Normalized deficiency concept

Administration & records

Inferred69 source-native tags

Administration, governance, QAPI, compliance programs and records.

Facilities cited

Citations

13,229

CMS current window

Facilities cited

6,565

CMS tags

Jurisdictions

code systems mapped

Universe

CMS

certified nursing homes

Method

Crosswalk

category level

Mapping methodology

How codes map to this concept

Code system: cms_ltc_survey_tags
Jurisdiction: US-CMS
Basis: CMS 'Deficiency Category' field on Health and Fire Safety Deficiencies datasets
Source categories: Administration Deficiencies
Confidence: Inferred Explicit category-level mapping, reviewed by hand; tag identity preserved.

Source-native tags in this concept

Tag	Description	Citations	Facilities
F-0867	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies	1,712	1,396
F-0849	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies	1,254	1,150
F-0835	Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies	1,161	1,025
F-0868	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies	1,018	929
F-0838	Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies	950	894
F-0851	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies	930	837
F-0770	Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies	909	828
F-0865	Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies	845	748
F-0847	Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies	590	564
F-0773	Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies	508	486
F-0940	Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies	341	331
F-0836	Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Administration Deficiencies	338	314
F-0944	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies	329	305
F-0837	Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies	268	242
F-0949	Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies	268	249
F-0850	Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies	214	194
F-0839	Employ staff that are licensed, certified, or registered in accordance with state laws. Administration Deficiencies	206	199
F-0941	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies	202	182
F-0840	Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Administration Deficiencies	184	170
F-0776	Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies	179	176
F-0848	Provide a neutral and fair arbitration process and agree to arbitrator and venue. Administration Deficiencies	172	170
F-0946	Provide training in compliance and ethics. Administration Deficiencies	166	155
F-0777	Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies	101	101
F-0775	Keep complete, dated laboratory records in the resident's record. Administration Deficiencies	67	62
F-0772	Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Administration Deficiencies	57	57
F-0843	Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Administration Deficiencies	55	55
F-0774	Help the resident with transportation to and from laboratory services outside of the facility. Administration Deficiencies	48	46
F-0844	Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Administration Deficiencies	47	46
F-0895	Have a Compliance and Ethics Program. Administration Deficiencies	42	40
F-0779	Keep signed and dated reports of x-rays and other diagnostic services in the residents record. Administration Deficiencies	26	23
F-0778	Help the resident make transportation arrangements to and from radiology services. Administration Deficiencies	24	22
F-0846	Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. Administration Deficiencies	6	6
F-0514	Keep accurate, complete and organized clinical records on each resident that meet professional standards. Administration Deficiencies	3	3
F-0540	Meet the legal definition of a skilled nursing facility or nursing facility. Administration Deficiencies	3	3
F-0771	Ensure laboratory services, blood blanks and transfusion services provided on-site meet requirements for certified laboratories. Administration Deficiencies	3	3
F-0493	Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Administration Deficiencies	1	1
F-0504	Provide or obtain laboratory services only when ordered by the attending physician. Administration Deficiencies	1	1
F-0518	Train all employees on what to do in an emergency, and carry out unannounced staff drills. Administration Deficiencies	1	1
F-0150	Meet the legal definition of a skilled nursing facility or nursing facility. Administration Deficiencies	0	0
F-0249	Ensure the activities program is directed by a qualified professional. Administration Deficiencies	0	0
F-0251	Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies	0	0
F-0490	Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Administration Deficiencies	0	0
F-0491	Be licensed under State and local laws. Administration Deficiencies	0	0
F-0492	Operate and provide services according to Federal, State, and local laws and professional standards. Administration Deficiencies	0	0
F-0499	Employ staff that are licensed, certified, or registered in accordance with state laws. Administration Deficiencies	0	0
F-0500	Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Administration Deficiencies	0	0
F-0502	Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Administration Deficiencies	0	0
F-0503	Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements. Administration Deficiencies	0	0
F-0505	Quickly tell the resident's doctor the results of laboratory tests. Administration Deficiencies	0	0
F-0506	Help the resident with transportation to and from laboratory services outside of the facility. Administration Deficiencies	0	0
F-0507	Keep complete, dated laboratory records in the resident's file. Administration Deficiencies	0	0
F-0508	Give or get x-rays and other tests in a timely manner to meet the needs of residents. Administration Deficiencies	0	0
F-0509	1) Give or get tests or x-rays that meet hospital requirements; or 2) to obtain an agreement for these services from an approved provider or supplier. Administration Deficiencies	0	0
F-0510	Give or get x-rays or tests only when they are ordered by the attending physician. Administration Deficiencies	0	0
F-0511	Tell the attending physician the results of x-rays and other tests, in a timely manner. Administration Deficiencies	0	0
F-0512	Help the resident in making transportation arrangements to and from radiology services. Administration Deficiencies	0	0
F-0513	Keep signed and dated reports of x-rays and other diagnostic services. Administration Deficiencies	0	0
F-0515	Keep clinical records for an appropriate amount of time. Administration Deficiencies	0	0
F-0516	Keep clinical record information safe. Administration Deficiencies	0	0
F-0517	Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Administration Deficiencies	0	0
F-0519	Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Administration Deficiencies	0	0
F-0520	Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Administration Deficiencies	0	0
F-0522	Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Administration Deficiencies	0	0
F-0523	Submit a timely, acceptable plan for facility closure, including notification of the appropriate entities and ensuring residents are transferred in a safe and orderly manner. Administration Deficiencies	0	0
F-0524	Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. Administration Deficiencies	0	0
F-0526	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies	0	0
F-0527	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies	0	0
F-0845	Submit a timely, acceptable plan for facility closure, including notification of the appropriate entities and ensuring residents are transferred in a safe and orderly manner. Administration Deficiencies	0	0
F-0866	Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Administration Deficiencies	0	0

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