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Flashcards in Administration Deck (47):

When the facility does not have an administrator, how soon must the facility secure one?

-Texas Only -19.1902
30 days


How long is the administrator required to work?

-Both -483.75/19.1902
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?

4 months:
. 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?

A physician


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?

1-Quality AND


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?

-Texas Only-19.1911

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?

Fed: F514/483.75(I)(5)
-Enough info to identify the resident
-Plan of Care
-Services Provided
-Results of any Preadmission Screenings Conducted by state (Passar/TB)
-Progress Notes
-Texas Only-19.1911
1-Face Sheet
2-ID info.
3-Assessments (both)
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
9-Discharge Info
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:

-Texas Only-19.1911
3-Each page must have NAME of RESIDENT


What are some of the "Observations" that fall under current information?

-Texas Only-19.1911
1-Current PRN Medication
3-Physical Complaints
4-Changes in: behavior/clinical signs
5-Any/All accidents or incidents
6-Flow sheets: bathing/elimination/fluid intake/vital signs/ambulation/weight
7-Activity Participation
8-Dietary Intake including rejections


What is the "Master Index" of residents?

-Texas Only-19.1912
A record of all residents admitted and discharged from the facility


How long must a facility keep the "Master Index"?

-Texas Only-19.1912
The record is permanent


What information of the residents are contained in the "Master Index"?

-Texas Only-19.1912
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?

-Fed Only-483.75-f-
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?

-Fed Only-483.75-f-
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?

-Fed Only-483.75-f-
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?

-Texas Only-19.1912-b
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?

-Texas Only-19.1912--c
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?

-Texas Only-19.1912-d
(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?

-Texas Only-19.1912-e
When the resident has been discharged for over 30 days.


Where must the original master legend (SIg. for Meds/Treatments/flow sheet) be kept?

-Texas Only-19.1912-f
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?

-Texas Only-19.1912-g-
1-Resident Name
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?"

-Texas Only-19.1914-a-3
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?

-Texas Only-19.1914-b-
30 days after the situation


When MUST the facility review and evaluate an disaster and recovery plan?

-Texas Only-19.1914-b
30 days after an Emergency situation OR
when there is a Remodel OR
Once a Year.


Who must be on the Quality Assessment Committee?

-Texas Only-19.1917-
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?

-Texas Only-19.1918
30 Days
[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?

-Texas Only-19.1921-k-
with in 72 hours of Admit.


How long must accident/incident reports be retained for?

-Texas Only-19.1923
At least 2 Years


How long must a facility keep resident financial records?
Provider financial records?
Reimbursement Financial records?
Claim financial records?

-Texas Only-19.1924

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?

-Texas Only-19.1925
72 Hours


IS a volunteer program mandatory in a facility?

-Texas Only-19.1928
No, but a program MUST be promoted


How much training is required of ALL nurse Types for people with DEMENTIA?

-Texas Only-19.1929
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?

-Texas Only-19.1929-
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?

-Texas Only-19.1917-
Once a year.


How soon after employment must Hep B vaccination be offered? Who must pay?

10 days
Facility pays


According to NAB , how many hours of continuing education is an administrator required to receive?

20 hours a year.


When must Tuberculosis screening happen? For residents? For employees (facility/contract)?

Fed: F441
Residents , upon admission and in line with state regulations
Texas: 19.1601(d)(2)
All residents must be screened at admission
All employees must be screened BEFORE providing services
All outside contract persons must provide evidence of screening BEFORE providing services IN the facility