All Residents Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

All residents who were present in the facility when the audit ran.

Business Rules

Tasks:

  1. Weekly Skin Check - Weekly Skin Check Assessment Completed (Q702)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a patient is at the facility when the audit runs
        THEN the patient must have a Weekly Skin Check Assessment with a status of ‘Complete’ that was completed within the past 7 days 

    3. Due Date:

      1. 7 Days after the most recent skin check.

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. When the patient is discharged

  2. Code Status Order - MD order for code status in place (Q703)

    1. Location in PCC:

      1. Orders

    2. Business Rule:

      1. IF a patient is at the facility when the audit runs, 
        THEN the patient must have an active MD order for their code status, with a code status on the resident dashboard

    3. Due Date:

      1. Within 24 hours of the most recent admission

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. When the patient is discharged

  3. Monthly Clinical Monitoring Assessment - Monthly assessment is completed (Q721)

    1. Location in PCC:

      1. Assessments

    2. Business Rule:

      1. IF a resident is a new admission
        THEN the resident must have a Monthly Clinical Monitoring Assessment with a status of ‘Complete’ that was completed within 30 days of their completed Nursing Admission Evaluation.

      2. IF a resident is at the facility when the audit runs
        THEN the resident must have a Monthly Clinical Monitoring Assessment with a status of ‘Complete’ that was completed within the past 30 days 

    3. Due Date:

      1. 30 Days after the most recent clinical monitoring assessment.

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. When the resident is discharged

  4. SNF Care Certification Order - MD order certifying need for SNF care in place (Q722)

    1. Location in PCC:

      1. Orders

    2. Business Rule:

      1. IF a resident is at the facility when the audit runs
        THEN the resident must have an active MD order stating “The resident is certified as being in continued need of nursing center level of care, long term or SNF”

    3. Due Date:

      1. Within 24 Hours of admission or readmission

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. When the resident is discharged