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EXHIBIT 288SURVEYOR WORKSHEET FOR SWING-BEDSMedicare Provider NumberVendor NumberFacility Name and AddressSurvey Date (A1)Type of Survey (circle)/ /Initial/ /Complaint/ /Recertification/ /Sample Validation/ /Follow-up/ /OtherSTATEZIP CODESurveyor / TitleSurveyor / TitleSurveyor / TitleSurveyor / TitleSurveyor / TitleSurveyor / TitleSurvey Team Composition(A2 Indicate the Number of Surveyors According to Discipline)/ // // // // // // stRecords AdministratorSocial WorkerQualified Mental Retardation Professional/ // // // // // // /A3 Indicate the Total Number of Surveyors On-Site:1H.I.J.K.L.M.N.Life Safety Code PsychologistOther
Name of Facility:HospitalCAHA1508C361REGULATIONMet§483.10 Resident rightsThe resident has a right to a dignified existence, self-determination, andcommunication with and access to persons and services inside and outside thefacility. A facility must protect and promote the rights of each resident, includingeach of the following rights:(b) Notice of rights and services.(3) The resident has the right to be fully informed in language that he or she canunderstand of his or her total health status, including but not limited to, his or hermedical condition;A1509C362§483.10(b)(4) The resident has the right to refuse treatment, to refuse toparticipate in experimental research, and to formulate an advance directive asspecified in paragraph 8 of this section; andA1510C363§483.10(b)(5) The facility must-(i) Inform each resident who is entitled to Medicaid benefits, in writing, at thetime of admission to the nursing facility or, when the resident becomes eligiblefor Medicaid of-(A) The items and services that are included in nursing facility services under theState plan and for which the resident may not be charged;(B) Those other items and services that the facility offers and for which theresident may be charged, and the amount of charges for those services; and(ii) Inform each resident when changes are made to the items and servicesspecified in paragraphs (5)(i)(A) and (B) of this section.(6) The facility must inform each resident before, or at the time of admission,and periodically during the resident's stay, of services available in the facility andof charges for those services, including any charges for services not coveredunder Medicare or by the facility's per diem rate.A1511C364§483.10(d) Free choice. The resident has the right to-(1) Choose a personal attending physician;A1512C365§483.10(d)(2) Be fully informed in advance about care and treatment and of anychanges in that care or treatment that may affect the resident's well-being; andA1513C366§483.10(d)(3) Unless adjudged incompetent or otherwise found to beincapacitated under the laws of the State, participate in planning care andtreatment or changes in care and treatment.2NotMetN/ACOMMENTS
Name of (e) Privacy and confidentiality. The resident has the right to personalprivacy and confidentiality of his or her personal and clinical records.(1) Personal privacy includes accommodations, medical treatment, written andtelephone communications, personal care, visits, and meetings of family andresident groups, but this does not require the facility to provide a private room foreach resident;(2) Except as provided in paragraph (e)(3) of this section, the resident mayapprove or refuse the release of personal and clinical records to any individualoutside the facility;(3) The resident's right to refuse release of personal and clinical records doesnot apply when-(i) The resident is transferred to another health care institution; or(ii) Record release is required by law.A1515C368§483.10(h) Work. The resident has the right to-(1) Refuse to perform services for the facility;(2) Perform services for the facility, if he or she chooses, when-(i) The facility has documented the need or desire for work in the plan of care;(ii) The plan specifies the nature of the services performed and whether theservices are voluntary or paid;(iii) Compensation for paid services is at or above prevailing rates; and(iv) The resident agrees to the work arrangement described in the plan of care.A1516C369§483.10(i) Mail. The resident has the right to privacy in written communications,including the right to-(1) Send and promptly receive mail that is unopened; and(2) Have access to stationery, postage, and writing implements at the resident'sown expense.A1517C370§483.10(j)Access and visitation rights.(1) The resident has the right and the facility must provide immediate access toany resident by the following:(vii) Subject to the resident's right to deny or withdraw consent at any time,immediate family or other relatives of the resident; and(viii) Subject to reasonable restrictions and the resident's right to deny orwithdraw consent at any time, others who are visiting with the consent of theresident.A1518C371§483.10(l) Personal property. The resident has the right to retain and usepersonal possessions, including some furnishings, and appropriate clothing, asspace permits, unless to do so would infringe upon the rights or health andsafety of other residents.3NotMetN/ACOMMENTS
