100 Essential Forms for Long-Term Care

100

Essential Forms for

Long-Term Care

Carol Marshall, MA Kate Brewer, PT, MBA, GCS, RAC-CT

Julie Ann Kemman, BBA Heather Stewart, RHIT

100 Essential Forms for Long-Term Care is published by HCPro, a division of BLR

Copyright ? 2014 HCPro, a division of BLR

All rights reserved. Printed in the United States of America. 5 4 3 2 1

Download forms and tools from this book with the purchase of this product.

ISBN: 978-1-55645-227-7

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HCPro provides information resources for the healthcare industry.

HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Carol Marshall, MA, Author Kate Brewer, PT, MBA, GCS, RAC-CT, Author Heather Stewart, RHIT, Author Julie Ann Kemman, BBA, Author Olivia MacDonald, Managing Editor Adrienne Trivers, Product Manager Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Manager Vicki McMahan, Sr. Graphic Designer Jason Gregory, Layout/Graphic Design Kelly Church, Cover Designer

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Contents

About the Authors.....................................................................................vii Section 1: Audit Forms................................................................................. 1

Form 1.1: Quality auditing form: Nursing documentation................................................................ 3 Form 1.2: Triple-check form........................................................................................................... 8 Form 1.3: Resident care status survey tool.................................................................................... 12 Form 1.4: Preadmission screen.................................................................................................... 17 Form 1.5: Dysphagia audit........................................................................................................... 19 Form 1.6: Psychotropic audit .......................................................................................................21 Form 1.7: Urinary catheter reminder order................................................................................... 24 Form 1.8: Urinary catheter checklist............................................................................................. 26 Form 1.9: Medical staff documentation audit ............................................................................... 28 Form 1.10: Safety rounds audit.................................................................................................... 30 Form 1.11: Kitchen/dietary audit.................................................................................................. 34 Form 1.12: Discharge record documentation audit.......................................................................... 7 Form 1.13: Skilled nursing facility self-audit................................................................................. 40 Form 1.14: MDS chart audit tool.................................................................................................. 42 Form 1.15: Compliance audit worksheet....................................................................................... 45 Form 1.16: CAA completion audit tool......................................................................................... 56 Form 1.17: Quarterly Medicare compliance guide......................................................................... 58 Form 1.18: Policy and procedure: Medicare Part A triple-check process.......................................... 60 Form 1.19: Policy and procedure: Medicare Part B triple-check process.......................................... 64 Form 1.20: Assessment itinerary announced site visit.................................................................... 67 Form 1.21: Sample checklist for unannounced audit...................................................................... 69 Form 1.22: Resident review worksheet..........................................................................................71 Form 1.23: Quality of life assessment resident interview............................................................... 73 Form 1.24: Quality of life assessment family interview.................................................................. 75 Form 1.25: Quality of life assessment group interview................................................................... 77 Form 1.26: Statement of deficiencies and plan of correction.......................................................... 79

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100 Essential Forms for Long-Term Care

Section 2: Documentation Forms............................................................... 81

Form 2.1: Admission database assessment................................................................................... 83 Form 2.2: Nursing care flow sheet................................................................................................ 92 Form 2.3: Monthly psychoactive summary................................................................................... 97 Form 2.4: Restraint elimination/reduction assessment..................................................................100 Form 2.5: Fall response assessment.............................................................................................102 Form 2.6: Care plan meeting education form...............................................................................105 Form 2.7: Fall risk assessment....................................................................................................109 Form 2.8: 48-hour post-fall monitoring form................................................................................ 111 Form 2.9: Incident/accident form................................................................................................ 114 Form 2.10: Pain assessment for those with communication barriers/dementia............................... 116 Form 2.11: Pain management tracking form................................................................................. 118 Form 2.12: Pain management assessment....................................................................................120 Form 2.13: ADL/restorative nursing flow sheet............................................................................122 Form 2.14: ADL data collection form...........................................................................................125 Form 2.15: Cognitive/mood/behavioral data collection flow sheet................................................127 Form 2.16: Restorative nursing flow sheet...................................................................................129 Form 2.17: Wandering assessment..............................................................................................132 Form 2.18: Product evaluation form............................................................................................135 Form 2.19: Transfer checklist (subacute to LTC units)..................................................................137 Form 2.20: Infection control tracking form...................................................................................139 Form 2.21: Readmission documentation pull list..........................................................................141 Form 2.22: Hospital readmission tracking tool.............................................................................143 Form 2.23: Rehospitalization tracking tool...................................................................................145 Form 2.24: Weight loss communication tool................................................................................147 Form 2.25: Against medical advice acknowledgment....................................................................149 Form 2.26: Anti-psychotic drug use assessment...........................................................................151 Form 2.27: Dehydration prevention checklist...............................................................................154 Form 2.28: Elopement drill.........................................................................................................156 Form 2.29: MDS therapy minutes................................................................................................159 Form 2.30: Swallowing protocol-feeding precaution checklist.......................................................161

Section 3: Accountability Reports............................................................ 165

