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Duty to Report to Life Safety - ANSWER All fires, explosions, natural disasters as well as preventable deaths, serious or life-threatening injuries caused by fires, explosions, and natural disasters shall be phoned in to the L/S Code Div. before the end of the next workday after the occurrence. The L/S Code Div. will furnish forms to fulfill written reporting within 15 calendar days.
Windows shall be no more than ____ above the ground. - ANS 36 inches
Windows must make up of the required floor area. - ANS Not less than 1/8.
Floor Area for Private Room - ANS 100 sq ft
Semi-Private Room Floor Area - ANS 80 sq ft
Mattresses should be at least X inches thick. - ANS 4 inches
Special Care Rooms required in what count? - ANSWER 1:30 beds, or major fraction thereof.
Minimum Storage Area: Medicine Room - ANSWER 75 sq ft
Bathing Facilities & Lavatories -- Minimum Count - ANSWER 2 per nursing unit
Nursing units may be no larger than X beds. - ANSWER 60 beds each
Shower Size shall be no smaller than __ x __ without curbing. - ANSWER 30x60 inches
Water Closet (toilet c. sink) in Res. Room must be no smaller than. - ANSWER 3x6 feet
Nursing units must include storage for: - ANSWER linens and wheelchairs
Resident Minimum Requirement for Physical Exams - ANSWER 30 days prior to admission and annually, thereafter.
Admission Requirements -- Resident TB Testing - ANSWER TB s/s, placement, and chest x-ray within last 30 days
ADLs - ANSWER Eating, Bathing, Dressing, and Grooming; Transferring and Ambulation; Good Nutrition, Personal Hygiene; and Toileting
Phys. Services Requirement - ANSWER NP, PA, or MD on call 24/
Residents must be seen by their provider: - ANSWER every 60 days.
Resident drug regimens are reviewed how often, and by whom? - ANSWER Every 30 days by a licensed pharmacist.
Medical Rec. must be completed within X days of d/c. - ANSWER 60
Med Rec are to be retained for X years after d/c. - ANSWER 5
In case of a minor, for how long should the M/R be retained? - ANSWER 3 years beyond the discharged's 21st birthday
Copies of diet changes and substitution records are kept on file for at least: - ANSWER 30 days.
There shall not be more than X hours between the evening and morning meal. - ANSWER 14
16 hours may be allowed between the evening and morning meals if: - ANSWER The resident has agreed to this and a nutritious snack that includes a source of protein is offered at bedtime.
Minimum Supply of Perishable Food - ANSWER 24 hours
Minimum Supply of Non-Perishable Food - ANSWER 72 hours
Dining Tables shall not seat more than X residents. - ANSWER 4-
Lighting in kitchen and dining room shall not be less than the intensity of: - ANSWER 30 foot candles.
Recommended Temp for Storage of Perishable Goods: Meats & Dairy Products - ANSWER 32-40.
Recommended Temp for Storage of Perishable Goods: Fruits & Veg - ANSWER 40-45.
If it is impractical to separate refrigeration for meat, dairy, fruit, and veggies, then the common refigerator must be at: - ANSWER 41 degrees.
Freezers shall be X degrees: - ANSWER 0 or below
Facilities with more than X beds shall provide for commercial refridgeration. - ANSWER 25+
For less than 25 beds, the kitchen shall be at least X. - ANSWER 200 sq ft
For Fac. of 25-60 beds, the kitchen shall not be less than: - ANSWER 10 sq ft/bed
For Fac. of 61-80 beds, the kitchen shall not be less than: - ANSWER 6 sq feet/bed for each bed over 60 in the home
For Fac. of 81-100 beds, the kitchen shall be no smaller than: - ANSWER 5 sq ft/bed for each bed over 80
For Fac. of 100+ beds, the kitchen shall be no smaller than: - ANSWER dictated by the applicable regulatory body.
Minimum passageway between working areas in kitchen: - ANSWER 3 feet.
Minimum ceiling height in kitchen: - ANSWER 8 feet.
Facilities with over 24 beds must have X grade appliances. - ANSWER commercial
Hand-washing dish sinks (3 compartment) shall be a minimum of X x Y x Z. - ANSWER 24x24x
Minimum Drain Board - ANSWER 30 inches on either side -- one to use for soiled and one for cleaning utensils.
