Fill - Free fillable CONCURRENT WITH FEDERAL SURVEY: SAME TEAM (California) PDF form

State SNF Relicensing Survey Workbook 2016

DATE(S) OF SURVEY:

License Number Facility Name & Address (City, State, Zip)

Type of Survey:

 CONCURRENT WITH FEDERAL SURVEY: SAME TEAM



CONCURRENT WITH FEDERAL SURVEY: SEPARATE TEAM

Name of Team Leader Evaluator & Professional Title

List Additional Evaluators & Titles List Additional Evaluators & Titles

SURVEY TEAM COMPOSITION (indicate the number of Evaluators according to discipline) Total # of Evaluators Onsite: _____________

HFEN

Pharmacist

Dietitian

Physician

Life Safety Code Surveyor/HFE

Health Information (Records)

Administrator

Infection Control Specialist

Occupational Therapist

Other Consultant

State SNF Relicensing Survey Workbook 2016

TABLE OF CONTENTS

Nursing Service

1

Pharmaceutical Service

15

Staff Development

29

Dietetic Service

33

Activity Program

39

Patient Rights

40

Physical Plant

47

Administrative Service

53

Other Approved Services (Optional Services)

87

State SNF Relicensing Survey Workbook 2016

NURSING SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

TITLE 22

NURSING SERVICE – GENERAL

72311

(a) Nursing service shall include, but not be limited to, the following:

(3) Notifying the attending licensed healthcare practitioner acting

within the scope of his or her professional licensure promptly of:

(G) The facility's inability to obtain or administer, on a prompt and

timely basis, drugs, equipment, supplies or services as prescribed

under conditions which present a risk to the health, safety or security

of the patient.

(b) All attempts to notify physicians shall be noted in the patient's

health record including the time and method of communication and

the name of the person acknowledging contact, if any. If the attending

physician or his designee is not readily available, emergency medical

care shall be provided as outlined in Section 72301(g).

NURSING SERVICE - ADMINISTRATION OF MEDICATIONS AND TREATMENTS

72313

(a) Medications and treatments shall be administered as follows:

(3) Tests and taking of vital signs, upon which administration of

medications or treatments are conditioned, shall be performed as

required and the results recorded.

(4) Preparation of doses for more than one scheduled administration

time shall not be permitted.

(5) All medications and treatments shall be administered only by

licensed medical or licensed nursing personnel with the following

exceptions:

(A) Students in the healing arts professions may administer

medications and treatments only when the administration or

medications and treatments is incidental to their course of study as

approved by the professional board or organization legally authorized

to give such approval.

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LOCATION OF EVIDENCES

(B) Unlicensed persons may, under the direct supervision of licensed

nursing or licensed medical personnel, during training or after

completion of training and demonstrated evidence of competence,

administer the following:

1. Medicinal shampoos and baths.

2. Laxative suppositories and laxative enemas.

3. Nonlegend topical ointments, creams, lotions and solutions when

applied to intact skin surfaces. Unlicensed persons shall not

administer any medication associated with treatment of eyes, ears,

nose, mouth, or genitourinary tract

(6) Medications shall be administered as soon as possible, but no

more than two hours after doses are prepared, and shall be

administered by the same person who prepares the doses for

administration. Doses shall be administered within one hour of the

prescribed time unless otherwise indicated by the prescriber.

(7) Patients shall be identified prior to administration of a drug or

treatment

(8) Drugs may be administered in the absence of a specific duration of

therapy on a licensed prescriber’s new drug order if the facility applies

its stop-order policy for such drugs. The prescriber shall be contacted

prior to discontinuing therapy as established by stop-order policy.

(b) No medication shall be used for any patient other than the patient

for whom it was prescribed.

(c) The time and dose of the drug or treatment administered to the

patient shall be recorded in the patient’s individual medication record

by the person who administers the drug or treatment. Recording shall

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include the date, the time and the dosage of the medication or type of

the treatment. Initials may be used, provided that the signature of the

person administering the medication or treatment is also recorded on

the medication or treatment record.

NURSING SERVICE - PATIENT CARE

72315

(j) Fluid intake and output shall be recorded for each patient as

follows:

(1) If ordered by the physician.

(2) For each patient with an indwelling catheter:

(A) Intake and output records shall be evaluated at least weekly and

each evaluation shall be included in the licensed nurses' progress

notes.

(B) After 30 days the patient shall be reevaluated by the licensed

nurse to determine further need for the recording of intake and output.

(k) The weight and length of each patient shall be taken and recorded

in the patient's health record upon admission, and the weight shall be

taken and recorded once a month thereafter.

NURSING SERVICE – STANDING ORDERS

72317

Standing orders shall not be used in skilled nursing facilities.

Exception- (HSC 1261.3); flu and

pneumococcal vaccinations

allowed.

NURSING SERVICE – RESTRAINTS

72319

(a) Written policies and procedures concerning the use of restraints

and postural supports shall be followed.

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72319 (cont.)

(b) Restraints shall only be used with a written order of a physician or

other person lawfully authorized to prescribe care. The order must

specify the duration and circumstances under which the restraints are

to be used. Orders must be specific to individual patients. In

accordance with Section 72317, there shall be no standing orders and

in accordance with Section 72319(i)(2)(A), there shall be no P.R.N.

orders for physical restraints.

(c) The only acceptable forms of physical restraints shall be cloth

vests, soft ties, soft cloth mittens, seat belts and trays with spring

release devices. Soft ties mean soft cloth which does not cause

abrasion and which does not restrict blood circulation.

(d) Restraints of any type shall not be used as punishment, as a

substitute for more effective medical and nursing care, or for the

convenience of staff.

(e) No restraints with locking devices shall be used or available for

use in a skilled nursing facility.

(g) Restraints shall be used in such a way as not to cause physical

injury to the patient and to insure the least possible discomfort to the

patient.

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REQUIREMENT

MET

NOT

MET

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LOCATION OF EVIDENCES

72319 (cont.)

(i) The requirements for the use of physical restraints are:

(1) Treatment restraints may be used for the protection of the patient

during treatment and diagnostic procedures such as, but not limited

to, intravenous therapy or catheterization procedures. Treatment

restraints shall be applied for no longer than the time required to

complete the treatment.

(2) Physical restraints for behavior control shall only be used on the

signed order of a physician or other person lawfully authorized to

prescribe care, except in an emergency which threatens to bring

immediate injury to the patient or others. In such an emergency an

order may be received by telephone, and shall be signed within 5

days. Full documentation of the episode leading to the use of the

physical restraint, the type of the physical restraint used, the length of

effectiveness of the restraint time and the name of the individual

applying such measures shall be entered in the patient's health

record.

72319 (cont.)

(A)Physical restraints for behavioral control shall only be used with a

written order designed to lead to a less restrictive way of managing,

and ultimately to the elimination of, the behavior for which the restraint

is applied. There shall be no PRN orders for behavioral restraints.

(B) Each patient care plan which includes the use of physical restraint

for behavior control shall specify the behavior to be eliminated, the

method to be used and the time limit for the use of the method.

(C) Patients shall be restrained only in an area that is under

supervision of staff and shall be afforded protection from other

patients who may be in the area

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STANDARD

REQUIREMENT

MET

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LOCATION OF EVIDENCES

72319 (cont.)

(j) When drugs are used to restrain or control behavior or to treat a

disordered thought process, the following shall apply:

(1) The specific behavior or manifestation of disordered thought

process to be treated with the drug is identified in the patient's health

record.

(2) The plan of care for each patient specifies data to be collected for

use in evaluating the effectiveness of the drugs and the occurrence of

adverse reactions.

(3) The data collected shall be made available to the prescriber in a

consolidated manner at least monthly

(4) PRN orders for such drugs shall be subject to the requirements of

this section.

NURSING SERVICE – NURSING STATION INFECTION CONTROL

INFORMATION ACCESSIBILITY

72321

(c) The following shall be available in each nurse’s station:

(1) The facility’s infection control policies and procedures.

(2) Name, address, and telephone numbers of local health

officers

NURSING SERVICE - CLEANING, DISINFECTING, AND STERILIZING

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LOCATION OF EVIDENCES

72323

(a) Each facility shall adopt a written manual on cleaning,

disinfecting and sterilizing procedures. The manual shall include

procedures to be used in the care of utensils, instruments,

solutions, dressings, articles and surfaces and shall be available

for use by facility personnel. All procedures shall be carried out

in accordance with the manual.

(b) Each facility shall make provisions for the cleaning and

disinfecting of contaminated articles and surfaces which cannot

be sterilized.

(c) Bedside equipment including but not limited to washbasins, emesis

basins, bedpans and urinals shall be sanitized only by one of the

following methods:

(1) Submersion in boiling water for a minimum of 30 minutes.

(2) Autoclaving at 15 pounds pressure and 121°C (250) for 20

minutes.

(3) Gas Sterilization.

(d) Chemicals shall not be used as a substitute for the methods

specified in (c) above.

(f) Individual patient care supply items designed and identified by the

manufacturer to be disposable shall not be reused.

Guidance Note: 72323 (c) (1-3) and

(d) is out dated. These items are

normally single patient use. Facility

must have policy and procedures

and follow manufactures

recommendations for use and

disposal. Please refer to 72323 (f)

below.

NURSING SERVICE – SPACE

72325

(a) An office or other suitable space shall be provided for the director

of nursing service.

(b) A nursing station shall be maintained in each nursing unit or

building.

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72325 cont

(c) Each nursing station shall have a cabinet, a desk, space for records,

a bulletin board, a telephone and a specifically designed and well

illuminated medication storage compartment with a lockable door. If a

separate medication room is maintained, it shall have a lockable door

and a sink with water connections for care of equipment and for hand

washing.

(d) If a refrigerator is provided in a nursing station, the refrigerator shall

meet the following standards:

(1) Be located in a clean area not subject to contamination by human

waste.

0 0

(2) Maintain temperatures at or below 7 C (45 F) for chilling.

0 0

(3) Maintain the freezer at minus 18 F ( F).

(4) Contain an accurate thermometer at all times.

(5) If foods are retained in the refrigerator, they shall be covered and

clearly identified as to contents and date initially covered.

PATIENT CARE POLICIES AND PROCEDURES

72523

(c) Each facility shall establish and implement policies and

procedures, including but not limited to:

(2) Nursing services policies and procedures which include:

(C) Screening of all patients for tuberculosis upon admission.

These procedures shall be determined by the patient care policy

committee. A tuberculosis screening procedure may not be

required if there is satisfactory written evidence available that a

tuberculosis screening procedure has been completed within 90

days of the date of admission to the facility. Subsequent

tuberculosis screening procedures shall be determined by the

attending physician.

Guidance Note: Program

Development and Oversight.

Tuberculosis screening on admission

and following the discovery of a new

case, and managing active cases

consistent with State requirements.

The regulations do not provide for prior

documentation in the wording. A

screening can include a review of the

patient’s records and an assessment

regarding testing that might or might not

be needed. Due to the above, Section

72523 (c) 2 (C) verbiage regarding

the 90 days exception has been

dropped

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STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72528

(a) It is the responsibility of the attending licensed healthcare

practitioner acting within the scope of his or her professional licensure

to determine what information a reasonable person in the patient's

condition and circumstances would consider material to a decision to

accept or refuse a proposed treatment or procedure. Information that

is commonly appreciated need not be disclosed. The disclosure of the

material information and obtaining informed consent shall be the

responsibility of the licensed healthcare practitioner who, acting within

the scope of his or her professional licensure, performs or orders the

procedure or treatment for which informed consent is required.

(b) The information material to a decision concerning the

administration of a psychotherapeutic drug or physical restraint, or the

prolonged use of a device that may lead to the inability of the patient

to regain use of a normal bodily function shall include at least the

following:

(1) The reason for the treatment and the nature and seriousness of

the patient's illness.

(2) The nature of the procedures to be used in the proposed treatment

including their probable frequency and duration

(3) The probable degree and duration (temporary or permanent) of

improvement or remission, expected with or without such treatment.

(4) The nature, degree, duration and probability of the side effects and

significant risks, commonly known by the health professions.

(5) The reasonable alternative treatments and risks, and why the

health professional is recommending this particular treatment.

(6) That the patient has the right to accept or refuse the proposed

treatment, and if he or she consents, has the right to revoke his or her

consent for any reason at any time.

(c) Before initiating the administration of psychotherapeutic drugs, or

physical restraints, or the prolonged use of a device that may lead to

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LOCATION OF EVIDENCES

the inability to regain use of a normal bodily function, facility staff shall

verify that the patient’s health record contains documentation that the

patient has given informed consent to the proposed treatment or

procedure. The facility shall also ensure that all decisions concerning

the withdrawal or withholding of life sustaining treatment are

documented in the patient’s health record.

(h) If a patient or his or her representative cannot communicate with

the physician because of language or communication barriers, the

facility shall arrange for an interpreter.

(2) When interpreters are used, documentation shall be placed in the

patient’s health record indicating the name of the person who acted as

the interpreter and his or her relationship to the patient and to the

facility.

PATIENTS’ HEALTH RECORDS

ADMISSION RECORDS

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LOCATION OF EVIDENCES

72545

(5) Date of admission.

(6) Date of discharge.

(7) Name, address and telephone number of guardian, authorized

representative, person or agency responsible for patient and next of

kin.

(8) Name, address and telephone number of attending physician and

the name, address and telephone number of the podiatrist, dentist or

clinical psychologist if such practitioner is primarily responsible for the

treatment of the patient.

(9) Name, address and telephone number of the designated alternate

physician.

(10) Admission diagnoses, known allergies and final diagnoses.

(11) Medicare and Medi-Cal numbers when appropriate.

(12) An inventory including but not limited to:

(A) Items of jewelry.

(B) Items of furniture.

(C) Radios, television and other appliances.

(D) Prosthetic and orthopedic devices.

(E) Other valuable items, so identified by the patient, family or

authorized representative.

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REQUIREMENT

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NOT

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N/A

LOCATION OF EVIDENCES

CONTENT OF HEALTH RECORDS

72547

(a) A facility shall maintain for each patient a health record which shall

include:

(1) Admission record.

(2) Current report of physical examination, and evidence of

tuberculosis screening.

(3) Current diagnoses

(4) The orders of a licensed health care practitioner acting within the

scope of his or her professional licensure, including drugs, treatment

and diet orders, progress notes, signed and dated on each visit. The

orders of a licensed health care practitioner acting within the scope of

his or her professional licensure shall be correctly recapitulated.

(5) Nurses’ notes which shall be signed and dated. Nurses’ notes

shall include:

(A) Records made by nurse assistants, after proper instruction, which

shall include:

1. Care and treatment of the patient.

2. Narrative notes of observation of how the patient looks, feels, eats,

drinks, reacts, interacts and the degree of dependency and motivation

toward improved health.

3. Notification to the licensed nurse of changes in the patient's

condition.

(B) Meaningful and informative nurses' progress notes written by

licensed nurses as often as the patient's condition warrants. However,

weekly nurses' progress notes shall be written by licensed nurses on

each patient and shall be specific to the patient's needs, the patient

care plan and the patient's response to care and treatments.

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LOCATION OF EVIDENCES

72547

(C) Name, dosage and time of administration of drugs, the route of

administration or site of injection, if other than oral. If the scheduled

time is indicated on the record, the initial of the person administering

the dose shall be recorded, provided that the drug is given within one

hour of the scheduled time. If the scheduled time is not recorded, the

person administering the dose shall record both initials and the time of

administration. Medication and treatment records shall contain the

name and professional title of staff signing by initials.