Guidelines for monthly reports (forms 3.1, 3.2, 3.3, 3.4)..............................................................166 Form 3.1: Sample monthly report: Director of nursing..................................................................167 Form 3.2: Sample monthly report: Assistant director of nursing....................................................170 Form 3.3: Sample monthly report: Non-nursing manager.............................................................172 Form 3.4: Sample monthly report: Maintenance director..............................................................174 Form 3.5: Task management sheet..............................................................................................176 Form 3.6: Utilization review/discharge meeting worksheet...........................................................179 Form 3.7: Satisfaction survey response tracking...........................................................................181

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Contents

Section 4: Regulatory Forms.................................................................... 183

Form 4.1: Gantt chart for regulatory planning..............................................................................185 Form 4.2: Standing meeting/committee guidelines.......................................................................188 Form 4.3: Root cause analysis worksheet.....................................................................................192 Form 4.4: State department of health survey preparation..............................................................195 Form 4.5: Frequently used ICD-9 codes in LTC: Mapping guide to ICD-10......................................197 Form 4.6: Transition to ICD-10 guide...........................................................................................200 Form 4.7: ICD-10 preparation survey: Knowledge base.................................................................202 Form 4.8: Preparation for ICD-10: Self-evaluation for coders.........................................................204

Section 5: Performance Improvement Forms............................................ 207

QAPI forms................................................................................................................................209 Form 5.1: QAPI form.................................................................................................................. 210 Form 5.2: QAPI form: Pain management sample.......................................................................... 211 Form 5.3: QAPI form: Fall reduction sample................................................................................213 Form 5.4: QAPI form: Transfers to hospital sample.......................................................................215 Form 5.5: QAPI form: Psychoactive drug use monitoring sample...................................................217 Form 5.6: QAPI form: Restraint reduction sample.........................................................................219 Form 5.7: QAPI form: Infection control and surveillance sample...................................................220 Form 5.8: Pain management data collection form for PIP..............................................................222 Form 5.9: Interdisciplinary action committee (IAC) form..............................................................224 Form 5.10: Performance improvement project assignment tool......................................................225

Section 6: Credentialing and Communication Forms................................ 227

Credentialing and privileging physicians and nurse practitioners: Procedures................................228 Form 6.1: Request for application intake form: General appointment............................................231 Form 6.2: Request for application intake form: Temporary appointment........................................232 Form 6.3: Credentialing cover letter: Initial appointment..............................................................233 Form 6.4: Credentialing cover letter: Reappointment....................................................................234 Form 6.5: Credentialing checklist: Initial appointment..................................................................235 Form 6.6: Credentialing checklist: Temporary appointment...........................................................236 Form 6.7: Credentialing checklist: Reappointment........................................................................237 Form 6.8: Licensure verification..................................................................................................238 Form 6.9: Credentialing phone verification form..........................................................................239 Form 6.10: Reappointment evaluation.........................................................................................240 Form 6.11: Temporary appointment form.....................................................................................242 Form 6.12: Professional exchange report.....................................................................................243 Form 6.13: Therapy and nursing communication form.................................................................245

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100 Essential Forms for Long-Term Care

Section 7: Additional Documentation Request Forms............................... 247

Form 7.1: Additional documentation request (ADR).....................................................................249 Form 7.2: Internal ADR tracking log............................................................................................251 Form 7.3: ADR appeal documentation checklist...........................................................................253 Form 7.4: Part A denial tracking/appeal request log.....................................................................255 Form 7.5: Part B denial tracking/appeal request log.....................................................................258 Form 7.6: RAC/ZPIC/CERT audit tracking log..............................................................................261

Forms and tools can be accessed with the purchase of this product.

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ABOUT THE AUTHORS

Carol Marshall, MA, is a risk management specialist based in Fort Worth, Texas. For the past 18 years, she has trained managers and staff members in long-term care facilities across the country about the benefits of exceptional customer service and risk management. She has offered training programs at numerous state conferences, professional groups, and individual facilities.

Kate Brewer, PT, MBA, GCS, RAC-CT, is the president of Greenfield Rehabilitation Agency, a company that provides physical, occupational, and speech-language pathology services in skilled nursing facilities. Having spent over 15 years in long-term care, Brewer has extensive experience in various processes and approaches to regulatory compliance from a Medicare and survey perspective. Her areas of expertise include therapy documentation and compliance with Medicare regulations, coordinating the MDS process to ensure optimal reimbursement and compliance, and bridging the gap between the different professions that work together in long-term care.

Julie Ann Kemman, BBA, president of Health Care Professional Consulting Services, Inc., has over 20 years of experience working within the long-term care community. She holds a bachelor's degree in business administration from Northwood University. Julie has held multiple corporate regional positions for a large nursing home chain and has been the cornerstone in staff training, compliance monitoring, and management. Health Care Professional Consulting Services, Incorporated, was started in July 2005 and provides skilled nursing organizations, assisted living, home health agencies, and outpatient rehabilitation providers a variety of consulting services, including billing, collections, training, policy writing, and software implementation.

Heather Stewart, RHIT, is a knowledgeable health information management consultant with more than 16 years of experience in the long-term care industry. Stewart has an extensive background in healthcare compliance, medical coding, and electronic health record implementation.

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