Question 1

A facility changed a resident’s insurance plan without notifying the resident. The  resident's representative was made aware of the change  when services that had previously been covered had been denied. What Reg and Ftag  does this fall under?

Accepted Answer

Regulatory  category -Resident Rights
F 572 Notice of Rights and Rules

Question 2

A surveyor reviewed Resident Council meeting minutes and interviewed residents, finding that facility staff had failed to discuss and review the residents’ rights with them during these meetings. What Reg and Ftag  does this fall under?

Accepted Answer

Regulatory  category -Resident Rights
F 572 Notice of Rights and Rule

Question 3

True or False: The resident has the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights to vote.

Accepted Answer

True

Question 4

An agency nurse is noted working on the Dementia unit. Upon reviewing staff competencies/training it was noted that that nurse had no recorded training concerning dementia. What Reg and F-tag would you cite?

Accepted Answer

Regulatory group- Nursing Services
F 726 Competent Nursing Staff

Question 5

A Facility Assessment was reviewed, it did not include a comprehensive eval of the facility’s training program or info describing how areas identified for training of new and existing staff would be completed. What Reg. and Ftag does this fall under

Accepted Answer

Regulatory group- Administration
F 838 Facility Assessment

Question 6

While performing a record review  for immunizations you notice that several other residents  info is in the in chart. What Regulatory group and Ftag would this  citation come under?

Accepted Answer

Regulatory group- Administration
F842 Resident Records

Question 7

A resident is transferred to another room  without notification to the resident or their representative. What Reg and Ftag do you cite

Accepted Answer

Regulatory  category -Resident Rights
F tag 580 Notification of of changes

Question 8

A facility does not have a  mental health professional on staff to provide mental health services to  that facility, it does not have an arrangement  to ensure that service is furnished to residents by an outside resource. What Reg and Ftag do you cite

Accepted Answer

Regulatory 840- Administration
F tag  Use of Outside Resources

Question 9

While performing  a closed record review you notice that there is no documentation concerning Influenza, Pneumococcal  or Varicella vaccines. What Reg group and Ftag  and, COMAR reg would this come under?

Accepted Answer

Reg group  Infection Prevention and Control 
F tag 883 Influenza and Pneumococcal Immunizations 
COMAR 1480 Resident Health Program- Immunizations

Question 10

A resident’s family member told a surveyor that residents have not been receiving water between meals for months.  Confirmed by staff during interview. Facility was unable to provide documentation that water was passed between meals.  What Reg/Ftag ?

Accepted Answer

Regulatory group - Food and Nutrition 
F807 Drinks Avail to Meet Needs/ Preferences/ Hydration

Question 11

Two residents were prevented from leaving the Activity Room on the dementia unit when a staff member physically blocked the door by sitting in a chair with a table next to her to restrict anyone from exiting. What Reg and Ftag do you cite?

Accepted Answer

Regulatory Group- Freedom from Abuse, Neglect, Exploitation
F603 Freedom from Involuntary seclusion

Question 12

You observed that a resident had regular utensils during a meal observation and the tray ticket did not include instructions for built up utensils as per the resident’s plan of care.

Accepted Answer

Reg Group-Food and Nutrition Services
Ftag 810 Assistive Devices- Eating Equipment/ Utensils

Question 13

A CNA “traded” $20 bills with a resident because the one he/she had did not work in the vending machine. The resident gave the CNA a different $20 and it was later identified that the $20 the CNA had provided was a counterfeit bill. Reg group and Ftag #

Accepted Answer

Reg group-Freedom from Abuse, Neglect and Exploitation
F602 -Free from Misappropriation/Exploitation

Question 14

Fire alarm system did not notify fire department or law enforcement if activated and water was leaking from the ceiling into the therapy hallway . Reg group and Ftag to be cited

Accepted Answer

Regulatory group- Physical Environment , 
F921 Safe/Functional/Sanitary/Comfortable Environment.

