SNF
Federal Regulatory Groups for Long Term Care *Substandard Quality of Care = one or more deficiencies with s/s levels of F, H, I, J, K, or L in Red
** Tag to be cited by Federal Surveyors Only
June 21, 2021 Page 1
F540 Definitions 483.12 Freedom from Abuse, Neglect, and Exploitation 483.24 Quality of Life 483.10 Resident Rights F600 *Free from Abuse and Neglect F675 *Quality of Life
F550 *Resident Rights/Exercise of Rights F602 *Free from Misappropriation/Exploitation F676 *Activities of Daily Living (ADLs)/ Maintain Abilities F551 Rights Exercised by Representative F603 *Free from Involuntary Seclusion F677 *ADL Care Provided for Dependent Residents F552 Right to be Informed/Make Treatment Decisions F604 *Right to be Free from Physical Restraints F678 *Cardio‐Pulmonary Resuscitation (CPR) F553 Right to Participate in Planning Care F605 *Right to be Free from Chemical Restraints F679 *Activities Meet Interest/Needs of Each Resident F554 Resident Self‐Admin Meds‐Clinically Appropriate F606 *Not Employ/Engage Staff with Adverse Actions F680 *Qualifications of Activity Professional F555 Right to Choose/Be Informed of Attending Physician F607 *Develop/Implement Abuse/Neglect, etc. Policies 483.25 Quality of Care F557 Respect, Dignity/Right to have Personal Property F608 *Reporting of Reasonable Suspicion of a Crime F684 Quality of Care F558 *Reasonable Accommodations of Needs/Preferences F609 *Reporting of Alleged Violations F685 *Treatment/Devices to Maintain Hearing/Vision F559 *Choose/Be Notified of Room/Roommate Change F610 *Investigate/Prevent/Correct Alleged Violation F686 *Treatment/Svcs to Prevent/Heal Pressure Ulcers F560 Right to Refuse Certain Transfers 483.15 Admission, Transfer, and Discharge F687 *Foot Care F561 *Self Determination F620 Admissions Policy F688 *Increase/Prevent Decrease in ROM/Mobility F562 Immediate Access to Resident F621 Equal Practices Regardless of Payment Source F689 *Free of Accident Hazards/Supervision/Devices F563 Right to Receive/Deny Visitors F622 Transfer and Discharge Requirements F690 *Bowel/Bladder Incontinence, Catheter, UTI F564 Inform of Visitation Rights/Equal Visitation Privileges F623 Notice Requirements Before Transfer/Discharge F691 *Colostomy, Urostomy, or Ileostomy Care F565 *Resident/Family Group and Response F624 Preparation for Safe/Orderly Transfer/Discharge F692 *Nutrition/Hydration Status Maintenance F566 Right to Perform Facility Services or Refuse F625 Notice of Bed Hold Policy Before/Upon Transfer F693 *Tube Feeding Management/Restore Eating Skills F567 Protection/Management of Personal Funds F626 Permitting Residents to Return to Facility F694 *Parenteral/IV Fluids F568 Accounting and Records of Personal Funds 483.20 Resident Assessments F695 *Respiratory/Tracheostomy care and Suctioning F569 Notice and Conveyance of Personal Funds F635 Admission Physician Orders for Immediate Care F696 *Prostheses F570 Surety Bond ‐ Security of Personal Funds F636 Comprehensive Assessments & Timing F697 *Pain Management F571 Limitations on Charges to Personal Funds F637 Comprehensive Assmt After Significant Change F698 *Dialysis F572 Notice of Rights and Rules F638 Quarterly Assessment At Least Every 3 Months F699 *{PHASE‐3} Trauma Informed Care F573 Right to Access/Purchase Copies of Records F639 Maintain 15 Months of Resident A ssessments F700 *Bedrails F574 Required Notices and Contact Information F640 Encoding/Transmitting Resident Assessment 483.30 Physician Services F575 Required Postings F641 Accuracy of Assessments F710 Resident's Care Supervised by a Physician F576 Right to Forms of Communication with Privacy F642 Coordination/Certification of A ssessment F711 Physician Visits‐ Review Care/Notes/Order F577 Right to Survey Results/Advocate Agency Info F644 Coordination of PASARR and Assessments F712 Physician Visits‐Frequency/Timeliness/Alternate NPPs F578 Request/Refuse/Discontinue Treatment;Formulate Adv Di F645 PASARR Screening for MD & ID F713 Physician for Emergency Care, Available 24 Hours F579 Posting/Notice of Medicare/Medicaid on Admission F646 MD/ID Significant Change Notification F714 Physician Delegation of Tasks to NPP F580 Notify of Changes (Injury/Decline/Room, Etc.) 483.21 Comprehensive Resident Centered Care Plan F715 Physician Delegation to Dietitian/Therapist F582 Medicaid/Medicare Coverage/Liability Notice F655 Baseline Care Plan 483.35 Nursing Services F583 Personal Privacy/Confidentiality of Records F656 Develop/Implement Comprehensive Care Plan F725 Sufficient Nursing Staff F584 *Safe/Clean/Comfortable/Homelike Environment F657 Care Plan Timing and Revision F726 Competent Nursing Staff F585 Grievances F658 Services Provided Meet Professional Standards F727 RN 8 Hrs/7 days/Wk, Full Time DON F586 Resident Contact with External Entities F659 Qualified Persons F728 Facility Hiring and Use of Nurse
F660 Discharge Planning Process F729 Nurse Aide Registry Verification, Retraining F661 Discharge Summary F730 Nurse Aide Perform Review – 12Hr/Year In‐ service F731 Waiver‐Licensed Nurses 24Hr/Day and RN Coverage F732 Posted Nurse Staffing Information
