Term
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Definition
| Exercise of Rights-Rights guaranteed to citizens and residents of the U.S. |
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Term
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Definition
| Rights Exercised by Others on Behalf of Residents-Regarding residents unable to act for themselves |
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Term
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Definition
| Access to Clinical Records-Time frame for resident visual access and copies made at cost |
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Term
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Definition
| Right to be fully informed re: health status-In a language the resident can understand and informed in advance |
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Term
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Definition
| Right to refuse treatments and right to formulate an advance directive |
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Term
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Definition
| Right to Information Regarding Legal Rights-resident informed in writing of his or her rights in a language he/she understands including Medicare and Medicaid benefits, related charges, services available in the facility, state client advocacy groups, filing complaints, Advance Directives and how to contact physician - Display written info for and regarding use of Medicaid & Medicare (see after F152). |
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Term
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Definition
| Notification of Changes-Required notifications to MD, legal rep, interested family and resident of injurious accident, significant change in condition-treatment, transfer or discharge, change in room or roommate or change in legal rights. Update address & phone number of legal rep or interested family |
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Term
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Definition
| Residents right to manage his or her funds |
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Term
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Definition
| Management of Personal Funds-safeguarding, management and accounting of resident funds deposited with facility - >$50 in interest bearing account, < $50 non-interest acct, notice of certain balances |
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Term
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Definition
| Conveyance Upon Death-resident funds and final accounting to probate jurisdiction, within 30 days |
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Term
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Definition
| Assurance of Financial Security-surety bond |
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Term
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Definition
| Limitation on Charges to Personal Funds-in regard to Medicaid and Medicare payments |
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Term
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Definition
| Free Choice-right to choose a personal physician |
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Term
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Definition
| Privacy and Confidentiality-personal privacy and confidentiality of personal & clinical records, including all info in residents records w/some exceptions (see after F516). |
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Term
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Definition
| Right to Voice Grievances-w/o discrimination or reprisal |
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Term
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Definition
| Right to Prompt Efforts to Resolve Grievances-by the facility |
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Term
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Definition
| Examination of Survey Results-posted notice re: where survey results and POC are available, in a place readily accessible to residents where they do not have to ask to see them. |
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Term
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Definition
| Right to Receive Information from Advocates |
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Term
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Definition
| Work-resident right to choose whether or not to perform services for the facility voluntarily for pay |
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Term
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Definition
| Mail-right to promptly receive and send mail, unopened |
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Term
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Definition
| Access to stationary, postage and writing implements-at residents' expense |
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Term
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Definition
| Access & Visitation Rights-immediate access to any rep of the Secretary, State, residents MD, LTC Ombudsman, APS & subject to the consent of the resident their family, friends or others providing health, social, legal or other serves to the resident. |
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Term
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Definition
| State Ombudsman-may examine a resident's clinical record w/the consent of the resident or their legal representative |
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Term
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Definition
| Telephone-reasonable access to a telephone where calls cannot be overheard - personal property retain & use |
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Term
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Definition
| Married Couples-right to share a room when both parties consent |
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Term
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Definition
| Self-Administration of Drugs-if IDT determines it is safe |
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Term
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Definition
| Refusal of Certain Transfers-right to refuse a transfer to another room if the purpose is to obtain Medicare or Medicaid eligibility |
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Term
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Definition
| Transfer and Discharge Requirements-conditions under which resident may be transferred or discharged out of the facility against his or her wishes |
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Term
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Definition
| Documentation-necessary when resident is transferred under above conditions |
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Term
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Definition
| Notice Before Transfer-notifications to be made before resident is transferred or discharged for above reasons, timing of notice & contents |
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Term
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Definition
| Orientation for Transfer or Discharge-sufficient to ensure a safe and orderly transfer or discharge |
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Term
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Definition
| Notice of Bed-Hold Policy and Readmission-written information prior to transfer or therapeutic leave stating duration and policy |
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Term
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Definition
| Permitting Resident to Return to Facility-facility must have policy for readmission after bed-hold period is exceeded |
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Term
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Definition
| Equal Access to Quality Care-transfer, discharge and provision of services must be the same regardless of payment source |