Question 15

A resident was found to be living on a secured unit. Interviews and record review found that the resident did not meet the clinical criteria for placement and that she was only on the unit due to the family’s preference.  What Reg and Ftag to cite

Accepted Answer

Regulatory Group- Freedom from Abuse, Neglect, Exploitation
F603 Freedom from Involuntary seclusion

Question 16

A resident set his shirt on fire while smoking. . Upon review of medical records it was noted that there is no documentation showing assessment or education provided to the resident pertaining to the facility's Safe Smoking Program

Accepted Answer

Reg group- Physical Environment regulatory group.
Ftag 926- Smoking Policies

Question 17

A death related to a resident turning over in bed, being trapped between the bed rail and mattress and suffocating because they could not move him/herself from this position . No documentation of bed inspections could be found. Reg/Ftag#

Accepted Answer

Physical Environment regulatory group
F909 Resident Bed,

Question 18

Facility failed to obtain a physician-ordered STAT lab testing when a change in condition was identified, resulting in actual harm to a resident who was transferred to the hospital and admitted with high white blood cell count and septic shock

Accepted Answer

Laboratory, Radiology, and Other Diagnostic Services regulatory group.
F770 Laboratory Services

Question 19

True or False Facility policies must identify the type and duration of transmission-based precautions required , ensuring that the precautions are the most restrictive to the resident and used for the least amount of time.

Accepted Answer

False:
False-facilities must ensure that the precautions are the least restrictive to the resident.

Question 20

While reviewing a staff GNA personnel file you notice that the GNA only had 11 hours annual in-service hours. What Reg and F-Tag to cite?

Accepted Answer

Reg group- Training Requirements
F947 Required In-Service Training for Nurse Aides 
12 hours is the minimum number of training hours,

Question 21

A  resident had been identified as at risk for social isolation. The facility was unable to provide evidence to surveyors that it  was identified in her care plan  nor were any individualized approaches put in place to address her need.

Accepted Answer

Behavioral Health Services Regulatory Group
 F743 No Pattern of Behavioral Difficulties Unless Avoidable,

Question 22

While  observing  a staff member taking BPs and reporting abnormal BPs. It was determined that the staff member was using the wrong size BP cuff so incorrect BP readings were being reported. Reg group and Ftag to cite?

Accepted Answer

Comprehensive Resident Centered Care Plans regulatory group
F659 Qualified Persons

Question 23

This regulation requires that a physician must personally approve in writing a recommendation that a person be admitted to a facility.

Accepted Answer

F 710 Resident's Care Supervised by a Physician

Question 24

True or False;
A non-physician practitioner (Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant) is allowed to provide a written recommendation that a person be admitted to a facility.

Accepted Answer

False
F710: A non-physician practitioner (Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant) is not allowed to provide this written recommendation.

Question 25

This regulation states that a nursing facility needs to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services functions.

Accepted Answer

F801 Qualified Dietary Staff

Question 26

Requirements for a Qualified Dietitian/Clinically Qualified Nutritional Professional in a nursing facility includes:

Accepted Answer

F 801
=>Bachelor’s degree accredited US college/university w/academic req. program in nutrition or dietetics.
Complete => 900 hrs. sup dietetics practice under a RD or nutrition professional(NP)
Licensed or certified as a RD or NP in the St. working

Question 27

True or False;
A facility needs to ensure that qualified professionals are involved in meeting the foot care needs of all residents.

Accepted Answer

True: F687 Foot Care 
Have a sound system in place to ensure proper trmt & care is provided to maintain mobility as well as optimal foot health. Care & trmt should meet PSoP, incl an indvd PoC to prevent comps assoc w/ overall medical condition

Question 28

During initial tour you observe a GNA while providing care for a resident charging her phone using a Residents cord. Interview the GNA: " My phone was dying so I'm just using her cord" The resident was unaware of the incident. Is this a concern?

Accepted Answer

Yes:
F602 Free from Misappropriation/Exploitation

Question 29

At 08:55 am you arrive to the room of newly admitted resident to find a GNA providing am care. The tv is showing Good Morning America.  At 09:00 am the GNA change channel to Joel Osteen. 
The GNA states: "Mr. Jakes's family said he watched this program e

Accepted Answer

Not a concern if verified in the PoC/family interview
If not F602 Free from Misappropriation/Exploitation 
Bonus If the PoC did not include the resident Jakes' preference?

Question 30

Bonus: If record review revealed the PoC did not include the resident Jakes' preference to watch this program would this be a concern? Why/Why not

Accepted Answer

Yes - Misappropriation/ Preferences /Dignity
Comprehensive Resident Centered Care Plan

Question 31

During a room observation you note on Resident Aga Christie's nightstand a candlestick, knife and a rope. The resident states that she had these item bought from the lounge in her home to decorate her room.
Is this a concern? Why/Why not?

