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SkilledNursingFacility

Policy&ProcedureManual

FEDERALREGULATIONS

November2017

[FACILTIYNAMEHERE]

CLINICALRISKPROGRAMSMANUALS

TheClinicalRiskProgramsManualswerereviewedandapprovedbytheQualityAssuranceCommitteeon___________________________.

______________________________________ ___________________NursingHomeAdministrator Date______________________________________ ___________________DirectorofNursing Date______________________________________ ___________________MedicalDirector Date______________________________________ ___________________AdditionalStaffMember/Title Date______________________________________ ___________________AdditionalStaffMember/Title Date______________________________________ ____________________AdditionalStaffMember/Title Date

RBHEALTHPARTNER'SPOLICYINDEX

I. PHASE2CROSSWALKS–COMPLIMENTSOFCMS

II. DEFINITIONSa. F540DefinitionofaFacility—SNF&NF

III. RESIDENTRIGHTSResidentRightsGeneralPolicy

a. F550ResidentRights/ExerciseofRightsb. F551RightsExercisedbyRepresentativec. F552RighttobeInformed/MakeTreatmentDecisionsd. F553RighttoParticipateinPlanningCaree. F554ResidentSelf-AdminMeds-ClinicallyAppropriatef. Self-AdministrationofMedicationProgramg. F555RighttoChoose/BeInformedofAttendingPhysicianh. F557Respect,Dignity/RighttohavePersonalPropertyi. F558ReasonableAccommodationsofNeeds/Preferencesj. F559Choose/BeNotifiedofRoom/RoommateChangek. F560RighttoRefuseCertainTransfersl. F561SelfDeterminationm. F562ImmediateAccesstoResidentn. F563Visitationo. F564InformofVisitationRights/EqualVisitationPrivilegesp. F565Resident/FamilyGroupandResponseq. F566RighttoPerformFacilityServicesorRefuser. F567Protection/ManagementofPersonalFundss. F568AccountingandRecordsofPersonalFundst. F569NoticeandConveyanceofPersonalFundsu. F570SuretyBond-SecurityofPersonalFundsv. F571LimitationsonChargestoPersonalFundsw. F572NoticeofRightsandRulesx. F573RighttoAccess/PurchaseCopiesofRecordsy. F574RequiredNoticesandContactInformationz. F575RequiredPostingsaa. F576RighttoFormsofCommunicationwithPrivacybb. F577RighttoSurveyResults/AdvocateAgencyInfocc. F578Request/Refuse/DiscontinueTreatmentdd. RefusalofExperimentalResearchee. AdvanceDirectiveTrackingProgramff. DoNotResuscitateOrdersgg. F579Posting/NoticeofMedicare/MedicaidonAdmissionhh. F580NotifyofChanges(Injury/Decline/Room,Etc.)ii. ChangeinConditionProcessjj. F582Medicaid/MedicareCoverage/LiabilityNoticekk. F583PersonalPrivacy/ConfidentialityofRecordsll. F584Safe/Clean/Comfortable/HomelikeEnvironmentmm. F585Grievances

nn. GrievanceProgramoo. F586ResidentContactwithExternalEntities

IV. FREEDOMFROMABUSE,NEGLECT,ANDEXPLOITATIONFreedomfromAbuse,Neglect,andExploitationGeneralPolicy

a. F600FreefromAbuseandNeglectF602FreefromMisappropriation/ExploitationF603FreefromInvoluntarySeclusion

b. F604RighttobeFreefromPhysicalRestraintsF605RighttobeFreefromChemicalRestraintsRestraintReductionProgram

c. F606NotEmploy/EngageStaffwithAdverseActionsd. F607Develop/ImplementAbuse/Neglect,etc.Policiese. F608ReportingofReasonableSuspicionofaCrime

F609ReportingofAllegedViolationsF610Investigate/Prevent/CorrectAllegedViolations

f. Abuse,Neglect,Exploitation,Preventiong. PersonalPropertyTheftandLossRiskh. PhotographsandSocialMediai. SexualAbusej. VideoSurveillanceClosed-CircuitTVs

V. ADMISSION,TRANSFER&DISHCARGEAdmission,TransferandDischargeGeneralPolicy

a. F620AdmissionPolicyb. F621EqualPracticesRegardlessofPaymentSourcec. F622TransferandDischargeRequirementsd. F623NoticeRequirementsBeforeTransfer/Discharge

F624PreparationforSafe/OrderlyTransfer/Dischargee. F625NoticeofBedHoldPolicyBefore/UponTransferf. BedHoldPolicyg. F626PermittingResidentstoReturntoFacility

VI. RESIDENTASSESSMENTSResidentAssessmentGeneralPolicy

a. F635AdmissionPhysicianOrdersforImmediateCareb. ResidentAssessmentInstrument(RAI)

F636ComprehensiveAssessments&TimingF637ComprehensiveAssessmentAfterSignificantChangeF638QuarterlyAssessmentAtLeastEvery3MonthsF639Maintain15MonthsofResidentAssessmentsF640Encoding/TransmittingResidentAssessmentF641AccuracyofAssessmentsF642Coordination/CertificationofAssessment

c. F644CoordinationofPASARRandAssessmentsF645PASARRScreeningforMD&IDF646MD/IDSignificantChangeNotification

VII. COMPREHENSIVERESIDENTCENTEREDCAREPLANSComprehensiveResidentCenteredCarePlansGeneralPolicy

a. F655BaselineCarePlanb. F656Develop/ImplementComprehensiveCarePlan

F657CarePlanTimingandRevisionF658ServicesProvidedMeetProfessionalStandardsF659QualifiedPersons

c. F660DischargePlanningProcessd. DischargePlanningProceduree. F661DischargeSummary

VIII. QUALITYOFLIFEQualityofLifeGeneralPolicy

a. F675QualityofLifeb. F676ActivitiesofDailyLiving(ADLs)/MaintainAbilities

F677ADLCareProvidedforDependentResidentsF678Cardio-PulmonaryResuscitation(CPR)

c. F679ActivitiesMeetInterest/NeedsofEachResidentF680QualificationsofActivityProfessional

IX. QUALITYOFCAREQualityofCareGeneralPolicy

a. F684QualityofCareb. F685Treatment/DevicestoMaintainHearing/Visionc. F686Treatment/ServicestoPrevent/HealPressureUlcersd. WoundPreventionPrograme. WoundManagementProgramf. CleanDressingChangeProcedureg. SkinPrepApplicationProcedureh. F687FootCarei. F688Increase/PreventDecreaseinROM/Mobilityj. SpecializedRehabilitativeandRestorativeServicesk. RestorativeNursingPrograml. RestorativeNursingBedMobilityProgramm. Mobilityn. F689FreeofAccidentHazards/Supervision/Deviceso. ReportingAccidentsandIncidentsp. MedicalErrorsOccurrenceReportingq. FallingStarProgramr. MissingResidents. Elopementt. F690Bowel/BladderIncontinence,Catheter,UTIu. BowelandBladderProgramv. IndwellingCatheterJustificationandRemovalw. F691Colostomy,Urostomy,orIleostomyCarex. AssistedNutritionandHydrationy. F692Nutrition/HydrationStatusMaintenance

z. F693TubeFeeding,Management/RestoreEatingSkillsaa. EnteralTubeFeedingviaBolusbb. EnteralTubeFeedingviaPumpcc. EnteralTubeFeedingviaGravityBagdd. ChangingaGastrostomyTubeee. Gastrostomy/JejunostomySiteCareff. CleaningandStoringReusableSyringegg. EnteralFeedingMedicationAdministrationhh. PlacementandResidualVolumeCheckforEnteralFeedingTubesii. F694Parenteral/IVFluidsjj. PICCLineRemovalProcedurekk. F695Respiratory/TracheostomyCareandSuctioningll. F696Prosthesesmm. F697PainManagementnn. PainManagementProgramoo. F698Dialysispp. F700Bedrails

X. PHYSICIANSERVICESPhysicianServicesGeneralPolicy

a. F710Resident'sCareSupervisedByaPhysicianF711PhysicianVisits—ReviewCare/Notes/OrdersF712PhysicianVisits–Frequency/Timeliness/AlternateNPPsF713PhysicianforEmergencyCare,Available24HoursF714PhysicianDelegationofTaskstoNPPF715PhysicianDelegationtoDietitian/Therapist

XI. NURSINGSERVICESNursingServicesGeneralPolicy

a. F725SufficientNursingStaffF726CompetentNursingStaffF727RN8Hrs./7day/Wk.FullTimeDON

b. F728FacilityHiringandUseofNursec. F729NurseAideRegistryVerification,Retraining

F730NurseAidePerformReview–12Hr/YearIn-serviced. F732PostedNurseStaffingInformation

XII. BEHAVIORHEALTHSERVICESBehaviorHealthServicesGeneralPolicy

a. F740BehavioralHealthServicesF741Sufficient/CompetentStaff-BehaviorHealthNeeds

b. F742Treatment/ServicesforMental/PsychosocialConcernsF743NoPatternofBehavioralDifficultiesUnlessUnavoidableF744Treatment/ServiceforDementiaF745ProvisionofMedicallyRelatedSocialServices

c. BehaviorManagementandPsychoactiveProgram

XIII. PHARMACYSERVICESPharmacyServicesGeneralPolicy

a. F755PharmacyServices/Procedures/Pharmacist/RecordsF759FreeofMedicationErrorRateof5%orMoreF760ResidentsAreFreeofSignificantMedErrorsF761Label/StoreDrugs&Biologicals

b. F756DrugRegimenReview,ReportIrregular,ActOnc. F757DrugRegimenisFreeFromUnnecessaryDrugs

F758FreeFromUnnecessaryPsychotropicMeds/PRNUsed. DrugRegimenReviewProcess

XIV. LABORATORY,RADIOLOGY,ANDOTHERDIAGNOSTICSERVICESLaboratory,Radiology,andOtherDiagnosticServicesGeneralPolicy

a. F770LaboratoryServicesF771BloodBankandTransfusionServicesF772LabServicesNotProvidedOn-SiteF773LabServicesPhysicianOrder/NotifyofResultsF774AssistwithTransportArrangementstoLabServicesF775LabReportsInRecord-LabName/AddressF776Radiology/OtherDiagnosticServicesF777Radiology/DiagnosticServicesOrdered/NotifyResultsF778AssistwithTransportArrangementstoRadiologyF779X-ray/DiagnosticReportInRecord–Sign/Dated

XV. DENTALDentalGeneralPolicy

a. F790Routine/EmergencyDentalServicesinSkilledNursingFacilitiesF791Routine/EmergencyDentalServicesNursingFacilities

XVI. FOODANDNUTRITIONSERVICESFoodandNutritionServicesGeneralPolicy

a. FoodandNutritionServicesF800ProvideDietMeetsNeedsofEachResidentF801QualifiedDietaryStaffF802SufficientDietarySupportPersonnelF808TherapeuticDietPrescribedbyPhysicianF809FrequencyofMeals/SnacksatBedtimeF810AssistiveDevices–EatingEquipment/UtensilsF812FoodProcurement,Store/Prepare/Serve–SanitaryF813PersonalFoodPolicyF814DisposalGarbage&RefuseProperly

b. MenusandNutritionalAdequacyF803MenusMeetResidentNeeds/PrepareinAdvance/Followed

c. FoodandDrinkF804NutritiveValue/AppearPalatable/PreferTempF805FoodInFormtoMeetIndividualNeedsF806ResidentAllergies,PreferencesandSubstitutes

F807DrinksAvailabletoMeetNeeds/Preferences/Hydrationd. F811FeedingAssistant–Training/Supervision/Residente. UseandStorageofFoodBroughtinbyFamilyorVisitorsf. WeightManagement

XVII. SPECIALIZEDREHABSERVICESSpecializedRehabServicesGeneralPolicy

a. F825Provide/ObtainSpecializedRehabServicesF826RehabServices—PhysicianOrder/QualifiedPerson

XVIII. ADMINISTRATIONAdministrationGeneralPolicy

a. F835AdministrationF836License/ComplyWithFederal/State/LocalLaw/ProfessionalStandardsF837GoverningBody

b. F838FacilityAssessmentc. F839StaffQualifications

F840UseofOutsideResourcesd. F841ResponsibilitiesofMedicalDirectore. F842ResidentRecords–IdentifiableInformationf. RecordRetentiong. F843TransferAgreementh. F844DisclosureofOwnershipRequirementsi. F845FacilityClosure–Administrator

F846FacilityClosurej. F849HospiceServicesk. F850QualificationsofSocialWorker>120Bedsl. F851PayrollBasedJournal

XIX. QUALITYASSURANCEANDPERFORMANCEIMPROVEMENT QualityAssuranceandPerformanceImprovement

a. F865QAPIProgram/Plan,Disclosure/GoodFaithAttemptF867QAPI/QAAImprovementActivities

b. F868QAACommittee

XX. INFECTIONCONTROLInfectionControlGeneralPolicy

a. F880InfectionPreventionandControlb. F881InfectionControl-AntibioticStewardshipProgramc. F883InfluenzaandPneumococcalImmunizationsResidentsd. InfluenzaandPneumococcalImmunizationsforStaffe. InfectionControl-StandardandTransmission-basedPrecautionsf. InfectionControl-CleaningandDisinfection/Non-criticalcareandsharedequipmentg. InfectionControl-CentralVenousCatheter/CentralLineAccessandMaintenanceh. InfectionControl-CleanDressingChangei. InfectionControl-FoodHandlingj. InfectionControl-HandHygiene

k. InfectionControl-IndwellingCatheterCarel. InfectionControl-IndwellingUrinaryCatheterUsem. InfectionControl-LinenManagementn. InfectionControl-MedicationAdministrationo. InfectionControl-PointofCareDevicesandInjectionSafetyp. InfectionControl-Tuberculosis(TB)ScreeningProgram

XXI. PHYSICALENVIRONMENTPhysicalEnvironmentGeneralPolicy

a. F906EmergencyElectricalPowerSystem(Blank)b. F907SpaceandEquipment

F908EssentialEquipment,SafeOperatingConditionc. F909ResidentBedd. ResidentRooms

F910BedroomsAccommodateNoMoreThan4ResidentsF912BedroomsMeasureatleast80squarefoot/residentF913BedroomsHaveDirectAccesstoExitCorridorF914BedroomsAssureFullVisualPrivacyF915BedroomsWindow/Floor,Bed/Furniture/ClosetF916BedroomsFloorAboveGradeF917BedroomsBed/Furniture/ClosetF918BedroomsEquipped/NearLavatory/Toilet

e. F919ResidentCallSystem—Rooms/Toilet/BathF920RequirementsforDiningandActivityRoomsF921Safe/Functional/Sanitary/ComfortableEnvironmentF922ProcedurestoEnsureWaterAvailabilityF923VentilationF924CorridorsHaveFirmlySecuredHandrailsF925MaintainsEffectivePestControlProgramF926SmokingPolicies

f. ResidentSmokingPolicy

XXII. TRAININGREQUIREMENTS TrainingRequirementsGeneralPolicy

a. F943Abuse,Neglect,andExploitationTrainingb. F947RequiredIn-ServiceTrainingforNurseAidesc. F948TrainingforFeedingAssistantsd. StaffEducationPlan

PLACETABFORPHASE2CROSSWALKSHERE

PHASE2TAGCROSSWALKS–COMPLIMENTSOFCMS

NewTag#

SQCTag?X=Yes

TagTitle CFR RegulatoryGroupingsTags/SubpartsImplementedinPhase3

OldTag#

RegulationTextthatwasMovedtoNewTag

F540 Definitions 483.5 F150 483.5

F550 X ResidentRights/ExerciseofRights

483.10(a)(1)(2)(b)(1)(2)

483.10ResidentRights

F151 483.10(b)(1)(2)

F551 RightsExercisedbyRepresentative

483.10(b)(3)-(7)(i)-(iii)


F152 483.10(b)(3)-(7)

F573 RighttoAccess/PurchaseCopiesofRecords

483.10(g)(2)(i)(ii)(3)

483.10ResidentRights F153 483.10(g)(2)(3)

F552 RighttobeInformed/MakeTreatmentDecisions

483.10(c)(1)(4)(5)483.10ResidentRights F154 483.10(c)(1)(4)(5)

F553 RighttoParticipateinPlanningCare

483.10(c)(2)(3) 483.10ResidentRights

F154 483.10(c)(2)(iii)

F578

Request/Refuse/DiscontinueTreatment;FormulateAdvanceDirectives

483.10(c)(6)(8)(g)(12)(i)-(v)

483.10ResidentRights F155 483.10(c)(6)(8)(g)(12)

F678 XCardio-PulmonaryResuscitation(CPR)

483.24(a)(3) 483.24QualityofLife F155 483.24(a)(3)

F572 NoticeofRightsandRules 483.10(g)(1)(16) 483.10ResidentRights

F156 483.10(g)(1)(16)

F574 RequiredNoticesandContactInformation 483.10(g)(4)(i)-(vi) 483.10Resident

Rights F156 483.10(g)(4)

F575 RequiredPostings 483.10(g)(5)(i)(ii) 483.10ResidentRights

F156 483.10(g)(5)

F579 Posting/NoticeofMedicare/MedicaidonAdmission

483.10(g)(13)483.10ResidentRights F156 483.10(g)(13)

F582 Medicaid/MedicareCoverage/LiabilityNotice

483.10(g)(17)(18)(i)-(v)


F156 483.10(g)(17)-(18)

F580 NotifyofChanges(Injury/Decline/Room,Etc.)

483.10(g)(14)(i)-(iv) 483.10ResidentRights F157 483.10(g)(14)

F567 Protection/ManagementofPersonalFunds

483.10(f)(10)(i)(ii) 483.10ResidentRights

F158 483.10(f)(10)(i)

F567 Protection/ManagementofPersonalFunds

483.10(f)(10)(i)(ii) 483.10ResidentRights

F159 483.10(f)(ii)

F568 AccountingandRecordsofPersonalFunds 483.10(f)(10)(iii)

483.10ResidentRights F159 483.10(f)(10(iii)

F569 NoticeandConveyanceofPersonalFunds

483.10(f)(10)(iv)(v) 483.10ResidentRights

F159 483.10(f)(iv)

F570 SuretyBond-SecurityofPersonalFunds

483.10(f)(10)(vi) 483.10ResidentRights

F161 483.10(f)(10(vi)

F571 LimitationsonChargestoPersonalFunds 483.10(f)(11)(i)-(iii)

483.10ResidentRights F162 483.10(f)(11)(i)-(iii)

F555 RighttoChoose/BeInformedofAttendingPhysician

483.10(d)(1)-(5) 483.10ResidentRights

F163 483.10(d)(1)(2)(4)(5)

F583 PersonalPrivacy/ConfidentialityofRecords

483.10(h)(1)-(3)(i)(ii)

483.10ResidentRights F164 483.10(h)(1)(3)(i)

F842 ResidentRecords-IdentifiableInformation

483.20(f)(5)483.70(i)(1)-(5)

483.20ResidentAssessments483.70Administration

F164 483.70(i)(2)

F585 Grievances 483.10(j)(1)-(4)483.10ResidentRights F165 483.10(j)(1)

F585 Grievances 483.10(j)(1)-(4)483.10ResidentRights F166 483.10(j)(2-4)

F577 RighttoSurveyResults/AdvocateAgencyInfo

483.10(g)(10)(11) 483.10ResidentRights

F167 483.10(g)(10)(i)(11)

F577 RighttoSurveyResults/AdvocateAgencyInfo

483.10(g)(10)(11)483.10ResidentRights F168 483.10(g)(10)(ii)

F586 ResidentContactwithExternalEntities

483.10(k) 483.10ResidentRights

F168 483.10(k)

F566 RighttoPerformFacilityServicesorRefuse

483.10(f)(9)(i)-(iv) 483.10ResidentRights

F169 483.10(f)(9)

F576 RighttoFormsofCommunicationwithPrivacy

483.10(g)(6)-(9)483.10ResidentRights F170

483.10(g)(8)(i)(9)(i)-(iii)


483.10(g)(6)-(9) 483.10ResidentRights

F171 483.10(g)(7)(ii)(iii)

F562 ImmediateAccesstoResident

483.10(f)(4)(i)(A)-(G)

483.10ResidentRights F172 483.10(f)(4)(i)

F563 RighttoReceive/DenyVisitors 483.10(f)(4)(ii)-(v)

483.10ResidentRights F172 483.10(f)(4)(ii)-(v)

F564 InformofVisitationRights/EqualVisitationPrivileges

483.10(f)(4)(vi)(A)-(D)


F172 483.10(f)(4)(vi)(A)-(D)

F583 PersonalPrivacy/ConfidentialityofRecords

483.10(h)(1)-(3)(i)(ii)

483.10ResidentRights F173 483.10(h)(3)(ii)


483.10(g)(6)-(9) 483.10ResidentRights

F174 483.10(g)(6)(7)(i)

F559 X Choose/BeNotifiedofRoom/RoommateChange 483.10(e)(4)-(6) 483.10Resident

Rights F175 483.10(e)(4)(5)

F554 ResidentSelf-AdminMeds-ClinicallyAppropriate

483.10(c)(7)483.10ResidentRights F176 483.10(c)(7)

F560 RighttoRefuseCertainTransfers

483.10(e)(7)(i)-(iii)(8)


F177 483.10(e)(7)-(8)

F622 TransferandDischargeRequirements

483.15(c)(1)(i)(ii)(2)(i)-(iii)

483.15Admission,Transfer,andDischarge

F201 483.15(c)(1)(i)(ii)

F622 TransferandDischargeRequirements

483.15(c)(1)(i)(ii)(2)(i)-(iii)


F202 483.15(c)(2)(i)-(iii)

F623 NoticeRequirementsBeforeTransfer/Discharge

483.15(c)(3)-(6)(8)


F203 483.15(c)(3)-(6)(8)

F624 PreparationforSafe/OrderlyTransfer/Discharge

483.15(c)(7)


F204 483.15(c)(7)

F625 NoticeofBedHoldPolicyBefore/UponTransfer 483.15(d)(1)(2)


F205 483.15(d)(1)(i)-(iv)(2)

F626 PermittingResidentstoReturntoFacility

483.15(e)(1)(2)


F206 483.15(e)(1)(2)

F621 EqualPracticesRegardlessofPaymentSource

483.15(b)(1)-(3)(c)(9)


F207 483.15(b)(1)-(3)(c)(9)

F620 AdmissionsPolicy 483.15(a)(1)-(7)


F208 483.15(a)(1)-(7)

F604 XRighttobeFreefromPhysicalRestraints

483.10(e)(1)483.12(a)(2)

483.10ResidentRights483.12FreedomfromAbuse,Neglect,andExploitation

F221483.10(e)(1),483.12(a)(2)

F604 XRighttobeFreefromPhysicalRestraints

483.10(e)(1)483.12(a)(2)


F222483.10(e)(1),483.12(a)(2)

F605 X RighttobeFreefromChemicalRestraints

483.10(e)(1)483.12(a)(2)


F222 483.10(e)(1),483.12(a)(2)

F600 X FreefromAbuseandNeglect

483.12(a)(1)

483.12FreedomfromAbuse,Neglect,andExploitation

F223 483.12(a)(1)

F602 XFreefromMisappropriation/Exploitation

483.12


F223 483.12

F603 XFreefromInvoluntarySeclusion 483.12(a)(1)


F223 483.12(a)(1)

F602 XFreefromMisappropriation/Exploitation

483.12


F224 483.12

F606 X NotEmploy/EngageStaffwithAdverseActions 483.12(a)(3)(4)


F225 483.12(a)(3)(4)

F609 XReportingofAllegedViolations 483.12(c)(1)(4)


F225 483.12(c)(1)(4)

F610 X Investigate/Prevent/CorrectAllegedViolation 483.12(c)(2)-(4)


F225 483.12(c)(2)-(4)

F607 XDevelop/ImplementAbuse/Neglect,etc.Policies

483.12(b)(1)-(4)


(b)(4)-Phase3WillnotbeinASPENuntilPhase3

F226 483.12(b)(1)-(4)

F943 Abuse,Neglect,andExploitationTraining 483.95(c)(1)-(3)

483.95TrainingRequirements F226 483.95(c)(1)-(3)

F550 XResidentRights/ExerciseofRights

483.10(a)(1)(2)(b)(1)(2)

483.10ResidentRights F240 483.10(a)(1)(2)

F550 X ResidentRights/ExerciseofRights

483.10(a)(1)(2)(b)(1)(2)


F241 483.10(a)(1)

F561 X SelfDetermination 483.10(f)(1)-(3)(8)483.10ResidentRights F242 483.10(f)(1)-(3)

F565 X Resident/FamilyGroupandResponse

483.10(f)(5)(i)-(iv)(6)(7)


F243 483.10(f)(5)(i)-(iii)(6)(7)

F565 XResident/FamilyGroupandResponse

483.10(f)(5)(i)-(iv)(6)(7)

483.10ResidentRights F244 483.10(f)(5)(iv)

F561 X SelfDetermination 483.10(f)(1)-(3)(8)483.10ResidentRights F245 483.10(f)(8)

F558 XReasonableAccommodationsofNeeds/Preferences

483.10(e)(3) 483.10ResidentRights

F246 483.10(e)(3)

F559 X Choose/BeNotifiedofRoom/RoommateChange

483.10(e)(4)-(6) 483.10ResidentRights

F247 483.10(e)(6)

F679 XActivitiesMeetInterest/NeedsofEachResident

483.24(c)(1) 483.24QualityofLife F248 483.24(c)(1)

F680 XQualificationsofActivityProfessional

483.24(c)(2)(i)(ii)(A)-(D)

483.24QualityofLife F249

483.24(c)(2)(i)(ii)(A)-(D)

F745 XProvisionofMedicallyRelatedSocialServices

483.40(d)483.40BehavioralHealthServices

F250 483.40(d)

F850 XQualificationsofSocialWorker>120Beds 483.70(p)(1)(2)

483.70Administration F251 483.70(p)(1)(2)

F557 Respect,Dignity/RighttohavePersonalProperty 483.10(e)(2)

483.10ResidentRights F252 483.10(e)(2)

F584 X Safe/Clean/Comfortable/HomelikeEnvironment 483.10(i)(1)-(7) 483.10Resident

Rights F252 483.10(i)(1)(i)(ii)

F584 X Safe/Clean/Comfortable/HomelikeEnvironment 483.10(i)(1)-(7) 483.10Resident

Rights F253 483.10(i)(2)

F584 XSafe/Clean/Comfortable/HomelikeEnvironment 483.10(i)(1)-(7)

483.10ResidentRights F254 483.10(i)(3)

F584 X Safe/Clean/Comfortable/HomelikeEnvironment

483.10(i)(1)-(7) 483.10ResidentRights

F256 483.10(i)(5)

F584 X Safe/Clean/Comfortable/HomelikeEnvironment

483.10(i)(1)-(7) 483.10ResidentRights

F257 483.10(i)(6)



F635 AdmissionPhysicianOrdersforImmediateCare

483.20(a) 483.20ResidentAssessments F271 483.20(a)

F636 ComprehensiveAssessments&Timing

483.20(b)(1)(2)(i)(iii)

483.20ResidentAssessments F272 483.20(b)(1)


483.20(b)(1)(2)(i)(iii)

483.20ResidentAssessments

F273 483.20(b)(2)(i)

F637 ComprehensiveAssmtAfterSignificantChange

483.20(b)(2)(ii) 483.20ResidentAssessments F274 483.20(b)(2)(ii)


483.20(b)(1)(2)(i)(iii)

483.20ResidentAssessments F275 483.20(b)(2)(iii)

F638 QuarterlyAssessmentAtLeastEvery3Months

483.20(c) 483.20ResidentAssessments

F276 483.20(c)

F641 AccuracyofAssessments 483.20(g)483.20ResidentAssessments F278 483.20(g)

F642 Coordination/CertificationofAssessment 483.20(h)-(j)

483.20ResidentAssessments F278 483.20(h)-(j)

F639 Maintain15MonthsofResidentAssessments

483.20(d) 483.20ResidentAssessments

F279 483.20(d)

F656 Develop/ImplementComprehensiveCarePlan 483.21(b)(1)

483.21ComprehensiveResidentCenteredCarePlans

F279 483.21(b)(1)

F553 RighttoParticipateinPlanningCare

483.10(c)(2)(3) 483.10ResidentRights

F280 483.10(c)(2)(i)(ii)(iv)(v)(3)(i)-(iii)

F657 CarePlanTimingandRevision 483.21(b)(2)(i)-(iii)


F280 483.21(b)(2)(i)-(iii)

F658 ServicesProvidedMeetProfessionalStandards

483.21(b)(3)(i)


F281 483.21(b)(3)(i)

F659 QualifiedPersons 483.21(b)(3)(ii)(iii)


(b)(iii)-Phase3WillnotbeinASPENuntilPhase3

F282 483.21(b)(3)(ii)

F661 DischargeSummary 483.21(c)(2)(i)-(iv)


F283 483.21(c)(2)(i)-(iii)

F660 DischargePlanningProcess 483.21(c)(1)(i)-(ix)


F284 483.21(c)(1)(i)-(ix)

F661 DischargeSummary 483.21(c)(2)(i)-(iv)


F284 483.21(c)(2)(iv)

F644 CoordinationofPASARRandAssessments

483.20(e)(1)(2) 483.20ResidentAssessments

F285 483.20(e)

F645 PASARRScreeningforMD&ID 483.20(k)(1)-(3) 483.20Resident

Assessments F285 483.20(k)(1)-(3)

F646 MD/IDSignificantChangeNotification

483.20(k)(4) 483.20ResidentAssessments

F285 483.20(k)(4)

F639 Maintain15MonthsofResidentAssessments

483.20(d)483.20ResidentAssessments F286 483.20(d)

F640 Encoding/TransmittingResidentAssessment

483.20(f)(1)-(4) 483.20ResidentAssessments

F287 483.20(f)(1)-(4)

F675 X QualityofLife 483.24 483.24QualityofLife

F309 483.24

F684 X QualityofCare 483.25483.25QualityofCare F309 483.25

F697 X PainManagement 483.25(k) 483.25QualityofCare F309 483.25(k)

F698 X Dialysis 483.25(l) 483.25QualityofCare

F309 483.25(l)

F744 X Treatment/ServiceforDementia

483.40(b)(3)483.40BehavioralHealthServices

F309 483.40(b)(3)

F676 XActivitiesofDailyLiving(ADLs)/MaintainAbilities

483.24(a)(1)(b)(1)-(5)(i)-(iii)

483.24QualityofLife F310 483.24(a)(b)(1)-(5)(i)-

(iii)

F676 XActivitiesofDailyLiving(ADLs)/MaintainAbilities

483.24(a)(1)(b)(1)-(5)(i)-(iii)

483.24QualityofLife F311 483.24(a)(1)

F677 XADLCareProvidedforDependentResidents 483.24(a)(2)

483.24QualityofLife F312 483.24(a)(2)

F685 XTreatment/DevicestoMaintainHearing/Vision

483.25(a)(1)(2)483.25QualityofCare F313 483.25(a)(1)-(2)

F686 XTreatment/SvcstoPrevent/HealPressureUlcers

483.25(b)(1)(i)(ii)483.25QualityofCare F314 483.25(b)(1)(i)(ii)

F690 XBowel/BladderIncontinence,Catheter,UTI

483.25(e)(1)-(3) 483.25QualityofCare

F315 483.25(e)(1)-(3)

F688 XIncrease/PreventDecreaseinROM/Mobility

483.25(c)(1)-(3)483.25QualityofCare F317 483.25(c)(1)

F688 XIncrease/PreventDecreaseinROM/Mobility

483.25(c)(1)-(3)483.25QualityofCare F318 483.25(c)(2)(3)

F742 XTreatment/SvcforMental/PsychosocialConcerns


F319 483.40(b)(1)

F743 XNoPatternofBehavioralDifficultiesUnlessUnavoidable


F320 483.40(b)(2)

F693 XTubeFeedingManagement/RestoreEatingSkills

483.25(g)(4)(5)483.25QualityofCare F322 483.25(g)(4)(5)

F689 XFreeofAccidentHazards/Supervision/Devices

483.25(d)(1)(2) 483.25QualityofCare

F323 483.25(d)(1)(2)

F700 X Bedrails 483.25(n)(1)-(4)483.25QualityofCare F323 483.25(n)(1)-(3)

F692 XNutrition/HydrationStatusMaintenance

483.25(g)(1)-(3) 483.25QualityofCare F325 483.25(g)(1)(3)

F692 XNutrition/HydrationStatusMaintenance

483.25(g)(1)-(3)483.25QualityofCare F327 483.25(g)(2)

F687 X FootCare 483.25(b)(2)(i)(ii)483.25QualityofCare F328 483.25(b)(2)(i)(ii)

F691 X Colostomy,Urostomy,orIleostomyCare

483.25(f) 483.25QualityofCare

F328 483.25(f)

F694 X Parenteral/IVFluids 483.25(h) 483.25QualityofCare F328 483.25(h)

F695 XRespiratory/TracheostomycareandSuctioning

483.25(i)483.25QualityofCare F328 483.25(i)

F696 X Prostheses 483.25(j)483.25QualityofCare F328 483.25(j)

F757 XDrugRegimenisFreeFromUnnecessaryDrugs

483.45(d)(1)-(6)483.45PharmacyServices F329 483.45(d)

F758 XFreefromUnnecPsychotropicMeds/PRNUse

483.45(c)(3)(e)(1)-(5)

483.45PharmacyServices

F329 483.45(e)(1)-(5)

F759 XFreeofMedicationErrorRatesof5%orMore

483.45(f)(1) 483.45PharmacyServices F332 483.45(f)(1)

F760 XResidentsAreFreeofSignificantMedErrors

483.45(f)(2)483.45PharmacyServices F333 483.45(f)(2)

F883 XInfluenzaandPneumococcalImmunizations

483.80(d)(1)(2) 483.80InfectionControl

F334 483.80(d)(1)(2)

F725 SufficientNursingStaff 483.35(a)(1)(2) 483.35NursingServices

F353 483.35(a)(1)(2)

F726 CompetentNursingStaff 483.35(a)(3)(4)(c) 483.35NursingServices

F353 483.35(a)(3)(4)

F727 RN8Hrs/7days/Wk,FullTimeDON

483.35(b)(1)-(3) 483.35NursingServices

F354 483.35(b)(1)-(3)

F731 Waiver-LicensedNurses24Hr/DayandRNCoverage

483.35(e)(1)-(7)(f)(1)(2)

483.35NursingServices F355 483.35(e)(1)-

(7)(f)(1)(2)

F732 PostedNurseStaffingInformation 483.35(g)(1)-(4) 483.35Nursing

Services F356 483.35(g)(1)-(4)

F800 ProvidedDietMeetsNeedsofEachResident

483.60 483.60FoodandNutritionServices

F360 483.60

F801 QualifiedDietaryStaff 483.60(a)(1)(2)483.60FoodandNutritionServices F361 483.60(a)(1)(2)

F802 SufficientDietarySupportPersonnel

483.60(a)(3)(b) 483.60FoodandNutritionServices

F362 483.60(a)(3)(b)

F803 MenusMeetResNeeds/PrepinAdvance/Followed

483.60(c)(1)-(7) 483.60FoodandNutritionServices F363 483.60(c)(1)-(7)

F804 NutritiveValue/Appear,Palatable/PreferTemp 483.60(d)(1)(2)

483.60FoodandNutritionServices F364 483.60(d)(1(2)

F805 FoodinFormtoMeetIndividualNeeds

483.60(d)(3) 483.60FoodandNutritionServices F365 483.60(d)(3)

F806 ResidentAllergies,PreferencesandSubstitutes

483.60(d)(4)(5)483.60FoodandNutritionServices F366 483.60(d)(4)(5)

F807 DrinksAvailtoMeetNeeds/Preferences/Hydration

483.60(d)(6) 483.60FoodandNutritionServices

F366 483.60(d)(6)

F808 TherapeuticDietPrescribedbyPhysician

483.60(e)(1)(2) 483.60FoodandNutritionServices F367 483.60(e)(1)(2)

F809 FrequencyofMeals/SnacksatBedtime

483.60(f)(1)-(3)483.60FoodandNutritionServices F368 483.60(f)(1)-(3)

F810 AssistiveDevices-EatingEquipment/Utensils 483.60(g) 483.60Foodand

NutritionServices F369 483.60(g)

F812 FoodProcurement,Store/Prepare/Serve-Sanitary

483.60(i)(1)(2) 483.60FoodandNutritionServices

F371 483.60(i)(1)(2)

F813 PersonalFoodPolicy 483.60(i)(3) 483.60FoodandNutritionServices

F371 483.60(i)(3)

F814 DisposeGarbage&RefuseProperly

483.60(i)(4) 483.60FoodandNutritionServices

F372 483.60(i)(4)

F811 FeedingAsst-Training/Supervision/Resident

483.60(h)(1)-(3)483.60FoodandNutritionServices F373 483.60(h)(1)-(3)

F948 TrainingforFeedingAssistants 483.95(h)

483.95TrainingRequirements F373 483.95(h)

F710 Resident'sCareSupervisedbyaPhysician

483.30(a)(1)(2)483.30PhysicianServices F385 483.30(a)(1)(2)

F711 PhysicianVisits-ReviewCare/Notes/Order 483.30(b)(1)-(3)

483.30PhysicianServices F386 483.30(b)(1)-(3)

F712

PhysicianVisits-Frequency/Timeliness/AlternateNPPs

483.30(c)(1)-(4)483.30PhysicianServices F387 483.30(c)(1)(2)

F712

PhysicianVisits-Frequency/Timeliness/AlternateNPPs

483.30(c)(1)-(4) 483.30PhysicianServices

F388 483.30(c)(3)(4)

F713 PhysicianforEmergencyCare,Available24Hours

483.30(d) 483.30PhysicianServices

F389 483.30(d)

F714 PhysicianDelegationofTaskstoNPP

483.30(e)(1)(4)(f) 483.30PhysicianServices F390 483.30(e)(1)(4)(f)

F715 PhysicianDelegationtoDietitian/Therapist 483.30(e)(2)(3)

483.30PhysicianServices F390 483.30(e)(2(3)

F825 Provide/ObtainSpecializedRehabServices

483.65(a)(1)(2)

483.65SpecializedRehabilitativeServices

F406 483.65(a)(1)(2)

F826 RehabServices-PhysicianOrder/QualifiedPerson 483.65(b)

483.65SpecializedRehabilitativeServices

F407 483.65(b)

F790 Routine/EmergencyDentalServicesinSNFs

483.55(a)(1)-(5) 483.55DentalServices F411 483.55(a)(1)-(5)

F791 Routine/EmergencyDentalServicesinNFs 483.55(b)(1)-(5) 483.55Dental

Services F412 483.55(b)(1)-(5)

F755

PharmacySvcs/Procedures/Pharmacist/Records

483.45(a)(b)(1)-(3) 483.45PharmacyServices

F425 483.45(a)(b)(1)

F756 DrugRegimenReview,ReportIrregular,ActOn

483.45(c)(1)(2)(4)(5)


F428 483.45(c)(1)(2)(4)(5)

F758 XFreefromUnnecPsychotropicMeds/PRNUse

483.45(c)(3)(e)(1)-(5)


F428 483.45(c)(3)

F755

PharmacySvcs/Procedures/Pharmacist/Records

483.45(a)(b)(1)-(3) 483.45PharmacyServices

F431 483.45(b)(2)(3)

F761 Label/StoreDrugs&Biologicals

483.45(g)(h)(1)(2) 483.45PharmacyServices

F431 483.45(g)-(h)

F880 InfectionPrevention&Control

483.80(a)(1)(2)(4)(e)(f)

483.80InfectionControl F441 483.80(a)(1)(2)(4)€

F915 ResidentRoomWindow483.90(a)(7)(e)(1)(vi)

483.90PhysicalEnvironment F454 483.90(a)(7)

F906 EmergencyPower 483.90(c)(1)(2)483.90PhysicalEnvironment F455 483.90(c)(1)(2)

F907 SpaceandEquipment 483.90(d)(1) 483.90PhysicalEnvironment

F455 483.90(d)(1)

F908 EssentialEquipment,SafeOperatingCondition

483.90(d)(2) 483.90PhysicalEnvironment

F456 483.90(d)(2)

F910 ResidentRoom 483.90(e) 483.90PhysicalEnvironment

F456 483.90(e)

F911 BedroomNumberofResidents 483.90(e)(1))(i)

483.90PhysicalEnvironment F457 483.90(e)(1))(i)

F912 BedroomsMeasureatLeast80SquareFt/Resident

483.90(e)(1)(ii)483.90PhysicalEnvironment F458 483.90(e)(1)(ii)

F913 BedroomsHaveDirectAccesstoExitCorridor

483.90(e)(1)(iii) 483.90PhysicalEnvironment

F459 483.90(e)(1)(iii)

F914 BedroomsAssureFullVisualPrivacy

483.90(e)(1)(iv)(v) 483.90PhysicalEnvironment F460 483.90(e)(1)(iv)(v)



F700 X Bedrails 483.25(n)(1)-(4) 483.25QualityofCare

F461 483.25(n)(4)

F909 ResidentBed 483.90(d)(3)483.90PhysicalEnvironment F461 483.90(d)(3)

F915 ResidentRoomWindow483.90(a)(7)(e)(1)(vi)

483.90PhysicalEnvironment F461 483.90(e)(1)(vi)

F916 ResidentRoomFloorAboveGrade

483.90(e)(1)(vii)483.90PhysicalEnvironment F461 483.90(e)(1)(vii)

F917 ResidentRoomBed/Furniture/Closet

483.10(i)(4)483.90(e)(2)(3)

483.10ResidentRights483.90PhysicalEnvironment

F461483.10(i)(4)483.90(e)(2)(3)

F918 BedroomsEquipped/NearLavatory/Toilet

483.90(f) 483.90PhysicalEnvironment

F462 483.90(f)

F919 ResidentCallSystem 483.90(g)(1)(2)483.90PhysicalEnvironment

(g)(1)-Phase3WillnotbeinASPENuntilPhase3

F463 483.90(g)(1)(2)

F920 RequirementsforDiningandActivityRooms 483.90(h)(1)-(4)

483.90PhysicalEnvironment F464 483.90(h)(1)-(4)

F921 Safe/Functional/Sanitary/ComfortableEnvironment

483.90(i) 483.90PhysicalEnvironment

F465 483.90(i)

F922 ProcedurestoEnsureWaterAvailability

483.90(i)(1) 483.90PhysicalEnvironment

F466 483.90(i)(1)

F923 Ventilation 483.90(i)(2) 483.90PhysicalEnvironment

F467 483.90(i)(2)

F924 CorridorsHaveFirmlySecuredHandrails


F468 483.90(i)(3)

F925 MaintainsEffectivePestControlProgram


F469 483.90(i)(4)

F835 Administration 483.70 483.70Administration F490 483.70

F836 License/Complyw/Fed/State/LocalLaw/ProfStd

483.70(a)-(c)483.70Administration F491 483.70(a)

F836 License/Complyw/Fed/State/LocalLaw/ProfStd

483.70(a)-(c) 483.70Administration

F492 483.70(b)(c)

F837 GoverningBody 483.70(d)(1)-(3) 483.70Administration

(d)(3)-Phase3WillnotbeinASPENuntilPhase3

F493 483.70(d)(1)-(3)

F728 FacilityHiringandUseofNurseAide

483.35(d)(1)-(3) 483.35NursingServices F494 483.35(d)(1)(2)

F728 FacilityHiringandUseofNurseAide

483.35(d)(1)-(3)483.35NursingServices F495 483.35(d)(3)

F729 NurseAideRegistryVerification,Retraining

483.35(d)(4)-(6) 483.35NursingServices

F496 483.35(d)(4)-(6)

F730 NurseAidePerformReview–12Hr/YearIn-service

483.35(d)(7) 483.35NursingServices F497 483.35(d)(7)

F726 CompetentNursingStaff 483.35(a)(3)(4)(c) 483.35NursingServices

F498 483.35(c)

F947 RequiredIn-ServiceTrainingforNurseAides 483.95(g)(1)-(4) 483.95Training

Requirements F498 483.95(g)(1)-(4)

F839 StaffQualifications 483.70(f)(1)(2)483.70Administration F499 483.70(f)(1)(2)

F840 UseofOutsideResources 483.70(g)(1)(2) 483.70Administration F500 483.70(g)(1)(2)(i)(ii)

F841 ResponsibilitiesofMedicalDirector

483.70(h)(1)(2) 483.70Administration F501 483.70(h)(1)(2)

F770 LaboratoryServices 483.50(a)(1)(i)

483.50Laboratory,Radiology,andOtherDiagnosticServices

F502 483.50(a)(1)

F771 BloodBlankandTransfusionServices 483.50(a)(1)(ii)


F502 483.50(a)(1)

F770 LaboratoryServices 483.50(a)(1)(i)


F503 483.50(a)(i)

F771 BloodBlankandTransfusionServices 483.50(a)(1)(ii)


F503 483.50(a)(ii)

F772 LabServicesNotProvidedOn-Site

483.50(a)(1)(iv)


F503 483.50(a)(iv)

F773 LabSvsPhysicianOrder/NotifyofResults

483.50(a)(2)(i)(ii)


F504 483.50(a)(2)(i)

F773 LabSvsPhysicianOrder/NotifyofResults

483.50(a)(2)(i)(ii)


F505 483.50(a)(2)(ii)

F774 AssistwithTransportArrangementstoLabSvcs

483.50(a)(2)(iii)


F506 483.50(a)(2)(iii)

F775 LabReportsinRecord-LabName/Address

483.50(a)(2)(iv)


F507 483.50(a)(2)(iv)

F776 Radiology/OtherDiagnosticServices 483.50(b)(1)(i)(ii)


F508 483.50(b)(1)

F776 Radiology/OtherDiagnosticServices

483.50(b)(1)(i)(ii)


F509 483.50(b)(i)(ii)

F777 Radiology/Diag.SvcsOrdered/NotifyResults 483.50(b)(2)(i)(ii)


F510 483.50(b(2)(i)

F777 Radiology/Diag.SvcsOrdered/NotifyResults

483.50(b)(2)(i)(ii)


F511 483.50(b)(2)(ii)

F778 AssistwithTransportArrangementstoRadiology

483.50(b)(2)(iii)


F512 483.50(b)(2)(iii)

F779 X-Ray/DiagnosticReportinRecord-Sign/Dated

483.50(b)(2)(iv)


F513 483.50(b)(2)(iv)


483.20(f)(5)483.70(i)(1)-(5)


F514 483.70(i)1)(5)


483.20(f)(5)483.70(i)(1)-(5)


F515 483.70(i)(4)(i)-(iii)


483.20(f)(5)483.70(i)(1)-(5)


F516 483.20(f)(5);483.70(i)(3)

F843 TransferAgreement 483.70(j)(1)(2) 483.70Administration F519 483.70(j)(1)(2)

F865 QAPIProgram/Plan,Disclosure/GoodFaithAttempt

483.75(a)(b)(f)(h)(i)

483.75QualityAssuranceandPerformanceImprovement

(a)(1)(3)(4)(b)(f)-Phase3WillnotbeinASPENuntilPhase3

F520 483.75(a)(2)(h)(i)

F866 QAPI/QAADataCollectionandMonitoring

483.75(c)(1)-(4)


Entiretag-Phase3WillnotbeinASPENuntilPhase3

F520 483.75(c)(1)-(4)

F867 QAPI/QAAImprovementActivities

483.75(d)(1)(2)(e)(1)-(3)(g)(2)


(d)(1)(2)(i)-(iii)(e)(1)-(3)(g)(2)(iii)willnotbeinASPENuntilPhase3

F520 483.75(g)(2)(ii)

F868 QAACommittee 483.75(g)(1)(i)-(iv)(2)(i)


(g)(1)(iv)-Phase3WillnotbeinASPENuntilPhase3

F520 483.75(g)(1)(i)-(iii)(2)(i)

F844 DisclosureofOwnershipRequirements

483.70(k)(1)-(3) 483.70Administration

F522 483.70(k)(1)-(3)

F845 Facilityclosure-Administrator 483.70(l)(1)-(3)

483.70Administration F523 483.70(l)(1)-(3)

F846 Facilityclosure 483.70(m) 483.70Administration

F524 483.70(m)

F849 HospiceServices 483.70(o)(1)-(4) 483.70Administration

F526 483.70(o)(1)-(4)

F851 PayrollBasedJournal 483.70(q)(1)-(5)483.70Administration F527 483.70(q)(1)-(5)

F608 X ReportingofReasonableSuspicionofaCrime

483.12(b)(5)(i)-(iii)


NoAssociatedTag

F655 BaselineCarePlan 483.21(a)(1)-(3)


NoAssociatedTag

F699 X TraumaInformedCare 483.25(m) 483.25QualityofCare


NoAssociatedTag

F740 BehavioralHealthServices

483.40483.40BehavioralHealthServices

NoAssociatedTag

F741 Sufficient/CompetentStaff-BehaveHealthNeeds

483.40(a)(1)(2)483.40BehavioralHealthServices

NoAssociatedTag

F838 FacilityAssessment 483.70(e)(1)-(3)483.70Administration NoAssociatedTag

F881 AntibioticStewardshipProgram

483.80(a)(3) 483.80InfectionControl

NoAssociatedTag

F882 InfectionPreventionistQualifications/Role 483.80(b)(1)-(4)(c) 483.80Infection

Control


NoAssociatedTag

F895 ComplianceandEthicsProgram

483.85(a)-(e)483.85ComplianceandEthicsProgram


NoAssociatedTag

F926 SmokingPolicies 483.90(i)(5)483.90PhysicalEnvironment NoAssociatedTag

F940 TrainingRequirements-General 483.95 483.95Training

Requirements


NoAssociatedTag

F941 CommunicationTraining 483.95(a) 483.95TrainingRequirements


NoAssociatedTag

F942 Resident’sRightsTraining 483.95(b)483.95TrainingRequirements


NoAssociatedTag

F944 QAPITraining 483.95(d) 483.95TrainingRequirements


NoAssociatedTag

F945 InfectionControlTraining 483.95(e)483.95TrainingRequirements


NoAssociatedTag

F946 ComplianceandEthicsTraining 483.95(f)(1)(2) 483.95Training

Requirements


NoAssociatedTag

F949 BehavioralHealthTraining

483.95(i) 483.95TrainingRequirements


NoAssociatedTag

PLACETABFORDEFINIT IONSHERE

POLICY/PROCEDURE

SUBJECT:Definitions

DATE:

INTENT:

ItisthepolicyofthefacilitytoacceptthefollowingdefinitionsasdescribedbytheCenterforMedicareandMedicaidServicesintothepoliciesandproceduresoutlinedwithinthismanual.

DEFINITIONS:

Asusedinthissubpart,thefollowingdefinitionsapply:

Abuse-Abuseisthewillfulinflictionofinjury,unreasonableconfinement,intimidation,orpunishmentwithresultingphysicalharm,painormentalanguish.Abusealsoincludesthedeprivationbyanindividual,includingacaretaker,ofgoodsorservicesthatarenecessarytoattainormaintainphysical,mental,andpsychosocialwell-being.Instancesofabuseofallresidents,irrespectiveofanymentalorphysicalcondition,causephysicalharm,painormentalanguish.Itincludesverbalabuse,sexualabuse,physicalabuse,andmentalabuseincludingabusefacilitatedorenabledthroughtheuseoftechnology.Willful,asusedinthisdefinitionofabuse,meanstheindividualmusthaveacteddeliberately,notthattheindividualmusthaveintendedtoinflictinjuryorharm.

Adverseevent-Anadverseeventisanuntoward,undesirable,andusuallyunanticipatedeventthatcausesdeathorseriousinjury,ortheriskthereof.

Commonarea-Commonareasareareasinthefacilitywhereresidentsmaygathertogetherwithotherresidents,visitors,andstafforengageinindividualpursuits,apartfromtheirresidentialrooms.Thisincludesbutisnotlimitedtolivingrooms,diningrooms,activityrooms,outdoorareas,andmeetingroomswhereresidentsarelocatedonaregularbasis.

Compositedistinctpart-1. Definition-Acompositedistinctpartisadistinctpartconsistingoftwoormore

noncontiguouscomponentsthatarenotlocatedwithinthesamecampus,asdefinedin§413.65(a)(2)ofthischapter.

2. Requirements-Inadditiontomeetingtherequirementsofspecifiedinthedefinitionof“distinctpart”ofthissection,acompositedistinctpartmustmeetallofthefollowingrequirements:a. ASNForNFthatisacompositeofmorethanonelocationwillbetreatedasa

singledistinctpartoftheinstitutionofwhichitisadistinctpart.Assuch,thecompositedistinctpartwillhaveonlyoneprovideragreementandonlyoneprovidernumber.

b. Iftwoormoreinstitutions(eachwithadistinctpartSNForNF)undergoachangeofownership,CMSmustapprovetheexistingSNFsorNFsasmeetingtherequirementsbeforetheyareconsideredacompositedistinctpartofasingleinstitution.Inmakingsuchadetermination,CMSconsiderswhetheritsapprovalordisapprovalofacompositedistinctpartpromotestheeffectiveandefficientuseofpublicmonieswithoutsacrificingthequalityofcare.IfthereisachangeofownershipofacompositedistinctpartSNForNF,theassignmentoftheprovideragreementtothenewownerwillapplytoalloftheapprovedlocationsthatcomprisethecompositedistinctpartSNForNF.

c. Toensurequalityofcareandqualityoflifeforallresidents,thevariouscomponentsofacompositedistinctpartmustmeetalloftherequirementsforparticipationindependentlyineachlocation.

d. Toensurequalityofcareandqualityoflifeforallresidents,thevariouscomponentsofacompositedistinctpartmustmeetalloftherequirementsforparticipationindependentlyineachlocation.

e. Useofcompositedistinctpartstosegregateresidentsbypaymentsourceoronabasisotherthancareneedsisprohibited.

Distinctpart-1. Definition-AdistinctpartSNForNFisphysicallydistinguishablefromthelarger

institutionorinstitutionalcomplexthathousesit,meetstherequirementsofthisparagraphandofparagraph(2)ofthisdefinition,andmeetstheapplicablestatutoryrequirementsforSNFsorNFsinsections1819or1919oftheAct,respectively.AdistinctpartSNForNFmaybecomprisedofoneormorebuildingsordesignatedpartsofbuildings(thatis,wings,wards,orfloors)thatare:Inthesamephysicalareaimmediatelyadjacenttotheinstitution'smainbuildings;otherareasandstructuresthatarenotstrictlycontiguoustothemainbuildingsbutarelocatedwithincloseproximityofthemainbuildings;andanyotherareasthatCMSdeterminesonanindividualbasis,tobepartoftheinstitution'scampus.Adistinctpartmustincludeallofthebedswithinthedesignatedarea,andcannotconsistofarandomcollectionofindividualroomsorbedsthatarescatteredthroughoutthephysicalplant.Theterm“distinctpart”alsoincludesacompositedistinctpartthatmeetstheadditionalrequirementsspecifiedinthedefinitionof“compositedistinctpart”ofthissection.

2. Requirements.Inadditiontomeetingtheparticipationrequirementsforlong-termcarefacilitiessetforthelsewhereinthissubpart,adistinctpartSNForNFmustmeetallofthefollowingrequirements:a. TheSNForNFmustbeoperatedundercommonownershipandcontrol(that

is,commongovernance)bytheinstitutionofwhichitisadistinctpart,asevidencedbythefollowing:i. TheSNForNFiswhollyownedbytheinstitutionofwhichitisadistinct

part.ii. TheSNForNFissubjecttotheby-lawsandoperatingdecisionsofcommon

governingbody.

iii. TheinstitutionofwhichtheSNForNFisadistinctparthasfinalresponsibilityforthedistinctpart’sadministrativedecisionsandpersonnelpolicies,andfinalapprovalforthedistinctpart’spersonnelactions.

iv. TheSNForNFfunctionsasanintegralandsubordinatepartoftheinstitutionofwhichitisadistinctpart,withsignificantcommonresourceusageofbuildings,equipment,personnel,andservices.

b. TheadministratoroftheSNForNFreportstoandisdirectlyaccountabletothemanagementoftheinstitutionofwhichtheSNForNFisadistinctpart.

c. TheSNForNFmusthaveadesignatedmedicaldirectorwhoisresponsibleforimplementingcarepoliciesandcoordinatingmedicalcare,andwhoisdirectlyaccountabletothemanagementoftheinstitutionofwhichitisadistinctpart.

d. TheSNForNFisfinanciallyintegratedwiththeinstitutionofwhichitisadistinctpart,asevidencedbythesharingofincomeandexpenseswiththatinstitution,andthereportingofitscostsonthatinstitution’scostreport.

e. AsingleinstitutioncanhaveamaximumofonlyonedistinctpartSNFandonedistinctpartNF.

f. (A)AninstitutioncannotdesignateadistinctpartSNForNF,butinsteadmustsubmitawrittenrequestwithdocumentationthatdemonstratesitmeetsthecriteriasetforthabovetoCMStodetermineifitmaybeconsideredadistinctpart.(B)TheeffectivedateofapprovalofadistinctpartisthedatethatCMSdeterminesallrequirements(includingenrollmentwiththefiscalintermediary(FI)aremetforapproval,andcannotbemaderetroactive.(C)TheinstitutionmustrequestapprovalfromCMSforallproposedchangesinthenumberofbedsintheapproveddistinctpart.

Exploitation-Exploitationmeanstakingadvantageofaresidentforpersonalgainthroughtheuseofmanipulation,intimidation,threats,orcoercion.

Facilitydefined-Forpurposesofthissubpart,facilitymeansaskillednursingfacility(SNF)thatmeetstherequirementsofsections1819(a),(b),(c),and(d)oftheAct,oranursingfacility(NF)thatmeetstherequirementsofsections1919(a),(b),(c),and(d)oftheAct.“Facility”mayincludeadistinctpartofaninstitution(asdefinedinparagraph(b)ofthissectionandspecifiedin§440.40and§440.155ofthischapter),butdoesnotincludeaninstitutionforindividualswithintellectualdisabilitiesorpersonswithrelatedconditionsdescribedin§440.150ofthischapter.ForMedicareandMedicaidpurposes(includingeligibility,coverage,certification,andpayment),the“facility”isalwaystheentitythatparticipatesintheprogram,whetherthatentityiscomprisedofallof,oradistinctpartof,alargerinstitution.ForMedicare,anSNF(seesection1819(a)(1)oftheAct),andforMedicaid,andNF(seesection1919(a)(1)oftheAct)maynotbeaninstitutionformentaldiseasesasdefinedin§435.1010ofthischapter.

Fullysprinklered-AfullysprinkleredlongtermcarefacilityisonethathasallareassprinkleredinaccordancewithNationalFireProtectionAssociation13“StandardfortheInstallationofSprinklerSystems”withouttheuseofwaiversortheFireSafetyEvaluationSystem.

Licensedhealthprofessional-Alicensedhealthprofessionalisaphysician;physicianassistant;nursepractitioner;physical,speech,oroccupationaltherapist;physicaloroccupationaltherapyassistant;registeredprofessionalnurse;licensedpracticalnurse;orlicensedorcertifiedsocialworker;orregisteredrespiratorytherapistorcertifiedrespiratorytherapytechnician.

Majormodification-Amodificationmeansthemodificationofmorethan50percent,ormorethan4,500squarefeet,ofthesmokecompartment.

Misappropriationofresidentproperty-meansthedeliberatemisplacement,exploitation,orwrongful,temporary,orpermanentuseofaresident’sbelongingsormoneywithouttheresident’sconsent.

Mistreatment-meansinappropriatetreatmentorexploitationofaresident.

Neglect-isthefailureofthefacility,itsemployeesorserviceproviderstoprovidegoodsandservicestoaresidentthatarenecessarytoavoidphysicalharm,pain,mentalanguish,oremotionaldistress.

Nurseaide-Anurseaideisanyindividualprovidingnursingornursing-relatedservicestoresidentsinafacility.Thistermmayalsoincludeanindividualwhoprovidestheseservicesthroughanagencyorunderacontractwiththefacility,butisnotalicensedhealthprofessional,aregistereddietitian,orsomeonewhovolunteerstoprovidesuchserviceswithoutpay.Nurseaidesdonotincludethoseindividualswhofurnishservicestoresidentsonlyaspaidfeedingassistantsasdefinedin§488.301ofthischapter.

Person-centeredcare-Forpurposesofthissubpart,person-centeredcaremeanstofocusontheresidentasthelocusofcontrolandsupporttheresidentinmakingtheirownchoicesandhavingcontrolovertheirdailylives.

Residentrepresentative-Forpurposesofthissubpart,thetermresidentrepresentativemeansanyofthefollowing:

1. Anindividualchosenbytheresidenttoactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;

2. ApersonauthorizedbyStateorFederallaw(includingbutnotlimitedtoagentsunderpowerofattorney,representativepayees,andotherfiduciaries)toactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;or

3. Legalrepresentative,asusedinsection712oftheOlderAmericansAct;or4. Thecourt-appointedguardianorconservatorofaresident.5. Nothinginthisruleisintendedtoexpandthescopeofauthorityofanyresident

representativebeyondthatauthorityspecificallyauthorizedbytheresident,StateorFederallaw,oracourtofcompetentjurisdiction.

