ALF SURVEY GUIDELINE INDEX
Facility Name: ______________________________________________
GENERAL LICENSE STANDARDS
____001 Facility is licensed to provide services in facility
____002 License displayed conspicuously
____003 Unlawful to own, operate w/out license
____004 Failure to license one fac. impacts all licensed facilities
____005 License valid for individ./firm to which issued
____006 Transferor respon./liable until transferee licensed
____007 CCRC facilities w/ pers. serv. Must have ALF lic.
____008 Licensed capacity not exceeded
____009 Co-located w/ N.H. may use shared staff; count once
____010 Clinic w/ co-located indep. living apts. used as out-pat.
____011 License valid for type care provided
____012 Provides one or more personal care services
____013 Change of administrator reported to Agency
____014 Written notice of CHOW w/in 7 days to residents
____015 Kickback, bonus, rebate, split fee unlawful for all
____016 Soliciting contributions for charity only; no other use
____017 Solicitation by threat, coercion, force prohibited
____018 Donation/contribut. not condition for state funded resid.
____019 Agency notified 90 days before voluntary closure
____020 30 days notice to residents prior to closing
____021 Unlawful to advertise personal services w/out license
____022 Assisted Living Facility appears on all advertising
____023 Freestanding ALF not advertise/imply any part a N.H.
____024 Include affiliation w/ religious org. & which one
____025 Non-CCRC facilities include license # in advertising
____026 New residents not admitted during moratorium
____027 Moratorium posted & visible to public
____028 Unlawful to knowingly refer to unlicensed facility
____029 No medical or other record is altered or falsified
____030 Revocation, suspension, denial notice posted
FISCAL STANDARDS
____100 Facility administered on sound financial basis
____101 Unlawful to w/hold evidence of financial instability
____102 Adverse court action/financial viability report in 7 days
____103 Access to records to determine financial stability
____104 Written records reflect assets, liabilities, income, expen.
____105 Resident funds or property held as trust funds
____106 Separate account for each resident, no co-mingling
____107 Advanced payments kept separate from facility funds
____108 Resident permits facility safekeeping $500/200
____109 Complete/accurate record of funds/personal effects
____110 Statements of residents funds provided in file
____111 Monthly written statement of any transactions
____112 Funds, property, advances held in Fla. bank institution
____113 W/in 30 days advise resident where money held
____114 If CHOW all deposits/funds transferred to new owner
____115 Transferor provides resident statement amt., where held
____116 Transferee gives resident written statement about funds
____117 Personal funds may be used by resident for anything
____118 Separate charges only w/ resident consent
____119 Fac. rep. payee/attorney-in-fact, get surety bond
____120 RP bond equals twice avg. mo. Income/SSI/OSS/SSDI
____121 Power/attorney equals twice avg. incom/prop./SS/OSS
____122 Owner, admin., employee can not act as guardian
____123 Refunds, funds, property returned upon resident death
12/1/06
Date: ________________
FACILITY RECORDS
____200 Maintain good business records; accessible
____201 Maintain up-to-date admission/discharge log
____202 Maintain log of all temporary/respite residents
____203 Record of major incidences w/in last 2 yrs.
____204 Documentation of radon testing if required
____205 Maintain liability insurance coverage at all times
____206 Admission package w/ required components
____207 Copy of all Alzheimer’s advertisements maintained
____208 Grievance procedure for receipt/respond to residents
____209 Proof of having annual fire inspection
____210 Maintains fire safety reports for the last 2 years
____211 Proof of satisfactory sanitation inspection by CHD
____212 Maintains all sanitation inspection reports for last 2 yrs
____213 Surveys, inspections, complaint reports for 5 years
____214 Survey, inspections, etc. available to residents/public
____215 Last inspection report posted in prominent place
____216 Required records available to Agency, ACPD, LTCOC
____217 Facility maintains up-to-date adverse incident reports
____218 Submitted preliminary adverse incident report w/in 1 day
____219 Submitted full adverse incident report w/in 15 days
____220 Liability claims against ALF reported to agency monthly
____221 Assessment of the facility’s risk management program
____222 Facility records should include elopement P&P
____223 Conducts at least 2 elopement drills per year
____224 Documents elopement drills; drills conducted per policies
RESIDENT RECORDS STANDARDS
____300 Maintained on premises
____301 Available to resident, et al, for inspection
____302 Contain specific demographic information on resident
____303 Contain a copy of medical examination
____304 Medical record have orders for medications/services, etc.
____305 Signed resident statement refusing therapeutic diet
____306 Weight record initiated at admission
____307 Residents receive assist w/ ADLs, weight record 6 mos.
____308 Written consent reg. non-lic. personnel admin. meds.
____309 Signed, dated contract between facility & resident
Contract shall contain 310 – 326:
____310 Services and accommodations
____311 Daily, weekly, monthly rates or charges
____312 List of available services & fees not in rate
____313 Provision for 30 days written notice of rate increase
____314 Rights, duties, obligations of resident
____315 Purpose of any advanced payment/deposit; refund policy
____316 Conditions when claims will be made against refund
____317 No more than 30 days notice of termination
____318 Written bed hold policy
____319 Religious organization & which one affiliated
____320 Written termination agreement if inappropriate resident
____321 Refund policy
____322 Written notification of claim; 14 days to respond
____323 Refund shall occur w/in 45 days vacated unit
____324 Notice of termination waived in death, medical reasons
____325 Advance payments returned 10 days discont. operation
____326 Refund/funds/property at death to rep. or via probate
____327 Alternate Care Cert./OSS Form CF-ES 1006, 3/98
____328 Doc. surrogate, guardian, power of attorney in file
____329 Documentation of resident being a hospice patient
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____330 Record keeping on independent residents limited
