State Operations Manual

1 State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Table of Contents (Rev. 26, 08-17-07) Transmittals for Appendix PP INDEX : Definitions Resident Rights (a) Exercise of Rights (b) Notice of Rights and Services (c) Protection of Resident Funds (d) Free Choice (e) Privacy and Confidentiality (f) Grievances (g) Examination of Survey Results (h) Work (i) Mail (j) Access and Visitation Rights (k) Telephone (l) Personal Property (m) Married Couples (n) Self-Administration of Drugs (o) Refusal of Certain Transfers Admission, Transfer, and Discharge Rights (a) Transfer, and Discharge (b) Notice of Bed-Hold Policy and Readmission (c) Equal Access to Quality Care (d) Admissions Policy Resident Behavior and Facility Practices (a) Restraints (b) Abuse (c) Staff Treatment of Residents (F224* and F226**) Quality of Life (a) Dignity (b) Self-Determination and Participation (c)

2 Participation in Resident and Family Groups (d) Participation in Other Activities (e) Accommodation of Needs (f) Activities (g) Social Services (h) Environment Resident Assessment (a) Admission Orders (b) Comprehensive Assessments (c) Quality Review Assessment (d) Use (e) Coordination (f) Automated Data Processing Requirement (g) Accuracy of Assessment (h) Coordination (i) Certification (j) Penalty for Falsification (k) Comprehensive Care Plans (l) Discharge Summary (m) Preadmission Screening for Mentally Ill Individuals and Individuals With Mental Retardation. Quality of Care (a) Activities of Daily Living (b) Vision and hearing (c) Pressure Sores (d) Urinary Incontinence (e) Range of motion. (f) Mental and Psychosocial Functioning (g) Naso-Gastric Tubes (h) Accidents (i) Nutrition (j) Hydration (k) Special Needs (l) Unnecessary Drugs (m) Medication Errors (n) Influenza and Pneumococcal Immunizations Nursing Services (a) Sufficient Staff (b) Registered Nurse (c) Nursing facilities (d) SNFs (e) Nurse Staffing Information Dietary Services (a) Staffing (b) Standard Sufficient Staff (c) Standard Menus and Nutritional Adequacy (d) Food (e) Therapeutic Diets (f) Frequency of Meals (g) Assistive Devices (h) Paid Feeding Assistants (i) Sanitary Conditions Physician Services (a) Physician Supervision (b) Physician Visits 7 (c) Frequency of Physician Visits (d) Availability of Physicians for Emergency Care (e) Physician Delegation of Tasks in SNFs (f)

3 Performance of Physician Tasks in NFs Specialized Rehabilitative Services (a) Provision of Services (b) Qualifications Dental Services (a) Skilled Nursing Facilities (b) Nursing Facilities Pharmacy Services (a) Procedures (b) Service Consultation (c) Drug Regimen Review (d) Labeling of Drugs and Biologicals (e) Storage of Drugs and Biologicals Infection Control (a) Infection Control Program (b) Preventing Spread of Infection (c) Linens Physical Environment (a) Life Safety From Fire (b) Emergency Power (c) Space and equipment (d) Resident Rooms (e) Toilet Facilities (f) Resident Call System (g) Dining and Resident Activities (h) Other Environmental Conditions Administration (a) Licensure (b) Compliance With Federal, State , and Local Laws and Professional Standards (c) Relationship to Other HHS Regulations (d) Governing Body (e) Required Training of Nursing Aides (f) Proficiency of Nurse Aides (g) Staff Qualifications (h) Use of Outside Resources (i) Medical Director (j) Laboratory Services (k) Radiology and Other Diagnostic Services (l) Clinical Records (m) Disaster and Emergency Preparedness (n) Transfer Agreement (o) Quality Assessment and Assurance (p) Disclosure of Ownership F150 Definitions (a) Facility defined.

4 For purposes of this subpart facility means, a skilled nursing facility (SNF) or a nursing facility (NF) which meets the requirements of 1819 or 1919(a), (b), (c), and (d) of the Social Security Act, the Act. Facility may include a distinct part of an institution specified in of this chapter, but does not include an institution for the mentally retarded or persons with related conditions described in of this chapter. For Medicare and Medicaid purposes (including eligibility, coverage, certification, and payment), the facility is always the entity which participates in the program, whether that entity is comprised of all of, or a distinct part of a larger institution. For Medicare, a SNF (see 1819(a)(1)), and for Medicaid, a NF (see 1919(a)(1)) may not be an institution for mental diseases as defined in Interpretive Guidelines The following are the statutory definitions at 1819(a) and 1919(a) of the Act for a SNF and a NF: Skilled nursing facility is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of 1861(1)) with one or more hospitals having agreements in effect under 1866.

5 And meets the requirements for a SNF described in subsections (b), (c), and (d) of this section. _____ Nursing facility is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; has in effect a transfer agreement (meeting the requirements of 1861(1)) with one or more hospitals having agreements in effect under 1866; and meets the requirements for a NF described in subsections (b), (c), and (d) of this section.

6 If a provider does not meet one of these definitions, it cannot be certified for participation in the Medicare and/or Medicaid programs. NOTE: If the survey team finds substandard care in , , or , follow the instructions for partial extended or extended surveys. Resident Rights The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights Interpretive Guidelines All residents in long term care facilities have rights guaranteed to them under Federal and State law. Requirements concerning resident rights are specified in , , , and Section is intended to lay the foundation for the remaining resident s rights requirements which cover more specific areas.

7 These rights include the resident s right to: Exercise his or her rights ( (a)); Be informed about what rights and responsibilities he or she has ( (b)); If he or she wishes, have the facility manage his personal funds ( (c)); Choose a physician and treatment and participate in decisions and care planning ( (d)); Privacy and confidentiality ( (e)); Voice grievances and have the facility respond to those grievances ( (f)); Examine survey results ( (g)); Work or not work ( (h)); Privacy in sending and receiving mail ( (i)); Visit and be visited by others from outside the facility ( (j)); Use a telephone in privacy ( (k)); Retain and use personal possessions ( (1)) to the maximum extent that space and safety permit; Share a room with a spouse, if that is mutually agreeable ( (m)); Self-administer medication, if the interdisciplinary care planning team determines it is safe ( (n)); and Refuse a transfer from a distinct part, within the institution ( (o)).

8 _____ A facility must promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. F151 (a) Exercise of Rights (a)(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 . (a)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. Interpretive Guidelines (a)(1) Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility s rules, as long as those rules do not violate a regulatory requirement.

9 _____ Intent (a)(2) This regulation is intended to protect each resident in the exercise of his or her rights. Interpretive Guidelines (a)(2) The facility must not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights. Facility behaviors designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not interference or coercion. Examples of facility practices that may limit autonomy or choice in exercising rights include reducing the group activity time of a resident trying to organize a residents group; requiring residents to seek prior approval to distribute information about the facility; discouraging a resident from hanging a religious ornament above his or her bed; singling out residents for prejudicial treatment such as isolating residents in activities; or purposefully assigning inexperienced aides to a resident with heavy care needs because the resident and/or his/her representative, exercised his/her rights.

10 Procedures (a)(2) Pay close attention to resident or staff remarks and staff behavior that may represent deliberate actions to promote or to limit a resident s autonomy or choice, particularly in ways that affect independent functioning. Because reprisals may indicate abuse, if the team determines that a facility has violated this requirement through reprisals taken against residents, then further determine if the facility has an effective system to prevent the neglect and abuse of residents. ( (c), F224-F225.) F152 (a)(3) -- In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident s behalf. (a)(4) -- 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.