Sexualabuse-isnon-consensualsexualcontactofanytypewitharesident.

Transferanddischarge-includesmovementofaresidenttoabedoutsideofthecertifiedfacilitywhetherthatbedisinthesamephysicalplantornot.Transferanddischargedoesnotrefertomovementofaresidenttoabedwithinthesamecertifiedfacility.

PLACETABFORRESIDENTRIGHTSHERE

POLICY/PROCEDURE

SUBJECT:ResidentRights

DATE:

INTENT:

AllresidentshaverightsguaranteedtothemunderFederalandStatelawsandregulations.Thispolicyisintendedtolaythefoundationfortheresidentrightsrequirementsinlong-termcarefacilities.Eachresidenthastherighttobetreatedwithdignityandrespect.Allactivitiesandinteractionswithresidentsbyanystaff,temporaryagencystafforvolunteersmustfocusonassistingtheresidentinmaintainingandenhancinghisorherself-esteemandself-worthandincorporatingtheresident’s,goals,preferences,andchoices.Whenprovidingcareandservices,staffwillrespecteachresident’sindividuality,aswellashonorandvaluetheirinput.

PROCEDURE:

Thispolicywillinclude:

1.ResidentRights/ExerciseofRights2.Rightsexercisedbyrepresentative3.RighttobeInformed/MakeTreatmentDecisions4.RighttoParticipateinPlanningCare5.ResidentSelf-AdminMeds-ClinicallyAppropriate6.RighttoChoose/BeInformedofAttendingPhysician7.Respect,Dignity/RighttohavePersonalProperty8.ReasonableAccommodationsofNeeds/Preferences9.Choose/BeNotifiedofRoom/RoommateChange10.RighttoRefuseCertainTransfers11.SelfDetermination12.ImmediateAccesstoResident13.RighttoReceive/DenyVisitors14.InformofVisitationRights/EqualVisitationPrivileges15.Resident/FamilyGroupandResponse16.RighttoPerformFacilityServicesorRefuse17.Protection/ManagementofPersonalFunds18.AccountingandRecordsofPersonalFunds19.NoticeandConveyanceofPersonalFunds20.SuretyBond-SecurityofPersonalFunds21.LimitationsonChargestoPersonalFunds22.NoticeofRightsandRules23.RighttoAccess/PurchaseCopiesofRecords24.RequiredNoticesandContactInformation25.RequiredPostings

26.RighttoFormsofCommunicationwithPrivacy27.RighttoSurveyResults/AdvocateAgencyInfo28.Request/Refuse/DiscontinueTreatment;FormulateAdvanceDirectives29.Posting/NoticeofMedicare/MedicaidonAdmission30.NotifyofChanges(Injury/Decline/Room,Etc.)31.Medicaid/MedicareCoverage/LiabilityNotice32.PersonalPrivacy/ConfidentialityofRecords33.Safe/Clean/Comfortable/HomelikeEnvironment34.Grievances35.ResidentContactwithExternalEntities

POLICY/PROCEDURE

SUBJECT:ResidentRights-ExerciseofRights

DATE:

INTENT:

AllresidentshaverightsguaranteedtothemunderFederalandStatelawsandregulations.Thispolicyisintendedtolaythefoundationfortheresidentrightsrequirementsinlong-termcarefacilities.Eachresidenthastherighttobetreatedwithdignityandrespect.Allactivitiesandinteractionswithresidentsbyanystaff,temporaryagencystafforvolunteersmustfocusonassistingtheresidentinmaintainingandenhancinghisorherself-esteemandself-worthandincorporatingtheresident’s,goals,preferences,andchoices.Whenprovidingcareandservices,staffwillrespecteachresident’sindividuality,aswellashonorandvaluetheirinput.

PROCEDURE:

1. Theresidenthasarighttoadignifiedexistence,self-determination,andcommunicationwithandaccesstopersonsandservicesinsideandoutsidethefacility.

2. Thefacilitywilltreateachresidentwithrespectanddignityandcareforeachresidentinamannerandinanenvironmentthatpromotesmaintenanceorenhancementofhisorherqualityoflife,recognizingeachresident’sindividuality.

3. Thefacilitywillprotectandpromotetherightsoftheresident.4. Thefacilitywillprovideequalaccesstoqualitycareregardlessofdiagnosis,severity

ofcondition,orpaymentsource.5. Thefacilitywillestablishandmaintainidenticalpoliciesandpracticesregarding

transfer,discharge,andtheprovisionofservicesundertheStateplanforallresidentsregardlessofpaymentsource.

6. TheresidenthastherighttoexercisehisorherrightsasaresidentofthefacilityandasacitizenorresidentoftheUnitedStates.

7. Thefacilitywillensurethattheresidentcanexercisehisorherrightswithoutinterference,coercion,discrimination,orreprisalfromthefacility.

8. Theresidenthastherighttobefreeofinterference,coercion,discrimination,andreprisalfromthefacilityinexercisinghisorherrightsandtobesupportedbythefacilityintheexerciseofhisorherrights.

9. Eachresidentwillbetreatedwithdignityandrespect.10. Allactivitiesandinteractionswithresidentsbyanystaff,temporaryagencystaffor

volunteerswillfocusonassistingtheresidentinmaintainingandenhancinghisorherself-esteemandself-worthandincorporatingtheresident’s,goals,preferences,andchoices.

11. Whenprovidingcareandservices,staffwillrespecteachresident’sindividuality,aswellashonorandvaluetheirinput.

POLICY/PROCEDURE

SUBJECT:ResidentRights-ResidentExercisebyRepresentative

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.Whenandwheretheresidenthasbeendeemedincapacitatedoradjudicatedincompetentinacourtoflaw,theResidentRepresentativewillbeaffordedthesamerighttoexercisetheresident’srightsonbehalfoftheresident.

DEFINITIONS:

Courtofcompetentjurisdiction-meansanycourtwiththeauthoritytohearanddetermineacaseorsuitwiththematterinquestion.Residentrepresentative-Forpurposesofthissubpart,thetermresidentrepresentativemaymeananyofthefollowing:

1. Anindividualchosenbytheresidenttoactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;

2. ApersonauthorizedbyStateorFederallaw(includingbutnotlimitedtoagentsunderpowerofattorney,representativepayees,andotherfiduciaries)toactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;or

3. Legalrepresentative,asusedinsection712oftheOlderAmericansAct;or4. Thecourt-appointedguardianorconservatorofaresident.5. Nothinginthisruleisintendedtoexpandthescopeofauthorityofanyresident

representativebeyondthatauthorityspecificallyauthorizedbytheresident,StateorFederallaw,oracourtofcompetentjurisdiction.

PROCEDURE:

1. Inthecaseofaresidentwhohasnotbeenadjudgedincompetentbythestatecourt,theresidenthastherighttodesignatearepresentative,inaccordancewithStatelawandanylegalsurrogatesodesignatedmayexercisetheresident’srightstotheextentprovidedbystatelaw.Thesame-sexspouseofaresidentmustbeaffordedtreatmentequaltothataffordedtoanopposite-sexspouseifthemarriagewasvalidinthejurisdictioninwhichitwascelebrated.a. Theresidentrepresentativehastherighttoexercisetheresident’srightstothe

extentthoserightsaredelegatedtotherepresentative.

b. Theresidentretainstherighttoexercisethoserightsnotdelegatedtoaresidentrepresentative,includingtherighttorevokeadelegationofrights,exceptaslimitedbyStatelaw.

2. Thefacilitymusttreatthedecisionsofaresidentrepresentativeasthedecisionsoftheresidenttotheextentrequiredbythecourtordelegatedbytheresident,inaccordancewithapplicablelaw.

3. Thefacilityshallnotextendtheresidentrepresentativetherighttomakedecisionsonbehalfoftheresidentbeyondtheextentrequiredbythecourtordelegatedbytheresident,inaccordancewithapplicablelaw.

4. Ifthefacilityhasreasontobelievethataresidentrepresentativeismakingdecisionsortakingactionsthatarenotinthebestinterestsofaresident,thefacilityshallreportsuchconcernswhenandinthemannerrequiredunderStatelaw.

5. InthecaseofaresidentadjudgedincompetentunderthelawsofaStatebyacourtofcompetentjurisdiction,therightsoftheresidentdevolvetoandareexercisedbytheresidentrepresentativeappointedunderStatelawtoactontheresident’sbehalf.Thecourt-appointedresidentrepresentativeexercisestheresident’srightstotheextentjudgednecessarybyacourtofcompetentjurisdiction,inaccordancewithStatelaw.a. Inthecaseofaresidentrepresentativewhosedecision-makingauthorityis

limitedbyStatelaworcourtappointment,theresidentretainstherighttomakethosedecisionsoutsidetherepresentative’sauthority.

b. Theresident’swishesandpreferencesmustbeconsideredintheexerciseofrightsbytherepresentative.

c. Totheextentpracticable,theresidentmustbeprovidedwithopportunitiestoparticipateinthecareplanningprocess.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RightToBeInformedandMakeTreatmentDecisions

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.

DEFINITIONS:

TotalHealthStatus-Totalhealthstatusincludesfunctionalstatus,nutritionalstatus,rehabilitationandrestorativepotential,abilitytoparticipateinactivities,cognitivestatus,oralhealthstatus,psychosocialstatus,andsensoryandphysicalimpairments.

Treatment-Treatmentreferstomedicalcare,nursingcare,andinterventionsprovidedtomaintainorrestorehealthandwell-being,improvefunctionallevel,orrelievesymptoms.

PROCEDURE:

Theresidenthastherighttobeinformedof,andparticipatein,hisorhertreatment,including:

1. Therighttobefullyinformedinlanguagethatheorshecanunderstandofhisorhertotalhealthstatus,includingbutnotlimitedto,hisorhermedicalcondition.

2. Therighttobeinformed,inadvance,ofthecaretobefurnishedandthetypeofcaregiverorprofessionalthatwillfurnishcare.

3. Therighttobeinformedinadvance,bythephysicianorotherpractitionerorprofessional,oftherisksandbenefitsofproposedcare,oftreatmentandtreatmentalternativesortreatmentoptionsandtochoosethealternativeoroptionheorsheprefers.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoParticipateinPlanningCare

DATE:

INTENT:


PROCEDURE:

1. Theresident’srighttoparticipateinthedevelopmentandimplementationofhisorherperson-centeredplanofcare,includingbutnotlimitedto:

a. Therighttoparticipateintheplanningprocess,includingtherighttoidentifyindividualsorrolestobeincludedintheplanningprocess,therighttorequestmeetingsandtherighttorequestrevisionstotheperson-centeredplanofcare.

b. Therighttoparticipateinestablishingtheexpectedgoalsandoutcomesofcare,thetype,amount,frequency,anddurationofcare,andanyotherfactorsrelatedtotheeffectivenessoftheplanofcare.

c. Therighttobeinformed,inadvance,ofchangestotheplanofcare.d. Therighttoreceivetheservicesand/oritemsincludedintheplanofcare.e. Therighttoseethecareplan,includingtherighttosignaftersignificant

changestotheplanofcare.

1. Thefacilitywillinformtheresidentoftherighttoparticipateinhisorhertreatmentandshallsupporttheresidentinthisright.

2. Theplanningprocesswill:a. Facilitatetheinclusionoftheresidentand/orresidentrepresentative.b. Includeanassessmentoftheresident’sstrengthsandneeds.c. Incorporatetheresident’spersonalandculturalpreferencesin

developinggoalsofcare.

3. Thefacilitystaffwillfacilitateanddocumentintheresident’sclinicalrecord,theinclusionoftheresidentorresidentrepresentativeinallaspectsofperson-centeredcareplanningandthatthisplanningincludestheprovisionofservicestoenabletheresidenttolivewithdignityandsupportstheresident’sgoals,choices,andpreferencesincluding,butnotlimitedto,goalsrelatedtothetheirdailyroutinesandgoalstopotentiallyreturntoacommunitysetting.

POLICY/PROCEDURE

SUBJECT:ResidentRight–SelfAdministrationofMeds–ClinicallyAppropriate

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowtheresidentandorlegalrepresentativeoftheresidenttherighttoself-administermedicationwhenithasbeendeemedbytheinterdisciplinaryteamthatitisclinicallyappropriate.

PROCEDURE:

1. Theresidenthasrighttoself-administermedicationsiftheinterdisciplinaryteamhasdeterminedthatthispracticeisclinicallyappropriate.

2. Whenaresidentrequeststoself-administermedication(s),itistheresponsibilityoftheinterdisciplinaryteam(IDT)todeterminethatitissafebeforetheresidentexercisesthatright.

3. Aresidentmayonlyself-administermedicationsaftertheIDThasdeterminedwhichmedicationsmaybeself-administered.

4. Whendeterminingifself-administrationisclinicallyappropriateforaresident,theIDTwillataminimumconsiderthefollowing:

a. Themedicationsappropriateandsafeforself-administration;b. Theresident’sphysicalcapacitytoswallowwithoutdifficultyandtoopen

medicationbottles;c. Theresident’scognitivestatus,includingtheirabilitytocorrectlyname

theirmedicationsandknowwhatconditionstheyaretakenfor;d. Theresident’scapabilitytofollowdirectionsandtelltimetoknowwhen

medicationsneedtobetaken;e. Theresident’scomprehensionofinstructionsforthemedicationstheyare

taking,includingthedose,timing,andsignsofsideeffects,andwhentoreporttofacilitystaff.

f. Theresident’sabilitytounderstandwhatrefusalofmedicationis,andappropriatestepstakenbystafftoeducatewhenthisoccurs.

g. Theresident’sabilitytoensurethatmedicationisstoredsafelyandsecurely.

5. Appropriatenotationofthesedeterminationswillbedocumentedintheresident’smedicalrecordandcareplan.

PROCEDURE

SUBJECT:Self-AdministrationofMedicationProgram

DATE:

POLICY:

Itisthepolicyofthefacilitytoallowtheresidentandorlegalrepresentativeoftheresidenttherighttoself-administermedicationwhenithasbeendeemedbytheinterdisciplinaryteamthatitisclinicallyappropriate.

PROCEDURE:

1. Thefacilitywillallowtheresidenttoself-administerdrugsiftheinterdisciplinaryteam,hasdeterminedthatthispracticeissafe.

2. TheadmittingNursewillasktheresidentandorresponsibleparty,iftheyareinterestedinparticipatingintheSelf-AdministrationofMedicationProgram.

3. Whentheresidentandorresponsiblepartyrequeststoparticipateintheprogram,theadmittingNursewillinformtheresident’sInterdisciplinaryTeam(IDT).

4. TheIDTmayconsistof:TheDirectorofNursingordesignee,UnitManager;ofwhichtheresidentresides,theMDS/CarePlanCoordinator,anOccupationalTherapist,aSpeechTherapist,theSocialServiceDirector,theresident’sphysicianorphysicianextender,anyotherstaffmemberstheteamdeemsappropriate.

5. Ifaresidentrequeststoself-administerdrugs,itistheresponsibilityoftheIDTtodeterminethatitissafefortheresidenttoself-administerdrugs,beforetheresidentmayexercisethatright.

6. Whendeterminingifself-administrationisclinicallyappropriateforaresident,theIDTwillataminimumconsiderthefollowing:

h. Themedicationsappropriateandsafeforself-administration;i. Theresident’sphysicalcapacitytoswallowwithoutdifficultyandtoopen

medicationbottles;j. Theresident’scognitivestatus,includingtheirabilitytocorrectlyname

theirmedicationsandknowwhatconditionstheyaretakenfor;k. Theresident’scapabilitytofollowdirectionsandtelltimetoknowwhen

medicationsneedtobetaken;l. Theresident’scomprehensionofinstructionsforthemedicationstheyare

taking,includingthedose,timing,andsignsofsideeffects,andwhentoreporttofacilitystaff.

m. Theresident’sabilitytounderstandwhatrefusalofmedicationis,andappropriatestepstakenbystafftoeducatewhenthisoccurs.

n. Theresident’sabilitytoensurethatmedicationisstoredsafelyandsecurely.

7. TheadmittingnurseordesigneewillcompletetheSelf-AdministrationofMedicationEvaluationandreportthefindingstotheUnitManagerordesignee.

8. Theinterdisciplinaryteammustalsodetermine:a. Whowillberesponsible(theresidentorthenursingstaff)forstorage(See

F431);Ifmedicationsarestoredattheresident’sbedside,alockboxorlockeddrawermustbeusedtostorethemedication(s);

b. Whowillberesponsible(theresidentorthenursingstaff)fordocumentationoftheadministrationofdrugs;Iftheresidentisresponsiblefordocumentation,maintainaMedicationAdministrationRecord(MAR)intheresident’sroomfortheresidenttosignandmaintainaduplicateMARfornursingstaff;aswellas,

c. Thelocationofthedrugadministration(e.g.,resident’sroom,nurses’station,oractivitiesroom).

9. OncetheresidenthasbeendeemedsafebytheIDTanorderwillbeobtainedfromtheresident’sphysicianorphysicianextenderlistingthemedication(s)thatmaybeself-administered,wherethemedicationswillbestored,whowillberesponsiblefordocumentationandthelocationofadministration.

10. Appropriatedocumentationoftheabovedeterminationswillbedocumentedintheresident’scareplan.

11. Theresidentwillbemonitoredeveryshiftforthefirstthreedaysforcompliancetotheprogram,withwrittendocumentationbythenursenotingfindings.Iffurtherevery-shiftmonitoringisneeded,itwillbebroughttotheattentionoftheUnitManager,whowilltheninformtheIDTandreportconcerns.Ifcomplianceisnotedwithinthefirstthreedays,thendailydocumentationwillbecompletedbythe3–11shiftnursesfortheremainingfourdaysofthefirstweek.

12. Weeklydocumentationwilloccurafterthefirstweekforthenexttwoweeksbythe3-11shiftnurses,followedperiodicmonitoring.

13. Thedecisionthataresidenthastheabilitytoself-administermedication(s)issubjecttoperiodicre-evaluationbasedonchangeintheresident’sstatus.

14. Theresidentwillbere-evaluatedontheirabilitytocontinuetoself-administermedicationsinconjunctionwiththeresidentassessmentinstrument.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoChoose/BeInformedofAttendingPhysician

DATE:

INTENT:


PROCEDURE:

1. Theresidenthastherighttochoosehisorherattendingphysician.2. Thephysicianmustbelicensedtopractice,and3. Ifthephysicianchosenbytheresidentrefusestoordoesnotmeetvisitation

requirements,thefacilitymayseekalternatephysicianparticipationtoassureprovisionofappropriateandadequatecareandtreatment.

4. Thefacilitywillensurethateachresidentremainsinformedofthename,specialty,andwayofcontactingthephysicianandotherprimarycareprofessionalsresponsibleforhisorhercare.

5. Thefacilitywillinformtheresidentifthefacilitydeterminesthatthephysicianchosenbytheresidentisunableorunwillingtomeetrequirementsspecifiedinthispartandthefacilityseeksalternatephysicianparticipationtoassureprovisionofappropriateandadequatecareandtreatment.

6. Thefacilitywilldiscussthealternativephysicianparticipationwiththeresidentandhonortheresident’spreferences,ifany,amongoptions.

7. Iftheresidentsubsequentlyselectsanotherattendingphysicianwhomeetstherequirements,thefacilitywillhonorthatchoice.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Respect,Dignity/RighttohavePersonalProperty

DATE:

INTENT:


PROCEDURE:

1. Theresidenthasarighttobetreatedwithrespectanddignity,includingtherighttoretainandusepersonalpossessions,includingfurnishings,andclothing,asspacepermits,unlesstodosowouldinfringeupontherightsorhealthandsafetyofotherresidents.

POLICY/PROCEDURE

SUBJECT:ResidentRight–ReasonableAccommodationsofNeeds/Preferences

DATE:

INTENT:

Itisthepolicyofthefacilitytoaccommodatetheneedsandpreferencesoftheresidentthatareessentialtocreatinganindividualized,home-likeenvironment..

PROCEDURE:

1. Theresidenthastherighttoresideandreceiveservicesinthefacilitywithreasonableaccommodationofresidentneedsandpreferencesexceptwhentodosowouldendangerthehealthorsafetyoftheresidentorotherresidents.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Choose/BeNotifiedofRoom/RoommateChange

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowtheresidentandortheirlegalrepresentativetherighttochoosearoommate,benotifiedofroomchangesaswellasroommatechangesinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Theresidenthas:1. Therighttosharearoomwithhisorherspousewhenmarriedresidentsliveinthe

samefacilityandbothspousesconsenttothearrangement.2. Therighttosharearoomwithhisorherroommateofchoicewhenpracticable,

whenbothresidentsliveinthesamefacilityandbothresidentsconsenttothearrangement.

3. Therighttoreceivewrittennotice,includingthereasonforthechange,beforetheresident’sroomorroommateinthefacilitychanges.

4. Therighttosharearoomwithwhomevertheywish,aslongasbothresidentsareinagreement.Thesearrangementswillincludeopposite-sexandsame-sexmarriedcouplesordomesticpartners,siblings,orfriends.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoRefuseCertainTransfers

DATE:

INTENT:

Itisthepolicyofthefacilitytoprotectresident’srighttorefusecertaintransfersinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Theresidenthastherighttorefusetotransfertoanotherroominthefacility,ifthepurposeofthetransferis:a. torelocatearesidentofaSNFfromthedistinctpartoftheinstitutionthatisa

SNFtoapartoftheinstitutionthatisnotaSNF,orb. torelocatearesidentofaNFfromthedistinctpartoftheinstitutionthatisa

NFtoadistinctpartoftheinstitutionthatisaSNF.c. solelyfortheconvenienceofstaff.

2. Aresident'sexerciseoftherighttorefusetransferdoesnotaffecttheresident'seligibilityorentitlementtoMedicareorMedicaidbenefits.

POLICY/PROCEDURE

SUBJECT:ResidentRight–SelfDetermination

DATE:

INTENT:


PROCEDURE:

1. Theresidenthastherighttoandthefacilitywillpromoteandfacilitateresidentself-determinationthroughsupportofresidentchoice,includingbutnotlimitedtothefollowing:a. Theresidenthasarighttochooseactivities,schedules(includingsleepingand

wakingtimes),healthcareandprovidersofhealthcareservicesconsistentwithhisorherinterests,assessments,andplanofcareandotherapplicableprovisionsofthispart.

b. Theresidenthasarighttomakechoicesaboutaspectsofhisorherlifeinthefacilitythataresignificanttotheresident.

c. Theresidenthasarighttointeractwithmembersofthecommunityandparticipateincommunityactivitiesbothinsideandoutsidethefacility.

d. Theresidenthasarighttoparticipateinotheractivities,includingsocial,religious,andcommunityactivitiesthatdonotinterferewiththerightsofotherresidentsinthefacility.

POLICY/PROCEDURE

SUBJECT:ResidentRight–ImmediateAccesstoResident

DATE:

INTENT:

Itisthepolicyoftheprovideaccesstotheresidentinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:1. Thefacilitymustprovideimmediateaccesstoanyresidentby:

a. AnyrepresentativeoftheSecretary,b. AnyrepresentativeoftheState,c. AnyrepresentativeoftheOfficeoftheStatelongtermcareombudsman,

(establishedundersection712oftheOlderAmericansActof1965,asamended2016(42U.S.C.3001etseq.),

d. Theresident’sindividualphysician,e. Anyrepresentativeoftheprotectionandadvocacysystems,asdesignated

bythestate,andasestablishedundertheDevelopmentalDisabilitiesAssistanceandBillofRightsActof2000(42U.S.C.15001etseq),

f. Anyrepresentativeoftheagencyresponsiblefortheprotectionandadvocacysystemforindividualswithmentaldisorder(establishedundertheProtectionandAdvocacyforMentallyIllIndividualsActof2000(42U.S.C.10801etseq.),and

g. Theresidentrepresentative.

POLICY/PROCEDURE

SUBJECT:Visitation

DATE:

INTENT:

Itisthepolicyofthefacilitytocomplywithstateandfederallawastovisitationandaccesstoresidents. PROCEDURE:

1. Thisfacilitywillpermitresidentstoreceivevisitorsofhisorherownchoosingatthetimeofhisorherchoosing,subjecttotheresident’srighttodenyvisitationwhenapplicable,andinamannerthatdoesnotimposeontherightsofanotherresident.

2. Thefacilitywillprovideimmediateaccesstoanyresidentby:a. AnyrepresentativeoftheSecretaryofHHS;b. AnyrepresentativeoftheStateofFlorida;c. AnyrepresentativeoftheOfficeoftheStateLongTermCare

Ombudsman;d. Theresident’sphysician;e. Anyrepresentativeoftheprotectionandadvocacysystems,as

designatedbytheStateofFlorida,andasestablishedundertheDevelopmentalDisabilitiesAssistanceandBillofrightsof2000;

f. AnyrepresentativeoftheagencyresponsiblefortheprotectionandadvocacysystemforindividualswithmentaldisorderasestablishedundertheProtectionandAdvocacyforMentallyIllIndividualsActof2000;

g. Theresidentrepresentative;orh. Immediatefamilyandotherrelativesoftheresident,subjecttothe

resident’srighttodenyorwithdrawconsentatanytime.

3. Thefacilitywillprovideimmediatetootherswhoarevisitingwiththeconsentoftheresident,subjecttoreasonableclinicalandsafetyrestrictionsandtheresident’srighttowithdrawordenyconsentatanytime:

a. Theclinicallynecessaryreasonsfordenyingaccessincludeinfectiousoutbreaksthatcouldpotentiallyaffectthepublic.

b. Thereasonablesafetyrestrictionsfordenyingaccessincludeinternalorexternaldisasters.

c. OtherreasonablerestrictionsaresubjecttothedecisionsofAdministrationwherethehealthandorsafetyofourresidents,stafforthepubliccouldbecompromised.

4. Thisfacilitywillprovidereasonableaccesstoaresidentbyanyentityorindividualthatprovideshealth,social,legalorotherservicestotheresident,subjecttotheresident’srighttodenyorwithdrawconsentatanytime.

5. Eachresidentand/orresidentrepresentativeshallreceiveacopyofthisfacility’spoliciesandproceduresforvisitationassetoutherein.

6. Eachresidentwillbeinformedastotherestrictionssetoutinsection3herein,thereasonsforeachandtowhomtheywillapply.

7. Eachresidentwillbeinformedoftheright,subjecttohisorherconsent,toreceivevisitorswhomheorshedesignates,including,butnotlimitedto,aspouse(includingasamesexspouse),adomesticpartner(includingasamesexdomesticpartner)afamilymember,orafriendandtherighttowithdrawconsentatanytime.

8. Thisfacilitywillnotrestrict,limitorotherwisedenyanyvisitationprivilegesonthebasisofrace,color,nationalorigin,religion,sex,genderidentity,sexualorientationordisability.

9. Visitorsmayenjoyfullandequalvisitationprivilegesconsistentwithresidentpreference.

POLICY/PROCEDURE

SUBJECT:ResidentRight–InformofVisitationRights/EqualVisitationPrivileges

DATE:

INTENT:

Itisthepolicyofthefacilitytoinformresidentsandresidentrepresentativesofvisitationrightsandprivilegesinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Thefacilitywillmeetthefollowingrequirements:

1. Informeachresident(orresidentrepresentative,whereappropriate)ofhisorhervisitationrightsandrelatedfacilitypolicyandprocedures,includinganyclinicalorsafetyrestrictionorlimitationonsuchrights,consistentwiththerequirementsofthissubpart,thereasonsfortherestrictionorlimitation,andtowhomtherestrictionsapply,whenheorsheisinformedofhisorherotherrightsunderthissection.

2. Informeachresidentoftheright,subjecttohisorherconsent,toreceivethevisitorswhomheorshedesignates,including,butnotlimitedto,aspouse(includingasame-sexspouse),adomesticpartner(includingasame-sexdomesticpartner),anotherfamilymember,orafriend,andhisorherrighttowithdrawordenysuchconsentatanytime.

3. Notrestrict,limit,orotherwisedenyvisitationprivilegesonthebasisofrace,color,nationalorigin,religion,sex,genderidentity,sexualorientation,ordisability.

4. Ensurethatallvisitorsenjoyfullandequalvisitationprivilegesconsistentwithresidentpreferences.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Resident/FamilyGroupandResponse

DATE:

INTENT:

Itisthepolicyofthefacilitytoencourageandassisttheresidenttoorganizeandparticipateinresidentgroupswithinthefacilityinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Theresidenthasarighttoorganizeandparticipateinresidentgroupsinthefacility.

1. Thefacilitywillprovidearesidentorfamilygroup,ifoneexists,withprivatespace;andtakereasonablesteps,withtheapprovalofthegroup,tomakeresidentsandfamilymembersawareofupcomingmeetingsinatimelymanner.

2. Staff,visitors,orotherguestswillattendresidentgrouporfamilygroupmeetingsonlyattherespectivegroup'sinvitation.

3. Thefacilitywillprovideadesignatedstaffpersonwhoisapprovedbytheresidentorfamilygroupandthefacilityandwhoisresponsibleforprovidingassistanceandrespondingtowrittenrequeststhatresultfromgroupmeetings.

4. Thefacilitywillconsidertheviewsofaresidentorfamilygroupandactpromptlyuponthegrievancesandrecommendationsofsuchgroupsconcerningissuesofresidentcareandlifeinthefacility.a. Thefacilitywillbeabletodemonstratetheirresponseandrationale

forsuchresponse.b. Thisshouldnotbeconstruedtomeanthatthefacilitymust

implementasrecommendedeveryrequestoftheresidentorfamilygroup.

5. Theresidenthasarighttoparticipateinfamilygroups.6. Theresidenthasarighttohavefamilymember(s)orotherresident

representative(s)meetinthefacilitywiththefamiliesorresidentrepresentative(s)ofotherresidentsinthefacility.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoPerformFacilityServicesorRefuse

DATE:

INTENT:


PROCEDURE:

1. Theresidenthasarighttochooseorrefusetoperformservicesforthefacilityandthefacilitywillnotrequirearesidenttoperformservicesforthefacility.

2. Theresidentmayperformservicesforthefacility,ifheorshechooses,when:a. Thefacilityhasdocumentedtheresident’sneedordesireforworkin

theplanofcare;b. Theplanspecifiesthenatureoftheservicesperformedandwhether

theservicesarevoluntaryorpaid;c. Compensationforpaidservicesisatoraboveprevailingrates;and d. Theresidentagreestotheworkarrangementdescribedintheplanof

care.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Protection/ManagementofPersonalFunds

DATE:

INTENT:

Itisthepolicyofthefacilitytoprotectandmanagethepersonalfundsoftheresidentinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.

PROCEDURE:

Theresidenthasarighttomanagehisorherfinancialaffairs.Thisincludestherighttoknow,inadvance,whatchargesafacilitymayimposeagainstaresident'spersonalfunds.

1. Thefacilitywillnotrequireresidentstodeposittheirpersonalfundswiththefacility.

2. Ifaresidentchoosestodepositpersonalfundswiththefacility,uponwrittenauthorizationofaresident,thefacilitywillactasafiduciaryoftheresident'sfundsandhold,safeguard,manage,andaccountforthepersonalfundsoftheresidentdepositedwiththefacility,asspecifiedinthissection.

DepositofFunds.

1. Thefacilitywilldepositanyresidents'personalfundsinexcessof$100inaninterestbearingaccountthatisseparatefromanyofthefacility'soperatingaccounts,andthatcreditsallinterestearnedonresident'sfundstothataccount.

2. Therewillbeaseparateaccountingforeachresident'sshare.Thefacilitywillmaintainaresident'spersonalfundsthatdonotexceed$100inanon-interestbearingaccount,interest-bearingaccount,orpettycashfund.

ResidentswhosecareisfundedbyMedicaid:

1. Thefacilitywilldeposittheresidents'personalfundsinexcessof$50inaninterestbearingaccountthatisseparatefromanyofthefacility'soperatingaccounts,andthatcreditsallinterestearnedonresident'sfundstothataccount.

2. Therewillbeaseparateaccountingforeachresident'sshare.Thefacilitywillmaintainpersonalfundsthatdonotexceed$50inanoninterestbearingaccount,interest-bearingaccount,orpettycashfund.

POLICY/PROCEDURE

SUBJECT:ResidentRight–AccountingandRecordsofPersonalFunds

DATE:

INTENT:

Itisthepolicyofthefacilitytoprotectandmanagethepersonalfundsoftheresidentinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.

PROCEDURE:

AccountingandRecords.

1. Thefacilitywillestablishandmaintainasystemthatassuresafullandcompleteandseparateaccounting,accordingtogenerallyacceptedaccountingprinciples,ofeachresident’spersonalfundsentrustedtothefacilityontheresident’sbehalf.

2. Thesystemwillprecludeanycomminglingofresidentfundswithfacilityfundsorwiththefundsofanypersonotherthananotherresident.

3. Theindividualfinancialrecordwillbeavailabletotheresidentthroughquarterlystatementsanduponrequest.

POLICY/PROCEDURE

SUBJECT:ResidentRight–NoticeandConveyanceofPersonalFunds

DATE:

INTENT:

Itisthepolicyofthefacilitytoprotecttheresident’spersonalfundsinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Noticeofcertainbalances.

ThefacilitywillnotifyeachresidentthatreceivesMedicaidbenefits:1. Whentheamountintheresident’saccountreaches$200lessthantheSSI

resourcelimitforoneperson,and2. That,iftheamountintheaccount,inadditiontothevalueoftheresident’s

othernonexemptresources,reachestheSSIresourcelimitforoneperson;theresidentmayloseeligibilityforMedicaidorSSI.

Conveyanceupondischarge,eviction,ordeath.

Uponthedischarge,eviction,ordeathofaresidentwithapersonalfunddepositedwiththefacility,thefacilitywillconveywithin30daystheresident’sfunds,andafinalaccountingofthosefunds,totheresident,orinthecaseofdeath,theindividualorprobatejurisdictionadministeringtheresident’sestate,inaccordancewithStatelaw.

POLICY/PROCEDURE

SUBJECT:ResidentRight–SuretyBond-SecurityofPersonalFunds

DATE:

INTENT:

Itisthepolicyofthefacilitytoprotecttheresident’spersonalfundsinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Assuranceoffinancialsecurity. Thefacilitywillpurchaseasuretybond,orotherwiseprovideassurancesatisfactorytotheSecretary,toassurethesecurityofallpersonalfundsofresidentsdepositedwiththefacility.

POLICY/PROCEDURE

SUBJECT:ResidentRight–LimitationonChargestoPersonalFunds

DATE:

INTENT:

Itisthepolicyofthefacilitytolimitchargestopersonalfundsinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. ThefacilitywillnotimposeachargeagainstthepersonalfundsofaresidentforanyitemorserviceforwhichpaymentismadeunderMedicaidorMedicare(exceptforapplicabledeductibleandcoinsuranceamounts).

2. Thefacilitymaychargetheresidentforrequestedservicesthataremoreexpensivethanorinexcessofcoveredservices.

3. DuringthecourseofacoveredMedicareorMedicaidstay,thefacilitywillnotchargearesidentforthefollowingcategoriesofitemsandservices:a. Nursingservices,b. FoodandNutritionservices,c. Anactivitiesprogram,d. Room/bedmaintenanceservices,e. Routinepersonalhygieneitemsandservicesasrequiredtomeetthe

needsofresidents,including,butnotlimitedto,hairhygienesupplies,comb,brush,bathsoap,disinfectingsoapsorspecializedcleansingagentswhenindicatedtotreatspecialskinproblemsortofightinfection,razor,shavingcream,toothbrush,toothpaste,dentureadhesive,denturecleaner,dentalfloss,moisturizinglotion,tissues,cottonballs,cottonswabs,deodorant,incontinencecareandsupplies,sanitarynapkinsandrelatedsupplies,towels,washcloths,hospitalgowns,overthecounterdrugs,hairandnailhygieneservices,bathingassistance,andbasicpersonallaundry,

f. Medically-relatedsocialservices,g. Hospiceserviceselectedbytheresidentandpaidforunderthe

MedicareHospiceBenefitorpaidforbyMedicaidunderastateplan.

4. Itemsandservicesthatmaybechargedtoresidents’fundsaregeneralcategoriesandexamplesofitemsandservicesthatthefacilitymaychargetoresidents’fundsiftheyarerequestedbyaresident,iftheyarenotrequiredtoachievethegoalsstatedintheresident’scareplan,ifthefacilityinformstheresidentthattherewillbeacharge,andifpaymentisnotmadebyMedicareorMedicaid:

a. Telephone,includingacellularphone,b. Television/radio,personalcomputerorotherelectronicdevicefor

personaluse,c. Personalcomfortitems,includingsmokingmaterials,notionsand

novelties,andconfections,d. Cosmeticandgroomingitemsandservicesinexcessofthoseforwhich

paymentismadeunderMedicaidorMedicare,e. Personalclothing,f. Personalreadingmatter,g. Giftspurchasedonbehalfofaresident,h. Flowersandplants,i. Costtoparticipateinsocialeventsandentertainmentoutsidethescope

oftheactivitiesprogram,j. Non-coveredspecialcareservicessuchasprivatelyhirednursesor

aides,k. Privateroom,exceptwhentherapeuticallyrequired(forexample,

isolationforinfectioncontrol),andl. Speciallypreparedoralternativefoodrequestedinsteadofthefood

andmealsgenerallypreparedbythefacility.

5. Thefacilitywillnotchargeforspecialfoodsandmeals,includingmedicallyprescribeddietarysupplements,orderedbytheresident’sphysician,physicianassistant,nursepractitioner,orclinicalnursespecialist.

6. Thefacilitywillonlychargearesidentforanynon-covereditemorserviceifsuchitemorserviceisspecificallyrequestedbytheresident.

7. Thefacilitywillnotrequirearesidenttorequestanyitemorserviceasaconditionofadmissionorcontinuedstay.

8. Thefacilitywillinform,orallyandinwriting,theresidentrequestinganitemorserviceforwhichachargewillbemadethattherewillbeachargefortheitemorserviceandwhatthechargewillbe.

POLICY/PROCEDURE

SUBJECT:ResidentRight–NoticeofRightsandRules

DATE:

INTENT:

Itisthepolicyofthefacilitytoinformitsresidentsandresidentinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

InformationandCommunication.

1. Theresidenthastherighttobeinformedofhisorherrightsandofallrulesandregulationsgoverningresidentconductandresponsibilitiesduringhisorherstayinthefacility.

2. Thefacilitywillprovideanoticeofrightsandservicestotheresidentpriortooruponadmissionandduringtheresident’sstay.

3. Thefacilitywillinformtheresidentbothorallyandinwritinginalanguagethattheresidentunderstandsofhisorherrightsandallrulesandregulationsgoverningresidentconductandresponsibilitiesduringthestayinthefacility.

4. ThefacilitywillalsoprovidetheresidentwiththeState-developednoticeofMedicaidrightsandobligations,ifany.

5. Receiptofsuchinformation,andanyamendmentstoit,mustbeacknowledgedinwriting.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoAccess/PurchaseCopiesofRecords

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowtheresidentaccesstopersonalandmedicalrecordspertainingtotheresidentinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:Theresidenthastherighttoaccesspersonalandmedicalrecordspertainingtohimorherself.

1. Thefacilitywillprovidetheresidentwithaccesstopersonalandmedicalrecordspertainingtohimorherself,uponanoralorwrittenrequest,intheformandformatrequestedbytheindividual,ifitisreadilyproducibleinsuchformandformat(includinginanelectronicformorformatwhensuchrecordsaremaintainedelectronically),or,ifnot,inareadablehardcopyformorsuchotherformandformatasagreedtobythefacilityandtheindividual,within24hours(excludingweekendsandholidays);and

2. Thefacilitywillallowtheresidenttoobtainacopyoftherecordsoranyportionsthereof(includinginanelectronicformorformatwhensuchrecordsaremaintainedelectronically)uponrequestand2workingdaysadvancenoticetothefacility.Thefacilitymayimposeareasonable,cost-basedfeeontheprovisionofcopies,providedthatthefeeincludesonlythecostof:

a. Laborforcopyingtherecordsrequestedbytheindividual,whetherinpaperorelectronicform;

b. Suppliesforcreatingthepapercopyorelectronicmediaiftheindividualrequeststhattheelectroniccopybeprovidedonportablemedia;and

c. Postage,whentheindividualhasrequestedthecopybemailed.

3. Thefacilitywillensurethatinformationisprovidedtoeachresidentinaformandmannertheresidentcanaccessandunderstand,includinginanalternativeformatorinalanguagethattheresidentcanunderstand.Summariesthattranslateinformationdescribedinparagraph(g)(2)ofthissectionmaybemadeavailabletothepatientattheirrequestandexpenseinaccordancewithapplicablelaw.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RequiredNoticesandContactInformation

DATE:

INTENT:


PROCEDURE:

Theresidenthastherighttoreceivenoticesorally(meaningspoken)andinwriting(includingBraille)inaformatandalanguageheorsheunderstands,including:

1. Thefacilitywillfurnishtoeachresidentawrittendescriptionoflegalrightswhichincludes:a. Adescriptionofthemannerofprotectingpersonalfunds.b. Adescriptionoftherequirementsandproceduresforestablishingeligibilityfor

Medicaid,includingtherighttorequestanassessmentofresourcesundersection1924(c)oftheSocialSecurityAct.

c. Alistofnames,addresses(mailingandemail),andtelephonenumbersofallpertinentStateregulatoryandinformationalagencies,residentadvocacygroupssuchastheStateSurveyAgency,theStatelicensureoffice,theStateLong-TermCareOmbudsmanprogram,theprotectionandadvocacyagency,adultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities,thelocalcontactagencyforinformationaboutreturningtothecommunityandtheMedicaidFraudControlUnit;and

d. AstatementthattheresidentmayfileacomplaintwiththeStateSurveyAgencyconcerninganysuspectedviolationofstateorfederalnursingfacilityregulations,includingbutnotlimitedtoresidentabuse,neglect,exploitation,misappropriationofresidentpropertyinthefacility,non-compliancewiththeadvancedirectivesrequirementsandrequestsforinformationregardingreturningtothecommunity.

2. InformationandcontactinformationforStateandlocaladvocacyorganizationsincludingbutnotlimitedtotheStateSurveyAgency,theStateLong-TermCareOmbudsmanprogram(establishedundersection712oftheOlderAmericansActof1965,asamended2016(42U.S.C.3001etseq)andtheprotectionandadvocacysystem(asdesignatedbythestate,andasestablishedundertheDevelopmentalDisabilitiesAssistanceandBillofRightsActof2000(42U.S.C.15001etseq.)

3. InformationregardingMedicareandMedicaideligibilityandcoverage;

4. ContactinformationfortheAgingandDisabilityResourceCenter(establishedunderSection202(a)(20)(B)(iii)oftheOlderAmericansAct);orotherNoWrongDoorProgram;

5. ContactinformationfortheMedicaidFraudControlUnit;and

6. Informationandcontactinformationforfilinggrievancesorcomplaintsconcerninganysuspectedviolationofstateorfederalnursingfacilityregulations,includingbutnotlimitedtoresidentabuse,neglect,exploitation,misappropriationofresidentpropertyinthefacility,non-compliancewiththeadvancedirectivesrequirementsandrequestsforinformationregardingreturningtothecommunity.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RequiredPostings

DATE:

INTENT:


PROCEDURE:

Thefacilitymustpost,inaformandmanneraccessibleandunderstandabletoresidents,residentrepresentatives:

1. Alistofnames,addresses(mailingandemail),andtelephonenumbersofallpertinentStateagenciesandadvocacygroups,suchastheStateSurveyAgency,theStatelicensureoffice,adultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities,theOfficeoftheStateLong-TermCareOmbudsmanprogram,theprotectionandadvocacynetwork,homeandcommunitybasedserviceprograms,andtheMedicaidFraudControlUnit;and

2. AstatementthattheresidentmayfileacomplaintwiththeStateSurveyAgencyconcerninganysuspectedviolationofstateorfederalnursingfacilityregulation,includingbutnotlimitedtoresidentabuse,neglect,exploitation,misappropriationofresidentpropertyinthefacility,andnon-compliancewiththeadvanceddirectivesrequirements(42CFRpart489subpartI)andrequestsforinformationregardingreturningtothecommunity.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoFormsofCommunicationwithPrivacy

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowaccesstoaphoneandprivacywhenmakingthosephonecallsinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Theresidenthastherighttohavereasonableaccesstotheuseofatelephone,includingTTYandTDDservices,andaplaceinthefacilitywherecallscanbemadewithoutbeingoverheard.Thisincludestherighttoretainanduseacellularphoneattheresident'sownexpense.

2. Thefacilitymustprotectandfacilitatethatresident'srighttocommunicatewithindividualsandentitieswithinandexternaltothefacility,includingreasonableaccessto:a. Atelephone,includingTTYandTDDservices;b. Theinternet,totheextentavailabletothefacility;andc. Stationery,postage,writingimplementsandtheabilitytosendmail.

3. Theresidenthastherighttosendandreceivemail,andtoreceiveletters,packagesandothermaterialsdeliveredtothefacilityfortheresidentthroughameansotherthanapostalservice,includingtherightto:a. Privacyofsuchcommunicationsconsistentwiththissection;andb. Accesstostationery,postage,andwritingimplementsattheresident'sown

expense.

4. Theresidenthastherighttohavereasonableaccesstoandprivacyintheiruseofelectroniccommunicationssuchasemailandvideocommunicationsandforinternetresearch.a. Iftheaccessisavailabletothefacilityb. Attheresident'sexpense,ifanyadditionalexpenseisincurredbythefacilityto

providesuchaccesstotheresident. c. SuchusemustcomplywithStateandFederallaw.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RighttoSurveyResults/AdvocateAgencyInfo

DATE:

INTENT:

ItisthepolicyofthefacilitytoinformitsresidentsofSurveyResultsandAdvocateAgenciesinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Theresidenthastherightto:

1. ExaminetheresultsofthemostrecentsurveyofthefacilityconductedbyFederalorStatesurveyorsandanyplanofcorrectionineffectwithrespecttothefacility;and

2. Receiveinformationfromagenciesactingasclientadvocates,andbeaffordedtheopportunitytocontacttheseagencies.

Thefacilitywill:

1. Postinaplacereadilyaccessibletoresidents,andfamilymembersandlegalrepresentativesofresidents,theresultsofthemostrecentsurveyofthefacility.

2. Havereportswithrespecttoanysurveys,certifications,andcomplaintinvestigationsmaderespectingthefacilityduringthe3precedingyears,andanyplanofcorrectionineffectwithrespecttothefacility,availableforanyindividualtoreviewuponrequest;and

3. Postnoticeoftheavailabilityofsuchreportsinareasofthefacilitythatareprominentandaccessibletothepublic.

4. Thefacilityshallnotmakeavailableidentifyinginformationaboutcomplainantsorresidents.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Request/Refuse/DiscontinueTreatment

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowtheresidenttobeinformedandmadeawareoftherisks,benefits,andprocedurestobeusedinprovidingtreatmentaswellasalternatives,ifany,andtogiveinformedconsentorrefusetreatment.Thisincludestheinstitutionofthetreatmentandthecontinuedapplicationoftreatment.Thetermtreatmentasusedhereinincludestreatments,servicesandmedications.

PROCEDURE:

1. Whiletheresident*canconsenttoorrefusetreatment,theresidentdoesnothavetherighttoreceivetheprovisionofmedicaltreatment,medicationsormedicalservicesdeemedmedicallyunnecessaryorinappropriate.

2. Priortochangingmedication,servicesortreatment,getinformedconsent,anddocumentintheresident'sclinicalrecord.Iftheindividualisunabletogiveinformedconsent,thennotificationisgiventheresident'srepresentative.Onceheorsheisabletoreceivesuchinformationitwillthenbeprovidedtotheindividualdirectlyattheappropriatetime.

3. Ifaresidentrefusesmedicationortreatment,thefacilitywillnotifytheresidentortheresident'slegalrepresentativeoftheconsequencesofsuchadecisionandmustdocumenttheresident'sdecisioninhisorhermedicalrecord.Thefacilitywillcontinuetoprovideotherservicestheresidentagreestoinaccordancewiththeresident'scareplan.

4. Ifaresident’srefusaloftreatmentbringsaboutasignificantchange,thefacilitywillreassesstheresidentandinstitutecareplanningchanges.

*Thetermresidentincludestheindividualwiththelegalrighttomakemedicaldecisionsonbehalfoftheresident.

POLICY/PROCEDURE

SUBJECT:ResidentRight–RefusalofExperimentalResearch

DATE:

INTENT:

ItisthepolicyofthefacilitytoallowtheresidenttherighttoparticipateortorefusetoparticipateinExperimentalResearch.

PROCEDURE:

1. Theresidenthastherighttorefusetoparticipateinexperimentalresearch.2. WhentheresidentchoosestoparticipateinExperimentalResearchthoseprograms

haveprotocolsthatthefacilitywouldhavetoadopt.

POLICY/PROCEDURE

SUBJECT:ResidentRight–AdvancedDirectiveTrackingProgram

DATE:

INTENT:

Itisthepolicyofthefacilitytohonortheadvancedirectivesofallresidentsandtomakeinformationavailabletotheresidentonhowtopreparesuchdirectives,shouldtheresidentnothavetheminplaceortochangeexistingdirectives.

PROCEDURE:

1. DuringtheadmissionprocesstheSocialServicesDirectorordesigneewilldiscusswitheachresidentand/orthepersonaccompanyingtheresidentthefollowing:a. Whethertheyhaveanadvancedirectivesuchasahealthcaresurrogate

designation,livingwillordurablepowerofattorney?b. WhethertheyhaveaUniformDoNotResuscitateform?c. Ifso,isitprintedonyellow(goldenrod)paper?d. Iftheyhavethoseformswiththem?Ifso,securecopies.e. Ifnot,inquireastowherethedocumentscanbefound.f. Iftheyareinthepossessionofathirdparty(thismaybethedoctor,family

member,friendorthelike)getcontactinformationforthatpartyandcontacthim/herasquicklyaspossibletogetacopy.

g. Iftheresidentiscapableofexecutinganadvancedirectiveanddoesnothavealivingwill,healthcaresurrogatedesignationand/oryellowDNROaskifhe/shewouldbeinterestedinpreparingone.StaffcannotprepareDurablePowersofAttorney.Thesemustbepreparedbyanattorneyorsomeoneatanattorney’sdirection.

2. Theresidentandorthepersonaccompanyingthemwillbegivenacopy,oftheadvancedirectivesinformation,includingtheformsusedbythefacility,whethertheyhavecompletedadvancedirectivesornot.Theresidentorthepersonaccompanyingthemshouldsignthattheyhavereceivedthisinformation.

3. Uponreceiptoftheadvanceddirectiveforms,copieswillbemadefortheresident’sclinicalrecordandwillbescannedintotheelectronicmedicalrecordundertheAdvanceDirectivesTab.CopiesshouldnotbemadeongoldenrodoryellowpaperexceptfortheUniformDoNotResuscitateOrder.

4. SocialServicesortheappropriatedesigneewillcarefullyreviewanyandalladvanceddirectiverelateddocumentstoensurethattheinformationiscompleteandthattherequirementsofthelawaremet.Ifthereisaquestionitistheresponsibilityofthereviewertoseekclarification.

5. SocialServicesortheappropriatedesigneeshouldvisittheresidentanddiscussadvancedirectiveswiththemtoensurethathe/shehasexecutedtheadvancedirectivesthathe/shewouldwant.

6. SocialServicesshouldalsoensurethatinformationwasgiventotheresidentonadmission.SocialServiceswilladvisetheresidentthatatanytimehe/shemayamend,revokeorwriteanewadvancedirectiveandstaffwillassist.Ifnoadvancedirectivesweredesired,explainthatthisisaresidentrightandtheresidentisnotrequiredtoprepareanadvancedirectivetostayinthefacility.Explanationofthisandresident’sresponseshouldalsobedocumentedintheclinicalrecord.

7. Ifthereisnodesignationofahealthcaresurrogateandtheresidentindicatesthattheydonotwishtonameone,socialservicesshouldexplaintheproxystatuteandinquireoftheresidentastowhoisavailableundertheproxystatuteandhowtocontactthatpersonorthosepeople.Thisshouldbedocumentedaccordingly.

8. Theindividualwhovisitedtheresidentasdescribedin#5,6,and7.Shoulddocumentthisconversationintheresident’ssocialservicesnotes.

9. Record-keeping:a. TheAdvanceDirectives,suchasLivingWill,HealthcareSurrogate,Durable

PowerofAttorney,shallbeplacedintheresident’srecordundertheAdvanceDirectiveTabandshallremaintherethroughouthis/herstay.

b. WhentheresidenthasaDoNotResuscitateOrder,placetheoriginalDNROdirectlybehindthefrontcoverofthemedicalrecordinaplasticsleevewithadditionalcopies,sothatitisthefirstdocumentyouseewhenyouopenthechart.

c. Acopyshallbescannedintotheresident’selectronicmedicalrecordandstoredundertheAdvanceDirectivesTab.

10. Trainingonadvanceddirectiveswillbeprovidedtohealthcarestaffduringinitialorientationandwillbeincorporatedinthefacility’sannualeducationplan.Thistrainingwillincludethetypesandmeaningofadvanceddirectivesandthecurrentapplicablelaws.Staffwillalsobetrainedthatresidentsmayrevokeoramendtheiradvancedirectivessolongastheyarecapableandshouldreporttothechargenurseifanyresidentexpressesadesiretodosointheirpresence.

11. Nursingandtheinterdisciplinaryteam(IDT)shallbeawarethatintheeventthataresidentisdeterminedincapableofmakingmedicaldecisionsbytheirattendingphysician(insomecaseswhenthereisaquestionofcapacity,aseconddoctormustbeconsulted),thenursingdepartmentshallnotifythepersonnamedasthesurrogateandgetawrittenacknowledgementofthatperson’sagreementtodoso.IfnursingorIDTstaffbelievethataresidentisnotcapableofmakingmedicaldecisionsbuthasnotbeendeclaredsobytheirattendingphysician,thatnurseshouldnotifythephysicianofthisconcernandaskforanexaminationoftheresident.Ifthephysiciandoesnotrespondpromptly,themedicaldirectorshouldbenotified.

12. Ifahealthcaresurrogatehasbeennamednursesshouldcontactthatpersonaboutanymedicaldecisions,changesinconditionandcareplanchangesofthatresident.Surrogateshouldbeinvitedtocareplanmeetings.

13. Ifthereisnosurrogatebutaproxyhasbeenappointedthatproxyshallbecontactedaswouldbethesurrogate.

14. Proxiesandsurrogatesmaymakethesamedecisionsexceptthatwhenalifeprolongingprocedureisimplicatedtheproxymustshowtheresident’swishesbyclearandconvincingevidence.Ifthewishesarenotknowntheproxyshouldconsultwiththephysiciantoensurethatthedecisionbeingmadeisinthebestinterestoftheresident.

15. Aresidentwhohasnotbeendeterminedincapableofmakingmedicaldecisionsandwhoappearstounderstandenoughinformationtomakecaredecisionsshouldbepermittedtodoso.Thisdoesnotrelievethenurseofcontactingthephysicianiftheresidentappearsunabletomakemedicaldecisions.

16. Thedeterminationofincapacitytomakemedicaldecisionsdoesnotmeanthattheresidentisincapableofmakingotherdecisions.

17. Allresidentswhowishtohaveresuscitationwithheldshouldhaveaphysician’sorderintheirmedicalrecord.ThegoldenroduniformDoNotResuscitateOrderisaphysician’sorderifproperlycompleted.Additionally,whenauniformDoNotResuscitateOrderisobtainedandcompleted,thenurseresponsibleforthatresidentwillobtainanorderintheelectronicmedicalrecord.

18. Intheeventthataresidentexperiencescardiopulmonaryarrestthenurseondutyshallimmediatelydeterminetheresident’sstatusasacodeorno-code.

19. Ifthepersonisafullcode,thenurseordesigneeshallbeginCardiopulmonaryresuscitationanddirectsomeonetocall911.

POLICY/PROCEDURE

SUBJECT:DoNotResuscitateOrders

DATE:

INTENT:

ItisthepolicyofthefacilitytohonorDoNotResuscitateOrdersinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Facilitystaffmaywithholdorwithdrawcardiopulmonaryresuscitationifpresentedwithanordernottoresuscitateexecutedpursuanttos.401.45.

2. Theabsenceofanordernottoresuscitateexecutedpursuanttos.401.45doesnotprecludeaphysicianfromwithholdingorwithdrawingcardiopulmonaryresuscitationasotherwisepermittedbylaw.Therefore,aproperlycompletedphysician'sorderinthechartshouldbehonored.

3. Thefacilitywillprovidethefollowingtoeachresidentorresident’srepresentative,atthetimeofadmission:a. Informationregardingadvancedirectives,b. WritteninformationconcerningthefacilitiespolicyonAdvanceDirectives,

includingDNROs,andc. InformationabouthowtoobtainaFloridaDoNotResuscitateOrderForm.

4. Thefacilitywilldocumentintheresident’srecordwhetherornotheorshehasexecutedaDNRO.

5. WhentheresidenthasexecutedaDNRO,acopyofthatdocumentwillbemadeapartoftheresident’srecord.

6. Whenthefacilityhasrequestedacopyoftheresident’sDNRO;thiswillbedocumentedintheresident’srecord.

7. ThefacilitywillhonoraproperlyexecutedDNROasfollows:a. Intheeventaresidentexperiencescardiopulmonaryarrest,stafftrainedin

cardiopulmonaryresuscitation(CPR)oralicensedhealthcareproviderispresentinthefacility,maywithholdcardiopulmonaryresuscitation.

b. Intheeventaresidentisreceivinghospiceservicesandexperiencescardiopulmonaryarrest,thefacilitystaffmustimmediatelycontactthehospiceprovider.

c. Thehospiceprocedureswilltakeprecedenceoverthoseofthefacility.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Posting/NoticeofMedicare/MedicaidonAdmission

DATE:

INTENT:

ItisthepolicyofthefacilitytoinformtheresidentandorlegalrepresentativeaboutMedicare/Medicaidbypostingsuchinformationwithinthefacilityandprovidingsuchinformationuponadmission.

PROCEDURE:

1. ThefacilitywilldisplayinthefacilitywritteninformationabouthowtoapplyforanduseMedicareandMedicaidbenefits.

2. ThefacilitywillalsoprovidetoresidentsandapplicantsforadmissionoralandwritteninformationabouthowtoapplyforanduseMedicareandMedicaidbenefits,andhowtoreceiverefundsforpreviouspaymentscoveredbysuchbenefits.

3. Documentationofreceiptofthisinformationwillbemaintainedwithintheresidentrecord.

POLICY/PROCEDURE

SUBJECT:ResidentRight–NotifyofChanges(Injury/Decline/Room,Etc.)

DATE:

INTENT:

Itisthepolicyofthefacilitytonotifytheresidentandorlegalrepresentativeofchangesinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Afacilitywillimmediatelyinformtheresident;consultwiththeresident’sphysician;andnotify,consistentwithhisorherauthority,theresidentrepresentative(s)whenthereis:a. Anaccidentinvolvingtheresidentwhichresultsininjuryandhasthepotentialfor

requiringphysicianintervention;b. Asignificantchangeintheresident’sphysical,mental,orpsychosocialstatus

(thatis,adeteriorationinhealth,mental,orpsychosocialstatusineitherlife-threateningconditionsorclinicalcomplications);

c. Aneedtoaltertreatmentsignificantly(thatis,aneedtodiscontinueanexistingformoftreatmentduetoadverseconsequences,ortocommenceanewformoftreatment);or

d. Adecisiontotransferordischargetheresidentfromthefacility.

2. Whenmakingnotificationthefacilitywillensurethatallpertinentinformationisavailableandprovideduponrequesttothephysician.

3. Thefacilitywillalsopromptlynotifytheresidentandtheresidentrepresentative,ifany,whenthereis:a. Achangeinroomorroommateassignmentasspecifiedin§483.10(e)(6);orb. AchangeinresidentrightsunderFederalorStatelaworregulations.

4. Thefacilitywillrecordandperiodicallyupdatetheaddress(mailingandemail)andphonenumberoftheresidentrepresentative(s).

5. Thefacilitywillnotifyalicensedphysicianwhenaresidentexhibitssignsofdementiaorcognitiveimpairmentorhasachangeofconditioninordertoruleoutthepresenceofanunderlyingphysiologicalconditionthatmaybecontributingtosuchdementiaorimpairment.Thenotificationmayoccurwithin30daysaftertheacknowledgementofsuchsignsbyfacilitystaff.Ifanunderlyingconditionisdeterminedtoexist,thefacilitywillarrange,withtheappropriatehealthcareprovider,thenecessarycareandservicestotreatthecondition.