____331 Resident records retained for 2 yrs after resident departs
RESIDENCY & ADMISSION CRITERIA
____400 Resident must be at least 18 years old
____401 Free from signs/symptoms of communicable disease
____402 Able perform ADLs w/ supervision or assistance.
____403 Able to transfer w/ assistance if necessary
____404 Capable of taking medications w/ asst. if necessary
____405 Fac. has nurse to administer meds; contracts 3rd party
____406 Special diet needs can be met by facility
____407 Not a danger to self or others, physician/mental h. prov.
____408 Not require 24 hr mental health treatment
____409 Resident shall not be bedridden
____410 Not have stage 3 or 4 pressure sore
____411 Stage 2 must meet stated criteria; improve
____412 Not require certain specified nursing services
____413 Not require 24 hr nursing supervision
____414 Not require skilled rehabilitative services
____415 Admission determined by the administrator on criteria
____416 Examin by MD, PA, or ARNP w/in 60 days prior
____417 Medical exam; Form 1823; address criteria specified
____418 Med. exams 30 days after admiss, on Form 1823, 1/06
____419 DOEA, DC&F placed residents use Form 1823, 1/06
____420 Admin. must obtain missing exam. Info. w/in 30 days
____421 CARES assessment may be substituted for med. eval.
____422 Examining MD, PA, ARNP has not financial interest
____423 Stage 2 retained if LNS lic. or contracts w/ H.H.
____424 Stage 2 retained if condition doc. in resident file
____425 Failure of stage 2 improve w/in 30 days/ discharged
____426 Bedridden no more than 7 days
____427 Resident no longer meets criteria can stay w/ hospice
____428 Discharge if res. no meet criteria or fac. no meet needs
____429 Admin. monitors for continued appropriate placement
____430 Involuntary examination/reason to believe mentally ill
____431 Involuntary examination/required documentation
____432 Voluntary admission/informed and expressed consent
____433 Transportation by law enforcement or authorized agency
STAFFING STANDARDS
____500 Administrator supervises ops/maint. & care of residents
____501 Administrator supervises max. of 3 any combination
____502 Administrator (Admin.)must be at least 21 years of age
____503 Administrator must have GED/high school diploma
____504 Admin. must complete core training w/in 3 mos.
____505 Admin. participates in 12 hrs continuing ed. each 2 yrs.
____506 Mgr appoint in writing for admin. w/ more than 1 fac.
____507 Manager (Mgr) completes core training w/in 3 mos.
____508 Admin/Mgr absent, staff member 18 yrs. designated
____509 Employees hired on/after 10/1/98 have level 1 screening
____510 DC non-lic. staff get 1hr in-service training, infect./sanit.
____511 DC staff train 1 hr in 30 days on major/adv. incid /em.
____512 DC staff train 1hr in 30 days resid. rights/report abuse
____513 DC non-lic. staff train 3 hrs, 30 days resid. needs/ADLs
____514 All ALF staff must rec. in-service training on elope. P/P
____515 Person lic/exempt under Ch.464 may provide med. care
____516 Staff assigned duties consist w/ ed., train, exper.,prepar.
____517 Agency may require add. training for deficiencies
____518 Facility shall maintain minimum staff hrs per week
____519 Non-DC staff not counted in minimum staffing
____520 Admin./mgn. count toward minimum staff if day to day
12/1/06
