NOTE: This sample template is used to assist nursing homes in
complying with COMAR 10.07.02.24 (Emergency Preparedness).
It is not meant to exclude other formats so long as they
include all elements of the regulations.
Nursing Home QA Survey, 2008
OHCQ Surveyors from the Nursing Home Technical Assistance Unit will be using a new survey tool that focuses on Patient Safety.
Click here for the Pressure Ulcer Rate Improvement Form (2008) Note: The 2008 Pressure Ulcer tool focuses on High Risk pressure ulcers in an effort to reduce Maryland's High Risk rate, however, LTC facilities must still determine whether acquired pressure ulcers are avoidable.
Instructions for using the Comprehensive Care Facilities & Extended Care Facilities Self-Report Form
The form was created for use by facilities to self-report alleged violations of neglect and abuse, including injuries of unknown source, and misappropriation of resident property/funds (refer to April 12, 2005 memorandum from Carol Benner regarding the clarification of reporting requirements). It is not mandatory that facilities use this form, but a facility must include, at a minimum, the information requested on this form.
The form should be used to forward both the “first report” and “results of investigation” to the OHCQ/Long Term Care Unit via fax 410-402-8113 or e-mail nhselfreport@dhmh.state.md.us.
The facility should complete the top of the form for the “first report” and forward to OHCQ within 24 hours of the incident.
The results of the investigation of the reported incident, should then be entered on the bottom of the form and be forwarded to OHCQ. One complete form (i.e., includes the first report and investigation results) should be forwarded within 5 days of the incident.
The Nursing Home Self-Report Form can be downloaded and viewed with Microsoft® or Word Adobe Acrobat®.
If you do not have Microsoft® Word click here to download the Microsoft® Word Viewer.
If you do not have Adobe® Acrobat click here to download the Adobe® Reader.
Diet Manual for Long Term Care Residents Click here for the order form for the Diet Manual, 2007 Edition Click here for the Table of Contents for the Diet Manual, 2007 Edition
SAMPLE STAFFING
A sample of how a facility could use an erasable white board with names hand written in to be in compliance with .55 A and B about staffing. Remember this is to be done per shift per unit or floor.
Click
here for the template in Adobe® Acrobat
Click
here for the template in Microsoft® Word