PROCEDURE

SUBJECT:ChangeinConditionProcess

DATE:

INTENT:

Thepurposeofthispolicyistoensurethefacilitypromptlyinformstheresident,consultstheresident’sphysician;andnotify,consistentwithhisorherauthority,resident’srepresentativewhenthereisachangerequiringnotification.

PROCEDURE:

Thefacilitymustinformtheresident,consultwiththeresident’sphysicianand/ornotifytheresident’sfamilymemberorlegalrepresentativewhenthereisachangerequiringsuchnotification.

Situationsrequiringnotificationinclude:

1. Anaccidentinvolvingtheresidentwhich:

a. Resultingininjury.b. Potentialtorequirephysicianintervention.

2. Asignificantchangeintheresident’sphysical,mental,orpsychosocialstatusthatis,adeteriorationinhealth,mental,orpsychosocialstatusineitherlife-threateningconditionsorclinicalcomplications.Thismayinclude:

a. life-threateningconditions,orb. Clinicalcomplications.

3. Aneedtoaltertreatmentsignificantly;thatis,aneedtodiscontinueanexistingformoftreatmentduetoadverseconsequences,ortocommenceanewformoftreatment.Thismayinclude:

a. Anewinfectionorwound.b. Discontinuingatreatmentorchangingamedicationdueto:

i. Adverseconsequences.ii. Acutecondition.iii. Exacerbationofachroniccondition.

4. Adecisiontotransferordischargetheresidentfromthefacility.

5. Thefacilitymustalsopromptlynotifytheresidentandtheresidentrepresentative,ifany,whenthereis:

a. Achangeinroomorroommateassignment,orb. AchangeinresidentrightsunderFederalorStatelaworregulations.

4. UpontheidentificationofachangeinconditioninaresidenttheNursewillcompleteanevaluationoftheresident’sstatus,anddocumentfindingsontheSBERChangeinConditionintheresident’selectronicmedicalrecord.

SituationstoConsider:

Competentindividuals:• Thefacilitymuststillcontacttheresident’sphysicianandnotifytheresidentandor

resident’srepresentative,ifknownandapprovedbytheresident.

• Afamilythatwishestobeinformedwoulddesignateamembertoreceivecalls.

• Whenaresidentismentallycompetent,suchadesignatedfamilymembershouldbenotifiedofsignificantchangesintheresident’shealthstatusbecausetheresidentmaynotbeabletonotifythempersonally,especiallyinthecaseofsuddenillnessoraccident.

Residentsincapableofmakingdecisions:• Therepresentativewouldmakeanydecisionsthathavetobemade.

• Theresidentshouldstillbetoldwhatishappeningtohimorher.

Deathofaresident:• Theresident’sphysicianistobenotifiedimmediatelyinaccordancewithStatelaw.

Noticeofroom/roommatechanges:• Necessarytoavoiddeclineinphysical,mental,orpsychosocialwell-being.

Contactinformationoftheresident’slegalrepresentativeorfamilymembermustberecordedandperiodicallyupdated.

RighttoPrivacy:

Thefacilityisrequiredtoinformtheresidentofhis/herrightsuponadmissionandduringtheresident’sstayincludingtheresident’srighttoprivacy(§483.10(h),F164).

Ifaresidentspecifiesthathe/shewishestoexercisethisrightandnotnotifyfamilymembersintheeventofasignificantchangeasspecifiedatthisrequirement,thefacilityshouldrespectthisrequest,whichwouldobviatetheneedtonotifytheresident’sinterestedfamilymemberorlegalrepresentative,ifknown.

Ifaresidentspecifiesthathe/shedoesnotwishtoexercisetherighttoprivacy,thenthefacilityisrequiredtocomplywiththenoticeofchangerequirements.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Medicaid/MedicareCoverage/LiabilityNoticeDATE:

INTENT:

ItisthepolicyofthefacilitytonotifytheresidentandorlegalrepresentativeofMedicaid/MedicareCoverage/Liabilityinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

Thefacilitywill:

1. InformeachMedicaid-eligibleresident,inwriting,atthetimeofadmissiontothenursingfacilityandwhentheresidentbecomeseligibleforMedicaidof:a. TheitemsandservicesthatareincludedinnursingfacilityservicesundertheState

planandforwhichtheresidentmaynotbecharged;b. Thoseotheritemsandservicesthatthefacilityoffersandforwhichtheresident

maybecharged,andtheamountofchargesforthoseservices.

2. InformeachMedicaid-eligibleresidentwhenchangesaremadetotheitemsandservices.

3. Informeachresidentbefore,oratthetimeofadmission,andperiodicallyduringtheresident’sstay,ofservicesavailableinthefacilityandofchargesforthoseservices,includinganychargesforservicesnotcoveredunderMedicare/Medicaidorbythefacility’sperdiemrate.a. WherechangesincoveragearemadetoitemsandservicescoveredbyMedicare

and/orbytheMedicaidStateplan,thefacilitymustprovidenoticetoresidentsofthechangeassoonasisreasonablypossible.

b. Wherechangesaremadetochargesforotheritemsandservicesthatthefacilityoffers,thefacilitymustinformtheresidentinwritingatleast60dayspriortoimplementationofthechange.

c. Ifaresidentdiesorishospitalizedoristransferredanddoesnotreturntothefacility,thefacilitymustrefundtotheresident,residentrepresentative,orestate,asapplicable,anydepositorchargesalreadypaid,lessthefacility’sperdiemrate,forthedaystheresidentactuallyresidedorreservedorretainedabedinthefacility,regardlessofanyminimumstayordischargenoticerequirements.

d. Thefacilitymustrefundtotheresidentorresidentrepresentativeanyandallrefundsduetheresidentwithin30daysfromtheresident’sdateofdischargefromthefacility.

e. Thetermsofanadmissioncontractbyoronbehalfofanindividualseekingadmissiontothefacilitymustnotconflictwiththerequirementsoftheseregulations.

POLICY/PROCEDURE

SUBJECT:ResidentRight–PersonalPrivacy/ConfidentialityofRecords

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovidetheresidentandorlegalrepresentativepersonalprivacyandconfidentialityofrecordsinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Theresidenthasarighttopersonalprivacyandconfidentialityofhisorherpersonalandmedicalrecords.

2. Personalprivacyincludesaccommodations,medicaltreatment,writtenandtelephonecommunications,personalcare,visits,andmeetingsoffamilyandresidentgroups,butthisdoesnotrequirethefacilitytoprovideaprivateroomforeachresident,

3. Thefacilitywillrespecttheresidentsrighttopersonalprivacy,includingtherighttoprivacyinhisorheroral(thatis,spoken),written,andelectroniccommunications,includingtherighttosendandpromptlyreceiveunopenedmailandotherletters,packagesandothermaterialsdeliveredtothefacilityfortheresident,includingthosedeliveredthroughameansotherthanapostalservice.

4. Theresidenthasarighttosecureandconfidentialpersonalandmedicalrecords.

5. Theresidenthastherighttorefusethereleaseofpersonalandmedicalrecordsexceptwhereapplicablefederalorstatelawsapply.

6. ThefacilitywillallowrepresentativesoftheOfficeoftheStateLong-TermCareOmbudsmantoexaminearesident'smedical,social,andadministrativerecordsinaccordancewithStatelaw.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Safe/Clean/Comfortable/HomelikeEnvironment

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideasafe,clean,comfortablehomelikeenvironmentsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Theresidenthasarighttoasafe,clean,comfortableandhomelikeenvironment,includingbutnotlimitedtoreceivingtreatmentandsupportsfordailylivingsafely.

2. Thefacilitymustprovideasafe,clean,comfortable,andhomelikeenvironment,allowingtheresidenttousehisorherpersonalbelongingstotheextentpossible.a. Thisincludesensuringthattheresidentcanreceivecareandservicessafelyand

thatthephysicallayoutofthefacilitymaximizesresidentindependenceanddoesnotposeasafetyrisk.

b. Thefacilityshallexercisereasonablecarefortheprotectionoftheresident'spropertyfromlossortheft.

3. Housekeepingandmaintenanceservicesnecessarytomaintainasanitary,orderly,andcomfortableinterior;

4. Cleanbedandbathlinensthatareingoodcondition;

5. Privateclosetspaceineachresidentroom;

6. Adequateandcomfortablelightinglevelsinallareas;

7. Comfortableandsafetemperaturelevels.FacilitiesinitiallycertifiedafterOctober1,1990mustmaintainatemperaturerangeof71to81°F;and

8. Forthemaintenanceofcomfortablesoundlevels.

POLICY/PROCEDURE

SUBJECT:ResidentRight–Grievances

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowtheresidentandorlegalrepresentativetovoiceagrievanceinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Theresidenthastherighttovoicegrievancestothefacilityorotheragencyorentitythathearsgrievanceswithoutdiscriminationorreprisalandwithoutfearofdiscriminationorreprisal.Suchgrievancesincludethosewithrespecttocareandtreatmentwhichhasbeenfurnishedaswellasthatwhichhasnotbeenfurnished,thebehaviorofstaffandofotherresidents,andotherconcernsregardingtheirLTCfacilitystay.

2. Theresidenthastherighttoandthefacilitywillmakeprompteffortsbythefacilitytoresolvegrievancestheresidentmayhave,inaccordancewiththisparagraph.

3. ThefacilitywillmaintainaGrievanceProgramwithadesignatedprofessionalresponsibleforgrievancemanagementthatanswerstotheAdministrator.

4. ThedesignatedprofessionalwillmaintainthefacilityGrievanceProgram.

5. Allresidents,staff,andvisitorswillhaveaccesstotheprofessionaldesignatedtomanagetheGrievanceProgram,GrievanceOfficer.

6. Residents,residentrepresentativesandStaffwillbeinformationonhowtofilegrievances.

7. Facilitystaffwillnotdiscourageresidentsortheirrepresentativesfilingofagrievanceandorthecommunicationwithfederal,state,orlocalofficials.

8. Thefacilitywillestablishagrievancepolicytoensurethepromptresolutionofallgrievancesregardingtheresidents’rights.

9. Uponrequest,thefacilitywillgiveacopyofthegrievancepolicytotheresident.Thegrievancepolicymustinclude:

a. Notifyingresidentindividuallyorthroughpostingsinprominentlocationsthroughoutthefacilityoftherighttofilegrievancesorally(meaningspoken)orinwriting;therighttofilegrievancesanonymously;thecontactinformationofthegrievanceofficialwithwhomagrievancecanbefiled,thatis,hisorhername,businessaddress(mailingandemail)andbusinessphonenumber;a

reasonableexpectedtimeframeforcompletingthereviewofthegrievance;therighttoobtainawrittendecisionregardinghisorhergrievance;andthecontactinformationofindependententitieswithwhomgrievancesmaybefiled,thatis,thepertinentStateagency,QualityImprovementOrganization,StateSurveyAgencyandStateLong-TermCareOmbudsmanprogramorprotectionandadvocacysystem;

b. IdentifyingaGrievanceOfficialwhoisresponsibleforoverseeingthegrievanceprocess,receivingandtrackinggrievancesthroughtotheirconclusions;leadinganynecessaryinvestigationsbythefacility;maintainingtheconfidentialityofallinformationassociatedwithgrievances,forexample,theidentityoftheresidentforthosegrievancessubmittedanonymously,issuingwrittengrievancedecisionstotheresident;andcoordinatingwithstateandfederalagenciesasnecessaryinlightofspecificallegations;

c. Asnecessary,takingimmediateactiontopreventfurtherpotentialviolationsofanyresidentrightwhiletheallegedviolationisbeinginvestigated;

d. Consistentwith§483.12(c)(1),immediatelyreportingallallegedviolationsinvolvingneglect,abuse,includinginjuriesofunknownsource,and/ormisappropriationofresidentproperty,byanyonefurnishingservicesonbehalfoftheprovider,totheadministratoroftheprovider;andasrequiredbyStatelaw;

e. Ensuringthatallwrittengrievancedecisionsincludethedatethegrievancewasreceived,asummarystatementoftheresident’sgrievance,thestepstakentoinvestigatethegrievance,asummaryofthepertinentfindingsorconclusionsregardingtheresident’sconcerns(s),astatementastowhetherthegrievancewasconfirmedornotconfirmed,anycorrectiveactiontakenortobetakenbythefacilityasaresultofthegrievance,andthedatethewrittendecisionwasissued;

f. TakingappropriatecorrectiveactioninaccordancewithStatelawiftheallegedviolationoftheresidents’rightsisconfirmedbythefacilityorifanoutsideentityhavingjurisdiction,suchastheStateSurveyAgency,QualityImprovementOrganization,orlocallawenforcementagencyconfirmsaviolationforanyoftheseresidents’rightswithinitsareaofresponsibility;and

g. Maintainingevidencedemonstratingtheresultofallgrievancesforaperiodofnolessthan3yearsfromtheissuanceofthegrievancedecision.

PROCEDURESUBJECT: GrievanceProgramDATE:

Purpose:

To promote an environment and culture open to feedback positive and or negative fromresidents,familymembers,employees,physicians,andanyothervisitors.Bothpositiveandnegative comments from these individuals helps to provide information which will beincorporated into policies, procedures, and practices within the organization that focus oncreatingacultureofexcellencethroughidentificationandresolutionwithincontinuousqualityimprovement.

RighttofileGrievances:residentsandvisitorshavetherighttopresentgrievancesonbehalfofhimselforherselforotherstothestafforadministratorofthefacilityeitherverballyorinwriting,togovernmentalofficials,ortoanyotherpersons;tofilegrievancesanonymously;toreceiveawrittendecisionrelatedtothegrievancefiled,ifrequested;torecommendchangesin policies and services to facility personnel; and to joinwith other residents or individualswithin or outside the facility towork for improvements in resident care, and be free fromrestraint, interference, coercion, discrimination, or reprisal. This right includes access toombudsmenandadvocatesandtherighttobeamemberof,tobeactivein,andtoassociatewithadvocacyorspecialinterestgroups.Therightalsoincludestherighttoprompteffortsbythefacilitytoresolveresidentgrievances,includinggrievanceswithrespecttothebehaviorofotherresidents.

Definition:

Agrievanceisaconcernthatcannotberesolvedtothesatisfactionofthepersonmakingtheobjectionatthebedsideandorimmediately.

Immediately:

Forthesakeofthisdocument,‘immediately’isdefinedaswithinfourorlesshours.

Policy:

It is thepolicyofthefacilitytoensurethat individualsareencouragedtodiscusscommentsandconcernswhichmaybepositiveornegativeandwhenindicatedtobringsuchtoaformalgrievancestatus.Theintentistoevaluatesuchmattersforthepurposeofresolutionaswellas performance improvement. Acceptance of a grievance does not mean the facilityrepresentative and or the facility agrees with the statement. Actions taken in response tocustomergrievancesareundertakenwiththegoalofimprovingcareandservicedeliveryandinclude,butarenotlimitedto,thefollowing:

§ investigationandmostpracticableresolution,§ routingtotheappropriatedepartmentsforongoingimprovement,

§ identifyingtrendsincare,servicedelivery,andsystemorganization,and§ developinglongtermsolutions,implementingchangestoimprovecare/servicesystems.

Process:

1. Grievances–grievancesare formalwrittenor verbal complaintsmade to the facilitywhen prompt or bedside resolution to the satisfaction of the person making theobjectionwasnotpossible.Grievancescanalsobemadeanonymously.Whenthereisagrievanceitwillbe:

a. DocumentedonthefacilityGrievanceReport.b. RoutedtotheGrievanceOfficer.c. ListedonthefacilityGrievanceTrackingLog.d. Discussedwiththeappropriateindividuals(suchasRiskManager,Directorof

Nursing,andAdministratorandadditionalstaff)aswarranted.e. Investigatedaccordingly.f. ReportedasrequiredbyStateandFederalLaws,aswarranted.g. Thegrievancedecisionswillincludethefollowing:dates,summarystatement

ofresident’sgrievance,andsummaryoffindings,statementconfirmingornotconfirminggrievance,correctionactionsasindicated,andthedatethatthewrittendecisionwasissuedtothepersonfilingthegrievance.

h. Discussedthroughmeetingswhichmaybeinpersonand/ortelephoneconferences.

i. Includedinfacilityqualityimprovementprogram.

2. The Director of Social Services is the key contact in the facility responsible toimplementtheGrievanceProcedure.IntheabsenceoftheSocialServiceDirector,theAdministrator,ortheirdesigneeisthekeyfacilitycontactforgrievances.

PinesofSarasota’sGrievanceOfficialJenniferTonnesen,MSWSocialServicesDirector1501N.OrangeAvenue,Sarasota,FL34236Email:[email protected]:(914)356-5696or(914)365-0250ext.2810

3. Grievanceformswillbesporadicallyplacedineasytofindlocationsinthefacilitysuchas nurses' stations, Social Service office, to encourage independent usage unlessassistanceisrequested.

4. Reviewwill occur during thedaily standupmeeting,which is heldMonday throughFriday,excludingholidays.

5. Whenagrievance isreceivedbyastaffmembertheywillnotifytheirsupervisorandforwardthecompletedreporttotheGrievanceOfficial.

6. Whenagrievance is receivedorallyandtheresidentdoesnotchoose tocompleteawrittenreport;thenthestaffmemberreceivingthegrievancewillcompletethereportandforwardittotheGrievanceOfficial.

7. If,atanytime,aresident/familymemberoravisitorcannotcompletetheGrievanceform,theSocialServiceDirectororfacilitystaffmemberwillassisttheresident/familymemberindoingsuch.

All grievances whether filed with staff or the Grievance Official will be completed by thefollowingprocedure:

1. Thegrievancewillbeloggedonthefacilitygrievancelog.

2. Atthetimeofthegrievance,theemployee’ssupervisorwillattempttointerveneinanappropriatemannerinanefforttoresolvethestatedgrievanceastheyrelatedtotheirdepartmentandservices.Ifthisisaccomplishedtothesatisfactionofthefilingparty,theinterventionswillbedocumentedandthecompletedgrievanceformwillbereturnedtotheSocialServicesDirectorofdesignee.

3. Ifthepersonfilingthegrievanceisnotsatisfiedwiththedepartmentmanager’sinterventions,theGrievanceOfficerwillcontactthemtoassistinresolutionandaskifthepersonwouldliketoreceivethedecisioninwriting.

4. Ifthepersonfilingthegrievancerequeststhedecisioninwriting,theGrievanceOfficerwillberesponsibleforcompletingtheGrievanceSummary,providingthemacopyandobtainingasignatureuponreceipt.

5. AllGrievanceSummarieswillincludeataminimum:thedatethegrievancewasreceived,asummarystatementoftheresident’sgrievance,thestepstakentoinvestigatethegrievance,asummaryofthepertinentfindingsorconclusionsregardingtheresident’sconcerns(s),astatementastowhetherthegrievancewasconfirmedornotconfirmed,anycorrectiveactiontakenortobetakenbythefacilityasaresultofthegrievance,andthedatethewrittendecisionwasissued.

6. ACopyoftheGrievanceSummarywillbemaintainedwiththeGrievanceReportandanyotherinvestigationfindingsrelatedtotheGrievance.

7. Allfacilitygrievanceinvestigationswillbeinitiatedassoonaspossibleafterthegrievanceisfiled.Completedandtimelyfollowupwillbeconductedbythedepartmentsupervisor,theGrievanceOfficerand/ortheAdministrator.

8. TheGrievanceLogwillbemaintainedbytheGrievanceOfficerandpresentedmonthlyatthefacilityQA/RMMeeting.

9. Althoughwehopethatthepersonfilingthegrievanceissatisfiedwiththeresultoftheinvestigation,he/shecancontacttheAdministratorortheLongTermCareOmbudsmanortheAgencyforHealthCareAdministration,iftheyarenot.

10. Grievanceswillbemaintainedforthreeyearsafterthedateofthegrievancedecision.

LongTermCareOmbudsmanCouncil:

4040EsplanadeWay,Suite380 Tallahassee,FL32399 1-888-831-7000LocalLongTermCareOmbudsmanCouncil:8695CollegePkwyFortMyers,FL33919(239)433-6702 AgencyforHealthCareAdministration:

2727MahanDriveTallahassee,FL32399(888)419-3456QualityImprovementOrganization:KEPRO(Area2)216-447-9604KEPRO.Communictaions@hcqis.orgMedicaidFraudControlUnit OfficeofInspectorGeneral U.S.DepartmentofHealth&HumanServices ATTN:HOTLINEPOBox23489Washington,DC20026

Phone:(800)HHS-TIPS[(800)447-8477]Fax:(800)223-8164TTY:(800)377-4950

FloridaMedicaidFraudControlUnitTheOfficeofMedicaidProgramIntegrityoftheInspectorGeneralattheAgencyforHealthCareAdministrationacceptscomplaintsassociatedwithMedicaidbillingfraud.ThesecomplaintsmaybefiledonlineusingtheMedicaidbillingfraudonlinecomplaintformat http://myfloridalegal.com/orbytelephoneat1-888-419-3456.

POLICY/PROCEDURE

SUBJECT:ResidentRight–ResidentContactwithExternalEntities

DATE:

INTENT:

Itisthepolicyofthefacilitytoallowtheresidenttohavecontactwithexternalentitiesinsuchamannertoacknowledgeandrespectresidentrights.

PROCEDURE:

1. Afacilitywillnotprohibitorinanywaydiscouragearesidentfromcommunicatingwithfederal,state,orlocalofficials,including,butnotlimitedto,federalandstatesurveyors,otherfederalorstatehealthdepartmentemployees,includingrepresentativesoftheOfficeoftheStateLong-TermCareOmbudsmanandanyrepresentativeoftheagencyresponsiblefortheprotectionandadvocacysystemforindividualswithmentaldisorder,regardinganymatter,whetherornotsubjecttoarbitrationoranyothertypeofjudicialorregulatoryaction.

PLACETABFORFREEDOMFROMABUSE,NEGLECT,ANDEXPLOITATIONHERE

POLICY/PROCEDURE

SUBJECT:FreedomfromAbuse,Neglect,andExploitation

DATE:

INTENT:

Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.

PROCEDURE:


1. FreefromAbuseandNeglect

2. FreefromMisappropriation/Exploitation

3. FreefromInvoluntarySeclusion

4. RighttobeFreefromPhysicalRestraints

5. RighttobeFreefromChemicalRestraints

6. NotEmploy/EngageStaffwithAdverseActions

7. Develop/ImplementAbuse/Neglect,etc.Policies

8. ReportingofReasonableSuspicionofaCrime

9. ReportingofAllegedViolations

10. Investigate/Prevent/CorrectAllegedViolation

POLICY/PROCEDURE

SUBJECT:FreedomfromAbuse,Neglect,Misappropriation,Exploitation

DATE:

INTENT:


PROCEDURE:

1. Theresidenthastherighttobefreefromabuse,neglect,misappropriationofresidentproperty,andexploitationasdefinedinthissubpart.Thisincludesbutisnotlimitedtofreedomfromcorporalpunishment,involuntaryseclusionandanyphysicalorchemicalrestraintnotrequiredtreatingtheresident’smedicalsymptoms.

2. Thefacilitywillnotuseverbal,mental,sexual,orphysicalabuse,corporalpunishment,orinvoluntaryseclusion.

POLICY/PROCEDURE

SUBJECT:FreedomfromPhysicalandChemicalRestraints

DATE:

INTENT:


PROCEDURE:

1. Therighttobefreefromanyphysicalorchemicalrestraintsimposedforpurposesofdisciplineorconvenience,andnotrequiredtotreattheresident'smedicalsymptoms.

2. Theresidenthastherighttobefreefromabuse,neglect,misappropriationofresidentproperty,andexploitationasdefinedinthissubpart.Thisincludesbutisnotlimitedtofreedomfromcorporalpunishment,involuntaryseclusionandanyphysicalorchemicalrestraintnotrequiredtreatingtheresident’smedicalsymptoms.

3. Thefacilitywillensurethattheresidentisfreefromphysicalorchemicalrestraintsimposedforpurposesofdisciplineorconvenienceandthatarenotrequiredtotreattheresident’smedicalsymptoms.

4. Whentheuseofrestraintsisindicated,thefacilitywillusetheleastrestrictivealternativefortheleastamountoftimeanddocumentongoingre-evaluationoftheneedforrestraints.

PROCEDURE

SUBJECT:RestraintReductionProgram

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovidecareandservicesrelatedtoresidentrespectanddignity,asitrelatestotheuseofphysicalandchemicalrestraints,accordingtostateandfederalregulations.

PROCEDURE:

1. Wheneverrestraintuseisconsidered,thefacilitywillexplaintotheresidentandorlegalrepresentativehowtheuseoftherestraintwouldtreattheresident’smedicalsymptomsandassisttheresidentinattainingormaintaininghis/herhighestpracticablelevelofphysicalorpsychologicalwell-being.

2. Thefacilitywillalsoexplainthepotentialnegativeoutcomesofrestraintusewhichinclude,butarenotlimitedto,declinesintheresident’sphysicalfunctioning(e.g.,abilitytoambulate)andmusclecondition,contractures,increasedincidenceofinfectionsanddevelopmentofpressuresores/ulcers,delirium,agitation,andincontinence.

3. Beforeusingadeviceformobilityortransfer,evaluationwillincludeareviewoftheresident’sbedmobility,andabilitytotransferbetweenpositions,toandfrombedorchair,tostandandtoilet.Alldocumentationofevaluations,communicationandcareplanningconsiderationswillbemaintainedintheresident’sclinicalrecord.

4. Theresidentwillbere-evaluatedfortheappropriateuseoftheleastrestrictivedeviceinconjunctionwiththeResidentAssessmentInstrument.

POLICY/PROCEDURE

SUBJECT:NotEmploy/EngageStaffwithAdverseActions

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywillnotemployorotherwiseengageindividualswho:

a. Havebeenfoundguiltyofabuse,neglect,exploitation,misappropriationofproperty,ormistreatmentbyacourtoflaw;

b. HavehadafindingenteredintotheStatenurseaideregistryconcerningabuse,neglect,exploitation,mistreatmentofresidentsormisappropriationoftheirproperty;or

c. Haveadisciplinaryactionineffectagainsthisorherprofessionallicensebyastatelicensurebodyasaresultofafindingofabuse,neglect,exploitation,mistreatmentofresidentsormisappropriationofresidentproperty.

2. ThefacilitywillreporttotheStatenurseaideregistryorlicensingauthoritiesanyknowledgeithasofactionsbyacourtoflawagainstanemployee,whichwouldindicateunfitnessforserviceasanurseaideorotherfacilitystaff.

POLICY/PROCEDURE

SUBJECT:Develop/ImplementAbuse/Neglect,etc.Policies

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywilldevelopandimplementwrittenpoliciesandproceduresthat:

a. Prohibitandpreventabuse,neglect,andexploitationofresidentsandmisappropriationofresidentproperty,

b. Establishpoliciesandprocedurestoinvestigateanysuchallegations,andc. Includetraining.

POLICY/PROCEDURE

SUBJECT:ReportingofReasonableSuspicionofaCrime&AllegedViolations

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywillensurereportingofcrimesoccurringinfederally-fundedlong-termcarefacilitiesinaccordancewithsection1150BoftheAct.

2. Thispolicyincludesbutisnotlimitedtothefollowingelements:a. Annuallycoveredindividualswillhavein-servicestrainingofthatindividual’s

obligationtocomplywiththefollowingreportingrequirements:i. EachcoveredindividualshallreporttotheStateAgencyandoneormore

lawenforcemententitiesforthepoliticalsubdivisioninwhichthefacilityislocatedanyreasonablesuspicionofacrimeagainstanyindividualwhoisaresidentof,orisreceivingcarefrom,thefacility.Eachcoveredindividualshallreportimmediately,butnotlaterthan2hoursafterformingthesuspicion,iftheeventsthatcausethesuspicionresultinseriousbodilyinjury,ornotlaterthan24hoursiftheeventsthatcausethesuspiciondonotresultinseriousbodilyinjury.

ii. Postingaconspicuousnoticeofemployeerights,asdefinedatsection1150B(d)(3)oftheAct.

iii. Prohibitingandpreventingretaliation,asdefinedatsection1150B(d)(1)and(2)oftheAct.

3. Inresponsetoallegationsofabuse,neglect,exploitation,ormistreatment,thefacilitywill:a. Ensurethatallallegedviolationsinvolvingabuse,neglect,exploitationor

mistreatment,includinginjuriesofunknownsourceandmisappropriationofresidentproperty,arereportedimmediately,butnotlaterthan2hoursaftertheallegationismade,iftheeventsthatcausetheallegationinvolveabuseorresultinseriousbodilyinjury,ornotlaterthan24hoursiftheeventsthatcausetheallegationdonotinvolveabuseanddonotresultinseriousbodilyinjury,totheadministratorofthefacilityandtootherofficials(includingtotheStateSurveyAgencyandadultprotectiveserviceswherestatelawprovidesforjurisdictionin

long-termcarefacilities)inaccordancewithStatelawthroughestablishedprocedures.

b. ReporttheresultsofallinvestigationstotheadministratororhisorherdesignatedrepresentativeandtootherofficialsinaccordancewithStatelaw,includingtotheStateSurveyAgency,within5workingdaysoftheincident,andiftheallegedviolationisverifiedappropriatecorrectiveactionmustbetaken.

4. Inresponsetoallegationsofabuse,neglect,exploitation,ormistreatment,thefacilitywill:a. Haveevidencethatallallegedviolationsarethoroughlyinvestigated.b. Preventfurtherpotentialabuse,neglect,exploitation,ormistreatmentwhilethe

investigationisinprogress.c. Reporttheresultsofallinvestigationstotheadministratororhisorher

designatedrepresentativeandtootherofficialsinaccordancewithStatelaw,includingtotheStateSurveyAgency,within5workingdaysoftheincident,andiftheallegedviolationisverifiedappropriatecorrectiveactionmustbetaken.

5. Ifseveralindividualsformasimilarsuspicion,theymaygrouptheirreportjointly.

6. Anymulti-personreportwillincludeidentificationofallindividualsmakingthereport.

7. Anyindividualmaymakebothanindividualreportandbepartofalargerreport.

8. ReportswillbemadetotheCityPolice@941-954-7025at2099AdamsLane,Sarasota,FloridaStateAgency(AHCA).PleasenotifytheAdministratorordesigneeaswell.

9. StaffmayusethefacilitySuspectedCrimeReportForm.

10. ThefacilityRiskManagerorDesigneewillberesponsiblefortheFormcompletionwhenastaffmemberdoesnotcompleteoneandwillalsoberesponsiblefortheinvestigationanddocumentationoffinalfindings.

11. ThefacilityRiskManagerordesigneewillberesponsibleformaintainingthealldocumentationrelatedtoallreportsofSuspectedCrime.

POLICY/PROCEDURE

SUBJECT:AbuseNeglectExploitationMistreatmentandMisappropriationofPropertyPrevention

DATE:

INTENT:


DEFINITIONS:

• Abuse is the willful infliction of injury, unreasonable confinement, intimidation, orpunishmentwithresultingphysicalharm,painormentalanguish.

• Neglectisthefailuretoprovidegoodsandservicesnecessarytoavoidphysicalharm,mentalanguish,ormental illness. Neglectoccurswhenfacilitystafffailstomonitorand/orsupervise thedeliveryofpatient/residentcareandservices toassurecare isprovidedasrequired.

• Verbal/WrittenAbuseisdefinedastheuseoforal,writtenorgesturedlanguagethatwillfully includesdisparagingandderogatory terms to residentsor their families,orwithin their hearing distance, regardless of their age, ability to comprehend, ordisability.Examplesofverbalabuse include,butarenot limitedto:threatsofharm;sayingthingstofrightenaresident,suchastellingaresidentthathe/shewillneverbeabletoseehis/herfamilyagain.

• SexualAbuse includes,but isnot limited to, sexualharassment, sexual coercion,orsexualassault.

• Physical Abuse includes hitting, slapping, pinching, pulling, and kicking. It alsoincludescontrollingbehaviorthroughcorporalpunishment.

• Mental Abuse includes, but is not limited to, humiliation, harassment, threats ofpunishment,ordeprivation.

• InvoluntarySeclusionisdefinedasseparationofaresidentfromotherresidentsorfromher/hisroomorconfinementtoher/hisroom(withorwithoutroommates)againsttheresident’swill,orthewilloftheresident’slegalrepresentative.EmergencyorshorttermmonitoredseparationfromotherResidentswillnotbeconsideredinvoluntaryseclusionandmaybepermittedifusedforalimitedperiodoftimeasatherapeuticinterventiontoreduceagitationuntilprofessionalstaffcandevelopaplanofcaretomeettheresident’sneeds.

• Thisfacility’sAbusePreventionistandRiskManagerisCharleneCimeno,RNLHRM.

• Residentsofthisfacilityshallbeprotectedfromoccurrencesofabuse,exploitation,misappropriationofproperty,mistreatmentorneglect.

• Staffandotherrelevantpartiesasdeterminedbymanagementshallbetrainedatleastannuallyonabuse,neglectandexploitation,proceduresforreportingincidentsofthisnature,dementiamanagementandabuseprevention.

PROCEDURE:

I. Screening:• Screenpotentialemployeesforahistoryofabuse,neglectormistreating

residents.Thisincludesattemptingtoobtaininformationfrompreviousemployersand/orcurrentemployers,andcheckingwiththeappropriatelicensingboardsandregistries.

• Thefacilitymustnotemployorotherwiseengageindividualswho:I. Havebeenfoundguiltyofabuse,neglect,exploitation,

misappropriationofproperty,ormistreatmentbyacourtoflaw;II. HavehadafindingenteredintotheStatenurseaideregistry

concerningabuse,neglect,exploitation,mistreatmentofresidentsormisappropriationoftheirproperty;or

III. Haveadisciplinaryactionineffectagainsthisorherprofessionallicensebyastatelicensurebodyasaresultofafindingofabuse,neglect,exploitation,mistreatmentofresidentsormisappropriationofresidentproperty.

• ThefacilitywillreporttotheStatenurseaideregistryorlicensingauthoritiesanyknowledgeithasofactionsbyacourtoflawagainstanemployee,whichwouldindicateunfitnessforserviceasanurseaideorotherfacilitystaff.

• ApplicantsforourVolunteerProgramarescreenedthroughtheVerifiedVolunteerbackgroundcheck.

• EligibilityofindividualsandentitiesareverifiedthroughtheOfficeoftheInspectorGeneral’s(OIG’s)ListofExcludedIndividuals/Entities(LEIE).Notemployofanyandallineligibleindividuals.

II. Training:• Trainemployees,throughorientationandon-goingsessionsonissuesrelated

toabuseprohibitionpracticessuchas:o Appropriateinterventionstodealwithaggressiveand/orcatastrophic

reactionsofresidents;o Howstaffshouldreporttheirknowledgerelatedtoallegationswithout

fearofreprisal;o Howtorecognizesignsofburnout,frustrationandstressthatmayleadto

abuse;

o Whatconstitutesabuse,neglectandmisappropriationofresidentproperty;

o Inadditiontothefreedomfromabuse,neglect,andexploitationrequirementsin§483.12,facilitiesmustalsoprovidetrainingtotheirstaffthatataminimumeducatesstaffon:1. Activitiesthatconstituteabuse,neglect,exploitation,and

misappropriationofresidentproperty.2. Proceduresforreportingincidentsofabuse,neglect,exploitation,or

themisappropriationofresidentproperty.3. Dementiamanagementandresidentabuseprevention.

III. Prevention:• Provideresidents,familiesandstaffinformationonhowandtowhomthey

mayreportconcerns,incidentsandgrievanceswithoutthefearofretribution;andprovidefeedbackregardingtheconcernsthathavebeenexpressed.

• Identify,correctandinterveneinsituationsinwhichabuse,neglectand/ormisappropriationofresidentpropertyismorelikelytooccur.

• Thisincludesananalysisof:o Featuresofthephysicalenvironmentthatmaymakeabuseand/orneglect

morelikelytooccur,suchassecludedareasofthefacility;o Thedeploymentofstaffoneachshiftinsufficientnumberstomeetthe

needsoftheresidents,andassurethatthestaffassignedhaveknowledgeoftheindividualresidents’careneeds;

o Thesupervisionofstafftoidentifyinappropriatebehaviors,suchasusingderogatorylanguage,roughhandling,ignoringresidentswhilegivingcare,directingresidentswhoneedtoiletingassistancetourinateordefecateintheirbeds;and

o Theassessment,careplanning,andmonitoringofresidentswithneedsandbehaviorswhichmightleadtoconflictorneglect,suchasresidentswithahistoryofaggressivebehaviors,residentswhohavebehaviorssuchasenteringotherresidents’rooms,residentswithself-injuriousbehaviors,residentswithcommunicationdisorders,thosethatrequireheavynursingcareand/oraretotallydependentonstaff.

IV. Identification:• Identifyevents,suchassuspiciousbruisingofresidents,occurrences,patterns,

andtrendsthatmayconstituteabuse;andtodeterminethedirectionoftheinvestigation.

V. Investigation:• Investigatedifferenttypesofincidents;and• Identifythestaffmemberresponsiblefortheinitialreporting,investigationof

allegedviolationsandreportingofresultstotheproperauthorities.

VI. Protection:•Protectresidentsfromharmduringaninvestigation.• Whenanallegationorsuspicionofoneoftheactivitiessetoutinthe

definitionshereinoccursthefacilityshall:1. Promptlyprotecttheresident(s)whois/aretheallegedvictim(s);2. Monitortheresidentforsignsandsymptomsofmental,emotionalor

physicalissues;3. Notifytheresident’sphysicianandappropriateresidentrepresentative;4. Protectotherresidentswhomightbeatrisk;5. Theprotectionsemployedshallbebasedonthedetailsoftheallegation;6. Ensurethatnoretributionoccurstothecomplainant;7. Immediatelyremovetheaccusedteammemberfromtheresidentareas

andtakefurtheractionwiththatteammemberaswarranted;and8. Anyemployeewhoissuspendedtohavecommittedanactassetoutin

thedefinitionshereinwillbeimmediatelysuspendedorplacedinapositioninwhichnofurtheractscouldoccur.Intheeventtheinvestigationidentifiesaperpetrator,thatindividualwillbeterminatedandreportedtotheirboard,whereapplicable.

VII. Reporting/Response:• Reportallallegedviolationsandallsubstantiatedincidentstothestateagency

andtoallotheragenciesasrequired,andtakeallnecessarycorrectiveactionsdependingontheresultsoftheinvestigation;

• ReporttotheStatenurseaideregistryorlicensingauthoritiesanyknowledgeithasofanyactionsbyacourtoflawwhichwouldindicateanemployeeisunfitforservice;and

• Analyzetheoccurrencestodeterminewhatchangesareneeded,ifany,topoliciesandprocedurestopreventfurtheroccurrences.

• Thefacilitymustdevelopandimplementwrittenpoliciesandproceduresthat:1. Ensurereportingofcrimesoccurringinfederally-fundedlong-termcare

facilitiesinaccordancewithsection1150BoftheSocialSecurityAct.Thepoliciesandproceduresmustincludebutarenotlimitedtothefollowingelements.

• Inresponsetoallegationsofabuse,neglect,exploitation,ormistreatment,thefacilitywill:

1. Ensurethatallallegedviolationsinvolvingabuse,neglect,exploitationormistreatment,includinginjuriesofunknownsourceandmisappropriationofresidentproperty,arereportedimmediately,butnotlaterthan2hoursaftertheallegationismade,iftheeventsthatcausetheallegationinvolveabuseorresultinseriousbodilyinjury,ornotlaterthan24hoursiftheeventsthatcausetheallegationdonotinvolveabuseanddonotresultinseriousbodilyinjury,totheadministratorofthefacilityandtootherofficials(includingtotheStateSurveyAgencyandadultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities)inaccordancewithStatelawthroughestablishedprocedures.

2. Haveevidencethatallallegedviolationsarethoroughlyinvestigated.3. Preventfurtherpotentialabuse,neglect,exploitation,ormistreatment

whiletheinvestigationisinprogress.4. Reporttheresultsofallinvestigationstotheadministratororhisorher

designatedrepresentativeandtootherofficialsinaccordancewithStatelaw,includingtotheStateSurveyAgency,within5workingdaysoftheincident,andiftheallegedviolationisverifiedappropriatecorrectiveactionmustbetaken.

POLICY/PROCEDURE

SUBJECT:PersonalPropertyTheftandLossRisk

DATE:

INTENT:TheFacilityprovidesforthereasonablesafekeepingofpersonalpropertyandfundsforresidentsinthefacilityperstateandfederalrequirements.

PROCEDURE:

1. TheFacilityrecommendsthatresidents,employees,andothersdonotbringitems of value into the facility. Facility reserves the right, whenevernecessaryfortheprotectionofvaluablesbeexcludedorremovedfromthefacility.Itisfurtherrecommendedthatresidentskeeponlysmallamountsofcashon theirperson,and thatemployees store theirparcels in the lockedtrunkoftheirvehicle.

2. The Facility has a safe for cash, wallets, and other valuables and alsoprovidesa lockedspace for small items, suchasahandbag, that residentsmaywishtosecure.

3. The Facility provides labeling of the resident's clothing and personalpropertyattheresidentsrequest.Werecommendthatyourequesttohaveitemslabeledsuchasrazors,glasses,cellphones,chargingcords,etc.

4. All theftsor lossof resident'soremployee'sproperty shall be reported totheFacility’smanagementorGrievanceOfficer immediately.Alleffortswillbemadetolocatethemissingitem.

5. The Facility documents all thefts and loss of resident's personal property.ThedocumentationismaintainedbytheSocialServicesDepartment.

6. The Facility’s loss prevention policy is provided to all residents andemployees.

7. TheftofpropertywillbereportedtothePoliceDepartmentintheFacility’sjurisdictionbymanagementatthedirectionoftheresidentoremployeeandwithnotificationoftheAdministrator.

8. Recommendationsforsafekeepingofyourpersonalitems:

a. Donotleaveyourwallet/purseinunlockeddrawers,cabinets,orinopen,non-secureareas.Alock-boxwillbeprovidedtoyouuponrequest.

b. Donotwrapitemsintissues/napkinsorplacethemonyourmealtray,underyourpillow,inyourtissuebox,etc.

c. Don't"flash"cashorothervaluables.d. Keepanycashorvaluablesinoursafe.

e. MakesureallyourpropertyislistedonyourInventoryRecordandisupdatedifnewitemsarebroughtin.Askastaffmembertolabelyourpersonalbelongings.

f. Reportpersonsyoudon'trecognizegoingfromroomtoroomorlookingsuspicious.

g. Reportanymissingitemsimmediately.

POLICY/PROCEDURE

SUBJECT:PhotographsandSocialMedia

DATE:

INTENT:

Thispolicyistoserveasageneralguidanceforemployeeuseofsocialmedia,whichshouldbebroadlyunderstoodforpurposesofthispolicytoincludeblogs,wikis,microblogs,messageboards,chatrooms,electronicnewsletters,onlineforums,socialnetworkingsites,andothersitesandservicesthatpermituserstoshareinformationwithothersinacontemporaneousmanner.

Asacompany,weunderstandthatsocialmediacanbeafunandrewardingwaytoshareyourlifeandopinionswithfamily,friend,andco-workersaroundtheworld.However,useofsocialmediaalsopresentscertainrisksandcarrieswithitcertainresponsibilities.Toassistemployeesinmakingresponsibledecisionsabouttheuseofsocialmedia,wehaveestablishedtheseguidelinesforappropriateuseofsocialmedia.

Itisveryimportantthatweprovideasafeandhomelikeenvironmentforourresidentssothattheyfeelprotected,freefromembarrassment,freeofabuseofanykindandsecurethattheirprivacyisprotected.Thisincludestheresidenthimself,theirprivatespaceandtheirbelongings.

POLICYINTERPRETATIONANDIMPLEMENTATION

GeneralGuidelines

TheprinciplesandguidelinesfoundintheCompanyPoliciesapplytoemployees’activitiesinrecordingandputtingthatinformationonasocialnetworkorprivatecommunicationsonline.Employeesaresolelyresponsibleforwhattheyrecordandpostonline.Beforecreatingonlinecontent,employeesshouldconsiderthattherearemanyrisksthatareinvolved.Employeesshouldkeepinmindthatanyoftheirconductthatadverselyaffectstheirjobperformance,theperformanceoffellowemployeesorotherwiseadverselyaffectsemployees,residents,suppliers,peoplewhoworkonbehalfoftheCompanyortheCompany’slegitimatebusinessinterestsmayresultindisciplinaryactionuptoandincludingtermination.

Implementation

1. Whilephotosmaybetakenofresidentsforclinicalpurposes,thesearemaintainedinconfidentialfilesforthatuseonly.Thismayincludeelopement,treatmentorothercare.

2. Employeesmustunderstandandfollowtheguidelinesrelatedtotheuseofsocialmedia,includingbutnotlimitedtotheProhibitionofHarassmentandDiscrimination

Policy,andensurepostingsareconsistentwiththesepolicies.Inappropriatepostingsthatmayincludediscriminatoryremarks,harassment,andthreatsofviolence,lackofrespectforresidents’privacyorsimilarinappropriateorunlawfulconductwillnotbetoleratedandmysubjectemployeestodisciplinaryactionuptoandincludingtermination.

3. Takingphotographsofresidents,theirbelongingsandtheirprivatespaceisnotpermitted.Anyphotographswhichshowresidentinformation,suchasachartinthebackgroundshouldnotbetaken.

4. ThisfacilityrespectstheEmployee’srighttoexpressconcernswiththeworkplaceandtheirconditionsofwork.Wewillnotimpedethisrightiflawfullyused.However,Employeesshouldusethefacility’sopendoorpolicyandcomplaintprocedurestoresolveanywork-relatedcomplaintsorconcerns,wheneverpossible.Thisdoesnotprecludeyoufrompostingcomplaintstoasocialmediaoutlet,butwilllikelygettheissueresolvedquickly.Shouldanemployeechoosetopostacomplaintorcriticism,theemployeeshouldavoidusingstatements,photographs,videooraudiothatreasonablycouldbeviewedasmalicious,obscene,threatening,orintimidating,thatdisparageresidents,orthatmightconstituteharassmentorbullying.Examplesofsuchconductmightincludeoffensivepostsmeanttointentionallyharmsomeone’sreputationratherthanexpressconcernsaboutworkingconditions,orpostsbymanagersthatcouldcontributetoahostileworkenvironmentonthebasisofrace,sex,disability,religionoranyotherstatusprotectedbylaworcompanypolicy.

5. Employeesareexpectedtomaintaintheconfidentialityofthecompany’sconfidentialinformationandallhealthrelatedorprivateinformationaboutourresidents.Employeesshouldnotcreatealinkfromtheirblogorwebsiteorothersocialnetworkingsitetoacompanywebsitewithoutidentifyingthemselvesasacurrentemployee.Employeesshouldexpressonlypersonalopinions,andneverrepresentthemselvesasacompanyspokesperson.

6. Employeesshouldrefrainfromusingsocialmediaonworktimeoronequipmentthecompanyprovides,exceptduringbreaks.Thisincludesbutisnotlimitedtointernet,email,cellphonesandcomputers.Employeesshouldneveruseacompanyemailaddresstoregisteronsocialnetworks,blogsorotheronlinetoolsutilizedforpersonaluse.

7. Althoughnotanexclusivelist,somespecificexamplesofprohibitedsocialmediaconductincludepostingphotographs,videos,audios,commentary,content,images,protectedhealthinformation,oranyothertypeofinformationprohibitedbyHIPAArules,lawsandregulationsregardingourresidents,imagesthataredefamatory,pornographic,proprietary,harassing,libelous,orthatcancreateahostileworkenvironment.Ifanemployeeisunsureofwhatsocialmediacontentisconsideredconfidential,he/sheshoulddirectinquiriestocompanyadministrationforguidance.Photographandvideosofresidents,theirprivatespaceandpropertyisalwaysconsideredconfidentialunlessmanagementhassecuredwrittenauthorizationforitsuse.

8. Willfulpostingofprotectedhealthinformation,images,commentary,orcontentmeanttodisparageresidents,oranyotherinformationsetoutinthispolicyisgroundsforimmediatedisciplinaryaction,uptoandincludingtermination,aswellasanyandalllegalramificationsfromsuchaction.

9. Willfulpostingofresidentprotectedhealthinformation,images,commentary,orcontentoranyothertypeofinformationprohibitedbyHIPAArules,lawsandregulationswillbeconsideredasmentallyand/oremotionallyabusive,andwillbeinvestigatedaccordingtothefacility’sANEPolicyandProcedure,includingmandatoryreportingtoregulatoryagencies.Willfulpostingofanyphotographsorvideoofanyresident,theirprivatespaceand/ortheirbelongingswillbeconsideredaviolationoftheirprivacyrightsandwillbetreatedasabove.

10. IfyouobserveanotherEmployeeoranoutsidepartysuchasavisitororfamilymembertakingphotographsorvideosoftheresidenttheyarevisitingandotherresidentsareinthearea,advisethepersonthattheotherresidentshavearighttoprivacy.Thesameactionshouldbetakenifthephotographorvideowillshowanotherresident’sprivatespaceorbelongings.Ifthepersondoesnotdiscontinuetakinginappropriatepicturesnotifyyoursupervisor.

11. Alsoifyouobserveanyonetakingapictureofaresidentwhichyoubelieveareasonablepersonwouldconsiderembarrassing,humiliatingordemeaning,notifyyoursupervisor.

12. ConsenttophotographsorvideostakenbyEmployeesmustbeinwritingandsignedbytheresidentortheresident’slegalrepresentativewhohasthatauthority.Youmusthavepermissionfromyoursupervisortotakephotographsorvideosusinganyresident’spermission.

13. Foradditionalinformationrefertothefacility’spolicyonuseofelectronicdevicesintheworkplaceandtheuseoffacility-ownedcomputersandotherelectronicequipmentandreportingabuse.

POLICY/PROCEDURE

SUBJECT:SexualAbuse

DATE:

INTENT:

Itisthepolicyofthefacilitytoimmediatelyreportandcompletesaninvestigationintheeventofallegationknownorsuspectedrelatedsexualabuse.

PROCEDURE:

IntheeventofanallegationofsexualabusepleaserefertothefacilityAbuseNeglectExploitationandMisappropriationtoincludeseparation,protection,outsidereport,investigationandcompletethefollowingasindicated:

1. Theinternalriskmanagerofthefacilitywillinvestigateeveryallegationofsexualmisconductwhichismadeagainstamemberofthefacility'spersonnelwhohasdirectpatientcontactwhentheallegationisthatthesexualmisconductoccurredatthefacilityoratthegroundsofthefacility.

2. Thefacilitywillimmediatelyreportallegationsofthisnaturetothelawenforcementandabuseregistry.APropermedicalevaluationshouldnotbedelayedinallegationsofrapeorsexualassault.Thefollowingprocesswillbefollowed:

a. Followdirectivesgivenbylawenforcement.b. Avoidshowingorcleansingtheresidentinanywaytoavoidwashingawayany

possibleevidence.c. Collect,bag,andtaganyandalllinensandorwashableitemsthatmayhave

comeincontactwiththeresident(e.g.,linen,towels,clothing,etc.).d. Tagthebagwithidentificationinformation(e.g.,residentname,datebagged,

timebagged,andthenameoftheindividualcompletingtheprocess,etc.).

3. Reporteveryallegationofsexualmisconducttotheadministratorimmediately;and

4. Notifytheresidentrepresentativeorguardianofthevictimthatanallegationofsexualmisconducthasbeenmadeandthataninvestigationisbeingconducted.

PLACETABFORADMISSION,TRANSFER,ANDDISCHARGEHERE

POLICY/PROCEDURE

SUBJECT:Admission,Transfer&Discharge

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoAdmissions,TransfersandDischargesinaccordancetoStateandFederalregulation.

PROCEDURE:


1.AdmissionsPolicy2.EqualPracticesRegardlessofPaymentSource3.TransferandDischargeRequirements4.NoticeRequirementsbeforeTransfer/Discharge5.PreparationforSafe/OrderlyTransfer/Discharge6.PermittingResidentstoReturntoFacility7.EqualPracticesRegardlessofPaymentSource8.ProhibitingCertainAdmissionPolicies

POLICY/PROCEDURE

SUBJECT:Admissions

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideadmissionsaccordingtostateandfederalregulations.

PROCEDURE:

1. Nopotentialorcurrentresidentwillberequestedorrequiredto:a. Waiveanyrightsaffordedbystate,localandfederallawapplicableto

nursingfacilities;b. WaiverightstoMedicareorMedicaidreimbursementforcareandservices;c. Waivepotentialliabilityforlossesofpersonalproperty;ord. Haveathirdpartyguarantorasaconditionofadmission,expedited

admissionorcontinuedstay.

2. Thefacilitymayrequestandrequirearesidentrepresentativewhohaslegalaccesstoaresident’sincomeorresourcesavailabletopayforfacilitycaretosignacontract,withoutincurringpersonalfinancialliability,toprovidefacilitypaymentfromtheresident’sincomeorresources.

3. Thefacilitywillnot,inthecaseofapersoneligibleforMedicaid,charge,solicit,acceptorreceive,inadditiontoanyamountotherwiserequiredtobepaidundertheStateplan,anygift,money,donationorotherconsiderationasapreconditionofadmission,expeditedadmissionorcontinuedstayinthefacility;however:

a. ThefacilitywillchargearesidenteligibleforMedicaidforitemsandservicestheresidenthasrequestedandreceived,andthatarenotspecifiedintheStateplanasincludedintheterm“nursingfacilityservices,”andwillgivepropernoticeoftheavailabilityandcostofthoseservicesandthattheyarenotaconditionofadmissionorcontinuedstay;and

b. Thefacilitywillnotifytheresidentand/ortheresidentrepresentativeofadditions,deletionsorchangesforthecostoftheseitemsorservices.

4. TheFacilitieswillprovideresidentsatthetimeofadmissionandperiodicallyduringresident’sstayof:

a. Servicesincludedunderstateplanandwhatisnotincluded;b. 60-daynoticewhenchangesaremadetowhatservicesarecoveredby

MedicareandMedicaid;c. Resident’seligibilityforMedicaid;d. Alistofnames,addresses,includingemailaddress,andtelephonenumbers

ofallpertinentStateregulatoryandinformationalagencies;

e. Long-TermCareOmbudsmanprogram;f. Informationaboutreturningtothecommunity;g. StatementresidentmayfileacomplaintwithStateSurveyAgency;andh. Filinggrievances.

5. Thefacilitywillnotifytheresidentofthefacility’sspecialcharacteristicsasfollows:a. RehabilitationUnitwithfacultystaffthatarelicensedandorcertified

therapist:i. Solostepii. Biodexiii. Bounce-backRoomiv. AquaticTherapy

b. Outpatienttherapyforcontinuityofcarec. ReadySteadyProgramd. Facilityacceptsmostinsuranceplanse. SmokeFreeFacilityf. In-houseTransportationg. EveningSecurityh. MultilingualStaffi. Conciergej. IntergenerationalActivitiesk. 80%ofmealspreparedfromscratchl. Secureddementiaunitm. FutureIndependentwingn. Allbedsexceptthebedsonthe3100and3200unitsarealldullycertified.

6. Facilitydoesnotacceptresidentswho:a. RequireTPNb. Requirepainpumpc. Haveatrachandrequiretrachcared. Ventilatordependente. Weighmorethan350poundsf. Requiredeepsuctioning

POLICY/PROCEDURE

SUBJECT:EqualPracticesRegardlessofPaymentSources

DATE:

INTENT:

Itisthepolicyofthefacilitytoensureresidentsaretreatedequallyregardingtransfer,discharge,andtheprovisionofservices,regardlessoftheirpaymentsource.

PROCEDURE:

1. Afacilitywillestablish,maintainandimplementidenticalpoliciesandpracticesregardingtransferanddischarge,andtheprovisionofservicesforallindividualsregardlessofsourceofpayment;

2. Thefacilitymaychargeanyamountforservicesfurnishedtonon-Medicaidresidentsunlessotherwiselimitedbystatelawandthesechargeswillbelistedwithintheadmissionpacket;and

3. TheStateisnotrequiredtoofferadditionalservicesonbehalfofaresidentotherthanservicesprovidedintheStateplan.

4. Roomchangesinacompositedistinctpart.Roomchangesinafacilitythatisacompositedistinctpart(asdefinedin§483.5)aresubjecttotherequirementsof§483.10(e)(7)andmustbelimitedtomoveswithintheparticularbuildinginwhichtheresidentresides,unlesstheresidentvoluntarilyagreestomovetoanotherofthecompositedistinctpart’slocations.

POLICY/PROCEDURE

SUBJECT:TransferandDischargeRequirements

DATE:

INTENT:

Itisthepolicyofthefacilitytoensureresidentsaretreatedequallyregardingtransfer,discharge,andtheprovisionofservices,regardlessoftheirpaymentsourceinaccordancetostateandfederalregulations.

PROCEDURE:

1. Thefacilitymustpermiteachresidenttoremaininthefacility,andnottransferordischargetheresidentfromthefacilityunless:a. Thetransferordischargeisnecessaryfortheresident’swelfareandthe

resident’sneedscannotbemetinthefacility;b. Thetransferordischargeisappropriatebecausetheresident’shealthhas

improvedsufficientlysotheresidentnolongerneedstheservicesprovidedbythefacility;

c. Thesafetyofindividualsinthefacilityisendangeredduetotheclinicalorbehavioralstatusoftheresident;

d. Thehealthofindividualsinthefacilitywouldotherwisebeendangered;e. Theresidenthasfailed,afterreasonableandappropriatenotice,topayfor

(ortohavepaidunderMedicareorMedicaid)astayatthefacility.Nonpaymentappliesiftheresidentdoesnotsubmitthenecessarypaperworkforthirdpartypaymentorafterthethirdparty,includingMedicareorMedicaid,deniestheclaimandtheresidentrefusestopayforhisorherstay.ForaresidentwhobecomeseligibleforMedicaidafteradmissiontoafacility,thefacilitymaychargearesidentonlyallowablechargesunderMedicaid;or

f. Thefacilityceasestooperate.g. Thefacilitywillnottransferordischargetheresidentwhiletheappealis

pending,pursuantto§431.230ofthischapter,whenaresidentexerciseshisorherrighttoappealatransferordischargenoticefromthefacilitypursuantto§431.220(a)(3)ofthischapter,unlessthefailuretodischargeortransferwouldendangerthehealthorsafetyoftheresidentorotherindividualsinthefacility.Thefacilitymustdocumentthedangerthatfailuretotransferordischargewouldpose.

Documentation:

Whenthefacilitytransfersordischargesaresidentunderanyofthecircumstances,thefacilitywillensurethatthetransferordischargeisdocumentedintheresident’smedicalrecordandappropriateinformationiscommunicatedtothereceivinghealthcareinstitutionorprovider.

1. Documentationintheresident’smedicalrecordwillinclude:a. Thebasisforthetransfer;b. Inthecaseofinabilitytomeetresidentneeds,thespecificresident

need(s)thatcannotbemet,thefacility’sattemptstomeettheresidentneeds,andtheserviceavailableatthereceivingfacilitytomeetthoseneed(s).

2. Theresident’sphysicianwillalsodocumentintheclinicalrecordwhenthetransferordischargeisnecessary.

3. Informationprovidedtothereceivingprovidermustincludeaminimumofthefollowing:a. Contactinformationofthepractitionerresponsibleforthecareofthe

resident;b. Residentrepresentativeinformationincludingcontactinformation;c. AdvanceDirectiveinformation;d. Allspecialinstructionsorprecautionsforongoingcare,asappropriate;e. Comprehensivecareplangoals;f. Allothernecessaryinformation,includingacopyoftheresident’s

dischargesummaryandanyotherdocumentation,asapplicable,toensureasafeandeffectivetransitionofcare.

POLICY/PROCEDURE

SUBJECT:NoticeRequirementsbeforeTransfer/Discharge

DATE:

INTENT:

Itisthepolicyofthefacilitytonotifytheresidentandortheirlegalguardianofthebeforetransferand/ordischargeaccordingtostateandfederalregulations.

PROCEDURE:

1. Beforethefacilitytransfersordischargesaresident,thefacilitywill:a. Obtainaphysician’sorderforthetransferandordischarge.b. Notifytheresidentand,ifknown,afamilymemberortheresident’s

representative(s)ofthetransferordischargeandthereasonsforthemoveinwritingandinalanguageandmannertheyunderstand.

c. ThefacilitywillsendacopyofthenoticetoarepresentativeoftheOfficeoftheStateLong-TermCareOmbudsman.

d. Recordthereasonsforthetransferordischargeintheresident’smedicalrecord;and

e. Includeinthenoticethefollowingitems:i. Thereasonfortransferordischarge;ii. Theeffectivedateoftransferordischarge;iii. Thelocationtowhichtheresidentistransferredordischarged;iv. Astatementthattheresidenthastherighttoappealtheactiontothe

State;v. Thename,addressandtelephonenumberoftheStatelongtermcare

Ombudsman;vi. Fornursingfacilityresidentswithdevelopmentaldisabilities,themailing

addressandtelephonenumberoftheagencyresponsiblefortheprotectionandadvocacyofdevelopmentallydisabledindividualsestablishedunderPartCoftheDevelopmentalDisabilitiesAssistanceandBillofRightsAct;and

vii. Fornursingfacilityresidentswhoarementallyill,themailingaddressandtelephonenumberoftheagencyresponsiblefortheprotectionandadvocacyofmentallyillindividualsestablishedundertheProtectionandAdvocacyforMentallyIllIndividualsAct.

