ALF SURVEY GUIDELINE INDEX

Facility Name: ______________________________________________ GENERAL LICENSE STANDARDS

____001 ____002 ____003 ____004 ____005 ____006 ____007 ____008 ____009 ____010 ____011 ____012 ____013 ____014 ____015 ____016 ____017 ____018 ____019 ____020 ____021 ____022 Facility is licensed to provide services in facility License displayed conspicuously Unlawful to own, operate w/out license Failure to license one fac. impacts all licensed facilities License valid for individ./firm to which issued Transferor respon./liable until transferee licensed CCRC facilities w/ pers. serv. Must have ALF lic. Licensed capacity not exceeded Co-located w/ N.H. may use shared staff; count once Clinic w/ co-located indep. living apts. used as out-pat. License valid for type care provided Provides one or more personal care services Change of administrator reported to Agency Written notice of CHOW w/in 7 days to residents Kickback, bonus, rebate, split fee unlawful for all Soliciting contributions for charity only; no other use Solicitation by threat, coercion, force prohibited Donation/contribut. not condition for state funded resid. Agency notified 90 days before voluntary closure 30 days notice to residents prior to closing Unlawful to advertise personal services w/out license Assisted Living Facility appears on all advertising

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 Alzheimers 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 facilitys 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

____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

ALF Survey Checklist

Page 2
____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 ____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 reqd 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

12/1/06

ALF Survey Checklist

Page 3
____704 Staff observe, are aware of general well being of resident ____705 General awareness of residents 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; -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 residents 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 residents 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 residents 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/ Alzheimers 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

ALF Survey Checklist

Page 4
____1104 ____1105 ____1106 ____1107 ____1108 ____1109 ____1110 ____1111 ____1112 ____1113 ____1114 ____1115 ____1116 ____1117 ____1118 ____1119 ____1120 ____1121 Initial/ Biennial staff training on HIV/ AIDS CPR/1st Aid trained staff in fac. at all times; document Unlic. staff providing assist. w/ meds, 4 hrs training 1st Unlic. staff assisting w/ meds, 2 hrs cont. ed. annually Food prep./hand staff 1-hr. train w/in 30 days employ. Person respon. for food service, 2 hrs. training annually Alzheimers reg./DC contact, train 4 hrs w/in 3 mos. Alzheimers direct care, train add. 4 hrs w/in 9 mos. Alzheimers direct care staff 4 hrs cont. ed. yearly Alz.s incidental contact, general written w/in 3 mos. Personal rec. contain copies of all licenses/certifications Personnel rec. contain compliance w/ level 1 bg screen No bkgd screening, no employ. unless exempted 17+ have written job descriptions for each position Staff by an agency/business entity, copy of contract Written work schedules kept for at least last 6 mos. Staff time sheets for at least last 6mos. Doc. of direct care staff & admins. elop. participation

12/1/06