Name of (m) Married couples. The resident has the right to share a room with hisor her spouse when married residents live in the same facility and both spousesconsent to the arrangement.A1522C373§483.12 Admission, transfer and discharge rights.(a) Transfer and discharge-(1) Definition: Transfer and discharge includes movement of a resident to abed outside of the certified facility whether that bed is in the same physical plantor not. Transfer and discharge does not refer to movement of a resident to abed within the same certified facility.A1523C374§483.12(a)(2) Transfer and discharge requirements. The facility must permiteach resident to remain in the facility, and not transfer or discharge the residentfrom the facility unless-(i) The transfer or discharge is necessary for the resident's welfare and theresident's needs cannot be met in the facility;(ii) The transfer or discharge is appropriate because the resident's health hasimproved sufficiently so the resident no longer needs the services provided bythe facility;(iii) The safety of individuals in the facility is endangered;(iv) The health of individuals in the facility would otherwise be endangered;(v) The resident has failed, after reasonable and appropriate notice, to pay for(or to have paid under Medicare or Medicaid) a stay at the facility. For a residentwho becomes eligible for Medicaid after admission to a facility, the facility maycharge a resident only allowable charges under Medicaid; or(vi) The facility ceases to operate.A1524C376§483.12(a)(3) Documentation. When the facility transfers or discharges aresident under any of the circumstances specified in paragraphs (a)(2)(i) through(v) of this section, the resident's clinical record must be documented. Thedocumentation must be made by-(i) The resident's physician when transfer or discharge is necessary underparagraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and(ii) A physician when transfer or discharge is necessary under paragraph(a)(2)(iv) of this section.A1525C377§483.12(a)(4) Notice before transfer. Before a facility transfers or discharges aresident, the facility must-(i) Notify the resident and, if known, a family member or legal representative ofthe resident of the transfer or discharge and the reasons for the move in writingand in a language and manner they understand.(ii) Record the reasons in the resident's clinical record; and(iii) Include in the notice the items described in paragraph (a)(6) of this section.4NotMetN/ACOMMENTS
Name of (a)(5) Timing of the notice.(i) Except when specified in paragraph (a)(5)(ii) of this section, the notice oftransfer or discharge required under paragraph (a)(4) of this section must bemade by the facility at least 30 days before the resident is transferred ordischarged.(ii) Notice may be made as soon as practicable before transfer or dischargewhen-(A) The safety of individuals in the facility would be endangered under paragraph(a)(2)(iii) of this section;(B) The health of individuals in the facility would be endangered, underparagraph (a)(2)(iv) of this section;(C) The resident's health improves sufficiently to allow a more immediatetransfer or discharge, under paragraph (a)(2)(ii) of this section;(D) An immediate transfer or discharge is required by the resident's urgentmedical needs, under paragraph (a)(2)(i) of this section; or(E) A resident has not resided in the facility for 30 days.A1527C379§483.12(a)(6) Contents of the notice. The written notice specified in paragraph(a)(4) of this section must include the following:(i) The reason for transfer or discharge;(ii) The effective date of transfer or discharge;(iii) The location to which the resident is transferred or discharged;(iv) A statement that the resident has the right to appeal the action to the State;(v) The name, address and telephone number of the State long term careombudsman;(vi) For nursing facility residents with developmental disabilities, the mailingaddress and telephone number of the agency responsible for the protection andadvocacy of developmentally disabled individuals established under Part C ofthe Developmental Disabilities Assistance and Bill of Rights Act; and(vii) For nursing facility residents who are mentally ill, the mailing address andtelephone number of the agency responsible for the protection and advocacy ofmentally ill individuals established under the Protection and Advocacy forMentally Ill Individuals Act.A1528C380§483.12(a)(7) Orientation for transfer or discharge. A facility must providesufficient preparation and orientation to residents to ensure safe and orderlytransfer or discharge from the facility.A1531C381§483.13 Resident behavior and facility practices.§483.13(a) Restraints. The resident has the right to be free from any physicalor chemical restraints imposed for purposes of discipline or convenience, andnot required to treat the resident's medical symptoms.5NotMetN/ACOMMENTS