(D) Justification for the results of the administration of all PRN

medications and the withholding of scheduled medications.

(E) Record of type of restraint and time of application and removal.

The time of application and removal shall not be required for postural

supports used for the support and protection of the patient.

(F) Medications and treatments administered and recorded as

prescribed.

(G) Documentation of oxygen administration.

(6) Temperature, pulse, respiration and blood pressure notations

when indicated.

(7) Laboratory reports of all tests prescribed and completed.

(8) Reports of all X-rays prescribed and completed.

(9) Progress notes written and dated by the activity leader at least

quarterly.

(10) Discharge planning notes when applicable.

(11) Observation and information pertinent to the patient's diet

recorded in the patient's health record by the dietitian, nurse or food

service supervisor.

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NOT

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(12) Records of each treatment given by the therapist, weekly

progress notes and a record of reports to the physician after the first 2

weeks of therapy and at least every 30 days thereafter. Progress

notes written by the social service worker if the patient is receiving

social services.

(13) Consent forms for prescribed treatment and medication not

included in the admission consent for care

(14) Condition and diagnoses of the patient at time of discharge or

final disposition.

(15) A copy of the transfer form when the patient is transferred to

another health facility.

(16) An inventory of all patients' personal effects and valuables as

defined in Section 72545 (a) (12) made upon admission and

discharge. The inventory list shall be signed by a representative of the

facility and the patient or his authorized representative with one copy

to be retained by each.

(17) The name, complete address and telephone number where the

patient was transferred upon discharge from the facility.

PATIENT IDENTIFICATION

72555

Each patient shall be provided with a wristband identification tag or

other means of identification which shall be worn at all times unless

the attending physician notes in the health record that the patient's

condition would not permit such identification. Minimum information

shall include the name of the patient and the name of the facility.

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MET

NOT

MET

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LOCATION OF EVIDENCES

HEALTH &

SAFETY

CODE

1254.7 (HSC)

(b) Every health facility licensed pursuant to this chapter shall, as a

condition of licensure, include pain as an item to be assessed at the

same time as vital signs are taken. The health facility shall ensure

that pain assessment is performed in a consistent manner that is

appropriate to the patient. The pain assessment shall be noted in the

patient's chart in a manner consistent with other vital signs.

1418.81 (HSC)

Medical intervention requiring informed consent when the resident is

lacking decision-making capacity; interdisciplinary team review.

(a) In order to assure the provision of quality patient care and as part

of the planning for that quality patient care, commencing at the time of

admission, a skilled nursing facility, as defined in subdivision (c) of

Section 1250, shall include in a resident's care assessment the

resident's projected length of stay and the resident's discharge

potential. The assessment shall include whether the resident has

expressed or indicated a preference to return to the community and

whether the resident has social support, such as family, that may help

to facilitate and sustain return to the community. The assessment

shall be recorded with the relevant portions of the minimum data set,

as described in Section 14110.15 of the Welfare & Institutions Code.

The plan of care shall reflect, if applicable, the care ordered by the

attending physician needed to assist the resident in achieving the

resident's preference of return to the community.

(b) The skilled nursing facility shall evaluate the resident's discharge

potential at least quarterly or upon a significant change in the

resident's medical condition.

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State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

PHARMACEUTICAL SERVICE

TITLE 22

PHARMACEUTICAL SERVICE – GENERAL

72353

(d) The facility shall not accept money, goods or services free or below

cost from any pharmacist or pharmacy as compensation or inducement

for referral of business to any pharmacy.

See also 72511 Use of Outside

Resources Under

Administrative Service.

PHARMACEUTICAL SERVICE – REQUIREMENTS

72355

a) Pharmaceutical service shall include, but is not limited to, the

following:

(1) Obtaining necessary drugs including the availability of 24-hour

prescription service on a prompt and timely basis as follows:

(A) Drugs ordered “Stat” that are not available in the facility emergency

drug supply shall be available and administered within one hour of the

time ordered during normal pharmacy hours. For those hours during

which the pharmacy is closed, drugs ordered “Stat” shall be available and

administered within two hours of the time ordered. Drugs ordered “Stat”

which are available in the emergency drug supply shall be administered

immediately.

(B) Anti-infectives and drugs used to treat severe pain, nausea, agitation,

diarrhea or other severe discomfort shall be available and administered

within four hours of the time ordered.

(C) Except as indicated above, all new drug orders shall be available on

the same day ordered unless the drug would not normally be started until

the next day

(D) Refill of prescription drugs shall be available when needed

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PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

PHARMACEUTICAL SERVICE – LABELING AND STORAGE OF DRUGS

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LOCATION OF EVIDENCES

72357

(d) Test reagents, germicides, disinfectants and other household

substances shall be stored separately from drugs and shall not be

accessible to patients.

(e) External use drugs in liquid, tablet, capsule or powder form shall be

stored separately from drugs for internal use.

(f) Drugs shall be stored in appropriate temperatures. Drugs required to

be stored at room temperature shall be stored at a temperature between

15 degrees C (59 degrees F) and 30 degrees C (86 degrees F). Drugs

requiring refrigeration shall be stored in a refrigerator between 2 degrees

C (36 degrees F) and 8 degrees C (46 degrees F). When drugs are

stored in the same refrigerator with food, the drugs shall be kept in a

closed container clearly labeled “drugs.”

(g) Drugs shall be stored in an orderly manner in cabinets, drawers or

carts of sufficient size to prevent crowding.

(h) Dose preparation and administration areas shall be well-lighted.

(j) Storage of nonlegend drugs at the bedside shall meet the following

conditions:

(1) The manner of storage shall prevent access by other patients.

Lockable drawers or cabinets need not be used unless alternate

procedures, including storage on a patient’s person or in an unlocked

drawer or cabinet are ineffective.

(2) The facility shall record in the patient health record the bedside

medications used by the patient, based on observation by nursing

personnel and/or information supplied by the patient.

(3) The quantity of each drug supplied to the patient for bedside storage

shall be recorded in the health record each time the drug is so supplied

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PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72357

k) Storage of legend drugs at the bedside shall meet the conditions of

72357(j) and shall in addition:

(1) Be specifically ordered by the prescriber of the drugs, and

(2) Be limited to sublingual or inhalation forms of emergency drugs

(l) Drugs shall not be kept in stock after the expiration date on the label

and no contaminated or deteriorated drugs shall be available for use.

(m) The drugs of each patient shall be kept and stored in their originally

received containers. No drug shall be transferred between containers.

(n) Discontinued drug containers shall be marked, or otherwise identified,

to indicate that the drug has been discontinued, or shall be stored in a

separate location which shall be identified solely for this purpose.

Discontinued drugs shall be disposed of within 90 days of the date the

drug order was discontinued, unless the drug is reordered within that time

PHARMACEUTICAL SERVICE – STOP ORDERS

72359

Written policies shall be established and implemented limiting the

duration of new drug orders in the absence of a prescriber's specific

indication for duration of therapy. The prescriber shall be contacted for

new orders prior to the termination time established by the policy. Such

policies shall include all categories of drugs.

PHARMACEUTICAL SERVICE – ORDERS FOR DRUGS

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STANDARD

REQUIREMENT

MET

NOT

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LOCATION OF EVIDENCES

(a) No drugs shall be administered except upon the order of a person

lawfully authorized to prescribe for and treat human illness.

72361

(b) All drug orders shall be written, dated, and signed by the person

lawfully authorized to give such an order. The name, quantity or specific

duration of therapy, dosage and time or frequency of administration of the

drug, and the route of administration if other than oral shall be specified.

“P.R.N.” order shall also include the indication for use of a drug.

(c) Verbal orders for drugs and treatments shall be received only by

licensed nurses, psychiatric technicians, pharmacists, physicians,

physician’s assistants from their supervising physicians only, and certified

respiratory therapists when the orders relate specifically to respiratory

care. Such orders shall be recorded immediately in the patient’s health

record by the person receiving the order and shall include the date and

time of the order. The order shall be signed by the prescriber within five

days.

(d) The signing of orders shall be by signature or a personal computer

key. Signature stamps shall not be used.

PHARMACEUTICAL SERVICE – DRUG ORDER PROCESSING

72363

Signed orders for drugs shall be transmitted to the issuing pharmacy

within 48 hours, either by written prescription of the prescriber or by an

order form which produces a direct copy of the order or by an

electronically reproduced facsimile.

PHARMACEUTICAL SERVICE – DRUG ORDER RECORDS

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20

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72365

Facilities shall maintain a record which includes, for each drug ordered by

prescription, the name of the patient, the drug name, and strength, the

date ordered, the date and amount received and the name of the issuing

pharmacy. The records shall be kept at least one year.

PHARMACEUTICAL SERVICE – PERSONAL MEDICATIONS

72367

(a) Medications brought by or with the patient on admission to the facility

shall not be used unless the contents of the containers have been

examined and positively identified after admission by the patient's

physician or a pharmacist retained by the facility.

(b) The facility may use drugs transferred from other licensed health

facilities or those drugs dispensed or obtained after admission from any

licensed or governmental pharmacy and may accept the delivery of those

drugs by any agent of the patient or pharmacy without the necessity of

identification by a physician or pharmacist.

PHARMACEUTICAL SERVICE – CONTROLLED DRUGS

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21

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72369

(a) Drugs listed in Schedules II, III and IV of the Federal Comprehensive

Drug Abuse Prevention and Control Act of 1970 shall not be accessible

to other than licensed nursing, pharmacy and medical personnel

designated by the licensee. Drugs listed in Schedule II of the above Act

shall be stored in a locked cabinet or a locked drawer separate from

noncontrolled drugs unless they are supplied on a scheduled basis as

part of a unit dose medication system.

(b) Separate records of use shall be maintained on all Schedule II drugs.

Such records shall be maintained accurately and shall include the name

of the patient, the prescription number, the drug name, strength and dose

administered, the date and time of administration and the signature of the

person administering the drug. Such records shall be reconciled at least

daily and shall be retained at least one year. If such drugs are supplied

on a scheduled basis as part of a unit dose medication system, such

records need not be maintained separately.

(c) Drug records shall be maintained for drugs listed in Schedules III and

IV of the above Act in such a way that the receipt and disposition of each

dose of any such drug may be readily traced. Such records need not be

separate from other medication records.

PHARMACEUTICAL SERVICE – DISPOSITION OF DRUGS

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22

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72371

(a) Drugs which have been dispensed for individual patient use and are

labeled in conformance with State and Federal law for outpatient use

shall be furnished to patients on discharge on the orders of the

discharging physician. If the physician's discharge orders do not include

provisions for drug dispositions, drugs shall be furnished to patients

unless:

(1) The discharging physician specifies otherwise, or

(2) The patient leaves or is discharged without a physician’s order or

approval, or

(3) The patient is discharged to a general acute care hospital, acute

psychiatric hospital, or acute care rehabilitation hospital or,

(4) The drug was discontinued prior to discharge or,

(5) The labeled directions for use are not substantially the same as most

current orders for the drug in the patient’s health record.

(b) A record of the drugs sent with the patient shall be made in the

patient’s health record.

(c) Patient’s drugs supplied by prescription which have been discontinued

and those which remain in the facility after discharge of the patient shall

be destroyed by the facility in the following manner:

(1) Drugs listed in Schedules II, III or IV of the Federal Comprehensive

Drug Abuse Prevention and Control Act of 1970 shall be destroyed by

the facility in the presence of a pharmacist and a registered nurse

employed by the facility. The name of the patient, the name and strength

of the drug, the prescription number, the amount destroyed, the date of

destruction and the signatures of the witnesses required above shall be

recorded in the patient’s health record or in a separate log. Such log shall

be retained for at least three years.

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23

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(2) Drugs not listed under Schedules II, III or IV of the Federal

Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be

destroyed by the facility in the presence of a pharmacist or licensed

nurse. The name of the patient, the name and strength of the drug, the

prescription number if applicable, the amount destroyed, the date of

destruction and the signatures of the person named above and one other

person shall be recorded in the patient’s health record or in a separate

log. Such log shall be retained for at least three years.

(d) Unless otherwise prohibited under applicable federal or state laws,

individual patient drugs supplied in sealed containers may be returned, if

unopened, to the issuing pharmacy for disposition provided that:

(1) No drugs covered under the Federal Comprehensive Drug Abuse

Prevention and Control Act of 1970 are returned.

(2) All such drugs are identified as to lot or control number.

(3) The signatures of the receiving pharmacist and a registered nurse

employed by the facility are recorded in a separate log which lists the

name of the patient, the name, strength, prescription number (if

applicable), the amount of the drug returned and the date of return. The

log must be retained for at least three years.

PHARMACEUTICAL SERVICE – UNIT DOSE MEDICATION SYSTEM

72373

In facilities utilizing a unit dose medication system, there shall be at least

a 24-hour supply of all patient medications on hand at all times, except

those drugs which are to be discontinued within the 24-hour period.

Drugs that are part of a unit dose medication system shall not exceed a

48-hour supply.

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24

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

PHARMACEUTICAL SERVICE – STAFF

72375

(a) Facilities shall retain a consulting pharmacist who devotes a sufficient

number of hours during a regularly scheduled visit, for the purpose of

coordinating, supervising and reviewing the pharmaceutical service

committee, or its equivalent, at least quarterly. The report shall include a

log or record of time spent in the facility. There shall be a written

agreement between the pharmacist and the facility which includes duties

and responsibilities of both.

(b) A pharmacist shall serve on the pharmaceutical service committee

and the patient care policy committee.

(c) A pharmacist shall review the drug regimen of each patient at least

monthly and prepare appropriate reports. The review of the drug regimen

of each patient shall include all drugs currently ordered, information

concerning the patient's condition relating to drug therapy, medication

administration records, and where appropriate, physician's progress

notes, nurse's notes, and laboratory test results. The pharmacists shall

be responsible for reporting, in writing, irregularities in the dispensing and

administration of drugs and other matters relating to the review of the

drug regimen to the administrator and director of the nursing service.

PHARMACEUTICAL SERVICE – EQUIPMENT & SUPPLIES

72377

(b) Emergency supplies as approved by patient care policy committee or

pharmaceutical service committee shall be readily available to each

nursing station. Emergency drug supplies shall meet the following

requirements:

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25

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(1) Legend drugs shall not be stored in the emergency supply, except

under the following conditions:

A) Injectable supplies of legend drugs shall be limited to a maximum of

three single doses in ampules or vials or one container of the smallest

available multi-dose vial and shall be in sealed, unused containers.

72377

(

(B) Sublingual or inhalation emergency drugs shall be limited to single

sealed containers of the smallest available size.

(2) The emergency drug supply shall be stored in a portable container

which is sealed in such a manner that the tamper-proof seal must be

broken to gain access to the drugs. The director of nursing service or

charge nurse shall notify the pharmacist when drugs have been used

from the emergency kit or when the seal has been broken. Drugs used

from the kit shall be replaced within 72 hours and the supply resealed by

the pharmacist.

(3) The contents of the supply shall be listed on the outside of the

container.

(4) The supply shall be checked at least monthly by the pharmacist.

(5) Separate records of use shall be maintained for drugs administered

from the supply. Such records shall include the name and dose of the

drug administered, name of the patient, the date and time of

administration and the signature of the person administering the dose.

For 72377 (C):

See HSC 1261.5 (a) & (b)

instead below to determine

facility compliance.

Rationale: 72377 (C) no longer

applies because it was

supplanted by HSC 1261.5 (a)

& (b).