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Term
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Definition
| Admissions Policy-regarding resident rights relative to Medicare or Medicaid benefits, cannot require 3rd party payment |
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Term
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Definition
| Physical Restraints-resident right to be free of restraints used for discipline or convenience and not necessary to treat medical symptoms |
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Term
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Definition
| Chemical Restraints-resident right to be free of restraints used for discipline or convenience and not necessary to treat medical symptoms |
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Term
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Definition
| Abuse-right to be free of instances of verbal, sexual, physical and/or mental abuse, corporal punishment or involuntary seclusion |
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Term
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Definition
| Staff Treatment of Residents-right to be free of instances of mistreatment, neglect or misappropriation of resident property |
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Term
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Definition
| Staff Treatment of Residents-facility development & implementation of policies to prohibit abuse |
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Term
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Definition
| Employees and Investigations of Alleged Violations-regarding employment of individuals w/a history of abusing, neglecting or mistreating residents AND reporting and investigation of possible mistreatment, neglect or abuse including injuries of unknown origin and prevention of further abuse during the investigation. |
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Term
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Definition
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Term
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Definition
| Dignity-maintain or enhances each resident's dignity and respect in full recognition of his or her individuality |
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Term
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Definition
| Self-Determination and Participation-right to choose activities, schedules and health care, interact w/members of the community and make choices about aspects of his or her life that are significant to resident |
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Term
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Definition
| Participation in Resident and Family Groups-right to organize and participate in resident and family groups |
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Term
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Definition
| Facility Responses to Resident and Family Groups-must listen to views and act upon grievances and recommendations |
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Term
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Definition
| Participation in Other Activities-right to participate in social, religious and community activities |
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Term
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Definition
| Accommodation of Needs-reasonable changes in physical environment and staff behavior to accommodate individual needs AND preferences & sufficient space & equipment in dining health services, recreation & program areas to enable staff to provide residents with bedding appropriate to weather and climate & functional furniture appropriate to resident's needs and individual closet space in the resident's bedroom w/clothes racks & shelves accessible to resident (see after F461). |
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Term
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Definition
| Notice of Change in Room or Roommate-before change takes place |
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Term
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Definition
| Activities-designed to meet the interests and the physical, mental and psychosocial well being of each resident |
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Term
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Definition
| Activity Director Qualifications |
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Term
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Definition
| Social Services-provide provision of medically related social services needs of each resident, to attain highest practicable….. |
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Term
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Definition
| Social Worker Qualifications |
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Term
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Definition
| Safe, Clean, Comfortable, Homelike Environment-right to retain and use personal possessions including clothing and furnishings as space permits and the resident wishes and resident rooms must be designed for adequate nursing care, comfort and privacy (see after F456 & F174) |
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Term
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Definition
| Housekeeping and Maintenance-to maintain a sanitary, orderly and comfortable interior |
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Term
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Definition
| Bed and Bath Linens-clean and in good condition |
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Term
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Definition
| Lighting-light levels suitable to tasks the resident chooses to perform or the facility staff must perform, adequate & comfortable in all areas |
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Term
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Definition
| Temperature-comfortable and safe to minimize residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds |
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Term
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Definition
| Sound-comfortable levels which do not interfere w/ residents' hearing, enhance privacy when privacy is desired and encourage interaction when social participation is desired |
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Term
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Definition
| Admission Orders-Physician's orders needed for immediate care |
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Term
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Definition
| Comprehensive Assessment-RAI: MDS, RAPs and other needs and strengths |
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Term
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Definition
| Frequency- within 14 days of admission |
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Term
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Definition
| Significant Change-described and time frame defined |
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Term
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Definition
| Annual-w/in 366 days of last full MDS |
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Term
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Definition
| Quarterly Review Assessments-quarterly MDS - not less than every 3 months |
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Term
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Definition
| Use-maintain 15 months in resident's active file |
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Term
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Definition
| Automated Data Processing-encoding and transmitting data, monthly transmittal requirements |
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Term
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Definition
