100 Essential Forms for Long-Term Care

1 100 Essential Forms for Long-Term care Carol Marshall, MA Julie Ann Kemman, BBA. Kate Brewer, PT, MBA, GCS, RAC-CT Heather Stewart, RHIT. 100 Essential Forms for Long-Term care provides convenient access to a compilation of Essential Forms that will save nursing home staff time and improve Marshall the documentation accuracy of every department in the Long-Term care facility. The updated content found in this new edition reflects recent regulatory changes to help Long-Term care providers stay compliant and ensure quality resident care . The updated Forms offer easy-to-understand descriptions of implementation Brewer processes and timing, and can be used as-is or customized to best meet the particular needs of nursing home staff. This book contains 100 of the most commonly utilized Forms in Long-Term care Kemman facilities, including: Clinical assessment Forms Survey readiness assessments Stewart Documentation Forms MDS tools Regulatory Forms Accountability reports Quality Assessment and Performance Improvement (QAPI) Forms PUB CODE.

2 Barcode 75 Sylvan Street | Suite A-101. of BLR. a division Danvers, MA 01923. 100. Essential Forms for Long-Term care Carol Marshall, MA Julie Ann Kemman, BBA. Kate Brewer, PT, MBA, GCS, RAC-CT Heather Stewart, RHIT. 100 Essential Forms for Long-Term care is published by HCPro, a division of BLR. Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed in the United States of America. 5 4 3 2 1. Download Forms and tools from this book with the purchase of this product. ISBN: 978-1-55645-227-7. No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro provides information resources for the healthcare industry. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

3 Carol Marshall, MA, Author Kate Brewer, PT, MBA, GCS, RAC-CT, Author Heather Stewart, RHIT, Author Julie Ann Kemman, BBA, Author Olivia MacDonald, Managing Editor Adrienne Trivers, Product Manager Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Manager Vicki McMahan, Sr. Graphic Designer Jason Gregory, Layout/Graphic Design Kelly Church, Cover Designer Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro 75 Sylvan Street, Suite A-101. Danvers, MA 01923. Telephone: 800-650-6787 or 781-639-1872. Fax: 800-639-8511. E-mail: Visit HCPro online at: and Contents About the Section 1: Audit 1. Form : Quality auditing form: nursing 3. Form : Triple-check 8. Form : Resident care status survey 12.

4 Form : Preadmission 17. Form : Dysphagia 19. Form : Psychotropic audit ..21. Form : Urinary catheter reminder 24. Form : Urinary catheter 26. Form : Medical staff documentation audit .. 28. Form : Safety rounds 30. Form : Kitchen/dietary 34. Form : Discharge record documentation 7. Form : Skilled nursing facility 40. Form : MDS chart audit 42. Form : Compliance audit 45. Form : CAA completion audit 56. Form : Quarterly Medicare compliance 58. Form : Policy and procedure: Medicare Part A triple-check 60. Form : Policy and procedure: Medicare Part B triple-check 64. Form : Assessment itinerary announced site 67. Form : Sample checklist for unannounced 69. Form : Resident review Form : Quality of life assessment resident 73. Form : Quality of life assessment family 75. Form : Quality of life assessment group 77. Form : Statement of deficiencies and plan of 79. 2014 HCPro iii 100 Essential Forms for Long-Term care Section 2: Documentation 81.

5 Form : Admission database 83. Form : nursing care flow 92. Form : Monthly psychoactive 97. Form : Restraint elimination/reduction Form : Fall response Form : care plan meeting education Form : Fall risk Form : 48-hour post-fall monitoring 111. Form : Incident/accident 114. Form : Pain assessment for those with communication 116. Form : Pain management tracking 118. Form : Pain management Form : ADL/restorative nursing flow Form : ADL data collection Form : Cognitive/mood/behavioral data collection flow Form : Restorative nursing flow Form : Wandering Form : Product evaluation Form : Transfer checklist (subacute to LTC units)..137. Form : Infection control tracking Form : Readmission documentation pull Form : Hospital readmission tracking Form : Rehospitalization tracking Form : Weight loss communication Form : Against medical advice Form : Anti-psychotic drug use Form : Dehydration prevention Form : Elopement Form : MDS therapy Form : Swallowing protocol-feeding precaution Section 3: Accountability 165.