2. Thefacilitywillprovidesufficientpreparationandorientationtoresidentstoensuresafeandorderlytransferandordischargefromthefacility.

3. Iftheinformationinthenoticechangespriortoeffectingthetransferordischarge,thefacilitywillupdatetherecipientsofthenoticeassoonaspracticableoncetheupdatedinformationbecomesavailable.

4. Aresidentmaychallengeadecisionbythefacilitytodischargeortransfertheresident.

5. Inthecaseoffacilityclosure,theindividualwhoistheadministratorofthefacilitywillprovidewrittennotificationpriortotheimpendingclosuretotheStateSurveyAgency,theOfficeoftheStateLong-TermCareOmbudsman,residentsofthefacility,andtheresidentrepresentatives,aswellastheplanforthetransferandadequaterelocationoftheresidents.

TimingofNotice:

1. Atleast30dayspriortoanyproposedtransferordischarge,thefacilitywillprovideadvancenoticeoftheproposedtransferordischargetotheresidentand,ifknowntoafamilymemberortheresident’slegalguardianorrepresentative,exceptinthefollowingcircumstances,thefacilityshallgivenoticeassoonaspracticablebeforethetransferordischarge:a. Thetransferordischargeisnecessaryforthewelfareandtheresident’s

needscannotbemetinthefacility,andthecircumstancesaredocumentedintheresident’smedicalrecordbytheresident’sphysician;or

b. Thehealthorsafetyofotherresidentsorfacilityemployeeswouldbeendangered,andtheresident’sphysicianorthemedicaldirectordocumentsthecircumstancesintheresident’smedicalrecordiftheresident’sphysicianisnotavailable.

WrittenNotice:

1. Thenoticewillbeinwritingandwillcontainallinformationrequiredbystateandfederallaw,rules,orregulationsapplicabletoMedicaidorMedicarecases.Theagencyshalldevelopastandarddocumenttobeusedbyallfacilitieslicensedunderthispartforpurposesofnotifyingresidentsofadischargeortransfer.Suchdocumentmustincludeameansforaresidenttorequestthelocallong-termcareombudsmancounciltoreviewthenoticeandrequestinformationaboutorassistancewithinitiatingafairhearingwiththedepartment'sOfficeofAppealsHearings.

2. Inadditiontoanyotherpertinentinformationincluded,theformshallspecifythereasonallowedunderfederalorstatelawthattheresidentisbeingdischargedortransferred,withanexplanationtosupportthisaction.Further,theformshallstatetheeffectivedateofthedischargeortransferandthelocationtowhichtheresidentisbeingdischargedortransferred.Theformshallclearlydescribetheresident'sappealrightsandtheproceduresforfilinganappeal,includingtherighttorequestthelocalombudsmancounciltoreviewthenoticeofdischargeortransfer.Acopyofthenoticemustbeplacedintheresident'sclinicalrecord,andacopymustbetransmittedtotheresident'slegalguardianorrepresentativeandtothelocalombudsmancouncilwithinfivebusinessdaysaftersignaturebytheresidentorresidentdesignee.

3. Thefacilitywillprovideanddocumentsufficientpreparationandorientationtoresidentstoensuresafeandorderlytransferordischargefromthefacility.Thisorientationmustbeprovidedinaformandmannerthattheresidentcanunderstand.

POLICY/PROCEDURE

SUBJECT:NoticeofBedHoldPolicyBefore/UponTransfer

DATE:

INTENT:

ItisthepolicyofthefacilitytonotifytheresidentandortheirlegalguardianoftheBedHoldPolicyaccordingtostateandfederalregulations.

PROCEDURE:

1. Beforethefacilitytransfersaresidenttoahospitalorallowsaresidenttogoontherapeuticleave,thenursingfacilitymustprovidewritteninformationtotheresidentorresidentrepresentativethatspecifies:a. Thedurationofthestatebed-holdpolicy,ifany,duringwhichthe

residentispermittedtoreturnandresumeresidenceinthenursingfacility;

b. Thereservebedpaymentpolicyinthestateplan,under§447.40ofthischapter,ifany;and

c. Thenursingfacility’spoliciesregardingbed-holdperiods.

2. Atthetimeoftransferofaresidentforhospitalizationortherapeuticleave,thefacilitywillprovidetotheresidentandtheresidentrepresentativewrittennotice,whichspecifiesthedurationofthebed-holdpolicy.

POLICY/PROCEDURE

SUBJECT:BedHoldPolicy

DATE:

INTENT:

ItisthepolicyofthefacilitytonotifytheresidentandortheirlegalguardianofthebeforetheBed-HoldPolicyandReadmissionaccordingtostateandfederalregulations.

PROCEDURE:

A. MEDICAIDRESIDENTSIf hospitalized, theDepartmentofChildrenandFamily Serviceswill pay to reserveabed for eight (8) days for eachmedically necessary hospitalization. If a resident ishospitalizedformorethaneightdays,theresidentwillbedischarged.Shouldabedbeunavailable when the resident is discharged from the hospital and an admission toanother facility is necessary, the resident will be notified of the first Medicaid bedavailableatthisfacility. Theresidentorfamilymembersmaypayprivatelytoholdabedaftertheeightpaiddaysrunout.Thepatientisstillresponsiblefortheirportionof thepatient responsibilityduring thebedholdperiod. Medicaidwillnotpay forabedholdwhenaresidentgoestothehospitaloronahomeleaveif5percentormoreof the Medicaid certified beds are available. The percentage of occupancy isdeterminedby the facility’soccupancy for thepreviousquarter. Youwillbenotifiedwithin24hoursifthisruleappliesoryoumayseetheAdministrator.

Additionally, Medicaid will pay for sixteen (16) days annually for therapeutic homevisits.Residentswhowishtohavemorethansixteendaysmaypayprivatelyforthem,inadvance.

B. MEDICAREPARTARESIDENTSBedsarenotreserved.IfaMedicareresidentisadmittedtothehospital,adischargefromthefacilityisnecessary.Whentheresidentisdischargedfromthehospital,theymaybeadmittedtothefacilityaccordingtobedavailability.TheMedicareBedmaybeheldprivately,see“C”below.

C. PRIVATEPAYRESIDENTS/HOSPICETheNursingFacilitywillreservetheresident’sbedforaperiodofuptothirty(30)daysfor any hospitalization, provided the Nursing Facility receives reimbursement, andarrangementstoholdthebedaremadeatthetimeoftransfertothehospital.

Hospicedoesnotpayforbedholds.

Inordertoreturntothefacility,theresidentmustneedtheservicesprovidedbythefacility. If theresidentwastransferredwiththeexpectationofreturningandcannot

return to the facility, the facilitywill complywith itspolicyonnoticeof transferanddischarge.Whenthefacilitytowhicharesidentreturnsisacompositedistinctparttheresidentwill be permitted to return to an available bed in the particular location of thecompositedistinctpartinwhichheorsheresidedpreviously.Ifabedisnotavailableinthatlocationatthetimeofreturn,theresidentmustbegiventheoptiontoreturntothatlocationuponfirstavailabilityofabedthere.ALL QUESTIONS REGARDING THE BED HOLD POLICY ARE TO BE DIRECTED TO THEADMINISTRATOROROFFICEMANAGER.

POLICY/PROCEDURE

SUBJECT:PermittingResidenttoReturntoFacility

DATE:

INTENT:

Itisthepolicyofthefacilitytopermittheresidenttoreturntofacilityaccordingtostateandfederalregulations.

PROCEDURE:

1. Afacilitywillestablishandfollowawrittenpolicyonpermittingresidentstoreturntothefacilityaftertheyarehospitalizedorplacedontherapeuticleave.

2. Thepolicywillprovideforthefollowing:a. Aresident,whosehospitalizationortherapeuticleaveexceedsthebed-hold

periodundertheStateplan,returnstothefacilitytotheirpreviousroomifavailableorimmediatelyuponthefirstavailabilityofabedinasemi-privateroomiftheresident:i. Requirestheservicesprovidedbythefacility;andii. IseligibleforMedicareskillednursingfacilityservicesorMedicaidnursing

facilityservices.b. Ifthefacilitythatdeterminesthataresidentwhowastransferredwithan

expectationofreturningtothefacility,cannotreturntothefacility,thefacilitymustcomplywiththerequirementsofparagraph(c)astheyapplytodischarges.

3. Whenthefacilitytowhicharesidentreturnsisacompositedistinctpart(asdefinedin§483.5),theresidentmustbepermittedtoreturntoanavailablebedintheparticularlocationofthecompositedistinctpartinwhichheorsheresidedpreviously.Ifabedisnotavailableinthatlocationatthetimeofreturn,theresidentmustbegiventheoptiontoreturntothatlocationuponthefirstavailabilityofabedthere.

PLACETABFORRESIDENTASSESSMENTSHERE

POLICY/PROCEDURE

SUBJECT:ResidentAssessment

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoResidentAssessment/InstrumentandProcessinaccordancetoStateandFederalregulation.

PROCEDURE:


1. AdmissionPhysicianordersforImmediateCare

2. Comprehensiveassessments&Timing

3. Comprehensiveassessmentaftersignificantchange

4. Quarterlyassessmentatleastevery3months

5. Maintain15monthsofresidentassessments

6. Encoding/TransmittingResidentAssessment

7. AccuracyofAssessments

8. Coordination/CertificationofAssessment

9. CoordinationofPASARRandAssessments

10. PASARRScreeningforMD&ID

11. MD/IDSignificantChangeNotification

POLICY/PROCEDURE

SUBJECT:AdmissionOrders

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideacareandservicesrelatedtoadmissionorders,accordingtostateandfederalregulations.

PROCEDURE:

1. Thefacilitywillhavephysicianordersfortheresident’simmediatecare,atthetimeofaresident’sadmission.

2. Theadmittingnursewillcalltheattendingphysicianandclarifyallordersonadmission.

3. TheadmittingorderswillbetranscribedtotheadmissionPhysicianOrderSheets(POS)oncetheordersareclarifiedorenteredintothefacilityelectronicmedicalrecord.

4. ThePOSswillbefaxedortransmittedelectronicallytothepharmacyinatimelymannertoensurereceiptoftheresident’smedicationsonthenextpharmacydelivery.

POLICY/PROCEDURE

SUBJECT:ResidentAssessmentInstrument(RAI)

DATE:

INTENT:

Itisthepolicyofthefacilitytoadheretothefollowingproceduresrelatedtotheproperdocumentationandutilizationofaresident’sMinimumDataSet(MDS)toensureacomprehensiveandaccurateassessmentofresidentswillbecompletedintheformatandinaccordancewithtimeframesstipulatedbytheDepartmentofHealthandHumanServicesCenterforMedicareandMedicaidServices.Thisassessmentsystemwillprovideacomprehensive,accurate,standardized,reproducibleassessmentofeachresident’sfunctionalcapacitiesandassiststafftoidentifyhealthproblemsforcareplandevelopment.

PROCEDURE:

CompletionoftheMinimumDataSet:

1. ResidentAssessmentInstrument.Afacilitywillcompleteacomprehensiveassessmentofaresident’sneeds,functionalandhealthstatus,strengths,goals,lifehistoryandpreferences,usingtheresidentassessmentinstrument(RAI)specifiedbyCMS.Theassessmentmustincludeatleastthefollowing:

a) Identificationanddemographicinformationb) Customaryroutine.c) Cognitivepatterns.d) Communication.e) Vision.f) Moodandbehaviorpatterns.g) Psychologicalwell-being.h) Physicalfunctioningandstructuralproblems.i) Continence.j) Diseasediagnosisandhealthconditions.k) Dentalandnutritionalstatus.l) SkinConditions.m) Activitypursuit.n) Medications.o) Specialtreatmentsandprocedures.p) Dischargeplanning.q) Documentationofsummaryinformationregardingtheadditional

assessmentperformedonthecareareastriggeredbythecompletionoftheMinimumDataSet(MDS).

r) Documentationofparticipationinassessment.Theassessmentprocessmustincludedirectobservationandcommunicationwiththeresident,aswellascommunicationwithlicensedandnon-licenseddirectcarestaffmembersonallshifts.

2. Aresident’sMinimumDataSet(MDS)iscompletedbyaninterdisciplinaryteam.Duringtheinitialassessmentperiod,dataiscollectedbyresidentobservationandcommunicationastheprimarysourceofinformation.Thefollowingdisciplineswillberesponsibletocompletethesesections:

a. ResidentMasterInformation,SectionAAandAcompletedbytheMDSCoordinatorondayofadmission.

b. Backgroundsection,AB-ACcompletedbytheMDSCoordinator.c. SectionsB,C,E,andQcompletedbytheSocialServicesDepartment.d. SectionKcompletedbytheCertifiedDietaryManager(CDM).e. SectionFcompletedbytheActivitiesDepartment.f. SectionO,P,GGandG(partial)completedonthework-sheetMDSbythe

MDSCoordinator.g. SectionsC,D,GG,G(partial),H,I,J,L,M,N,O,P,Q(partial)andS,are

enteredintothecomputersoftware,MatrixbytheMDSCoordinator.

3. Allsectionsoftheassessmentareencodedandclosedbyeachinterdisciplinaryteam(IDT)memberasassignedabove.ThecomputersoftwarehasstandardizededitsdefinedbyCMSandtheState.AnyinformationontheencodedMDSthatdoesnotpassCMS–specifiededitsaremadepriortothecompletion.ComputerizedCAA’sareconfirmed,utilizingasection“V”worksheet.TheMDSCoordinatorcompletesSectionVlistingthelocationanddateoftheCAAassessmentdocumentation.ThecompletedMDSisverifiedandsignedbytheMDSCoordinator.Staffmemberswhocompleteportionsoftheassessmentattesttotheaccuracyoftheirsectionsbysignature.Interdisciplinarycareplanningiscompletedwithinseven(7)daysofthecompletionoftheMDSadmissionassessment.

4. Assessmentsarealsocompletedforresidentswhohaveexperienceda“SignificantChange.”Within14daysafterthefacilitydetermines,orshouldhavedetermined,thattherehasbeenasignificantchangeintheresident’sphysicalormentalcondition.(Forpurposeofthissection,a“significantchange”meansamajordeclineorimprovementintheresident’sstatusthatwillnotnormallyresolveitselfwithoutfurtherinterventionbystafforbyimplementingstandarddisease-relatedclinicalinterventions,thathasanimpactonmorethanoneareaoftheresident’shealthstatus,andrequiresinterdisciplinaryrevieworrevisionofthecareplan,orboth.)AsignificantchangeinstatusMDSisrequiredwhenaresidentelects,andrevokesthehospicebenefit,andifdeclineorimprovementfrombaselinein2ormoreareasoftheresident’sfunctionalstatus.

5. Quarterlyassessmentsarealsodoneforresidentsevery3months,atleastevery92daysfollowingacomprehensiveassessment.Annual,entry,dischargeandre-

entryassessmentsarecompletedfollowingtheguidelinesindicatedintheFinalRuleandtheRAIMDSVersion3.0Guidelines.

6. Theassessmentwillaccuratelyreflecttheresident’sstatus.

7. Aregisterednursewillconductorcoordinateeachassessmentwiththeappropriateparticipationofhealthprofessionals.

8. Aregisterednursewillsignandcertifythattheassessmentiscompleted.

9. Eachindividualwhocompletesaportionoftheassessmentmustsignandcertifytheaccuracyofthatportionoftheassessment.

ElectronicTransmissionandValidation:

1. PPSandQuarterlyAssessmentswillbetransmittedwithin14daysofcompletiondate.

2. Comprehensiveassessmentswillbetransmittedwithin14daysoftheCarePlancompletiondate.

3. TheMDSCoordinatorwilltransmitthefileandprinttheinitialandfinalValidationReport.

4. TheMDSCoordinatorwillfacilitatethecorrectionofanyfatalerrorsimmediatelyandretransmittheassessmentuntilanacceptedValidationReportisreceived.

5. TheMDSCoordinatorwillalsoaddressnon-fatalerrorsusingtheQualityImprovementandEvaluationSystem(QIES)AssessmentSubmissionandProcessing(ASAP)systemMDS3.0ProviderUser’sGuide.

6. TheMDSCoordinatorwillmaintainValidationReportsinatransmittalnotebooktobeorganizedbymonth.

7. TheMDSCoordinatorwillprovideacopy,thesamedaytothebusinessofficedesigneeoftheinitialandfinalValidationReportthatacknowledgesacceptanceoftheMDSintotheQIESASAPforallPPSAssessments.

8. TheValidationReportwillbeconfirmedbytheBusinessOfficedesigneepriortobillingtheRUGfordatesofserviceontheUB(UniformBill)toinclude:a. ConfirmedRUGb. Acceptancec. AccuracyofARDPerassessmentbilledd. Accuracyofnumberofdaysbilledperassessment/claim

9. CopiesofthePPSAssessmentValidationReportswillbemaintainedinthebusinessoffice,organizedchronologicallyforthree(3)years.CopiesofOBRAAssessmentValidationReportswillbemaintainedintheMDSofficeforaone-yeartimeperiodorfromcertificationsurveytocertificationsurvey.

10. TofacilitatereceivingValidationReportsonatimelybasis,theMDSCoordinatorwilltransmitasfrequentlyasnecessarytoobtaintimelyValidationofMDSacceptanceintotheQIESASAPdatabase.

MaintenanceofAssessmentData:

1. Fifteen(15)monthsofassessmentdatawillbemaintainedonsiteintheresident’sactiveclinicalrecordorinalocationeasilyaccessibletothenursingstaffandusetheresultsoftheassessmentstodevelop,reviewandrevisetheresident’scomprehensivecareplan.Theformofstoragemaybeelectronicorhardcopy.ThemostrecentcomprehensiveassessmentwithCAA’swillbemaintainedasahardcopyintheresident’s/patient’sclinicalrecord.ComputerMDSsoftware(AnswersonDemand“AOD”)hasthecapacitytoprintallassessmentsfortheperioduponrequest.BackupforMDSdataisdonenightlytoserverslocatedbothonsiteatthefacilityandoffsiteatacyber-securelocationselectedbythefacility’sInformationTechnologyvendor.Formoredetailedinformationconcerningthefacility’sdataback-upprocedures,pleaseseethefacility’sITManual.

Training:

1. MDSdocumentationoverviewisprovidedatanewhire’sorientationalongwithacopyoftheMDSforreview.

ProgramSecurity:

1. PasswordstothecomputerMDSSoftwareareissuedbytheAssistantDirectorofNursing(ADON).

2. ComputerswiththeMDSprogramarelocatedinthefollowingoffices:HealthcareAdministrator,DirectorofNursing,MDSCoordinator,AdmissionCoordinator,SocialServicesCoordinator,Dietary,ActivityDirectorandMedicalRecords.Eachofthesecomputersarepasswordprotected,thuslimitingaccesstoapprovedusers.

3. Additionally,thefollowingsecuritymeasuresareinplace:a. TheHealthCareAdministrator,theMDSCoordinatorandthecomputer

softwarevendor(Enterfacilitysoftwarevendorhere)coordinatetheadministrativeaspectoftheMDS.

b. When“Creatinganewuser”specialconsiderationwillbegiventodetermineassignedprivileges(“ReadOnly,”“ReadandEdit,”“FullAdministrativePrivileges”etc.)

c. AregisterofMDSprogramusersiskeptlockedintheHealthcareAdministrator’sofficefornecessaryaccess.

Confidentiality/ResidentIdentifiableInformation:

1. AutomatedRAIinformation,aspartoftheclinicalrecord,issafeguardedasconfidentialinformation.Thefacilitywillnotreleaseinformationthatisresidentidentifiabletothepublic.Thefacilitymayreleaseinformationthatisresident

identifiabletoanagentonlyinaccordancewithacontractunderwhichtheagentagreesnottouseordisclosetheinformationexcepttotheextentthefacilityitselfispermittedtodoso.Allresident’shealthinformationwillbehandledinasafe,secure,andconfidentialmanner.

ResidentConsent:

1. EachresidentwillbeinformeduponadmissionandconsentwillbeobtainedforelectronictransmissionoftheMDS.

DateBackupandRestoreProcess:

1. Backup–TheMDSsoftwareislocatedonthefacility’sserver.Theprogramanddataarebackeduptobothonsiteandoffsiteserversnightlybythefacility’sInformationTechnologyVendor.Restoreandtestrestorefunctionsarealsocompletedbythefacility’sInformationTechnologyVendor.Formoredetailedinformationconcerningthefacility’sdataback-upanddatarestorationprocedures,pleaseseethefacility’sITManual.

POLICY/PROCEDURE

SUBJECT:Coordination-Pre-AdmissionScreeningandResidentReview (PASRR)program

DATE:

INTENT:

ItisthepolicyofthefacilitytoassurethatallresidentsadmittedtothefacilityreceiveaPre-AdmissionScreeningandResidentReview,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywillcoordinateassessmentswiththepre-admissionscreeningandresidentreview(PASARR)programunderMedicaidinsubpartCofthisparttothemaximumextentpracticabletoavoidduplicativetestingandeffort.

2. Coordinationincludes:a. IncorporatingtherecommendationsfromthePASARRlevelIIdetermination

andthePASARRevaluationreportintoaresident’sassessment,careplanning,andtransitionsofcare.

b. ReferringalllevelIIresidentsandallresidentswithnewlyevidentorpossibleseriousmentaldisorder,intellectualdisability,orarelatedconditionforlevelIIresidentreviewuponasignificantchangeinstatusassessment.

3. PreadmissionScreeningforindividualswithamentaldisorderandindividualswithintellectualdisability.Thefacilitywillnotadmit,onorafterJanuary1,1989,anynewresidentswith:a. Mentaldisorder,unlesstheStatementalhealthauthorityhasdetermined,

basedonanindependentphysicalandmentalevaluationperformedbyapersonorentityotherthantheStatementalhealthauthority,priortoadmission:

i. That,becauseofthephysicalandmentalconditionoftheindividual,theindividualrequiresthelevelofservicesprovidedbyanursingfacility;and

ii. Iftheindividualrequiressuchlevelofservices,whethertheindividualrequiresspecializedservicesformentalretardation.

b. Exceptionsforpurposesofthissectioninclude:i. Thepreadmissionscreeningprogramunderparagraph(k)(1)ofthis

sectionneednotprovidefordeterminationsinthecaseofthereadmissiontoanursingfacilityofanindividualwho,afterbeingadmittedtothenursingfacility,wastransferredforcareinahospital.

ii. TheStatemaychoosenottoapplythepreadmissionscreeningprogramunderparagraph(k)(1)ofthissectiontotheadmissiontoa

nursingfacilityofanindividual:whoisadmittedtothefacilitydirectlyfromahospitalafterreceivingacuteinpatientcareatthehospital,whorequiresnursingfacilityservicesfortheconditionforwhichtheindividualreceivedcareinthehospital,andwhoseattendingphysicianhascertified,beforeadmissiontothefacilitythattheindividualislikelytorequirelessthan30daysofnursingfacilityservices.

c. Mentalretardation,asdefinedinparagraph(m)(2)(ii)ofthissection,unlesstheStatementalretardationordevelopmentaldisabilityauthorityhasdeterminedpriortoadmission:i. That,becauseofthephysicalandmentalconditionoftheindividual,

theindividualrequiresthelevelofservicesprovidedbyanursingfacility;and

ii. Iftheindividualrequiressuchlevelofservices,whethertheindividualrequiresspecializedservicesformentalretardation.

4. Definitionsforpurposesofthissection:a. Anindividualisconsideredtohaveamentaldisorderiftheindividualhasa

seriousmentaldisorderdefinedin483.102(b)(1).b. Anindividualisconsideredtohaveanintellectualdisabilityiftheindividual

hasanintellectualdisabilityasdefinedin§483.102(b)(3)orisapersonwitharelatedconditionasdescribedin435.1010ofthischapter.

5. Anursingfacilitymustnotifythestatementalhealthauthorityorstateintellectualdisabilityauthority,asapplicable,promptlyafterasignificantchangeinthementalorphysicalconditionofaresidentwhohasmentalillnessorintellectualdisabilityforresidentreview.

INSERTCOMPREHENSIVERESIDENTCENTEREDCAREPLANSTABHERE

POLICY/PROCEDURE

SUBJECT:ComprehensiveResidentCenteredCarePlans

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoComprehensiveResidentCenteredCarePlansinaccordancetoStateandFederalregulation.

PROCEDURE:


1. BaselineCarePlan

2. Develop/ImplementComprehensiveCarePlan

3. CarePlanTimingandRevision

4. ServicesProvidedMeetProfessionalStandards

6. QualifiedPersons

7. DischargePlanningProcess

8. DischargeSummary

POLICY/PROCEDURE

SUBJECT:BaselineCarePlan

DATE:

INTENT:

Itisthepolicyofthefacilitytopromoteseamlessinterdisciplinarycareforourresidentsbyutilizingtheinterdisciplinaryplanofcarebasedonassessment,planning,treatment,serviceandintervention.Itisutilizedtoplanforandmanageresidentcareasevidencedbydocumentationfromadmissionthroughdischargeforeachresident.EveryresidentwillhaveanInterdisciplinaryCarePlan,withtheInterimInterdisciplinaryCarePlaninitiatedwithin24hoursofadmission.Thecareplanwillidentifypriorityproblemsandneedstobeaddressedbytheinterdisciplinaryteam,andwillreflecttheresident’sstrengths,limitationsandgoals.Thecareplanwillbecomplete,current,realistic,timespecificandappropriatetotheindividualneedsforeachresident.Therewillbeongoingdocumentationofthenursingprocessrelatedtoresidentneedsfromadmissiontodischarge.TheinterdisciplinaryplanofcarewillbedevelopedthroughcollaborativeeffortsoftheInterdisciplinaryTeamandotherhealthcareprofessionals.Itwillbeconsistentwiththemedicalplanofcareandthosedisciplinesthathavedirectinvolvementwiththeresident’scare.Theresidentand/orfamilymemberwillbeinvolvedinthecareplanning.Thecareplanwillcontaininformationaboutthephysical,emotional/psychological,psychosocial,spiritual,educationalandenvironmentalneedsasappropriate.TheInterimInterdisciplinaryCarePlanwillbelocatedinthecareplansectionoftheMedicalRecord.Itisourpurposetoensurethateachresidentisprovidedwithindividualized,goal-directedcare,whichisreasonable,measurableandbasedonresidentneeds.Aresident’scareshouldhavetheappropriateinterventionandprovideameansofinterdisciplinarycommunicationtoensurecontinuityinresidentcare.

PROCEDURE:

Thefacilitywilldevelopandimplementabaselinecareplanforeachresidentthatincludestheinstructionsneededtoprovideeffectiveandperson-centeredcareoftheresidentthatmeetprofessionalstandardsofqualitycare.Thebaselinecareplanwill:

1. Bedevelopedwithin48hoursofaresident’sadmission.

2. Includetheminimumhealthcareinformationnecessarytoproperlycareforaresidentincluding,butnotlimitedto:a. Initialgoalsbasedonadmissionorders.b. Physicianorders.c. Dietaryorders.d. Therapyservices.e. Socialservices.f. PASARRrecommendation,ifapplicable.

3. Thefacilitymaydevelopacomprehensivecareplaninplaceofthebaselinecare

planifthecomprehensivecareplan:a. Isdevelopedwithin48hoursoftheresident’sadmission.b. Meetstherequirementssetforthinparagraph(b)ofthissection(excepting

paragraph(b)(2)(i)ofthissection).

4. Thefacilitywillprovidetheresidentandtheirrepresentativewithasummaryofthebaselinecareplanpriortothecompletionofthecomprehensivecareplan,thatincludesbutisnotlimitedto:a. Theinitialgoalsoftheresident.b. Asummaryoftheresident’smedicationsanddietaryinstructions.c. Anyservicesandtreatmentstobeadministeredbythefacilityand

personnelactingonbehalfofthefacility.d. Anyupdatedinformationbasedonthedetailsofthecomprehensivecare

plan,asnecessary.

POLICY/PROCEDURE

SUBJECT:ComprehensiveResidentCenteredCarePlans

DATE:

INTENT:

Itisthepolicyofthefacilitytopromoteseamlessinterdisciplinarycareforourresidentsbyutilizingtheinterdisciplinaryplanofcarebasedonassessment,planning,treatment,serviceandintervention.Itisutilizedtoplanforandmanageresidentcareasevidencedbydocumentationfromadmissionthroughdischargeforeachresident.

EveryresidentwillhaveanInterdisciplinaryCarePlan,withtheInterimInterdisciplinaryCarePlaninitiatedwithin24hoursofadmission.Thecareplanwillidentifypriorityproblemsandneedstobeaddressedbytheinterdisciplinaryteam,andwillreflecttheresident’sstrengths,limitationsandgoals.Thecareplanwillbecomplete,current,realistic,timespecificandappropriatetotheindividualneedsforeachresident.Therewillbeongoingdocumentationofthenursingprocessrelatedtoresidentneedsfromadmissiontodischarge.TheinterdisciplinaryplanofcarewillbedevelopedthroughcollaborativeeffortsoftheInterdisciplinaryTeamandotherhealthcareprofessionals.Itwillbeconsistentwiththemedicalplanofcareandthosedisciplinesthathavedirectinvolvementwiththeresident’scare.Theresidentand/orfamilymemberwillbeinvolvedinthecareplanning.

Thecareplanwillcontaininformationaboutthephysical,emotional/psychological,psychosocial,spiritual,educationalandenvironmentalneedsasappropriate.

TheInterimInterdisciplinaryCarePlanwillbelocatedinthecareplansectionoftheMedicalRecord.

Itisourpurposetoensurethateachresidentisprovidedwithindividualized,goal-directedcare,whichisreasonable,measurableandbasedonresidentneeds.Aresident’scareshouldhavetheappropriateinterventionandprovideameansofinterdisciplinarycommunicationtoensurecontinuityinresidentcare.

PROCEDURE:

1. ThefollowinghealthcareprofessionalscontributetotheInterdisciplinaryCarePlanbycollaborationanddirectdocumentation:RN,LPN,CNA,PhysicalTherapist,OccupationalTherapist,SpeechTherapist,RespiratoryTherapist,ActivityDirector,SocialServicesCoordinator,Dietitian,PhysicianandotherappropriatemembersoftheCarePlanTeam.Otherspecialtyareasavailableforconsultationwhenneededinclude,butarenotlimitedtodiabetic,pain,wound,psychological,hospiceandpharmacyprofessionals.

2. Thefacilitymustdevelopandimplementacomprehensiveperson-centeredcareplanforeachresident,consistentwiththeresidentrightssetforthat§483.10(c)(2)and§483.10(c)(3),thatincludesmeasurableobjectivesandtimeframestomeetaresident'smedical,nursing,andmentalandpsychosocialneedsthatareidentifiedinthecomprehensiveassessment.Thecomprehensivecareplanmustdescribethefollowing:

a. Theservicesthataretobefurnishedtoattainormaintaintheresident'shighestpracticablephysical,mental,andpsychosocialwell-beingasrequiredunder§483.24,§483.25or§483.40;and

b. Anyservicesthatwouldotherwiseberequiredunder§483.24,§483.25or§483.40butarenotprovidedduetotheresident'sexerciseofrightsunder§483.10,includingtherighttorefusetreatmentunder§483.10(c)(6).

c. AnyspecializedservicesorspecializedrehabilitativeservicesthenursingfacilitywillprovideasaresultofPASARRrecommendations.IfafacilitydisagreeswiththefindingsofthePASARR,itmustindicateitsrationaleintheresident’smedicalrecord.

d. Inconsultationwiththeresidentandtheresident’srepresentative(s):i. Theresident’sgoalsforadmissionanddesiredoutcomes.ii. Theresident’spreferenceandpotentialforfuturedischarge.

Facilitiesmustdocumentwhethertheresident’sdesiretoreturntothecommunitywasassessedandanyreferralstolocalcontactagenciesand/orotherappropriateentities,forthispurpose.

iii. Dischargeplansinthecomprehensivecareplan,asappropriate,inaccordancewiththerequirementssetforthinparagraph(c)ofthissection.

3. Theresidentwillhavetherighttoparticipateinthedevelopmentandimplementationofhisorherperson-centeredplanofcare,includingbutnotlimitedto:

a. Therighttoparticipateintheplanningprocess,includingtherighttoidentifyindividualsorrolestobeincludedintheplanningprocess,therighttorequestmeetingsandtherighttorequestrevisionstotheperson-centeredplanofcare.

b. Therighttoparticipateinestablishingtheexpectedgoalsandoutcomesofcare,thetype,amount,frequency,anddurationofcare,andanyotherfactorsrelatedtotheeffectivenessoftheplanofcare.

c. Therighttoreceivetheservicesand/oritemsincludedintheplanofcare.d. Therighttoseethecareplan,includingtherighttosignaftersignificant

changestotheplanofcare.

4. Thefacilitywillinformtheresidentoftherighttoparticipateinhisorhertreatmentandshallsupporttheresidentinthisright.

5. Theplanningprocesswill:a. Facilitatetheinclusionoftheresidentand/orresidentrepresentative.b. Includeanassessmentoftheresident’sstrengthsandneeds.

c. Incorporatetheresident’spersonalandculturalpreferencesindevelopinggoalsofcare.

DevelopingtheCarePlan:

1. Acomprehensivecareplanwillbe:a. Developedwithin7daysaftercompletionofthecomprehensive

assessment.b. Preparedbyaninterdisciplinaryteam,thatincludesbutisnotlimitedto:

i. Theattendingphysician.ii. Aregisterednursewithresponsibilityfortheresident.iii. Anurseaidewithresponsibilityfortheresident.iv. Amemberoffoodandnutritionservicesstaff.v. Totheextentpracticable,theparticipationoftheresidentandthe

resident'srepresentative(s).Anexplanationmustbeincludedinaresident’smedicalrecordiftheparticipationoftheresidentandtheirresidentrepresentativeisdeterminednotpracticableforthedevelopmentoftheresident’scareplan.

vi. Otherappropriatestafforprofessionalsindisciplinesasdeterminedbytheresident'sneedsorasrequestedbytheresident.

c. Reviewedandrevisedbytheinterdisciplinaryteamaftereachassessment,includingboththecomprehensiveandquarterlyreviewassessments.

2. Theservicesprovidedorarrangedbythefacility,asoutlinedbythecomprehensivecareplan,willmeetprofessionalstandardsofquality.

3. Eachdisciplinewillcheckand/oraddinterventions/approachestoincludebutnotlimitedto:a. Theinterventionstatementsdescribethosemeasuresperformedbythestaff

tohelptheresidentachievetheexpectedoutcomesb. Interventionalentriesreflectactivitiesthatincorporateobservations,

assessments,managementandteachingcomponentsthatwillrestore,maintainand/orpromotetheresident’swell-being.

c. Eachplannedinterventionwillbespecificandincludeparametersforfrequencyandtimeschedule.

4. Eachdisciplinewillcheckoraddexpectedoutcomesandgoals.Expectedoutcomesdescribetherealisticshort-rangegoalstobeachievedbytheresidentwithinaspecifictimeframe.

5. Theseactivitieswillbecompletedforeachpatientproblem.

6. Computergeneratedplansofcarearecompletedwithinseven(7)daysofthecomprehensiveMDSassessment.Theindividualizedcareplanbasedontheinterdisciplinaryassessmentisthereforecompletedwithintwenty-one(21)daysofadmission.Thecareplanwillbemaintainedinthecareplansectionoftheresident’smedicalrecord.

UpdatingCarePlans:

1. Careplansaremodifiedbetweencareplanconferencewhenappropriatetomeettheresident’scurrentneeds,problemsandgoals.

2. Stand-upmeetingsoftheDirectorofNursing,SocialServicesCoordinator(ifappropriate),MDSCoordinator,RegisteredDietician,ActivitiesDirectorandTherapyProfessionalareheldtoreviewthecurrentstatusofskilledresidentsanddetermineneededinterventionstomeetresidentgoals.

3. TheCarePlanwillbeupdatedand/orrevisedforthefollowingreasons:a. Significantchangeintheresident’scondition.b. Achangeinplannedinterventions.c. Goalsareobtainedandnewgoalsestablishedtomeetcurrentresidentneeds

and/orgoalsd. Newdiagnosis,newmedications,orabnormallabs.

4. Anyrevision,additions,ordeletiontotheplanofcarewillbedatedandinitialed.

5. Revisionsinvolvingthecareofotherdisciplinesaredonethroughconsultativeandcollaborativeeffortsanddocumentedasabove.

6. Dischargeplanningconcernswillbeidentifiedbyalldisciplinesthroughongoingassessment.Thelicensednursewillmakeappropriatereferralstointerdisciplinaryteammembersasnecessary.

7. AllresidentsarediscussedwiththeInterdisciplinaryTeamtoprovidecontinuedappropriateinterventionsbasedontheresident’sgoals,careneeds,anddischargeplanning.

ResolutionofProblems:

1. Whenoutcomes/goalsareattained,anevaluationoftheproblemwillbedocumented,datedandinitialedbytheinterdisciplinary(ID)teammembers.

Resident/ResidentRepresentativeInvolvement:

1. Residentsareinvolvedindecisionsregardingtheprovisionofcare.

2. Discussionswithresident/representativemayoccurduringadmission,duringresidentcareconferences,andanytimeanewdiagnosisisestablishedand/ortheplanofcareissignificantlyaltered.

3. Regularlyscheduledresidentcareconferencesareheldbythe21stdayafteradmission,quarterly,annually,orifasignificantchangeinstatusoccurs.

4. Theresident,residentrepresentativeandhealthcareprovidersareinvitedtoattendandprovideinputintotheplanningprocess.

CAA’sprovidefurtherassessmentoftriggeredMDSareas,andenablesstafftofurtheranalyzeassessmentfindingstodevelopacomprehensiveplanofcare.

POLICY/PROCEDURE

SUBJECT:DischargePlanningProcess

DATE:

INTENT:

ItisthepolicyofthefacilitytoassurethatthedischargeplanningprocessisimplementedinaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywilldevelopandimplementaneffectivedischargeplanningprocessthatfocusesontheresident’sdischargegoals,thepreparationofresidentstobeactivepartnersandeffectivelytransitionthemtopost-dischargecare,andthereductionoffactorsleadingtopreventablereadmissions.

2. Thefacility’sdischargeplanningprocessmustbeconsistentwiththedischargerightssetforthat483.15(b)asapplicableand:

a. Ensurethatthedischargeneedsofeachresidentareidentifiedandresultinthedevelopmentofadischargeplanforeachresident.

b. Includeregularre-evaluationofresidentstoidentifychangesthatrequiremodificationofthedischargeplan.Thedischargeplanmustbeupdated,asneeded,toreflectthesechanges.

c. Involvetheinterdisciplinaryteam,asdefinedby§483.21(b)(2)(ii),intheongoingprocessofdevelopingthedischargeplan.

d. Considercaregiver/supportpersonavailabilityandtheresident’sorcaregiver’s/supportperson(s)capacityandcapabilitytoperformrequiredcare,aspartoftheidentificationofdischargeneeds.

e. Involvetheresidentandresidentrepresentativeinthedevelopmentofthedischargeplanandinformtheresidentandresidentrepresentativeofthefinalplan.

f. Addresstheresident’sgoalsofcareandtreatmentpreferences.g. Documentthataresidenthasbeenaskedabouttheirinterestinreceiving

informationregardingreturningtothecommunity.h. Iftheresidentindicatesaninterestinreturningtothecommunity,the

facilitymustdocumentanyreferralstolocalcontactagenciesorotherappropriateentitiesmadeforthispurpose.

i. Facilitieswillupdatearesident’scomprehensivecareplananddischargeplan,asappropriate,inresponsetoinformationreceivedfromreferralstolocalcontactagenciesorotherappropriateentities.

j. Ifdischargetothecommunityisdeterminedtonotbefeasible,thefacilitymustdocumentwhomadethedeterminationandwhy.

k. ForresidentswhoaretransferredtoanotherSNForwhoaredischargedtoaHHA,IRF,orLTCH,assistresidentsandtheirresidentrepresentativesin

selectingapost-acutecareproviderbyusingdatathatincludes,butisnotlimitedtoSNF,HHA,IRF,orLTCHstandardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceusetotheextentthedataisavailable.Thefacilitywillensurethatthepost-acutecarestandardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceuseisrelevantandapplicabletotheresident’sgoalsofcareandtreatmentpreferences.

l. Document,completeonatimelybasisbasedontheresident’sneeds,andincludeintheclinicalrecord,theevaluationoftheresident’sdischargeneedsanddischargeplan.Theresultsoftheevaluationmustbediscussedwiththeresidentorresident’srepresentative.Allrelevantresidentinformationmustbeincorporatedintothedischargeplantofacilitateitsimplementationandtoavoidunnecessarydelaysintheresident’sdischargeortransfer.

PROCEDURE

SUBJECT:DischargePlanning

DATE:

INTENT:

Itisthepolicyofthefacilitytodevelopandimplementaneffectivedischargeplanningprocessthatfocusesontheresident’sdischargegoals,thepreparationofresidentstobeactivepartnersandeffectivelytransitionthemtopost-dischargecare,andthereductionoffactorsleadingtopreventablereadmissions,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacility’sdischargeplanningprocesswillbeconsistentwiththedischargerightssetforthat483.15(b)asapplicable.

2. Thefacilitywillensurethatthedischargeneedsofeachresidentareidentifiedandresultinthedevelopmentofadischargeplanforeachresident.

3. Thefacilitywillincluderegularre-evaluationofresidentstoidentifychangesthatrequiremodificationofthedischargeplan.Thedischargeplanmustbeupdated,asneeded,toreflectthesechanges.

4. Thefacilitywillinvolvetheinterdisciplinaryteam,asdefinedby§483.21(b)(2)(ii),intheongoingprocessofdevelopingthedischargeplan.

5. Thefacilitywillconsidercaregiver/supportpersonavailabilityandtheresident’sorcaregiver’s/supportperson(s)capacityandcapabilitytoperformrequiredcare,aspartoftheidentificationofdischargeneeds.

6. Thefacilitywillinvolvetheresidentandresidentrepresentativeinthedevelopmentofthedischargeplanandinformtheresidentandresidentrepresentativeofthefinalplan.

7. Thefacilitywilladdresstheresident’sgoalsofcareandtreatmentpreferences.

8. Thefacilitywilldocumentthataresidenthasbeenaskedabouttheirinterestinreceivinginformationregardingreturningtothecommunity.

9. Iftheresidentindicatesaninterestinreturningtothecommunity,thefacilitywilldocumentanyreferralstolocalcontactagenciesorotherappropriateentitiesmadeforthispurpose.

10. TheFacilitywillupdatearesident’scomprehensivecareplananddischargeplan,asappropriate,inresponsetoinformationreceivedfromreferralstolocalcontactagenciesorotherappropriateentities.

11. Ifdischargetothecommunityisdeterminedtonotbefeasible,thefacilitymustdocumentwhomadethedeterminationandwhy.

12. ForresidentswhoaretransferredtoanotherSNForwhoaredischargedtoaHHA,IRF,orLTCH,assistresidentsandtheirresidentrepresentativesinselectingapost-acutecareproviderbyusingdatathatincludes,butisnotlimitedtoSNF,HHA,IRF,orLTCHstandardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceusetotheextentthedataisavailable.Thefacilitymustensurethatthepost-acutecarestandardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceuseisrelevantandapplicabletotheresident’sgoalsofcareandtreatmentpreferences.

13. Document,completeonatimelybasisbasedontheresident’sneeds,andincludeintheclinicalrecord,theevaluationoftheresident’sdischargeneedsanddischargeplan.Theresultsoftheevaluationmustbediscussedwiththeresidentorresident’srepresentative.Allrelevantresidentinformationmustbeincorporatedintothedischargeplantofacilitateitsimplementationandtoavoidunnecessarydelaysintheresident’sdischargeortransfer.

14. Apost-dischargeplanofcarethatisdevelopedwiththeparticipationoftheresidentand,withtheresident’sconsent,theresidentrepresentative(s),whichwillassisttheresidenttoadjusttohisorhernewlivingenvironment.

15. Thepost-dischargeplanofcarewillindicatewheretheindividualplanstoreside,anyarrangementsthathavebeenmadefortheresident’sfollowupcareandanypost-dischargemedicalandnon-medicalservices.

POLICY/PROCEDURE

SUBJECT:DischargeSummary

DATE:

INTENT:

ItisthepolicyofthefacilitytoassurethatadischargesummaryiscompletedinaccordancetoStateandFederalrequirements.

PROCEDURE:

1. Whenthefacilityanticipatesdischarge,aresidentmusthaveadischargesummarythatincludes,butisnotlimitedto,thefollowing:

a. Apost-dischargeplanofcarethatisdevelopedwiththeparticipationoftheresidentand,withtheresident’sconsent,theresidentrepresentative(s),whichwillassisttheresidenttoadjusttohisorhernewlivingenvironment.

b. Thepost-dischargeplanofcaremustindicatewheretheindividualplanstoreside,anyarrangementsthathavebeenmadefortheresident’sfollowupcareandanypost-dischargemedicalandnon-medicalservices.

2. Whenthefacilityanticipatesdischarge,aresidentmusthaveadischargesummarythatincludes,butisnotlimitedto,thefollowing:

a. Arecapitulationoftheresident'sstaythatincludes,butisnotlimitedto,diagnoses,courseofillness/treatmentortherapy,andpertinentlab,radiology,andconsultationresults.

b. Afinalsummaryoftheresident'sstatustoincludeitemsinparagraph(b)(1)of§483.20,atthetimeofthedischargethatisavailableforreleasetoauthorizedpersonsandagencies,withtheconsentoftheresidentorresident’srepresentative.

c. Reconciliationofallpre-dischargemedicationswiththeresident’spost-dischargemedications(bothprescribedandover-the-counter).

PLACETABFORQUALITYOFLIFEHERE

POLICY/PROCEDURE

SUBJECT:QualityofLife

DATE:

INTENT:

Itisthepolicyofthefacilitytospecifytheresponsibilitytocreateandsustainanenvironmentthathumanizesandindividualizeseachresident’squalityoflifebyensuringallstaff,acrossallshiftsanddepartments,understandtheprinciplesofqualityoflife,andhonorandsupporttheseprinciplesforeachresident;andthatthecareandservicesprovidedareperson-centered,andhonorandsupporteachresident’spreferences,choices,valuesandbeliefs.

PROCEDURE:


1. QualityofLife

2. ActivitiesofDailyLiving(ADLs)/MaintainAbilities

3. ADLCareProvidedforDependentResidents

4. Cardio-PulmonaryResuscitation(CPR)

5. ActivitiesMeetInterest/NeedsofEachResident

6. QualificationsofActivityProfessional

POLICY/PROCEDURE

SUBJECT:QualityofLife

DATE:

INTENT:


PROCEDURE:

Qualityoflifeisafundamentalprinciplethatappliestoallcareandservicesprovidedtofacilityresidents.

Eachresidentwillreceiveandthefacilitywillprovidethenecessarycareandservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being,consistentwiththeresident’scomprehensiveassessmentandplanofcare.

POLICY/PROCEDURE

SUBJECT:ActivitiesofDailyLiving(ADLs)/MaintainAbilities

DATE:

INTENT:


PROCEDURE:

1. Basedonthecomprehensiveassessmentofaresidentandconsistentwiththeresident’sneedsandchoices,thefacilitywillprovidethenecessarycareandservicestoensurethataresident'sabilitiesinactivitiesofdailylivingdonotdiminishunlesscircumstancesoftheindividual'sclinicalconditiondemonstratethatsuchdiminutionwasunavoidable.

2. Thefacilitywillensurearesidentisgiventheappropriatetreatmentandservicestomaintainorimprovehisorherabilitytocarryouttheactivitiesofdailyliving.

3. Thefacilitywillprovidecareandservicesforthefollowingactivitiesofdailyliving:a. Hygiene–bathing,dressing,grooming,andoralcare,b. Mobility—transferandambulation,includingwalking,c. Elimination-toileting,d. Dining-eating,includingmealsandsnacks,e. Communication,including:

i. Speech,ii. Language,andiii. Otherfunctionalcommunicationsystems.

4. Aresidentwhoisunabletocarryoutactivitiesofdailylivingwillreceivethenecessaryservicestomaintaingoodnutrition,grooming,andpersonalandoralhygiene;andbasiclifesupport,includingCPR,ifandwhentheresidentrequiringsuchemergencycarepriortothearrivalofemergencymedicalpersonnelandsubjecttorelatedphysicianordersandtheresident’sadvancedirectives.

5. Thefacilitywillensurethatresidentsreceivepropertreatmentandassistivedevicestomaintainvisionandhearingabilitiesby:a. Makingappointments,and

b. Byarrangingfortransportationtoandfromtheofficeofapractitionerspecializinginthetreatmentofvisionorhearingimpairmentortheofficeofaprofessionalspecializingintheprovisionofvisionorhearingassistivedevices.

POLICY/PROCEDURE

SUBJECT:ActivitiesMeetInterest/NeedsofEachResident

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywillprovide,basedonthecomprehensiveassessmentandcareplanandthepreferencesofeachresident,anongoingprogramtosupportresidentsintheirchoiceofactivities,bothfacility-sponsoredgroupandindividualactivitiesandindependentactivities,designedtomeettheinterestsofandsupportthephysical,mental,andpsychosocialwell-beingofeachresident,encouragingbothindependenceandinteractioninthecommunity.

2. Theactivitiesprogrammustbedirectedbyaqualifiedprofessionalwhoisaqualifiedtherapeuticrecreationspecialistoranactivitiesprofessionalwho:a. Islicensedorregistered,ifapplicable,bytheStateinwhichpracticing;andb. Is:

i. EligibleforcertificationasatherapeuticrecreationspecialistorasanactivitiesprofessionalbyarecognizedaccreditingbodyonorafterOctober1,1990;or

ii. Has2yearsofexperienceinasocialorrecreationalprogramwithinthelast5years,oneofwhichwasfull-timeinatherapeuticactivitiesprogram;or

iii. Isaqualifiedoccupationaltherapistoroccupationaltherapyassistant;oriv. HascompletedatrainingcourseapprovedbytheState.

PLACETABFORQUALITYOFCAREHERE

POLICY/PROCEDURE

SUBJECT:QualityofCare

DATE:

INTENT:

Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.

PROCEDURE:


1. QualityofCare

2. Treatment/DevicestoMaintainHearing/Vision

3. Treatment/ServicestoPrevent/HealPressureUlcers

4. FootCare

5. Increase/PreventDecreaseinROM/Mobility

6. FreeofAccidentHazards/Supervision/Devices

7. Bowel/BladderIncontinence,Catheter,UTI

8. Colostomy,Urostomy,orIleostomyCare

9. Nutrition/HydrationStatusMaintenance

10. TubeFeedingManagement/RestoreEatingSkills

11. Parenteral/IVFluids

12. Respiratory/TracheostomyCareandSuctioning

13. Prostheses

14. PainManagement

15. Dialysis

16. Bedrails

POLICY/PROCEDURE

SUBJECT:QualityofCare

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethateachresidentreceiveandthefacilityprovidesthenecessarycareandservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being,inaccordancewiththecomprehensiveassessmentandplanofcare,inaccordancewithStateandFederalRegulations.

DEFINITIONS:

Qualityofcareisafundamentalprinciplethatappliestoalltreatmentandcareprovidedtofacilityresidents.Basedonthecomprehensiveassessmentofaresident,thefacilitymustensurethatresidentsreceivetreatmentandcareinaccordancewithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’choices.

PROCEDURE:

1. Thefacilitywillensurethattheresidentobtainsoptimalimprovementordoesnotdeterioratewithinthelimitsofaresident’srighttorefusetreatmentandwithinthelimitsofrecognizedpathologyandthenormalagingprocess.

2. Thefacilitywillensurethattheresidentreceivespropertreatmentandassistivedevicestomaintainvisionandhearingabilities,thefacilitymust,ifnecessary,assisttheresidentinmakingappointments,andbyarrangingfortransportationtoandfromtheofficeofapractitionerspecializinginthetreatmentofvisionorhearingimpairmentortheofficeofaprofessionalspecializingintheprovisionofvisionorhearingassistivedevices.

3. Basedonthecomprehensiveassessmentoftheresident,thefacilitywillensurethattheresidentreceivescare,consistentwithprofessionalstandardsofpractice,topreventpressureulcersanddoesnotdeveloppressureulcersunlesstheindividual’sclinicalconditiondemonstratesthattheywereunavoidable;andaresidentwithpressureulcersreceivesnecessarytreatmentandservices,consistentwithprofessionalstandardsofpractice,topromotehealing,preventinfectionandpreventnewulcersfromdeveloping.

4. Thefacilitywillensurethatresidentsreceivepropertreatmentandcaretomaintainmobilityandgoodfoothealth,thefacilitywillprovidefootcareandtreatment,inaccordancewithprofessionalstandardsofpractice,includingtopreventcomplicationsfromtheresident’smedicalcondition(s);andifnecessary,assisttheresidentinmakingappointmentswithaqualifiedperson,andarrangingfortransportationtoandfromsuchappointments.

5. Thefacilitywillensurethataresidentwhoentersthefacilitywithoutlimitedrangeofmotiondoesnotexperiencereductioninrangeofmotionunlesstheresident’sclinicalconditiondemonstratesthatareductioninrangeofmotionisunavoidable;andaresidentwithlimitedrangeofmotionreceivesappropriatetreatmentandservicestoincreaserangeofmotionand/ortopreventfurtherdecreaseinrangeofmotion.Aresidentwithlimitedmobilityreceivesappropriateservices,equipment,andassistancetomaintainorimprovemobilitywiththemaximumpracticableindependenceunlessareductioninmobilityisdemonstrablyunavoidable.

6. Thefacilitywillensurethattheresidentenvironmentremainsasfreeofaccidenthazardsasispossible;andeachresidentreceivesadequatesupervisionandassistancedevicestopreventaccidents.

7. Thefacilitywillensurethataresidentwhoiscontinentofbladderandbowelonadmissionreceivesservicesandassistancetomaintaincontinenceunlesshisorherclinicalconditionisorbecomessuchthatcontinenceisnotpossibletomaintain.Foraresidentwithurinaryincontinence,basedontheresident’scomprehensiveassessment,thefacilitywillensurethataresidentwhoentersthefacilitywithoutanindwellingcatheterisnotcatheterizedunlesstheresident’sclinicalconditiondemonstratesthatcatheterizationwasnecessary;aresidentwhoentersthefacilitywithanindwellingcatheterorsubsequentlyreceivesoneisassessedforremovalofthecatheterassoonaspossibleunlesstheresident’sclinicalconditiondemonstratesthatcatheterizationisnecessaryandaresidentwhoisincontinentofbladderreceivesappropriatetreatmentandservicestopreventurinarytractinfectionsandtorestorecontinencetotheextentpossible.Foraresidentwithfecalincontinence,basedontheresident’scomprehensiveassessment,thefacilitywillensurethataresidentwhoisincontinentofbowelreceivesappropriatetreatmentandservicestorestoreasmuchnormalbowelfunctionaspossible.

8. Thefacilitywillensurethatresidents,whorequirecolostomy,ureterostomy,orileostomyservices,receivesuchcareconsistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresident’sgoalsandpreferences.

9. Thefacilitywillensurethatresidentsmaintainacceptableparametersofnutritionalstatus,suchasusualbodyweightordesirablebodyweightrangeandelectrolytebalance,unlesstheresident’sclinicalconditiondemonstratesthatthisisnotpossibleorresidentpreferencesindicateotherwise;isofferedsufficientfluidintaketomaintainproperhydrationandhealth;andisofferedatherapeuticdietwhenthereisanutritionalproblemandthehealthcareproviderordersatherapeuticdiet.

10. Thefacilitywillensurethataresidentwhohasbeenabletoeatenoughaloneorwithassistanceisnotfedbyenteralmethodsunlesstheresident’sclinicalconditiondemonstratesthatenteralfeedingwasclinicallyindicatedandconsentedtobytheresident;andaresidentwhoisfedbyenteralmeansreceivestheappropriatetreatmentandservicestorestore,ifpossible,oraleatingskillsandtopreventcomplicationsofenteralfeedingincludingbutnotlimitedtoaspirationpneumonia,

diarrhea,vomiting,dehydration,metabolicabnormalities,andnasal-pharyngealulcers.

11. Thefacilitywillensurethatparenteralfluidswillbeadministeredconsistentwithprofessionalstandardsofpracticeandinaccordancewithphysicianorders,thecomprehensiveperson-centeredcareplan,andtheresident’sgoalsandpreferences.

12. Thefacilitywillensurethataresident,whoneedsrespiratorycare,includingtracheostomycareandtrachealsuctioning,isprovidedsuchcare,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,theresidents’goalsandpreferences.

13. Thefacilitywillensurethataresidentwhohasaprostheticdeviceisprovidedcareandassistance,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,theresidents’goalsandpreferences,towearandbeabletousetheprostheticdevice.

14. Thefacilitywillensurethatpainmanagementisprovidedtoresidentswhorequiresuchservices,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.

15. Thefacilitywillensurethatresidentswhorequiredialysisreceivesuchservices,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.

16. Thefacilitywillattempttouseappropriatealternativespriortoinstallingasideorbedrail.Ifabedorsiderailisused,thefacilitywillensurecorrectinstallation,use,andmaintenanceofbedrails,includingbutnotlimitedtothefollowingelements.

a. Assesstheresidentforriskofentrapmentfrombedrailspriortoinstallation.b. Reviewtherisksandbenefitsofbedrailswiththeresidentorresident

representativeandobtaininformedconsentpriortoinstallation.c. Ensurethatthebed’sdimensionsareappropriatefortheresident’ssizeand

weight.d. Followthemanufacturers’recommendationsandspecificationsforinstalling

andmaintainingbedrails.

17. ThefacilitywillprovidecaretoresidentswiththediagnosisofDementia.

18. Thefacilitywillprovidetrainingtostaffrelatedtotheabovementionedprogramsaswellastrainingrequiredbystateandfederalregulationsrelatedtotheabovementionedareas.Stafftrainingmaybefacilitatedthroughanycombinationofin-personinstruction,webinarsandorsupervisedpracticaltraininghoursandwillbecompetencybased.

POLICY/PROCEDURE

SUBJECT:Treatment/DevicestoMaintainHearing/Vision

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywillensurethatresidentsreceivepropertreatmentandassistivedevicestomaintainvisionandhearingabilities,thefacilitywill,ifnecessary,assisttheresident:

a. Inmakingappointments,andb. Byarrangingfortransportationtoandfromtheofficeofapractitioner

specializinginthetreatmentofvisionorhearingimpairmentortheofficeofaprofessionalspecializingintheprovisionofvisionorhearingassistivedevices.

2. TheDirectorofSocialServicesorDesigneewillcoordinatethecareandservicesrelatedtovisionandhearingneedsofourresidents.

3. WhenidentifiedthevisionandorhearingneedsofaresidentwillbecommunicatedtotheDirectorofSocialServicesorDesignee.

4. Thiscommunicationwillbedocumentedintheresident’sclinicalrecord.

5. OncetheDirectorofSocialServicesorDesigneehasmadearrangementsforvisionandorhearingneedsoftheresident,theywilldocumentthearrangedservicesintheresident’sclinicalrecord.

6. ThefacilityutilizesoutsideserviceprovidersforVisionandHearingServices.

7. Residentsareseenwithinthefacility.

8. Documentationofservicesprovidedwillbemaintainedwithintheresident’smedicalrecord.

POLICY/PROCEDURE

SUBJECT:Treatment/ServicestoPrevent/HealPressureUlcers

DATE:

INTENT:


PROCEDURE:

1. ThefacilitywillensurethatbasedonthecomprehensiveAssessmentofaresident:

a. Aresidentreceivescare,consistentwithprofessionalstandardsofpractice,topreventpressureulcersanddoesnotdeveloppressureulcersunlesstheindividual’sclinicalconditiondemonstratesthattheywereunavoidable;and

b. Aresidentwithpressureulcersreceivesnecessarytreatmentandservices,consistentwithprofessionalstandardsofpractice,topromotehealing,preventinfectionandpreventnewulcersfromdeveloping.

2. Uponadmission,theresidentwillreceiveaheadtotoeskinchecktoidentifyanyskinissues.

3. Interventionswillbeimplementedintheresident’splanofcaretopreventpressuresoredevelopment,whentheresidenthasnoareasofconcern.

4. Whentheresidentisadmittedwithapressuresore(s)theadmittingnursewilldocumentthesize,location,odor(ifany),drainage(ifany),andcurrenttreatmentordered.

5. Interventionswillbeimplementedintheresident’splanofcaretopreventdeteriorationandpromotehealingofthepressuresore.

6. Theadmittingnursewillnotifytheattendingphysicianaswellastheresidentandorresident’srepresentativeoftheconditionofthepressuresoreonadmission.

