DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES RESIDENTREVIEWWORKSHEET Facility Name: __________________________________________ Resident Name: ___________________________________Provider Number: _______________________________________ Resident Identifier: _________________________________Surveyor Name: _________________________________________ Birthdate: ___________ Unit: ________ Rm #: ___________Surveyor Number: ____________ Discipline: _________________ Orig. Admission Date: _____ Readmission Date: ________ Survey Date: ______________________________________ Payment Source: Admission: __________________________ Current: ____________________________Diagnosis:______________________________________________________________________________________________________________________________________________________________________________________________________________Interviewable: Yes No Type of Review: Comprehensive Focused Closed Record Selected for Individual Interview: Yes No Selected for Family Interview and Observation of Non-Interviewable Resident: Yes No Focus/Care Areas:______________________________________________________________________________________________________________________________________________________________________________________________________Instructions: Any regulatory areas related to the sampled residents needs are to be included in this review. Initial that each section was reviewed if there are no concerns. If there are concerns, document your investigation. Document all pertinent resident observations and information from resident, staff, family interviews and record reviews for every resident in the sample. SECTION A: RESIDENTROOM REVIEW: Evaluate if appropriate requirements are met in each of the following areas, including the accommodation of needs: Adequate accommodations are made for resident privacy, Environment is homelike, comfortable and attractive; including bed curtains. accommodations are made for resident personal items and Call bells are functioning and accessible to residents his/her modifications. Bedding, bath linens and closet space is adequate for resident Resident is able to use his/her bathroom without difficulty. needs. Adequate space exists for providing care to residents. Resident care equipment is clean and in good repair. Resident with physical limitations (e.g., walker, wheelchair) Room is safe and comfortable in the following areas: is able to move around his/her room. temperature, water temperature, sound level and lighting.THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)_____ Document concerns and follow-up on Surveyor Notes sheet page 4. SECTION B: RESIDENTDAILY LIFE REVIEW: Evaluate if appropriate requirements are met in each of the following areas: Resident appears well groomed and reasonably attractive Facility activities program meets residents individually (e.g., clean clothes, neat hair, free from facial hair). assessed needs and preferences. Staff treats residents respectfully and listens to resident Medically related social services are identified and provided requests. Note staff interaction with both communicative when appropriate. and non-communicative residents. Restraints are used only when medically necessary. Staff is responsive to resident requests and call bells. (see 483.13(a)) Residents are free from unexplained physical injuries and Resident is assisted with dining when necessary. there are no signs of resident abuse. (e.g. residents do not appear frightened around certain staff members.) THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)_____ Document concerns and follow-up on Surveyor Notes sheet page 4. Form CMS-805(7-95) >>>> 2 Resident Review Worksheet (continued) SECTION C: ASSESSMENTOF DRUG THERAPIES Review all the over-the-counter and prescribed medications taken by the resident during the last 7 days. Evaluate drug therapy for indications/reason, side effects, Correlate drug therapy with residents clinical condition. dose, review of therapy/monitoring, and evidence of unnecessary medications including antipsychotic drugs. If you note concerns with drug therapy, review the pharmacists report. See if the physician or facility has responded to recommendations or concerns. THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)_____ Medications/Dose/Schedule Medications/Dose/Schedule Medications/Dose/Schedule Document concerns and follow-up on page 4. SECTION D: RAI/CARE REVIEWSHEET (Includes both MDS and use of RAPS): Reason for the most current RAI: Annual Initial Significant Change Date of Most Recent RAI _______ Date of Comparison/ Quarterly RAI ________ For a comprehensive reviewcomplete a review of all care areas specific to the resident, all ADL functional areas, cognitive status, and MDS categories triggering a RAP. For a focused review: Phase I: Complete a review of those requirements appropriate to focus and care areas specific to the resident. Phase II: Complete a review of requirements appropriate to focus areas. For both comprehensiveand focused reviewsrecord only the applicable sections and relevant factors about the clinical status indicating an impairment orchanges between reviews. If the current RAI is less than 9 months old, scan and compare with the previous RAI and most recent quarterly review. If the RAI is 9 months or older, compare the current RAI with the most recent quarterly review. Note any differences for the applicable areas being reviewed. Review the RAPsummary and care planning. Look for implementation of the care plan as appropriate to the comprehensive or focused review. Note specifically the effects of care or lack of care. If the resident declined or failed to improve relative to expectations, determine if this was avoidable or unavoidable. For closed records, complete a review of theapplicable areas of concern. Use the additional MDS item blocks on page 3 to document other sections or additional concerns. Dining observation;If there are concerns with weight loss or other nutritional issues, observe resident dining and review adequacy of meals served and menus. THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)_____ Document concerns and follow-up on page 4. Form CMS-805(7-95) Page 2>>>> 3 Resident Review Worksheet (continued) Notes/Dates/Times/Source and Tag:Observations and Interview for resident and implementation of ca