1261.5 HSC replaces 72377

(C) (See reference above)

HEALTH &

SAFETY CODE

ADMINISTRATION OF IMMUNIZATIONS BY REGISTERED NURSE OR LICENSED

PHARMACIST WITHOUT PATIENT-SPECIFIC ORDERS

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26

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1261.3 (HSC)

(a) Notwithstanding any other provision of law, for a patient aged 50

years or older, a registered nurse or licensed pharmacist may administer

in a skilled nursing facility, as defined in subdivision (c) of Section 1250,

influenza and pneumococcal immunizations pursuant to standing orders

and without patient-specific orders if all of the following criteria are met:

(1) The skilled nursing facility medical director, as defined in Section

72305 of Title 22 of the California Code of Regulations, has approved the

immunization standing orders established by the facility.

1261.3 (HSC)

(2) The standing orders meet the recommendations of the Advisory

Committee on Immunization Practices (ACIP) of the federal Centers for

Disease Control and Prevention.

EMERGENCY SUPPLIES FOR HEALTH FACILITIES: ORAL DOSAGE FORM OR

SUPPOSITORY FORM DRUGS, STORAGE, AND DOSAGE LIMITS

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27

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1261.5 (HSC)

(a) The number of oral dosage form or suppository form drugs provided

by a pharmacy to a health facility licensed pursuant to subdivision (c) or

(d), or both subdivisions (c) and (d), of Section 1250 of this code for

storage in a secured emergency supplies container, pursuant to Section

4119 of the Business and Professions Code, shall be limited to 48. The

State Department of Public Health may limit the number of doses of each

drug available to not more than 16 doses of any separate drug dosage

form in each emergency supply.

(b) Not more than four of the 48 oral form or suppository form drugs

secured for storage in the emergency supplies container shall be

psychotherapeutic drugs, except that the department may grant a

program flexibility request to the facility to increase the number of

psychotherapeutic drugs in the emergency supplies container to not more

than 10 if the facility can demonstrate the necessity for an increased

number of drugs based on the needs of the patient population at the

facility. In addition, the four oral form or suppository form

psychotherapeutic drug limit shall not apply to a special treatment

program service unit distinct part, as defined in Section 1276.9.

The department shall limit the number of doses of psychotherapeutic

drugs available to not more than four doses in each emergency supply.

Nothing in this section shall alter or diminish informed consent

requirements, including, but not limited to, the requirements of Section

1418.9.

1261.5 (HSC)

(c) Any limitations established pursuant to subdivisions (a) and (b) on the

number and quantity of oral dosage or suppository form drugs provided

by a pharmacy to a health facility licensed pursuant to subdivision (c) [a

SNF] or (d) [an ICF], or both subdivisions (c) and (d), of Section 1250 for

storage in a secured emergency supplies container shall not apply to an

automated drug delivery system, as defined in Section 1261.6, when a

pharmacist controls access to the drugs.

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28

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

AUTOMATED DRUG DELIVERY SYSTEM IN A SNF, ICF, OR NF

1261.6 (HSC)

(a)(1) For purposes of this section and Section 1261.5, an “automated

drug delivery system” means a mechanical system that performs

operations or activities, other than compounding or administration,

relative to the storage, dispensing, or distribution of drugs. An automated

drug delivery system shall collect, control, and maintain all transaction

information to accurately track the movement of drugs into and out of the

system for security, accuracy, and accountability.

(2) For purposes of this section, “facility” means a health facility licensed

pursuant to subdivision (c), (d), or (k), of Section 1250 that has an

automated drug delivery system provided by a pharmacy.

(3) For purposes of this section, “pharmacy services” means the

provision of both routine and emergency drugs and biologicals to meet

the needs of the patient, as prescribed by a physician.

See Antipsychotic Tool and

Survey Guidance Job Aids

If you come across an

automated drug delivery system

please call your pharmacist for

added consultation.

(b) Transaction information shall be made readily available in a written

format for review and inspection by individuals authorized by law. These

records shall be maintained in the facility for a minimum of three years.

(c) Individualized and specific access to automated drug delivery systems

shall be limited to facility and contract personnel authorized by law to

administer drugs.

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29

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(d)(1) The facility and the pharmacy shall develop and implement written

policies and procedures to ensure safety, accuracy, accountability,

security, patient confidentiality, and maintenance of the quality, potency,

and purity of stored drugs. Policies and procedures shall define access to

the automated drug delivery system and limits to access to equipment

and drugs.

(2) All policies and procedures shall be maintained at the pharmacy

operating the automated drug delivery system and the location where the

automated drug delivery system is being used.

(e) When used as an emergency pharmaceutical supplies container,

drugs removed from the automated drug delivery system shall be limited

to the following:

(1) A new drug order given by a prescriber for a patient of the facility for

administration prior to the next scheduled delivery from the pharmacy, or

72 hours, whichever is less. The drugs shall be retrieved only upon

authorization by a pharmacist and after the pharmacist has reviewed the

prescriber’s order and the patient’s profile for potential contraindications

and adverse drug reactions.

(2) Drugs that a prescriber has ordered for a patient on an as-needed

basis, if the utilization and retrieval of those drugs are subject to ongoing

review by a pharmacist.

(3) Drugs designed by the patient care policy committee or

pharmaceutical service committee of the facility as emergency drugs or

acute onset drugs. These drugs may be retrieved from an automated

drug delivery system pursuant to the order of a prescriber for emergency

or immediate administration to a patient of the facility. Within 48 hours

after retrieval under this paragraph, the case shall be reviewed by a

pharmacist.

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30

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(f) When used to provide pharmacy services pursuant to Section 4119.1

of the Business and Professions Code, the automated drug delivery

system shall be subject to all of the following requirements:

(1) Drugs removed from the automated drug delivery system for

administration to a patient shall be in properly labeled units of

administration containers or packages.

(2) A pharmacist shall review and approve all orders prior to a drug being

removed from the automated drug delivery system for administration to a

patient. The pharmacist shall review the prescriber’s order and the

patient’s profile for potential contraindications and adverse drug

reactions.

(3) The pharmacy providing services to the facility pursuant to Section

4119.1 of the Business and Professions Code shall control access to the

drugs stored in the automated drug delivery system.

(4) Access to the automated drug delivery system shall be controlled and

tracked using an identification or password system or biosensor.

(5) The automated drug delivery system shall make a complete and

accurate record of all transactions that will include all users accessing the

system and all drugs added to, or removed from, the system.

(6) After the pharmacist reviews the prescriber’s order, access by

licensed personnel to the automated drug delivery system shall be limited

only to drugs ordered by the prescriber and reviewed by the pharmacist

and that are specific to the patient. When the prescriber’s order requires

a dosage variation of the same drug, licensed personnel shall have

access to the drug ordered for that scheduled time of administration.

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31

State SNF Re-licensing Survey Workbook 2016

PHARMACEUTICAL SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(g) The stocking of an automated drug delivery system shall be

performed by a pharmacist. If the automated drug delivery system utilizes

removable pockets, cards, drawers, or similar technology, the stocking

system may be done outside of the facility and be delivered to the facility

if all of the following conditions are met:

(1) The task of placing drugs into the removable pockets, cards, or

drawers is performed by a pharmacist or by an intern pharmacist or a

pharmacy technician working under the direct supervision of a

pharmacist.

(2) The removable pockets, cards, or drawers are transported between

the pharmacy and the facility in a secure tamper-evident container.

(3) The facility, in conjunction with the pharmacy, has developed policies

and procedures to ensure that the pockets, cards, or drawers are

properly placed into the automated drug delivery system.

(h) Review of the drugs contained within, and the operation and

maintenance of, the automated drug delivery system shall be done in

accordance with law and shall be the responsibility of the pharmacy. The

review shall be conducted on a monthly basis by a pharmacist and shall

include a physical inspection of the drugs in the automated drug delivery

system, an inspection of the automated drug delivery system machine for

cleanliness, and a review of all transaction records in order to verify the

security and accountability of the system

(i) Drugs dispensed from an automated drug delivery system that meets

the requirements of this section shall not be subject to the labeling

requirements of Section 4076 of the Business and Professions Code or

Section 111480 of this code if the drugs to be placed into the automated

drug delivery system are in unit dose packaging or unit of use and if the

information required by Section 4076 of the Business and Professions

Code and Section 111480 of this code is readily available at the time of

drug administration. For purposes of this section, unit dose packaging

includes blister pack cards

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32

State SNF Re-licensing Survey Workbook 2016

STAFF DEVELOPMENT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

TITLE 22

ONGOING FACILITY PERSONNEL EDUCATIONAL PROGRAM

72517

(a) Each facility shall have an ongoing educational program planned and

conducted for the development and improvement of necessary skills and

knowledge for all facility personnel. Each program shall include, but not be

limited to:

(1) Problems and needs of the aged, chronically ill, acutely ill and disabled

patients.

(2) Prevention and control of infections.

(3) Interpersonal relationship and communication skills.

(4) Fire prevention and safety.

(5) Accident prevention and safety measures.

(6) Confidentiality of patient information.

(7) Preservation of patient dignity, including provision for privacy.

(8) Patient rights and civil rights.

(9) Signs and symptoms of cardiopulmonary distress.

(10) Choking prevention and intervention.

(b) In addition to (a) above, all licensed nurses shall have training in

cardiopulmonary resuscitation.

(c) Records of each staff development program shall be maintained. The

records shall include name and title of presenter, date of presentation, title

of subject presented, description of content and the signatures of those

attending.

State SNF Relicensing Survey Field Notes - (Click to Go Back to Table of Contents)

33

training program.

State SNF Re-licensing Survey Workbook 2016

STAFF DEVELOPMENT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

HEALTH &

SAFETY CODE

DEMENTIA TRAINING STANDARDS ACT

1263 (HSC)

(a) This section shall be known and may be cited as the Dementia Training

Standards Act of 2001.

Guidance Note: Not applicable

to pediatric skilled facilities.

(b) (1) Any certified nurse assistant employed by a skilled nursing facility or

intermediate care facility shall have completed at least two hours of initial

dementia-specific training as part of the facility's orientation program. The

training shall be completed within the first 40 hours of employment.

(2) The facility shall develop a dementia-specific training component within

the existing orientation program, to be implemented no later than July 1,

2002.

(3) The facility's modified orientation program shall be reviewed by the

department in a phase in schedule that begins no later than July 1, 2002,

and is completed no later than July 1, 2005.

(c) Any certified nursing assistant employed by a skilled nursing facility or

intermediate care facility shall participate in a minimum of five hours of

dementia-specific in-service training per year, as part of the facility's in-

service training.

STATE-APPROVED CERTIFIED NURSING AIDE TRAINING PROGRAM

REQUIREMENTS

1337.1 (HSC)

A skilled nursing or intermediate care facility shall adopt an approved

training program that meets standards established by the state department.

The approved training program shall consist of at least the following:

(a) An orientation program to be given to newly employed nurse assistants

prior to providing direct patient care in skilled nursing or intermediate care

facilities.

Guidance Note: Applies to a

facility that has a State-

approved certified nursing aide

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34

State SNF Re-licensing Survey Workbook 2016

STAFF DEVELOPMENT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(b) (1) A precertification training program consisting of at least 60

classroom hours of training on basic nursing skills, patient safety and

rights, the social and psychological problems of patients, and resident

abuse prevention, recognition, and reporting pursuant to subdivision (e).

The 60 classroom hours of training may be conducted within a skilled

nursing or intermediate care facility or in an educational institution.

(2) In addition to the 60 classroom hours of training required under

paragraph (1), the precertification training program shall consist of at least

100 hours of supervised and on-the-job training clinical practice. The 100

hours may consist of normal employment as a nurse assistant under the

supervision of either the director of nurse training or a licensed nurse

qualified to provide nurse assistant training who has no other assigned

duties while providing the training.

(3) At least two hours of the 60 hours of classroom training and at least four

hours of the 100 hours of the supervised clinical training shall address the

special needs of persons with developmental and mental disorders,

including mental retardation, Alzheimer's disease, cerebral palsy, epilepsy,

dementia, Parkinson's disease, and mental illness.

(4) In a precertification training program subject to this subdivision, credit

shall be given for the training received in an approved precertification

training program adopted by another skilled nursing or intermediate care

facility.

(5) This subdivision shall not apply to a skilled nursing or intermediate care

facility that demonstrates to the state department that it employs only nurse

assistants with a valid certification.

(e) (1) The approved training program shall include, within the 60 hours of

classroom training, a minimum of six hours of instruction on preventing,

recognizing, and reporting instances of resident abuse utilizing those

courses developed pursuant to Section 13823.93 of the Penal Code, and a

minimum of one hour of instruction on preventing, recognizing, and

reporting residents' rights violations.

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35

State SNF Re-licensing Survey Workbook 2016

STAFF DEVELOPMENT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1337.1 (HSC)

(2) A minimum of four hours of instruction on preventing, recognizing, and

reporting instances of resident abuse, including instruction on preventing,

recognizing, and reporting residents' rights violations, shall be included

within the total minimum hours of continuing education or in-service training

required and in effect for certified nursing assistants.

1337.3 (HSC)

(c) Notwithstanding Section 1337.1, the approved training program shall

consist of at least the following:

(1) A 16-hour orientation program to be given to newly employed nurse

assistants prior to providing direct patient care, and consistent with federal

training requirements for facilities participating in the Medicare or Medicaid

programs.

(2) (A) A certification training program consisting of at least 60 classroom

hours of training on basic nursing skills, patient safety and rights, the social

and psychological problems of patients, and elder abuse recognition and

reporting pursuant to subdivision (e) of Section 1337.1. The 60 classroom

hours of training may be conducted within a skilled nursing facility, an

intermediate care facility, or an educational institution.

(B) In addition to the 60 classroom hours of training required under

subparagraph (A), the certification program shall also consist of 100 hours

of supervised and on-the-job training clinical practice. The 100 hours may

consist of normal employment as a nurse assistant under the supervision of

either the director of staff development or a licensed nurse qualified to

provide nurse assistant training who has no other assigned duties while

providing the training.

1337.4 (HSC)

Every skilled nursing or intermediate care facility shall designate a licensed

nurse as a director of staff development who shall be responsible for the

management of the approved training program.

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36

State SNF Re-licensing Survey Workbook 2016

DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

TITLE 22

DIETETIC SERVICE – FOOD SERVICE

72335

(a) The dietetic service shall provide food of the quality and quantity to

meet each patient’s need in accordance with the physicians’ orders

and to meet “The Recommended Daily Dietary Allowance,” the most

current edition, adopted by the Food and Nutrition Board of the

National Research Council of the National Academy of Sciences, and

the following:

(3) Patient food preferences shall be adhered to as much as possible

and substitutes for all food refused shall be from appropriate food

groups. Condiments such as salt and pepper or sugar shall be

available at each meal unless contraindicated by the diet order.

(4) Table service shall be provided for all patients who can and wish to

eat at a table. Tables of appropriate height shall be provided for

patients in wheelchairs.

(5) No food ordered for the facility shall be diverted or taken from the

facility. No rebates shall be received or allowed to the facility or its

owners, directors, officers or employees’ from any commercial food

source.

(6) When food is provided by an outside resource, the facility shall

ensure that all federal, state and local requirements are met. The

facility shall maintain a written plan, adequate space, equipment and

food supplies to provide patients’ food service in emergencies.

(7) Recipes for all items that are prepared for regular and therapeutic

diets shall be available and used to prepare attractive and palatable

meals, in which nutritive values, flavor and appearance are conserved.