| Accuracy of Assessments-each person signs as to accuracy of portion of MDS he/she completes, RN coordinates, penalty for falsification |
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Term
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Definition
| Comprehensive Care Plans Developed-based on RAI, measurable objectives and timetables |
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Term
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Definition
| Comprehensive Care Plans Timing, Participation & Review-due 7 days after RAI completed, prepared and reviewed by IDT including residents, legal reps (see before F164) |
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Term
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Definition
| Professional Standards of Quality |
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Term
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Definition
| Qualified Persons - in accordance with written POC |
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Term
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Definition
| Discharge Summary-for the anticipated transfer or discharge to a lower or equal level of care, recap and final summary of status |
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Term
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Definition
| Post-Discharge Plan of Care-plan to meet continuing care needs |
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Term
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Definition
| Pre-Admission Screening for Mentally Ill Individuals and Individuals w/Mental Retardation |
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Term
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Definition
| Care and Services-for quality of care deficiencies not covered by F tags 310-333 |
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Term
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Definition
| ADLs-residents abilities do not diminish |
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Term
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Definition
| Care and Services to Maintain or Improve Abilities-residents abilities are maintained or improved |
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Term
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Definition
| Care and Services to Maintain Good Nutrition, Grooming & Personal & Oral Hygiene-dependent residents |
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Term
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Definition
| Vision and Hearing-maintain abilities, treatment and assistive devices |
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Term
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Definition
| Pressure Ulcers-those without do not develop, those with receive treatment & services to treat & prevent |
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Term
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Definition
| Urinary Incontinence-Catheter-to prevent use; prevent UTIs & restore bladder function |
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Term
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Definition
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Term
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Definition
| ROM-treatment to increase ROM and/or prevent further decline |
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Term
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Definition
| Mental and Psychosocial Functioning-Treatment-to treat adjustment difficulties (F406) |
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Term
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Definition
| Mental and Psychosocial Functioning-Prevention-to prevent a pattern of decreased social interaction, and/or increased withdrawal, anger or depressive behaviors |
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Term
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Definition
| Naso-Gastric Tube-prevention of use |
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Term
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Definition
| Naso-Gastric Tube-appropriate treatment & services to prevent complications |
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Term
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Definition
| Accidents-to provide environment as free of accident hazards as possible & Supervision and Assistance Devices-to prevent accidents |
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Term
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Definition
| Nutritional Status-maintenance of body weight, protein levels and other indications of nutritional status. Therapeutic diet - when there is a nutritional problem |
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Term
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Definition
| Hydration - provide sufficient fluid to maintain |
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Term
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Definition
| Special Needs-injections, parenteral & enteral fluids, colostomy, ureterostomy or ileostomy, tracheostomy, tracheal suctioning, respiratory care, foot care and prostheses. |
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Term
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Definition
| Unnecessary Drugs-in excessive dose, for excessive duration w/o adequate monitoring, adequate indications for its use and/or in the presence of adverse consequences. Antipsychotic Drugs-Prevention of use-unless necessary to treat a specific condition. Antipsychotic Drugs-Attempting to discontinue-through gradual dose reductions and behavioral interventions |
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Term
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Definition
| Medication Errors-facility rate of less than 5% |
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Term
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Definition
| Medication Errors-free of significant errors |
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Term
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Definition
| Influenza & Pneumococcal Immunizations - policies/procedures to offer, document in medical record |
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Term
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Definition
| Sufficient staff-licensed nurses 24 hours per day in sufficient numbers to meet needs of residents according to care plans, licensed nurse as charge nurse on each tour of duty |
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Term
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Definition
| Registered Nurse-at least 8 consecutive hours a day, 7 days a week, DNS may be charge nurse if average daily census is 60 or less |
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Term
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Definition
| Waivers-conditions under which waivers might be possible |
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Term
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Definition
| Nurse Staffing Information - requirements regarding daily posting |
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Term
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Definition
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Term
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Definition
| Qualified Staff-dietitian full time, part time or consultant |
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Term
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Definition
| Sufficient Staff- carry out dietary services |
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Term
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Definition
| Menus and Nutritional Adequacy - meet nutritional needs of residents, prepare in advance & follow |
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Term
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Definition
| Food-prepared to conserve nutrition, flavor an appearance and that is palatable at & at proper temperature |