Name of (b) Abuse. The resident has the right to be free from verbal, sexual,physical, and mental abuse, corporal punishment, and involuntary seclusion.A1533C383§483.13(c) Staff treatment of residents. The facility must develop andimplement written policies and procedures that prohibit mistreatment, neglect,and abuse of residents and misappropriation of resident property.(1) The facility must—(i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, orinvoluntary seclusion;A1534C384§483.13(c)(1)(ii) Not employ individuals who have been-(A) Found guilty of abusing, neglecting, or mistreating residents by a court oflaw; or(B) Have had a finding entered into the State nurse aide registry concerningabuse, neglect, mistreatment of residents or misappropriation of their property;and(iii) Report any knowledge it has of actions by a court of law against anemployee, which would indicate unfitness for service as a nurse aide or otherfacility staff to the State nurse aide registry or licensing authorities.(2) The facility must ensure that all alleged violations involving mistreatment,neglect, or abuse, including injuries of unknown source, and misappropriation ofresident property are reported immediately to the administrator of the facility andto other officials in accordance with State law through established procedures(including to the State survey and certification agency).(3) The facility must have evidence that all alleged violations are thoroughlyinvestigated, and must prevent further potential abuse while the investigation isin progress.(4) The results of all investigations must be reported to the administrator or hisdesignated representative and to other officials in accordance with State law(including to the State survey and certification agency) within 5 working days ofthe incident, and if the alleged violation is verified appropriate corrective actionmust be taken.6NotMetN/ACOMMENTS
Name of Facility:HospitalCAHREGULATIONMetA1537C385§483.15 Condition of Participation: Quality of life. A facility must care for itsresidents in a manner and in an environment that promotes maintenance orenhancement of each resident's quality of life.(f) Activities.(1) The facility must provide for an ongoing program of activities designed tomeet, in accordance with the comprehensive assessment, the interests and thephysical, mental, and psychosocial well-being of each resident.(2) The activities program must be directed by a qualified professional who-(i) Is a qualified therapeutic recreation specialist or an activities professionalwho-(A) Is licensed or registered, if applicable, by the State in which practicing; and(B) Is eligible for certification as a therapeutic recreation specialist or as anactivities professional by a recognized accrediting body on or after October 1,1990; or(ii) Has 2 years of experience in a social or recreational program within the last 5years, 1 of which was full-time in a patient activities program in a health caresetting; or(iii) Is a qualified occupational therapist or occupational therapy assistant; or(iv) Has completed a training course approved by the State.A1538C386§483.15(g) Social Services.(1) The facility must provide medically-related social services to attain ormaintain the highest practicable physical, mental, and psychosocial well-being ofeach resident.(2) A facility with more than 120 beds must employ a qualified social worker ona full-time basis.(3) Qualifications of social worker. A qualified social worker is an individualwith-(i) A bachelor's degree in social work or a bachelor's degree in a humanservices field including but not limited to sociology, special education,rehabilitation counseling, and psychology; and(ii) One year of supervised social work experience in a health care settingworking directly with individuals.7NotMetN/ACOMMENTS
Name of Facility:HospitalCAHN/AC388REGULATIONMet§483.20 Condition of Participation: Resident assessment.The facility must conduct initially and periodically a comprehensive, accurate,standardized, reproducible assessment of each resident's functional capacity.(b) Comprehensive assessment.(1) Resident assessment instrument. A facility must make a comprehensive assessmentof a resident’s needs. The assessment must include at least the following:(i)Identification and demographic information.(ii)Customary routine.(iii) Cognitive patterns.(iv) Communication.(v)Vision.(vi) Mood and behavior patterns.(vii) Psychosocial well-being.(viii) Physical functioning and structural problems.(ix) Continence.(x)Disease diagnoses and health conditions.(xi) Dental and nutritional status.(xii) Skin condition.(xiii) Activity pursuit.(xiv) Medications.(xv) Special treatments and procedures.(xvi) Discharge potential.(xvii) Documentation of summary information regarding theassessment performed through the resident assessment protocols.(xviii) Documentation of participation in assessment.additionalThe assessment process must include direct observation and communicationwith the resident, as well as communication with licensed and non-licenseddirect care staff members on all shifts.N/AC389§483.20(b)(2) When required.Subject to the timeframes prescribed in§413.343(b) of this chapter, a facility must conduct a comprehensiveassessment of a resident in accordance with the timeframes specified inparagraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in§413.343(b) of this chapter do not apply to CAHs.(i) Within 14 calendar days after admission, excluding readmissions in whichthere is no significant change in the resident’s physical or mental condition. (Forpurposes of this section, “readmission” means a return to the facility following atemporary absence for hospitalization or for therapeutic leave.)N/AC390§483.20(2)(ii) Within 14 calendar days after the facility determines, or shouldhave determined, that there has been a significant change in the resident’sphysical or mental condition. (For purposes of this section, a “significantchange” means a major decline or improvement in the resident’s status that willnot normally resolve itself without further intervention by staff or by implementingstandard disease-related clinical interventions, that has an impact on more thanone area of the resident’s health status, and requires inter-disciplinary review orrevision of the care plan, or both.)(iii) Not less often than once every 12 months.8NotMetN/ACOMMENTS