Federal Regulatory Groups for Long Term Care *Substandard Quality of Care = one or more deficiencies with s/s levels of F, H, I, J, K, or L in Red
** Tag to be cited by Federal Surveyors Only
June 21, 2021 Page 2
483.40 Behavioral Health F811 Feeding Asst ‐Training/Supervision/Resident 483.90 Physical Environment F740 Behavioral Health Services F812 Food Procurement, Store/Prepare/Serve ‐ Sanitary F906 Emergency Electrical Power System F741 Sufficient/Competent Staff‐Behav Health Needs F813 Personal Food Policy F907 Space and Equipment F742 *Treatment/Svc for Mental/Psychosocial Concerns F814 Dispose Garbage & Refuse Properly F908 Essential Equipment, Safe Operating Condition F743 *No Pattern of Behavioral Difficulties Unless Unavoidable 483.65 Specialized Rehabilitative Services F909 Resident Bed F744 *Treatment /Service for Dementia F825 Provide/Obtain Specialized Rehab Services F910 Resident Room F745 *Provision of Medically Related Social Services F826 Rehab Services‐ Physician Order/Qualified Person F911 Bedroom Number of Residents 483.45 Pharmacy Services 483.70 Administration F912 Bedrooms Measure at Least 80 Square Ft/Resident F755 Pharmacy Svcs/Procedures/Pharmacist/ Records F835 Administration F913 Bedrooms Have Direct Access to Exit Corridor F756 Drug Regimen Review, Report Irregular, Act On F836 License/Comply w/Fed/State/Local Law/Prof Std F914 Bedrooms Assure Full Visual Privacy F757 *Drug Regimen is Free From Unnecessary Drugs F837 Governing Body F915 Resident Room Window F758 *Free from Unnec Psychotropic Meds/PRN Use F838 Facility Assessment F916 Resident Room Floor Above Grade F759 *Free of Medication Error Rate sof 5% or More F839 Staff Qualifications F917 Resident Room Bed/Furniture/Closet F760 *Residents Are Free of Significant Med Errors F840 Use of Outside Resources F918 Bedrooms Equipped/Near Lavatory/Toilet F761 Label/Store Drugs & Biologicals F841 Responsibilities of Medical Director F919 Resident Call System 483.50 Laboratory, Radiology, and Other Diagnostic Services F842 Resident Records ‐ Identifiable Information F920 Requirements for Dining and Activity Rooms F770 Laboratory Services F843 Transfer Agreement F921 Safe/Functional/Sanitary/ Comfortable Environment F771 Blood Blank and Transfusion Services F844 Disclosure of Ownership Requirements F922 Procedures to Ensure Water Availability F772 Lab Services Not Provided On‐Site F845 Facility closure‐Administrator F923 Ventilation F773 Lab Svs Physician Order/Notify of Results F846 Facility closure F924 Corridors Have Firmly Secured Handrails F774 Assist with Transport Arrangements to Lab Svcs F847 Enter into Binding Arbitration Agreements F925 Maintains Effective Pest Control Program F775 Lab Reports in Record‐Lab Name/Address F848 Select Arbitrator/Venue, Retention of Agreements F926 Smoking Policies F776 Radiology/Other Diagnostic Services F849 Hospice Services 483.95 Training Requirements F777 Radiology/Diag. Svcs Ordered/Notify Results F850 *Qualifications of Social Worker >120 Beds F940 {PHASE‐3} Training Requirements ‐ General F778 Assist with Transport Arrangements to Radiology F851 Payroll Based Journal F941 {PHASE‐3} Communication Training F779 X‐Ray/Diagnostic Report in Record‐Sign/Dated 483.75 Quality Assurance and Performance Improvement F942 {PHASE‐3} Resident’s Rights Training 483.55 Dental Services F865 QAPI Program/Plan, Disclosure/Good Faith Attempt F943 Abuse, Neglect, and Exploitation Training F790 Routine/Emergency Dental Services in SNFs F866 {PHASE‐3} QAPI/QAA Data Collection and Monitoring F944 {PHASE‐3} QAPI Training F791 Routine/Emergency Dental Services in NFs F867 QAPI/QAA Improvement Activities F945 {PHASE‐3} Infection Control Training 483.60 Food and Nutrition Services F868 QAA Committee F946 {PHASE‐3} Compliance and Ethics Training F800 Provided Diet Meets Needs of Each Resident 483.80 Infection Control F947 Required In‐Service Training for Nurse Aides F801 Qualified Dietary Staff F880 Infection Prevention & Control F948 Training for Feeding Assistants F802 Sufficient Dietary Support Personnel F881 Antibiotic Stewardship Program F949 {PHASE‐3} Behavioral Health Training F803 Menus Meet Res Needs/Prep in Advance/Followed F882 Infection Preventionist Qualifications/Role F804 Nutritive Value/Appear, Palatable/Prefer Temp F883 *Influenza and Pneumococcal Immunizations F805 Food in Form to Meet Individual Needs F884 **Reporting – National Health Safety Network F806 Resident Allergies, Preferences and Substitutes F885 Reporting – Residents, Representatives & Families F807 Drinks Avail to Meet Needs/P references/ Hydration F886 COVID‐19 Testing‐Residents & Staff F808 Therapeutic Diet Prescribed by Physician F887 COVID‐19 Immunization F809 Frequency of Meals/Snacks at Bedtime 483.85 Compliance and Ethics Program F810 Assistive Devices ‐ Eating Equipment/Utensils F895 {PHASE‐3} Compliance and Ethics Program