Food shall be served attractively, at appropriate temperatures with

appropriate eating utensils and in a form to meet individual needs.

Guidance Note: The

regulation refers to use of

prepared food brought in by a

food service company, (i.e.

caterer, cafeteria, etc.) or

from another separate facility

on campus, (i.e. assisted

living facility).

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DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(b) A current profile card shall be maintained for each patient,

indicating diet order, likes, dislikes, allergies to foods, diagnosis and

instructions or guidelines to be followed in the preparation and serving

of food for the patient.

DIETETIC SERVICE – DIET MANUAL

72337

A current therapeutic diet manual, approved by the dietitian and the

patient care policy committee, shall be readily available to the attending

physician, nursing and dietetic personnel. It shall be reviewed annually

and revised at least every five years.

DIETETIC SERVICE – MENUS

72341

(a) Menus for regular and therapeutic diets shall be written at least one

week in advance, dated and posted in the kitchen at least one week in

advance.

(b) All menus shall be approved by the dietitian.

(c) If any meal served varies from the planned menu, the change and

the reason for the change shall be noted in writing on the posted menu

in the kitchen.

(d) Menus shall provide a variety of foods and indicate standard

portions at each meal. Menus shall be varied for the same day of

consecutive weeks duration and shall be revised quarterly.

(e) Menus shall be adjusted to include seasonal commodities.

(f) Menus shall be planned with consideration of cultural background

and food habits of patients.

(g) A copy of the menu as served shall be kept on file for at least 30

days.

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DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(h) Itemized records of food purchases shall be kept for one year and

available for review by the Department. Food purchases invoices are

acceptable provided they list amounts and types of foods purchased.

DIETETIC SERVICE – SANITATION

72345

(b) All utensils, counters, shelves and equipment shall be kept clean,

maintained in good repair and shall be free from breaks, corrosion,

open seams, cracks and chipped areas.

(c) Plastic ware, china and glassware that cannot be sanitized or are

hazardous because of chips, cracks or loss of glaze shall be discarded.

DIETETIC SERVICE – CLEANING

& DISINFECTION OF UTENSILS

72347

(d) After disinfection, the utensils shall be allowed to drain and dry in

racks or baskets on nonabsorbent surfaces. Drying cloths shall not be

used.

DIETETIC SERVICE – EQUIPMENT & SUPPLIES

72349

(a) Equipment of the type and in the amount necessary for the proper

preparation, serving and storing of food and for proper dishwashing

shall be provided and maintained in good working order.

(b) Fixed and mobile equipment in the dietetic service area shall be

located to assure sanitary and safe operation and shall be of sufficient

size to handle the needs of the facility.

(c) The dietetic service area shall be ventilated in a manner that will

maintain comfortable working conditions, remove objectionable odors,

fumes and prevent excessive condensation.

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DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(d) Food supplies shall meet the following standards:

(1) At least one week’s supply of staple foods and at least two days’

supply of perishable foods shall be maintained on the premises. Food

supplies shall meet the requirements of the weekly menu including the

therapeutic diets ordered.

(2) All food shall be of good quality and procured from sources

approved or considered satisfactory by federal, state or local

authorities. Food in unlabeled, rusty, leaking, broken containers or

cans with side seam dents, rim dents or swells shall not be retained or

used.

(4) Milk shall be served in individual containers or from a dispensing

device which has been approved for such use, by the local health

department or from the original container. Milk shall be dispensed

directly into the glass or other container from which the patient drinks.

(5) Catered foods and beverages from, a source outside the licensed

facility shall be prepared, packed, properly identified, stored and

transported in compliance with these regulations and other applicable

federal, state and local codes.

DIETETIC SERVICE – STAFF

72351

(a) A dietitian shall be employed on a full-time, part-time or consulting

basis. Part-time or consultant services shall be provided on the

premises at appropriate times on a regularly scheduled basis. A

written record of the frequency, nature and duration of the consultant’s

visits shall be maintained.

Smart Tool available

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DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(b) If a dietitian is not employed full-time, a full-time person who is a

graduate of a state approved course that provides 90 or more hours of

classroom instruction in food supervision shall be employed to be

responsible for the operation of the food service. The dietetic

supervisor may also cook, provided sufficient time is allowed for

managerial responsibilities.

Smart Tool available

See also HSC 1265.4 further

below for further instructions

(d) Current work schedules by job titles and weekly time schedules by

job titles shall be posted.

(e) Dietetic service personnel shall be trained in basic food sanitation

techniques, wear clean clothing, and a cap or a hair net, and shall be

excluded from duty when affected by skin infection or communicable

diseases. Beards and mustaches which are not closely cropped and

neatly trimmed shall be covered.

(f) Employees’ street clothing stored in the kitchen shall be in a closed

area separate from food or items used in food services.

(g) Kitchen sinks shall not be used for hand washing. Separate hand

washing facilities with soap, running water and individual towels shall

be provided.

(h) Persons other than dietetic service personnel shall not be allowed

in the kitchen areas unless required to do so in the performance of their

duties.

HEALTH & SAFETY

CODE

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DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(b) The dietetic services supervisor shall have completed at least one of the

following educational requirements:

(1) A baccalaureate degree with major studies in food and nutrition, dietetics, or

food management and has one year of experience in the dietetic service of a

licensed health facility.

(2) A graduate of a dietetic technician training program approved by the

American Dietetic Association*, accredited by the Commission on Accreditation

for Dietetics Education, or currently registered by the Commission on Dietetic

Registration.

Smart Tool available

*Guidance Note: the Dietary

Managers Association (DMA) is now

called the Association of Nutrition and

Foodservice Professionals (ANFP).

The certification is still called

Certified Dietary Manager

(CDM). Also, the American

Dietetic Association (ADA) is

now called the Academy of

Nutrition and Dietetics (AND)

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DIETETIC SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

HSC 1265.4

(3) A graduate of a dietetic assistant training program approved by the

American Dietetic Association.

(4) Is a graduate of a dietetic services training program approved by

the Dietary Managers Association* and is a certified dietary manager

credentialed by the Certifying Board of the Dietary Managers

Association*, maintains this certification, and has received at least six

hours of in-service training on the specific California dietary service

requirements contained in Title 22 of the California Code of

Regulations prior to assuming full-time duties as a dietetic services

supervisor at the health facility.

(5) Is a graduate of a college degree program with major studies in

food and nutrition, dietetics, food management, culinary arts, or hotel

and restaurant management and is a certified dietary manager

credentialed by the Certifying Board of the Dietary Managers

Association*, maintains this certification, and has received at least six

hours of in-service training on the specific California dietary service

requirements contained in Title 22 of the California Code of

Regulations prior to assuming full-time duties as a dietetic services

supervisor at the health facility.

(6) A graduate of a state approved program that provides 90 or more

hours of classroom instruction in dietetic service supervision, or 90

hours or more of combined classroom instruction and instructor led

interactive Web-based instruction in dietetic service supervision.

(7) Received training experience in food service supervision and

management in the military equivalent in content to paragraph (2), (3),

or (6).

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State SNF Re-licensing Survey Workbook 2016

ACTIVITY PROGRAM

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

TITLE 22

ACTIVITY PROGRAM – REQUIREMENTS

72381

(d) The activity leader, at a minimum, shall:

(5) Post the activity schedule conspicuously, in large visible print, for the

information of patients and staff.

(6) Request and maintain equipment and supplies.

(7) Develop and maintain contacts with community agencies and

organizations.

72385

ACTIVITY PROGRAM – STAFF

(b) An activity program leader shall be designated by and be responsible

to the administration. An activity program leader shall meet one of the

following requirements:

(1) Have two years of experience in a social or recreational program

within the past five years, one year of which was full-time in a patient

activities program in a health care setting.

(2) Be an occupational therapist, art therapist, music therapist, dance

therapist, recreation therapist or occupational therapy assistant.

(3) Have satisfactorily completed at least 36 hours of training in a course

designed specifically for this position and approved by the Department

and shall receive regular consultation from an occupational therapist,

occupational therapy assistant or recreation therapist who has at least

one year of experience in a health care setting.

Guidance Note: (F249) Federal

regulatory language gives the

option to follow the state

requirements for activity program

leader (the activity program leader

requirement state option is listed

under the section 72385(b)(3) see

regulation to the left.

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State SNF Re-licensing Survey Workbook 2016

PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

PATIENT RIGHTS

TITLE 22

72527

(a) Patients have the rights enumerated in this section and the facility shall

ensure that these rights are not violated. The facility shall establish and

implement written policies and procedures which include these rights and

shall make a copy of these policies available to the patient and to any

representative of the patient. The policies shall be accessible to the public

upon request. Patients shall have the right:

(23) To be free from any requirement to purchase drugs or rent or

purchase medical supplies or equipment in accordance with provisions of

Section 1320 of the Health and Safety Code.

(See HSC 1320 further below)

(e) Patients’ rights policies and procedures established under this section

concerning consent, informed consent and refusal or treatments or

procedures shall include, but not be limited to the following:

(1) How the facility will verify that informed consent was obtained or a

treatment or procedure was refused pertaining to the administration of

psychotherapeutic drugs or physical restraints or the prolonged used or a

device that may lead to the inability of the patient to regain the use of a

normal bodily function.

(2) How the facility, in consultation with the patient’s physician, will identify

consistent with current statutory case law, who may serve as a patient’s

representative when an incapacitated patient has no conservator or

attorney in fact under a valid Durable Power of Attorney for Health Care.

HEALTH &

SAFETY CODE

442.5 (HSC)

(d) Counseling may include, but is not limited to, discussions about the

outcomes for the patient and his or her family, based on the interest of the

patient. Information and counseling, as described in subdivision (b), may

occur over a series of meetings with the health care provider or others

who may be providing the information and counseling based on the

patient’s needs.

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PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(e) The information and counseling sessions may include a discussion of

treatment options in a manner that the patient and his or her family can

easily understand. If the patient requests information on the costs of

treatment options, including the availability of insurance and eligibility of

the patient for coverage, the patient shall be referred to the appropriate

entity for that information.

(f) The notification made pursuant to paragraph (1) of subdivision (a) shall

not be required if the patient or other person authorized to make health

care decisions, as defined in Section 4617 of the Probate Code, for the

patient has already received the notification.

(g) For purposes of this section, “health care decisions” has the meaning

set forth in Section 4617 of the Probate Code.

(h) This section shall not be construed to interfere with the clinical

judgment of a health care provider in recommending the course of

treatment.

442.7 (HSC)

If a health care provider does not wish to comply with his or her patient’s

request or, when applicable, the request of another person authorized to

make health care decisions, as defined in Section 4617 of the Probate

Code, for the patient for information on end-of-life options, the health care

provider shall do both of the following:

(a) Refer or transfer a patient to another health care provider that shall

provide the requested information.

(b) Provide the patient or other person authorized to make health care

decisions for the patient with information on procedures to transfer to

another health care provider that shall provide the requested information.

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PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1320 (HSC)

A skilled nursing facility or intermediate care facility shall not require

patients to purchase drugs, or rent or purchase medical supplies or

equipment, from any particular pharmacy or other source.

1418.9 (HSC)

(a) If the attending physician and surgeon of a resident in a skilled nursing

facility prescribes, orders, or increases an order for an antipsychotic

medication for the resident, the physician and surgeon shall do both of the

following:

(1) Obtain the informed consent of the resident for purposes of

prescribing, ordering, or increasing an order for the medication.

(2) Seek the consent of the resident to notify the resident’s interested

family member, as designated in the medical record. If the resident

consents to the notice, the physician and surgeon shall make reasonable

attempts, either personally or through a designee, to notify the interested

family member, as designated in the medical record, within 48 hours of the

prescription, order, or increase of an order.

1599.61 (HSC)

(a) By January 1, 2000, all skilled nursing facilities, as defined in

subdivision (c) of Section 1250, intermediate care facilities, as defined in

subdivision (d) of Section 1250, and nursing facilities, as defined in

subdivision (k) of Section 1250,shall use a standard admission agreement

developed and adopted by the department.

This standard agreement shall comply with all applicable state and federal

laws.

(b) (1) No facility shall alter the standard agreement unless so directed by

the department.

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PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(d) By January 1, 2000, the department shall consolidate and develop

one comprehensive Patients’ Bill of Rights that includes the provisions

contained in Chapter 3.9 (commencing with Section 1599), the regulatory

resident rights for skilled nursing facilities under Section 72527 of Title 22

of the California Code of Regulations, the regulatory resident rights for

intermediate care facilities under Section 73523 of Title 22 of the

California Code of Regulations, and the rights afforded residents under

Section 483.10 et seq. of Title 42 of the Code of Federal Regulations.

(d) cont

This comprehensive Patients’ Bill of Rights shall be a mandatory

attachment to all skilled nursing facility, intermediate care facility, and

nursing facility contracts as specified in Section 1599.74 of this chapter.

(f) Translated copies of the Patients’ Bill of Rights shall be made available

to all long-term health care facilities in the state, including skilled nursing

facilities, intermediate care facilities, and nursing facilities. It shall be the

responsibility of the long-term health care facilities to duplicate and

distribute the translated versions of the Patients’ Bill of Rights with

admissions agreements, when appropriate.

ADMISSION CONTRACTS

1599.62 (HSC)

(a) Contracts of admission shall not include unlawful waivers of facility

liability for the health and safety or personal property of residents. No

contract of admission shall include any provision which the facility knows

or should know to be deceptive or unlawful under state or federal law.

1599.63 (HSC)

(a) Every long-term health care facility shall make complete blank copies

of its admission contract immediately available to the public at cost, upon

request.

(b) Every long-term health care facility shall post conspicuously in a

location accessible to public view within the facility either a complete copy

of its admission contract or notice of the availability of it from the facility.

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STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1599.70 (HSC)

(a) No contract of admission may require a security deposit from a Medi-

Cal beneficiary who applies for admission to the facility as a Medi-Cal

patient.

(b) Any security deposit from a person paying privately upon admission

shall be returned within 14 days of the private account being closed, or

first Medi-Cal payment, whichever is later, and with no deduction for

administration or handling charges.

1599.75 (HSC)

(a) When referring to a resident's obligation to observe facility rules, the

contract of admission shall indicate that the rules must be reasonable, and

that there is a facility procedure for suggesting changes in the rules.

(b) The contract of admission shall specify that a copy of the facility

grievance procedure, for resolution of resident complaints about facility

practices, is available.

(c) The agreement shall also inform residents of their right to contact the

State Department of Health Services or the long-term care ombudsman,

or both, regarding grievances against the facility.

1599.79 (HSC)

Every contract of admission shall meet the requirements of Section 72520

of Title 22 of the California Administrative Code, which requires that the

facility offer to hold a bed for the resident in the event the resident must be

transferred to an acute care hospital for seven days or less. The facility

shall also give the resident or a representative for the resident, notice of

the rights to a bedhold at the time of transfer. The resident or

representative for the resident has 24 hours from receipt of notice to

request the bedhold. The contract of admission shall state that the facility

shall offer the next available appropriate bed to the resident in the event

the facility fails to follow this required procedure. The facility shall inform

the resident that Medi-Cal will pay for up to seven bedhold days.

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PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

PROBATE

CODE

PATIENT RIGHTS: INFORMED CONSENT

4730

Before implementing a health care decision made for a patient, a

supervising health care provider, if possible, shall promptly communicate

to the patient the decision made and the identity of the person making the

decision.