Name of ) Comprehensive care plans.(1) The facility must develop a comprehensive care plan for each resident thatincludes measurable objectives and timetables to meet a resident’s medical,nursing, mental and psychosocial needs that are identified in the comprehensiveassessment. The care plan must describe the following-(i) The services that are to be furnished to attain or maintain the resident’shighest practicable physical, mental, and psychosocial well-being as requiredunder §483.25; and(ii) Any services that would otherwise be required under §483.25 but are notprovided due to the resident’s exercise of rights under §483.10, including theright to refuse treatment under §483.10(b)(4).N/AC396§483.20(k)(2) A comprehensive care plan must be-(i) Developed within 7 days after the completion of the comprehensiveassessment;(ii) Prepared by an interdisciplinary team, that includes the attending physician,a registered nurse with responsibility for the resident, and other appropriate staffin disciplines as determined by the resident’s needs, and, to the extentpracticable, the participation of the resident, the resident’s family or theresident’s legal representative; and(iii) Periodically reviewed and revised by a team of qualified persons after eachassessment.N/AC397§483.20(k)(3) The services provided or arranged by the facility must-(i) Meet professional standards of quality; andN/AC398§483.20(k)(3)(ii) Be provided by qualified persons in accordance with eachresident’s written plan of care.A1541C399§483.20(l) Discharge summary.When the facility anticipates discharge a resident must have a dischargesummary that includes-(1) A recapitulation of the resident’s stay;(2) A final summary of the resident’s status to include items in paragraph (b)(2)of this section, at the time of the discharge that is available for release toauthorized persons and agencies, with the consent of the resident or legalrepresentative; and(3) A post-discharge plan of care that is developed with the participation of theresident and his or her family, which will assist the resident to adjust to his or hernew living environment.9NotMetN/ACOMMENTS
Name of OMMENTS§483.25(i) Nutrition.Based on a resident's comprehensive assessment, the facility must ensure thata resident-(1) Maintains acceptable parameters of nutritional status, such as bodyweight and protein levels, unless the resident's clinical condition demonstratesthat this is not possible; andN/AC401(2) Receives a therapeutic diet when there is a nutritional problem.A1544C402§483.45 Specialized rehabilitative services.(a) Provision of services.If specialized rehabilitative services such as, but not limited to, physical therapy,speech-language pathology, occupational therapy, and mental healthrehabilitative services for mental illness and mental retardation, are required inthe resident's comprehensive plan of care, the facility must-(1) Provide the required services; or(2) Obtain the required services from an outside resource (in accordance with§483.75(h) of this part) from a provider of specialized rehabilitative services.A1545C403§483.45(b) Qualifications.Specialized rehabilitative services must be provided under the written order of aphysician by qualified personnel.A1548C404§483.55 Dental services.The facility must assist residents in obtaining routine and 24-hour emergencydental care.A1549C405§483.55(a) Skilled nursing facilities. A facility(1) Must provide or obtain from an outside resource, in accordance with§483.75(h) of this part, routine and emergency dental services to meet theneeds of each resident;(2) May charge a Medicare resident an additional amount for routine andemergency dental services;10Tags A549, A550 andC405, C406apply to Medicare reimbursement
Name of ACOMMENTS§483.55(a)(3) Must if necessary, assist the resident-(i) In making appointments; and(ii) By arranging for transportation to and from the dentist's office; and(4) Promptly refer residents with lost or damaged dentures to a dentist.A1551C407§483.55(b) Nursing facilities. The facility(1) Must provide or obtain from an outside resource, in accordance with§483.75(h) of this part, the following dental services to meet the needs of eachresident:(i) Routine dental services (to the extent covered under the State plan); and(ii)Emergency dental services;A1552C408§483.55(b)(2) Must, if necessary, assist the resident-(i) In making appointments; and(ii) By arranging for transportation to and from the dentist’s office; and(3) Must promptly refer residents with lost or damaged dentures to a dentist.11Tags A551, A552 andC407, C408apply to Medicaid Reimbursement
medical condition; A1509 C362 §483.10(b)(4) The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph 8 of this section; and A1510 C363 §483.10(b)(5) The facility must--