Accepted Answer

Residents should be encouraged to bring their personal possessions when possible.
Yes: personal possessions, including furnishings, clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Question 32

Bonus: What Regulatory requirement would you Clue in on this mystery?

Accepted Answer

F557 Respect, Dignity/ Right to have Personal Property

Question 33

During the initial tour several surveyors noted several rooms where furniture was in disrepair.: off track drawers, missing dressing knobs etc. Is this an issue?

Accepted Answer

Yes: The facility must provide “Functional furniture appropriate to the resident’s needs, ...

Question 34

Bonus: Under what regulatory requirement would you find this statement?

Accepted Answer

F 917: Functional furniture appropriate to the resident’s needs” means that the furniture in each resident’s room contributes to
(F 921-Safe/Functional/Sanitary/ Comfortable Environment)

Question 35

A closed record review revealed  Chen Cic became febrile :staff made many attempts to reach the physician, w/ no response contacted the DON to get permission to transfer the resident to the hospital.  Physician on vacation w/ no assigned coverage

Accepted Answer

F713 Physician for for Emergency Care, Available 24 Hours

Question 36

Mr. Domino Crusty requests on Tuesday to have $50  in cash available from his account to treat his grandchildren to pizza night on Saturday.   Is the facility required to honor the request? What regulation  would you find this slice of information under?

Accepted Answer

F567 Protection/Management of Personal Funds
The Resident has a right  to manage his or her financial affairs.

Question 37

Ms. P Xerox asked the SW to make copies of her 3 page physical exam report for her personal records. The SW stated that it would cost $45 to reproduced. Is this a reasonable? In what regulation would you find a resolution to this duplicating dilemma ?

Accepted Answer

F573 Right to Access/ Purchase Copies of Records
The facility may charge a “reasonable” cost-based fee to provide copies of records,

Question 38

Bonus ?s : Can the facility charge a fee for a record search for records?
What about service fees for typing forms or envelopes?

Accepted Answer

No: The fee only include the cost of labor for copying the records, cost of supplies for creating paper copies (or electronic media if the copy is requested on portable media), and any associated postage for mailing the copied records.

Question 39

During a tour on all floors of the facility surveyor noted that the facility staff were consistently not monitoring the temperature of  the medication refrigerators on their units.
What regulation /F-tag would you find guidance ?

Accepted Answer

F761 Label/Store Drugs & Biologicals

Question 40

Bonus:  F761 was one of the most frequently cited deficiency on standard surveys under the new LTCSP.
 Under what situations/circumstance/s would a surveyor find deficient practices regarding this regulation?

Accepted Answer

MAO/PW Proper labeling of drugs and biologicals
Multi-use vials/ single use medications
Discarding expired meds timely
security of narcotics 
Cleanliness of med rooms/ carts
Controlled substance logs maintenance
Controlled medication destruction