4731

(a) A supervising health care provider who knows of the existence of an

advance health care directive, a revocation of an advance health care

directive, or a designation or disqualification of a surrogate, shall promptly

record its existence in the patient's health care record and, if it is in writing,

shall request a copy. If a copy is furnished, the supervising health care

provider shall arrange for its maintenance in the patient's health care

record.

(b) A supervising health care provider who knows of a revocation of a

power of attorney for health care or a disqualification of a surrogate shall

make a reasonable effort to notify the agent or surrogate of the revocation

or disqualification.

4732

A primary physician who makes or is informed of a determination that a

patient lacks or has recovered capacity, or that another condition exists

affecting an individual health care instruction or the authority of an agent,

conservator of the person, or surrogate, shall promptly record the

determination in the patient's health care record and communicate the

determination to the patient, if possible, and to a person then authorized to

make health care decisions for the patient.

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PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

4733

Except as provided in Sections 4734 and 4735, a health care provider or

health care institution providing care to a patient shall do the following:

(a) Comply with an individual health care instruction of the patient and with

a reasonable interpretation of that instruction made by a person then

authorized to make health care decisions for the patient.

(b) Comply with a health care decision for the patient made by a person

then authorized to make health care decisions for the patient to the same

extent as if the decision had been made by the patient while having

capacity.

4734

(a) A health care provider may decline to comply with an individual health

care instruction or health care decision for reasons of conscience.

(b) A health care institution may decline to comply with an individual health

care instruction or health care decision if the instruction or decision is

contrary to a policy of the institution that is expressly based on reasons of

conscience and if the policy was timely communicated to the patient or to

a person then authorized to make health care decisions for the patient.

4735

A health care provider or health care institution may decline to comply with

an individual health care instruction or health care decision that requires

medically ineffective health care or health care contrary to generally

accepted health care standards applicable to the health care provider or

institution.

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PATIENT RIGHTS

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

4736

A health care provider or health care institution that declines to comply

with an individual health care instruction or health care decision shall do

all of the following:

(a) Promptly so inform the patient, if possible, and any person then

authorized to make health care decisions for the patient.

(b) Unless the patient or person then authorized to make health care

decisions for the patient refuses assistance, immediately make all

reasonable efforts to assist in the transfer of the patient to another health

care provider or institution that is willing to comply with the instruction or

decision.

(c) Provide continuing care to the patient until a transfer can be

accomplished or until it appears that a transfer cannot be accomplished.

In all cases, appropriate pain relief and other palliative care shall be

continued.

PHYSICAL PLANT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

TITLE 22

POSTING

72209

The license or a true copy thereof shall be conspicuously posted in a

location accessible to public view within the facility.

NURSING SERVICE – SPACE

72325

(a) An office or other suitable space shall be provided for the director of

nursing service.

(b) A nursing station shall be maintained in each nursing unit or building.

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STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(c) Each nursing station shall have a cabinet, a desk, space for records,

a bulletin board, a telephone and a specifically designed and well

illuminated medication storage compartment with a lockable door. If a

separate medication room is maintained, it shall have a lockable door

and a sink with water connections for care of equipment and for hand

washing.

(d) If a refrigerator is provided in a nursing station, the refrigerator shall

meet the following standards:

(1) Be located in a clean area not subject to contamination by human

waste.

0 0

(2) Maintain temperatures at or below 7 C (45 F) for chilling.

0 0

(3) Maintain the freezer at minus 18 F ( F).

(4) Contain an accurate thermometer at all times.

(5) If foods are retained in the refrigerator, they shall be covered and

clearly identified as to contents and date initially covered.

PROGRAM FLEXIBILITY

72213

(a) All skilled nursing facilities shall maintain compliance with the

licensing requirements. These requirements do not prohibit the use of

alternate concepts, methods, procedures, techniques, equipment,

personnel qualifications or the conducting of pilot projects, provided such

exceptions are carried out with the provisions for safe and adequate

care and with the prior written approval of the department. Such

approval shall provide for the terms and conditions under which the

exception is granted. A written request and substantiating evidence

supporting the request shall be submitted by the applicant or licensee to

the Department.

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PHYSICAL PLANT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(b) Any approval of the Department granted under this Section, or a true

copy thereof, shall be posted immediately adjacent to the facility's

license.

CONSUMER INFORMATION TO BE POSTED

72503

(a) The following consumer information shall be conspicuously posted in

a prominent location accessible to the public:

(1) Name, license number and date of employment of the current

administrator of the facility.

(2) A listing of all services and special programs provided in the facility

and those provided through written contracts.

(3) The current and following week's menus for regular and therapeutic

diets.

(4) A notice that the facility's written admission and discharge policies

are available upon request.

(6) The names and addresses of all previous owners of the facility.

(7) A listing of all other skilled nursing and intermediate care facilities

owned by the same person, firm, partnership, association, corporation or

parent or subsidiary corporation, or a subsidiary of the parent

corporation.

(8) A statement that an action to revoke the facility's license is pending, if

such an action has been initiated by the filing of an accusation, pursuant

to Section 11503 of the Government Code, and the accusation has been

served on the licensee.

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PHYSICAL PLANT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(9) A notice of the name, address, and telephone number of the District

Office of the L&C Division, Department of Health Services, having

jurisdiction over the facility.

PATIENT ROOMS

72609

(a)Each patient room shall be labeled with a number, letter or

combination of the two for identification.

(b) Patients' rooms shall not be kept locked when occupied except in

rooms approved by the Department for seclusion of psychiatric

patients.

c) Only upon the written approval of the Department may any exit door,

corridor door, yard enclosures or perimeter fences be locked to egress.

d) Patient rooms approved for use by ambulatory patients only shall be

identified as follows: The words "Reserved for Ambulatory Patient" in

letters at least 1.25 centimeters (one-half inch) high shall be posted on

the outside of the door or on the wall alongside the door where they are

visible to persons entering the room

SPACE AND EQUIPMENT FOR AUTOCLAVING, STERILIZING AND DISINFECTING

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PHYSICAL PLANT

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72619

(a) A facility shall:

(1) Maintain disposable sterile supplies in the amount necessary to

meet the anticipated needs of the patients, or

(2) Maintain autoclave equipment, or

(3) Make contractual arrangements for outside autoclaving and

sterilizing services.

(b) If a facility maintains a central supply and sterilizing area, it shall

include but not be limited to:

(1) An autoclave or sterilizer, which shall be maintained in operating

condition at all times.

(A) Autoclaves shall be equipped with time recording thermometers

in addition to the standard mercury thermometers, except for

portable sterilizers and autoclaves.

(B) Instructions for operating autoclaves and sterilizers shall be

posted in the area where the autoclaves and sterilizers are located.

(2) Work space.

(3) Storage space for sterile supplies.

(4) Storage space for unsterile supplies.

(5) Equipment for cleaning and sterilizing of utensils and supplies.

(c) The facility shall provide for:

(1) Effective separation of soiled and contaminated supplies and

equipment from the clean and sterilized supplies and equipment.

(2) Clean cabinets for the storage of sterile supplies and equipment.

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(3) An orderly system of rotation of supplies so that the supplies

stored first shall be used first and that multi-use supplies shall be

reautoclaved as they become outdated.

(4) Dating of materials sterilized.

(5) Loading of the autoclave or sterilizer.

(6) Checking of recording and indicating thermometers. Recording

thermometer charts shall be on file for one year.

(7) Conducting monthly bacteriological tests. Reports of test results

for the last 12 months shall be retained on file.

(8) Length of aeration time for materials that are gas-sterilized.

LAUNDRY

72623

(a) When a facility operates its own laundry, such laundry shall be:

(1) Located in relationship to other areas so that steam, odors, lint and

objectionable noises do not reach patient or personnel areas.

(2) Adequate in size, well-lighted and ventilated to meet the needs of the

facility.

(3) Laundry equipment shall be of a suitable capacity, kept in good

repair and maintained in a sanitary condition.

(4) The laundry space shall be maintained in a clean and sanitary

condition.

(b) If the facility does not maintain a laundry service, the commercial

laundry utilized shall meet the standards of this section.

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NOT

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LOCATION OF EVIDENCES

(c) Laundry areas shall have, at a minimum, the following:

(1) Separate rooms for the storage of clean linen and soiled linen.

(2) Handwashing and toilet facilities maintained at locations convenient

for laundry purposes.

(3) Separate linen carts labeled "soiled" or "clean linen" and constructed

of washable materials which shall be laundered or suitably cleaned as

needed to maintain sanitation.

(d) Written procedures for handling, storage, transportation and

processing of linens shall be posted in the laundry and shall be

implemented.

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LOCATION OF EVIDENCES

TITLE 22

REQUIRED SERVICES

72301

(e) Arrangements shall be made for an advisory dentist to participate at

least annually in the staff development program for all patient care

personnel and to approve oral hygiene policies and practices for the

care of patients.

(g) The facility shall make arrangements for a physician or physicians to

be available to furnish emergency medical care if the attending

physician, or designee, is unavailable. The telephone numbers of those

physicians shall be posted in a conspicuous place in the facility.

PHYSICIAN’S SERVICES – MEDICAL DIRECTOR

72305

(b) The medical director shall:

(4) Be responsible for reviewing employees' pre-employment and

annual health examination reports.

LICENSEE – GENERAL DUTIES

72501

(b) The licensee, if an administrator, may act as the administrator or

shall appoint an administrator, to carry out the policies of the licensee. A

responsible adult who is knowledgeable in the policies and procedures

of the licensee shall be appointed, in writing, to carry out the policies of

the licensee in the absence of the administrator. If the administrator is to

be absent for more than 30 consecutive days, the licensee shall appoint

an acting administrator to carry out the day-to-day functions of the

facility.

(c) The licensee shall delegate to the designated administrator, in

writing, authority to organize and carry out the day-to-day functions of

the facility.

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(d) Except where provided for in approved continuing care agreements,

or except when approved by the Department, no facility owner,

administrator, employee or representative thereof shall act as guardian

or conservator of a patient therein or of that patient's estate, unless that

patient is a relative within the second degree of consanguinity.

(e) The licensee shall employ an adequate number of qualified

personnel to carry out all the functions of the facility and shall provide for

initial orientation of all new employees, a continuing in-service training

program and competent supervision.

(f) If language or communication barriers exist between skilled nursing

facility staff and patients, arrangements shall be made for interpreters or

for the use of other mechanisms to ensure adequate communication

between patients and personnel.

(g) The Department may require the licensee to provide additional

professional, administrative or supportive personnel whenever the

Department determines through a written evaluation that additional

personnel is needed to provide for the health and safety of patients.

(h) The licensee shall ensure that all employees serving patients or the

public shall wear name and title badges unless contraindicated.

ADVERTISING

72509

(a) No skilled nursing facility shall make or disseminate false or

misleading statements or advertise by any other manner or means any

false or misleading claims regarding facilities or services provided.

(b) No skilled nursing facility shall use the words "Approved by the

California Department of Health Services" or any other words conveying

the same idea in any advertising material.

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(c) The term "rehabilitation" shall not be used unless the facility has

rehabilitation services which are approved by the Department.

USE OF OUTSIDE RESOURCES

72511

(a) If a facility does not employ qualified personnel to render a specific

service to be provided by the facility, there shall be arrangements

through a written agreement with outside resources which shall meet

the standards and requirements of these regulations.

(b) Copies of affiliation agreements, contracts or written arrangements

for advice, consultation, services, training or transportation, with other

facilities, organizations or individuals, public or private agencies, shall

be on file in the facility’s administrative office. These shall be readily

available for inspection and review by the Department.

(c) The affiliation agreement, contracts and written arrangements shall

include, but not be limited to:

(1) Description of the services to be provided.

(2) Financial arrangements.

(3) Methods by which the services are to be provided.

(4) Conditions upon which the agreement, contract or written

arrangement can be terminated.

(5) Time frame of the affiliation agreement, contract or written

arrangement.

(6) Effective date of affiliation agreement, contract or written

arrangement.

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LOCATION OF EVIDENCES

(7) Date affiliation agreement, contract or written arrangement was

signed.

(8) Signatures of all parties to the written agreement.

(d) The outside resource, when acting as a consultant, shall apprise the

administrator in writing of recommendations, plans for implementation

and continuing assessment through dated and signed reports which

shall document the length of the visit and shall be retained by the

administrator for follow-up action and evaluation of performance. The

administrator shall provide evidence of review of the recommendations.

ADMINISTRATOR

72513

(a) Each skilled nursing facility shall employ or otherwise provide an

administrator to carry out the policies of the licensee. The administrator

shall be responsible for the administration and management of only one

skilled nursing facility unless all of the following conditions are met:

(1) If other skilled nursing facilities for which the administrator is

responsible are in the same geographic area, and within one hour

surface travel time of each other, and are operated by the same

governing body.

(2) The administrator shall not be responsible for more than three

facilities or a total of no more than 200 beds.

(3) The administrator shall designate a responsible adult who is

knowledgeable in the policies and procedures of the licensee in each

facility to be responsible for carrying out the policies of the licensee in

the administrator's absence.

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(e) The administrator shall be responsible for informing the Department,

via telephone within 24 hours of any unusual occurrences as specified

in Section 72541. If the unusual occurrence involves the discontinuance

or disruption of services occurring during other than regular business

hours of the Department or its designee, a telephone report shall be

made immediately upon the resumption of business hours of the

Department.

(f) The administrator or designee shall be responsible for screening

patients for admission to the facility to ensure that the facility admits only

those patients for whom it can provide adequate care. The

administrator, or designee, shall conduct preadmission personal

interviews as appropriate with the patient's physician, the patient, the

patient's next of kin or sponsor or the representative of the facility from

which the patient is being transferred. A telephone interview may be

substituted when a personal interview is not feasible.

ADMISSION OF PATIENTS

72515

The licensee shall:

(b) Accept and retain only those patients for whom it can provide

adequate care.

PATIENT TRANSFERS

72519

(a)The licensee shall maintain written transfer agreements with other

nearby facilities to make the services of those facilities accessible and to

facilitate the transfer of patients. Complete and accurate patient

information, in sufficient detail to provide for continuity of care shall be

transferred with the patient at time of transfer.

ADMINISTRATIVE POLICIES & PROCEDURES

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LOCATION OF EVIDENCES

72521

(c) Each facility shall establish at least the following:

(6) Procedures for reporting of unusual occurrences.

(d) The facility shall have a written organizational chart showing the

major programs of the facility, the person in charge of each program, the

lines of authority, responsibility and communication and the staff

assignments.

REQUIRED COMMITTEES

72525

(a) Each facility shall have at least the following committees: patient

care policy, infection control and pharmaceutical service.

(b) Minutes of every committee meeting shall be maintained in the

facility and indicate names of members present, date, length of meeting,

subject matter discussed and action taken.

(c) Committee composition and function shall be as follows:

(1) Patient care policy committee.

(A) A patient care policy committee shall establish policies governing the

following services: Physician, dental, nursing, dietetic, pharmaceutical,

health records, housekeeping, activity programs and such additional

services as are provided by the facility.

(B) The committee shall be composed of: at least one physician, the

administrator, the director of nursing service, a pharmacist, the activity

leader and representatives of each required service as appropriate.

(c) Committee composition and function shall be as follows:

(1) Patient care policy committee.

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LOCATION OF EVIDENCES

(A) A patient care policy committee shall establish policies governing the

following services: Physician, dental, nursing, dietetic, pharmaceutical,

health records, housekeeping, activity programs and such additional

services as are provided by the facility.

