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
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
TITLE 22
72311
72313
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72315
72317
Exception- (HSC 1261.3); flu and
pneumococcal vaccinations
allowed.
72319
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72319 (cont.)
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72319 (cont.)
72319 (cont.)
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72319 (cont.)
72321
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72323
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.
72325
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72325 cont
72523
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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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72528
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72545
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72547
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72547
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
72555
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State SNF Relicensing Survey Workbook 2016
NURSING SERVICE
STATE
STANDARD
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
HEALTH &
SAFETY
CODE
1254.7 (HSC)
1418.81 (HSC)
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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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State SNF Re-licensing Survey Workbook 2016
PHARMACEUTICAL SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
PHARMACEUTICAL SERVICE LABELING AND STORAGE OF DRUGS
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State SNF Re-licensing Survey Workbook 2016
PHARMACEUTICAL SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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State SNF Re-licensing Survey Workbook 2016
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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State SNF Re-licensing Survey Workbook 2016
PHARMACEUTICAL SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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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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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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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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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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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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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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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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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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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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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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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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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.
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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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37
State SNF Re-licensing Survey Workbook 2016
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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38
State SNF Re-licensing Survey Workbook 2016
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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39
State SNF Re-licensing Survey Workbook 2016
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
State SNF Relicensing Survey Field Notes - (Click to Go Back to Table of Contents)
40
State SNF Re-licensing Survey Workbook 2016
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
State SNF Relicensing Survey Field Notes - (Click to Go Back to Table of Contents)
41
State SNF Re-licensing Survey Workbook 2016
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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42
State SNF Re-licensing Survey Workbook 2016
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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43
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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44
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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45
State SNF Re-licensing Survey Workbook 2016
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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46
State SNF Re-licensing Survey Workbook 2016
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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State SNF Re-licensing Survey Workbook 2016
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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PATIENT RIGHTS
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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State SNF Re-licensing Survey Workbook 2016
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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PHYSICAL PLANT
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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PHYSICAL PLANT
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
(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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PHYSICAL PLANT
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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.
PHYSICIANS 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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
(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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
(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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
(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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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ADMINISTRATIVE SERVICE
STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
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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(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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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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(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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BREACHES
(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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MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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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STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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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STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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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LOCATION OF EVIDENCES
(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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STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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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STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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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STATE
STANDARD
REQUIREMENT
MET
NOT
MET
N/A
LOCATION OF EVIDENCES
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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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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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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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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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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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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STANDARD
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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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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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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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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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