Food Prep Sink - ANSWER Double Compartment c. drain board at the end of sink.
There must be a minimum of X number of ice machines in the Facility. - ANSWER 1
If only one, then location of the ice machine must be: - ANSWER adjacent to, but outside of the kitchen.
Administrator - ANSWER a person who is delegated the responsibility for the interpretation, implementation, and proper application of policies and programs established by governing authorities
Bed Capacity - ANSWER the largest number which may be installed or set up in a facility at any one time for use of residents as stated on the certificate of licensure
Bed Count - ANSWER the number of beds actually set up in a Fac.
Change of Ownership - ANSWER the acquisition of 50%+ of a Fac.
Criminal Record Check Affadavit - ANSWER Form 210
"Employee" within Criminal Record Checks - ANSWER any individual employed by a covered entity, to include contract associates providing care in the resident's room
Covered Entity - ANSWER licensed Facility or professional healthcare staffing agency
Licensed Entity - ANSWER hospital, SNF, personal care home, home health agency, or hospice
Day Shift - ANSWER 8 hours between 6A-6P
Governing Authority - owner(s), Board of Governors, Board of Trustees, or other similar body responsible for the management of a Fac.
Infectious Medical Waste - wastes that may contain pathogens having a sufficient virulence and quantity that exposure to the waste by a susceptible host has been shown in certain cases to result in an infectious disease
Institution for the Aged or Infirm AKA "Facility" - ANSWER a place which provides group living arrangements for four or more persons that are unrelated to the operator and who are provided food, shelter, and personal care
IGRA - ANSWER whole blood test used to diagnose TB
Mantoux Test - ANSWER method of skin testing for TB that is performed by injecting .1mL of purified protein derivative-tuberculin containing 5 TB units into the dermis with a needle and syringe
Mantoux Test Reading Times - ANSWER 48-72 hours
Medical Waste - ANSWER waste generated in direct resident care or in diagnostic or research areas that, while non-infectious, is aesthetically repugnant if found in the environment
Maximum Nursing Unit Size - ANSWER 60 beds
How many hours of CE credit per year must a QDM maintain? ANSWER 15 hrs approved by the Dietary Manager's Association or the American Dietetic Association
Restraint - ANSWER any means -- physical or chemical -- that is intentionally used to restrict the freedom of movement of a person
Significant TB Skin Test - ANSWER reaction of 5mM or greater, when:
- The person is known/suspected to have HIV.
- Contact with persons with active TB infection.
- Positive chest x-ray.
- Persons who inject IV drugs.
There shall at all times be no less than X number of employees present in the facility in case of an emergency. - ANSWER 2
Licenses are to be posted. - ANSWER in a conspicuous place on the premises and shall be available for inspection by any interested person
On what date does the Facility License expire annually? - ANSWER March 31
Licenses are/are not transferrable? - ANSWER Non-Transferable
What 4 things does it take to renew the Facility's license? - ANSWER Application for Renewal; Payment of Renewal Fee; Approval of the Annual Report; Maintenance of Conformity with Minimum Standards
Denial/Renewal/Issuance of License Includes but is not Limited to the Following: - ANSWER Fraud; Willful or Repeated Failure to Comply with R/R; Use of Alcohol or Narcotics in a fashion that Creates harm for the Residents; Felony conviction against the Licensee; Abuse, Negligence, or Malpractice; Public Misrepresentation of the Facility and Services
If a license is denied or revoked, how many days does the licensee have after receiving notification to request an administrative hearing? ANSWER 10 days
Within how many days of a licensure denial will an administrative hearing be held? ANSWER 30 days
Within how many days following an administrative hearing is a final decision in the matter considered to be concluded? ANSWER 30 days
For whom does ultimate responsibility for the administration and compliance of the Facility rest? - ANSWER the governing body, owner, or NHA
Each facility shall have a written organizational chart that includes: - ANSWER Establishment of line authority, responsibilities, and relationships -- written personnel policies and job descriptions shall be prepared and given to each employee.
Relationship to Governing Authority - ANSWER The NHA, staff, and auxiliary organizations shall be directly or indirectly responsible to the governing authority.
The licensee shall be. - ANSWER the person who the licensing agency will hold responsible for the operation of the home in compliance with these regulations.