7. Thepressuresore(s)willbeevaluatedweeklyandthenursewilldocumentthesize,location,odor(ifany),drainage(ifany),andcurrenttreatmentordered.

8. Thenursewillnotifythephysiciananytimethepressuresoreisshowingsignsofnon-healingorinfectionandrequesttreatmentorderchanges.

9. Thenursewillnotifytheresidentandortheresident’srepresentativeofanychangesrelatedtotheimprovement,deteriorationand/ortreatmentchangesonanon-goingbasis.

WOUNDPREVENTIONPROGRAM

SUBJECT:WoundPrevention

DATE:

PURPOSE:

Thepurposeofthisprogramistoassistthefacilityinthecare,servicesanddocumentationrelatedtotheoccurrence,treatment,andpreventionofpressureaswellas,non-pressurerelatedwounds.

PROCESS:

1. UponadmissionandinconjunctionwiththeResidentAssessmentInstrument(RAI)andwhenasignificantchangeintheresidentstatusoccurs,theresident’sskinwillbeevaluatedhead-to-toebylicensednurseutilizingaBradenScaleObservation.

2. Weeklyskincheckswillbeconductedbythelicensednurse.Thiswillbedocumentedintheresident’sElectronicMedicalRecord(EMR).

3. Daily,duringroutinecare,theCertifiedNursingAssistant(CNA)willobservetheresident’sskin.Whenabnormalitiesarenotedthiswillbecommunicatedtothelicensednurseandthelicensednursewillproceedasmentionedinstep2andcompleteaWoundEvent.

4. Allresidentswillhavethefollowingnursingcareproceduresimplemented:a. SkinHygiene–

i. Dailywithcleanser,rinseanddrythoroughlyii. Asneededtokeeplocalareasofskinclean,dryandfreeofbody

wastessuchasurine,feces,perspirationandwounddrainageiii. Dailywithcarelubricatetheskinwithlotion,tokeepitsoftandpliableiv. Duringcareinspecttheskinforsignsandsymptomsofskin

breakdown

b. Activity–i. Astoleratedbytheresidentencourageambulationandoutofbed

activity

c. PressureRelief–i. Allresidentswillhaveapressureredistributionmattressii. Astoleratedbytheresidentencouragemobilityiii. Asneededpositionandrepositiontheresidentwithpillowsandother

supportivedevices,iv. Asneededkeepfoundationsheetsdryandstretchtoavoidwrinklesv. Wheelchaircushionasindicated

d. SkinProtection–

i. Avoidshearingforcesbykeepingtheheadofbedlessthan45degrees(unlesscontraindicated)

ii. Usealiftsheetwhenliftingtheresidentinbed,donotslideiii. Whentheresidentrequiresincontinencebrief,checkformoisture

frequentlyandapplyhousestockbarriercreamaftereachincontinentepisode

iv. Providepaddingforcasts,splintsandbracesandcheckforrednessv. ApplySkinPrepto:

1. Skinbeforeapplyingadhesives2. Earstoprotectfromoxygencannulairritation3. Bonyprominencesinareasofhighfriction4. Everymorningandeveningtoheels,whenapplicable.

e. Nutrition/Hydration–i. Provideawell-balanceddietii. Encouragefluids,unlesscontraindicated

PointofEmphasis:

ThefacilitycomplieswithStateandFederalguidelinesasitrelatestowoundpreventionanddefinitions.AdherencetothisprogramisunderthedirectionoftheDON.

WOUNDMANAGEMENTPROGRAM

SUBJECT:WoundManagement

DATE:

PURPOSE:

Thepurposeofthisprogramistoassistthefacilityinthecare,servicesanddocumentationrelatedtotheoccurrence,treatment,andpreventionofpressureaswellas,non-pressurerelatedwounds.

PROCESS:

1. AllresidentsadmittedtofacilitywillhaveaBradenScaleObservationcompletedatthetimeofadmission,inconjunctionwitheachquarterlyandannualassessment,withanysignificantchangeassessmentandasdeemednecessarybytheInterdisciplinaryTeam;thisincludesthedevelopmentofanewlyidentifiedpressureulcer.Theadmittingnurseisresponsibleforcompletingtheform.Theadmittingnursewillthenberesponsibleforinitiatingtheappropriateinterventionssuchasensuringtreatmentorder(s)areinplace,pressurereductiondevicesareorderedandorrequested,i.e.specialtymattressandwheelchaircushion,andthattheinterim/baselinecareplanisinitiated.

2. TheadmittingnursewilltheninitiateandcompletetheInitialWoundExamforeachwoundthathasbeenidentified.

3. TheadmittingnursewillberesponsibleforinformingtheUnitMangerorotherdesignatedsupervisorofthewoundsothatthewoundcanbethendocumentedontheappropriatetrackinglog.TheUnitManagerorotherdesignatedsupervisorwillberesponsibleforupdatingthelogandeveryThursdayturningthecompletedtrackinglogstotheDirectorofNursing,theMDSDepartmentandtheDietaryDepartment

4. TheUnitManagerswillberesponsibleforthecreationofthemonthlycumulativereportofallwoundsontheirindividualunitsandpresentthisreportatthemonthlyRiskManagement/QualityAssuranceMeeting.

5. Thefacilityutilizesanoutsidewoundcarespecialist,toassistwithwoundmanagementandtreatment,whoprovidesweeklyvisitstoresidentswithwounds.Thewounddescriptioninformationobtainedfromthisproviderwillbescannedintotheelectronicmedicalrecordandmaintainedunderthedocumentssection.

6. TheUnitManagerordesigneewillberesponsibleforcompletingtheWoundExamObservationutilizingtheinformationobtainedduringthatweek’svisit.

7. Oncethewoundhasbeenidentifiedasbeinghealed,thephysicianaswellastheresidentand/orresident’srepresentativewillbenotifiedandthisnotificationwillbedocumentedintheresident’sclinicalrecord.

8. ThenurseidentifyingthewoundasbeinghealedwillnotifytheUnitManagerordesigneethatthewoundishealedandtheUnitManagerordesigneewilldocumentontheappropriatewoundlogthatthewoundishealed.

PointofEmphasis:

ThefacilitycomplieswithStateandFederalguidelinesasitrelatestowoundpreventionanddefinitions.AdherencetothisprogramisunderthedirectionoftheDON.

PROCEDURE

SUBJECT:CleanDressingChange

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurechangedressingsinaccordancewithStateandFederalRegulations,andnationalguidelines.PROCEDURE:

1. Verifyandreviewphysician’sorderforprocedure.

2. Performhandhygieneandassembleequipmentandsuppliesneededfordressingchange.

3. Identifytheresidentandexplaintheprocedure.

4. Evaluateresident’spainandtheneedforpainmedication.

5. Putongloves.Adjustbedsidestand/tabletowaistlevel.Cleanbedsidestand/tablewithgermicidaldisposablecloth.Establishacleanfield.

6. Placetheresident’strashcanwithineasyreach.

7. Removeglovesandperformhandhygiene.

8. Set-upsuppliesonbarrier.

9. Positiontheresidentforcomfort.

10. Performhandhygiene.

11. Putoncleangloves.

12. Removedressingandplaceintheresident’strashcan.


14. Putoncleangloves

15. Cleansewoundwithgauzeandprescribedcleaningsolutionusingsingleoutwardstrokes.Useseparategauzeforeachcleansingwipe.

16. Usedrygauzetopatthewounddry.

17. Removeglovesandpreformhandhygiene.


19. Applycleandressingasorderedandensurethedressingisdated.


21. Repositiontheresidentandensurethecalllightisinplace.

22. Discardalldisposableitemsintotheappropriatereceptacle.

23. Cleanthebedsidestand/tablewithgermicidaldisposablecloth.

24. Removetrashfromresident’sroom.

25. Washanddryhandsthoroughly.

26. Documentthecompletionofdressingchangeonthetreatmentrecord.

PROCEDURE

SUBJECT:SkinPrepApplication

DATE:

PROCEDURE:

Thepurposeofthisprocedureistoprovideguidelinesfortheapplicationofskinprep.

1. Assembleequipmentandsuppliesneeded.






7. Removethebarrierwipefromwrappingandwipeoverarea(s)ofbonyprominenceand/orhighfriction.

8. Repositiontheresidentforcomfortasneeded.


10. Documentandreportanychangestoresident’sskinintegrity.

POLICY/PROCEDURE

SUBJECT:FootCare

DATE:

INTENT:


PROCEDURE:

Toensurethatresidentsreceivepropertreatmentandcaretomaintainmobilityandgoodfoothealth,thefacilitymust:

1. Providefootcareandtreatment,inaccordancewithprofessionalstandardsofpractice,includingpreventingcomplicationsfromtheresident’smedicalcondition(s).

2. Ifnecessary,assisttheresidentinmakingappointmentswithaqualifiedperson,andarrangingfortransportationtoandfromsuchappointments.

3. TheDirectorofSocialServicesorDesigneewillcoordinatethecareandservicesrelatedtofootcareandtreatmentforourresidents.

4. WhenidentifiedthefootcareandtreatmentneedsofaresidentwillbecommunicatedtotheDirectorofSocialServicesorDesignee.

5. Thiscommunicationwillbedocumentedintheresident’sclinicalrecord.

6. OncetheDirectorofSocialServicesorDesigneehasmadearrangementsforfootcareandtreatmentfortheresident,theywilldocumentthearrangedservicesintheresident’sclinicalrecord.

7. Documentationtoincludebutmaynotbelimitedto:a. Servicesneeded;b. Dateandtimeofappointment;c. TransportationServices,(Whattransportationcompany)d. Pickuptime;ande. Whowillbeaccompanyingtheresident?

POLICY/PROCEDURE

SUBJECT:Increase/PreventDecreaseinROM/Mobility

DATE:

INTENT:


PROCEDURE:

Thefacilitywillensurethataresidentwhoentersthefacilitywithoutlimitedrangeofmotiondoesnotexperiencereductioninrangeofmotionunlesstheresident’sclinicalconditiondemonstratesthatareductioninrangeofmotionisunavoidable;and

1. Aresidentwithlimitedrangeofmotionreceivesappropriatetreatmentandservicestoincreaserangeofmotionand/ortopreventfurtherdecreaseinrangeofmotion.

2. Aresidentwithlimitedmobilityreceivesappropriateservices,equipment,andassistancetomaintainorimprovemobilitywiththemaximumpracticableindependenceunlessareductioninmobilityisdemonstrablyunavoidable.

POLICY/PROCEDURE

SUBJECT:SpecializedRehabilitativeandRestorativeServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideSpecializedRehabilitativeandRestorativeServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Thefacilitywillprovidespecializedrehabilitativeservicessuchas,butnotlimitedtophysicaltherapy,speechlanguagepathology,occupationaltherapy,respiratorytherapy,andrehabilitativeservicesformentalillnessandintellectualdisabilityorservicesofalesserintensityassetforthat§483.120(c),arerequiredintheresident’scomprehensiveplanofcare.

2. Thefacilitywill:a. Providetherequiredservices;orb. Inaccordancewith§483.70(g),obtaintherequiredservicesfromanoutside

resourcethatisaproviderofspecializedrehabilitativeservicesandisnotexcludedfromparticipatinginanyfederalorstatehealthcareprogramspursuanttosection1128and1156oftheAct.

3. Thefacilitywillensurethatspecializedrehabilitativeservicesareprovidedunderthewrittenorderofaphysicianbyqualifiedpersonnel.

4. Thefacilitywillproviderestorativeservicessuchasbutnotlimitedtowalking,transfertraining,bowelandorbladdertraining,bedmobility,RangeofMotion(ROM),splintandbrace,eatingand/orswallowing,amputation/prosthesescareandcommunication,whennecessaryasindicatedbytheassessmentoftheinterdisciplinaryteam.

PROCEDURE

SUBECT:RestorativeNursingProgram

DATE:

INTENT:

ItisthepolicyofthefacilitytoassisteachResidenttoattainandormaintaintheirindividualhighestmostpracticablefunctionallevelofindependenceandwell-being,inaccordancetoStateandFederalRegulations.

PROCEDURE:

1. EachresidentwillbescreenedandorevaluatedbytheNursedesignatedtooverseetherestorativenursingprocessforinclusionintotheappropriatefacilityrestorativenursingprogram(s)whenithasbeenidentifiedbytheinterdisciplinaryteamthattheresidentisinneedormaybenefitfromsuchprogram(s).

2. Thescreeningwillincludetheresidentortheirrepresentative’sinput,choices,andexpectationsrelatedtoparticipatingintherestorativenursingprogram.

3. Thefacilityrestorativenursingprogramwillincludebutnotbelimitedtothefollowingprograms:

a. Hygiene–bathing,dressing,grooming,andoralcare,b. Mobility—transferandambulation,includingwalking,prostheticandorsplint

applicationwithorwithoutactiveandorpassiverangeofmotion,bedmobility,

c. Elimination-toileting,bowelandbladder,d. Dining-eating,includingmealsandsnacks,e. Communication,including:

i. Speech,ii. Language,iii. Otherfunctionalcommunicationsystems

4. Theaboveprogramswillbedocumentedonthefacilitydesignatedrestorativecareforms/toolsintheresident’selectronicmedicalrecord.

5. Basedonclinicalevaluationandongoingconsiderationresidentsmaybeplacedinoneormoreoftheabovelistedprogramsatonetime.

6. Thedesignatednursewillberesponsibleforthefollowing:a. Obtainingordersfortheresident’srestorativeprogram,b. Documentationonamonthlybasis(ataminimum),andc. Initiationandupdatingrestorativecareplans.

7. Onceinanappropriaterestorativenursingprogram,thedesignatednursewillcontinuetomonitortheresident’sprogress.

8. Thedesignatednursewillevaluatetherestorativedocumentationmonthlytodetermineifthereareanychangesneededtotheexistingprogramandmakeamonthlyprogressnote,intheresident’selectronicmedicalrecordrelatedtothisevaluation.

9. Foractiveprograms,theresidentwouldnormallybeexpectedtoreflectprogresswithinafour-weekperiod.

10. Formaintenanceprograms,theresidentwouldnormallybeexpectedtohavealreadyreachedtheirhighestlevelofpotentialandthethereforebesupportedtomaintaintheirlevelandifclinicallypossiblestaveofffurtherdecline.

11. Intheeventthatitisclinicallycontraindicatedforaresidenttoparticipateinarestorativecareprogram,thedesignatednursewilldiscusswiththephysicianorextenderandifthatismedicallydetermined,thephysicianorextenderwillprovideanordertodirectthestaffaccordingly.

POINTOFEMPHASIS:

Itisrecognizedthatthereareoccasionswhenresidentsmayhaveunavoidabledeclineswhichmaynotbereversiblewhichmightnotbeunderthecontrolofthefacility.

Furthermore,itisrecognizedthatsomeresidentsmaynotwishtoparticipateinrestorativecareprogrammingwhichwillberespectedaselectionofchoiceanddocumentedaccordingly.

POLICY/PROCEDURE

SUBJECT: RestorativeNursingBedMobilityProgram

DATE:

POLICY:

Thefacilitymustensurethattheresidentobtainsoptimalimprovementordoesnotdeterioratewithinthelimitsofaresident’srighttorefusetreatment,andwithinthelimitsofrecognizedpathologyandthenormalagingprocess.TheNursingRestorativeBedMobilityProgramwillassisttheresidenttobecomemoreindependentinrepositioningandmovinghimself/herselfinbed.

PROCEDURE:

1. IdentifyingResidentsWhoCouldBenefitfromaRestorativeBedMobilityProgram.

a. Theresidentsadmittedfromthecommunity(homeorhospital)whoexpects/orplanstoreturnhomeafterrestand/orrehabilitation.

Examples:RecentSurgery AccidentVictimPneumonia HeartAttackHiporotherFracture MildStrokeFallwithInjury Amputee

b. Theresidentwhohadarecentexacerbationofachronicdiseasewhodesirestoreturntotheirpriorleveloffunction,oratleastmaintainthisnewlevel.

Examples: Arthritis,Parkinson’sdisease,COPD

c. Anyresidentwitharecentcardiovascularaccident(CVA)whohasafairlevelofalertnessandisparticipatinginphysicaltherapy.

d. Anyresidentwithcognitiveimpairment,whoisalert,followsimpledirections,hasfunctionalmotorskills,iscooperativeanddemonstratesthepotentialtoincreasebedmobilityskills.

e. Anyresidentwhothestafffeelshastheabilitytoincreasetheirlevelofbedmobilityabilityregardlessoftheresident’sphysicalormentallimitations.

f. Asaruleofthumb,anyresidentwithadeficitinbedmobilityabilitiesshouldbeevaluatedforpossiblerestorativeprogrammingor,ataminimum,handoverhandassistance.

2. GeneralRestorativeApproaches:

a. Afactorcriticaltothesuccessofrestorativeprogrammingintheseareasistheresident’sbeliefsandexpectationsconcerningtheirabilityforbedmobility.The

residentsmustbemotivatedandbelievetheycanandwillprogress.Atthesametime,staffmustalsobelievethattheresidentcanachievethegoalsset.

b. Providedailyroutineandstructureforboththeresidentandstaffonaseven-daybasis.

c. AdministrativenursingstaffmustbeinterestedandfeelthisprogramisvaluableandconveythistotheCNAscarryingoutthedailyprogramoritwillnotbesuccessful.Thechargenursesetsthetone.

d. AllowCNAstospendextratimeandeffortwiththoseresidentsinrestorativebedmobilityprograms.Allowtheresidenttimeandefforttodoasmuchastheycan,therebyimprovingtheirskillsgradually.

e. Activitiescanpromoteexercisegroups,hugtherapy,andmovementgamestoassistinincreasinggeneralstrengthandendurance.

f. ReferanyresidenttoOccupationalTherapy(OT)forscreeningifthereisanyquestiononprotocolorneedforadaptivedevicesortechniques.AskOTtowriteabedmobilityprogramprotocoltofollow.Thetherapistmaypicktheresidentupfordirectservicesbeforestartingtherestorativeprogram.

g. Useyouroccupationaltherapist(OT)asconsultanttotherestorativebedmobilityprogram.Thetherapistcaninstructnursingstaffonusefultechniquestotrywiththeresident.Justasthetherapistobservesandmakesrecommendationsforrestorativeprograms,thetherapistcanalsoobserveandmonitorthebedmobilityprogramonaweeklyormonthlybasis.

h. Socialservicesshouldvisitrestorativeresidentsweeklytoencourageandmotivatethemtocontinueparticipationandefforts.Encouragetheresidentstoexpresstheirgoals.

• “Iwanttositupinbedbymyself”• “Iwanttositonthesideofthebedbymyself”• “Iwanttoturnoverbymyself”

i. ResidentswhoshouldbereferredtoOTforscreeningandareusuallytreateddirectlyforbedmobilitytraininginOTareresidentswithrecenthipandarmfractures,CVAs,acutearthritisandbacksurgery.

3.TheRestorativeCareProcess:

a. Residentidentifiedforneedofprogram:I. ByphysicianorderII. FromMinimumDataSetorResidentAssessmentProtocolTrigger(ADL

Functional/RehabilitationPotential)III. DuringinitialcareplanorcareplanreviewIV. ByrecommendationfromphysicaloroccupationaltherapyV. BynursingpermonthlyreviewVI. Byactivitieswhennotingactivitylevel

VII. Bysocialservicewhennotingchangeinemotionalorself-esteemlevel

b. Documentation:

Exampleofmonthlyprogressnote,whichwouldbewrittenintheappropriatespaceontheNursing/RehabRestorativeProgramRecord.

“Mrs.Cahnisparticipatingwellinherdailyrestorativeprogramforbedmobility.Shehasprogressedfromdependenttoturningsidetoside,goingfrompronetosittingpositionanddanglinglegsoffbedwithminimalassistandactiveparticipation.Sheismotivatedbutstilltireseasily.Continuefourmoreweeks.”

B.Garlin,RN

c. Discontinueformalprogrammingwhentheresidentreachesindependenceormaintenancestatus.Thehighestgoal(bedmobility)reachedmaybeestablishedasamaintenanceplan.

d. Asareminder,thecareplanshouldalwaysbeupdatedtoreflectcurrentresidentstatus.

4.BedMobilityGuidelines:

a. ScootingupinBedI. Explaintotheresidentwhattheyaregoingtodo.II. Takethepillowoutfromundertheirhead.III. Havetheresidentbendtheir/herhipsandkneessotheycanpositiontheirfeet

flatonbed.IV. Havetheresidentbendtheirelbowsandpositiontheirhandsflatonthebed

betweenwaistandhips.V. Assistresidentinstabilizingtheirlegsbygentlyholdingtheirankles.VI. Instructtheresidentthatonthecountofthreetheyaretolifttheirheadandat

thesametimepushdownwiththeirfeetandarmsresultingwiththemscootingupinbed.

VII. Ifresidentissuccessfulinscootingasufficientdistance,havethemstraightentheirlegsoutonthebed.Ifnot,havetheresidentrepositionhislegsandarmsandrepeatstep6.

Note:IFatrapezeisonthebed,havetheresidentholdontothebaroverheadandwhentheypushesupwiththeirlegspullupwiththeirarms.

b. ScootingSidetoSideI. Explaintotheresidentwhattheyaregoingtodo.II. Havetheresidentbendtheirhipsandkneessotheycanpositiontheirfeetflat

onbed.III. Dependingonwhichsidetheresidentisgoingtoscoottoward,havethe

residentplacethatfootclosertothissideofbed.

IV. Havetheresidenteitherreachtowardthesideofthebedorgrasptherailofthesidetheywillbemovingtoward.Bendtheresident’sotherelbowandplacetheirhandflatonthebedbetweentheirhipandwaist.

V. Stabilizelegsbygentlyholdingontotheankles.VI. Onthecountof3,havetheresidentlifttheirhipsoffthebedandswingthem

sideways.Atthesametimepullwiththehandgraspingthesideofbed/railandpushwithoppositehand.

VII. Ifscootingtheoppositedirection,thenrepositionfeetandarmsandrepeatthestepabove.

POLICY/PROCEDURE

SUBJECT:Mobility

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethattheresidentsreceiverangeofmotion,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywillensurethatbasedonthecomprehensiveassessmentofaresident:

a. thataresidentwhoentersthefacilitywithoutlimitedrangeofmotiondoesnotexperiencereductioninrangeofmotionunlesstheresident’sclinicalconditiondemonstratesthatareductioninrangeofmotionisunavoidable;and

b. aresidentwithlimitedrangeofmotionreceivesappropriatetreatmentandservicestoincreaserangeofmotionand/ortopreventfurtherdecreaseinrangeofmotion.

c. aresidentwithlimitedmobilityreceivesappropriateservices,equipment,andassistancetomaintainorimprovemobilitywiththemaximumpracticableindependenceunlessareductioninmobilityisdemonstrablyunavoidable.

2. Thefacilitywillensurethattheresidentreachesandmaintainshisorherhighestlevelofrangeofmotionandtopreventavoidabledeclineofrangeofmotion.

POLICY/PROCEDURE

SUBJECT:FreeofAccidentHazards/Supervision/Devices

DATE:

INTENT:


PROCEDURE:

1. Thefacilitymustensurethat:a. Theresidentenvironmentremainsasfreeofaccidenthazardsasispossible;andb. Eachresidentreceivesadequatesupervisionandassistancedevicestoprevent

accidents.

POLICY/PROCEDURE

SUBJECT:ReportingAccidentsandIncidents

DATE:

INTENT:

ItisthepolicyofthefacilitytoreportAccidentsandIncidentsinaccordancetoStateandFederalregulations.

PROCEDURE:

1. TheIncidentandAccidentReportingSystemwillincludeacomprehensiveprocesswhichwillallowfor:

a. Collectionoftheincidentandaccidentoccurrenceb. Investigateincidentsandaccidentsc. Evaluateinjuriesofunknownsource(IUS)d. TrackandTrendincidentsandaccidents

2. TheEventReportwillbecompletedbyNurseassignedtotheresidentatthetimeoftheeventoradesignatedNurse.

3. TheInvestigationwillbeinitiatedbytheNurseManagerordesigneewithin72calendarhoursfromtheevent.

4. TheRiskManagerorDesigneewillcompletetheinvestigationtoincludetheIUSToolwhenindicated.

5. TheUnitManagerordesigneewilladdtheinvestigationresultsintotheEventandcloseitafter72hours.

6. TheRiskManagerordesigneewilltrackincidentsandaccidentsonthefacilitysurveillancelogtodeterminepatternsandtrends.

7. MonthlyduringthefacilityRiskManagementQualityAssuranceMeetingtheresultsoftheIncidentandAccidentTrackingSystemwillbeevaluated.

8. Thefacilitywillensurethat:a. Theresidentenvironmentremainsasfreefromaccidenthazardsasis

possible;andb. Eachresidentreceivesadequatesupervisionandassistancedevicesto

preventaccidents.c. Everyattemptismadetouseappropriatealternativespriortoinstallingaside

orbedrail.Ifabedorsiderailisused,thefacilitymustensurecorrectinstallation,use,andmaintenanceofbedrails,includingbutnotlimitedtothefollowingelements.I. Assesstheresidentforriskofentrapmentfrombedrailspriorto

installation.

II. Reviewtherisksandbenefitsofbedrailswiththeresidentorresidentrepresentativeandobtaininformedconsentpriortoinstallation.

III. Ensurethatthebed’sdimensionsareappropriatefortheresident’ssizeandweight.

9. Thefacilitywillprovideanenvironmentthatisfreefromaccidenthazardsoverwhichthefacilityhascontrolandprovidessupervisionandassistivedevicestoeachresidenttopreventavoidableaccidents.Thisincludes:

a. Identifyinghazard(s)andrisk(s);b. Evaluatingandanalyzinghazard(s)andrisk(s);c. Implementinginterventionstoreducehazard(s)andrisk(s);andd. Monitoringforeffectivenessandmodifyinginterventionswhennecessary.

10. Thefacilitywillidentifyeachresidentatriskforaccidentsand/orfalls,andadequatelyplancareandimplementprocedurestopreventaccidents.

11. Thefacilitywillensureeachresidentreceivesadequatesupervisionandassistancedevicestopreventaccidents.

12. Thefacilitywilldevelopmentandimplementanaccidentandincidentreportingsystemthatwillreportadverseincidentstotheriskmanager,ortohisorherdesignee,within3businessdaysaftertheiroccurrence.

13. Thereportingsystemwillconsistof:a. Reportallallegedviolationsandallsubstantiatedincidentstothestate

agencyandtoallotheragenciesasrequired,andtakeallnecessarycorrectiveactionsdependingontheresultsoftheinvestigation;

b. ReporttotheStatenurseaideregistryorlicensingauthoritiesanyknowledgeithasofanyactionsbyacourtoflawwhichwouldindicateanemployeeisunfitforservice;and

c. Analyzetheoccurrencestodeterminewhatchangesareneeded,ifany,topoliciesandprocedurestopreventfurtheroccurrences.

14. Thefacilitywilldevelopandimplementwrittenpoliciesandproceduresthat:a. Ensurereportingofcrimesoccurringinfederally-fundedlong-termcare

facilitiesinaccordancewithsection1150BoftheSocialSecurityAct.Thepoliciesandproceduresmustincludebutarenotlimitedtothefollowingelements:

i. Inresponsetoallegationsofabuse,neglect,exploitation,ormistreatment,thefacilitywill:§ Ensurethatallallegedviolationsinvolvingabuse,neglect,

exploitationormistreatment,includinginjuriesofunknownsourceandmisappropriationofresidentproperty,arereportedimmediately,butnotlaterthan2hoursaftertheallegationismade,iftheeventsthatcausetheallegationinvolveabuseorresultinseriousbodilyinjury,ornotlaterthan24hoursiftheeventsthatcausetheallegationdonotinvolveabuseanddonotresultinseriousbodilyinjury,totheadministratorofthefacility

andtootherofficials(includingtotheStateSurveyAgencyandadultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities)inaccordancewithStatelawthroughestablishedprocedures.

§ Haveevidencethatallallegedviolationsarethoroughlyinvestigated.

§ Preventfurtherpotentialabuse,neglect,exploitation,ormistreatmentwhiletheinvestigationisinprogress.

§ ReporttheresultsofallinvestigationstotheadministratororhisorherdesignatedrepresentativeandtootherofficialsinaccordancewithStatelaw,includingtotheStateSurveyAgency,within5workingdaysoftheincident,andiftheallegedviolationisverifiedappropriatecorrectiveactionmustbetaken.

15. Thefacilitywilldevelopappropriatemeasurestominimizetheriskofadverse

incidentstoresidents,including,butnotlimitedto,educationandtraininginriskmanagementandriskpreventionforallnon-physicianpersonnel,asfollows:

a. RiskManagementTrainingatorientationb. RiskManagementTraining-1HourAnnually

16. Thefacilitywillconductaninternalriskmanagementandqualityassuranceprogramwillincludetheuseofincidentreportstobefiledwiththeriskmanagerandfacilityadministrator.Theriskmanagershallhavefreeaccesstoallresidentrecordsofthelicensedfacility.Theincidentreportsarepartoftheworkpapersoftheattorneydefendingthelicensedfacilityinlitigationrelatingtothelicensedfacilityandaresubjecttodiscovery,butarenotadmissibleasevidenceincourt.Apersonfilinganincidentreportisnotsubjecttocivilsuitbyvirtueofsuchincidentreport.Aspartoftheeachinternalriskmanagementandqualityassuranceprogram,theincidentreportsshallbeusedtodevelopcategoriesofincidentswhichidentifyproblemareas.Onceidentified,proceduresshallbeadjustedtocorrecttheproblemareas.

17. Thefacilitywillforpurposesofreportingtotheagencywillusetheterm"adverseincident"whichmeans:Aneventoverwhichfacilitypersonnelcouldexercisecontrolandwhichisassociatedinwholeorinpartwiththefacility'sintervention,ratherthantheconditionforwhichsuchinterventionoccurred,andwhichresultsinoneofthefollowing:

a. Death;b. Brainorspinaldamage;c. Permanentdisfigurement;d. Fractureordislocationofbonesorjoints;e. Alimitationofneurological,physical,orsensoryfunction;f. Anyconditionthatrequiredmedicalattentiontowhichtheresidenthasnot

givenhisorherinformedconsent,includingg. failuretohonoradvanceddirectives;orh. Anyconditionthatrequiredthetransferoftheresident,withinoroutsidethe

facility,toaunitprovidingamoreacutelevelofcareduetotheadverseincident,ratherthattheresident'sconditionpriortotheadverseincident;or

i. Aneventreportedtolawenforcementoritspersonnelforinvestigation;orj. Residentelopement,iftheelopementplacestheresidentatriskofharmor

injury.

18. Thefacilitywillensuretheriskmanager:a. Investigateseveryallegationofsexualmisconductwhichismadeagainsta

memberofthefacility'spersonnelwhohasdirectpatientcontactwhentheallegationisthatthesexualmisconductoccurredatthefacilityoratthegroundsofthefacility;

b. Reportseveryallegationofsexualmisconducttotheadministratorofthelicensedfacility;and

c. Notifiestheresidentrepresentativeorguardianofthevictimthatanallegationofsexualmisconducthasbeenmadeandthataninvestigationisbeingconducted.

19. Thefacilitywillinitiateaninvestigationandnotifytheriskmanagerifthefacilitydeterminestheeventtomeetthedefinitionofan“adverseevent”.Theriskmanagerwillsubmitanadverseincidentreporttotheagencyforeachadverseincidentwithin15calendardaysafteritsoccurrence.

PROCEDURE

SUBJECT:MedicalErrorsOccurrenceReporting

APPROVED:

INTENT:

Itisthepolicyofthefacilitytoevaluateanyconcernsrelatedtomedicalandormedicationerrors.

PROCEDURE:

1. Intheeventthatamedicalandormedicationerrorisdetected,theindividualdetectingitwillcompletetheMedicationVarianceEvent.

2. Thisreportwillbebasedonthetypeoferrorandwillbereportedtotheappropriatesupervisorordesigneeifthatsupervisorisunavailable.

3. ThecompletedMedicalErrorOccurrenceRecordwillbereviewedthenextbusinessdaybyandsignedbytheRiskManager,AdministratorandDirectorofNursing.

4. ThecompletedMedicalErrorOccurrenceRecordwillbereviewedbytheMedicalDirector.

5. Basedontheerroroutsidereportingmayberequiredtoincludebutnotlimitedto:a. 1-800-96-ABUSE,andorb. FederalAbuseNeglectExploitation,andorc. StateAdverseIncident,andord. FederalElderJusticeActSuspicionofaCrimee. FederalOccupationalSafetyandHealthAdministrationf. ProfessionalLicensureandCertificationBoardsg. Other

POINTOFEMPHASIS:

Allerrorswillbereviewedandevaluatedwiththegoalofidentificationofriskandoragapanalysistodeterminecorrection,systematicchangeswhenindicated,in-serviceandeducation,andappropriatefollow-upwithmonitoring.

PROCEDURE

SUBJECT:FallReductionProgram

DATE:

INTENT:

Allresidentswillreceiveadequatesupervision,assistanceandassistivedevicestoaidinthepreventionoffalls.Eachresidentwillbeevaluatedforsafetyrisksincludingfallsandaccidents.Careplanswillbecreatedandimplementedbasedontheindividual’sriskfactorstoaidinthepreventionoffalls.AllFallsaretobeinvestigatedandmonitored.Thefacilitywillmaintainarecordthatcontainsalistofallincidentsandfalls.TherecordingtrendsarereportedanddiscussedatQualityAssuranceRiskManagementCommitteeMeetingsmonthlyandquarterly.TheRiskManagerisresponsibleforcoordinatingallinvestigations.IftheIncident/FallmeetstheAdverseIncidentcriteria,theAdverseReportingprocedurewillbefollowedaccordingtoStateLaws.

ItisthepolicyofthefacilitytoreportAccidentsandIncidentsinaccordancetoStateandFederalregulations.

DEFINITIONS:

An"accident"isanunexpected,unintendedeventthatcancausearesidentbodilyinjury.

A“fall”istheunintentionalcomingtorestonalowersurface,suchasachair,thebedorthefloororontothenextlowersurface(e.g.,ontoabed,chair,orbedsidemat).

An“interceptedfall”occurswhenaresidentwouldhavefallenifheorshehadnotcaughthim/herselforhadnotbeeninterceptedbyanotherperson(thisisstillconsideredafallregardlessiftheresidentdoesnothitthefloor).

A“fracturerelatedtoafall”isanydocumentedbonefracture(inaproblemlistfromamedicalrecord,anx-rayreport,orbyahistoryoftheresidentorcaregiver)thatoccurredasadirectresultofafallorwasrecognizedandlaterattributedtothefall.Donotincludefracturescausedbytraumarelatedtocarcrashesorpedestrianversuscaraccidentsorimpactofanotherpersonorobjectagainsttheresident.

FallsareNOTaresultofanoverwhelmingexternalforce(e.g.,aresidentpushesanotherresident).

PROGRAMSTEPS:

I. INVESTIGATIVEGUIDELINES

A. Checkresidentforinjuries.i. VitalSigns

ii. Neuro-checks,forheadinjuriesorun-witnessedfallandresidentunabletocommunicateifhehithis/herhead.

iii. Visualcheckforcuts,bruises,abrasions,rednessordeformities.B. SecureresidentC. CallPost-FallHuddleandcompleteformD. Ifinjuryisserious,contactphysicianorcall911immediatelyE. ContactNHAF. ContactDONG. ContactSupervisor,orUnitManagerH. Notifyphysician,family/responsiblepartyoffallI. CompleteIncident/EventReportJ. UpdatetheFallEvaluationtoolinMatrixK. StartInvestigativeReportL. ObtaindetailedstatementsfromANYwitnesses.Statementsmustbesigned

withthecorrectdateandtimeforfallswithseriousinjuries.M. DocumentintheNursesNotes:

i. Observedcircumstances;residentfell,slidfromchair,foundonfloor,etc.ii. Noteifanyinjuriesiii. Physiciancontactediv. ResidentRepresentativecontactedv. VitalSignsvi. Neuro-checksvii. Anymedicationstakenviii. TimeofToileting(ifpertinent)ix. Anyotherpertinentobservationsx. ImplementanydirectionsgivenbytheAdministratorand/orRNoncall.xi. UsetheFallInterventionformforpossibleimmediateapproachestousein

careoftheresident.N. Continuetoobserveresidentthroughoutshiftandprovideathoroughreport

forthenextoncomingshift(includesNursesandC.N.A.s)O. Eachnurse,eachshiftwillobserveresidentanddocumentfor72hoursinthe

resident’smedicalrecord.i. VitalSignsii. Neuro-checks(forunwitnessedfalls)iii. Behaviorchangesiv. Physicalchangesv. Neurologicalchanges

P. Ifresidenthastobesentoutofthefacility,initiatetheAbuseandorAdverseIncidentinvestigationprocess.NotifytheRiskManager.

Q. UsetheFallInterventionformforpossibleimmediateapproachestoimplementstatuspostincident/fall.

R. RiskManageristoaddtheresidenttotheIncident/Fallfollowuplog.

II. QualityAssurance/RiskManagementGuidelines

A. ResponsibilityofRiskManager/Designee• ReviewIncidentreportforcompleteness

• EnsureFallEvaluationToolhasbeenupdated• CompleteInvestigativeReport• TaketheincidenttoStandupmeetingforreviewandcareplanreviewthe

nextbusinessday.• Therapytoscreenresidentthatfallsasreferredandrecommend

appropriateinterventions.• Careplanistobeupdatedwithanynewinterventions.• NursingstaffistodocumentQshiftfor72hours.• TrendingandTrackingtobecompletedatendofmonthandreportgiven

attheQAPImonthly/quarterlymeetings.• TheAbuseandAdverseReportingProtocoltobeinitiatedwhen

appropriate.

B. TheInterdisciplinaryPlanofCare(IPOC)teamwillmeetwithinthesameperiodoftimeanddiscussthecausativefactors,interventionstopreventanotherfall,maketherapyreferralasnecessaryandrevisethecareplanifnecessary.

C. Rehabilitationtherapywillscreenreferredresidentwithin24hoursafterafall,unlessthefalloccursonaweekend,thenthescreenwillbedoneonMonday.Theywillthenobtainanorderfortheappropriatecourseoftreatmentorwritearestorativeprogramthatwillassistinreducingfurtherfalls.

D. Whenaresidenthasmorethanonefallina24-72hourperiodoftime,onescreeningandrecommendationwillsufficeunlesstheIPOCteamdeemsotherwise.

E. IftheresidentsustainedaninjuryrequiringcarethatyoucannotprovideorAbuseissuspectedoralleged,theninitiatetheappropriatereportingrequirementsforStateandFederalreporting.

III. FallReductionProgram“FallingStarProgram”

A. ProgramGoal:

TheFallingStarProgramisacomprehensiveprogramdesignedtoidentifyandaddressresidents‘activelyatrisk’forfalls.Thisisinaccordancetoassistingresidentsmaintainasafeandcomfortableenvironmentwhileresidinginthefacility.Bycreatingsuchaprogram,ourgoalswillbetoreducethenumberoffallsandorfallswithinjuryonamonthly,quarterly,andannualbasis.

B. StaffInvolvement:

TheFallingStarProgramwillbeafullfacilityprogramincludingalldisciplines24hoursaday,sevendaysaweek.TheFallingStarProgramwillbein-servicedtoallfacilitystaffonhire,annually,andPRNasdictatedbyDepartmentHeadsand/ortheAdministrator.

C. Criteria:ThecriteriaforinclusioninthePrograminclude:

1. Residenthasbeenidentifiedasafallrisk(fallscoreof15orgreater)ontheiradmissionSafetyRiskEvaluationorontheiradmissionminimumdataset(MDS),and/or

2. Theresidentisonananticoagulantand/or3. HasmoderatetosevereOsteoporosis.4. Residenthasanewfallfromstanding,sitting,lyingposition.

ThecriteriafordiscontinuanceofaresidentintheProgram:

1. ResidentwasplacedonprogramasanewadmitwithaFRAof15orhigherandhasremainedfallfreefor30days,

2. Residentisnolongeridentifiedasamoderate/highfallriskfor30ormoredays,

3. Residentwasplacedonprogramafter2ormorefallsin30daysandhasremainedfallfreefor60days,

4. ResidentwhowasplacedonprogramforbeingonanticoagulantwithFRAof10orhigherandhasremainedfallfreefor30days,andor

5. Residentwasplacedonprogramduetofallwithmajorinjuryandhasremainedfallfreefor90days.

6. Residentiscapableoffollowingsafetyinstructionsand/orrememberstousethecallbell.(IDT)discussion.

7. TheInterDisciplinaryTeamdecision.

D. TheFallingStarIdentification:

1. ResidentswhoareincludedintheFallingStarProgramwillbeidentifiedwithaStar.TheStarwillbeplacedoutsideresident’sroom(withtheresident’sbednumberwrittenneatlyoffcenterforidentificationwheninsemi-privaterooms),wheelchairs,walkers,and/orcanes.

E. Programdescriptionwillinclude:

1. Monitorshowerroomsfornon-slipsurfaces,2. Monitorallassistiveequipment(e.g.,wheelchairs,walkers,etc.)for

brokenorlooseparts,3. Keepfloorsinthehallwaysandroomsdryandclutter-free,4. Identifyallresidentsatriskforfalls,5. Monitormedicationsforside-effectsthatcancausedizziness,6. Monitorhandrailsandotherobjectsforsharpedges,brokenparts,etc.,7. Removeitemsthatareoutofplaceinroomsandresidentcommonareas

toavoidtripping(e.g.,trashcans,linencarts,etc.),8. Checkresidentswhoareusingalarms(bed,chair),9. Monitorlightingforburntoutlightbulbs,and10. STOP,LOOK,andLISTEN

IV. FORMS

• IncidentReport

• FallInvestigationReport• Incident/Fallfollow-uplog• FallReviewandInterventions–PossibleImmediateApproaches• Accident/IncidentSurveillanceTrackingLog

PointofEmphasis:

Eachtimeanemployee(anydepartment)walkspastaresidentroomorresidentidentifiedwithaSTARtheemployeewillSTOP,LOOK,andLISTENtoassurethattheresidentissafeandnotinanunsafesituation.

POLICY/PROCEDURESUBJECT:MissingResident

DATE:

INTENT:

It is the intent of the facility to be aware of its resident’s usual habits and locations asreasonably practicable. This is with the intent of not invading privacy but to identify apossiblemissingresident.

PROCEDURE:

1. In theevent that any staffmember identifies that they cannot finda resident in aplace that the resident is anticipated to be, the staff member will alert theirsupervisor for assistance once affirming that the resident was not signed out onleave,andifnot,informtheNurse.

2. TheNurseontheUnitwillassumecontrolofthesearchandgatherallavailablestaffand begin an immediate preliminary search of the area and immediate premises.Areas to be searched include but are not limited to resident rooms, bathrooms,utilityrooms,showerrooms,activityrooms,andlockedareasnormallynotaccessibletoresidents.

3. Staffwill also search the unit in order to identify any other residents thatmaybemissing.

4. While staff are conducting the search, the Nurse assigned to the Unit will makephonecallstoalerttheAdministrator,DirectorofNursingandRiskManagerofthemissingresident.

5. Thefacilityhasdesignatedtheterm“MR”astheuniversalpageforthoseresidentswhoaredeterminedtobemissingandunabletobelocatedatthattime.

6. The Nurse will notify the Receptionist and a “MR” will be paged throughout thecampus supervisor would alert staff of the identity of the resident and directdesignatedstafftoparticipateinthesearch.

7. Staffontheunitwillmakecopiesoftheresident’sphotographtobedistributed.

8. The Nurse in charge of the search will not assume that the resident has left thefacilityandwill:a. Re-affirm if the resident couldbeoutof the facilityonanauthorized leaveor

passbyreviewingthefacilitysignoutprocess;b. DetermineifitisprudenttocalltheResidentsfamilyorothervisitorsifthereisa

possible concern that the residentwas takenout andpotentially theydid notsigntheresidentout;

c. If the resident is not authorized to leave the facility independently, initiate asearchofthefacilityandpremisesbyassigningstafftolookinvariousareas;

d. Iftheresidentisnotlocatedinareasonableamountoftime,theAdministratorandtheDirectorofNursing(DON),theresident’srepresentative,theAttendingPhysician,andlawenforcementofficialswillbenotifiedasindicated;and

e. Iftheresidentremainsunabletobelocatedandorisnotauthorizedtoleavethefacilityindependently;Initiateanextensivesearchofthesurroundingarea.

9. When amissing resident is not locatedwithin the confines of the facility building,then theNurse inchargewoulddirectdesignatedstaff toparticipate inanoutsidefacility grounds search, which may include but is not limited to the roof of thebuilding,theparkinglot,andanyoutsideparkedvehicles,etc.

6. In the event that a staff member observes a resident attempting to leave thepremiseswithoutsupervisionandisconcernedthattheresidentwouldnotnormallybeappropriatetodosoindependently,thestaffmemberwill:a. Call for assistance then calmly approach the resident, (attempt to initiate a

friendly chat as possible), and in a courteousmanner attempt to re-direct orguidetheresidentbackintothefacility;

b. If the resident is upsetor agitatedand is not easily re-directedor guided, thestaffmemberwill continuewalkingwith the resident eithernext toorbehindthemtoprovidesupport,supervision,andsafety;and

c. If theresident isnotabletobere-directedorguidedand isoutof thefacility,the staffmemberwill alert another staffmember or supervisor for assistancewhilestayingwiththeresident(e.g.,useofcellularphone,tellthenextpersonthestaffmembersee’stopleasegetassistance,mayneedtoverballyyellout,etc.).

7. When a residentwhowasmissing is found, unless theywerewith their family orothersupportingindividual,thenursewill:a. Examinetheresidentforpossibleinjuries;b. NotifytheAttendingPhysicianforconsultation;c. NotifythefacilityAdministratorordesignee;d. Notifytheresident’sdesignatedrepresentative;e. DiscusswiththeAdministrator,DONS,ordesigneeifitisprudenttoprovidethe

residentwith1:1orotherlevelofsupervision;f. Completethefacilityappropriatereporttodocumenttheevent;andg. Completeappropriatedocumentationintheresident’smedicalrecord.

8. The supervisor or designee will also instruct staff members to verify any otherresidentthathasbeen identifiedasatriskofwandering is inthebuildingtoaffirmtheirsafety.

Ifthefacilityutilizessignalingdevicesproceedto#9

9. Iftheresidentusesanelectronicdevicethatalarms,thesupervisorordesigneewill:a. Determine if an electronic protection device normally used by the resident, if

any,ispresentand,ifso,thelocationofthedeviceontheresident’sbody;

b. Testanyusedelectronicprotectiondevicebothontheresidentandattachedtoorassociatedwithanydoorways;

c. Alert theMaintenanceDirectoror theirdesignee’s in theevent that there isamechanicaldeviceinvolvedinthesituation;

d. In the event that there is any doorway equipmentmalfunction supervision ofthatareawillbeprovidedunlessthereisonlyoneresidentatriskinwhichcasetheassignedstaffmemberwillprovide1:1orotherfrequencyofobservationtotheresidentasdeterminedbythephysicianandorsupervisor;and

e. Re-evaluate the resident’s risk for possible elopement regardless if this eventmayconstituteanelopementornot.

POLICY/PROCEDURE

SUBJECT:Elopement

DATE:

INTENT:

It is the intent of the facility to be aware of its resident’s usual habits and locations asreasonablypracticable.Thisiswiththeintentofnotinvadingprivacybuttoidentifypossibleelopement.

DEFINITION:

Elopementincludeswhenaresidentleavesthepremisesorasafeareawithoutauthorizationand/ornecessarysupervisionplacingtheresidentatriskforharmorinjury.

PROCEDURE:

1. In theevent that any staffmember identifies that they cannot finda resident in aplace that the resident is anticipated to be, the staff member will alert theirsupervisor for assistance once affirming that the resident was not signed out onleave.

2. Thesupervisorwouldassumecontrolofthesearch.

3. Thesupervisorwouldalertstaffoftheidentityoftheresidentanddirectdesignatedstafftoparticipateinthesearch.

4. Thesupervisorinchargeofthesearchwillnotassumethattheresidenthasleftthefacilityandwill:a. Re-affirm if the resident couldbeoutof the facilityonanauthorized leaveor

passbyreviewingthefacilitysignoutprocess;b. DetermineifitisprudenttocalltheResidentsfamilyorothervisitorsifthereisa

possible concern that the residentwas takenout andpotentially theydid notsigntheresidentout;

c. If the resident is not authorized to leave the facility independently, initiate asearchofthefacilityandpremisesbyassigningstafftolookinvariousareas;

d. Iftheresidentisnotlocatedinareasonableamountoftime,theAdministratorandtheDirectorofNursing(DON),theresident’srepresentative,theAttendingPhysician,andlawenforcementofficialswillbenotifiedasindicated;and

e. Iftheresidentremainsunabletobelocatedandorisnotauthorizedtoleavethefacilityindependently;Initiateanextensivesearchofthesurroundingarea.

5. When amissing resident is not locatedwithin the confines of the facility building,then the supervisor in charge would direct designated staff to participate in anoutside facilitygrounds search,whichmay includebut isnot limited to the roofofthebuilding,theparkinglot,andanyoutsideparkedvehicles,etc.

6. In the event that a staff member observes a resident attempting to leave thepremiseswithoutsupervisionandisconcernedthattheresidentwouldnotnormallybeappropriatetodosoindependently,thestaffmemberwill:

a. Call for assistance then calmly approach the resident, (attempt to initiate afriendlychataspossible),andinacourteousmannerattempttore-directorguidetheresidentbackintothefacility;

b.Iftheresidentisupsetoragitatedandisnoteasilyre-directedorguided,thestaffmemberwillcontinuewalkingwiththeresidenteithernexttoorbehindthemtoprovidesupport,supervision,andsafety;and

c.Iftheresidentisnotabletobere-directedorguidedandisoutofthefacility,thestaffmemberwillalertanotherstaffmemberorsupervisorforassistancewhile staying with the resident (e.g., use of cellular phone, tell the nextpersonthestaffmembersee’stopleasegetassistance,mayneedtoverballyyellout,etc.).

7. When a resident who wasmissing is found unless they were with their family orothersupportingindividual,thenursewill:

a. Examinetheresidentforpossibleinjuries;b. NotifytheAttendingPhysicianforconsultation;c. NotifythefacilityAdministratorordesignee:d. Notifytheresident’sdesignatedrepresentative;e. DiscusswiththeAdministrator,DONS,ordesigneeif it isprudenttoprovide

theresidentwith1:1orotherlevelofsupervision;f. Completethefacilityappropriatereporttodocumenttheevent;andg. Complete appropriate documentation to include in the resident’s medical

record.

8. The supervisor or designee will also instruct staff members to verify any other resident that has been identified as at risk of wandering is in the building to affirm their safety.

Ifthefacilityutilizessignalingdevicesproceedto#9

9. Iftheresidentusesanelectronicdevicethatalarms,thesupervisorordesigneewill:a. Determineifanelectronicprotectiondevicenormallyusedbytheresident,if

any,ispresentand,ifso,thelocationofthedeviceontheresident’sbody;b. Testanyusedelectronicprotectiondevicebothontheresidentandattached

toorassociatedwithanydoorways;c. AlerttheMaintenanceDirectorortheirdesignee’sintheeventthatthereisa

mechanicaldeviceinvolvedinthesituation;d. Intheeventthatthereisanydoorwayequipmentmalfunctionsupervisionof

thatareawillbeprovidedunless there isonlyone residentat risk inwhichcase the assigned staff member will provide 1:1 or other frequency ofobservationtotheresidentasdeterminedbythephysicianandorsupervisor;and

e. Re-evaluatetheresident’sriskforpossibleelopementregardlessifthiseventmayconstituteanelopementornot.

POLICY/PROCEDURE

SUBJECT:Incontinence

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethattheresidentsreceivecareandservicestopreventtheuseofanindwellingcatheter,unlessclinicallynecessaryandpromotesurinarycontinenceofitsresidents,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywillensurethatresidentwhoiscontinentofbladderandbowelonadmissionreceivesservicesandassistancetomaintaincontinenceunlesshisorherclinicalconditionisorbecomessuchthatcontinenceisnotpossibletomaintain.

2. Foraresidentwithurinaryincontinence,basedontheresident’scomprehensiveassessment,thefacilitywillensurethat:

a. Aresidentwhoentersthefacilitywithoutanindwellingcatheterisnotcatheterizedunlesstheresident’sclinicalconditiondemonstratesthatcatheterizationwasnecessary;

b. Aresidentwhoentersthefacilitywithanindwellingcatheterorsubsequentlyreceivesoneisassessedforremovalofthecatheterassoonaspossibleunlesstheresident’sclinicalconditiondemonstratesthatcatheterizationisnecessaryand

c. Aresidentwhoisincontinentofbladderreceivesappropriatetreatmentandservicestopreventurinarytractinfectionsandtorestorecontinencetotheextentpossible.

3. Foraresidentwithfecalincontinence,basedontheresident’scomprehensiveassessment,thefacilitywillensurethataresidentwhoisincontinentofbowelreceivesappropriatetreatmentandservicestorestoreasmuchnormalbowelfunctionaspossible.

PROCEDURE

SUBJECT:BowelandBladderProgram

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethattheresidentsreceivecareandservicestopreventtheuseofanindwellingcatheter,unlessclinicallynecessaryandpromotesurinarycontinenceofitsresidents,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. AllresidentsadmittedtofacilitywillhaveaBowelandBladderContinenceEvaluationpreformedatthetimeofadmission,inconjunctionwitheachquarterlyandannualassessment,withanysignificantchangeassessmentandasdeemednecessarybytheInterdisciplinaryTeam;thisincludestheremovalofanindwellingurinarycatheter.

2. Theadmittingnurseordesigneeisresponsibleforcompletingtheinitialevaluation.

3. Theadmittingnurseordesigneewillthenberesponsibleforinitiatingthe3-DayResidentTracking/TrendingBowelandBladderPatternwiththeresident’sname,roomnumberanddateforallnewadmissions.

4. TheC.N.A.responsiblefortheresidentatthetimeofadmissionwillbeginthe

trackingandtrendingdocumentationontheform.

5. Afterthe3daystheUnitManagerordesigneewillreviewthedocumentationlookingforanestablishedpattern.

6. TheUnitManagerordesigneealongwiththeInterdisciplinaryTeamwillevaluatetheappropriateprogramfortheresidentandrefertoRestorativeifappropriate.

7. Whenappropriate,theUnitManagerordesigneewillinitiatetheRestorative

Boweland/orBladderRetrainingProgram.Thisisa14dayprogram.

8. TheC.N.A.responsiblefortheresidentwilldocumentontheRestorativeBowelandBladderForm.

9. After14daystheUnitManagerordesigneewillreevaluatetheappropriatenesstocontinuewithcurrentplanorchangethecurrentplan.

PROCEDURE

SUBJECT:IndwellingCatheterJustificationandRemoval

DATE:

POLICY:

Itisthepolicyofthefacilitytoensurethattheresidentsreceivecareandservicestopreventtheuseofanindwellingcatheter,unlessclinicallynecessaryandpromotesurinarycontinenceofitsresidents,inaccordancewithStateandFederalRegulations.PROCEDURE:

1. Whenaresidentisadmittedwithanindwellingcatheter,theadmittingnursewillcompletetheIndwellingUrinaryCatheterJustificationForm.

2. Theadmittingnursewilldocumenttheindwellingcathetersizeandobtainanorderfromthephysicianorphysicianextendertochangethecatheterasneededforblockage,aswellasobtainasupportingdiagnosisforuseofthecatheter.

3. Theadmittingnursewillalsoobtainorderstoperformcathetercareoneachshift,toirrigatethecatheterasneededforocclusionorblockage,andmaychangeindwellingurinarycathetertoobtainurinalysiswhencatheterhasbeeninplaceforgreaterthan14days.

4. Whenthereisnosupportingdiagnosisfortheuseoftheindwellingurinarycatheter,theadmittingnursewillobtainanorderfromthephysicianorphysicianextendertoremove,alongwithordersfornotificationwhentheresidentdoesnotvoid.

5. Oncetheindwellingurinarycatheterhasbeenremovedthenurseremovingthecatheterwilldocumentthisintheelectronicmedicalrecordandinitiatethe3-daytrackingandtrendingFormforthenursingassistanttodocumentvoiding.

6. Updatethecareplanasindicatedbasedonoutcome.

POLICY/PROCEDURE

SUBJECT:Colostomy,Urostomy,orIleostomyCare

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideColostomy,Urostomy,orIleostomyCareServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

Thefacilitywillensurethataresidentwhorequirescolostomy,urostomy,orileostomyservices,receivesuchcareconsistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresident’sgoalsandpreferences.

POLICY/PROCEDURE

SUBJECT:Nutrition/HydrationStatusMaintenance

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideNutrition/HydrationStatusMaintenanceServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Basedonaresident'scomprehensiveassessment,thefacilitywillensurethataresident:a. Maintainsacceptableparametersofnutritionalstatus,suchasusualbody

weightordesirablebodyweightrangeandelectrolytebalance,unlesstheresident’sclinicalconditiondemonstratesthatthisisnotpossibleorresidentpreferencesindicateotherwise;

b. Isofferedsufficientfluidintaketomaintainproperhydrationandhealth;c. Isofferedatherapeuticdietwhenthereisanutritionalproblemandthe

healthcareproviderordersatherapeuticdiet.

2. Basedonaresident'scomprehensiveassessment,thefacilitywillensurethataresident:EnteralNutrition:

a. Aresidentwhohasbeenabletoeatenoughaloneorwithassistanceisnotfedbyenteralmethodsunlesstheresident’sclinicalconditiondemonstratesthatenteralfeedingwasclinicallyindicatedandconsentedtobytheresident;and

b. Aresidentwhoisfedbyenteralmeansreceivestheappropriatetreatmentandservicestorestore,ifpossible,oraleatingskillsandtopreventcomplicationsofenteralfeedingincludingbutnotlimitedtoaspirationpneumonia,diarrhea,vomiting,dehydration,metabolicabnormalities,andnasal-pharyngealulcers.

POLICY/PROCEDURE

SUBJECT:AssistedNutritionandHydration

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurethattheresidentsreceivecareandservicesrelatedtoNaso-GastricTubesorgastrostomytube,inaccordancewithStateandFederalRegulations.PROCEDURE:

1. Thefacilitywillensurethatbasedonthecomprehensiveassessmentofaresident:a. Aresidentwhohasbeenabletoeatenoughaloneorwithassistanceisnotfed

byenteralmethodsunlesstheresident’sclinicalconditiondemonstratesthatenteralfeedingwasclinicallyindicatedandconsentedtobytheresident;and

b. Aresidentwhoisfedbyenteralmeansreceivestheappropriatetreatmentandservicestorestore,ifpossible,oraleatingskillsandtopreventcomplicationsofenteralfeedingincludingbutnotlimitedtoaspirationpneumonia,diarrhea,vomiting,dehydration,metabolicabnormalities,andnasal-pharyngealulcers..

2. Thefacilitywillensurethatanaso-gastrictubeorgastrostomytubefeedingis

utilizedonlyafteradequateassessment,andtheresident’sclinicalconditionmakesthistreatmentnecessary.

3. Maintainsacceptableparametersofnutritionalstatus,suchasusualbodyweightordesirablebodyweightrangeandelectrolytebalance,unlesstheresident’sclinicalconditiondemonstratesthatthisisnotpossibleorresidentpreferencesindicateotherwise;

4. Isofferedatherapeuticdietwhenthereisanutritionalproblemandthehealth

careproviderordersatherapeuticdiet.

5. Isofferedsufficientfluidintaketomaintainproperhydrationandhealth. *Note - This Policy includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic, Jejunostomy, and enteral fluids.

POLICY/PROCEDURE

SUBJECT:EnteralFeeding

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideadequatenutritionandhydrationtoensurethatresidentsattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beinginaccordancetoStateandFederalregulation.

PROCEDURE:

ResidentsAdmittedtoFacilityWithoutTubeFeedings:

Aresidentwhohasbeenabletoeatenoughaloneorwithassistanceisnotfedbygastrictubeunlesstheresident’sclinicalconditiondemonstratesthatuseofagastrictubewasunavoidable.Clinicalconditionsdemonstratingthatnourishmentviaagastrictubeisunavoidableinclude:

• Theinabilitytoswallowwithoutchokingoraspiration(i.e.,incasesofParkinson’sdisease,pseudobulbarpalsy,AdvancedstagesofDementiaoresophagealdiverticulum).

• Lackofsufficientalertnessfororalnutrition(i.e.,comatose),and• Malnutritionnotattributabletoasinglecauseorcausesthatcanbe

isolatedandreversed.• Thereisdocumentedevidencethefacilityhasnotbeenabletomaintainor

improvetheresident’snutritionalstatusthroughoralintake.

