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The following federal regulation revisions and F numbers apply to surveys started on or after November 28, 2017.
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1. |
The facility must make the results of the most recent survey available for examination in
a place readily accessible to residents and must post a notice of the
availability of reports of all surveys made at the facility during the
preceding 3 years in areas prominent and accessible to the public. (42CFR
483.10(g)(10)(11) F 577 )
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2. |
The facility
must establish a grievance policy to the prompt resolution of grievances the
resident may have, including those with respect to care and treatment, the
behavior of staff and other residents and other concerns. (42CFR 483.10(j)(1)-(4)) F 585 )
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3. |
The services
provided or arranged by the facility as outlined by the comprehensive care
plan must meet professional standards of quality. (42CFR 483.21(b)(3)(i) F 658 )
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4. |
The services
provided or arranged by the facility must be provided by qualified persons in
accordance with each resident's written plan of care. (42CFR 483.21(b)(3)(ii)
F 659 )
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5. |
The medical
care of each resident in always supervised by a physician. (42CFR 483.30(a)(1)(2) F 710)
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6. |
The facility
must have sufficient nursing staff with the appropriate competencies and
skill sets to provide nursing and related services that assure resident
safety and attain or maintain the highest practical well-being of
residents. Sufficient numbers of
licensed nurses and other nursing personnel including but not limited to
nurse aides must be provided on a 24-hour basis with a licensed nurse as
charge nurse on each tour of duty.
(42CFR 483.35(a)(1)(2) F 725 )
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7. |
The facility
must have sufficient nursing staff with the appropriate competencies and
skill sets to provide nursing and related services that assure resident
safety and attain or maintain the highest practical well-being of
residents. The facility must ensure
nursing staff and nurse aides have the competencies necessary to care for
each resident’s need. (42CFR 483.35(a)(3)(4)(c) F 726 )
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8. |
The facility
receives registry verification that individuals have met competency
evaluation requirements before allowing an individual to serve as a nurse
aide unless the individual can otherwise prove they have met competency
evaluation requirements and requires individuals who have not provided nursing or nursing-related services within
24 consecutive months complete a new training and
competency evaluation program (42CFR 483.35(d)(4)-(6) F 729 )
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9. |
The facility
must complete a performance review of every nurse aide at least once every
twelve months and must provide regular in-service education based on the
outcome of these reviews. (42CFR
483.35(d)(7) F 730 )
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10. |
The facility provides medically related social services to residents. (42CFR 483..40(d) F 745 )
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11. |
The facility
must designate a physician to serve as medical director responsible for
implementation of resident care policies and the coordination of medical care
in the facility. (42CFR 483.70(h)(1)(2) F 841 )
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12. |
The facility
develops a documented, effective, data-driven quality assurance and a
performance improvement (QAPI) program designed to be ongoing, comprehensive
and to address the full range of care provided by the facility. The facility ensures that the QAPI program
is implemented, adequately resourced, identifies problems, evaluates
effectiveness of corrective actions and presents clear expectations set
around safety, quality, rights, choice and respect. (42CFR 483.75(a)(b)(f)(h)(i) F 865 )
and/or;
The facility quality assessment and assurance committee develops and implements appropriate plans of action
to correct identified quality deficiencies (42 CFR 483.75(g)(2)(ii) F 867)
and/or;
The facility maintains a quality assessment and assurance committee consisting of the director of nursing services;
the medical Director of his/her designee; and at least 3 other members of the facility’s staff that coordinates and
evaluates activities under the QAPI program (42CFR483.75(g)(1)(i)-(iii)(2)(i) F 868)
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13. |
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. Identified incidents of infection and
corrective measures must be recorded and the infection control program must
be reviewed yearly and updated as necessary. (42CFR 483.80(a)(1)(2)(4)(e)(f))
F 880 )
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The following federal regulation revisions and F numbers apply to previous surveys before November 28, 2017.
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1. |
Efforts are made by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.
(42CFR 483.10(f) (2) F 166 )
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2. |
The facility must make the results of the most recent survey available for examination in a place readily accessible to residents and must post a notice of their availability.
(42CFR 483.10(g) (1) F 167 )
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3. |
The facility provides medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (42CFR 483.15(g)(1) F 250 )
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4. |
The services provided or arranged by the facility meet professional standards of quality. (42CFR 483.20(k)(3)(i) F 281 )
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5. |
The services provided or arranged by the facility are provided by qualified persons in accordance with each resident's written plan of care. (42CFR 483.20(d) (3) (ii) F 282 )
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6. |
The facility has a sufficient number of nursing staff on a 24-hour basis to provide nursing and related services to maintain the highest practicable, physical, mental and psychosocial well-being of each residentthat meet resident identified needs. (42CFR 483.30(a) F 353 )
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7. |
The facility ensures that the medical care of each resident is supervised by a physician. (42CFR 483.40(a) F 385 )
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8. |
The facility maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection which includes; Isolation of residents when necessary; prohibiting employees with a communicable disease from direct contact with residents or their food; Requiring staff to wash their hands each direct resident contact; And handling linens so as to prevent the spread of infection. (42CFR 483.65 F 441 )
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9. |
The facility receives registry verification that individuals have met competency evaluation requirements before allowing an individual to serve as a nurse aide unless the individual can otherwise prove they have met competency evaluation requirements and requires individuals who have not provided nursing or nursing-related services within 24 consecutive months complete a new training and competency evaluation program (42CFR 483.75(e) (5)-(7) F 496 )
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10. |
The facility completes a competency performance review of every nurse aide at least once every twelve months and provides regular in-service education based on the outcome of these reviews that ensure the continuing competence of the nurse aide.
(42CFR 483.75(e) (8) F 497 )
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11. |
The facility has a designated physician serving as medical director responsible for the coordination of medical care. (42CFR 483.75(i) F 501 )
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12. |
The facility maintains clinical records on each resident that are accurately documented, readily accessible, systematically organized and sufficient to identify the resident, provide resident assessments, plans of care and services provided and progress notes. (42CFR 483.75(l) (1) F 514 )
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13. |
The facility maintains a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff that develops and implements appropriate plans to correct quality deficiencies (42CFR 483.75(o)(1) F 520 )
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