The licensee shall initially furnish: - ANSWER 3 references and a description of the corporation structure
The administrator: Primary responsibilities include - ANSWER authority and responsibility for the operation of the facility in all its administrative and professional functions subject only to the policies enacted by the governing authority and to such orders as it may issue.
There shall be a qualified person present in the facility responsible to the administrator in matters of administration. - ANSWER who shall represent them during the absence. The person shall not be a resident of the facility.
The administrator shall be chosen primarily for administrative abilites: - ANSWER to establish proper working relationship with MD/PA/NP and employees of the facility.
Minimum age of an administrator: - ANSWER 21
The administrator shall be a person of: - ANSWER reputable and responsible character and in such state of physical and mental health as will permit them to satisfactorily direct the activities and services of the facility.
Agreements between facility and resident relative to cost of care shall include adequate provisions for X. ANSWER .emergency medical or hospital care as may be required by resident.
No licensee, owner, or administrator of X may serve as the resident's legal guardian. - ANSWER direct financial interest in the performance of the Facility
Prior to admitting residents to the Facility, the following must be developed and submitted to the licensing agency. - ANSWER Schedules for admitting residents
Licensed facilities shall develop and implement EOPs based on what method? - ANSWER All Hazards
What are the 6 areas of consideration in developing an all-inclusive EOP: - ANSWER Communications; Resources and Assets; Safety and Security; Staffing; Utilities; Clinical Activities
EOPs must be drilled and reviewed within what time frame? - ANSWER annually
In writing, documentation of approval of the EOP must be provided when X is submitted.
- ANSWER application for the renewal of the license of the facility
Fire drills shall be conducted how often and on what schedule? - ANSWER One shift per quarter.
Employees shall participate in how many fire drills annually? - ANSWER four
A fire evacuation plan for the Facility shall be. - ANSWER posted in a conspicuous place and kept current.
Each Facility shall provide an office space and/or administrative office to include: - ANSWER a desk, file drawer or cabinet, and related office equipment and supplies.
Facilities caring for more than X residents should provide separate room(s) for the administrative facilities. - ANSWER 25+
Each Facility shall provide X for the public. - ANSWER a waiting room or space
X shall list the Facility telephone in his name. - ANSWER the Facility itself
How many telephones, and in what arrangement, shall there be in a Facility? - ANSWER Each facility shall have an adequate number of telephones and extensions to summon help in case of fire or other emergency, and these shall be located so as to be quickly accessible from all parts of the building.
Any licensing agencies should be consulted in doing the disciplinary checks along with X. - ANSWER criminal history record checks
Date of Criminal Record Check Requirement Enaction - ANSWER July 1, 2003
If there are events which are revealed in inspection of the Criminal History Background Check, then. - ANSWER a work waiver must be issued by the Facility.
What convictions, other than felonies would make an applicant ineligible for employment? -ANSWER Drug possession or sales; murder; manslaughter; armed robbery; rape; sexual battery; sex offenses; child abuse; arson; grand larceny; burglary; gratification of lust; aggravated assault; and felonious abuse or battery of a vulnerable adult.
Covered entities shall maintain on file evidence of verification. - ANSWER of the employee's disciplinary status, if any, with licensing agencies and evidence of submission of the employee's fingerprints to the licensing agency with the signed affidavit with notarized letter addressing the suitability of the employee for such
Facilities polices on employee health screenings shall be in writing and include the following: - RECORDING ANNUAL EXAMINATIONS
WHAT CONSTITUTES AN ADEQUATE HEALTH EXAMINATION
WHO IS THE QUALIFIED MEDICAL PROFESSIONAL TO CONDUCT THE EXAMINATION
Before employment with a licensed facility and before the employee has contact with any resident, each employee shall be screened for X. - ANSWER TB
What types of TB testing are permissible under R/R? - ANSWER 1. A whole blood IGRA test -or-
2 A Two-Step Skin Test within 30 days of hire.
When a two-step skin test is obtained for an employee, how many days do the results need to be noted in the employee's personnel folder? - ANSWER 7 days
Significant reactions or signs of active TB for more than three weeks require. - ANSWER consultation with a provider, a chest x-ray to be interpreted by a Board-Certified Radiologist, and evidence of therapy approved by the MSDH Tuberculosis Program.