____521 Vacant positions/absent staff not counted in minimum
____522 Qualified staff to meet the needs of all residents
____523 Staff observe residents, record & report
____524 One staff always present trained in 1st aid and CPR
____525 17+ residents 1 staff awake all hrs.
____526 17+ capacity facilities maintain time sheets on all staff
____527 Written 24 hr. work schedule for staffing pattern
____528 Staff in facility w/ access to facility/resident records
____529 Paid or volunteer resident not left in charge
____530 Staff suspect communicable disease removed from duty
MEDICATION STANDARDS
____600 Resident may not be compelled to take medication
____601 Residents capable allowed to self-administer meds.
____602 Consult w/ resident on any medication problems
____603 Contact health care provider resident changes due to meds
____604 Nurse manages a pill organizer for self-admin.
____605 Nurse manages pill organizer in designated manner
____606 Nurse instructs resident how to use pill organizer
____607 Fac. keeps orig. med. label or listing of specifics
____608 Takes approp. steps when pill organizer meds not taken
____609 Assistance w/ meds. requires nurse or trained unlic. staff
____610 Trained staff follow specific steps when assists w/ meds.
____611 Reactions to meds reported to HC provider/ documented
____612 Residents away from facility must have options for meds
____613 Med. administration done by ARNP, RN, LPN, PA
____614 Performance of clinical lab tests complies w/ CLIA
____615 MOR maintained for each administered/assisted resident
____616 Annual physician eval. of residents on chemical restraints
____617 In-room meds. locked or in secure place when resident out
____618 Administered meds must be centrally stored; others can be
____619 Centrally stored meds locked up at all times
____620 Centrally stored meds free of dampness, abnormal temps
____621 Central stored meds must be available to staff giving meds
____622 Central stored meds kept separate by each resident
____623 Discontinued, unexpired meds returned to resident; stored
____624 Meds returned when facility stay ended
____625 Abandoned/expired meds disposed of w/in 30 days
____626 Only prop. labeled/dispensed drugs kept or adm. by fac
____627 Only pharmacist transfers meds, except pill organizers
____628 PRN meds must have specific provider instructions
____629 Changes in Meds require a written provider order
____630 Nurse may take medication change orders by telephone
____631 Prescriptions filled and refilled in a timely manner
____632 Sample drugs in original package or meets req’d labeling
____633 Stock OTC for multiple use not permitted
____634 OTC centrally stored must be labeled appropriately
____635 OTC meds prescribed become a prescription
____636 Unlic. self-admin. meds require written consent
____637 Employ/contract pharmacist/nurse Class I, II/uncorr. III
____638 Pharm/Nurse visit w/in 7 days class I,II; 14 days class III
____639 Copy of pharmacist/nurses license
____640 Corr. action plan 10 days from onsite consul/nurse visit
____641 Quarterly on-site corr. action plan updates to agency
RESIDENT CARE STANDARDS
____700 Provides care & services appropriate to resident needs
____701 Personal supervision offered as appropriate to residents
____702 Monitor quality/quantity of therapeutic diet
____703 Fac. documents resident refusal of therapeutic diet
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____704 Staff observe, are aware of general well being of resident
