Flashcards in Administration Deck (47):
When the facility does not have an administrator, how soon must the facility secure one?
-Texas Only -19.1902
How long is the administrator required to work?
40 hours a week on admin duties
What is the grace period for nurse aids to complete there training, before the facility either has to hire them or let them go?
. A facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis, unless has completed training.
What must the facility (buss office) due before they can hire a nurse aid?
They must make sure the person is on a the registry verification, and is not found to have abuse , neglect , or mistreatment in there background.
When must a nurse aid be "re-trained"?
2 years with no NURSE work.
there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation,
How often is the facility required to do a performance review of every nurse aid?
At least once a year / every 12 months
What is the minimum time for in-service trainings of nurse aids?
No less than 12 hours of in-service a year.
who must serve as a the medical director of a facility?
What is the responsibility of the medical director?
1-implementation of resident care policies AND
2-coordination of medical care.
When using outside resources the facility assumes responsibility for?
When can the facility ORDER lab tests?
Only when ordered by the attending physician.
*Same with Radiology and other diagnostic services
How soon must the facility notify the attending physician of LAB results?
ASAP // promptly
*Same with Radiology and other diagnostic services
How long must clinical records be retained for?
What is the clinical records is that of a minor?
5 years AFTER medical services have ended.
** Minor is 3 years after reaches legal age.
What ID information must the clinical record contain?
2-Full Name of Resident
5-Health Insurance Claim Number (If Applicable)
6-DOB - Date of birth
7-Clinical Record Number (If Applicable)
What info must the clinical record contain?
-Enough info to identify the resident
-Plan of Care
-Results of any Preadmission Screenings Conducted by state (Passar/TB)
4-All plans of Care
6-All clinical documentation from ALL healthcare peoples - Due 14 Days after Admit:
-History- / Physical Exam / Diagnoses / ETA of Discharge / Rehab Potential / any previous yearly medical exams
8-Directives and Powers of Attorney
10-Intial medical Evaluation
11-Nurse "Observations" - Current Info
12-Date an hour of all drug treatments
13-Documentation of special procedures preformed
All clinical documentation that is in the residents clinical record must:
3-Each page must have NAME of RESIDENT
What are some of the "Observations" that fall under current information?
1-Current PRN Medication
4-Changes in: behavior/clinical signs
5-Any/All accidents or incidents
6-Flow sheets: bathing/elimination/fluid intake/vital signs/ambulation/weight
8-Dietary Intake including rejections
What is the "Master Index" of residents?
A record of all residents admitted and discharged from the facility
How long must a facility keep the "Master Index"?
The record is permanent
What information of the residents are contained in the "Master Index"?
2-DOB - Date of Birth
3-DOA - Date of Admission
4-DOD - Date of discharge
5-SS# / Medicaid # / Medicare #
What are the duties of the administrator when a facility closes?
1-submit a written notification to: residents or REPS, state ombudsman, State Survey Agency
2-Make sure NO new Admits
3-Written plan, in the submitted notice, of the transfer of all residents
What is the responsibility of the facility when a building closes?
Facility must have policies and procedures for the administrator on how to handle the closure
How much notification is required before a facility can close?
60 days --
Unless: it is a case where the STATE of the FED pulled facility from the Medicare / Medicaid Program, then DATE is determined by them
In the event of a facility closure/ change of ownership / change of administrator / what must happen to the clinical records?
1-New management must maintain medical information required for the continuity of care- It must be Documented- photo copies are OK.
2-If Change of ownership then the two parties will agree in writing who will be responsible for the retention or records.
When is the only time you can use an eraser?
medication/treatment/diet section of the resident care plan
** All records must be in Ink or printed.
What must always remain in the active clinical record?
(1) current history and physical,
(2) current physician's orders and progress notes,
(3) current resident assessment instrument (RAI) and subsequent quarterly reviews; in Medicaid-certified facilities, all RAIs and Quarterly Reviews for the prior 15-month period,
(4) current care plan,
(5) most recent hospital discharge summary or transfer form
(6) current nursing and therapy notes,
(7) current medication and treatment records,
(8) current lab and x-ray reports, and
(9) the admission record; and
(10) the current permanency plan.
If a resident is discharged from and the later re-admitted, when must the resident be treated as if he is a NEW admit in the clinical record?
When the resident has been discharged for over 30 days.
Where must the original master legend (SIg. for Meds/Treatments/flow sheet) be kept?
In the DON's office or the clinical records office.
When it is ok to the destroy clinical records (after the 5 year after resident is gone), what must be documented about the destruction of the clinical record?
2-Medical Record number
3-SSN/Medicaid/Medicare # OR
5-Date and Signature of PERSON destroying RECORD.
Is it Required to have a CLINICAL RECORDS SUPERISOR who is in charge of all the clinical RECORDS?
Both NAB P.52 / Texas 19.1913
Yes, Must Identify who that person is.
-Texas Only- 19.1913-
And must be in writing who that person is, AND
must be Registered (RHIA), (RHIT), OR
have experience in the field AND
receives consultation every 180 days from a RHIA or RHIT
**RHIA- Registered Health Information Administrator
**RHIT-Registered Health Information Technician
In terms of an Emergency Situation what is a "Receiving Facility?"
a facility or location that has agreed to receive the residents of another facility who are evacuated due to an emergency situation
How soon after an emergency situation occurs must a facility review and evaluate to determine change to the plan?
30 days after the situation
When MUST the facility review and evaluate an disaster and recovery plan?
30 days after an Emergency situation OR
when there is a Remodel OR
Once a Year.
Who must be on the Quality Assessment Committee?
Physician (does not need to be Medical Director)
3 other Staff
How often does the Quality Assessment Committee meet?
At least once a Quarter (3 Months)
When must the facility give notice of a change of ownership or management?
[Admin/DON/Owner/] all fall with in this REG.-Both-
Is it required to make an inventory list of personal property when a resident is admitted into a facility?
with in 72 hours of Admit.
How long must accident/incident reports be retained for?
At least 2 Years
How long must a facility keep resident financial records?
Provider financial records?
Reimbursement Financial records?
Claim financial records?
Minimum of 3 years and 90 days. After termination of the contract period. OR
3 years after the end of the Federal fiscal year.
How soon must a license holder notify DADS in Writing of a SIGNFIICANT CHANGE in FINANCES?
IS a volunteer program mandatory in a facility?
No, but a program MUST be promoted
How much training is required of ALL nurse Types for people with DEMENTIA?
1 hour of Training a YEAR.
** So at least one Training for the year must be on dementia
What are the minimum hour requirements of In-service Meetings?
1-Licensed Personnel 2 hours PER quarter
2-Nurse Aids 12 Hours a Year.
** Records of attendance must be kept for each employee
How often must the Nurse Dept. submit a annual report to the quality assurance committee?
Once a year.
How soon after employment must Hep B vaccination be offered? Who must pay?
According to NAB , how many hours of continuing education is an administrator required to receive?
20 hours a year.