For individuals with a history of a prior positive, X must be documented in annual TB testing. -ANSWER Documenting the history of prior positive and review of symptoms of active TB.
Symptoms
The follow-up skin test must be given and recorded within X days of hire. -ANSWER 14
The two-step protocol or IGRA is to be done for any new employee who has never been skin tested, or for whom. - ANSWER a negative test cannot be documented within the past 12 months.
If the employer has documentation to support that there has been a negative test within the past 12 months. - ANSWER one test within 30 days of hire or anniversary will satisfy the TB testing requirement.
Both
What information needs to be recorded on an admission form in the Facility? - ANSWER
- Name
- Date of Admission
- Address
- Race
- Sex
- Marital Status
- Religious Preference
- Date of Birth
- Name, Address, & Contact of RP
- Name and Contact of Attending
- Date & Reason for Discharge
The facility shall maintain written policies and procedures regarding X in consultation with residents and/or their representatives. - ANSWER Resident's Rights
Written policies concerning resident's rights must be provided to: - ANSWER Residents, their Representatives, Sponsoring Agency or Lawful Representative, and to the Public
There should be documented evidence that the staff of the Facility are trained and involved in the implementation of these policies and procedures at least X. - ANSWER annually
Resident's Rights and Responsibilities shall be posted. - ANSWER for public viewing throughout the Facility
Resident's Rights are acknowledged through. - ANSWER written acknowledgement of receiving information on rights and responsibilities within the Facility before or at the time of admission.
Residents may expect to be free from X and Y. - ANSWER Physical and Mental Abuse
Residents are exempt from X unless ordered by an MD, PA, or NP - OR- unless they become a threat to their own or another resident's safety. - ANSWER Restraints -- chemical or physical
Physical or chemical restraints are only permitted where indicated by X, not for Y. - ANSWER Medical Conditions; Staff Convenience
The application of a restraint must be countersigned by a physician's order within X hours. - ANSWER 24 hours
Residents have the right to expect the storage of X and confidential treatment of Y. - ANSWER Personal Property; Medical Records
Residents are entitled to a safe environment in which they may prevent their records from being released without permission except in the case of X. - ANSWER Prevailing Law of Third-Party Payment Contract
Alzheimer's Disease - ANSWER A chronic progressive disease of unknown cause that attacks brain cells or tissues.
No more than X % of the resident census of the A/D unit shall require assistance during any staffing shift as described and required herein. - ANSWER 10%
A/D Unit orientation for staff shall include: - ANSWER 1. The licensed facility's philosophy related to the care of residents with A/D.
- A description of A/D.
- Policies and procedures of the licensed facility specific to the general approach to care provided in the A/D Unit, including therapies provided; treatment modalities; admission, discharge, and transfer criteria; basic services provided within the A/D unit; policies regarding restraints, wandering and egress control, and medication management; nutrition management techniques; staff training; and family activities.
- Common behavior problems and recommended behavior management.
Dementia - ANSWER A clinical syndrome characterized by a decline of long duration in mental function in an alert individual.
Minimum requirements for nursing staff in an A/D unit shall be based on the ratio of X hours of nursing care per resident per 24 hours. - ANSWER 3 hours
A/D Admission and Discharge Criteria - ANSWER 1. Only residents with a primary diagnosis of A/D whose needs can be met by the licensed facility, shall be admitted.
- For licensed facilities that are personal care homes, a person shall not be admitted or continue to reside in an A/D unit if the person does not meet the admission criteria for the licensed facility, unless otherwise exempted by such applicable laws and regulations.
- The licensed facility shall identify, at time of admission and during continued stay, which of the residents' needs for services are consistent with the above rule and regulations, and which of the residents should be transferred to an appropriate level of care.
Therapeutic activities shall be provided to the residents of the A/D unit X days per week.
For Social Services, the A/D unit shall provide one of the following: - ANSWER 1. A licensed social worker.
- Licensed professional counselor.
- Licensed marriage and family therapist.
The social service consultation fo an A/D unit shall be onsite, and shall be a minimum of X hours per month. - ANSWER 8 hours
There should be, as a minimum, at least X square feet of common multipurpose space per A/D unit resident but shall in no case be less than Y square feet.