____705 General awareness of resident’s whereabouts
____706 Significant change/discharge reported appro. persons
____707 Maintain written record of significant changes
____708 Provide ongoing activities program
____709 Facility consults w/ resident on activities
____710 Activities scheduled 6 days, 12 hrs per week
____711 Activities calendar posted in every building
____712 Assist arranging medical appointments, remind residents
____713 Provide or arrange transportation to medical, etc. appts.
____714 Facility not require residents to see a particular provider
____715 Offer supervision or assistance w/ ADLs
____716 May contract w/ nurse; pill organizers, admin. meds.
____717 Resident Bill of Right or summary posted in full view
____718 Facility complies with Resident Bill of Rights
____719 Written grievance procedures for resident complaints
____720 HRAC, LTCOC, ACPD address & phone # posted
____721 Fla. Abuse Hotline 1-800-962-2873 posted in full view
____722 Residents not required to work w/out compensation
____723 Convenient access to phone; 17 + in each building
____724 No physical restraints; ½-bed rails w/ written order
____725 Physician notified of resident signs of dementia
____726 Dementia care/services arranged by fac /health provider
____727 At risk elopement residents must have identification
___728 At risk elopement residents must have picture ID on file
____729 ALFs have written detailed P&P for responding to elope.
NUTRITION & DIETARY STANDARDS
____800 Admin/designee in writing respon. for total food service
____801 Admin./designee perform duties safe/sanitary manner
____802 Provide regular, nutritional, therapeutic meals
____803 10th edit. RDA, FNB, NRC nutritional standard used
____804 RDA met w/ variety of foods, standardized recipes
____805 RDA to be made available to each resident
____806 Regular & therapeutic menus reviewed annually
____807 Portion sizes indicated on menus or separate sheet
____808 Menus dated, planned at least 1 wk in advance
____809 Residents encouraged to participate in meal plans
____810 Menus conspicuously posted or available
____811 Substitutions noted before/at meals; kept on file 6 mos.
____812 Therapeutic diets prepared & served as ordered
____813 Buffet/family/select style identify therapeutic diet items
____814 No more14 hrs supper to breakf; > 2,< 6 between meals
____815 Snacks shall be offered at least once per day
____816 Food served attractively at safe & palatable temps
____817 Residents encouraged to eat in dining room
____818 Sufficient supply of eating ware; adaptive equip. as need
____819 3-day supply non-perishable food; # of wkly meals
____820 Non-perishable will meet specified criteria; water
____821 Catered food meets all dietary standards
____822 Catering contract on file in facility
____823 Dietitian/nutritionist hired for class I, II, uncorr.III
____824 On-site visit w/in 7 class I,II; 14 days uncorr.class III
____825 Copy of dietit/nutrit. license/registration on file
____826 Signed, dated dietary consult. Corrective action plan
____827 Quarterly on-site corrective action plan updates; agency
EMERGENCY MANAGEMENT
____900 Comp. Emergency Mgn. Plan submitted for approval
____901 Review & submit substantive CEMP changes annually
____902 Staff trained in their duties & responsibilities of the Plan
____903 Maintain communication thru local law enforce.or EMP
____904 Evacuate when directed by Emergency Mgn Personnel
12/1/06
____905 Report evacuation to local EM/agency w/in 6 hrs
____906 Not reoccupy till cleared by local EM
____907 Relocate residents of structurally damaged facility
____908 Facility knows location of all relocated residents
____909 Contact person 24 hrs, 7 days till facility reoccupied
____910 Assist with re-location; resident needs/preferences
____911 Provide emerg. shelter over lic. capacity IF conditions met
PHYSICAL PLANT STANDARDS - FACILITY TOUR …