Name that F-Tag

LTC Federal Regulations

Question	Answer
A facility changed a resident’s insurance plan without notifying the resident. The resident's representative was made aware of the change when services that had previously been covered had been denied. What Reg and Ftag does this fall under?	Regulatory category -Resident Rights F 572 Notice of Rights and Rules
A surveyor reviewed Resident Council meeting minutes and interviewed residents, finding that facility staff had failed to discuss and review the residents’ rights with them during these meetings. What Reg and Ftag does this fall under?	Regulatory category -Resident Rights F 572 Notice of Rights and Rule
True or False: The resident has the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights to vote.	True
An agency nurse is noted working on the Dementia unit. Upon reviewing staff competencies/training it was noted that that nurse had no recorded training concerning dementia. What Reg and F-tag would you cite?	Regulatory group- Nursing Services F 726 Competent Nursing Staff
A Facility Assessment was reviewed, it did not include a comprehensive eval of the facility’s training program or info describing how areas identified for training of new and existing staff would be completed. What Reg. and Ftag does this fall under	Regulatory group- Administration F 838 Facility Assessment
While performing a record review for immunizations you notice that several other residents info is in the in chart. What Regulatory group and Ftag would this citation come under?	Regulatory group- Administration F842 Resident Records
A resident is transferred to another room without notification to the resident or their representative. What Reg and Ftag do you cite	Regulatory category -Resident Rights F tag 580 Notification of of changes
A facility does not have a mental health professional on staff to provide mental health services to that facility, it does not have an arrangement to ensure that service is furnished to residents by an outside resource. What Reg and Ftag do you cite	Regulatory 840- Administration F tag Use of Outside Resources
While performing a closed record review you notice that there is no documentation concerning Influenza, Pneumococcal or Varicella vaccines. What Reg group and Ftag and, COMAR reg would this come under?	Reg group Infection Prevention and Control F tag 883 Influenza and Pneumococcal Immunizations COMAR 1480 Resident Health Program- Immunizations
A resident’s family member told a surveyor that residents have not been receiving water between meals for months. Confirmed by staff during interview. Facility was unable to provide documentation that water was passed between meals. What Reg/Ftag ?	Regulatory group - Food and Nutrition F807 Drinks Avail to Meet Needs/ Preferences/ Hydration
Two residents were prevented from leaving the Activity Room on the dementia unit when a staff member physically blocked the door by sitting in a chair with a table next to her to restrict anyone from exiting. What Reg and Ftag do you cite?	Regulatory Group- Freedom from Abuse, Neglect, Exploitation F603 Freedom from Involuntary seclusion
You observed that a resident had regular utensils during a meal observation and the tray ticket did not include instructions for built up utensils as per the resident’s plan of care.	Reg Group-Food and Nutrition Services Ftag 810 Assistive Devices- Eating Equipment/ Utensils
A CNA “traded” $20 bills with a resident because the one he/she had did not work in the vending machine. The resident gave the CNA a different $20 and it was later identified that the $20 the CNA had provided was a counterfeit bill. Reg group and Ftag #	Reg group-Freedom from Abuse, Neglect and Exploitation F602 -Free from Misappropriation/Exploitation
Fire alarm system did not notify fire department or law enforcement if activated and water was leaking from the ceiling into the therapy hallway . Reg group and Ftag to be cited	Regulatory group- Physical Environment , F921 Safe/Functional/Sanitary/Comfortable Environment.
A resident was found to be living on a secured unit. Interviews and record review found that the resident did not meet the clinical criteria for placement and that she was only on the unit due to the family’s preference. What Reg and Ftag to cite	Regulatory Group- Freedom from Abuse, Neglect, Exploitation F603 Freedom from Involuntary seclusion
A resident set his shirt on fire while smoking. . Upon review of medical records it was noted that there is no documentation showing assessment or education provided to the resident pertaining to the facility's Safe Smoking Program	Reg group- Physical Environment regulatory group. Ftag 926- Smoking Policies
A death related to a resident turning over in bed, being trapped between the bed rail and mattress and suffocating because they could not move him/herself from this position . No documentation of bed inspections could be found. Reg/Ftag#	Physical Environment regulatory group F909 Resident Bed,
Facility failed to obtain a physician-ordered STAT lab testing when a change in condition was identified, resulting in actual harm to a resident who was transferred to the hospital and admitted with high white blood cell count and septic shock	Laboratory, Radiology, and Other Diagnostic Services regulatory group. F770 Laboratory Services
True or False Facility policies must identify the type and duration of transmission-based precautions required , ensuring that the precautions are the most restrictive to the resident and used for the least amount of time.	False: False-facilities must ensure that the precautions are the least restrictive to the resident.
While reviewing a staff GNA personnel file you notice that the GNA only had 11 hours annual in-service hours. What Reg and F-Tag to cite?	Reg group- Training Requirements F947 Required In-Service Training for Nurse Aides 12 hours is the minimum number of training hours,
