Surveyor Foc Ck Lst Level4 by IFY9nc7Y

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									                                                     STATE OF MAINE
                                           Division of Licensing and Certification
                                               Community Services Programs

                      LEVEL IV FOCUSED SURVEY CHECKLIST                               Met      Not Met

Facility Name:

Program Specialist Name:

Date:


3.25 Rates and Contracts
3.25.3.6 grievance proced., tenancy oblig.,
           resid. rgts, admission policy

5 Resident Rights
5.10 freedom from abuse, neglect, exploitation
5.11 rights regarding restraints & adversive
     conditioning
5.25 mandatory reporting

6 Alzheimer's/Dementia Unit Standards
6.2.1.1 documentation of legal rep.
6.2.1.2 documentation of diagnoses of Alz. disease/dementia
6.3.3 Physical Safety
6.3.3.1 unit to have policies/procedures for resident wandering
6.5 Pre-service training for Alz./Dimentia Care Units (8 hrs. of
     classroom orient. and 8 hrs. clinical orient. to all new employees)

7 Medications and Treatments
7.1 use of safe & accept. proced.
7.1.1 residents receive meds in correct dose, time and route
7.1.2 no injectable meds admin. by unlic. person
       except bee sting kits & insulin
7.1.3 before use of bee sting kit unlic. person to be trained by RN
7.1.4 for diabetic residents, unlic. staff to be trained
       by R.N.
7.1.6 no med. to be admin. or discont. without order
7.1.7 orders for meds/treatments signed/dated (12mo)
7.2 Administration of Medications
7.2.1 self administration
7.2.3 unlic. staff admin. meds need to take Dept. approved
       course (CRMA)
7.3 Medication Storage
7.3.2 meds kept in orig. containers, locked in cabinet with sep. cubicles
7.3.3 internal and external meds kept separate
7.4 temp absences: meds leaving facility < = or >
     72 hrs.
7.5 medication labeling (perscript #, resid. full name, etc.)
7.6 improperly labeled meds.
7.7 expired & discontinued meds
7.9 destroying medications: (destruction/return within 60 days)


   For Official Use Only                                 Page 1 of 3                 ALLS.601 (Rev. 11/05)
                                                   STATE OF MAINE
                                         Division of Licensing and Certification
                                             Community Services Programs

                      LEVEL IV FOCUSED SURVEY CHECKLIST                             Met      Not Met

7.10 Schedule II Controlled Substances
7.10.1 individual record
7.10.2 recorded & signed count of II's once per day if
        used that day
7.10.3 on hand II's counted weekly, kept in bound book
7.10.4 II's double locked in separate locked box
7.10.5 disposal of II's
7.12 medication/treatment admin. records
7.14 breathing apparatus: documentation
7.16 documentation of RN inservice tng for unlic.
      staff
7.17 document. of inservice or proced. taught by prof. to be in employee file

8 Verification of Credentials (Lic. Staff, C.N.A.'s…)

10 Administration
10.4 Department approved tng course; 12 hrs annual
     tng.
10.9 administrative responsibilities

11 Administrative and Resident Records
11.1.3 statement from doctor showing date of last
        annual physical
11.1.7 incident reports
11.4 personal funds
11.4.1 permission to manage resident funds
11.4.2 itemized accounting of resident funds

12 Standards For Resident Care
12.2 resident assessment
12.3.1 service plan
12.4 progress notes
12.10 facility promptly coord./assist in accessing approp. services for
        residents
13 Staffing
13.2.1 < =10 beds, 1 adult present at all times
         whenever residents are present
13.4.1.1 Minimum Staff to Bed Ratios ( > 10 beds)
            1:12 (7am-3pm)
            1:18 (3pm-11pm)
            1:30 (11pm-7am)
13.5 Employee records
13.6 Staff Training, Education & Qualifications
13.6.1 within 120 days of hire (except C.N.A.'s and
         licensed staff) direct care staff working 20hrs
         per wk to complete Dept. approved course
13.9 Registered Nurse Services
      7-10 resid., services provided quarterly



   For Official Use Only                                Page 2 of 3                ALLS.601 (Rev. 11/05)
                                                  STATE OF MAINE
                                        Division of Licensing and Certification
                                            Community Services Programs

                     LEVEL IV FOCUSED SURVEY CHECKLIST                             Met      Not Met

    11-25 resid., services provided every 60 days
    26-40 resid., services provided monthly
    40 + resid., services provided weekly
13.10 Pharmicist Consultant Services
       > 10 beds retain services quarterly

14 Dietary Services
14.1 Dietary Coordinator
14.6 therapeutic diets, physician order needed
14.8 food supply: supplies for perishables to last 48hrs, non-perish. to
      last 3 days


Level I - 1 record Level III - 2 records Greater than 50 beds, 10% (5 records)
Level II - 2 records Level IV - 10% or 3 records Possibly 1 new admit
1 Discharge/Death (could be omitted if home has had a good track record)




   For Official Use Only                               Page 3 of 3                ALLS.601 (Rev. 11/05)

								
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