____1000 Comply w/ building codes – new or renovations
____1001 Promotes residential non-medical environment; safe
____1002 Structurally sound, interior & exterior
____1003 Peeling paint, torn carpet, etc. must be replaced
____1004 Windows, doors, appliances, etc. in good working order
____1005 Furniture/furnishings clean, functional, good repair
____1006 Obtain sanitation inspection every 365 days
____1007 Required radon testing completed
____1008 Bldgs under 1 license on contiguous property
____1009 Increase/decrease in capacity takes prior approval
____1010 Change in space to resident use need prior approval
____1011 Outside temp 65F or below, 72 inside during wake hours
____1012 Outside temp 65F or below, 68 inside during sleep hours
____1013 Individually controlled thermostats controlled by individ.
____1014 Awake hrs, mechanical cooling, 85F in, 89 or below out
____1015 90 degrees out, indoor no more than 81F degrees
____1016 No resident in any area exceeding 90 degrees Fahrenheit
____1017 Resident have option to choose own roommate
____1018 Single bedroom 80 sq. feet usable floor space
____1019 Multi-occupancy bedroom, 60 sq.ft. usable floor space
____1020 Newly liced./renov. after 4/16/00, max of 2 to a bedroom
____1021 Licensed before 10/17/99, max of 4 to bedroom
____1022 Bdrms open to corridor, outside, common area
____1023 Resident has option of using own stuff as space permits
____1024 Bedroom furnishings-storage, table, light, clean bed
____1025 Separate reading, social, leisure room
____1026 35 sq. ft. living and dining space per resident
____1027 Dining room accommodates communal dining
____1028 Adult day care services an additional 35 sq.ft. per client
____1029 Day care residents may not use residents bedrooms
____1030 Separate sleeping space for live-in staff
____1031 Master or duplicate key to resident’s bedrooms
____1032 1 toilet & sink/ 6 residents; 1 tub/shower per 8 residents
____1033 Portable bedside commodes have privacy
____1034 Bathroom has door, single toilet has a lock from inside
____1035 Master or duplicate key to resident’s bathrooms
____1036 Non-slip/skid safety surface in showers & bathtubs
____1037 Grab bars on all showers & bathtubs
____1038 Grab bars next to commode after 4/16/00 new/renovated
____1039 Bathroom access not thru another resident’s bedroom
____1040 Linens/personal laundry clean, no tears, stains, odors, etc.
____1041 Secured areas have egress or perimeter control devices
____1042 Residents in secure area able to move freely throughout
____1043 Resid. able to enter/exit w/out superv. have keys/codes
____1044 Staff trained in level 1 w/ Alzheimer’s in secure area
STAFF RECORDS STANDARDS
____1100 Personnel record contains copy of original employ appl.
____1101 Verification of freedom from communicable disease
____1102 New staff 30 days to statement freedom communicable
____1103 Freedom from TB documented annually; false positive
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____1104 Initial/ Biennial staff training on HIV/ AIDS

____1105 CPR/1st Aid trained staff in fac. at all times; document
____1106 Unlic. staff providing assist. w/ meds, 4 hrs training 1st
____1107 Unlic. staff assisting w/ meds, 2 hrs cont. ed. annually
____1108 Food prep./hand staff 1-hr. train w/in 30 days employ.
____1109 Person respon. for food service, 2 hrs. training annually
____1110 Alzheimer’s “reg./DC contact”, train 4 hrs w/in 3 mos.
____1111 Alzheimer’s “direct care”, train add. 4 hrs w/in 9 mos.
____1112 Alzheimer’s direct care staff 4 hrs cont. ed. yearly
____1113 Alz.’s “incidental contact”, general written w/in 3 mos.
____1114 Personal rec. contain copies of all licenses/certifications
____1115 Personnel rec. contain compliance w/ level 1 bg screen
____1116 No bkgd screening, no employ. unless exempted
____1117 17+ have written job descriptions for each position
____1118 Staff by an agency/business entity, copy of contract
____1119 Written work schedules kept for at least last 6 mos.
____1120 Staff time sheets for at least last 6mos.
____1121 Doc. of direct care staff & admins.’ elop. participation

12/1/06