6 Guidelines for monthly reports ( Forms , , , )..166. Form : Sample monthly report: Director of Form : Sample monthly report: Assistant director of Form : Sample monthly report: Non- nursing Form : Sample monthly report: Maintenance Form : Task management Form : Utilization review/discharge meeting Form : Satisfaction survey response iv 2014 HCPro Contents Section 4: Regulatory 183. Form : Gantt chart for regulatory Form : Standing meeting/committee Form : Root cause analysis Form : State department of health survey Form : Frequently used ICD-9 codes in LTC: Mapping guide to Form : Transition to ICD-10 Form : ICD-10 preparation survey: Knowledge Form : Preparation for ICD-10: Self-evaluation for Section 5: Performance Improvement 207. QAPI Form : QAPI 210. Form : QAPI form: Pain management 211. Form : QAPI form: Fall reduction Form : QAPI form: Transfers to hospital Form : QAPI form: Psychoactive drug use monitoring Form : QAPI form: Restraint reduction Form : QAPI form: Infection control and surveillance Form : Pain management data collection form for Form : Interdisciplinary action committee (IAC) Form : Performance improvement project assignment Section 6: Credentialing and Communication 227.

7 Credentialing and privileging physicians and nurse practitioners: Form : Request for application intake form: General Form : Request for application intake form: Temporary Form : Credentialing cover letter: Initial Form : Credentialing cover letter: Form : Credentialing checklist: Initial Form : Credentialing checklist: Temporary Form : Credentialing checklist: Form : Licensure Form : Credentialing phone verification Form : Reappointment Form : Temporary appointment Form : Professional exchange Form : Therapy and nursing communication 2014 HCPro v 100 Essential Forms for Long-Term care Section 7: Additional Documentation Request 247. Form : Additional documentation request (ADR)..249. Form : Internal ADR tracking Form : ADR appeal documentation Form : Part A denial tracking/appeal request Form : Part B denial tracking/appeal request Form : RAC/ZPIC/CERT audit tracking Forms and tools can be accessed with the purchase of this product.

8 Vi 2014 HCPro ABOUT THE AUTHORS. Carol Marshall, MA, is a risk management specialist based in Fort Worth, Texas. For the past 18. years, she has trained managers and staff members in Long-Term care facilities across the country about the benefits of exceptional customer service and risk management. She has offered training programs at numerous state conferences, professional groups, and individual facilities. Kate Brewer, PT, MBA, GCS, RAC-CT, is the president of Greenfield Rehabilitation Agency, a company that provides physical, occupational, and speech-language pathology services in skilled nursing facilities. Having spent over 15 years in Long-Term care , Brewer has extensive experience in various processes and approaches to regulatory compliance from a Medicare and survey perspective. Her areas of expertise include therapy documentation and compliance with Medicare regulations, coordinating the MDS process to ensure optimal reimbursement and compliance, and bridging the gap between the different professions that work together in Long-Term care .

9 Julie Ann Kemman, BBA, president of Health care Professional Consulting Services, Inc., has over 20 years of experience working within the Long-Term care community. She holds a bachelor's degree in business administration from Northwood University. Julie has held multiple corporate regional positions for a large nursing home chain and has been the cornerstone in staff training, compliance monitoring, and management. Health care Professional Consulting Services, Incorporated, was started in July 2005 and provides skilled nursing organizations, assisted living, home health agencies, and outpatient rehabilitation providers a variety of consulting services, including billing, collections, training, policy writing, and software implementation. Heather Stewart, RHIT, is a knowledgeable health information management consultant with more than 16 years of experience in the Long-Term care industry.

10 Stewart has an extensive background in healthcare compliance, medical coding, and electronic health record implementation. 2014 HCPro vii Section 1. Audit Forms 1. Quality auditing form: nursing documentation 2. Triple-check form 3. Resident care status survey tool 4. Preadmission screen 5. Dysphagia audit 6. Psychotropic audit 7. Urinary catheter reminder order 8. Urinary catheter checklist 9. Medical staff documentation audit 10. Safety rounds audit 11. Kitchen/dietary audit 12. Discharge record documentation audit 13. Skilled nursing facility self-audit 14. MDS chart audit tool 15. Compliance audit worksheet 16. CAA completion audit tool 17. Quarterly Medicare compliance guide 18. Policy and procedure: Medicare Part A triple-check process 19. Policy and procedure: Medicare Part B triple-check process 20. Assessment itinerary announced site visit 2014 HCPro 1. 100 Essential Forms for Long-Term care 21.