1. Physicianshoulddocumenttheclinicalconditionsdemonstratingtheneedforatubefeeding,andtheresident,his/herfamilyorlegalrepresentativeshouldbeconsultedregardingtheuseofafeedingtube.

2. Documentationinthemedicalrecordshouldrevealidentificationoftheriskformalnutrition,andwhatthefacilitydidtomaintainoralfeeding,priortoinsertingafeedingtube.

3. Whereswallowingdifficultiesareidentified,theresidentshouldreceiveappropriatetherapiestoimproveorenhanceswallowingskills,asappropriate.

4. Documentationinthemedicalrecordshouldrevealconsultationwiththedietitian.ResidentsAdmittedtoFacilityWithTubeFeedingsAlreadyInPlace:Aresidentwhoisfedbyagastrostomytubeshallreceivetheappropriatetreatmentandservicestopreventaspirationpneumonia,diarrhea,vomiting,

dehydration,metabolicabnormalitiesandtorestore,ifpossible,normaleatingskills.

5. AdmittingNursewillobtainPhysicianOrdersforTubeFeedingFormula.

6. TheDietitianwillbenotifiedofthetubefeedingordersandassessnutrition/hydrationneedsoftheresident.Basedontheoutcomeofassessmentthedietitianwillmakerecommendationsfortubefeedingtype,rate,volumeandwaterflushes.

7. TheNursewillreviewtheDietitian’srecommendationswiththePhysicianandobtainorders.

8. AFeedingPumpwillbeutilizedforallEnteralFeedings,unlessotherwisecontraindicated.

9. ProperelevationoftheResident’sheadwillbemaintainedaccordingtoResident’scondition.

10. Priortotheflushingofafeedingtube,theadministrationofmedicationviaafeedingtube,ortheprovidingoftubefeedings,thenurseperformingtheprocedureensurestheproperplacementofthefeedingtube.

11. Universalprecautionsandcleantechniquewillbeutilizedwhenstopping,starting,flushing,andgivingmedicationsthroughthefeedingtube.

12. Theplanofcareshouldaddresstube-feedinguse,strategiestopreventcomplicationsincluding,butnotlimitedto:aspirationpneumonia,diarrhea,vomiting,dehydration,metabolicabnormalitiesandtorestore,ifpossible,normaleatingskills.

PROCEDURE

SUBJECT:EnteralTubeFeedingviaBolus

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideenteralfeedingasorderedbythephysicianviabolustoensureadequatenutritionforresidentsthatareunabletomaintaintheirnutritionorally.

PROCEDURE:

1. Obtainaphysicianordertoincludethefollowinginformation:a. Resident’sname,androomnumberb. Typeofformulac. RouteofdeliveryAccesssited. Method(Bolus)e. Numberofcans/ornumberofCC’sforadministrationf. Flushesbeforeandafterbolusfeedingg. Freewaterflushorderh. HOBelevationi. Changingsyringeandtubingevery24hours

2. ChecktheEnteralAdministrationRecord.

3. Placeyoursuppliesonacleanoverbedtable/bedsidestandandarrangesotheycanbeeasilyreached.

4. Positionheadofbedat30-45degreesunlessmedicallycontraindicated.

5. Washhandsanddrythoroughly.

6. Donnegloves.

7. Providebarriertoprotectresident’sclothing.

8. Verifyplacementofthetubeusingthefacility’sprocedure.

9. Checkgastricresidualvolumeusingthefacility’sprocedure.

10. Iftheplacementispositiveandgastricresidualvolumeiswithintheamountacceptableforthatresident,proceedtoinitiatingtheenteralfeeding.

11. Attacha60mllargetipsyringewithoutthebarreltothetubeandunclampthetube.ElevatethesyringeapproximatelyTwelvetoEighteen(12-18)inchesabovetheresidentsheadiflengthoftubeallows.

12. Fillthesyringewiththeprescribeamountofwater(roomtemperature)flushasordered.Unclampthetubeandallowflushtoflowbygravity.

13. Fillthesyringewiththeformulaandallowtoflowbygravityuntiltheprescribeamountisadministered.

14. Followthefeedingwiththeprescribedamountofwaterflush(roomtemperature)

15. Plugtheendoftheenteraltubeandsecureit.

16. Instructtheresidenttoremainuprightorleaveheadofbedelevatedforapproximatelyone(1)hourtopreventaspiration

17. Discarddisposablesuppliesinthedesignatedcontainers.

18. Cleanreusableequipment.

19. Cleanoverbedtableandreturntoproperposition.

20. Maketheresidentcomfortable.

21. Placecalllightineasyreachforresident.

22. Removeglovesandwashhands.

23. Documentontheresident’smedicalrecordtoincludeanycomplicationandnotifythephysicianasneeded.

PROCEDURE

SUBJECT:EnteralTubeFeedingviaPump

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideenteralfeedingasorderedbythephysicianviapumptoensureadequatenutritionforresidentsthatareunabletomaintaintheirnutritionorally.

PROCEDURE:

1. Obtainaphysicianordertoincludethefollowinginformation:j. Resident’sname,androomnumberk. Typeofformulal. RouteofdeliveryAccesssitem. Method(pump)n. Rateofadministration(numberofcans/ornumberofCC’s)o. Numberofhourstoadministerp. Timetostartandendq. Freewaterflushorderr. HOBelevations. Changingsyringeandtubingevery24hours

2. ChecktheEnteralAdministrationRecord

3. Labeltheenteralfeedingbag/bottle,toincludethetubing,withthefollowinginformation:a. Resident’snameandroom#b. Typeofformula(ifusingbags)c. Dateandtimeformulaisbeinghungd. Rateofadministration



6. Washhandsanddrythoroughly

7. Donnegloves

8. Attachtheenteraltubingtothepumpandprimethetubing




12. Clamptheenteraltubeandremovetheplug.

13. Connecttheprimedfeedingpumpsettotheenteraltube(G-Tube,NGT,Jejunostomytube)andunclampthetube.Setrateandpressstartforcontinuousfeeding




17. Maketheresidentcomfortable

18. Placecalllightineasyreachforresident

19. Removeglovesandwashhands


PROCEDURE

SUBJECT:EnteralTubeFeedingviaGravityBag

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideenteralfeedingasorderedbythephysicianviagravitybagtoensureadequatenutritionforresidentsthatareunabletomaintaintheirnutritionorally.

PROCEDURE:

1. Obtainaphysicianordertoincludethefollowinginformation:a. Resident’sname,androomnumberb. Typeofformulac. RouteofdeliveryAccesssited. Method(GravityBag)e. Numberofcans/ornumberofCC’sforadministrationf. Flushesbeforeandaftergravityfeedingg. Freewaterflushorderh. HOBelevationi. Changingsyringeandtubingevery24hours

2. ChecktheEnteralAdministrationRecord.


4. Maintainheadofbedat30-45degreesunlessmedicallycontraindicated.

5. Preformhandhygiene.

6. Donnegloves.

7. Providebarriertoprotectresident’sclothing.




11. Pourprescribedamountofenteralfeedingintoenteralfeedingbagandprimetubing.Clamptubing.

12. Removetheplugfromtheenteralfeedingtubeandflushasorder.

13. HangenteralfeedingbagonIVpoleapproximatelyeighteen(18)inchesaboveresident’shead.Connecttoenteraltubeandallowfeedingtoflowbygravity.

14. Followfeedingwithprescribedflushorder.

15. Whenflushcompleted,disconnectbagfromenteraltube

16. Instructtheresidenttoremainuprightorleaveheadofbedelevatedforapproximatelyone(1)hourtopreventaspiration.




20. Maketheresidentcomfortable.

21. Placecalllightineasyreachforresident.

22. Removeglovesandwashhands.


PROCEDURE

SUBJECT:ChangingaGastrostomyTubeDATE:

INTENT:

Itisthepolicyofthefacilitytomaintainnutritionalsupportforresidentsunabletoobtainnourishmentorally

PROCEDURE:

1. Obtainaphysician’sorderfortheprocedure

2. ThisprocedureisperformedbyaRegisteredNurseonly.

3. Assembleequipmentandsuppliesa. Towelorotherbarrierb. Gastrostomytube(sizeorderedbyphysician)c. Watersolublelubricantd. Two(2)10mlsyringese. Normalsaline;f. Sterilewaterg. Personalprotectiveequipment(Gown,gloves,mask,eveshield).

4. Placeprotectivebarrieronacleanbedside

5. Placeequipmentonbedsidetableandarrangesuppliessotheycanbeeasily

reached.

6. Washhands

7. Putongloves

8. Openpackagewithnewgastrostomytubeandcheckforproperinflationbyinflatingtheballoonwith(10)mlofsterilewater,thendeflateballoon.

9. Leavenewtubeinpackage

10. Deflateballooninexistinggastrostomytubeusing(10)mlsyringe.

11. Applygentlepressurewithnon-dominanthandandthenpullgastrostomytubeupwardwithdominanthanduntiloutoftheabdomen.

12. Cleanthestomasitewithnormalsaline.

13. Removethenewtubefromthepackagebythelargeendofthetube

14. Applylubricanttothetipofthetubeandgentlyinsertsix(6)toeight(8)inchesintothestomasite

15. Inflatetheballoonwithfive(5)ml(orasrecommendedbythemanufacturer)ofsterilewater

16. Pullgastrostomytubeupwarduntilballoonisrestingagainsttheinsideofthestomachandsecure

17. Iftubenotinusethenclampuntilneeded

18. Stopforanyresistanceandattemptagain.

19. Ifreplacingatubethatwasremovedtraumatically,ensureanabdominalX-RAYidcompletedpriortouse.

20. Discarddisposablesupplies.

21. Cleanoverbedtableandreturntoitsproperposition.

22. Ensureresidentiscomfortablewithcalllightaccess.

23. Documentprocedureintheresident’smedicalrecordandnotifythephysicianasneeded.

PROCEDURE

SUBJECT:Gastrostomy/JejunostomySiteCare

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideGastrostomyandJejunostomysitecaretodecreasetheriskofinfection.

PROCEDURE:

1. Obtainaphysicianordertoincludethefollowinginformation:t. Resident’sname,androomnumberu. Typeofsolutionforcleansingv. Frequencyoftreatment

2. Arrangesuppliessotheycanbeeasilyreachedonacleansurface

3. Washhandsandputoncleangloves

4. ForNewSitesonly:a. Evaluateforpainandmedicateasindicatedpriortoprocedure.b. Usinggauzepadswithnormalsaline,gentlycleantheareaimmediately

surroundingthetubeandcontinueworkingoutwardinacircularfashion.Besureyoucleanunderthebolster.

c. Iftheresidenthasa“Button”,useacotton-tippedapplicatortocleantheareaandrotatethedeviceonceeveryday

d. Patdryaftercleaninge. Applyointmentiforderedf. Coverwithdressingasordered

5. Forestablishedsites:

a. Evaluateforpainandmedicateasindicatedpriortoprocedure.b. Usinggauzepads,soapandwater,gentlycleantheareaimmediately

surroundingthetubeandcontinueworkingoutwardinacircularmotion.Besuretocleanunderthebolster.

c. Iftheresidenthasa‘Button”,useacotton-tippedapplicatortocleantheareaandrotatethedevicedaily.

d. Patdryaftercleaninge. Donotplaceadressingoverthesiteunlessotherwiseorderedf. Evaluatestomasiteforsignsofredness,painorsoreness,swellingordrainage.

Documentifpresentandnotifytheresident’sphysician.g. Discarddisposablesuppliesindesignatedcontainersh. Cleansurfaceusedforsuppliesi. Makeresidentcomfortable

j. Ensureresidentcanreachcallbellk. Removeglovesanddiscardinappropriatecontainerl. Washhands

6. Documenttheprocedureintheresident’smedicalrecord.

PROCEDURE

SUBJECT:CleaningandStoringReusableSyringeUsedDuringEnteralFeeding

DATE:

INTENT:

Itisthepolicyofthefacilitytocleanandstoresyringesusedduringenteralfeedinginamannerthatdecreasestheriskofinfection.

PROCEDURE:

1. Withgloveson,separatethebarrelandtheplunger

2. Rinsebothpieceswithwarmuntilclean

3. Useacleanpapertowelanddrythebarrelthoroughly,dryplungeralso

4. Storeseparatelyinaziplockbagorasealedcontainer

5. Removegloves

6. Washhands

7. Replacedsyringeevery24hours

PROCEDURE

SUBJECT:EnteralFeedingMedicationAdministration

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideappropriatemedicationadministrationtoresidentswhoreceivetheirmedicationsviaanenteralfeedingtubetoensurethatresidentsattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beinginaccordancetoStateandFederalregulation.

PROCEDURE:

ResidentsAdmittedtoFacilityWithAnEnteralFeedingTube:

1. Theadmittingnursewillobtainthemedicationordersuponadmissiontothefacility.

2. Documentationinthemedicalrecordadmissionorderswillidentifytherouteofadministrationforthosemedications.

3. Residentswhoareabletotakemedicationsbymouthwillbeencouragedtodoso.

4. Forthoseresidentswhoaretoreceive“NothingbyMouth”(NPO)allapplicablemedicationwillbeadministeredviatheenteralfeedingtube.

5. TheadmittingnursewillnotifythepharmacythattheresidentisNPOandallmedicationsaretobeadministeredviatheenteralfeedingtubeandrequestaPharmacistreviewofmedicationsforcompatibility.

6. Priortotheflushingofafeedingtube,theadministrationofmedicationviaafeedingtube,ortheprovidingoftubefeedings,thenurseperformingtheprocedureensurestheproperplacementofthefeedingtube.

7. Priortomedicationadministrationflushthetubewith30mlofwater,mixeachcrushedmedicationwith5-10mlofwaterandflushwith10mlofwaterbetweeneachmedicationandflushwith30mlofwaterafterlastmedication.

8. Universalprecautionsandcleantechniquewillbeutilizedwhenstopping,starting,flushing,andgivingmedicationsthroughthefeedingtube.

9. Theplanofcarewilladdresstube-feedinguse,strategiestopreventcomplicationsincluding,butnotlimitedto:aspirationpneumonia,diarrhea,vomiting,dehydration,metabolicabnormalitiesandtorestore,ifpossible,normaleatingskills.

PROCEDURE

SUBJECT:PlacementandResidualVolumeCheckforEnteralFeedingTubes

DATE:

INTENT:

Itisthepolicyofthefacilitytoverifyplacementofthefeedingtubeandappropriatelevelsofgastricresidualtodecreasetheriskofaspiration,nauseaandorvomitingduringfeedingadministration.

PROCEDURE:

1. Obtainaphysicianordertoincludethefollowing:a. Frequencytocheckplacementandresidual(recommendationsfornew

Gastrostomytuberesidualcheckisevery2-4hrs.untilresidentdemonstratetheabilitytoemptystomach).

b. Parameterforgastricresidualvolumebeforefeedingandormedicationsareheld.



4. Washhandsanddrythoroughly

5. Putongloves

6. Usingtheauscultorymethod(forgastrostomytube)a. Protecttheresident’sclothingb. Attachalargetip60ccsyringewithapproximately10ccofairtothefeeding

tube.c. Auscultatetheabdomen(approximately3inchesbelowthesternum)while

injectingtheairfromthesyringeintothetubing.d. Listenforthe“whooshing”soundtocheckplacementofthetubeinthe

stomach

7. Aspiratethestomachcontent:a. Ifthereis100ccormoreofgastricresidualvolume,holdthefeedingand

recheckinone(1)hour.Ifstill100ccormorenotifythephysician.b. Replaceaspiratedstomachcontents.

8. IfacceptableplacementandGastricResidualVolumeverified,flushfeedingtube

with30ccofwaterorasorderedbythephysician.

9. Administeredfeedingandormedicationsasordered.




13. Maketheresidentcomfortable

14. Placecalllightineasyreachforresident

15. Removeglovesandwashhands


POLICY/PROCEDURE

SUBJECT:Parenteral/IVFluids

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideParenteral/IVFluidsServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

Parenteralfluidsmustbeadministeredconsistentwithprofessionalstandardsofpracticeandinaccordancewithphysicianorders,thecomprehensiveperson-centeredcareplan,andtheresident’sgoalsandpreferences.

PROCEDURESUBJECT:PICCLineRemovalProcedure

DATE:

PURPOSE:

Thepurposeofthisprocedureistoassistthefacilityinthecare,servicesanddocumentationrelatedtotheremovalofPeripherallyInsertedCentralCatheter.

PROCEDURE:

1. Verifydoctor'sorderstoremovePICCline.

2. Gathersuppliesneeded:a. 1pair-non-sterileglovesb. 2Moisture-proofdrapesc. Alcoholpadorswabd. Sutureremovalkit(scissors,forceps),iflineissuturedine. PPE's-mask,glovesf. 1pair-sterileglovesg. Chlorhexidineskinpreph. Sterile4x4gauzei. Occlusivedressingj. Tapemeasurek. Hemostat

3. Introduceselftoresidentandprovideprivacy.

4. Explaindoctor'sordersandthePICClineremovalprocess;answeranyquestionstheresidentmayhaveabouttheprocedure.

5. Performhandhygieneanddonnon-sterilegloves.

6. Turnoffinfusionpump,disconnectandclamplumens,ifpresent.

7. Positiontheresidentinasupinepositionwiththeinsertionarmextended.

8. Placemoisture-proofdrapeunderresident'sarm.

9. Instructresidenttoturnheadaway(oppositedirection)fromPICClinesiteandavoidmovingarm.

10. CleanseoldPICClinedressingwithalcoholswabtoreleasetransparentdressing.

11. Removetheolddressingbycarefullyliftingthedistaledgeofthedressingtowardtheproximaledge.

12. Removeallcathetersecuringdevice{s,)ifpresent:a. IfsuturesaresecuringthePICClineinplace,carefullyusethesterilescissorto

cut,thenusethesterileforcepstoremovetheloosenedsutureandpullthethreadfromtheskin

13. Removeanddisposeofglovesandolddressing.

14. Donstandardprecautionspersonalprotectiveequipment(PPE):a. Maskb. Gown,asindicatedc. Protectiveeyewear

15. Placemoisture-proofdrapeontocleanworksurfaceandopensterilesuppliesontodrape.

16. Donsterilegloves.

17. AssessPICClineinsertionsite.

18. Applychlorhexidineskinpreptoinsertionsiteandatleastthree(3)inchesaround.

19. Usetwo(2)fingersofthenon-dominanthandtoholdthesterile4x4gauzejustaboveinsertionsite.

20. Instructresidenttotakeadeepbreathandhold.

21. Graspthecatheterneartheinsertionsiteusingdominanthandandwhilekeepingthecatheterparalleltothearm,slowlywithdrawaboutone(1)inch(2.5cm)atatime;continuetheprocedureuntilthecatheteriscompletelyremoved.a. Ifthereisresistancewhenwithdrawing,STOP!DonotremovePICClineusing

forceorpullingagainstresistance.b. Ifresistanceoccurs,takingthefollowingmeasuresthatmayresolveissue:

i. Releaseanypressurealongcatheterpathii. Waitafewminutestoallowveintorelax;venousspasmcancause

resistanceiii. Applywarmpacksproximaltotheinsertionsite;warmthmayhelpto

relaxtheveinwallsiv. Repositionthearmandtryagain

c. Ifresistancecontinues-STOP!i. Cleansite,re-prep,securethecatheter,re-dressthesiteandnotifythe

physicianimmediatelyd. Ifthecatheterbreakswhilewithdrawing:

i. Clampcatheterusingasterilehemostat,ifenoughprojectsfromtheinsertionsite

ii. Carefullyconsidertheoptiontocontinuewithdrawal22. Usesterile4x4gauzetoapplypressureforafewminutestositeaftercatheter

removal.

23. Instructresidenttoexhaleandbreathenormally.

24. Assesssite,ifnobleedingispresent,leavethesterile4x4gauzeinplaceandcoverwithanocclusivedressing.a. Ifbleedingcontinues,continuetoholdforafewmoreminutes.

25. Evaluateconditionofcatheter-measurewithapapertapemeasureandconfirmthatitisfullyintact.a. Anon-intactcatheterisanemergentsituation!b. Breakageandretainedfragmentsofthecathetercanbecomedislodgedand

causeanembolismi. Immobilizethelimbandinstructtheresidenttoavoidmovingthearmii. Carefullyapplydressing,avoiddislodgingfragmentsiii. Measureremovedcathetertodeterminehowmuchisretainediv. Saveallcatheterpiecesforsubsequentreportofmedicaldevicefailurev. Notifyphysicianofpotentialembolusvi. Preparepatientforpossibletransport

26. Repositionresidentinacomfortableposition.

27. Documentthefollowing:a. Initialresidentassessmentb. Descriptionoftheprocedure:resident'sposition,insertionsite,aseptic

technique,standardprecautions,draping,safetymeasures,hemostasis,dressing

c. Resident'stoleranceoftheprocedured. Conditionanddispositionoftheremovedcatheter

POLICY/PROCEDURE

SUBJECT:Respiratory/TracheostomyCareandSuctioning

DATE:

INTENT:

Theintentofthispolicyisthateachresidentreceivesnecessaryrespiratorycareandservicesthatisinaccordancewithprofessionalstandardsofpractice,theresident’scareplan,andtheresident’schoice.

PROCEDURE:

Thefacilitywillensurethataresident,whoneedsrespiratorycare,includingtracheostomycareandtrachealsuctioning,isprovidedsuchcare,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,theresidents’goalsandpreferences.

POLICY/PROCEDURE

SUBJECT:Prostheses

DATE:

INTENT:

Theintentofthispolicyisthateachresidentreceivesnecessarycareandservicesthatisinaccordancewithprofessionalstandardsofpractice,theresident’scareplan,andtheresident’schoice.

PROCEDURE:

Thefacilitymustensurethataresidentwhohasaprosthesisisprovidedcareandassistance,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,theresidents’goalsandpreferences,towearandbeabletousetheprostheticdevice.

POLICY/PROCEDURE

SUBJECT:PainManagement

DATE:

INTENT:

Theintentofthispolicyisthateachresidentreceivesnecessarycareandservicesthatisinaccordancewithprofessionalstandardsofpractice,theresident’scareplan,andtheresident’schoice.

PROCEDURE:

Thefacilitymustensurethatpainmanagementisprovidedtoresidentswhorequiresuchservices,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.

PROCEDURE

SUBJECT:PainManagementProgram

DATE:

POLICY:

Thefacilityshallprovideadequatemanagementofpaintoensurethatresidentsattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being.

PROCEDURE:

1. Evaluatetheresidentforpainuponadmission,duringperiodicscheduledassessments,andwithchangeinconditionorstatus(e.g.,afterafall,withchangeinbehaviorormentalstatus).

2. Behavioralsignsandsymptomsthatmaysuggestthepresenceofpainincludebutarenotlimitedto:

a. Changeingaitb. Lossoffunctionc. Declineinactivityleveld. Resistingcare,strikingoute. Bracing,guardingorrubbingf. Fidgeting,increasedorrecurringrestlessnessg. Facialexpressions:grimacing,frowning,fear,grindingofteethh. Changeinbehavior:depressedmood,decreasedparticipationinusual

activitiesofdailylivingi. Lossofappetitej. Sleepingpoorlyk. Sighing,groaning,crying,breathingheavily

3. Assessmentandevaluationbytheappropriatemembersoftheinterdisciplinaryteammayinclude:

a. Askingthepatienttoratetheintensityofhis/herpainusinganumericalscaleoraverbalorvisualdescriptorthatisappropriateandpreferredbytheresident.

b. Reviewoftheresident’sdiagnosesorconditionsandanyadditionalfactorsthatmaybecausingorcontributingtopain.

c. Identifyingkeycharacteristicsofthepain(Examples:Duration,Frequency,Location,Onset,PatternandRadiation)

d. Obtainingdescriptorsofthepain(Examples:Aching,Burning,Throbbing,Tingling,Stabbing)

e. Determiningfactorsthatmakethepainbetterorworsef. Identifyingrecentexacerbationsofchronicpaing. Impactofpainonqualityoflifeh. Currentprescribedpainmedications,dosageandfrequency

i. Notealltreatmentsthepatientisreceivingforpainincludingnon-pharmacologictherapies.

j. Theresident’sgoalsforpainmanagementandhis/hersatisfactionwiththecurrentlevelofpaincontrol

k. Theeffectivenessofspecificdrugsandothertreatmentsusedinthepasttotreatpain.

4. Iftheresident’spainisnotcontrolledbythecurrenttreatmentregimen,thepractitionershouldbenotified.

5. Theinterdisciplinaryteamandtheresidentcollaboratetoarriveatpertinent,realisticandmeasurablegoalsfortreatment.

6. Factorsinfluencingthechoiceoftreatmentsinclude:a. Thepatient’sunderlyingdiagnosesorconditionsthatarecausingor

contributingtopainb. Thecauses,location,natureandseverityofpainc. Thepatient’spreferencesexpressedeitherdirectlyorinanadvance

directived. Possibleadversemedicationeffects

7. Non-pharmacologicalpainmanagementinterventionsincludebutarenotlimitedto:

a. Adjustingroomtemperatureb. Smoothinglinensc. Turningandrepositioningtoacomfortablepositiond. Loosenanyconstrictivebandageordevicee. Applysplinting(e.g.,pilloworfoldedblanket)f. Physicalmodalities(e.g.,coldcompress,warmshowerorbath)g. Exercisestoaddressstiffnessh. Cognitive/behavioralinterventions(e.g.,music,diversions,paineducation)

8. Pharmacologicalinterventionsshouldfollowasystematicapproach.

9. Theinterdisciplinaryteamisresponsiblefordevelopingapainmanagementregimen.

10. Thefollowingaregeneralprinciplesforprescribinganalgesicsinthelong-termcaresetting:

a. Evaluatethepatient’smedicalconditionandcurrentmedicationregimentodeterminethemostappropriatetherapyforpain

b. Considerwhetherthemedicalliteraturecontainsevidence-basedrecommendationsforspecificregimentstotreatidentifiedcausesofpain

c. Usetheleastinvasiverouteofadministrationpossibled. Forchronicpain,beginwithalowdoseandtitratecarefullyuntilcomfortis

achievede. Foracutepain,beginwithalowormoderatedoseasneededandtitrate

morerapidlythanforchronicpain

f. Reassessandadjustthedosetooptimizepainreliefwhilemonitoringandtryingtominimizeormanagesideeffects

g. Someclinicalconditionsmayrequireseveralanalgesicsoradjuvantmedications,documentationshouldhelpclarifytherationaleforatreatmentregimenandtoacknowledgeassociatedrisks

11. Reassesspatientswithpainregularlybasedonthefacility’sestablishedintervals.

12. Ifwhenre-evaluated,findingsindicatepainisnotadequatelycontrolled,revisethepainmanagementregimenandplanofcareasindicated.

13. Ifpainhasresolvedorthereisnolongeranindicationforpainmedication,theinterdisciplinaryteamshouldworktodiscontinueortaper(asneededtopreventwithdrawalsymptoms)analgesics.

PROCEDURE

SUBJECT:Dialysis

DATE:

POLICY:

ThefacilityshallprovideadequatemanagementofDialysisServicestoensurethatresidentsattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being.

PROCEDURE:

Thefacilitymustensurethatresidentswhorequiredialysisreceivesuchservices,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.

PROCEDURE

SUBJECT:Bedrails

DATE:

POLICY:

ThefacilityshallprovideadequatemanagementofBedrailstoensurethatresidentsattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being.

PROCEDURE:

1. Thefacilitywillattempttouseappropriatealternativespriortoinstallingasideorbedrail.

2. Ifabedorsiderailisused,thefacilitywillensurecorrectinstallation,use,andmaintenanceofbedrails,includingbutnotlimitedtothefollowingelements.a. Assesstheresidentforriskofentrapmentfrombedrailspriortoinstallation.b. Reviewtherisksandbenefitsofbedrailswiththeresidentorresident

representativeandobtaininformedconsentpriortoinstallation.c. Ensurethatthebed’sdimensionsareappropriatefortheresident’ssizeand

weight.d. Followthemanufacturers’recommendationsandspecificationsforinstalling

andmaintainingbedrails.

3. Theadmittingnursewillevaluatetheresidentfortheuseofbed/siderails.

4. Whenbed/siderailsarerequestedbytheresident/residentrepresentative,theadmittingnursewillcompletetheSideRailEvaluation.

5. Whenbed/siderailsaredeemedtobeappropriatefortheresident,uponcompletionoftheSideRailEvaluation,theadmittingnursewillreviewrisksandbenefitsandobtaininformedconsent.

PLACEPHYSICIANSERVICESTABHERE

POLICY/PROCEDURE

SUBJECT:PhysicianServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoPhysicianServicesinaccordancetoStateandFederalregulation.

PROCEDURE:


1. Residents’CareSupervisedbyaPhysician

2. PhysicianVisits–ReviewCare/Notes/Orders

3. PhysicianVisits–Frequency/Timeless/AlternateNPPs

4. PhysicianforEmergencyCare,Available24Hours

5. PhysicianDelegationofTaskstoNPP

6. PhysicianDelegationtoDietitian/Therapist

POLICY/PROCEDURE

SUBJECT:PhysicianServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidePhysicianServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Eachresidentorresidentrepresentativewillbeallowedtoselecthisorherownprivatephysician.

2. Aphysicianwillapproveinwritingarecommendationthatanindividualbeadmittedtothefacility.

3. Aphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistmustprovideordersfortheresident’simmediatecareandneeds.

4. Eachresidentwillremainunderthecareofaphysician.

5. Allphysicianorotherhealthcareprofessionalverbalorders,includingtelephoneorders,willbeimmediatelyrecorded,dated,andsignedbythepersonreceivingtheorder.

6. Allverbaltreatmentorderswillbecountersignedbythephysicianorotherhealthcareprofessionalonthenextvisittothefacility.

7. Physicianordersmaybetransmittedbyfacsimilemachine.Itisnotnecessaryforaphysiciantore-signafacsimileorderwhenhevisitsafacility.

8. Allphysicianorderswillbefollowedasprescribedandifnotfollowed,thereasonshallberecordedontheresident'smedicalrecordduringthatshift.

9. Thefacilitywillensurethatanotherphysiciansupervisesthemedicalcareofresidentswhentheirattendingphysicianisunavailable.

10. Thefacilitymustprovideorarrangefortheprovisionofphysicianservices24hoursaday,incaseofemergency.

11. Thephysicianwill:

a. Reviewtheresident’stotalprogramofcare,includingmedicationsandtreatments,ateachvisit;

b. Write,sign,anddateprogressnotesateachvisit;and

c. Signanddateallorderswiththeexceptionofinfluenzaandpneumococcalpolysaccharidevaccines,whichmaybeadministeredperphysician-approvedfacilitypolicyafteranassessmentforcontraindications.

12. Theresidentsmustbeseenbyaphysicianatleastonceevery30daysforthefirst90daysafteradmission,andatleastonceevery60thereafter.

13. Aphysicianvisitisconsideredtimelyifitoccursnotlaterthan10daysafterthedatethevisitwasrequired.

14. Allrequiredphysicianvisitswillbemadebythephysicianpersonally.

15. Attheoptionofthephysician,requiredvisitsinSNFs,aftertheinitialvisit,mayalternatebetweenpersonalvisitsbythephysicianandvisitsbyaphysicianassistant,nursepractitionerorclinicalnursespecialistinaccordancetofederalandstatelaws.

16. Aphysicianmaydelegatetaskstoaphysicianassistant,nursepractitioner,orclinicalnursespecialistwho:

a. Meetstheapplicabledefinitionin§491.2ofthischapteror,inthecaseofaclinicalnursespecialist,islicensedassuchbytheState;

b. IsactingwithinthescopeofpracticeasdefinedbyStatelaw;andc. Isunderthesupervisionofthephysician.

17. Aresident’sattendingphysicianmaydelegatethetaskofwritingdietaryorders,consistentwith§483.60,toaqualifieddietitianorotherclinicallyqualifiednutritionprofessionalwho:

a. IsactingwithinthescopeofpracticeasdefinedbyStatelaw;andb. Isunderthesupervisionofthephysician.

18. Aresident’sattendingphysicianmaydelegatethetaskofwritingtherapyorders,consistentwith§483.65,toaqualifiedtherapistwho:

a. IsactingwithinthescopeofpracticeasdefinedbyStatelaw;andb. Isunderthesupervisionofthephysician.

19. Aphysicianmaynotdelegateataskwhentheregulationsspecifythatthephysicianmustperformitpersonally,orwhenthedelegationisprohibitedunderStatelaworbythefacility’sownpolicies.

20. AttheoptionofState,anyrequiredphysiciantaskinaNF(includingtaskswhichtheregulationsspecifymustbeperformedpersonallybythephysician)mayalsobesatisfiedwhenperformedbyanursepractitioner,clinicalnursespecialist,orphysicianassistantwhoisnotanemployeeofthefacilitybutwhoisworkingincollaborationwithaphysician.

INSERTNURSINGSERVICESTABHERE

POLICY/PROCEDURE

SUBJECT:NursingServices,General

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoNursingServicesinaccordancetoStateandFederalregulation.

PROCEDURE:


1. SufficientNurseStaff

2. CompetentNursingStaff

3. RN8Hours/7Days/WeekFullTimeDON

4. FacilityHiringandUseofNurse

5. NurseAideRegistryVerification,Retraining

6. NurseAidePerformReview–12Hour/YearIn-service

7. Waiver-LicensedNurses24Hour/DayandRNCoverage

8. PostedNurseStaffingInformation

POLICY/PROCEDURE

SUBJECT:NursingServices

DATE:

INTENT:

Itisthepolicyofthefacilitytoassurethatthereissufficientqualifiednursingstaffavailableatalltimestoprovidenursingandrelatedservicestomeettheresidents’needssafelyandinamannerthatpromoteseachresident’srights,physical,mentalandpsychosocialwell-being.

POLICY:

1. Thefacilitywillhavesufficientnursingstaffwiththeappropriatecompetenciesandskillssetstoprovidenursingandrelatedservicestoassureresidentsafetyandattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beingofeachresident,asdeterminedbyresidentassessmentsandindividualplansofcare.

2. Thefacilitywillprovideservicesbysufficientnumbersofeachofthefollowingtypesofpersonnelona24-hourbasistoprovidenursingcaretoallresidentsinaccordancewithresidentcareplans:

a. Exceptwhenwaivedunderparagraph(e)ofthissection,licensednurses;and

b. Othernursingpersonnel,includingbutnotlimitedtonurseaides.

3. Exceptwhenwaivedunderparagraph(e)ofthissection,thefacilitymustdesignatealicensednursetoserveasachargenurseoneachtourofduty.

4. Thefacilitywillhavesufficientnursingstaffwiththeappropriatecompetenciesandskillssetstoprovidenursingandrelatedservicestoassureresidentsafetyandattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beingofeachresident,asdeterminedbyresidentassessmentsandindividualplansofcareandconsideringthenumber,acuityanddiagnosesofthefacility’sresidentpopulationinaccordancewiththefacilityassessment.

5. Thefacilitywillensurethatlicensednurseshavethespecificcompetenciesandskillsetsnecessarytocareforresidents’needs,asidentifiedthroughresidentassessments,anddescribedintheplanofcare.

6. Providingcareincludesbutisnotlimitedtoassessing,evaluating,planningandimplementingresidentcareplansandrespondingtoresident’sneeds.

7. Thefacilitywillensurethatnurseaidesareabletodemonstratecompetencyin

skillsandtechniquesnecessarytocareforresidents’needs,asidentifiedthroughresidentassessments,anddescribedintheplanofcare.

8. Exceptwhenwaived,thefacilitymustusetheservicesofaregisterednurseforatleast8consecutivehoursaday,7daysaweek.

9. Exceptwhenwaived,thefacilitymustdesignatearegisterednursetoserveasthedirectorofnursingonafulltimebasis.

10. Thedirectorofnursingmayserveasachargenurseonlywhenthefacilityhasanaveragedailyoccupancyof60orfewerresidents.

POLICY/PROCEDURE

SUBJECT:NursingServices-RequirementforFacilityHiringandUseofNurseAides

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoNursingServicesinaccordancetoStateandFederalregulation.

POLICY:

1. Thefacilitywillnotuseanyindividualworkinginthefacilityasanurseaideformorethan4months,onafull-timebasis,unless:a. Thatindividualiscompetenttoprovidenursingandnursingrelatedservices;

i. Thatindividualhascompletedatrainingandcompetencyevaluationprogram,oracompetencyevaluationprogramapprovedbytheState;or

ii. Thatindividualhasbeendeemedordeterminedcompetentasprovidedin§483.150(a)and(b).

2. Thefacilitywillnotuseonatemporary,perdiem,leasedoranybasisotherthanapermanentemployeeanyindividualwhodoesnotmeettherequirementsofacertifiednursingassistant.

3. Afacilitymustnotuseanyindividualwhohasworkedlessthan4monthsasanurseaideinthatfacilityunlesstheindividual:a. Isafull-timeemployeeinaState-approvedtrainingandcompetencyevaluation

program;b. HasdemonstratedcompetencethroughsatisfactoryparticipationinaState-

approvednurseaidetrainingandcompetencyevaluationprogramorcompetencyevaluationprogram;or

c. Hasbeendeemedordeterminedcompetentasprovidedin§483.150(a)and(b).

POLICY/PROCEDURE

SUBJECT:NursingServices-RegistryVerificationandRetraining

DATE:

INTENT:

Itisthepolicyofthefacilitytoverifynursingregistryandprovidein-servicetraininginaccordancetoStateandFederalregulation.

POLICY:

1. Beforeallowinganindividualtoserveasanurseaide,thefacilitywillreceiveregistryverificationthattheindividualhasmetcompetencyevaluationrequirementsunless:a. Theindividualisafull-timeemployeeinatrainingandcompetencyevaluation

programapprovedbytheState;orb. Theindividualcanprovethatheorshehasrecentlysuccessfullycompleteda

trainingandcompetencyevaluationprogramorcompetencyevaluationprogramapprovedbytheStateandhasnotyetbeenincludedintheregistry.Facilitiesmustfollowuptoensurethatsuchanindividualactuallybecomesregistered.

2. Beforeallowinganindividualtoserveasanurseaide,thefacilitywillseekinformationfromeveryStateregistryestablishedundersections1819(e)(2)(A)or1919(e)(2)(A)oftheActthatthefacilitybelieveswillincludeinformationontheindividual.

3. If,sinceanindividual’smostrecentcompletionofatrainingandcompetencyevaluationprogram,therehasbeenacontinuousperiodof24consecutivemonthsduringnoneofwhichtheindividualprovidednursingornursing-relatedservicesformonetarycompensation,theindividualmustcompleteanewtrainingandcompetencyevaluationprogramoranewcompetencyevaluationprogram.

4. Thefacilitywillcompleteaperformancereviewofeverynurseaideatleastonceevery12months,andmustprovideregularin-serviceeducationbasedontheoutcomeofthesereviews.Thein-servicetrainingwillcomplywiththerequirementsof§483.95(g).

POLICY/PROCEDURE

SUBJECT:NursingServices-NurseStaffingInformation

DATE:

INTENT:

Itisthepolicyofthefacilitytomakestaffinginformationreadilyavailableinareadableformattoresidentsandvisitorsatanygiventime..

POLICY:

1. Thefacilitywillpostthefollowinginformationonadailybasis:a. Facilityname.b. Thecurrentdate.c. Thetotalnumberandtheactualhoursworkedbythefollowingcategories

oflicensedandunlicensednursingstaffdirectlyresponsibleforresidentcarepershift:

i. Registerednurses.ii. Licensedpracticalnursesorlicensedvocationalnurses(asdefined

underStatelaw).iii. Certifiednurseaides.

d. Residentcensus.

2. Thefacilitywillpostthenursestaffingdataonadailybasisatthebeginningofeachshift.

3. Datamustbepostedasfollows:a. Clearandreadableformat.b. Inaprominentplacereadilyaccessibletoresidentsandvisitors.

4. Thefacilitywill,uponoralorwrittenrequest,makenursestaffingdataavailabletothepublicforreviewatacostnottoexceedthecommunitystandard.

5. Thefacilitywillmaintaintheposteddailynursestaffingdataforaminimumof18months,orasrequiredbyStatelaw,whicheverisgreater.

PLACETABFORBEHAVIORALHEALTHSERVICESHERE

POLICY/PROCEDURE

SUBJECT:BehavioralHealthServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideMentalHealthServicesinaccordancetoStateandFederalregulations.

PROCEDURE:


1. BehavioralHealthServices

2. Sufficient/CompetentStaff-BehavioralHealthNeeds

3. Treatment/ServicesforMental/PsychosocialConcerns

4. NoPatternofBehavioralDifficultiesUnlessUnavoidable

5. Treatment/ServiceforDementia

6. ProvisionofMedicallyRelatedSocialServices

POLICY/PROCEDURE

SUBJECT:BehavioralHealthServices

DATE:

INTENT:

Theintentofthispolicyistoensurethatthefacilityhassufficientstaffmemberswhopossessthebasiccompetenciesandskillssetstomeetthebehavioralhealthneedsofresidentsforwhomthefacilityhasassessedanddevelopedcareplans.

PROCEDURE:

1. Eachresidentwillreceiveandthefacilitywillprovidethenecessarybehavioralhealthcareandservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being,inaccordancewiththecomprehensiveassessmentandplanofcare.

2. Behavioralhealthencompassesaresident’swholeemotionalandmentalwell-being,whichincludes,butisnotlimitedto,thepreventionandtreatmentofmentalandsubstanceusedisorders.

3. Thefacilitywillhavesufficientstaffwhoprovidedirectservicestoresidentswiththeappropriatecompetenciesandskillssetstoprovidenursingandrelatedservicestoassureresidentsafetyandattainormaintainthehighestpracticablephysical,mentalandpsychosocialwell-beingofeachresident,asdeterminedbyresidentassessmentsandindividualplansofcareandconsideringthenumber,acuityanddiagnosesofthefacility’sresidentpopulation.

4. Thesecompetenciesandskillssetsinclude,butarenotlimitedto,knowledgeofandappropriatetrainingandsupervisionfor:a. Caringforresidentswithmentalandpsychosocialdisorders,aswellas

residentswithahistoryoftraumaand/orpost-traumaticstressdisorder,thathavebeenidentifiedinthefacilityassessment,and

b. Implementingnon-pharmacologicalinterventions.

POLICY/PROCEDURE

SUBJECT:Treatment/ServicesforMental/PsychosocialConcerns

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideBehavioralHealthServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Thefacilitywillensurethat,aresidentwhodisplaysorisdiagnosedwithmentaldisorderorpsychosocialadjustmentdifficulty,orwhohasahistoryoftraumaand/orpost-traumaticstressdisorder,receivesappropriatetreatmentandservicestocorrecttheassessedproblemortoattainthehighestpracticablementalandpsychosocialwell-being;and

2. Thefacilitywillensurethat,aresidentwhoseassessmentdidnotrevealorwhodoesnothaveadiagnosisofamentalorpsychosocialadjustmentdifficultyoradocumentedhistoryoftraumaand/orpost-traumaticstressdisorderdoesnotdisplayapatternofdecreasedsocialinteractionand/orincreasedwithdrawn,angry,ordepressivebehaviors,unlesstheresident'sclinicalconditiondemonstratesthatdevelopmentofsuchapatternwasunavoidable.

3. Aresident,whodisplaysorisdiagnosedwithdementia,receivestheappropriatetreatmentandservicestoattainormaintainhisorherhighestpracticablephysical,mental,andpsychosocialwell-being.

4. Ifrehabilitativeservicessuchasbutnotlimitedtophysicaltherapy,speech-languagepathology,occupationaltherapy,andrehabilitativeservicesformentaldisordersandintellectualdisability,arerequiredintheresident'scomprehensiveplanofcare,thefacilitywill:a. Providetherequiredservices,includingspecializedrehabilitationservices;orb. ObtaintherequiredservicesfromanoutsideresourceorfromaMedicare

and/orMedicaidproviderofspecializedrehabilitativeservices.

5. ThefacilitywillnotadmitanynewresidentswithmentalillnessunlesstheStatementalhealthauthorityhasdetermined,basedonanindependentphysicalandmentalevaluationperformedbyapersonorentityotherthantheStatementalhealthauthority,priortoadmissionthat:a. becauseofthephysicalandmentalconditionoftheindividual,theindividual

requiresthelevelofservicesprovidedbyanursingfacility;andb. Iftheindividualrequiressuchlevelofservices,whethertheindividualrequires

specializedservicesformentalretardation.

6. Thefacilitywillprovidemedically-relatedsocialservicestoattainormaintainthehighestpracticablephysical,mentalandpsychosocialwell-beingofeachresident.

PROCEDURE

SUBJECT:BehaviorandPsychoactiveManagementProgram

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovidecareandservicestopromoteourresident’squalityoflife.Itisthephilosophyofthefacilitythatallresidentbehaviorhasmeaning.Ourfacilitywillworkdiligentlytominimizetheuseofpsychoactivemedicationsinitsresidentpopulation.

PROCEDURE:

Philosophy:TheFacilitybelievesthatallresidentbehaviorhasmeaning.ItisthepledgeofourFacilitytoworktoidentifythecauseandmeaningofbehaviorsthataredistressingandaffectnegativelyontheresident’squalityoflife.OurFacilitywillworkdiligentlytominimizeuseofpsychoactivemedicationsinitsresidentpopulation.

Facility’sBehaviorManagementProgramwillconsistof:

1. AneffectiveInterdisciplinaryBehaviorManagementCommittee.2. Ensuringathoroughandcomprehensiveassessmentoftheresident’sneeds,

behaviors,andpriormedicationandmedicalhistory.3. Monitoringtheresident’sbehavior(s)toestablishpatterns,determineintensity

andbehaviorfrequency,andidentifyingthespecific(“targeted”)behavior(s)thataredistressingtotheresidentwhicharedecreasingtheresident’squalityoflife.

4. Thoroughlyassessingtheneedfortheinclusionofpsychoactivemedicationsintotheresident’smedicationregime.

5. Alongwiththeresidentandtheirrepresentative,weighingtherisksandbenefitsofaddingoreliminatingpsychoactivemedications.

6. Planningandimplementingappropriateinterventionsintotheresident’splanofcare.

7. EvaluatingtheeffectivenessofPharmacologicalandnon-pharmacologicalinterventions.

8. Monitoringforanyadversesideeffectsofmedications,whichincludescompletionofAbnormalInvoluntaryMovementScale(AIMS)asperrecognizedstandardsofpractice.

Purpose:

1. Toimplementthemostdesirableandeffectiveinterventionsthatmeetboththeknownandunknownneedsoftheresident,tochange,modify,decrease,oreliminatebehaviorsthataredistressingtotheresident,and/oraredecreasingorimpactingontheresidents’qualityoflife.

2. Toincreasedesiredbehaviors,promoteresidentsafetyandsecurity,andtoenhancetheresident’sabilitytointeractpositivelywithhis/herenvironment.

BehaviorManagementTeamCareProcess:

1. Medicationsareanintegralpartofresidentcare.TheBehaviorManagementTeamwilleffectivelymanagethepsychoactivemedicationprocessfortheresidentsby:

a. RecognizingandIdentifyingproblemswhichaffecttheresident’sbehavior,

b. Evaluatinganddefiningcausativefactorsoftheidentifiedbehaviorsandanyrelateddiagnosis,

c. Managing,treating,developing,andimplementingeffectiveapproaches,d. Monitoringonaregularbasis,andwithchangeintheapproaches

implementedforeffectiveness;ande. Re-evaluating,assessing,andmodifyingapproachesasneeded.

RoleoftheBehaviorManagementTeam:MedicationManagement

1. TheBehaviorManagementTeamwillmeetmonthlytoreviewthoseresidentsreceivingpsychoactivemedications.

2. TheBehaviorManagementTeamwillreviewResidentsreceivingpsychoactivemedicationsatleastquarterlyforneedtocontinueuse,whetherthedosecontinuestobeappropriate,andwhenthefollowingoccurs:

• Aclinicallysignificantchangeincondition/status*• Aneworrecurrentclinicallysignificantsymptom*• Aworseningofanexistingproblemorcondition*• Anunexplaineddeclineinfunctionorcondition*• Acuteonsetofpsychiatricdisordersordistressedbehavior*

*AlicensednurseandSocialServicerepresentativefamiliarwiththeresidentwillinitiallyevaluatetheresidentwhoisexperiencinganyoftheabovechanges,willdocumenttheevaluationintheresident’smedicalrecord.Thelicensednursewillinformtheresident’sphysicianandrepresentative,andwillcommunicatethisinformationtoamemberoftheBehaviorManagementCommittee.

3. TheBehaviorManagementCommitteewillreviewtheadmissionsand,readmissionsofresidentswhoareadmittedwithapsychoactivemedication.

4. TheBehaviorManagementCommitteewilleducatethemselvesandappropriateStafftounderstandtheindicationsandgoalsforusingthemedicationbyobtainingathoroughresidenthistoryrelatedtouseofpsychoactivemedication.

5. TheBehaviorManagementCommitteewillensurethatthefacilitystaffprovideEffectivemonitoringtoinclude:

a. Evaluatingresident’sprogresstowardsachievingtherapeuticgoalsb. Recognizingwhenadverseconsequencesmaybemaybeorhavealready

emerged

c. Evaluatingwhetherthemedicationmaybeimplicatedinanadverseconsequence,and

d. Modifyingthemedicationregimeifindicated

6. TheDirectorofNursingorDesigneewillmakearequesttodiscontinuemedicationsthathavea“blackbox”warning,ormedicationswhichhavethepotentialtocausesignificantadverseconsequenceswhenidentifiedonadmissionandrequestswillbemadeforalternatemedicationtherapy.

7. TheBehaviorManagementCommitteewillconsistofatleastthefollowing:a. DirectorofNursing/designeeb. SocialServicesc. ConsultingPharmacistd. NurseManager(s)e. ActivityDepartmentRepresentativef. DietaryRepresentative(AsdeterminedbyCommittee)

**ThecommitteechairwillbetheDirectorofSocialServices

8. TheBehaviorManagementCommitteewillensuretheprescriber’sorderfortheDoseofmedicationisbasedonthefollowing:

a. Resident’sdiagnosisb. Residentsignsandsymptomsc. Resident’scurrentcondition,age,labs,andotherrelatedtestsd. Co-existingmedicationregimee. Duplicatetherapydoesnotoccurunlesscurrentstandardsofclinical

practiceanddocumentedclinicalrationaleconfirmthebenefitTaperingandGradualDoseReduction(GDR)

Definition:GDRisdefinedas“thestepwisetaperingofadosetodetermineifsymptoms,conditions,orriskscanbemanagedbyalowerdoseorifthedoseormedicationcanbediscontinued.”

GoalsofGradualDoseReductionaretoachievethelowesteffectivedose;todiscontinuethemedicationsthatnolongerbenefittheresident;andtominimizeexposuretoincreasedriskofadverseconsequences.

GradualDoseReductionisindicatedwhentheresident’sclinicalconditionhasimprovedorstabilizedortheunderlyingcausesofsymptomshaveresolvedandthetypeofmedicationrequiresgradualreductionofthedosageinordertoavoidadverseconsequencesthatcouldoccurifthemedicationisstoppedabruptly.

Theresident’sresponsetomedicationsisnotonlyevaluatedbytheBehaviorManagementTeam.Evaluationandconsiderationoftheresident’smedicationtocontinue,reduceordiscontinuemustalsotakeplaceduring:

a. Monthlymedicationregimenreviewbytheconsultingpharmacistb. Reviewofcareplanandmonthlyrenewalofordersc. QuarterlyMDSreview

d. Dailybehaviormonitoringeveryshifte. Residentandfamilystaffingmeetings

GuidelinesforGradualDoseReduction:

1. Duringthefirstyearifreceivinganantipsychoticorotherpsychopharmacologicmedication,atleastoneattemptatGDRordosetapering.

2. Asecondattempt,inasubsequentquarterthesameyear(12monthperiod)unlessthefirstattemptdemonstratedthatGDRortaperingwasclinicallycontraindicated.Theattemptsshouldbeatleastamonthapart.

3. Afterthefirstyear,GDRortaperingshouldbeattemptedonceayear.

4. GDRortaperingmaybeconsideredclinicallycontraindicatediftheresident’stargetedsymptomsworsenedorreturnedduringthereduction.IfthisoccursthephysicianmustdocumenttheclinicalrationalewhyfurtherGDRattemptsshouldnotbedone(furtherattemptsmaycauseimpairmentofresidentfunction,increasedistressedbehavior(s),causepsychiatricinstabilitybyexacerbatinganunderlyingmedicalorpsychiatricdisorder.

5. Residentsreceivingsedative/hypnoticmedicationroutinelymusthaveattemptstotaperthemedicationduringeachquarter.Beforetaperingadoseofsedative/hypnoticisconsideredcontraindicatedfortheremainderofthatyear,taperingmusthavebeenattemptedduringtheprevious3quartersanddocumentedbythephysicianasunsuccessful.

RegulatoryLanguageofF-757(UnnecessaryMedications)

1. F-757CRF483.45(d)Eachresident’sdrugregimenmustbefreefromunnecessarydrugs.Anunnecessarydrugisanydrugwhenused:

a. Inexcessivedose(includingduplicatedrugtherapy);orb. Forexcessiveduration;orc. Withoutadequatemonitoring;ord. Withoutadequateindicationsforitsuse;ore. Inthepresenceofadverseconsequenceswhichindicatethedoseshould

bereducedordiscontinued;orf. Anycombinationsofthereasonsabove.

2. F-758CFR483.45(c)Apsychotropicdrugisanydrugthataffectsbrainactivitiesassociatedwithmentalprocessesandbehavior.Thesedrugsinclude,butarenotlimitedto,drugsinthefollowingcategories:

a. Anti-psychotic;b. Anti-depressant;c. Anti-anxiety;andd. Hypnotic

3. BasedontheregulatorymandatesofCMSrelatedtounnecessarydrugs;ananti-psychotic,antidepressant,antianxiety,andahypnoticmedicationwillnotbe

initiatedunlesstheBehaviorManagementCommitteehasdeterminedthemedicationisnecessarytotreataspecificcondition.Thetargetedbehaviorscausingtheresidentdistressmustbeclearlyidentified.

4. Non-pharmacologicalinterventionspreviouslyattemptedwithoutsuccessmustbedocumented.Theconditionmustbecomprehensivelyassessedandtherationaleclearlydocumentedintheresident’smedicalrecord.Acomprehensivecareplanmustbeinplacewiththeproblem/conditionidentified,measurablegoalsdetermined,andinterventionsinplacetomanage/decrease/eliminatethebehaviors.

GoalsforuseofPsychoactiveMedications:Tomaintainorimprovefunctionandwellbeing.

1. TheBehaviorManagementCommitteeandtheresident’sphysicianwillensurethatpsychoactivemedicationsareadministeredforthefollowingreasonsonly:

a. Topreventadiseaseorasymptomb. Diagnoseaconditionoradiseasec. Cureanillnessd. Sloworarrestadiseaseprocesse. Reduceoreliminatesymptomsf. Toachieveapositivephysical,mental,andpsychosocialoutcome.

2. TheBehaviorManagementCommitteewillensurethefollowinghasbeencompletedbeforeapsychoactivemedicationisadministered:

a. Anaccurateandcompleteassessmentoftheresident’sconditionandgoalsfortreatment.

b. Monitoringfortheanticipatedresponsetothemedication.c. Considerationofclinicalstandardsofpracticeandmanufacturer’s

guidelinesregardingdoseandduration,andconsiderationoftheresident’sageandpossiblesystemsfailurerelatedtoaging.

d. Considerationofthetypeorcharacteristicsofthemedication,inconjunctionwiththeresident’spresentmedicationregime.

e. Considerationofadministeringthelowestpossibledosefortheshortest,yeteffectiveduration.

f. Therootcauseoftheresident’scondition,symptom,ordiseasehasbeenassessedandconsidered/identifiedandtheresident’splanofcarereflectsthisassessment.

g. Contributingfactorsandtriggersforthesymptom/behaviorhavebeenassessed/identifiedandapproachesputinplacetoreduce/eliminatetheimpediments,triggers,andcauses.

h. Appropriatenon-pharmacologicalinterventionshavebeenidentifiedandimplementedbasedonanindividualresidentassessmentthatinclude:

i. Modificationoftheresident’senvironment;ii. Modification/eliminationofpsychologicalstressorstoaccommodate

theresident’spreviouslifelongactivities,habits,orroles;iii. Modificationofstaff/residentinteractions;and

iv. Behavioralinterventions.NOTE:ThisprogramisbasedonthefollowingrecognizedStandardsofClinicalPracticeandReferences:

1. CentersforMedicare&Medicaid(CMS)F-329;UnnecessaryMedicationsGuidanceTrainingInstructorsGuide42CFR483.45;

2. GuidelinesfortheEvaluationofDementiaandAge-RelatedCognitiveDecline.APAPresidentialTaskForceontheAssessmentofAge-ConsistentMemoryDeclineandDementia.

3. AmericanPsychologicalAssociation,February1998;4. ClinicalPracticeGuidelines-TheAmericanGeriatricsSociety2001;5. BehaviorAssociatedwithDementia,M.Smith,MS,ARNP,CSandK.Buckwalter,

PhD,RN,FAANAJN,AmericanJournalofNursing,July2005,Vol.107Number7;6. CDC-HealthInformationforOlderAdults-MentalHealth

http://www.cdc.gov/aging/info.htm;7. AppropriateUseofAntipsychoticsforResidentswithDementiaintheLong-Term

CareSettingL.J.CohenW.J.Burke1999

PLACETABFORPHARMACYSERVICESHERE

POLICY/PROCEDURE

SUBJECT:PharmacyServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoPharmacyServicesinaccordancetoStateandFederalregulation.

PROCEDURE:


1. PharmaceuticalServices–Procedures,RegisteredPharmacist(RPH),Records

2. DrugRegimenReview,ReportIrregular,Acton

3. DrugRegimenisFreeFromUnnecessaryDrugs

4. FreefromUnnecessaryPsychotropicMeds/PRNUse

5. FreeofMedicationErrorRatesof5%orMore

6. ResidentsAreFreeofSignificantMedErrors

7. Label/StoreDrugs&Biologicals

POLICY/PROCEDURE

SUBJECT:PharmacyServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidePharmacyServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Thefacilitywillemployorobtaintheservicesofalicensedpharmacistwho:a. Providesconsultationonallaspectsoftheprovisionofpharmacyservicesinthe

facility.b. Establishesasystemofrecordsofreceiptanddispositionofallcontrolleddrugs

insufficientdetailtoenableanaccuratereconciliation;andc. Determinesthatdrugrecordsareinorderandthatanaccountofallcontrolled

drugsismaintainedandperiodicallyreconciled.

2. Thefacilitywillhonortherighttofreedomofchoiceinselectingapharmacy;toobtainpharmaceuticalsuppliesandservices,attheresident'sownexpenseorthroughTitleXIXoftheSocialSecurityAct;andtoobtaininformationabout,andtoparticipatein,community-basedactivitiesprograms,unlessmedicallycontraindicatedasdocumentedbyaphysicianintheresident'smedicalrecord.

3. Whenaresidentchoosestouseacommunitypharmacyandthefacilityinwhichtheresidentresidesusesaunit-dosesystem,thepharmacyselectedbytheresidentshallbeonethatprovidesacompatibleunit-dosesystem,providesservicedelivery,andstocksthedrugsnormallyusedbylong-termcareresidents.

4. Thefacilitywillprovideroutineandemergencydrugsandbiologicaltoitsresidentsorobtainthemunderanagreement.

5. Thefacilitywillprovidepharmaceuticalservicesincludingproceduresthatassuretheaccurateacquiring,receiving,dispensing,andadministrationofalldrugsandbiologicalstomeettheneedsofeachresident.

6. Thefacilityutilizesonlypersonsauthorizedunderstaterequirementstoadministermedications.

7. Iforderedbytheresident'sphysician,theresidentmay,upondischarge,takeallcurrentprescriptiondrugswithhim.Aninventoryofthedrugsreleasedshallbecompleted,willbedatedandsignedbyboththepersonreleasingthedrugsandthepersonreceivingthedrugs,andwillbeplacedintheresident'srecord.

8. ThefacilitywillmaintainanEmergencyMedicationKit,thecontentsofwhichshallbedeterminedinconsultationwiththeMedicalDirector,DirectorofNursingandPharmacist,anditwillbeinaccordancewithfacilitypoliciesandprocedures.Thekitwillbereadilyavailableandwillbekeptsealed.Allitemsinthekitwillbeproperlylabeled.ThefacilitywillmaintainanaccuratelogreceiptanddispositionofeachitemintheEmergencyMedicationKit.AninventoryofthecontentsoftheEmergencyMedicationKitwillbeattachedtotheoutsideofthekit.Ifthesealisbroken,thekitwillberesealedthenextbusinessdayafteruse.

9. Thefacilitywillensurethatitisfreeofmedicationerrorratesof5percentorgreaterandthatresidentsarefreeofanysignificantmedicationerrors.