(B) The committee shall be composed of: at least one physician, the

administrator, the director of nursing service, a pharmacist, the activity

leader and representatives of each required service as appropriate.

(C) The committee shall meet at least annually.

(D) The patient care policy committee shall have the responsibility for

reviewing and approving all policies relating to patient care. Based on

reports received from the facility administrator, the committee shall

review the effectiveness of policy implementation and shall make

recommendations for the improvement of patient care.

(E) The committee shall review patient care policies annually and revise

as necessary. Minutes shall list policies reviewed.

(2) Infection control committee.

(A) An infection control committee shall be responsible for infection

control in the facility.

(B) The committee shall be composed of representatives from the

following services; physician, nursing, administration, dietetic,

pharmaceutical, activities, housekeeping, laundry and maintenance.

(C) The committee shall meet at least quarterly

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LOCATION OF EVIDENCES

(D) The functions of the infection control committee shall include, but not

be limited to:

1. Establishing, reviewing, monitoring and approving policies and

procedures for investigating, controlling and preventing infections in the

facility.

2. Maintaining, reviewing and reporting statistics of the number, types,

sources and locations of infections within the facility.

(3) Pharmaceutical service committee.

(A) A pharmaceutical service committee shall direct the pharmaceutical

services in the facility.

(B) The committee shall be composed of the following: a pharmacist, the

director of nursing service, the administrator and at least one physician.

(C) The committee shall meet at least quarterly.

(D) The functions of the pharmaceutical service committee shall include,

but not be limited to:

1. Establishing, reviewing, monitoring and approving policies and

procedures for safe procurement, storage, distribution and use of drugs

and biologicals.

2. Reviewing and taking appropriate action on the pharmacist’s quarterly

report.

3. Recommending measures for improvement of services and the

selection of pharmaceutical reference materials.

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MET

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LOCATION OF EVIDENCES

LIABILITY FOR RENT & RETURN OF RENTAL ADVANCE

72531

(b) Whenever accommodations in a skilled nursing facility are rented by

or for a patient on a month to month basis, the renter or his heir, legatee

or personal representative shall not be liable for any rent due under the

rental agreement for accommodations beyond the date on which the

patient died.

(c) Any advance of rent by the renter shall be returned to the heir,

legatee or personal representative of the patient no later than two weeks

after discharge or death of the patient.

EMPLOYEE PERSONNEL RECORDS

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LOCATION OF EVIDENCES

72533

(a) Each facility shall maintain current complete and accurate personnel

records for all employees.

(1) The record shall include:

(A) Full name.

(B) Social Security number

(C) Professional license or registration number, if applicable.

(D) Employment classification.

(E) Information as to past employment and qualifications.

(F) Date of beginning employment.

(G) Date of termination of employment.

(H) Documented evidence of orientation to the facility.

(I) Performance evaluations.

72533

(2) Such records shall be retained for at least three years following

termination of employment. Employee personnel records shall be

maintained in a confidential manner, and shall be made available to

authorized representatives of the Department upon request.

SMART Tool Available

(b) Records of hours and dates worked by all employees during at least

the most recent 12-month period shall be kept on file at the place of

employment or at a central location within the State of California. Upon

request such records shall be made available, at a time and location

specified by the Department.

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REQUIREMENT

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LOCATION OF EVIDENCES

(c) A permanent log of the temporary health services personnel

employed in the facility shall be kept for three years, and shall include

the following:

(1) Employee's full name.

(2) Name of temporary health services personnel agency.

(3) Professional license and registration number and date of expiration.

(4) Verification of health status.

(5) Record of hours and dates worked.

72535

(a) All employees working in the facility, including the licensee, shall

have a health examination within 90 days prior to employment or within

seven days after employment and at least annually thereafter by a

person lawfully authorized to perform such a procedure. Each such

examination shall include a medical history and physical evaluation. The

report signed by the examiner shall indicate that the person is

sufficiently free of disease to perform assigned duties and does not

have any health condition that would create a hazard for himself, fellow

employees, or patients or visitors.

Patient Health Record

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MET

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LOCATION OF EVIDENCES

72543

(a) Records shall be permanent, either typewritten or legibly written in

ink, be capable of being photocopied and shall be kept on all patients

admitted or accepted for care. All health records of discharged patients

shall be completed and filed within 30 days after discharge date and

such records shall be kept for a minimum of 7 years, except for minors

whose records shall be kept at least until 1 year after the minor has

reached the age of 18 years, but in no case less than 7 years. All

exposed X-ray film shall be retained for seven years. All required

records, either originals or accurate reproductions thereof, shall be

maintained in such form as to be legible and readily available upon the

request of the attending physician, the facility staff or any authorized

officer, agent, or employee of either, or any other person authorized by

law to make such request

(d) The Department shall be informed within three business days, in

writing, whenever patient health records are defaced or destroyed before

termination of the required retention period.

(e) If the ownership of the facility changes, both the licensee and the

applicant for the new license shall, prior to the change of ownership,

provide the Department with written documentation stating:

(1) That the new licensee shall have custody of the patients' health

records and that these records or copies shall be available to the former

licensee, the new licensee and other authorized persons; or

(2) That other arrangements have been made by the licensee for the

safe preservation and the location of the patients' health records, and

that they are available to both the new and former licensees and other

authorized persons; or

(3) The reason for the unavailability of such records.

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MET

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MET

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LOCATION OF EVIDENCES

(f) Patients’ health records shall be current and kept in detail consistent

with good medical and professional practice based on the service

provided to each patient Such records shall be filed and maintained in

accordance with these requirements and shall be available for review by

the Department. All entries in the health record shall be authenticated

with the date, name, and title of the persons making the entry.

(h) Patient health records shall be filed in an accessible manner in the

facility or in health record storage. Storage of records shall provide for

prompt retrieval when needed for continuity of care. Health records can

be stored off the facility premises only with the prior approval of the

Department.

(i) The patient health record shall not be removed from the facility,

except for storage after the patient is discharged, unless expressly and

specifically authorized by the Department.

EXTERNAL DISASTER AND MASS CASUALTY PROGRAM

72551

(a) A written external disaster and mass casualty program plan shall be

adopted and followed. The plan shall be developed with the advice and

assistance of county or regional and local planning offices and shall not

conflict with county and community disaster plans. A copy of the plan

shall be available on the premises for review by the Department.

(b) The plan shall provide procedures in event of community and

widespread disasters. The written plan shall include at least the

following:

(1) Sources of emergency utilities and supplies, including gas, water,

food and essential medical supportive materials.

(2) Procedures for assigning personnel and recalling off-duty personnel

(3) Unified medical command. A chart of lines of authority in the facility

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(4) Procedures for the conversion of all usable space into areas for

patient observation and immediate care of emergency admissions.

(5) Prompt transfer of casualties when necessary and after preliminary

medical or surgical services have been rendered, to the facility most

appropriate for administering definitive care. Procedures for moving

patients from damaged areas of the facility to undamaged areas.

(6) Arrangements for provision of transportation of patients including

emergency housing where indicated. Procedures for emergency

transfers of patients who can be moved to other health facilities,

including arrangements for safe and efficient transportation and transfer

information.

(7) Procedures for emergency discharge of patients who can be

discharged without jeopardy into the community, including prior

arrangements for their care, arrangements for safe and efficient

transportation and at least one follow-up inquiry within 24 hours to

ascertain that patients are receiving required care.

(8) Procedures for maintaining a record of patient relocation.

(9) An evacuation plan, including evacuation routes, emergency phone

numbers of physicians, health facilities, the fire department and local

emergency medical services agencies and arrangements for the safe

transfer of patients after evacuation.

(10) A tag containing all pertinent personal and medical information

which shall accompany each patient who is moved, transferred,

discharged or evacuated.

(11) Procedures for maintaining security in order to keep relatives,

visitors and curious persons out of the facility during a disaster.

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(12) Procedures for providing emergency care to incoming patients from

other health facilities.

(13) Assignment of public relations liaison duties to a responsible

individual employed by the facility to release information to the public

during a disaster.

FIRE & INTERNAL DISASTERS

72553

(a) A written fire and internal disaster plan incorporating evacuation

procedures shall be developed with the assistance of qualified fire,

safety and other appropriate experts. A copy of the plan shall be

available on the premises for review by the staff and the Department.

(b) The written plan shall include at least the following:

(4) Priority for notification of staff including names and telephone

numbers.

(7) Procedures for moving patients from damaged areas of the facility to

undamaged areas.

(9) Procedures for emergency discharge of patients who can be

discharged without jeopardy into the community, including prior

arrangements for their care, arrangements for safe and efficient

transportation and at least one follow-up inquiry within 24 hours to

ascertain that patients are receiving their required care.

(10) A disaster tag containing all pertinent personal and medical

information to accompany each patient who is moved, transferred,

discharged or evacuated.

(11) Procedures for maintaining a record of patient relocation.

(12) Procedures for handling incoming or relocated patients.

(13) Other provisions as dictated by circumstances.

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MET

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LOCATION OF EVIDENCES

1336.3 (HSC)

(a) In the event of an emergency, such as earthquake, fire, or flood

which threatens the safety or welfare of patients in a facility, the facility

shall do all of the following:

(1) Notify, as soon as possible, family members, patients' guardians, the

state department, and the ombudsperson for that facility of the

emergency and the steps that the facility plans to take for the patient's

welfare.

(2) Provide the services set forth in subdivision (a) of Section 1336.2 if

further relocation of the patient is necessary.

(3) Undertake prompt medical assessment of, and provide counseling

as needed to, patients whose further relocation is not necessary but

who have suffered or may suffer adverse health consequences due to

the emergency or sudden transfer.

(b) Each facility shall adopt a written emergency preparedness plan and

shall make that plan available to the state department upon request.

The plan shall comply with the requirements in this section and the state

department's Contingency Plan for Licensed Facilities. The facility, as

part of its emergency preparedness planning, shall seek to enter into

reciprocal or other agreements with nearby facilities and hospitals to

provide temporary care for patients in the event of an emergency. The

facility shall report to the state department the name of any facility or

hospital which fails or refuses to enter into such agreements and the

stated reason for that failure or refusal.

HEALTH & SAFETY CODE

1261 (HSC)

(a) A health facility shall allow a patient's domestic partner, the children

of the patient's domestic partner, and the domestic partner of the

patient's parent or child to visit, unless one of the following is met:

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1261 (HSC)cont

(1) No visitors are allowed.

(2) The facility reasonably determines that the presence of a particular

visitor would endanger the health or safety of a patient, member of the

health facility staff, or other visitor to the health facility, or would

significantly disrupt the operations of a facility.

(3) The patient has indicated to health facility staff that the patient does

not want this person to visit.

(b) This section may not be construed to prohibit a health facility from

otherwise establishing reasonable restrictions upon visitation, including

restrictions upon the hours of visitation and number of visitors.

(c) For purposes of this section, "domestic partner" has the same

meaning as that term is used in Section 297 of the Family Code.

1262.7 (HSC)

(a) A skilled nursing facility, as defined in subdivision (c) of Section

1250, shall admit a patient only upon a physician's order and only if the

facility is able to provide necessary care for the patient.

(b) The administrator or designee of a skilled nursing facility shall be

responsible for screening patients for admission to the facility to ensure

that the facility admits only those patients for whom it can provide

necessary care. The administrator, or his or her designee, shall conduct

preadmission personal interviews as appropriate with the patient's

physician, the patient, the patient's next of kin or sponsor, or the

representative of the facility from which the patient is being transferred.

A telephone interview may be conducted when a personal interview is

not feasible.

(a) A health facility, as defined in subdivision (a), (b), (c), or (f) of Section

1250, shall develop, implement, and comply with a patient safety plan

for the purpose of improving the health and safety of patients and

reducing preventable patient safety events. The patient safety plan shall

be developed by the facility, in consultation with the facility's various

health care professionals.

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1279.6 (HSC)

b) The patient safety plan required pursuant to subdivision (a) shall, at a

minimum, provide for the establishment of all of the following:

(1) A patient safety committee or equivalent committee in composition

and function. The committee shall be composed of the facility's various

health care professionals, including, but not limited to, physicians,

nurses, pharmacists, and administrators. The committee shall do all of

the following:

(A) Review and approve the patient safety plan.

(B) Receive and review reports of patient safety events as defined in

subdivision (c).

(C) Monitor implementation of corrective actions for patient safety

events

D) Make recommendations to eliminate future patient safety events.

(E) Review and revise the patient safety plan, at least once a year, but

more often if necessary, to evaluate and update the plan, and to

incorporate advancements in patient safety practices.

(2) A reporting system for patient safety events that allows anyone

involved, including, but not limited to, health care practitioners, facility

employees, patients, and visitors, to make a report of a patient safety

event to the health facility.

(3) A process for a team of facility staff to conduct analyses, including,

but not limited to, root cause analyses of patient safety events. The

team shall be composed of the facility's various categories of health

care professionals, with the appropriate competencies to conduct the

required analyses.

(4) A reporting process that supports and encourages a culture of safety

and reporting patient safety events.

(5) A process for providing ongoing patient safety training for facility

personnel and health care practitioners.

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ADMINISTRATIVE SERVICE

STATE

STANDARD

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(c) For the purposes of this section, patient safety events shall be

defined by the patient safety plan and shall include, but not be limited to,

all adverse events or potential adverse events as described in Section

1279.1 that are determined to be preventable, and health-care-

associated infections (HAI), as defined in the federal Centers for

Disease Control and Prevention's National Healthcare Safety Network,

or its successor, unless the department accepts the recommendation of

the Healthcare Associated Infection Advisory Committee, or its

successor, that are determined to be preventable.

1279.7 (HSC)

(a) A health facility, as defined in subdivision (a), (b), (c), or (f) of Section

1250, shall implement a facility-wide hand hygiene program.

(b) Beginning January 1, 2011, a health facility, as defined in subdivision

(a), (b), (c), or (f) of Section 1250, is prohibited from using an

intravenous connection, epidural connection, or enteral feeding

connection that would fit into a connection port other than the type it was

intended for, unless an emergency or urgent situation exists and the

prohibition impairs the ability to provide health care.

1279.8 (HSC)

(a) Every health facility, as defined in subdivision (c), (d), (e), (g), (h), (i),

or (m) of Section 1250, shall, for the purpose of addressing issues that

arise when a patient is missing from a facility, develop and comply with

an absentee notification plan as part of the written plans and procedures

that are required pursuant to federal or state law. The plan shall include

and be limited to the following: a requirement that an administrator of

the facility, or his or her designee, inform the patient’s authorized

representative when that patient is missing from the facility and the

circumstances in which an administrator of the facility, or his or her

designee, shall notify local law enforcement when a patient is missing

from the facility.

(b) This section does not apply to state hospitals under the jurisdiction of

the State Department of State Hospitals when the executive director of

the state hospital, or his or her designee, determines that informing the

patient’s authorized representative that a patient is missing will create a

risk to the safety and security of the state hospital

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(a) A clinic, health facility, home health agency, or hospice licensed

pursuant to Section 1204, 1250, 1725, or 1745 shall prevent unlawful or

unauthorized access to, and use or disclosure of, patients’ medical

information, as defined in Section 56.05 of the Civil Code and consistent

with Section 1280.18.