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Term
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Definition
| Food-in a form to meet individual needs, cut, chopped or ground |
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Term
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Definition
| Substitutes-offer similar nutritive value to those who refuse |
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Term
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Definition
| Therapeutic Diets-prescribed by physician |
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Term
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Definition
| Frequency of Meals-3 meals daily at community times, snacks at bedtime |
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Term
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Definition
| Assistive Devices-special eating equipment and utensils needed for independent eating |
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Term
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Definition
| Sanitary Conditions-procure food from approved sources & Sanitary Conditions-food storage, preparation, distribution and service |
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Term
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Definition
| Sanitary Conditions-garbage and refuse |
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Term
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Definition
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Term
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Definition
| Physician Supervision-every admit approved by physician and every resident must have physician, each residents' care supervised & physician available in absence of attending |
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Term
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Definition
| Physician Visits-review care, make progress notes and sign and date all orders |
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Term
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Definition
| Frequency of Physician Visits-every 30 days for first 990 days, then every 60 days thereafter |
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Term
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Definition
| Physician Substitutes-alternate visits may be by physician assistant, nurse practitioner or clinical nurse specialist |
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Term
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Definition
| Availability of Physicians for Emergency Care-available 24 hours per day |
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Term
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Definition
| Physician Delegation of Tasks-physician assistant, nurse practitioner or clinical nurse specialist |
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Term
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Definition
| Provision of Services-such as PT, OT, speech-language pathology & mental health rehab services for mental illness and mental retardation |
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Term
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Definition
| Qualifications - rehab services under written order of physician |
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Term
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Definition
| Skilled Nursing Facilities- the facility may charge Medicare residents , must provide or obtain routine and emergency dental services to meet needs of resident by making appointments, arranging transport and promptly referring residents w/lost or damaged dentures |
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Term
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Definition
| Nursing Facilities-w/o charging, depending on State plan, the facility must provide or obtain routine and emergency dental services to meet needs of resident by making appointments, arranging transport and promptly referring residents w/lost or damaged dentures. |
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Term
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Definition
| Pharmacy Services-the facility must provide routine and emergency drugs and biologicals. Procedures-accurate acquiring, receiving, dispensing and administering. Service Consultation-Licensed Pharmacist provide consultation, |
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Term
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Definition
| Drug Regimen Review-each resident's drug regimen reviewed at least monthly by licensed Pharmacist. Reporting Irregularities-must be reported to physician and DNS. Reports Acted Upon-Physician and DNS must respond in some manner to the report, need not agree with pharmacist |
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Term
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Definition
| The Pharmacist - establishes system of accounting for controlled substances. Labeling of Drugs and Biologicals-In accordance w/currently accepted professional principles and include name of drug, strength and expiration date. Storage of Drugs and Biologicals-All are kept locked and at proper temperature and Schedule II drugs are separately locked |
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Term
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Definition
| Infection Control Program-designed to investigate, control and prevent infections, decide on isolation procedures when needed and maintain record of incidents and corrective actions related to infections. Preventing Spread of Infection-facility isolates resident when the infection control program determines this is necessary. Employee Contact-those with communicable diseases and infectious skin lesions are kept from contact w/residents or their food. Hand Washing-staff required to hand wash to prevent the spread of disease. Linens-handled, stored, processed and transported to prevent spread of infection |
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Term
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Definition
| Life Safety from Fire-compliance with Life Safety Code |
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Term
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Definition
| Emergency Power-emergency electrical power w/an emergency generator when life support systems are used and adequate power for lighting all entrances and exits, & equipment to maintain the fire detection, alarm and extinguishing systems |
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Term
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Definition
| Essential Patient Care Equipment-mechanical and electrical equipment maintained in safe operating condition |
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Term
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Definition
| Residents per Bedroom-no more than 4 |
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Term
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Definition
| Bedroom Size-at least 80 square feet in multiple rooms and 100 square feet in single resident rooms |
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Term
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Definition
| Access to Exit Corridor-per life safety code cannot be waivered |
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Term
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Definition
| Full Visual Privacy-by design or equipment and have ceiling suspended curtains in newer facilities |
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Term
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Definition
| Window and Floor-at least one window to the outside and a floor at or above grade level. Private Accessible Closet Space |
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Term
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Definition
| Toilet Facilities-each room equipped w/or located near toilet facilities |
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Term
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Definition