10. Drugsandbiologicalsusedinthefacilitywillbelabeledinaccordancewithcurrentlyacceptedprofessionalprinciples,andincludetheappropriateaccessoryandcautionaryinstructions,andtheexpirationdatewhenapplicable.

11. InaccordancewithStateandFederallaws,thefacilitywillstorealldrugsandbiologicalsinlockedcompartmentsunderpropertemperaturecontrolsandpermitonlyauthorizedpersonneltohaveaccesstothekeys.

12. Thefacilitywillprovideseparatelylocked,permanentlyaffixedcompartmentsforstorageofcontrolleddrugslistedinScheduleIIoftheComprehensiveDrugAbusePreventionandControlActof1976andotherdrugssubjecttoabuse,exceptwhenthefacilityusessingleunitpackagedrugdistributionsystemsinwhichthequantitystoredisminimalandamissingdosecanbereadilydetected.

POLICY/PROCEDURE

SUBJECT:PharmacyServices–DrugRegimenReview

DATE:

INTENT:

Theintentofthispolicyisthatthefacilitymaintainstheresident’shighestpracticablelevelofphysical,mentalandpsychosocialwell-beingandpreventsorminimizesadverseconsequencesrelatedtomedicationtherapytotheextentpossible,byprovidingoversightbyalicensedpharmacist,attendingphysician,medicaldirector,andthedirectorofnursing(DON).

PROCEDURE:

1. Thedrugregimenofeachresidentwillbereviewedatleastmonthlybyalicensedpharmacistandthepharmacistwillreportanyirregularitiestotheattendingphysician,thefacility’smedicaldirectorandthedirectorofnursingandthesereportswillbeactedupon.

2. Irregularitiesinclude,butarenotlimitedto,anydrugthatmeetsthefollowingcriteria:a. Excessivedose(includingduplicatedrugtherapy);orb. Excessiveduration;orc. Withoutadequatemonitoring;ord. Withoutadequateindicationsforitsuse;ore. Inthepresenceofadverseconsequenceswhichindicatethedoseshouldbe

reducedordiscontinued;orf. Anycombinationsofthereasonsabove.

3. Thisreviewwillincludeareviewoftheresident’smedicalchart.

4. Thepharmacistwillreportanyirregularitiestotheattendingphysicianandthefacility’smedicaldirectoranddirectorofnursing,andthesereportswillbeactedupon.

5. Anyirregularitiesnotedbythepharmacistduringthisreviewwillbedocumentedonaseparate,writtenreportthatissenttotheattendingphysicianandthefacility’smedicaldirectoranddirectorofnursingandlists,ataminimum,theresident’sname,therelevantdrug,andtheirregularitythepharmacistidentified.

6. Theattendingphysicianmustdocumentintheresident’smedicalrecordthattheidentifiedirregularityhasbeenreviewedandwhat,ifany,actionhasbeentakentoaddressit.Ifthereistobenochangeinthemedication,theattendingphysicianshoulddocumenthisorherrationaleintheresident’smedicalrecord.

7. Thefacilitywilldevelopandmaintainpoliciesandproceduresforthemonthlydrugregimenreviewthatinclude,butarenotlimitedto,timeframesforthedifferentstepsintheprocessandstepsthepharmacistmusttakewhenheorsheidentifiesanirregularitythatrequiresurgentactiontoprotecttheresident.

POLICY/PROCEDURE

SUBJECT:PharmacyServices–DrugRegimenFreeFromUnnecessaryDrugs

DATE:

INTENT:

Theintentofthispolicyiseachresident’sentiredrug/medicationregimenismanagedandmonitoredtopromoteormaintaintheresident’shighestpracticablemental,physical,andpsychosocialwellbeing;thefacilityimplementsgradualdosereductions(GDR)andnon-pharmacologicalinterventions,unlesscontraindicated,priortoinitiatingorinsteadofcontinuingpsychotropicmedication;andPRNordersforpsychotropicmedicationsareonlyusedwhenthemedicationisnecessaryandPRNuseislimited.

PROCEDURE:

1. Eachresident’sdrugregimenmustbefreefromunnecessarydrugs.Anunnecessarydrugisanydrugwhenused:a. Inexcessivedose(includingduplicatedrugtherapy);orb. Forexcessiveduration;orc. Withoutadequatemonitoring;ord. Withoutadequateindicationsforitsuse;ore. Inthepresenceofadverseconsequenceswhichindicatethedoseshouldbe

reducedordiscontinued;orf. Anycombinationsofthereasonsstated

2. Apsychotropicdrugisanydrugthataffectsbrainactivitiesassociatedwithmentalprocessesandbehavior.Thesedrugsinclude,butarenotlimitedto,drugsinthefollowingcategories:a. Anti-psychotic;b. Anti-depressant;c. Anti-anxiety;andd. Hypnotic

3. Basedonacomprehensiveassessmentofaresident,thefacilitywillensurethat:a. Residentswhohavenotusedpsychotropicdrugsarenotgiventhesedrugs

unlessthemedicationisnecessarytotreataspecificconditionasdiagnosedanddocumentedintheclinicalrecord;

b. Residentswhousepsychotropicdrugsreceivegradualdosereductions,andbehavioralinterventions,unlessclinicallycontraindicated,inanefforttodiscontinuethesedrugs;

c. ResidentsdonotreceivepsychotropicdrugspursuanttoaPRNorderunlessthatmedicationisnecessarytotreatadiagnosedspecificconditionthatisdocumentedintheclinicalrecord;and

d. PRNordersforpsychotropicdrugsarelimitedto14days.Except,iftheattendingphysicianorprescribingpractitionerbelievesthatitisappropriatefor

thePRNordertobeextendedbeyond14days,heorsheshoulddocumenttheirrationaleintheresident’smedicalrecordandindicatethedurationforthePRNorder.

e. PRNordersforanti-psychoticdrugsarelimitedto14daysandcannotberenewedunlesstheattendingphysicianorprescribingpractitionerevaluatestheresidentfortheappropriatenessofthatmedication.

PLACETABFORLABORATORY,RADIOLOGY,ANDOTHERDIAGNOSITCSERVICESHERE

POLICY/PROCEDURE

SUBJECT:Laboratory,Radiology,andOtherDiagnosticServices

DATE:

INTENT:

Itisthepolicyofthisfacilitytoensurethatlaboratory,radiology,andotherdiagnosticservicesmeettheneedsofresidents,thatresultsarereportedpromptlytotheorderingprovidertoaddresspotentialconcernsandfordiseaseprevention,provideforresidentassessment,diagnosis,andtreatment,andthatthefacilityhasestablishedpoliciesandprocedures,andisresponsibleforthequalityandtimelinessofserviceswhetherservicesareprovidedbythefacilityoranoutsideresource.

PROCEDURE:

Thispolicywillincludethefollowing:

1. LaboratoryServices

2. BloodBankandTransfusionServices

3. LabServicesNotProvidedOn-Site

4. LabServicesPhysicianOrder/NotifyofResults

5. AssistwithTransportArrangementstoLabServices

6. LabReportsinRecord-LabNameAddress

7. Radiology/OtherDiagnosticServices

8. Radiology/DiagnosticServicesOrdered/NotifyofResults

9. AssistwithTransportationArrangementstoRadiology

10. X-ray/DiagnosticReportInRecord–Sign/Dated

POLICY/PROCEDURE

SUBJECT:DiagnosticServices

DATE:

INTENT:

Itisthepolicyofthisfacilitytoensurethatlaboratory,radiology,andotherdiagnosticservicesmeettheneedsofresidents,thatresultsarereportedpromptlytotheorderingprovidertoaddresspotentialconcernsandfordiseaseprevention,provideforresidentassessment,diagnosis,andtreatment,andthatthefacilityhasestablishedpoliciesandprocedures,andisresponsibleforthequalityandtimelinessofserviceswhetherservicesareprovidedbythefacilityoranoutsideresource.

PROCEDURE:

1. Thefacilitywillprovideorobtainlaboratoryservicestomeettheneedsofitsresidentsandwillberesponsibleforthequalityandtimelinessoftheservices.

2. Thefacilitydoesnotprovidelaboratoryservicesonsite.Ithasanagreementtoobtaintheseservicesfromalaboratorythatmeetstheapplicablerequirementsofpart493oftheFederalRegulations.

3. Thefacilitywillprovideorobtainlaboratoryservicesonlywhenorderedbyaphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistinaccordancewithstatelaw,includingscopeofpracticelaws.

4. Thefacilitywillpromptlynotifytheorderingphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistoflaboratoryresultsthatfalloutsideofclinicalreferencerangesinaccordancewithfacilitypoliciesandproceduresfornotificationofapractitionerorpertheorderingphysician’sorders.

5. Thefacilitywillassisttheresidentinmakingtransportationarrangementstoandfromthesourceofservice,iftheresidentneedsassistance.

6. Thefacilitywillfileintheresident’sclinicalrecordlaboratoryreportsthataredatedandcontainthenameandaddressofthetestinglaboratory.

7. Thefacilitywillprovideorobtainradiologyandotherdiagnosticservicestomeettheneedsofitsresidents.

8. Thefacilitydoesnotprovideitsowndiagnosticservices.IthasanagreementtoobtaintheseservicesfromaproviderorsupplierthatisapprovedtoprovidetheseservicesunderMedicare.

9. Thefacilitywillprovideorobtainradiologyandotherdiagnosticservicesonlywhenorderedbyaphysician,physicianassistant;nursepractitionerorclinicalnursespecialistinaccordancewithStatelaw,includingscopeofpracticelaws.

10. Thefacilitywillpromptlynotifytheorderingphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistofresultsthatfalloutsideofclinicalreferencerangesinaccordancewithfacilitypoliciesandproceduresfornotificationofapractitionerorpertheorderingphysician’sorders.

11. Thefacilitywillfileintheresident’sclinicalrecordx-rayanddiagnosticreportsthataresignedanddated.

PLACETABFORDENTALSERVICESHERE

POLICY/PROCEDURE

SUBJECT:Dental

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoDentalServicesinaccordancetoStateandFederalregulation.

PROCEDURE:


1.Routine/emergencydentalservicesinSkilledNursingFacilitiesandNursingFacilities

POLICY/PROCEDURE

SUBJECT:DentalServices

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethatresidentsobtainneededdentalservices,includingroutinedentalservices;toensurethefacilityprovidestheassistanceneededorrequestedtoobtaintheseservices;toensuretheresidentisnotinappropriatelychargedfortheseservices;andifareferraldoesnotoccurwithinthreebusinessdays,documentationofthefacility’stoensuretheresidentcouldstilleatanddrinkadequatelywhileawaitingdentalservicesandtheextenuatingcircumstancesthatledtothedelay.

PROCEDURE:

1. Thefacilitywillprovidefromanoutsidesourceroutineand24-houremergencydentalservicestomeettheneedsofeachresident.

2. Thefacilitywill,ifnecessaryorifrequested,assisttheresident;:a. Makingappointments;andb. Arrangingfortransportationtoandfromthedentalserviceslocation;andc. Willpromptly,within3days,referresidentswithlostordamageddenturesfor

dentalservices.d. Ifareferraldoesnotoccurwithin3days,thefacilitywillprovidedocumentation

ofwhattheydidtoensuretheresidentcouldstilleatanddrinkadequatelywhileawaitingdentalservicesandtheextenuatingcircumstancesthatledtothedelay.

3. ThefacilitymaychargeaMedicareresidentanadditionalamountforroutineandemergencydentalservices.

4. ThefacilitywillassistresidentswhoareeligibleandwishtoparticipatetoapplyforreimbursementofdentalservicesasanincurredmedicalexpenseundertheStateplan.

PLACETABFORFOODANDNUTRITIONSERVICESHERE

POLICY/PROCEDURE

SUBJECT:FoodandNutritionServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoDietaryServicesinaccordancetoStateandFederalregulation.

PROCEDURE:


1. ProvidedDietMeetsNeedsofeachResident

2. QualifiedDietaryStaff

3. SufficientDietarySupportPersonnel

4. MenusMeetResidentNeeds/PreparedinAdvance/Followed

5. NutritiveValue/Appearance,Palatable/PreferredTemperature

6. FoodinFormtoMeetIndividualNeeds

7. ResidentAllergies,PreferencesandSubstitutes

8. DrinksAvailabletoMeetNeeds/Preferences/Hydration

9. TherapeuticDietPrescribedbyPhysician

10. FrequencyofMeals/SnacksatBedtime

11. AssistiveDevices–EatingEquipment/Utensils

12. FeedingAssistant–Training/Supervision/Resident

13. FoodProcurement,Store/Prepare/Serve–Sanitary

14. PersonalFoodPolicy

15. DisposeGarbage&RefuseProperly

POLICY/PROCEDURE

SUBJECT:FoodandNutritionServices

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethatfacilitystaffsupportsthenutritionalwell-beingoftheresidentswhilerespectinganindividual’srighttomakechoicesabouthisorherdiet.

PROCEDURE:

1. Thefacilitywillprovideeachresidentwithanourishing,palatable,well-balanceddietthatmeetshisorherdailynutritionalandspecialdietaryneeds,takingintoconsiderationthepreferencesofeachresident.

2. Thefacilitywillemploysufficientstaffwiththeappropriatecompetenciesandskillssetstocarryoutthefunctionsofthefoodandnutritionservice,takingintoconsiderationresidentassessments,individualplansofcareandthenumber,acuityanddiagnosesofthefacility’sresidentpopulationinaccordancewiththefacilityassessment.

3. Aqualifieddietitianorotherclinicallyqualifiednutritionprofessionaleitherfull-time,part-time,oronaconsultantbasis.Aqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisonewho:a. Holdsabachelor’sorhigherdegreegrantedbyaregionallyaccredited

collegeoruniversityintheUnitedStates(oranequivalentforeigndegree)withcompletionoftheacademicrequirementsofaprograminnutritionordieteticsaccreditedbyanappropriatenationalaccreditationorganizationrecognizedforthispurpose.

b. Hascompletedatleast900hoursofsuperviseddieteticspracticeunderthesupervisionofaregistereddietitianornutritionprofessional.

c. IslicensedorcertifiedasadietitianornutritionprofessionalbytheStateinwhichtheservicesareperformed.InaStatethatdoesnotprovideforlicensureorcertification,theindividualwillbedeemedtohavemetthisrequirementifheorsheisrecognizedasa“registereddietitian”bytheCommissiononDieteticRegistrationoritssuccessororganization,ormeetstherequirementsofparagraphs(a)(1)(i)and(ii)ofthissection.

d. FordietitianshiredorcontractedwithpriortoNovember28,2016,meetstheserequirementsnolaterthan5yearsafterNovember28,2016orasrequiredbystatelaw.

4. Ifaqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisnotemployedfull-time,thefacilitymustdesignateapersontoserveasthedirectoroffoodandnutritionserviceswho:a. FordesignationspriortoNovember28,2016,meetsthefollowing

requirementsnolaterthan5yearsafterNovember28,2016,ornolaterthan1yearafterNovember28,2016fordesignationsafterNovember28,2016,is:i. Acertifieddietarymanager;orii. Acertifiedfoodservicemanager;oriii. Hassimilarnationalcertificationforfoodservicemanagementand

safetyfromanationalcertifyingbody;oriv. Hasanassociate’sorhigherdegreeinfoodservicemanagementor

inhospitality,ifthecoursestudyincludesfoodserviceorrestaurantmanagement,fromanaccreditedinstitutionofhigherlearning;and

b. InStatesthathaveestablishedstandardsforfoodservicemanagersordietarymanagers,meetsStaterequirementsforfoodservicemanagersordietarymanagers,and

c. Receivesfrequentlyscheduledconsultationsfromaqualifieddietitianorotherclinicallyqualifiednutritionprofessional.

5. AmemberoftheFoodandNutritionServicesstaffmustparticipateontheinterdisciplinaryteam.

6. Theresidentswillreceiveandconsumefoodsintheappropriateformand/ortheappropriatenutritivecontentasprescribedbythephysicianand/orassessedbytheinterdisciplinaryteam,whichmaintainsacceptableparametersofnutritionalstatus,suchasbodyweightandproteinlevels,unlesstheresident’sclinicalconditiondemonstratesthatitisnotpossibleandreceivedatherapeuticdietwhenthereisanutritionalproblem.

7. Theattendingphysicianmaydelegatetoaregisteredorlicenseddietitianthetaskofprescribingaresident’sdiet,includingatherapeuticdiet,totheextentallowedbyStatelaw.

8. Eachresidentwillreceiveandthefacilitywillprovideatleastthreemealsdailyatregulartimescomparabletonormalmealtimesinthecommunity,orinaccordancewithresidentneeds,preferences,requests,andplanofcare.

9. Therewillbenomorethan14hoursbetweensubstantialeveningmealandbreakfastthefollowingdayexceptwhenanourishingsnackisservedatbedtime,upto16hoursmayelapsebetweenasubstantialeveningmealandbreakfastthefollowingdayifaresidentgroupagreestothismealspan,andanourishingsnackisserved.

10. Suitable,nourishingalternativemealsandsnackswillbeprovidedtoresidentswhowanttoeatatnon-traditionaltimesoroutsideofscheduledmealservicetimes,consistentwiththeresidentplanofcare.

11. Thefacilitywillmaintainaone-weeksupplyofnon-perishablefoodandsuppliesthatrepresentsagooddiet.

12. Thefacilitywillprovidespecialeatingequipmentandutensilsforresidentswhoneedthemandappropriateassistancetoensurethattheresidentcanusetheassistivedeviceswhenconsumingmealsandsnacks.

13. ThefacilitywillprocurefoodfromsourcesapprovedorconsideredsatisfactorybytheFederal,Stateorlocalauthoritiesandstore,prepare,distributeandservefoodundersanitaryconditionsfollowingpropersanitationandfoodhandlingpracticestopreventtheoutbreakoffoodborneillness.

a. Thismayincludefooditemsobtaineddirectlyfromlocalproducers,subjecttoapplicableStateandlocallawsorregulations.

b. Thisprovisiondoesnotprohibitorpreventfacilitiesfromusingproducegrowninfacilitygardens,subjecttocompliancewithapplicablesafegrowingandfood-handlingpractices.

c. Thisprovisiondoesnotprecluderesidentsfromconsumingfoodsnotprocuredbythefacility.

14. Thefacilitywillstore,prepare,distributeandservefoodinaccordancewithprofessionalstandardsforfoodservicesafety.

15. Thefacilitywillhaveapolicyregardinguseandstorageoffoodsbroughttoresidentsbyfamilyandothervisitorstoensuresafeandsanitarystorage,handling,andconsumption.

16. Thefacilitywilldisposeofgarbageandrefuseproperly,garbageandrefusecontainerswillbemaintainedingoodcondition,andgarbagereceptacleswillbecoveredwhentransportedtothedumpsterfromthekitchen.

POLICY/PROCEDURE

SUBJECT:DietaryServices–MenusandNutritionalAdequacy

DATE:

INTENT:

Itisthepolicyofthefacilitytoassurethatmenusaredevelopedandpreparedtomeetresidentchoicesincludingtheirnutritional,religious,cultural,andethnicneedswhileusingestablishednationalguidelines.

PROCEDURE:

Menuswill:1. Meetthenutritionalneedsofresidentsinaccordancewithestablishednational

guidelines.;

2. Bepreparedinadvance;

3. Befollowed;

4. Reflect,basedonafacility’sreasonableefforts,thereligious,culturalandethnicneedsoftheresidentpopulation,aswellasinputreceivedfromresidentsandresidentgroups;

5. Beupdatedperiodically;

6. Bereviewedbythefacility’sdietitianorotherclinicallyqualifiednutritionprofessionalfornutritionaladequacy;and

7. Nothinginthisparagraphshouldbeconstruedtolimittheresident’srighttomakepersonaldietarychoices.

POLICY/PROCEDURE

SUBJECT:DietaryServices–FoodandDrink

DATE:

INTENT:

ItisthepolicyofthefacilityToassurethatthenutritivevalueoffoodisnotcompromisedanddestroyedbecauseofprolonged;foodstorage,light,andairexposure;orcookingoffoodsinalargevolumeofwater;orholdingonsteamtable.

PROCEDURE:

Thefacilitywillprovidetoeachresident:

1. Foodpreparedbymethodsthatconservenutritivevalue,flavor,andappearance;

2. Foodanddrinkthatispalatable,attractive,andatasafeandappetizingtemperature.

3. Foodpreparedinaformdesignedtomeetindividualneeds.

4. Foodthataccommodatesresidentallergies,intolerances,andpreferences.

5. Appealingoptionsofsimilarnutritivevaluetoresidentswhochoosenottoeatfoodthatisinitiallyservedorwhorequestadifferentmealchoice.

6. Drinks,includingwaterandotherliquidsconsistentwithresidentneedsandpreferencesandsufficienttomaintainresidenthydration.

POLICY/PROCEDURE

SUBJECT:DietaryServices–PaidFeedingAssistants

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideassistancewithmealsbyutilizingPaidFeedingAssistantswhenevernecessaryinaccordancetoStateandFederalregulation.

PROCEDURE:

1. Afacilitymayuseapaidfeedingassistant,asdefinedin§488.301if:a. ThefeedingassistanthassuccessfullycompletedaState-approved

trainingcoursethatmeetstherequirementsof§483.160beforefeedingresidents;and

b. TheuseoffeedingassistantsisconsistentwithStatelaw.

2. Afeedingassistantmustworkunderthesupervisionofaregisterednurse(RN)orlicensedpracticalnurse(LPN).

3. Inanemergency,afeedingassistantmustcallasupervisorynurseforhelp.

4. Thefacilitywillensurethatafeedingassistantprovidesdiningassistanceonlyforresidentswhohavenocomplicatedfeedingproblems.

5. Complicatedfeedingproblemsinclude,butarenotlimitedto,difficulty

swallowing,recurrentlungaspirations,andtubeorparenteral/IVfeedings.

6. Thefacilitywillbaseresidentselectionontheinterdisciplinaryteam’sassessmentandtheresident’slatestassessmentandplanofcare.Appropriatenessforthisprogramshouldbereflectedinthecomprehensivecareplan.

7. Afacilitymustnotuseanyindividualworkinginthefacilityasapaidfeeding

assistantunlessthatindividualhassuccessfullycompletedaState-approvedtrainingprogramforfeedingassistants.

POLICY/PROCEDURE

SUBJECT:DietaryServices–FoodBroughtintheFacilitybyFamilyorVisitors

DATE:

INTENT:

Itistherightoftheresidentsofthisfacilitytohavefoodbroughtinbyfamilyorothervisitors.Thefoodwillbehandledinawaytoensurethesafetyoftheresident.

PROCEDURE:

1. Familymembersorothervisitorsmaybringtheresidentfoodoftheirchoosing.

2. Allfooditemsthatarealreadypreparedbythefamilyorvisitorbroughtinwillbelabeledwithnameanddated.

a. Thefacilitywillrefrigeratelabelanddatedprepareditemsinthenourishmentrefrigerator.

b. Thepreparedfoodmustbeconsumedwithin3days.c. Ifnotconsumedwithin3days,foodwillbethrownaway.d. Thefacilitywillnotberesponsibleformaintaininganyreusableitems.

3. Allfooditemsbroughtinthataremanufacturedanddonotrequirerefrigeration,maybekeptintheresidentroominsideaclosedcontainerthatisprovidedbytheresident.

4. Itistheresponsibilityoftheresidentand/orresidentrepresentativetomaintainsaidcontaineranditemsinthecontainer.

5. Allitemsnotmaintainedaresubjectedtobeingthrownawayifnotremovedbytheresidentand/orresidentrepresentative.

PROCEDURE

SUBJECT:WeightManagement

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoweightmanagementinaccordancetoStateandFederalregulation.

PROCEDURE:

1. AllResidentsadmittedtothefacilitywillbeweighedaccordingtothefollowingschedule:dayoneonadmission,daytwo,andthenweeklyx4weeks.

2. Allresidentswillbeweightedonamonthlybasisunlessotherwiseorderedbythephysicianordeemednecessarybythedieticianandortheinterdisciplinaryteam.

3. Monthlyweightswillbecompletedbythefifthofeachmonth.

4. Dietarywillevaluateallweightsbytheseventhofeachmonth.

5. Are-weightwillbeobtainedforanyweightchangeof+/-(3)lbs.fromthepreviousweightunlessotherparametershavebeenorderedbythephysician.

6. Allre-weightswillbeobtainedimmediately.There-weightprocesswillbevisualizedbyalicensenurse.

7. Allweightswillbedocumentedintheresident’selectronicmedicalrecord.

8. Weightswillbeobtainedatthesametimeofdaypreferablyinthemorningandwiththesamescaletoensureconsistency.

9. Thescalewillbezeroedoutpriortoweighingtheresidentbythestaffmemberobtainingtheweight.

10. Forresidentsbeingweighedinawheelchair,besuretoobtainthewheelchairweightfirst,includinganycushions/devicesinuseandsubtractweightfromtotalweight,eachtimetheresidentisweighed.

11. Oncearesidentisclearedbytherapyforsafetransferandstandingbycontactguardassistofoneperson,weightsmaybeobtainedbystandingtheresident.

12. Thephysicianandtheresidentorresidentrepresentativewillbenotifiedbytheresident’snurseofanysignificantunexpectedandorunplannedweightchanges.Thenursewilldocumentthenotificationintheresident’selectronicmedicalrecordbycompletingtheEventReport.

PLACETABFORSPECIALIZEDREHABSERVICESHERE

POLICY/PROCEDURE

SUBJECT:SpecializedRehabServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoSpecializedRehabServicesinaccordancetoStateandFederalregulation.

PROCEDURE:


1. Provide/ObtainSpecializedRehabServices

2. RehabServices–PhysicianOrder/QualifiedPerson

POLICY/PROCEDURE

SUBJECT:SpecializedRehabilitativeandRestorativeServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideSpecializedRehabilitativeandRestorativeServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Thefacilitywillprovidespecializedrehabilitativeservicessuchas,butnotlimitedtophysicaltherapy,speechlanguagepathology,occupationaltherapy,respiratorytherapy,andrehabilitativeservicesformentalillnessandintellectualdisabilityorservicesofalesserintensityassetforthat§483.120(c),arerequiredintheresident’scomprehensiveplanofcare.

2. Thefacilitywill:a. Providetherequiredservices;orb. Obtaintherequiredservicesfromanoutsideresourcethatisaproviderof

specializedrehabilitativeservicesandisnotexcludedfromparticipatinginanyfederalorstatehealthcareprogramspursuanttosection1128and1156oftheAct.

3. Thefacilitywillensurethatspecializedrehabilitativeservicesareprovidedunderthewrittenorderofaphysicianbyqualifiedpersonnel.

4. Thefacilitywillproviderestorativeservicessuchasbutnotlimitedtowalking,transfertraining,bowelandorbladdertraining,bedmobility,RangeofMotion(ROM),splintandbrace,eatingand/orswallowing,amputation/prosthesescareandcommunication,whennecessaryasindicatedbytheassessmentoftheinterdisciplinaryteam.

PLACETABFORADMINISTRATIONHERE

POLICY/PROCEDURE

SUBJECT:Administration

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoAdministrationinaccordancetoStateandFederalregulation.

PROCEDURE:

TheAdministrationofthefacilitywillensurethefollowing:

1. Administration

2. License/ComplywithFed/State/LocalLaw/ProfessionalStandards

3. GoverningBody

4. FacilityAssessment

5. StaffQualifications

6. UseofOutsideResources

7. ResponsibilitiesofMedicalDirector

8. ResidentRecords-IdentifiableInformation

9. TransferAgreement

10. DisclosureofOwnershipRequirements

11. Facilityclosure-Administrator

12. Facilityclosure

13. HospiceServices

14. QualificationsofSocialWorker>120Beds

15. PayrollBasedJournal

POLICY/PROCEDURE

SUBJECT:Administration

DATE:

INTENT:

ItisthepolicyofthefacilitytobeAdministered,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywillbeadministeredinamannerthatenablesittouseitsresourceseffectivelyandefficientlytoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beingofeachresident.

2. ThefacilitywillbelicensedunderapplicableStateandlocallaw.

3. ThefacilitywilloperateandprovideservicesincompliancewithallapplicableFederal,State,andlocallaws,regulations,andcodes,andwithacceptedprofessionalstandardsandprinciplesthatapplytoprofessionalsprovidingservicesinsuchafacility.

4. ThefacilitywillmeettheapplicableprovisionsofotherHHSregulations,includingbutnotlimitedtothosepertainingtonondiscriminationonthebasisofrace,color,ornationalorigin(45CFRpart80);nondiscriminationonthebasisofdisability(45CFRpart84);nondiscriminationonthebasisofage(45CFRpart91);nondiscriminationonthebasisofrace,color,nationalorigin,sex,age,ordisability(45CFRpart92);protectionofhumansubjectsofresearch(45CFRpart46);andfraudandabuse(42CFRpart455)andprotectionofindividuallyidentifiablehealthinformation(45CFRparts160and164).Violationsofsuchotherprovisionsmayresultinafindingofnon-compliancewiththisparagraph.

5. Thefacilitywillhaveagoverningbody,ordesignatedpersonsfunctioningasagoverningbody,thatislegallyresponsibleforestablishingandimplementingpoliciesregardingthemanagementandoperationofthefacility;and

6. Thegoverningbodyappointstheadministratorwhois:a. LicensedbytheStatewherelicensingisrequired;b. Responsibleforthemanagementofthefacility;andc. Reportstoandisaccountabletothegoverningbody.

POLICY/PROCEDURE

SUBJECT:FacilityAssessment

DATE:

INTENT:

Theintentofthefacilityassessmentisforthefacilitytoevaluateitsresidentpopulationandidentifytheresourcesneededtoprovidethenecessarycareandservicestheresidentsrequire,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywillconductanddocumentafacility-wideassessmenttodeterminewhatresourcesarenecessarytocareforitsresidentscompetentlyduringbothday-to-dayoperationsandemergencies.

2. Thefacilitywillreviewandupdatethatassessment,asnecessary,andatleastannually.

3. Thefacilitywillalsoreviewandupdatethisassessmentwheneverthereis,orthefacilityplansfor,anychangethatwouldrequireasubstantialmodificationtoanypartofthisassessment.

4. Thefacilityassessmentwilladdressorinclude:a. Thefacility’sresidentpopulation,including,butnotlimitedto:

i. Boththenumberofresidentsandthefacility’sresidentcapacity;ii. Thecarerequiredbytheresidentpopulationconsideringthetypes

ofdiseases,conditions,physicalandcognitivedisabilities,overallacuity,andotherpertinentfactsthatarepresentwithinthatpopulation;

iii. Thestaffcompetenciesthatarenecessarytoprovidethelevelandtypesofcareneededfortheresidentpopulation;

iv. Thephysicalenvironment,equipment,services,andotherphysicalplantconsiderationsthatarenecessarytocareforthispopulation;and

v. Anyethnic,cultural,orreligiousfactorsthatmaypotentiallyaffectthecareprovidedbythefacility,including,butnotlimitedto,activitiesandfoodandnutritionservices.

b. Thefacility’sresources,includingbutnotlimitedto:i. Allbuildingsand/orotherphysicalstructuresandvehicles;ii. Equipment(medicalandnon-medical);iii. Servicesprovided,suchasphysicaltherapy,pharmacy,and

specificrehabilitationtherapies;

iv. Allpersonnel,includingmanagers,staff(bothemployeesandthosewhoprovideservicesundercontract),andvolunteers,aswellastheireducationand/ortrainingandanycompetenciesrelatedtoresidentcare;

v. Contracts,memorandumsofunderstanding,orotheragreementswiththirdpartiestoprovideservicesorequipmenttothefacilityduringbothnormaloperationsandemergencies;and

vi. Healthinformationtechnologyresources,suchassystemsforelectronicallymanagingpatientrecordsandelectronicallysharinginformationwithotherorganizations.

c. Afacility-basedandcommunity-basedriskassessment,utilizinganall-hazardsapproach.

POLICY/PROCEDURE

SUBJECT:StaffQualifications

DATE:

INTENT:

ItisthepolicyofthefacilitytoemployNursingAides,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Thefacilitywillprovideemployonafull-time,part-timeorconsultantbasisprofessionalsnecessarytocarryouttheprovisionsoftheserequirements.

2. Thefacilitywillensurethatprofessionalstaffarelicensed,certified,orregisteredinaccordancewithapplicablestatelaws.

3. Thefacilitywillensurethatwhenservicesarenotabletobeprovidedbyacurrentemployeethenthefacilitywillhavethatservicefurnishedtoitsresidentsbyapersonoragencyoutsidethefacilityunderawrittenarrangementthatthefacilityassumesresponsibilityforthatincludes:

a. Obtainingservicesthatmeetprofessionalstandardsandprinciplesthatapplytoprofessionalsprovidingservicesinthefacility,and

b. Ensuringthetimelinessofsuchservices.

POLICY/PROCEDURE

SUBJECT:MedicalDirector

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideMedicalDirectorServicesinaccordancetoStateandFederalregulations.

PROCEDURE:

1. ThefacilitywillhaveonlyoneMedicalDirectorwhowillbealicensedphysicianinaccordancetoStateandFederalguidelines.

2. AMedicalDirectorwhodoesnothavehospitalprivilegeswillbecertifiedorcredentialedthrougharecognizedcertifyingorcredentialingbody,suchasJointCommissiononAccreditationofHealthcareOrganizations(JCAHO).

3. Aphysicianwillhavehis/herprincipalofficewithin60milesoftheFacilityandmaybeMedicalDirectorofamaximumof10nursinghomesatanyonetime.

4. ThefacilityshallappointaMedicalDirectorwhoshallvisitthefacilityatleastonceamonthandreview:

a.allnewpoliciesandprocedures, b.allnewincidentandaccidentreports c.themostrecentgrievancelogs

5. TheMedicalDirectorwill,incollaborationwiththefacility,coordinatethemedicalcareandtheimplementationofresidentcarepolicies,withinthefacility.

6. TheMedicalDirectorappointedbythefacilitywillmeetatleastmonthlywiththeriskmanagementcommitteeandnolessthanquarterlywiththequalityassessmentandassurancecommitteeofthefacility.Thefacilitymaycombinebothcommittees.

PointofEmphasis:

TheMedicalDirectordutiesareseparatefromtheresponsibilitiesofresidentattendingphysician.

POLICY/PROCEDURE

SUBJECT:MedicalRecords

DATE:

INTENT:

ItisthepolicyofthefacilitytomaintainMedicalRecordsinaccordancetoStateandFederalregulations.

PROCEDURE:


1. Thefacilitywilldesignateafull-timeemployeeasbeingresponsibleandaccountableforthefacility'smedicalrecords.IfthisemployeeisnotaqualifiedMedicalRecordPractitioner,thenthefacilityshallhavetheservicesofaqualifiedMedicalRecordPractitioneronaconsultantbasis.

2. Thefacilitywillmaintainclinicalrecordsoneachresidentinaccordancewithacceptedprofessionalstandardsandpracticesthatarecomplete,accuratelydocumented,readilyaccessible,systematicallyorganizedandinclude:

a. Theresident’sadmissionsanddischarges;b. Medicalandgeneralhealthstatus;c. PersonalandSocialhistory;d. Identityandaddressofnextofkinorresponsibleparty;e. Theresident’scomprehensivecareplan;f. Theresultsofanypreadmissionscreeningandresidentreview

evaluationsanddeterminationsconductedbytheState;g. Physician’s,nurse’s,andotherlicensedprofessional’sprogressnotes;

andh. Laboratory,radiologyandotherdiagnosticservicesreports.

3. Thefacilitywillretainmedicalrecordsforthetimeperiodrequiredbystatelawor:

a. Fiveyearsfromthedateofdischargewhenthereisnorequirementinstatelaw;and

b. Foraminor,threeyearsaftertheresidentreacheslegalageunderstatelaw.

4. Thefacilitywillnotreleaseinformationtothepublicthatisresident-identifiabletothepublic.

5. Thefacilitymayreleaseinformationthatisresident-identifiabletoanonlyinaccordancewithacontractunderwhichtheagentagreesnottouseordisclosetheinformationexcepttotheextentthefacilityitselfispermittedtodoso.

6. Thefacilitywillsafeguardclinicalrecordinformationagainstloss,destructionorunauthorizeduse.

7. Unlessexpresslyprohibitedbyalegallycompetentresident,thefacilitywillfurnishtothespouse,guardian,surrogate,proxy,orattorneyinfact,ofacurrentresident,within7workingdaysafterreceiptofawrittenrequest,orofaformerresident,within10workingdaysafterreceiptofawrittenrequest,acopyofthatresident'srecordswhichareinthepossessionofthefacility.Suchrecordswillincludemedicalandpsychiatricrecordsandanyrecordsconcerningthecareandtreatmentoftheresidentperformedbythefacility,exceptprogressnotesandconsultationreportsectionsofapsychiatricnature.Copiesofsuchrecordswillnotbeconsideredpartofadeceasedresident'sestateandmaybemadeavailablepriortotheadministrationofanestate,uponrequest,tothespouse,guardian,surrogate,proxy,orattorneyinfact.

8. Thefacilitymaychargeareasonablefeeforthecopyingofresidentrecords.Suchfeewillnotexceed$1perpageforthefirst25pagesand25centsperpageforeachpageinexcessof25pages.

9. Thefacilitywillallowanysuchspouse,guardian,surrogate,proxy,orattorneyinfact,toexaminetheoriginalrecordsinitspossession,ormicrofilmsorothersuitablereproductionsoftherecords,uponsuchreasonabletermsasshallbeimposed,tohelpassurethattherecordsarenotdamaged,destroyed,oraltered.

POLICY/PROCEDURE

SUBJECT:RecordRetention

APPROVED:

INTENT:

ItisthepolicyofthefacilitytoretainallrecordsinaccordancetoStateandFederalRegulationsorasoutlinedinpayercontracts,whicheverislonger.Intheabsenceofregulations,thestateGeneralRecordsSchedule(GS4)forPublicHospitals,HealthCareFacilitiesandMedicalProviderswillbeutilizedforguidanceastorecordretentiontimeframes.

PROCEDURE:

RetentionPeriods

MedicalRecords

1. Willberetainedforaperiodofseven(7)yearsfromthedateofdischargeorperiodoutlinedbypayercontracts,whicheverislonger.

2. Minorsa. Recordswillberetainedforthree(3)yearsafteraresident

reacheseighteen(18)yearsold.

SurveyandInspectionReports–includingbutnotlimited,toinspectionreports,noticeofcorrections,in-housesurveys,correctionofdeficiencies.(FloridaRecordRetentionScheduleGS-4)

1. Retainforfive(5)yearsfollowingnextsurveyreportissued.

BiomedicalWasteRecords–includingbutnotlimitedto,trainingrecords,signedbiomedicaltrackingformsormailreceipts,andlogs.

1. Retainforthree(3)calendaryears

DietaryRecipeRecords–standardizedreciperecordsusedforresidentmealpreparationthatmayincludenutritionalanalysis,ingredients,andservingsize.

1. Retainuntilobsoleteorsuperseded

Menus–includesbutisnotlimitedto,listoffoodchoicesavailableforspecificmealsandsnacksonspecificdaysatspecifictimes.

1. Retainforsix(6)months

DietitianConsultantReports/Summaries

1. Retainfortwo(2)years

InfectionControlProgramReports–includingbutnotlimitedto,trainingmaterials,andrecordsusedtoidentify,evaluateandreportinfections.

1. Retainforfive(5)calendaryears

MedicationInventoryRecords–includingbutnotlimitedto,inventorysheetsforcontrolledclassI-Vsubstances,logsforemergencydrugkit,etc.

1. Retainfortwo(2)years

Manuals,Policies,andProcedures(Revised)

1. Retainforseven(7)yearsfromdateofrevision

Medicare/MedicaidRecords-includingallfinancialandadministrativerecordsregardingMedicareandMedicaidclaims,reimbursementandanyotheractivities.

1. Retainforfive(5)years,unlessauditissuesarepending.2. Ifauditissuesarepending,retainuntilauditsareresolved.

RiskManagementRecords–includesbutnotlimitedto,staffeducationandtraining,patientgrievancereviews,committeemeetingminutes,investigations,etc.

1. Retainforseven(7)calendaryears

IncidentReports/Records–includingbutnotlimitedto,incidentformsandlogs.Mayincludesecurityand/orinjuryincidentsoranyworkplacedisturbance(i.e.firealarms,electronicmedicalrecordsystemoutages,etc.)

1. Retainforseven(7)yearsfromdateofincident

PayrollandSupportingDocuments–Includingbutnotlimitedtoattendanceandleaverecords,deductionauthorizations,ledgers,etc.

1. Three(3)fiscalyears

PersonnelRecords–includingvolunteersandtemporarystaff

1. Three(3)fiscalyearsafterseparationorterminationofemployment

Schedules(Daily,Weekly,orMonthly)

1. Retainoriginaldocumentsforseven(7)years.

ResidentContracts–includingbutnotlimitedtoadmissionagreementsandanyaddendumstosuchcontracts.

1. Retainforfive(5)yearsaftercontractexpiration.

RecordDestruction

1. RecordstobedestroyedwillbeenteredontoaRecordDisposalLog2. RecordDisposalApprovalFormwillbecompletedbyHealthInformation

ManagementCoordinator,orOtherDepartmentManager/Coordinatorresponsibleforrecorddestruction.

3. TheRecordDisposalLogandRecordDisposalApprovalFormwillbesubmittedwithtoAdministratorforreviewandsignature.

4. OnceRecordDisposalisapproved,PreparerwillcontactDisposalCompanytoschedulerecorddisposal.

a. ProperDisposalMethodsforPaperRecordsi. Shreddingii. Incineratingiii. Pulpingiv. Pulverizing

b. ProperDisposalMethodsforElectronicMediai. Degaussingii. Pulverizingiii. Shreddingiv. Incinerating

5. Upondisposalofrecords,PreparerwillobtainReceiptofDisposal/DestructionfromtheDisposalCompany.

6. RecordDisposalLog,RecordDisposalApprovalandReceiptofDisposalwillberetainedindefinitely.

REFERENCES:

GeneralRecordsScheduleforPublicHospitals,HealthCareFacilitiesandMedicalProviders;FloridaDepartmentofStateDivisionofLibraryandInformationServices;February19,2015(http://dos.myflorida.com/media/693585/gs04.pdf)RecordkeepingRequirements;U.S.EqualEmploymentOpportunityCommission;Retrieved:January26,2017fromhttps://www.eeoc.gov/employers/recordkeeping.cfm

POLICY/PROCEDURE

SUBJECT:TransferAgreement

DATE:

INTENT:

ItisthepolicyofthefacilitytomaintainaTransferAgreementinaccordancetoStateandFederalregulations.

PROCEDURE:

1. ThefacilitywillhaveineffectawrittentransferagreementwithoneormorehospitalsapprovedforparticipationundertheMedicareandMedicaidprogramsthatreasonablyassuresthat:

a. Residentswillbetransferredfromthefacilitytothehospital,andensuredoftimelyadmissiontothehospitalwhentransferismedicallyappropriateasdeterminedbytheattendingphysicianor,inanemergencysituation,byanotherpractitionerinaccordancewithfacilitypolicyandconsistentwithstatelaw;and

b. Medicalandotherinformationneededforcareandtreatmentofresidentsand,whenthetransferringfacilitydeemsitappropriate,fordeterminingwhethersuchresidentscanreceiveappropriateservicesorreceiveservicesinalessrestrictivesettingthaneitherthefacilityorthehospital,orreintegratedintothecommunitywillbeexchangedbetweentheproviders.

2. Thefacilitywillattemptingoodfaithtoenterintoanagreementwithahospitalsufficientlyclosetothefacilitytomaketransferfeasible.

POLICY/PROCEDURE

SUBJECT:DisclosureofOwnership

DATE:

INTENT:

ItisthepolicyofthefacilitytomaintainDisclosureofOwnershipinaccordancetoStateandFederalregulations.

PROCEDURE:

1. ThefacilitywillprovidewrittennoticetotheStateagencyresponsibleforlicensingthefacilityatthetimeofchange,ifachangeoccursin:

a. Personswithanownershiporcontrolinterest;b. Theofficers,directors,agents,ormanagingemployees;c. Thecorporation,association,orothercompanyresponsibleforthe

managementofthefacility;ord. Thefacility’sadministratorordirectorofnursing.

2. Thenoticewillincludetheidentityofeachnewindividualorcompany.

POLICY/PROCEDURE

SUBJECT:FacilityClosure

DATE:

INTENT:

Itisthepolicyofthefacilitytohandleafacilityclosure,shoulditoccur,inaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Anyindividualwhoistheadministratorofthefacilitywill:a. SubmittotheStateSurveyAgency,theStateLTCombudsman,

residentsofthefacility,andthelegalrepresentativesofsuchresidentsorotherresponsibleparties,writtennotificationofanimpendingclosure:

i. Atleast60dayspriortothedateofclosure;orii. InthecaseofafacilitywheretheSecretaryoraState

terminatesthefacility'sparticipationintheMedicareand/orMedicaidprograms,notlaterthanthedatethattheSecretarydeterminesappropriate;

2. Ensurethatthefacilitydoesnotadmitanynewresidentsonorafterthedateonwhichsuchwrittennotificationissubmitted;and

3. Includeinthenoticetheplan,thathasbeenapprovedbytheState,forthetransferandadequaterelocationoftheresidentsofthefacilitybyadatethatwouldbespecifiedbytheStatepriortoclosure,includingassurancesthattheresidentswouldbetransferredtothemostappropriatefacilityorothersettingintermsofquality,services,andlocation,takingintoconsiderationtheneeds,choice,andbestinterestsofeachresident.

POLICY/PROCEDURE

SUBJECT:HospiceServices

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecollaborativecarewithHospiceproviderstoensurethatourresident’sendoflifepreferencesandchoicesarehonored.

PROCEDURE:

1. Thefacilitywilldoeitherofthefollowing:

a. ArrangefortheprovisionofhospiceservicesthroughanagreementwithoneormoreMedicare-certifiedhospices;or

b. NotarrangefortheprovisionofhospiceservicesatthefacilitythroughanagreementwithaMedicare-certifiedhospiceandassisttheresidentintransferringtoafacilitythatwillarrangefortheprovisionofhospiceserviceswhenaresidentrequestsatransfer.

2. Whenhospicecareisfurnishedinthefacilitythroughanagreementthefollowingrequirementswillbemet:

a. Thefacilitywillensurethatthehospiceservicesmeetprofessionalstandardsandprinciplesthatapplytoindividualsprovidingservicesinthefacility,andtothetimelinessoftheservices.

b. ThefacilitywillhaveawrittenagreementwiththehospicethatissignedbyanauthorizedrepresentativeofthehospiceandanauthorizedrepresentativeoftheLTCfacilitybeforehospicecareisfurnishedtoanyresident.Thewrittenagreementmustsetoutatleastthefollowing:

i. Theservicesthehospicewillprovide;ii. Thehospice’sresponsibilitiesfordeterminingtheappropriatehospice

planofcareasspecifiedin§418.112(d)ofthisregulation;iii. TheservicestheLTCfacilitywillcontinuetoprovidebasedoneach

resident’splanofcare;iv. Acommunicationprocess,includinghowthecommunicationwillbe

documentedbetweentheLTCfacilityandthehospiceprovider,toensurethattheneedsoftheresidentareaddressedandmet24hoursperday;and

v. AprovisionthattheLTCfacilityimmediatelynotifiesthehospiceaboutthefollowing;

o Asignificantchangeintheresident’sphysical,mental,

social,oremotionalstatus,

o Clinicalcomplicationsthatsuggestaneedtoaltertheplanofcare,

o Aneedtotransfertheresidentfromthefacilityforanycondition,and

o Theresident’sdeath.

c. Aprovisionstatingthatthehospiceassumesresponsibilityfordeterminingtheappropriatecourseofhospicecare,includingthedeterminationtochangethelevelofservicesprovided.

d. AnagreementthatitistheLTCfacility’sresponsibilitytofurnish24-hourroomandboardcare,meettheresident’spersonalcareandnursingneedsincoordinationwiththehospicerepresentative,andensurethatthelevelofcareprovidedisappropriatelybasedontheindividualresident’sneeds.

e. Adelineationofthehospice’sresponsibilities,includingbutnotlimitedto,providingmedicaldirectionandmanagementofthepatient;nursing;counseling(includingspiritual,dietary,andbereavement);socialwork;providingmedicalsupplies,durablemedicalequipment,anddrugsnecessaryforthepalliationofpainandsymptomsassociatedwiththeterminalillnessandrelatedconditions;andallotherhospiceservicesthatarenecessaryforthecareoftheresident’sterminalillnessandrelatedconditions.

f. AprovisionthatwhentheLTCfacilitypersonnelareresponsiblefortheadministrationofprescribedtherapies,includingthosetherapiesdeterminedappropriatebythehospiceanddelineatedinthehospiceplanofcare,theLTCfacilitypersonnelmayadministerthetherapieswherepermittedbyStatelawandasspecifiedbytheLTCfacility.

g. AprovisionstatingthattheLTCfacilitymustreportallallegedviolationsinvolvingmistreatment,neglect,orverbal,mental,sexual,andphysicalabuse,includinginjuriesifunknownsource,andmisappropriationofpatientpropertybyhospicepersonnel,tothehospiceadministratorimmediatelywhentheLTCfacilitybecomesawareoftheallegedviolation.

h. AdelineationoftheresponsibilitiesofthehospiceandtheLTCfacilitytoprovidebereavementservicestoLTCfacilitystaff.

3. EachLTCfacilityarrangingfortheprovisionofhospicecareunderawrittenagreementmustdesignateamemberofthefacility’sinterdisciplinaryteamwhoisresponsibleforworkingwithhospicerepresentativestocoordinatecaretotheresidentprovidedbytheLTCfacilitystaffandhospicestaff.

4. Theinterdisciplinaryteammembermusthaveaclinicalbackground,withintheirStatescopeofpracticeact,andhavetheabilitytoassesstheresidentorhaveaccesstosomeonethathastheskillsandcapabilitiestoassesstheresident.

5. Thedesignatedinterdisciplinaryteammemberisresponsibleforthefollowing:

a. CollaboratingwithhospicerepresentativesandcoordinatingLTCfacilitystaffparticipationinthehospicecareplanningprocessforthoseresidentsreceivingtheseservices;

b. Communicatingwithhospicerepresentativesandotherhealthcareprovidersparticipatingintheprovisionofcarefortheterminalillness,relatedconditions,andotherconditions,toensurequalityofcareforthepatientandfamily;

c. EnsuringthattheLTCfacilitycommunicateswiththehospicemedicaldirector,thepatient’sattendingphysician,andotherpractitionersparticipatingintheprovisionofcaretothepatientasneededtocoordinatethehospicecarewiththemedicalcareprovidedbyotherphysicians;and

d. Obtainingthefollowinginformationfromthehospice;

i. Themostrecenthospiceplanofcarespecifictoeachpatient,ii. Hospiceelectionform,iii. Physiciancertificationandrecertificationoftheterminalillness

specifictoeachpatient,iv. Namesandcontactinformationforhospicepersonnelinvolved

inhospicecareofeachpatient,v. EmergencyInstructionsonhowtoaccessthehospice’s24-

houron-callsystem,vi. Hospicemedicationinformationspecifictoeachpatient,andvii. Hospicephysicianandattendingphysician(ifany)orders

specifictoeachpatient.

6. EnsurethattheLTCfacilitystaffprovidesorientationinthepoliciesandproceduresofthefacility,includingpatientrights,appropriateforms,andrecordkeepingrequirements,tohospicestafffurnishingcaretoLTCresidents.

7. EachLTCfacilityprovidinghospicecareunderawrittenagreementmustensurethateachresident'swrittenplanofcareincludesboththemostrecenthospiceplanofcareandadescriptionoftheservicesfurnishedbytheLTCfacilitytoattainormaintaintheresident'shighestpracticablephysical,mental,andpsychosocialwell-being,asrequired.

POLICY/PROCEDURE

SUBJECT:SocialServices

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovidecareandservicesrelatedtosocialservices,accordingtostateandfederalregulations.

PROCEDURE:

1. Thefacilitywillprovidemedicallyrelatedsocialservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beingofeachresident.

2. Medicallyrelatedsocialservicesmeansservicesprovidedbythefacility’sstafftoassistresidentsinmaintainingorimprovingtheirabilitytomanagetheireverydayphysical,mental,andpsychosocialneeds.Theseservicesmightinclude:a. Makingarrangementsforobtainingneededadaptiveequipment,

clothing,andpersonalitems;b. Maintainingcontactwithfacility(withresident’spermission)toreport

onchangesinhealth,currentgoals,dischargeplanning,andencouragementtoparticipateincareplanning;

c. Assistingstafftoinformresidentsandthosetheydesignateabouttheresident’shealthstatusandhealthcarechoicesandtheirramifications;

d. Makingreferralsandobtainingservicesfromoutsideentities(e.g.,talkingbooks,absenteeballots,communitywheelchairtransportation);

e. Assistingresidentswithfinancialandlegalmatters(e.g.,applyingforpensions,referralstolawyers,referralstofuneralhomesforpreplanningarrangements);

f. Dischargeplanningservices(e.g.,helpingtoplacearesidentonawaitinglistforcommunitycongregateliving,arrangingintakeforhomecareservicesforresidentsreturninghome,assistingwithtransferarrangementstootherfacilities);

g. Providingorarrangingprovisionofneededcounselingservices;h. Throughtheassessmentandcareplanningprocess,identifyingand

seekingwaystosupportresidents’individualneeds;i. Promotingactionsbystaffthatmaintainorenhanceeachresident’s

dignityinfullrecognitionofeachresident’sindividuality;

j. Assistingresidentstodeterminehowtheywouldliketomakedecisionsabouttheirhealthcare,andwhetherornottheywouldlikeanyoneelsetobeinvolvedinthosedecisions;

k. Findingoptionsthatmostmeetthephysicalandemotionalneedsofeachresident;

l. Providingalternativestodrugtherapyorrestraintsbyunderstandingandcommunicatingtostaffwhyresidentsactastheydo,whattheyareattemptingtocommunicate,andwhatneedsthestaffmustmeet;

m. Meetingtheneedsofresidentswhoaregrieving;andn. Findingoptions,whichmostmeettheirphysicalandemotionalneeds.

3. Thefacilitywithmorethan120bedsmustemployaqualifiedsocialworkeronafull-timebasis.

4. Aqualifiedsocialworkerisanindividualwith:a. Aminimumofabachelor’sdegreeinsocialworkorabachelor’sdegree

inahumanservicesfieldincludingbutnotlimitedtosociology,gerontology,specialeducation,rehabilitationcounseling,andpsychology;and

b. Oneyearofsupervisedsocialworkexperienceinahealthcaresettingworkingdirectlywithindividuals.

POLICY/PROCEDURE

SUBJECT:MandatorySubmissionofUniformFormatStaffingInformation

DATE:

INTENT:ItisthepolicyofthefacilitytocompletesubmissionofstaffinginformationbasedonpayrolldatainauniformformatasspecifiedbyCMS.Long-termcarefacilitiesmustelectronicallysubmittoCMScompleteandaccuratedirectcarestaffinginformation,includinginformationforagencyandcontractstaff,basedonpayrollandotherverifiableandauditabledatainauniformformataccordingtospecificationsestablishedbyCMS.

DIRECTCARESTAFFDEFINTION:DirectCareStaffarethoseindividualswho,throughinterpersonalcontactwithresidentsorresidentcaremanagement,providecareandservicestoallowresidentstoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being.Directcarestaffdoesnotincludeindividualswhoseprimarydutyismaintainingthephysicalenvironmentofthelongtermcarefacility(forexample,housekeeping).PROCEDURE:

1. ThefacilitymustsubmittoCMScompleteandaccuratedirectcarestaffingdata,toInclude:

a. Thecategoryofworkforeachpersonondirectcarestaff(including,butnotlimitedto,whethertheindividualisaregisterednurse,licensedpracticalnurse,licensedvocationalnurse,certifiednursingassistant,therapist,orothertypeofmedicalpersonnelasspecifiedbyCMS);

b. Residentcensusdata;andc. Informationondirectcarestaffturnoverandtenure,andonthehours

ofcareprovidedbyeachcategoryofstaffperresidentperday(including,butnotlimitedto,startdate,enddate(asapplicable),andhoursworkedforeachindividual).

2. Thefacilitywilldistinguishemployeesfromagencyandcontractworkers.

3. Thefacilitywillreportinformationaboutdirectcarestaff,thefacilitymustspecifywhethertheindividualisanemployeeofthefacility,orisengagedbythefacilityundercontractorthroughanagency.

4. ThefacilitywillsubmitasdirectedbyCMStoCMSduringtheestablishedstaffingreportingperiods.

Weanticipaterevisiontothispolicyassomewillsubmitinternallyandsomeexternallythrougha3rdpartyprovider.

INSERTQUALITYASSURANCEANDPERFORMANCEIMPROVEMENTTABHERE

POLICY/PROCEDURE

SUBJECT:QualityAssuranceandPerformanceImprovement

DATE:

INTENT:

ThesepoliciesareintendedtoensurethefacilitydevelopsaplanthatdescribestheprocessforconductingQAPI/QAAactivities,suchasidentifyingandcorrectingqualitydeficienciesaswellasopportunitiesforimprovement,whichwillleadtoimprovementinthelivesofnursinghomeresidents,throughcontinuousattentiontoqualityofcare,qualityoflife,andresidentsafety.

POLICY:


1. QAPIProgram/Plan,Disclosure/GoodFaithAttempt

2. QAPI/QAAImprovementActivities

3. QAACommittee

POLICY/PROCEDURE

SUBJECT:QualityAssuranceandPerformanceImprovement

DATE:

INTENT:


POLICY:

Thefacility,willdevelop,implement,andmaintainaneffective,comprehensive,data-drivenQAPIprogramthatfocusesonindicatorsoftheoutcomesofcareandqualityoflife.

Thefacilitywill:

1. MaintaindocumentationanddemonstrateevidenceofitsongoingQAPIprogramthatmeetstherequirementsofthissection.Thismayincludebutisnotlimitedtosystemsandreportsdemonstratingsystematicidentification,reporting,investigation,analysis,andpreventionofadverseevents;anddocumentationdemonstratingthedevelopment,implementation,andevaluationofcorrectiveactionsorperformanceimprovementactivities;

2. PresentitsQAPIplantoaStateSurveyAgencyorFederalsurveyorateachannualrecertificationsurveyanduponrequestduringanyothersurveyandtoCMSuponrequest;and

3. PresentdocumentationandevidenceofitsongoingQAPIprogram'simplementationandthefacility'scompliancewithrequirementstoaStateSurveyAgency,FederalsurveyororCMSuponrequest.

4. AfacilitymustdesignitsQAPIprogramtobeongoing,comprehensive,andtoaddressthefullrangeofcareandservicesprovidedbythefacility.

5. Itmust:a. Addressallsystemsofcareandmanagementpractices;b. Includeclinicalcare,qualityoflife,andresidentchoice;c. Utilizethebestavailableevidencetodefineandmeasureindicatorsof

qualityandfacilitygoalsthatreflectprocessesofcareandfacilityoperationsthathavebeenshowntobepredictiveofdesiredoutcomesforresidentsofaSNForNF.

d. Reflectthecomplexities,uniquecare,andservicesthatthefacilityprovides.

6. Thegoverningbodyand/orexecutiveleadership(ororganizedgrouporindividualwhoassumesfulllegalauthorityandresponsibilityforoperationofthefacility)isresponsibleandaccountableforensuringthat:

a. AnongoingQAPIprogramisdefined,implemented,andmaintainedandaddressesidentifiedpriorities.

b. TheQAPIprogramissustainedduringtransitionsinleadershipandstaffing;

c. TheQAPIprogramisadequatelyresourced,includingensuringstafftime,equipment,andtechnicaltrainingasneeded;

d. TheQAPIprogramidentifiesandprioritizesproblemsandopportunitiesthatreflectorganizationalprocess,functions,andservicesprovidedtoresidentsbasedonperformanceindicatordata,andresidentandstaffinput,andotherinformation.

e. Correctiveactionsaddressgapsinsystems,andareevaluatedforeffectiveness;and

f. Clearexpectationsaresetaroundsafety,quality,rights,choice,andrespect.

7. AStateortheSecretarymaynotrequiredisclosureoftherecordsofsuchcommitteeexceptinsofarassuchdisclosureisrelatedtothecomplianceofsuchcommittee.

8. Goodfaithattemptsbythecommitteetoidentifyandcorrectqualitydeficiencieswillnotbeusedasabasisforsanctions.

POLICY/PROCEDURE

SUBJECT:QAACommittee

DATE:

INTENT:


POLICY:

Thequalityassessmentandassurancecommitteereportstothefacility'sgoverningbody,ordesignatedperson(s)functioningasagoverningbodyregardingitsactivities,includingimplementationoftheQAPIProgram.