1280.15 (HSC)

(a) continued

. For purposes of this section, internal paper records, electronic mail, or

facsimile transmissions inadvertently misdirected within the same facility

or health care system within the course of coordinating care or

delivering services shall not constitute unauthorized access to, or use or

disclosure of, a patient’s medical information. The department, after

investigation, may assess an administrative penalty for a violation of this

section of up to twenty-five thousand dollars ($25,000) per patient

whose medical information was unlawfully or without authorization

accessed, used, or disclosed, and up to seventeen thousand five

hundred dollars ($17,500) per subsequent occurrence of unlawful or

unauthorized access, use, or disclosure of that patient’s medical

information. For purposes of the investigation, the department shall

consider the clinic’s, health facility’s, agency’s, or hospice’s history of

compliance with this section and other related state and federal statutes

and regulations, the extent to which the facility detected violations and

took preventative action to immediately correct and prevent past

violations from recurring, and factors outside its control that restricted

the facility’s ability to comply with this section. The department shall

have full discretion to consider all factors when determining whether to

investigate and the amount of an administrative penalty, if any, pursuant

to this section

(b) (1) A clinic, health facility, home health agency, or hospice to which

subdivision (a) applies shall report any unlawful or unauthorized access

to, or use or disclosure of, a patient’s medical information to the

department no later than 15 business days after the unlawful or

unauthorized access, use, or disclosure has been detected by the clinic,

health facility, home health agency, or hospice.

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(2) Subject to subdivision (c), a clinic, health facility, home health

agency, or hospice shall also report any unlawful or unauthorized

access to, or use or disclosure of, a patient’s medical information to the

affected patient or the patient’s representative at the last known

address, or by an alternative means or at an alternative location as

specified by the patient or the patient’s representative in writing

pursuant to Section 164.522(b) of Title 45 of the Code of Federal

Regulations, no later than 15 business days after the unlawful or

unauthorized access, use, or disclosure has been detected by the clinic,

health facility, home health agency, or hospice. Notice may be provided

by email only if the patient has previously agreed in writing to electronic

notice by email.

PATIENT PROPERTY/VALUABLES AND THEFT & LOSS PROGRAM

1289.3 (HSC)

(a) A long-term health care facility, as defined in Section 1418, which

fails to make reasonable efforts to safeguard patient property shall

reimburse a patient for or replace stolen or lost patient property at its

then current value. The facility shall be presumed to have made

reasonable efforts to safeguard patient property if the facility has shown

clear and convincing evidence of its efforts to meet each of the

requirements specified in Section 1289.4. The presumption shall be a

rebuttable presumption, and the resident or the resident’s representative

may pursue this matter in any court of competent jurisdiction.

1289.4 (HSC)

A theft and loss program shall be implemented by the long-term health

care facilities within 90 days after January 1, 1988. The program shall

include all of the following:

(a) Establishment and posting of the facility's policy regarding theft and

investigative procedures.

(b) Orientation to the policies and procedures for all employees within

90 days of employment.

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(c) Documentation of lost and stolen patient property with a value of

twenty-five dollars ($25) or more and, upon request, the documented

theft and loss record for the past 12 months shall be made available to

the State Department of Health Services, the county health department,

or law enforcement agencies and to the office of the State Long-Term

Care Ombudsman in response to a specific complaint. The

documentation shall include, but not be limited to, the following:

(1) A description of the article.

(2) Its estimated value.

(3) The date and time the theft or loss was discovered.

(4) If determinable, the date and time the loss or theft occurred.

(5) The action taken.

(d) A written patient personal property inventory is established upon

admission and retained during the resident's stay in the long-term health

care facility. A copy of the written inventory shall be provided to the

resident or the person acting on the resident's behalf. Subsequent

items brought into or removed from the facility shall be added to or

deleted from the personal property inventory by the facility at the written

request of the resident, the resident's family, a responsible party, or a

person acting on behalf of a resident. The facility shall not be liable for

items which have not been requested to be included in the inventory or

for items which have been deleted from the inventory. A copy of a

current inventory shall be made available upon request to the resident,

responsible party, or other authorized representative. The resident,

resident's family, or a responsible party may list those items which are

not subject to addition or deletion from the inventory, such as personal

clothing or laundry, which are subject to frequent removal from the

facility.

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(e) Inventory and surrender of the resident's personal effects and

valuables upon discharge to the resident or authorized representative in

exchange for a signed receipt.

(f) Inventory and surrender of personal effects and valuables following

the death of a resident to the authorized representative in exchange for

a signed receipt. Immediate notice to the public administrator of the

county upon the death of a resident without known next of kin as

provided in Section 7600.5 of the Probate Code.

(g) Documentation, at least semiannually, of the facility's efforts to

control theft and loss, including the review of theft and loss

documentation and investigative procedures and results of the

investigation by the administrator and, when feasible, the resident

council.

(h) Establishment of a method of marking, to the extent feasible,

personal property items for identification purposes upon admission and,

as added to the property inventory list, including engraving of dentures

and tagging of other prosthetic devices.

(i) Reports to the local law enforcement agency within 36 hours when

the administrator of the facility has reason to believe patient property

with a then current value of one hundred dollars ($100) or more has

been stolen. Copies of those reports for the preceding 12 months shall

be made available to the State Department of Health Services and law

enforcement agencies.

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(j) Maintenance of a secured area for patients' property which is

available for safekeeping of patient property upon the request of the

patient or the patient's responsible party. Provide a lock for the

resident's bedside drawer or cabinet upon request of and at the expense

of the resident, the resident's family, or authorized representative. The

facility administrator shall have access to the locked areas upon

request.

(k) A copy of this section and Sections 1289.3 and 1289.5 is provided by

a facility to all of the residents and their responsible parties, and,

available upon request, to all of the facility's prospective residents and

their responsible parties.

(l) Notification to all current residents and all new residents, upon

admission, of the facility's policies and procedures relating to the

facility's theft and loss prevention program.

1289.5 (HSC)

No provision of a contract of admission, which includes all documents

which a resident or his or her representative is required to sign at the

time of, or as a condition of, admission to a long-term health care

facility, shall require or imply a lesser standard of responsibility for the

personal property of residents than is required by law.

1318 (HSC)

(a) The director shall require as a condition precedent to the issuance,

or renewal, of any license for a health facility, if the licensee handles or

will handle any money of patients within the health facility, that the

applicant for the license or the renewal of the license file or have on file

with the state department a bond executed by an admitted surety

insurer in a sum to be fixed by the state department based upon the

magnitude of the operations of the applicant, but which sum shall not be

less than one thousand dollars ($1,000), running to the State of

California and conditioned upon the licensee's faithful and honest

handling of the money of patients within the health facility.

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(b) Every person injured as a result of any improper or unlawful handling

of the money of a patient of a health facility may bring an action in a

proper court on the bond required to be posted by the licensee pursuant

to this section for the amount of damage the person suffered as a result

thereof to the extent covered by the bond.

(c) The failure of any licensee under this section to maintain on file with

the state department a bond in the amount prescribed by the director or

who embezzles any patient's trust funds shall constitute cause for the

revocation of the license.

(d) The provisions of this section shall not apply if the licensee handles

less than twenty-five dollars ($25) per patient and less than five hundred

dollars ($500) for all patients in any month.

(e) The director may exempt licensed health facilities of the types

specified in subdivisions (a), (b), (c), and (f) of Section 1250 from the

requirements of this section. However, the exemption from the bond

purchase requirements of this section shall not affect the financial

liability of such health facilities.

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1418.21 (HSC)

1418.21. (a) A skilled nursing facility that has been certified for purposes

of Medicare or Medicaid shall post the overall facility rating information

determined by the federal Centers for Medicare and Medicaid Services

(CMS) in accordance with the following requirements:

(1) The information shall be posted in at least the following locations, in

the facility:

(A) An area accessible and visible to members of the public.

(B) An area used for employee breaks.

(C) An area used by residents for communal functions, such as dining,

resident council meetings, or activities.

(2) The information shall be posted on white or light-colored paper that

includes all of the following, in the following order:

(A) The full name of the facility, in a clear and easily readable font of at

least 28 point.

(B) The full address of the facility in a clear and easily readable font of at

least 20 point.

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1418.21 (HSC)

(C) The most recent overall star rating given by CMS to that facility,

except that a facility shall have seven business days from the date when

it receives a different rating from the CMS to include the updated rating

in the posting. The star rating shall be aligned in the center of the page.

The star rating shall be expressed as the number that reflects the

number of stars given to the facility by the CMS. The number shall be in

a clear and easily readable font of at least two inches print.

(D) Directly below the star symbols shall be the following text in a clear

and easily readable font of at least 28 point:

“The above number is out of 5 stars.”

(E) Directly below the text described in subparagraph (D) shall be the

following text in a clear and easily readable font of at least 14 point:

“This facility is reviewed annually and has been licensed by the State of

California and certified by the federal Centers for Medicare and

Medicaid Services (CMS). CMS rates facilities that are certified to

accept Medicare or Medicaid. CMS gave the above rating to this facility.

A detailed explanation of this rating is maintained at this facility and will

be made available upon request. This information can also be accessed

online at the Nursing Home Compare Internet Web site at

http://www.medicare.gov/NHcompare . Like any information, the Five-

Star Quality Rating System has strengths and limits. The criteria upon

which the rating is determined may not represent all of the aspects of

care that may be important to you. You are encouraged to discuss the

rating with facility staff. The Five-Star Quality Rating System was

created to help consumers, their families, and caregivers compare

nursing homes more easily and help identify areas about which you may

want to ask questions.

Nursing home ratings are assigned based on ratings given to health

inspections, staffing, and quality measures. Some areas are assigned a

greater weight than other areas. These ratings are combined to

calculate the overall rating posted here.”

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(F) Directly below the text described in subparagraph (E), the following

text shall appear in a clear and easily readable font of at least 14 point:

“State licensing information on skilled nursing facilities is available on

the State Department of Public Health’s Internet Web site at:

www.cdph.ca.gov, under Programs, Licensing and Certification, Health

Facilities Consumer Information System.”

(3) For the purposes of this section, “a detailed explanation of this

rating” shall include, but shall not be limited to, a printout of the

information explaining the Five-Star Quality Rating System that is

available on the CMS Nursing Home Compare Internet Web site. This

information shall be maintained at the facility and shall be made

available upon request.

(4) The requirements of this section shall be in addition to any other

posting or inspection report availability requirements.

(b) Violation of this section shall constitute a class B violation, as

defined in subdivision (e) of Section 1424 and, notwithstanding Section

1290, shall not constitute a crime. Fines from a violation of this section

shall be deposited into the State Health Facilities Citation Penalties

Account, created pursuant to Section 1417.2.

(c) This section shall be operative on January 1, 2011.

1418.91 (HSC)

(a) A long-term health care facility shall report all incidents of alleged

abuse or suspected abuse of a resident of the facility to the department

immediately, or within 24 hours.

1421.1 (HSC)

(a) Within 24 hours of the occurrence of any of the events specified in

subdivision (b), the licensee of a skilled nursing facility shall notify the

department of the occurrence. This notification may be in written form if

it is provided by telephone facsimile or overnight mail, or by telephone

with a written confirmation within five calendar days.

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1421.1 (HSC)

(a) continued

The information provided pursuant to this subdivision may not be

released to the public by the department unless its release is needed to

justify an action taken by the department or it otherwise becomes a

matter of public record. A violation of this section is a class “B” violation.

(b) All of the following occurrences shall require notification pursuant to

this section:

(1) The licensee of a facility receives notice that a judgment lien has

been levied against the facility or any of the assets of the facility or the

licensee.

(2) A financial institution refuses to honor a check or other instrument

issued by the licensee to its employees for a regular payroll.

(3) The supplies, including food items and other perishables, on hand in

the facility fall below the minimum specified by any applicable statute or

regulation.

(4) The financial resources of the licensee fall below the amount

needed to operate the facility for a period of at least 45 days based on

the current occupancy of the facility. The determination that financial

resources have fallen below the amount needed to operate the facility

shall be based upon the current number of occupied beds in the facility

multiplied by the current daily Medi-Cal reimbursement rate multiplied by

45 days.

(5) The licensee fails to make timely payment of any premiums required

to maintain required insurance policies or bonds in effect, or any tax lien

levied by any government agency.

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1424.6 (HSC)

Failure by a developmental center to report incidents as required under

subdivision (a) of Section 4427.5 of the Welfare and Institutions Code

shall be deemed a class B violation if the incident occurs in a distinct

part long-term health care facility, and shall be subject to the penalties

specified in Section 1424.5 for distinct part skilled nursing facilities or

distinct part intermediate care facilities, or Section 1424 for other distinct

part long-term health care facilities.

1429 (HSC)

a) Each class “AA” and class “A” citation specified in subdivisions (c)

and (d) of Section 1424 that is issued, or a copy or copies thereof, shall

be prominently posted for 120 days. The citation or copy shall be posted

in a place or places in plain view of the patients or residents in the long-

term health care facility, persons visiting those patients or residents, and

persons who inquire about placement in the facility.

(1) The citation shall be posted in at least the following locations in the

facility:

(A) An area accessible and visible to members of the public.

(B) An area used for employee breaks.

(C) An area used by residents for communal functions, such as dining,

resident council meetings, or activities.

(2) The citation, along with a cover sheet, shall be posted on a white or

light-colored sheet of paper, at least 8 1⁄2 by 11 inches in size, that

includes all of the following information:

(A) The full name of the facility, in a clear and easily readable font in at

least 28-point type.

(B) The full address of the facility, in a clear and easily readable font in

at least 20-point type.

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1429 (HSC)

(3) The facility may post the plan of correction.

(4) The facility may post a statement disputing the citation or a

statement showing the appeal status, or both.

(5) The facility may remove and discontinue the posting required by this

section if the citation is withdrawn or dismissed by the department.

(b) Each class “B” citation specified in subdivision (e) of Section 1424

that is issued pursuant to this section and that has become final, or a

copy or copies thereof, shall be retained by the licensee at the facility

cited until the violation is corrected to the satisfaction of the department.

Each citation shall be made promptly available by the licensee for

inspection or examination by any member of the public who so requests.

In addition, every licensee shall post in a place or places in plain view of

the patient or resident in the long-term health care facility, persons

visiting those patients or residents, and persons who inquire about

placement in the facility, a prominent notice informing those persons

that copies of all final uncorrected citations issued by the department to

the facility will be made promptly available by the licensee for inspection

by any person who so requests.

(c) A violation of this section shall constitute a class “B” violation, and

shall be subject to a civil penalty in the amount of one thousand dollars

($1,000), as provided in subdivision (e) of Section 1424.

Notwithstanding Section 1290, a violation of this section shall not

constitute a crime. Fines imposed pursuant to this section shall be

deposited into the State Health Facilities Citation Penalties Account,

created pursuant to Section 1417.2.

1599.64 (HSC)

(a) All abbreviated contracts of admission and contracts of admission

shall be printed in black type of not less than 10-point type size, on plain

white paper. The print shall appear on one side of the paper only.

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(b) The contract shall be written in clear, coherent, and unambiguous

language, using words with common and everyday meanings. It shall be

appropriately divided, and each section captioned.

(c) The contract for a skilled nursing facility shall have an attachment

that is placed before any other attachment and that shall disclose the

name of the owner and licensee of the skilled nursing facility and the

name and contact information of a single entity that is responsible for all

aspects of patient care and the operation of the facility.

(d) An abbreviated contract of admission shall include a statement

indicating that respite care services, as defined in Section 1418.1,

provided by the skilled nursing facility or intermediate care facility is not

a Medi-Cal covered service and can only be provided by the facility on a

private-pay or third-party payor basis, unless the person is participating

in a Medicaid waiver program pursuant to Section 1396n of Title 42 of

the United States Code, or other respite care service already covered by

the Medi-Cal program.