| Resident Call System-nurses station must be equipped to receive resident calls through a communication system from resident rooms and toilet/bathing facilities |
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Term
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Definition
| Dining and Resident Activities-one or more rooms designed for resident dining & activities which are well lighted, well ventilated, adequately furnished and w/sufficient space |
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Term
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Definition
| Other Environmental Conditions-safe, functional, sanitary and comfortable environment for residents, staff and the public |
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Term
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Definition
| Emergency Source of Water |
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Term
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Definition
| Outside Ventilation-by means of windows and/or mechanical ventilation to maintain acceptable temperature, humidity and odor levels |
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Term
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Definition
| Corridor Handrails-firmly secured to the wall on each side of the corridor |
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Term
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Definition
| Pest Control-facility is free of pests and rodents |
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Term
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Definition
| Administration-effectively and efficiently |
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Term
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Definition
| Licensure-state licensure |
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Term
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Definition
| Compliance w/Federal, State and Local Laws and Professional Standards-in regard to health, safety and sanitation |
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Term
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Definition
| Governing Body and Required Training of Nursing Aides-defines nurse aide |
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Term
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Definition
| Nurse Aide Training-requirements after 4 months of employment, non-permanent employees - must not use those who do not meet requirements |
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Term
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Definition
| Nurse Aide Competency-requirements during first 4 months |
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Term
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Definition
| Registry Verification-of competency evaluation requirements |
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Term
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Definition
| Regular In-service Education-Based on annual, individual nurse aide performance reviews, special needs of residents and care of the cognitively impaired |
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Term
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Definition
| Proficiency of Nurse Aides-demonstrated competency in skills and techniques necessary to care for residents' needs |
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Term
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Definition
| Staff Qualifications-professional staff to be licensed, certified or registered in accordance w/State laws |
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Term
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Definition
| Use of Outside Resources-professional staff not employed by the facility |
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Term
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Definition
| Medical Director-responsibilities |
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Term
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Definition
| Provision of Lab Services-facility responsibility for quality and timeliness of services |
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Term
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Definition
| Lab Services Requirements-federal requirements to be met |
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Term
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Definition
| Physician Orders for Lab Services-needed |
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Term
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Definition
| Physician Notification of Results-required promptly |
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Term
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Definition
| Transportation-provide assistance to resident in making arrangements |
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Term
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Definition
| Results in Clinical Record - name & address of testing lab |
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Term
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Definition
| Radiology and Other Diagnostic Services-facility responsibility for quality and timeliness of services |
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Term
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Definition
| Conditions of Participation-federal requirements to be met |
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Term
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Definition
| Physicians Orders-Radiology-needed, provide or obtain when ordered |
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Term
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Definition
| Physician Notification of Results-Radiology-required promptly |
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Term
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Definition
| Transportation-provide assistance to resident in making arrangements |
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Term
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Definition
| Results in Clinical Record - file, sign & dated reports |
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Term
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Definition
| Clinical Records-complete, accurately documented, readily accessible, and systematically organized and what the record must contain (see before F517) |
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Term
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Definition
| Clinical Record Retention-length of time defined |
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Term
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Definition
| Clinical Record Safeguards-against loss, destruction or unauthorized use |
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Term
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Definition
| Disaster and Emergency Preparedness Plans-must be detailed and written regarding all potential emergencies and disasters such as fire, severe weather, and missing residents |
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Term
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Definition
| Disaster and Emergency Preparedness Training-drills/training for all employees |
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Term
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Definition
| Transfer Agreement-w/one or more nearby hospitals in writing |
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Term
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Definition
| Quality Assessment and Assurance Committee-consisting of DNS, physician and at least 3 other staff members, frequency & purpose of meetings |
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Term
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Definition
| Disclosure of Ownership-changes in ownership and management, which must be reported |
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