Thecommitteewill:1. Developandimplementappropriateplansofactiontocorrectidentified

qualitydeficiencies;

2. Regularlyreviewandanalyzedata,includingdatacollectedundertheQAPIprogramanddataresultingfromdrugregimenreviews,andactonavailabledatatomakeimprovements.

3. Afacilitymustmaintainaqualityassessmentandassurancecommitteeconsistingataminimumof:

a. Thedirectorofnursingservices;b. TheMedicalDirectororhis/herdesignee;c. Atleastthreeothermembersofthefacility'sstaff,atleastoneofwho

mustbetheadministrator,owner,aboardmemberorotherindividualinaleadershiprole.

4. Thequalityassessmentandassurancecommitteereportstothefacility'sgoverningbody,ordesignatedperson(s)functioningasagoverningbodyregardingitsactivities,includingimplementationoftheQAPIprogram.

5. Thecommitteemust:a. Meetatleastquarterlyandasneededtocoordinateandevaluate

activitiesundertheQAPIprogram,suchasidentifyingissueswithrespecttowhichqualityassessmentandassuranceactivities,includingperformanceimprovementprojectsrequiredundertheQAPIprogram,arenecessary.

PLACETABFORINFECTIONCONTROLHERE

POLICY/PROCEDURE

SUBJECT:InfectionControl,General

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoInfectionControlinaccordancetoStateandFederalregulation.

PROCEDURE:

1. Infectionpreventionandcontrolprogram

2. AntibioticStewardshipProgram

3. InfluenzaandPneumococcalImmunization

POLICY/PROCEDURE

SUBJECT:InfectionPreventionandControlandSurveillanceProgram

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurethattheInfectionControlProgramisdesignedtoprevent,identify,report,investigate,andcontrolthespreadofinfectionsandcommunicablediseaseforallresidents,staff,volunteers,visitors,andotherindividualsprovidingservicesunderacontractualarrangement;provideasafe,sanitaryandcomfortableenvironment;andtohelppreventthedevelopmentandtransmissionofdiseaseandinfection,inaccordancewithStateandFederalRegulations,andnationalguidelines. PROCEDURE:

1. Thefacilitywillestablishandmaintainaninfectionpreventionandcontrolprogramunderwhichit:

a. Prevents,identifies,reports,investigates,andcontrolsthespreadofinfectionsandcommunicablediseaseinthefacility;

b. Conductssurveillanceforearlydetectionofinfections,clusters/outbreaks,andreportablediseasesandtotrackandtrendsurveillancedata;

c. Decideswhenandhowisolationshouldbeappliedtoanindividualresident;d. Prohibitsstaffwithacommunicableinfectionordiseaseorinfectedskin

lesionsfromdirectcontactwithresidentsortheirfood,ifdirectcontactwilltransmitthedisease/infection;and

e. Maintainsarecordofincidentsandcorrectiveactionsrelatedtoinfectionpreventionandcontrol.

2. Whentheinfectioncontrolprogramdeterminesthataresidentneedsisolationtopreventthespreadofinfection,thefacilitywillisolatetheresidentusingtheleastrestrictiveoptiongivencurrentcircumstances.(PleaseseetheStandardandTransmission-basedPrecautionsPolicyformoredetailedinformationregardingisolation.)

3. Thefacilitywillprovidepersonalprotectiveequipment(PPE)tosupportcompliancewithstandardandtransmission-basedprecautionsandensurethatitisreadilyavailableforstaffuse.StaffarerequiredtoadheretostandardprecautionsandusePPEaccordingtostandardprecautions.

4. Thefacilitywillprohibitstaffwithacommunicabledisease/infectionorhasinfectedskinlesionsfromdirectcontactwithresidentsortheirfood,ifdirectcontactwilltransmitthedisease.

a. TheCDCguidelinesforisolationandCDCguidelinesforinfectioncontrolinhealthcarepersonnel,1998willbeusedtodetermineemployeeexclusion.Employeesaretoreportsignsandsymptomsofillnesstotheirsupervisor.ThesupervisorwillreporttotheinfectionpreventiondesigneewhowilldetermineworkexclusionsasneededperCDCguidelines.

b. Allskinlesionsmustbecoveredanddressingsmustbedry.c. Staffthataresymptomaticofinfluenza-like-illnessarenottoprovidedirect

residentcarefor7daysaftersymptomonsetoruntil24hoursafterresolutionofsymptoms,whicheverislonger.

5. Thefacilitywillrequirestafftoperformhandhygieneasindicatedbynationalguidelines(Seehandhygienepolicyformoredetails).

6. Thefacilitywillensurelinensareproperlyhandled,stored,processed,andtransportedinawaytopreventthespreadofinfection(Seelinensmanagementpolicyformoredetails).

7. Thefacilitywillprovideinfectionpreventionandcontroltraininguponhireandongoingthroughouttheyearasneededinthefollowingareas:

a. Handhygiene;b. Standardprecautions;c. Transmission-basedprecautions;d. Personalprotectiveequipment;e. Propercleaninganddisinfectionofequipment;f. Properhandlingoflinens;g. Biomedicalwaste;h. Tuberculosisriskfactors,signs,andsymptoms;i. HIV/AIDS/bloodbornepathogens;andj. Otherinfectionpreventionandcontroltopicsasdeterminedby

programneeds(i.e.persurveillancedata)andopportunitiesforimprovement.

8. Thefacilityistomaintainasurveillancesystemwiththecapacitytoidentifypossiblecommunicablediseaseandinfectionsbeforetheycanspreadtootherpersonsinthefacility.

a. Toidentifyinfectionsthefollowinginformationregardingresidentsisreviewedonanongoingbasisandinformationistobecommunicatedbystaffinmeetings(e.g.morningmeeting)tothepersonresponsibleforinfectionpreventionandcontrol:

i. Signsandsymptoms(newlydevelopedorongoingandobservationsmadebystaffprovidingwoundcare);

ii. Laboratoryandotherdiagnostictestingorders;iii. Laboratoryandotherdiagnostictestingresults;iv. Newantibioticstarts;andv. Newadmissionrecords.

b. Thepersonresponsibleforinfectionpreventionandcontrolwillusetheinformationgatheredthroughthesevariousmeanstoidentifywhorequiresisolationprecautionsandtowhatextentaswellaswhichmedicalrecordsneedtobereviewedforsurveillancepurposes.

c. Nationallyrecognizedsurveillancecasedefinitions,knownastheMcGeercriteria,andthecriteriasetforthbytheCDC’sNationalHealthcareSafetyNetworkwillbeusedtoidentifyinfectionsforsurveillancepurposes.Onlythoseinfectionsmeetingthesecriteriawillberecorded.Thefacilitywilluse(insertnameofformthatwillbeusedforcollectingsurveillancedata)formstosupportdatacollectionandevaluationofmedicalrecordfordocumentinginfectionsforsurveillanceanddataanalysis.

d. Surveillancedataandprocessmeasuredata,suchashandhygienecomplianceandcompliancewithisolationprecautions,willbeanalyzedonamonthlybasis.Surveillancedatawillbetrackedandtrendedasnecessarytoidentifyclusteringofinfections,increasingordecreasingincidenceandprevalenceofinfections,andidentifyingopportunitiesforimprovementincurrentpracticesandevents/incidentsneedingcorrectiveactionplansorprocessimprovementactionplans.

e. Surveillancereportswillincludeinfection(i.e.outcome)dataandprocessmeasuredata(i.e.handhygienecompliance)tothedirectorofnursingandmedicaldirectoronamonthlybasis.ReportswillalsobereviewedbytheQualityAssuranceandAdvisorycommittee.

f. Anystaffwhosuspectaninfectionorcommunicablediseasethatmaywarrantisolationistonotifythepersonresponsibleforinfectionpreventionandcontrolortheirdesigneeorthedirectorofnursingtoensureisolationisappropriatelyimplementedwhennecessary.

g. Thelocalhealthdepartmentwillbenotifiedofallreportablediseasesidentifiedandofanyclustersoroutbreaksofanydiseaseinaccordancewithstatelaw.Allclustersandoroutbreakswillbeinvestigatedtoidentifybreachesininfectioncontrolandoropportunitiestoimprovecurrentpractices.

9. Anystaffmemberthatsuspectsabreachininfectionpreventionandcontrolpracticeorpolicyistoreportthistothepersonresponsiblefortheinfectionpreventionandcontrolprogramorthedirectorofnursingassoonaspossible.

10. AllsharedmedicalequipmentwillbecleanedusinganEPA-approveddisinfectantwipeeffectiveagainstTBandHepatitisB.

11. Thefacilitywillreviewitsinfectionpreventionandcontrolprogramannually,evaluateeffectiveness,andupdatetheprogramasneeded.

POLICY/PROCEDURE

SUBJECT:InfectionControl-AntibioticStewardship

DATE:

INTENT:ItisthepolicyofthefacilitytosupportthejudicioususeofantibioticsinaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

1. Thefacilitywillestablishprotocolsforantibioticprescribinginaccordancewithnationalguidelinesandtreatmentprotocols.

2. Thefacilitywillestablishalgorithmsforappropriatediagnostictesting(i.e.obtainingcultures)forspecificinfections.

3. Thefacilitywillsummarizeantibioticuseonaquarterlybasisandusethedatatoevaluateadherencetoantibioticprescribingprotocolsandappropriatediagnostictestingprotocols.

4. Thefacilitywillprovideanantibiogramannuallytomedicalstafftosupportprescribingpractices.

5. Prescribersaretodocumentdose,duration,andindicationforallantibioticprescriptions.

POLICY/PROCEDURE

SUBJECT:InfectionControl-InfluenzaandPneumococcalImmunizationsforResidents

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurethattheresidentreceivesInfluenzaandPneumococcalimmunizations,inaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

InfluenzaImmunization

1. Beforeofferingtheinfluenzaimmunization,eachresidentandortheresidentrepresentativereceiveseducationregardingthebenefitsandpotentialsideeffectsoftheimmunization;

2. EachresidentisofferedaninfluenzaimmunizationOctober1throughMarch31annually,unlesstheimmunizationismedicallycontraindicatedortheresidenthasalreadybeenimmunizedduringthistimeperiod;

3. Theresidentandortheresidentrepresentativehastheopportunitytorefuseimmunization;and

4. Theresident’smedicalrecordincludesdocumentationthatindicates,ataminimum,thefollowing:

i. Thattheresidentorresidentrepresentativewasprovidededucationregardingthebenefitsandpotentialsideeffectsofinfluenzaimmunization;and

ii. Thattheresidenteitherreceivedtheinfluenzaimmunizationordidnotreceivetheinfluenzaimmunizationduetomedicalcontraindicationsorrefusal.

PneumococcalImmunization

1. Beforeofferingthepneumococcalimmunization,eachresidentandorresidentrepresentativereceiveseducationregardingthebenefitsandpotentialsideeffectsoftheimmunization;

2. Eachresidentisofferedpneumococcalimmunization,unlesstheimmunizationismedicallycontraindicatedortheresidenthasalreadybeenimmunized;

3. Theresidentandorresidentrepresentativehastheopportunitytorefuseimmunization;and

4. Theresident’smedicalrecordincludesdocumentationthatindicates,ata

minimum,thefollowing:i. Thattheresidentorresidentrepresentativewasprovidededucation

regardingthebenefitsandpotentialsideeffectsofpneumococcalimmunization;and

ii. Thattheresidenteitherreceivedthepneumococcalimmunizationordidnotreceivethepneumococcalimmunizationduetomedicalcontraindicationorrefusal.

5. PneumococcalimmunizationwillbeofferedinaccordancewithCDCimmunizationalgorithmforPCV13andPPS23.http://www.cdc.gov/vaccines/vpd-vac/pneumo/downloads/adult-vax-clinician-aid.pdf

POLICY/PROCEDURE

SUBJECT:InfluenzaandPneumococcalImmunizationPolicyforStaff

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurethatappropriateinfectionpreventionandcontrolmeasuresaretakentopreventthespreadofinfectioninaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

1. AllfacilitystaffaretobeofferedinfluenzavaccinationeachyearinaccordancewiththeCentersforDiseaseControlandPrevention(CDC)andtheAdvisoryCommitteeonImmunizationPractices(ACIP)recommendations.

2. Staffwhoarenotvaccinatedarerequiredtosignavaccinationdeclinationform.

3. Staffwhoarenotvaccinatedarerequiredtoproperlywearamaskatalltimesinthefacilitywhentherearemedium–highlevels/local,regional,orwidespreadlevelsofinfluenzacirculatinginthecommunityperpublichealthreports.

4. AllfacilitystaffandresidentsaretobeofferedpneumococcalvaccinationinaccordancewiththeCentersforDiseaseControlandPrevention(CDC)andtheAdvisoryCommitteeonImmunizationPractices(ACIP)recommendations.

PROCEDURE

SUBJECT:InfectionControl-StandardandTransmission-basedPrecautions

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurethatappropriateinfectionpreventionandcontrolmeasuresaretakentopreventthespreadofcommunicablediseaseandinfectionsinaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

StandardPrecautions

1. Allstaffaretoadheretostandardprecautions.

a. Personalprotectiveequipmentistobeworntoprotecthealthcareworkers(i.e.haveabarrier)fromcontactwithbodyfluids.

b. Personalprotectiveequipmentincludesgloves,gowns,masks,gogglesandorfaceshield.

c. Thepersonalprotectiveequipmentwornwillvarybytaskbeingperformedandlikelihoodofexposuretobodyfluid.

2. Standardprecautionsapplytoallresidents.

Transmission-basedPrecautions

1. Transmission-basedprecautionsincludeairborne,contact,anddropletprecautions.Residentsrequiringairborneprecautionswillbetransferredtoahospitalorotherhealthcarefacilitywithairborneprecautioncapability.Residentsthatrequirecontactandordropletprecautionsmayremainatthisfacility.

2. Transmission-basedprecautionsareappliedinadditiontostandardprecautionsandinaccordancewithnationallyrecognizedguidelinessuchasthosefromtheCentersforDiseaseControlandPrevention(CDC),AssociationforProfessionalsinInfectionControl(APIC),andortheSocietyforHealthcareEpidemiologyofAmerica(SHEA).TheCentersforDiseaseControlandPreventionIsolationGuidelinesaretheprimaryresourcefordeterminingthetypeanddurationofisolationprecautions.

3. Whenaresidentisplacedontransmission-basedprecautions(i.e.isolation),theleastrestrictiveoptionforisolationgivencurrentcircumstanceswillbeused.

4. Transmission-basedprecautionsareappliedpresumptivelyoruponfirstsuspicionthataresidentmayhaveaninfectionthatrequirestransmission-basedprecautions.

5. Thedurationoftransmission-basedprecautions/isolationwillbebasedonnationallyrecognizedguidelinesanddeterminationstoremoveresidentsfromisolationprecautionswillbemadeonacase-by-casebasisbytheinfectionpreventionist/personsresponsibleforinfectionpreventionandcontrolprogramortheirdesigneeandorthedirectorornursing.Ataminimum,residentsmustbeasymptomaticandallbodyfluidsmustbecontainedinordertodiscontinueisolationprecautions.

a. Whenthereisanincreaseintheprevalenceofacertaintypeofinfectionorinfectionsduetothesameorganism,isolationprecautionsmayneedtobeextendeduntilcolonizationpressure(i.e.bioburden)decreasesinthefacility.

6. Allstaffincludingenvironmentalservicesstaffaretocomplywithtransmission-basedprecautions.

7. Todesignatearoomfortransmission-basedprecautions,asignwillbeplacedinthepocketofthecaddyandisyellowincolorforallinfectionsexceptC-Diff.Staffwillbenotifiedofthetypeoftransmission-basedprecautionsaresidentisplaceonandthereason.Staffarenotifiedduringshiftreport.

8. Anisolationcaddywithpersonalprotectiveequipmentandothersupplieswillbeplacedattheentranceoftheresidentroom.Ataminimum,thiscaddywillincludeappropriatepersonalprotectiveequipmentanddisinfectingwipes.

9. DisinfectantwipesareanEPA-registeredhospitaldisinfectanteffectiveagainstHBVorhaveatuberculocidalclaim.(PleaseseesectionbelowforrequirementsforroomsofresidentswithC.difficile.)

10. Allsharedmedicalequipmentusedin(transmission-basedprecautions)residentroomwillbewipeddownwithdisinfectingwipeuponexitoftheroom.Whenpossible,equipmentwillbededicatedtotheresidentwhileonprecautionsordisposableequipmentwillbeused.

11. Whenaresidentisplacedontransmission-basedprecautions,theresidentandtheirfamilymembersandvisitorsareeducatedabouttransmission-basedprecautions.

12. Contactprecautionsareimplementedmostoftenforresidentswhohaveaninfectionduetoanepidemiologicallyimportantorganismsuchasmulti-drugresistantorganism(MDRO).

a. Staffaretoputongownsandglovesuponroomentryandremovegownsandglovesuponexitofresidentroom.

b. Aprivateroomispreferredforresidentsoncontactprecautions.Cohortingresidentsoncontactprecautionswillbemadeonacase-by-casebasisbasedonriskoftransmissionbetweenroommates.

c. Residentsaretoremainintheirroomswhileoncontactisolationprecautions.Exceptions,forspecifiedactivity/time-limitedactivitythatdoesnotputotherresident’shealthatrisk,maybemadeonacase-by-casebasisbytheinfectioncontroldesigneeordirectorofnursing.

d. ResidentswithurinarytractinfectionsduetoMDRO(i.e.ESBL)arenotrequiredtobeplacedoncontactprecautionsaslongasallbodyfluidscanbecontained.Staffaretoweargownsandgloveswhenprovidingcareintheresident’sroom.

e. ResidentswithwoundinfectionsduetoMDRO(i.e.MRSA)arenotrequiredtobeplacedoncontactprecautionsaslongasallbodyfluidsarecontained(i.e.woundcanremaincoveredanddressingremainsdry).Staffaretoweargownsandgloveswhenprovidingcareintheresident’sroom.

f. Aterminal/deeproomcleaningistobecompletedwhenaresidentisremovedfromcontactprecautions.

13. ResidentswithC.difficileinfectionwillbeplacedonspecialcontactprecautions.a. Specialcontactprecautionsrequiretheuseofgownsandglovesuponentry

toroom,soapandwaterforhandhygieneaftercontactwiththeresidentortheircareenvironment.Gownsandglovesshouldberemovedanddiscardedatroomexit.

b. SpecialcontactprecautionsalsorequiretheuseofanEPA-approvedsporicidalorbleachbasedproductwithEPA-approvedclaimforkillingC.difficilesporesforcleaninganddisinfectionoftheresidentroomandequipment.

c. Residentroomsforspecialcontactprecautionswillbedesignatedwithabluesign.

d. Aresidentrequiringspecialcontactprecautionsisgivenpriorityforaprivateroom.Ifaprivateroomisnotavailable,roomplacementwillbeevaluatedanddeterminedbytheinfectioncontroldesignee.Ataminimum,residentswithC.difficileinfectionwillnotshareacommodewithanyotherresident(e.g.mayrequireuseofbedsidecommode).

e. Theresidentwillremainonspecialcontactprecautionsaslongastheyaresymptomatic.Todiscontinueprecautions,theresidentmustbeasymptomatic(i.e.nodiarrhea).Occasionally,specialcontactisolationmayneedtobeextendedbeyondthedurationofdiarrheaandshouldbereviewedonacase-by-casebasiswithinfectioncontroldesignee.

f. Residentsaretoremainintheirroomswhileonspecialcontactprecautions.g. Whenpossible,therapyserviceswillbeprovidedintheresident’sroom.If

therapycannotbeprovidedintheresident’sroom,andalloftheresident’sbodyfluidscanbecontained,thentheresidentmaybethelastpatientscheduledforthedayinthetherapyroom.Aterminalcleaning(usingappropriatedisinfectant)ofthetherapyareaandallequipmentusedduring

therapysessionwillbecompletedimmediatelyaftertheresidentcompletestherapy.

h. Ifresidentmustbetransportedfortherapyservices,priortotransporttocleanclothesmustbeputontheresident.Handsmustbewashedwithsoapandwater.Allequipment(i.e.wheelchairs,walkers,etc.)mustbewipeddownwithappropriatedisinfectingwipeuponexitoftheroom.

i. Aterminal/deeproomcleaningistobecompletedusinganEPA-approvedsporicidalorbleachsolutionof1:10whenaresidentisremovedfromspecialcontactprecautions.

14. Dropletprecautionsareimplementedmostoftenforresidentswhohaverespiratoryillness.

a. Staffaretoputonamaskuponroomentryandremoveduponroomexitofresidentplacedondropletprecautions.

b. Aprivateroomispreferredforresidentsplacedondropletprecautions.Cohortingresidentsondropletprecautionswillbemadeonacase-by-casebasisbasedonriskoftransmissionofinfection.

c. Ifaresidentondropletprecautionsmustsharearoom,thecurtainbetweenresidentsistoremainpulledacrossroom(toserveasabarrierbetweenresidents)atalltimeswhileresidentisondropletprecautions.

d. Residentsrequiringdropletprecautionsmayleavetheirroomiftheywearamaskatalltimeswhileoutoftheirroomandhandhygienecanbeperformedpriortoroomexit.Iftheresidentcannottolerateamask,thentheresidentistostayintheirroomwhileondropletprecautions.

e. Dropletprecautionsmaybeimplementedinadditiontocontactprecautionsforsomerespiratoryinfectionssuchas(butnotlimitedto)pneumoniaduetoMDRO,Adenovirus,andRSV(PleaseseeCDCIsolationGuidelinesforcompletelist.

f. Aterminal/deeproomcleaningistobecompletedwhenaresidentisremovedfromdropletprecautions.

RespiratoryHygiene/Etiquette

1. Staffaretoperformrespiratoryhygienebycoughingandsneezingintoarm,sleeve,ortissue.

2. Handhygieneistobeperformedafterdiscardingsoiledtissueoraftersoilinghands.

3. Staffaretoeducateresidentsandvisitorsontheimportanceofrespiratoryhygiene.

4. Staffthataresymptomaticofinfluenza-like-illnessarenottoprovidedirectresidentcarefor7daysaftersymptomonsetoruntil24hoursafterresolutionofsymptoms,whicheverislonger.

POLICY/PROCEDURE

SUBJECT:InfectionControl-CleaningandDisinfection/Non-criticalcareandsharedequipment

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethatappropriateinfectionpreventionandcontrolmeasuresaretakentoprovideasafe,sanitary,andcomfortableenvironmenttopreventthespreadofinfectioninaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

1. Cleaninganddisinfectionofthefacilityincludingresidentroomsiscompletedinaccordancewithenvironmentalservicespoliciesandprocedures.

2. Residentrooms,includingroomsofresidentsontransmission-basedprecautions,arecleaneddaily.

a. RoomsofresidentswithClostridiumdifficileinfectionarecleanedanddisinfectedinaccordancewithtransmission-basedprecautionspolicy.

3. Whenresidentsareintheirroomattimeofcleaning,staffaretobecarefulnottodisturbdustorcleanabovearesident’shead.

4. Environmentalservicesstaffistofocusoncleaninganddisinfectionofhigh-touchsurfacessuchasTVremotes,callbuttons,over-bedtables,etc.

5. Non-criticalmedicalequipment(equipmentthatonlycomesincontactwithintactskin)istobewipeddownwithadisinfectantwipeoncepershiftandasneededwhensoiled.Anyequipmentusedinroomswhilearesidentisontransmission-basedprecautionsistobecleanedwithadisinfectantwipeimmediatelyafteruse/uponexitofroom.

a. Wheelchairsthatarededicatedtooneresidentarecleanedanddisinfectedonaregularscheduleandasneededwhensoiled.

b. Wheelchairsthatarenotdedicatedshouldbewipeddownafteruse/priortoremovalfromresidentroom.

6. Workstationonwheels/computeronwheelsaretobewipedwithdisinfectantwipebyresidentcarestaffoncepershift,asneededwhensoiled,andimmediatelyafteruseintheroomofaresidentontransmission-basedprecautions.

7. DisinfectantwipesareanEPA-registeredhospitaldisinfectantwithtuberculocidalclaim(i.e.intermediateleveldisinfectant).Floorsmaybecleanedwithlow-leveldisinfectant.

8. Terminal/Deeproomcleaningistobecompletedwhenaresidentisremovedfromtransmission-basedprecautions.

9. Privacycurtainsareremovedandlaunderedonaregularschedule,asneededwhensoiled,andwhenaresidentisremovedfromtransmission-basedprecautions.

BloodandBodyFluidSpills

1. Staffcleaningupbloodandbodyfluidspillsaretowearappropriatepersonalprotectiveequipment(basedonsizeandlocationofspillanddisinfectantproductused).

2. Anabsorbentmaterialsuchascottonmopheadorpapertowelsshouldbeusedtosoakupblood/bodyfluidpriortocleaningareawithdisinfectant.AnEPA-registereddisinfectanteffectiveagainstbloodbornepathogensincludingHepatitisBorbleachsolutionisusedtocleanarea.

3. Materialscontaminatedwithbloodorbodyfluids(excepturineandfeceswithoutthepresenceofblood)arediscardedintobiohazardouswastecontainers.

POLICY/PROCEDURE

SUBJECT:InfectionControl-CentralVenousCatheter/CentralLineAccessandMaintenance

DATE:

INTENT:


PROCEDURE:

1. Performhandhygienepriortoaccessingacentrallineorperformingadressingchangeanddonamaskandcleanorsterilegloves.

2. Anytimethecentrallineisaccessed,theaccessportorhubisscrubbedwithanappropriateantiseptic(e.g.chlorhexidine,povidoneiodine,aniodophor,or70%alcohol).

3. Onlysteriledevicesmaybeusedwhenaccessingacentralline.

4. Dressingsthatarewet,soiled,ordislodgedshouldbereplacedusingaseptictechniquewithsterileorcleangloves.Otherwise,transparentdressingsarechangedeveryseven(7)daysandsterilegauzedressingsarechangedeverytwo(2)days.

POLICY/PROCEDURE

SUBJECT:InfectionControl-CleanDressingChange

DATE:

INTENT:

ItisthepolicyofthefacilitytoensurechangedressingsinaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

1. Verifyandreviewphysician’sorderforprocedure.

2. Performhandhygieneandassembleequipmentandsuppliesneededfordressingchange.


4. Evaluateresident’spainandtheneedforpainmedication.

5. Putongloves.Adjustbedsidestand/tabletowaistlevel.Cleanbedsidestand/tablewithgermicidaldisposablecloth.Establishacleanfield.



8. Set-upsuppliesonbarrier.


10. Performhandhygiene.


12. Removedressingandplaceintheresident’strashcan.


14. Putoncleangloves

15. Cleansewoundwithgauzeandprescribedcleaningsolutionusingsingleoutwardstrokes.Useseparategauzeforeachcleansingwipe.

16. Usedrygauzetopatthewounddry.

17. Removeglovesandpreformhandhygiene.


19. Applycleandressingasorderedandensurethedressingisdated.


21. Repositiontheresidentandensurethecalllightisinplace.

22. Discardalldisposableitemsintotheappropriatereceptacle.

23. Cleanthebedsidestand/tablewithgermicidaldisposablecloth.

24. Removetrashfromresident’sroom.


26. Documentthecompletionofdressingchangeonthetreatmentrecord.

POLICY/PROCEDURE

SUBJECT:InfectionControl-FoodHandling

DATE:

INTENT:

Itisthepolicyofthefacilitytoprocure,store,prepare,distribute,andservefoodundersanitaryconditionsfollowingpropersanitationandfoodhandlingpracticestopreventtheoutbreakoffoodborneillnessinaccordancewithStateandFederalRegulations.

PROCEDURE:

1. Foodservicesstaffaretowashhandswhen:enteringafoodpreparationarea;beforeputtingongloves;beforepreparingfood;whenchangingtasks(i.e.switchingfromworkingwithrawfoodstoreadytoeatfoods);afterhandlingsoileddishes,utensils,andequipment;afterusingthebathroom;aftercoughing,sneezing,eatingordrinking;andafterhandlingshellfish.

2. Handsaretobewashedinsinksdesignatedforhandwashingonly.

3. Ready-to-eatfoodsshouldnotbetouchedwithbarehands.

4. Single-useglovesarenottobeusedformorethanonetask.Changeglovesandperformhandhygienebetweentasks.

5. Thefacilitywillprohibitemployeeswithsignsorsymptomsofinfection(i.e.vomiting,diarrhea,jaundice,sorethroatwithfever)thatmaybetransmittedtoresidentsoranyexposedboiloropen,infectedwoundorcutsonthehandsorarmsfromcontactwithresidentsortheirfood.

6. Foodservicesstaffaretoeatanddrinkindesignatedareasawayfromexposedfood,foodequipment,utensils,oritemsthatrequireprotection.

7. Temperaturesofrefrigeratorsandfreezerswillbemonitoreddailyanddocumented.Refrigeratorsshouldbe<40⁰Fandthefreezerat0⁰Forbelow.

8. Foodsaretobecookedtoappropriatetemperatures.

9. Foodaretobeheldatappropriatetemperatureswhilebeingserved.Monitoringoffoodtemperaturesusingfoodthermometershouldbeperformedregularly.

10. Foodshouldbeproperlylabeledandexpiredfoodswillbediscarded.

11. Foodleftoutatroomtemperatureformorethantwo(2)hourswillbediscarded.

POLICY/PROCEDURE

SUBJECT:InfectionControl-HandHygiene

DATE:

INTENT:

ItisthepolicyofthefacilitytoperformhandhygieneinaccordancewithnationalstandardsfromtheCentersforDiseaseControlandPreventionandtheWorldHealthOrganization.

PROCEDURE:

1. Soapandwaterisrequiredforhandhygienewhen:a. Handsarevisiblysoiled;b. AftercaringforresidentwithdiarrhealinfectionsuchasC.difficile;c. Afterpotentialexposuretobodyfluid;d. Beforeandaftereatingorhandlingfood;ande. Afterpersonaluseoftoilet.

2. Alcohol-basedhandrubmaybeusedforallotherhandhygieneopportunities(e.g.whensoapandwaterisnotindicatedper#1above).AccordingtotheWorldHealthOrganization,handhygieneistobeperformed:a. Priortocaringforaresident;b. Priortoperformingaproceduresuchasbloodglucosemonitoringor

cathetercare;c. Whenmovingfromacontaminatedbodysitetoacleanbodysitesuchas

whenchangingabrieforwounddressing;d. Aftercaringforaresidentincludingafterremovinggloves;ande. Aftercontactwiththeresidentenvironment.

3. TheCentersforMedicareandMedicaidStateOperationsManualindicatesthathandhygieneshouldbeperformed:a. Whencomingonduty;b. Beforeandafterperforminganyinvasiveprocedure(e.g.fingerstickblood

sampling);c. Beforeandafterenteringisolationprecautionsettings;d. Beforeandafterassistingaresidentwithmeals;e. Beforeandafterassistingaresidentwithpersonalcare;f. Beforeandafterhandlingperipheralvascularcathetersandotherinvasive

devices;g. Beforeandafterinsertingindwellingcatheters;h. Beforeandafterchangingadressing;i. Uponandaftercomingincontactwitharesident’sintactskin(e.g.when

takingapulseorbloodpressure,andliftingaresident);

j. Beforeandafterassistingaresidentwithtoileting;k. Afterblowingorwipingnose;l. Aftercontactwitharesident’smucousmembranesandbodyfluidsor

excretions;m. Afterhandlingsoiledorusedlinens,dressing,bedpans,catheters,and

urinals;n. Afterhandlingsoiledequipmentorutensils;o. Afterremovingglovesoraprons;andp. Aftercompletingduty.

4. Residentcarestaffmustkeepfingernailsshort,nolongerthan¼ofaninch.

5. Residentcarestaffarenotpermittedtohaveartificialnailsornailextendersofanytype.

6. Residentcarestaffmaywearfingernailpolishhoweverpolishmustnotbechipped.Ifastaffmemberhaschippednailpolish,theywillbeaskedtoremovetheirnailpolishimmediately.

POLICY/PROCEDURE

SUBJECT:InfectionControl-IndwellingCatheterCare

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurethattheresidentsreceivecareandservicestopreventurinarytractinfectionsinthoseresidentswithanindwellingcatheter,inaccordancewithstandardsofpractice.

PROCEDURE:

1. Performhandhygienebeforebeginningtheprocedureandassembleallsupplies.

2. Knockbeforeenteringroom,introduceselfandexplainproceduretotheresident.

3. Placesuppliesonthebedsidestandorover-bedtableandarrangesuppliessothattheycanbeeasilyreached.Pullthecubiclecurtainaroundthebedforprivacy.

4. Performhandhygieneandputongloves.

5. Positionresidentforcomfort.

6. Usingdisposablewipescleanse:femalelabiawithsingledownward,cleansingstrokeusingadifferentsideofthewipeforeachcleansingstrokeforeachsideofthelabiaandtheurethralmeatus;maleglanswithcircularstrokesfromthemeatusoutward,usingadifferentsideofwipeforeachcleansingcircularstrokeasneeded.Foruncircumcisedmales,retracttheforeskincleansethemeatusasdescribedandreturnforeskintonormalposition.

7. Securecathetertubingwithnon-dominanthandandwithasingledownward,

cleansingstrokecleansecathetertubingfrommeatustowardscollectionbag.

8. Turnresidentonsidetoperformbacksidecleansingagainusingsinglecleansingstrokesfromfronttobackandrepositionresidentforcomfort.

9. Discardsupplies,removeglovesandwashhands.

POLICY/PROCEDURE

SUBJECT:InfectionControl-IndwellingUrinaryCatheterUse

DATE:

INTENT:

ItisthepolicyofthefacilitytoensuretheappropriateuseofindwellingurinarycathetersinaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

1. IndwellingurinarycathetersaretobeusedwhenindicatedaccordingtonationalguidelinessuchasthosebytheHealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC)Guidelines(oftenreferredtoastheCentersforDiseaseControlandPreventionguidelines).Exceptionsmaybemadeonacase-by-casebasisuponevaluationbyinfectionpreventionandcontrolcoordinator,directorofnursing,andorderingphysician.

2. IndicationsforusingindwellingurinarycathetersperHICPACguidelinesinclude:a. Residenthasacuteurinaryretentionorbladderoutletobstruction;b. Needforaccuratemeasurementsofurinaryoutputincriticallyill

residents;c. Perioperativeuseforselectedmedicalprocedures;d. Toassistinhealingofopensacralorperinealwoundsinincontinent

residents;e. Residentrequiresprolongedimmobilization;andf. Toimprovecomfortforendoflifecare.

3. Urinarycathetersarenottobeusedtomanageincontinence.

4. Urinarycathetersaretobediscontinuedwhenresidentnolongermeetsindicationforuse.Resident’sindicationforuseofanindwellingurinarycatheterisreviewedregularlybynursingstaff.

5. Indwellingurinarycathetersanddrainagebagsshouldnotbechangedatroutineorfixedintervals.Indwellingurinarycathetersanddrainagebagsarechangedwhenthereisindicationofinfection,obstruction,orasclinicallyindicated.

6. Ifanindwellingurinarycatheterhasbeeninplacefor14daysormore,itshouldbechangedpriortocollectingaurinespecimenforlaboratorytesting.

POLICY/PROCEDURE

SUBJECT:InfectionControl-LinenManagement

DATE:

INTENT:

Itisthepolicyofthefacilitytoensurelinensarehandlinginawaytopreventcross-contaminationandthespreadofinfectioninaccordancewithStateandFederalRegulations,andnationalguidelines.

PROCEDURE:

1. Cleanlinensaretobekeptcoveredandprotectedfromdustandothercontaminantspriortouse.

2. Cleanlinensaretonottocomeincontactwithstaffclothing(i.e.carrylinensawayfromthebody).

3. Cleanlinensshouldnottouchthefloorwhenfolded.

4. Laundryequipmentshouldbeproperlymaintainedaccordingtomanufacturer’sinstructions.

5. Cleananddirtylinenareasshouldbeseparateandclearlydesignated.Onlycleanlinensaretransportedoncleancartsandonlydirtylinensaretransportedincontainersdesignatedfordirtylinens.

6. Dirtylinensarecontainedinaclosedcontainerorbag.

7. Dirtylinensarenottocomeincontactwithstaffclothing(i.e.agownmayberequiredtopreventcontactbetweenstaffclothingandsoiledlinens).

8. Dirtylinensaretobehandledinawaytopreventaerosolizinginfectiousagents(i.e.donotshakelinens).

9. Dirtylinensshouldbefoldedinwardsothatmostofthecontaminationistowardtheinside.

POLICY/PROCEDURE

SUBJECT:InfectionControl-MedicationAdministration

DATE:

INTENT:


PROCEDURE:

1. Handhygieneisperformedpriortohandlinganymedication.

2. Knockbeforeenteringroom,introduceselfandletresidentknowwhatmedicationsyouwillbeprovidingandifanysideeffectsareexpected.

3. Verifytheresident’sidentityusingtwoidentifierssuchasnameanddateofbirth.

4. Verifymedicationnameandlabelcomparedtophysicianorderormedicationadministrationrecord(MAR),verifydosage,andverifyrouteofadministration(i.e.orally,intravenous,orsubcutaneous).

5. Verifymedicationisbeingprovidedattherighttimeperphysicianorders/medicationadministrationrecord.

6. Documentmedicationtaken,orrefusedbyresident,includingtimeandresidentresponsetomedication.

7. Expiredmedicationsaretobeproperlydiscarded.Medicationsarelabeledandexpirationdatesarecheckedregularly.

8. Syringesareunwrappedattimeofuse.

9. Medicationsaretobedrawnupinacleanarea(i.e.awayfromsinksandnotinresidentroom).

10. Ifthesterilityofamedicationiscompromised,orsuspectedofbeingcompromised,themedicationisdiscarded.

11. Refrigeratorsusedtostoremedicationsdonotincludeanyitemsotherthanmedications.

12. Temperatureismonitoreddailyanddocumented.

POLICY/PROCEDURE

SUBJECT:InfectionControl-PointofCareDevicesandInjectionSafety

DATE:

INTENT:


PROCEDURE:

1. SharedpointofcaredevicesaretobecleanedanddisinfectedbeforeandaftereachusewithadisinfectantwipeincludedonEnvironmentalProtectionAgency(EPA)ListD(https://www.epa.gov/pesticide-registration/list-d-epas-registered-antimicrobial-products-effective-against-human-hiv-1)Ifdeviceisvisiblysoiled,itistobewipedcleanpriortousingdisinfectantwipe.

2. Pointofcaredevicesthatarenotsharedaretobestoredinplasticbagsthatareproperlylabeledwithresident’snameinordertopreventcross-contaminationwhiledeviceisnotinuse.Pointofcaredevicesaretobewipedclean/disinfectedaccordingtomanufacturer’sinstructions.

3. Onlyasinglesetofsupplies(i.e.teststrips,lancets,etc.)maybetakenintotheresidentroom.Anyadditionalsuppliesthataretakenintotheroomthatarenotusedaretobeproperlydiscardedintheresidentroom.

4. Suppliesarenottobecarriedinpocketsofclothing.

5. Alllancets,fingerstickdevices,andinjectionequipmentaretobedisposedofinanapprovedsharpscontaineratpointofuse.

6. Insulinpensarenotshared.Insulinpensareassignedtooneperson.

InjectionSafety

1. Allneedlesandsyringesareusedonlyonetime.

2. Onlyacleanneedleandcleansyringemaybeusedtoenteramedicationvial.

3. Bagsorbottlesofintravenoussolutionmayonlybeusedforoneresident.

POLICY/PROCEDURE

SUBJECT:InfectionControl-Tuberculosis(TB)ScreeningProgram

DATE:

INTENT:

ItisthepolicyofthefacilitytoensuretheimplementationofaTuberculosisScreeningPrograminaccordancewithStateandFederalRegulations,andtheCentersforDiseaseControlandPrevention(CDC)guidelines.

PROCEDURE:

1. ThefacilityinfectioncontrolcoordinatorordesigneeisresponsiblefortheTBprogram.

2. ThefacilitywillconductaTuberculosis(TB)riskassessmentannually.

3. Thefacilitystaffwillbetrainedonsigns,symptoms,andriskfactorsforTB.

4. ThefacilitywillscreenallstaffuponhireforTB.a. Staffwhotestpositive,willrequireachestX-rayandfollow-up

assessmentbyahealthcareprovider.

5. Thefacilitywillscreensymptomaticandorhighriskresidentsuponadmission.

6. Thefacilitywillre-screenstaffforTBbasedontheresultsoftheannualriskassessmentandCDCguidelines.Ifthefacilityisinthelowriskcategory,asdefinedbyCDC,thenstaffwillnotbere-screened.

7. Thefacilitymayre-screenstaffandresidentssuspectedofbeingexposedtoapersonwithTB.

8. ResidentssuspectedofhavingorhavingactiveTBwillbetransferredtoafacilitywithairborneprecautioncapabilityassoonaspossible.

9. ThefacilitywillnotifythelocalhealthdepartmentofsuspectedorconfirmedTBcasetoconductaninvestigationtoidentifypotentialhealthcarestaffexposures.Thefacilitywillfollowpublichealthguidanceregardingpost-exposurescreeningandprophylaxisprotocols.

10. StaffwhodevelopactiveTBinfectionwillbeexcludedfromworkuntiltheyaredeterminedtonotbeinfectiousbyamedicalprovider.Thistypicallyoccursafterreceiptofadequatetherapy(i.e.antibiotics),coughhasresolved,andtherearethreeconsecutivesputumsmearsnegativeforacid-fastbacilli.

11. ResidentswillbeassesseduponadmissionforsignsandsymptomsofTBandriskfactorsforTBexposure.IfresidentissuspectedofhavingTBwillbereferredformedicalevaluation.ResidentswhomaybeathighriskforhavinghadarecentexposuretoTBwillbescreened(i.e.skintest).

PLACETABFORPHYSICALENVIRONMENTHERE

POLICY/PROCEDURE

SUBJECT:PhysicalEnvironment

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoPhysicalEnvironmentinaccordancetoStateandFederalregulation.

PROCEDURE:


1. EmergencyElectricalPowerSystem

2. SpaceandEquipment

3. EssentialEquipment,SafeOperatingCondition

4. ResidentBed

5. ResidentRoom

6. BedroomNumberofResidents

7. BedroomsMeasureatLease80SquareFt/Resident

8. BedroomsHaveDirectAccesstoExitCorridor

9. BedroomsAssureFullVisualPrivacy

10. ResidentRoomWindow

11. ResidentRoomFloorAboveGrade

12. ResidentRoomBed/Furniture/Closet

13. BedroomsEquipped/NearLavatory/Toilet

14. ResidentCallSystem

15. RequirementsforDiningandActivityRooms

16. Safe/Functional/Sanitary/ComfortableEnvironment

17. ProcedurestoEnsureWaterAvailability

18. Ventilation

19. CorridorsHaveFirmlySecuredHandrails

20. MaintainsEffectivePestControlProgram

21. SmokingPolicies

POLICY/PROCEDURE

SUBJECT:EmergencyElectricalPowerSystem

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideEmergencyElectricalPowerinaccordancetoStateandFederalregulations.

PROCEDURE:Thispolicyhasintentionallybeenleftblank

POLICY/PROCEDURE

SUBJECT:SpaceandEquipment

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideareaslargeenoughtocomfortablyaccommodatetheneedsoftheresidentswhousuallyoccupythisspaceandEquipmentmaintainedinsafeandworkingorder,inaccordancetoStateandFederalregulations.

PROCEDURE:

1. Thefacilitywillprovidesufficientspaceandequipmentindining,healthservices,recreation,andprogramareastoenablestafftoprovideresidentswithneededservicesasrequiredbythesestandardsandasidentifiedineachresident’sassessmentandplanofcare.

2. Theseareaswillhavespaceforstoringandutilizingmobilitydevices,assistivetechnology,physicaltherapyoradaptiveequipmentasidentifiedintheresidentassessmentandplanofcare.

3. Thefacilitywillmaintainallmechanical,electrical,andpatientcareequipmentinsafeoperatingcondition.

4. Equipmentwillbemaintainedaccordingtomanufacturer’srecommendations.

POLICY/PROCEDURE

SUBJECT:ResidentBed

DATE:

INTENT:

Itisthepolicyofthefacilitytomaintainessentialequipmentinasafeoperatingcondition,inaccordancetoStateandFederalregulations.

PROCEDURE:

1. ThefacilitywillconductRegularinspectionofallbedframes,mattresses,andbedrails,ifany,aspartofaregularmaintenanceprogramtoidentifyareasofpossibleentrapment.

2. Whenbedrailsandmattressesareusedandpurchasedseparatelyfromthebedframe,thefacilitywillensurethatthebedrails,mattress,andbedframearecompatible.

3. Thefacilitymayreferto“GuidetoBedSafetyRailsinHospitals,NursingHomesandHomeHealthCare:TheFacts”astotheproperdimensionsanddistancesapartofvariouspartsofthebedsuchasdistancebetweenbedframesandmattresses,bedrailsandmattressetc.toprevententrapmentbyusersofthebed.

POLICY/PROCEDURE

SUBJECT:ResidentRooms

DATE:

INTENT:

Itisthepolicyofthefacilitytoprovideareaslargeenoughtocomfortablyaccommodatetheneedsoftheresidentswhousuallyoccupythisspace,inaccordancetoStateandFederalregulations.

PROCEDURE:

1. Residentroomswillbedesignedandequippedforadequatenursingcare,comfort,andprivacyofresidents.

2. Thefacilitywillensurebedroomswill:a. Accommodatenomorethanfourresidents,forfacilitiesthatreceive

approvalofconstructionorreconstructionplansbyStateandlocalauthoritiesorarenewlycertifiedafterNovember28,2016,bedroomsmustaccommodatenomorethantworesidents;

b. Measureatleast80squarefeetperresidentinmultipleresidentbedrooms,andatleast100squarefeetinsingleresidentrooms;

c. Havedirectaccesstoanexitcorridor;d. Bedesignedorequippedtoassurefullvisualprivacyforeachresident;e. Exceptinprivaterooms,eachbedmusthaveceilingsuspendedcurtains,

whichextendaroundthebedtoprovidetotalvisualprivacyincombinationwithadjacentwallsandcurtains;

f. Haveatleastonewindowtotheoutside;g. Haveaflooratorabovegradelevel;andh. Eachresidentroomwillbeequippedwithorlocatedneartoiletand

bathingfacilities.ForfacilitiesthatreceiveapprovalofconstructionfromStateandlocalauthoritiesorarenewlycertifiedafterNovember28,2016,eachresidentialroommusthaveitsownbathroomequippedwithatleastacommodeandsink.

3. Thefacilitywillprovideeachresidentwith:a. Aseparatebedofpropersizeandheightforthesafetyandconvenience

oftheresident;b. Aclean,comfortablemattress;c. Beddingappropriatetotheweatherandclimate;d. Functionalfurnitureappropriatetotheresident’sneeds,ande. Individualclosetspaceintheresident’sbedroomwithclothesracksand

shelvesaccessibletotheresident.

POLICY/PROCEDURE

SUBJECT:SafeEnvironment

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideasafeenvironmentinaccordancetoStateandFederalregulations.

PROCEDURE:

1. Thefacilitywillbedesigned,constructed,equippedandmaintainedtoprotectthehealthandsafetyofresidents,personnel,andthepublic.

2. Thefacilitywillmaintainallessentialmechanical,electricalandpatientcareequipmentinsafeoperatingcondition.

3. Thefacilitywillprovideoneormoreroomsdesignatedforresidentdiningandactivities.

4. Thefacilitywillensurethatthedesignatedareasarewelllighted,wellventilated,adequatelyfurnishedandhavesufficientspacetoaccommodateallactivities.

5. Thefacilitywillprovideasafe,functional,sanitary,andcomfortableenvironmentforresidents,staffandthepublic.

6. Thefacilitywillhaveadequateoutsideventilationbymeansofwindows,ormechanicalventilation,oracombinationofthetwo.

7. Thefacilitywillmaintainthefacilitypremisesandequipmentandconductitsoperationsinasafeandsanitarymanner.

8. Thefacilitywillprovideasafe,clean,comfortable,andhomelikeenvironment,whichallowstheresidenttousehisorherpersonalbelongingstotheextentpossible.

9. Thefacilitywillprovide:a. housekeepingandmaintenanceservicesnecessarytomaintainasanitary,

orderly,andcomfortableinterior;b. cleanbedandbathlinensthatareingoodcondition;c. privateclosetspaceforeachresident;d. furniture,suchasabed-sidecabinet,drawerspace;e. adequateandcomfortablelightinglevelsinallareas;f. comfortableandsafetemperaturelevels;andg. maintaincomfortablesoundlevels.Individualradios,TVsandothersuch

transmittersbelongingtotheresidentwillbetunedtostationsoftheresident'schoice.

10. Thefacilitywillequipcorridorswithfirmlysecuredhandrailsoneachside.

11. Thefacilitywillmaintainaneffectivepestcontrolprogramsothatthefacilityisfreeofpestsandrodents.

12. Thefacilitywillmaintainadequatelightinglevelsinallareassuitabletotaskstheresidentchoosestoperformorthefacilitystaffmustperform.Comfortablelightingwillminimizeglareandprovidemaximumresidentcontrol,wherefeasible,tomaintainorenhanceindependentfunctioning.

13. Thefacilitywillmaintaincomfortableandsafetemperaturelevelsbetween71-81degreesF(Fahrenheit).

14. Thefacilitywillmaintaincomfortablesoundlevelsthatdonotinterferewithresident’shearingandenhanceprivacyandsocialinteractionasdesired.

15. Thefacilitywillbeadequatelyequippedtoallowresidentstocallforstaffassistancethroughacommunicationsystemwhichrelaysthecalldirectlytoastaffmemberortoacentralizedstaffworkareafromtoiletandbathingfacilities.

16. Thefacilitywillestablishpolicies,inaccordancewithapplicableFederal,State,andlocallawsandregulations,regardingsmoking,smokingareas,andsmokingsafetythatalsotakeintoaccountnon-smokingresidents.

17. Thefacilitywillestablishprocedurestoensurethatwaterisavailabletoessentialareaswhenthereisalossofnormalwatersupply.

POLICY/PROCEDURE

SUBJECT:ResidentSmoking

DATE:

INTENT:

Thisfacilityprovidesasafeandhealthyenvironmentforresidents,visitors,andemployees,includingsafetyasrelatedtosmoking.Safetyprotectionsapplytosmokingandnon-smokingresidentsinaccordancetoStateandFederalregulations.

PROCEDURE:

1. InaccordancewiththeFloridaCleanIndoorAirActandCityandCountyOrdinances,allindoorsmokingisprohibited.

2. Effective3/1/04,PinesofSarasotaSNFwasdesignatedasasmoke-freefacility.ResidentswhosmokearenotpermittedtosmokeinanypartofthePinesofSarasotaCampus.

3. Forresidentsadmittedpriorto3/1/04whoneedsupervision,staffwillaccommodateresident’srequesttosmokeonan“asneeded”basis.

4. Iffoundviolatingthefacilitypolicy,theindividualwillbeaskedtoextinguishthelightedtobaccoproductandmaybegivena30daywrittennoticetoleave.Residentswhofailtoimmediatelydiscontinueuseofalltobaccoproducts,paraphernaliaandorelectroniccigarettes,whichmaybedeemedasafetyhazardtoresidents,stafforvisitorsimmediatedischargewillbenecessary.

5. Employeesarepermittedtosmokeonlyduringtheirmealorauthorizedbreaksindesignatedarea.

6. Chewingtobaccoproductsarenotpermitted.

7. ElectronicSmokingDevicesarenotpermitted.

8. Safetymeasuresforthedesignatedsmokingareawillinclude,butnotlimitedto:a. Protectionfromweatherconditions(i.e.covered).b. Provisionofashtraysmadeofnoncombustiblematerialandsafedesign.c. Accessiblemetalcontainerswithself-closingcoversintowhichashtrayscanbe

emptied.d. Accessiblefireextinguisher.e. Prohibitionofoxygenuseinthesmokingarea.f. StaffSupervision.

9. Nosmokingsignswillbemaintainedonthedoororgatewhereoxygenisusedor

stored.

10. Residentsandfamilymemberswillbenotifiedofthispolicyduringtheadmissionprocess,andasneeded.

11. Allresidentswillbeaskedabouttobaccouseduringtheadmissionprocess,andinconjunctionwiththeRAIProcess.

12. NewlyadmittedresidentswhosmokewillnotbepermittedtosmokeonCampus.

13. Ifaresidentwhosmokesexperiencesanydeclineinconditionorcognition,he/shewillbereassessedforabilitytosmokeindependentlyand/ortoevaluatewhetheranyadditionalsafetymeasuresareindicated.

14. Allsafesmokingmeasureswillbedocumentedoneachresident’scareplanandcommunicatedtoallstaff,visitors,andvolunteers.Supervisionwillbeprovidedasindicatedoneachresident’scareplan.

15. Ifaresidentorfamilymemberdoesnotabidebythesmokingpolicyorcareplan(e.g.smokingmaterialsareprovideddirectlytotheresident,smokinginnon-smokingareas,doesnotwearprotectivegear),theplanofcaremayberevisedtoincludeadditionalmeasuressuchasroomsearches,prohibitedsmoking,orevendischarge.

16. Residentswillbeallowedtosmokeattheirdiscretion332.

17. IfyouareasmokerandwouldlikeSmokingCessationEducationmaterialspleaseseebelow:

WebsitesVisitthesewebsitesforself-helpsupportandeducationmaterial:www.quitnet.com www.americanheart.orgwww.ffsoline.org www.cancer.orgwww.quitsmokingsupport.com www.smokefree.govwww.gotaquit.com www.cancer.govwww.lungusa.comPhoneSupport1-877-UCANNOWor877-822-6669–FloridaQuitforlifelineprovidesfivefreecounselingsessions1-800-4CANCERor800-422-6237–NationalCancerInstituteprovidesfreesmokingcessationbyphone1-866-66-STARTor866-667-8278–GreatStartCampaigntoreducesmokingduringpregnancy

INSERTTABFORTRAININGREQUIREMENTSHERE

POLICY/PROCEDURE

SUBJECT:TrainingRequirements

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovideaStaffEducationPlaninaccordancewithStateandFederalregulations.

PROCEDURE:


1. AbuseNeglectandExploitationTraining

2. RequiredIn-ServiceTrainingforNurseAides

3. TrainingforFeedingAssistants

POLICY/PROCEDURE

SUBJECT:Abuse,NeglectandExploitationTraining

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywilldevelop,implement,andmaintainaneffectivetrainingprogramforallnewandexistingstaff;individualsprovidingservicesunderacontractualarrangement;andvolunteers,consistentwiththeirexpectedroles.

2. Thefacilitywilldeterminetheamountandtypesoftrainingnecessarybasedonafacilityassessment.

POLICY/PROCEDURE

SUBJECT:RequiredIn-serviceTrainingforNurseAides

DATE:

INTENT:


PROCEDURE:

1. Trainingtopicswillincludebutarenotlimitedto:a. Abuse,neglect,andexploitationtrainingtoincludeinadditiontothe

freedomfromabuse,neglect,andexploitationrequirements,activitiesthatconstituteabuse,neglect,exploitation,andmisappropriationofresidentpropertyandproceduresforreportingincidentsofabuse,neglect,exploitation,orthemisappropriationofresidentproperty;

b. Dementiamanagement&abusepreventiontraining,c. Careofthecognitivelyimpaired;andd. Trainingoffeedingassistants.

2. Requiredin-servicetrainingfornurseaideswill:a. Besufficienttoensurethecontinuingcompetenceofnurseaides,butmust

benolessthan12hoursperyear.b. Includedementiamanagementtrainingandresidentabuseprevention

training.c. Addressareasofweaknessasdeterminedinnurseaides'performance

reviewsandfacilityassessmentandmayaddressthespecialneedsofresidentsasdeterminedbythefacilitystaff.

d. Fornurseaidesprovidingservicestoindividualswithcognitiveimpairments,alsoaddressthecareofthecognitivelyimpaired.

3. Thefacilitywillnotuseanyindividualworkinginthefacilityasapaidfeeding

assistantunlessthatindividualhassuccessfullycompletedaState-approvedtrainingprogramforfeedingassistants.

POLICY/PROCEDURE

SUBJECT:StaffEducationPlan

DATE:

INTENT:


PROCEDURE:

1. Thefacilitywilldevelop,implement,andmaintainawrittenstaffeducationplan,whichensuresacoordinatedprogramforstaffeducationforallfacilityemployees.

2. Thestaffeducationplanwillbereviewedatleastannuallybythequalityassurancecommitteeandrevisedasneeded.

3. Thefacilitywillensurethestaffeducationplanincludesbothpre-serviceandannualrequirements.

4. Thestaffeducationplanshallensurethateducationisconductedannuallyforallfacilityemployees,ataminimum,inthefollowingareas:a. Preventionandcontrolofinfection;b. Fireprevention,emergencyprocedures-lifesafety,anddisasterpreparedness;c. Abuse,Neglect,andExploitationd. Accidentpreventionandsafetyawarenessprograms;e. Resident'srightstoincludeAdvanceDirectives;f. OSHATraining–BiomedicalWastePlanandBloodbornePathogensg. FederallawRequirementsforLongTermCareFacilities,whichisincorporated

byreference,andstaterulesandregulations;andh. TheFlorida"RighttoKnow,"Law.

5. Thestaffeducationplanwillensurethatallnon-licensedemployeesofthenursinghomecompleteaninitialeducationalcourseonHIV/AIDS.Iftheemployeedoesnothaveacertificateofcompletionatthetimetheyarehired,theymusthavetwohourswithinsixmonthsofemployment.Allemployeesshallhaveaminimumofonehourbiennially.

6. Thefacilitywillensure,whenemployedbyanursinghomefacilityfora12-monthperiodorlonger,anursingassistant,tomaintaincertification,shallsubmittoaperformancereviewevery12monthsandmustreceiveregularin-serviceeducationbasedontheoutcomeofsuchreviews.

7. Thefacilitywillensurethatthein-servicetrainingbesufficienttoensurethecontinuingcompetenceofnursingassistantsandmustmeetthestandardsspecifiedintheStateRegulationsandinclude,ataminimum:

a. Techniquesforassistingwitheatingandproperfeeding;b. Principlesofadequatenutritionandhydration;c. Techniquesforassistingandrespondingtothecognitivelyimpairedresident

ortheresidentwithdifficultbehaviors;d. Techniquesforcaringfortheresidentattheend-of-life;ande. Recognizingchangesthatplacearesidentatriskforpressureulcersandfalls;

andf. Includedementiamanagementtrainingandresidentabuseprevention

training;andg. Addressareasofweaknessasdeterminedinnursingassistantperformance

reviewsandmayaddressthespecialneedsofresidentsasdeterminedbythenursinghomefacilitystaff.

8. Thefacilitywillensurethatnursingstaffareabletodemonstratecompetencyinskillsandtechniquesnecessarytocareforresidents’needs,asidentifiedthroughresidentassessments,anddescribedintheplanofcare.

9. Thefacilitywillensurethatallemployeeswhoareexpectedto,orwhoseresponsibilitiesrequirethemto,havedirectcontactwithresidentswithAlzheimer'sdiseaseorarelateddisordermust,inadditiontobeingprovidedtheinformationrequired,alsohaveaninitialtrainingofatleast1hourcompletedinthefirst3monthsafterbeginningemployment.Thistrainingmustinclude,butisnotlimitedto,anoverviewofdementiasandmustprovidebasicskillsincommunicatingwithpersonswithdementia.Anindividualwhoprovidesdirectcarewillbeconsideredadirectcaregiverandmustcompletetherequiredinitialtrainingandanadditional3hoursoftrainingwithin9monthsafterbeginningemployment.Thistrainingwillinclude,butisnotlimitedto,managingproblembehaviors,promotingtheresident'sindependenceinactivitiesofdailyliving,andskillsinworkingwithfamiliesandcaregivers.

10. ThefacilitywillensurethatRiskManagementtrainingbeapartofthefacilitiesnewhireorientation.

11. ThefacilitywillensurethatRiskManagementtrainingbeapartoftheannuallyrequiredstaffeducationplan.

12. Thefacilityhaschosentouseanon-lineeducationsystemtomeettheeducationalrequirementsforallstaffmembers.

13. Therequirededucationisassignedtoanindividualstaffmemberbasedontheirposition.

14. Eachquartertherewillbedifferentrequirededucationtopicsthatmustbecompletedbystaff.

15. Quarterlyeachemployee’seducationrecordisprintedtoevaluatecomplianceandthesereportsareforwardedtotheappropriatedepartmentmanager.

16. TheAdministratorordesigneewillberesponsiblefortheoversightoftheprogram.

POLICY/PROCEDURE

SUBJECT:TrainingforFeedingAssistants

DATE:

INTENT:

ItisthepolicyofthefacilitytoprovidetrainingtofeedingassistantsinaccordancewithStateandFederalregulations.

PROCEDURE:

1. ThefacilitywillnotuseanyindividualworkingasapaidfeedingassistantunlessthatindividualhassuccessfullycompletedaState-approvedtrainingprogramforfeedingassistants,asspecifiedin§483.160.