NAC449.9986. Scope of deficiencies: Criteria for evaluation.

     1. The scope of the deficiencies must be evaluated using the criteria prescribed in this section.

     2. A deficiency of scope level one consists of one or an isolated number of unrelated incidents in the sample surveyed. A deficiency is of this scope if it involves 20 percent or less of the recipients sampled in a facility.

     3. A deficiency is scope level two if the Bureau identifies a pattern of incidents at the facility, including any deficiencies involving recipients who require particular kinds of care, treatment or service. The number or percentage of recipients or staff involved in the incidents or the repeated occurrences of incidents in short succession may also establish a pattern by indicating a reasonable degree of predictability of similar incidents. A deficiency is also of this scope if it involves more than 20 percent but not more than 50 percent of the recipients sampled in a facility.

     4. A deficiency is of scope level three if it occurs in a sufficient number or percentage of recipients or staff or with sufficient regularity over time that it may be considered systemic or pervasive in or by the facility. A deficiency is also of this scope if it involves more than 50 percent of the recipients sampled in a facility.

     (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)