(e) An abbreviated contract of admission shall specify the discharge

date agreed to upon admission by the skilled nursing facility or

intermediate care facility and the person being admitted or his or her

representative. This discharge date shall be binding as a ground for

discharge in addition to any other ground for discharge pursuant to

federal or state law and regulations.

(f) An abbreviated contract of admission shall include a statement

informing the person being admitted for respite care services that the

contract is designed specifically for the provision of respite care services

and cannot be used for any other type of admission to the facility.

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1599.645 (HSC)

(a) Within 30 days of approval of a change of ownership by the

California Department of Public Health, the skilled nursing facility shall

send written notification to all current residents and patients and to the

primary contacts listed in the admission agreement of each resident and

patient. The notice shall disclose the name of the owner and licensee of

the skilled nursing facility and the name and contact information of a

single entity that is responsible for all aspects of patient care and the

operation of the facility.

(b) The Department shall accept a copy of the written notice and a copy

of the list of individuals and mailing addresses to whom the facility sent

the notification as satisfactory evidence that the facility provided the

required written notification.

WELFARE &

INSTITUTIONS

CODE

14006.3 (W&I)

The department, at the time of application or the assessment pursuant

to Section 14006.6, and any nursing facility enrolled as a provider in the

Medi-Cal program, prior to admitting any person, shall provide a clear

and simple statement, in writing, in a form and language specified by the

department, to that person, and that person's spouse, legal

representative, or agent, if any, that explains the resource and income

requirements of the Medi-Cal program including, but not limited to,

certain exempt resources, certain protections against spousal

impoverishment, and certain circumstances under which an interest in a

home may be transferred without affecting Medi-Cal eligibility.

Does not apply for Title 18

Medicare-only SNFs.

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14019.7 (W&I)

(a) Notwithstanding Section 14019.4 and if permitted by federal law, a

relative of a skilled nursing facility resident who is a beneficiary under

this chapter may pay an additional amount to the facility to enable the

resident to obtain requested noncovered services, such as a private

room, telephone, or television, or for bed hold days that exceed a period

paid for under the state plan.

(b) The additional charge for requested noncovered services shall not

exceed the amount charged to private pay residents. The additional

charge for bed hold days shall not exceed the rate paid for by the Medi-

Cal program for a covered bed hold day. The additional charge for a

private room shall not exceed the difference between the private pay

rate for a semiprivate room and a private room.

(c) Prior to accepting supplemental payment for holding a bed for a

resident in a facility, a facility shall disclose to the relative the resident's

right under federal law to be readmitted without charge upon the first

availability of a bed in a semiprivate room in that facility, other state and

federal laws regarding bed hold rights, the average number of bed

vacancies at that facility for the past month, and the current number of

bed vacancies. Written information regarding bed vacancies shall be

provided to the relative at the first available opportunity.

(d) The ability of a resident's relative to pay an additional amount for non

covered services shall not be a condition of admission.

14022.3 (W&I)

Long-term health care facilities shall reveal to applicants for admission,

or their designated representatives, orally and in writing and prior to

admission, whether the facility participates in the Medi-Cal program, and

the circumstances under which the law permits a Medi-Cal recipient to

be transferred involuntarily.

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14110.4 (W&I)

(a) All laundry services for all apparel, linen, garments, towels, and

hospital gowns shall be provided by a nursing facility or any category of

intermediate care facility for the developmentally disabled at no cost to a

recipient under this chapter. These laundry services shall be considered

as part of the basic care provided by the facility under the daily rate

provided for pursuant to this chapter. The director shall, if necessary,

adjust the daily rate to provide for the costs of these services. A facility

may, however, charge the patient a fee to provide special drycleaning or

treatment for a garment needing this care, when the garment is owned

by the patient and when the regular laundry service is not

appropriate.(b) A facility shall provide a periodic hair trim as part of its

care for all patients who are recipients under this chapter. This service

shall be included as part of the daily rate provided for pursuant to this

chapter. The director shall, if necessary, adjust the daily rate to provide

for the costs of these services. A facility may, however, charge a fee for

beauty shop services for patients who request special treatments or

styling of their hair.

14110.8 (W&I)

(b) No facility may require or solicit, as a condition of admission into the

facility, that a Medi-Cal beneficiary have a responsible party sign or

cosign the admissions agreement. No facility may accept or receive, as

a condition of admission into the facility, the signature or co signature of

a responsible party for a Medi-Cal beneficiary.

14124.7 (W&I)

(a) No long-term health care facility participating as a provider under the

Medi-Cal program shall seek to evict out of the facility or, effective

January 1, 2002, transfer within the facility, any resident as a result of

the resident changing his or her manner of purchasing the services from

private payment or Medicare to Medi-Cal, except that a facility may

transfer a resident from a private room to a semiprivate room if the

resident changes to Medi-Cal payment status. This section also applies

to residents who have made a timely and good faith application for

Medi-Cal benefits and for whom an eligibility determination has not yet

been made.

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ADMINISTRATIVE SERVICE

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

14124.10 (W&I)

No licensed long-term health care facility participating as a provider

under the Medi-Cal program shall discriminate against a Medi-Cal

patient on the basis of the source of payment for the facility's services

that are required to be provided to individuals entitled to services under

the Medi-Cal program. Nothing in this section shall be construed to

prohibit a facility from charging private-pay patients for services required

to be provided to Medi-Cal patients or which are in addition to those

required under the Medi-Cal program. This section applies to licensed

long-term health care facilities, to the extent not prohibited by federal

law.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

PHYSICAL THERAPY SERVICE UNIT- SPACE

72411

(b) A sink shall be provided in the treatment area and shall have

controls other than hand controls.

(c) The toilet facilities shall be located nearby and equipped with grab

bars on both sides of the commode and the space shall be of sufficient

size to allow for patient transfer activities.

OCCUPATIONAL THERAPY SERVICE UNIT – EQUIPMENT

72419

(a) Necessary equipment shall be available to provide the occupational

therapy services offered. The equipment shall include but not be limited

to:

(1) Supportive slings, supportive and assistive hand splints and the

materials from which to fabricate these and other assistive devices.

(2) Adaptive devices to aid in the performance of daily living skills such

as eating, dressing, grooming and writing, with instructions for their use.

(3) Equipment and supplies for the development of creative skills.

(4) Means and supplies for adapting equipment for reeducation in

activities of daily living.

OCCUPATIONAL THERAPY SERVICE UNIT – SPACE

72421

(a) Space shall be provided for the necessary equipment needed to

provide occupational therapy. The minimum floor area shall be 28

square meters (300 square feet), no dimension of which shall be less

than 3.7 meters (12 feet).

(b) A sink shall be provided in the treatment area and shall have

controls not requiring the use of hands.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72421

(c) The toilet facilities shall be located nearby and equipped with grab

bars on both sides of the commode, and the space shall be of sufficient

size to allow for patient transfer activities.

SPEECH PATHOLOGY AND/OR AUDIOLOGY SERVICE UNIT – SERVICES

72423

(a) “Speech pathology and/or audiology services” means those services

referred or ordered by a licensed healthcare practitioner acting within

the scope of his or her professional licensure or certification, for the

provision of diagnostic screening and preventive and corrective therapy

for persons with speech, hearing and/or language disorders.

(b) Speech pathology and/or audiology service shall include but not be

limited to the following:

(1) Conducting and preparing written initial and continuing assessment

of a patient.

(2) Notes written and entered in the patient’s health record after each

treatment. The notes shall indicate the treatment performed, the

reaction of the patient to the treatment, and be signed by the speech

pathologist or audiologist.

(3) Instruction of other health team personnel and family members in

methods of assisting the patient to improve or correct a speech or

hearing disorder.

(c) A speech pathology and/or audiology service unit shall meet the

following requirements:

(1) Patient health records shall contain a patient’s history and signed

orders for treatment.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(2) Progress notes shall be written at least weekly and entered in the

patient health record and shall be signed by the speech pathologist

and/or audiologist.

SPEECH PATHOLOGY AND/OR

AUDIOLOGY SERVICE UNIT – STAFF

72427

(a) Each speech pathology service unit shall employ a speech

pathologist for a sufficient number of hours to meet the needs of the

patients and requirements of Section 72469.

(b) Each audiology service unit shall employ an audiologist for a

sufficient number of hours to meet the needs of the patients and

requirements of Section 72469.

SPEECH PATHOLOGY AND/OR

AUDIOLOGY SERVICE UNIT – EQUIPMENT

72429

(a) Necessary equipment shall be available to provide the speech

pathology and/or audiology services offered. The equipment shall

include but not be limited to:

(1) A diagnostic clinical audiometer.

(2) Diagnostic tests and materials.

SPEECH PATHOLOGY AND/OR

AUDIOLOGY SERVICE UNIT – SPACE

72431

Space free of ambient noise shall be provided by the facility to produce

valid test results.

SOCIAL WORK SERVICE UNIT – SERVICES

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

72433

(b) Social work services unit shall include but not be limited to the

following:

(1) Interview and written assessment of each patient within five days

after admission to the service.

(2) Development of a plan, including goals and treatment, for social

work services for each patient who needs such services, with

participation of the patient, the family, the patient's licensed healthcare

practitioner acting within the scope of his or her professional licensure,

the director of nursing services and other appropriate staff.

(3) Weekly progress reports in the patient’s health record written and

signed by the social worker, social work assistant or social work aide.

(4) Participation in regular staff conferences with the attending licensed

healthcare practitioner acting within the scope of his or her professional

licensure, the director of nursing service and other appropriate

personnel.

(6) Orientation and in-service education of other staff members on all

shifts shall be conducted at least monthly by the social worker in charge

of the social work service.

SOCIAL WORK SERVICE UNIT –

EQUIPMENT AND SUPPLIES

72439

(a) Office equipment and supplies necessary for the social work service

unit shall be available.

SOCIAL WORK SERVICE UNIT – SPACE

72441

Accessible space shall be provided for privacy in interviewing,

telephoning, conferences, and for operation of the unit.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

SPECIAL TREATMENT PROGRAM SERVICE – SERVICES

72445

(a) The program objective shall be to provide a program aimed at

improving the adaptive functioning of chronic mentally disordered

patients to enable some patients to move into a less restrictive

environment and prevent other patients from regressing to a lower level

of functioning.

(c) In order to qualify for special treatment program services approval,

the facility shall have, initially, a minimum of 30 patients whose need for

special treatment program services is reviewed and approved by the

local mental health director or designee.

(d) The facility program plan shall include provisions for accomplishing

the following:

(3) A minimum average of 27 hours per week of direct group or

individual program service for each patient.

HEALTH &

SAFETY CODE

SPECIAL TREATMENT PROGRAM SERVICE – SERVICES (CONTINUED)

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1262 (HSC)

(a) When a mental health patient is being discharged from one of the

facilities specified in subdivision (c), the patient and the patient's

conservator, guardian, or other legally authorized representative shall

be given a written aftercare plan prior to the patient's discharge from the

facility. The written aftercare plan shall include, to the extent known, all

of the following components:

(1) The nature of the illness and follow up required.

(2) Medications including side effects and dosage schedules. If the

patient was given an informed consent form with his or her medications,

the form shall satisfy the requirement for information on side effects of

the medications.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1262 (HSC)

(3) Expected course of recovery.

(4) Recommendations regarding treatment that are relevant to the

patient's care.

(5) Referrals to providers of medical and mental health services.

(6) Other relevant information.

(b) The patient shall be advised by facility personnel that he or she may

designate another person to receive a copy of the aftercare plan. A

copy of the aftercare plan shall be given to any person designated by

the patient.

(c) Subdivision (a) applies to all of the following facilities:

(6) A skilled nursing facility with a special treatment program, as

described in Section 51335 and Sections 72443 to 72475, inclusive, of

Title 22 of the California Code of Regulations.

(d) For purposes of this section, "mental health patient" means a person

who is admitted to the facility primarily for the diagnosis or treatment of a

mental disorder.

1276.9 (HSC)

(a) A special treatment program service unit distinct part shall have a

minimum 2.3 nursing hours per patient per day.

(b) For purposes of this section, “special treatment program service unit

distinct part” means an identifiable and physically separate unit of a

skilled nursing facility or an entire skilled nursing facility that provides

therapeutic programs to an identified population group of persons with

mental health disorders.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

1276.9 (HSC)

(c) For purposes of this section, "nursing hours" means the number of

hours of work performed per patient day by aides, nursing assistants, or

orderlies, plus two times the number of hours worked per patient day by

registered nurses and licensed vocational nurses (except directors of

nursing in facilities of 60 or larger capacity), and, in the distinct part of

facilities and freestanding facilities providing care for the

developmentally disabled or mentally disordered, by licensed psychiatric

technicians who perform direct nursing services for patients in skilled

nursing and intermediate care facilities, except when the skilled nursing

and intermediate care facility is licensed as a part of a state hospital

(d) A special treatment program service unit distinct part shall also have

an overall average weekly staffing level of 3.2 hours per patient per day,

calculated without regard to the doubling of nursing hours, as described

in paragraph (1) of subdivision (b) of Section 1276.5, for the special

treatment program service unit distinct part.

(e) The calculation of the overall staffing levels in these facilities for the

special treatment program service unit distinct part shall include staff

from all of the following categories:

(1) Certified nurse assistants.

(2) Licensed vocational nurses.

(3) Registered nurses.

(4) Licensed psychiatric technicians.

(5) Psychiatrists.

(6) Psychologists.

(7) Social workers.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

(8) Program staff who provide rehabilitation, counseling, or other

therapeutic services.

WELFARE &

INSTITUTIONS

CODE

SPECIAL TREATMENT PROGRAM SERVICE – SERVICES (CONTINUED):

PATIENT LEAVE OF ABSENCES

14108.1 (W&I)

Any recipient receiving care in a nursing facility under this chapter, as

part of a certified special treatment program for mentally disordered

persons, or as a part of a mental health therapeutic and rehabilitative

program approved and certified by a local mental health director, is

entitled to be temporarily absent from those facilities. The State

Department of Health Services shall, with consultation from the State

Department of Mental Health, develop regulations within 60 days of the

effective date of this act establishing the periods of time and conditions

under which temporary absences shall be permitted. These regulations

shall require that absences be in accordance with an individual patient

care plan and also provide for absences due to hospitalization for an

acute condition. The limits on temporary leaves of absence established

by the State Department of Health Services by regulation shall not be

less than 30 days per year. During these temporary absences, the State

Department of Health Services shall reimburse the facility for the cost of

maintaining the vacant accommodations at a rate to be determined by

the department which shall be less than the normal reimbursement rate.

14108.2 (W&I)

Except as provided by Section 14108 and Section 14108.1, any

recipient of services under this chapter who is residing in a long-term

care facility shall be permitted to be temporarily absent from such

facilities for up to 18 days per year, not including days of bed hold for

acute hospitalization. The department may approve additional days of

leave on an individual basis, not to exceed 12 days per year, exclusive

of days of bed hold for acute hospitalization.

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OTHER APPROVED SERVICES (OPTIONAL SERVICES)

STATE

STANDARD

REQUIREMENT

MET

NOT

MET

N/A

LOCATION OF EVIDENCES

14108.2 (W&I)

.

All such leaves of absence shall be in accordance with an individual

patient care plan as approved by the attending physician. The director

shall adopt regulations establishing the conditions under which

additional leave days shall be authorized. The director may establish

reasonable limits on the duration of any period of absence.

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Regulation/Concern

Source

Evaluator Notes (Include Date/Time/Location

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