, clean, sturdy and in good repair. Parking lot is clean, striped and well lit. Handicap stall is present and clearly marked with signage. Lawn /grounds are well kept, neat in appearance and wellmanicured without trash or clutter. Shrubbery is trimmed and flowerbeds weeded. Lawn furniture is clean, in good repair and adequate. Lawn hoses are stored and do not pose a tripping hazard. Entrance landscaped seasonally. Out of season decorations removed timely. Outside potted plants alive & well groomed. Entrances clean, well lit and without clutter. Front door clean, in good repair with weather stripping secure. Sidewalk poses no tripping hazards and is in good repair. Receptacle for cigarettes available at entrance and is emptied regularly. Lobby neatly organized, lighting appropriate (all bulbs working), low noise levels (including overhead paging). Greeted upon entrance by a staff member. Inside “potted” plants alive / well groomed. Staff members appropriately dressed with name badge. Visible office spaces neatly organized and clutter free. All areas odor free. Public restrooms clean and comfortable. Public posting information is well organized and easily accessible (i.e., State Survey Results, other required info by law). Facility has a feel of comfort and is not institutional. Hallways are free of obstruction. Dining areas are clean, neat and offer a home like appeal. Resident smoking area clean of cigarette butts and other trash. Available ashtrays and trash cans cleaned/dumped at least daily if not more often. Patio furniture clean, good repair and adequate. Patio poses no tripping hazards and is in good repair. Staff smoking area clean of cigarette butts and other trash. Available ashtrays and trash cans cleaned/dumped at least daily if not more often. Area around dumpsters are clean and clutter free. Lids on dumpsters are closed. Laundry and Dietary outside areas clean and uncluttered. Surrounding area outside storage buildings clean and uncluttered. Gutters and down spouts securely attached and function properly. Siding/brick is in good repair, not chipped, cracked or broken nor is paint chipped. Window panes are in good condition without chipped paint and no broken windows. Window screens are clean, not torn and in good repair.

5.45


SURVEYOR NOTES WORKSHEET Facility Name:

Surveyor ProviderName: Number: Surveyor Number:

Observation Dates: From ---------

TAG/CONCERNS

Discipline:

To ------

DOCUMENTATION

Form CMS-807 (7/95)

5.46

ADMINISTRATION CHECKLIST Area Past survey reports displayed Medicare/Medicaid benefit information displayed Resident Trust Fund Balanced Surety Bond equals one and one half times the total amount of the average resident fund balance Ombudsman information posted Private access to a telephone available for residents Administrator licensure current Contract book current Safety Committee meetings held regularly Disclosure of ownership Bed Reconciliation form Waiver(s) available if applicable Daily Nursing staffing posted and current

Yes

No

Comments

5.47

CONTRACT BOOK CHECKLIST Contract Activities Consultant Audiologist Background Check Barber/Beauty Biohazardous Waste Blood Products Cable TV CLIA Waiver Dentist Dialysis (all providers) Electrical E.T. Nurse (Wound Nurse) Facility Insurance Fire Alarm P/M Hospice (all providers) Laboratory Landscaping Medical Director Medical Records Consultant Mobile x-ray Modified Barium Study Nursing Agency (supplemental staffing) Optometrist Oxygen Pest Control Pharmacy Pharmacy Consultant Podiatrist Psychiatrist Psychologist RT Agreement Radon Testing Dietitian Consultant Social Services Consultant Sprinkler System P/M Surety Bond Therapy PT Therapy OT Therapy SLP Therapy RT Transfer Agreement Utilization Review

License Insurance

N/A

N/A

Comments

N/A

N/A N/A N/A

N/A N/A

N/A

N/A N/A

N/A

N/A N/A

N/A

5.48

PERSONNEL FILE CHECK LIST Instructions: 1.

2. 3. 4. 5.

Complete review on charts indicated in columns across Indicate with a √ if complete Utilize “I” for incomplete Utilize “N/A” for not applicable D/H = department head

Criteria Hiring Information Orientation

Separate Personnel Records (keep in a separate location from personnel file and with very limited access) Other

Requirement Pre-Employment References

R.N.

R.N.

L.P.N.

L.P.N.

C.N.A.

C.N.A.

D/H

D/H

HRLY

HRLY

Comments

Credentials/License Verified Checklist for General Orientation Checklist for Dept. Orientation Signature Resident Rights Standards of Conduct Employee Handbook > Facility Policies Fire & Disaster Plan State Specific: Abuse & Neglect Medical File: TB Testing HepB Consents/documentation Criminal Background checks I-9 Information EDL checked

Family Care Registry C.N.A. Registry OIG Drug testing

5.49

ENVIRONMENT

5.50

PHYSICAL PLANT ROUNDS - INITIAL TOUR Facility:

TAG #

Date:

STANDARD

MET NOT MET COMMENTS INFECTION CONTROL: EXTERIOR OF BUILDING

F-372 Trash Control F-372 Dumpster Secure F-469, F-371 Pest Control INTERIOR OF BUILDING F-252, F-253 F-253, F-441 F-469, F-371 F-371 F-371 F-371 F-371 F-371 F-371 F-441, F-253 F-441,F-431 F-441, F-431 F-441, F-431 F-441, F-431 F-441, F-431 F-441, F-431 F-441, F-431 F-441, F-431 F-441, F-431 F-441, F-431

Odor Cleanliness Pest Control Thermometers in refrigerator Freezer 0 degrees or below Refrigerator