A resident had been identified as at risk for social isolation. The facility was unable to provide evidence to surveyors that it was identified in her care plan nor were any individualized approaches put in place to address her need.	Behavioral Health Services Regulatory Group F743 No Pattern of Behavioral Difficulties Unless Avoidable,
While observing a staff member taking BPs and reporting abnormal BPs. It was determined that the staff member was using the wrong size BP cuff so incorrect BP readings were being reported. Reg group and Ftag to cite?	Comprehensive Resident Centered Care Plans regulatory group F659 Qualified Persons
This regulation requires that a physician must personally approve in writing a recommendation that a person be admitted to a facility.	F 710 Resident's Care Supervised by a Physician
True or False; A non-physician practitioner (Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant) is allowed to provide a written recommendation that a person be admitted to a facility.	False F710: A non-physician practitioner (Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant) is not allowed to provide this written recommendation.
This regulation states that a nursing facility needs to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services functions.	F801 Qualified Dietary Staff
Requirements for a Qualified Dietitian/Clinically Qualified Nutritional Professional in a nursing facility includes:	F 801 =>Bachelor’s degree accredited US college/university w/academic req. program in nutrition or dietetics. Complete => 900 hrs. sup dietetics practice under a RD or nutrition professional(NP) Licensed or certified as a RD or NP in the St. working
True or False; A facility needs to ensure that qualified professionals are involved in meeting the foot care needs of all residents.	True: F687 Foot Care Have a sound system in place to ensure proper trmt & care is provided to maintain mobility as well as optimal foot health. Care & trmt should meet PSoP, incl an indvd PoC to prevent comps assoc w/ overall medical condition
During initial tour you observe a GNA while providing care for a resident charging her phone using a Residents cord. Interview the GNA: " My phone was dying so I'm just using her cord" The resident was unaware of the incident. Is this a concern?	Yes: F602 Free from Misappropriation/Exploitation
At 08:55 am you arrive to the room of newly admitted resident to find a GNA providing am care. The tv is showing Good Morning America. At 09:00 am the GNA change channel to Joel Osteen. The GNA states: "Mr. Jakes's family said he watched this program e	Not a concern if verified in the PoC/family interview If not F602 Free from Misappropriation/Exploitation Bonus If the PoC did not include the resident Jakes' preference?
Bonus: If record review revealed the PoC did not include the resident Jakes' preference to watch this program would this be a concern? Why/Why not	Yes - Misappropriation/ Preferences /Dignity Comprehensive Resident Centered Care Plan
During a room observation you note on Resident Aga Christie's nightstand a candlestick, knife and a rope. The resident states that she had these item bought from the lounge in her home to decorate her room. Is this a concern? Why/Why not?	Residents should be encouraged to bring their personal possessions when possible. Yes: personal possessions, including furnishings, clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Bonus: What Regulatory requirement would you Clue in on this mystery?	F557 Respect, Dignity/ Right to have Personal Property
During the initial tour several surveyors noted several rooms where furniture was in disrepair.: off track drawers, missing dressing knobs etc. Is this an issue?	Yes: The facility must provide “Functional furniture appropriate to the resident’s needs, ...
Bonus: Under what regulatory requirement would you find this statement?	F 917: Functional furniture appropriate to the resident’s needs” means that the furniture in each resident’s room contributes to (F 921-Safe/Functional/Sanitary/ Comfortable Environment)
A closed record review revealed Chen Cic became febrile :staff made many attempts to reach the physician, w/ no response contacted the DON to get permission to transfer the resident to the hospital. Physician on vacation w/ no assigned coverage	F713 Physician for for Emergency Care, Available 24 Hours
Mr. Domino Crusty requests on Tuesday to have $50 in cash available from his account to treat his grandchildren to pizza night on Saturday. Is the facility required to honor the request? What regulation would you find this slice of information under?	F567 Protection/Management of Personal Funds The Resident has a right to manage his or her financial affairs.
Ms. P Xerox asked the SW to make copies of her 3 page physical exam report for her personal records. The SW stated that it would cost $45 to reproduced. Is this a reasonable? In what regulation would you find a resolution to this duplicating dilemma ?	F573 Right to Access/ Purchase Copies of Records The facility may charge a “reasonable” cost-based fee to provide copies of records,
Bonus ?s : Can the facility charge a fee for a record search for records? What about service fees for typing forms or envelopes?	No: The fee only include the cost of labor for copying the records, cost of supplies for creating paper copies (or electronic media if the copy is requested on portable media), and any associated postage for mailing the copied records.
During a tour on all floors of the facility surveyor noted that the facility staff were consistently not monitoring the temperature of the medication refrigerators on their units. What regulation /F-tag would you find guidance ?	F761 Label/Store Drugs & Biologicals
Bonus: F761 was one of the most frequently cited deficiency on standard surveys under the new LTCSP. Under what situations/circumstance/s would a surveyor find deficient practices regarding this regulation?	MAO/PW Proper labeling of drugs and biologicals Multi-use vials/ single use medications Discarding expired meds timely security of narcotics Cleanliness of med rooms/ carts Controlled substance logs maintenance Controlled medication destruction

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