skilled nursing facility policy & procedure manual · xi. nursing services nursing services...
TRANSCRIPT
[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
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)
483.10ResidentRights
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)
483.10ResidentRights
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)
F576 RighttoFormsofCommunicationwithPrivacy
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)
483.10ResidentRights
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)
F576 RighttoFormsofCommunicationwithPrivacy
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)
483.10ResidentRights
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)
483.15Admission,Transfer,andDischarge
F202 483.15(c)(2)(i)-(iii)
F623 NoticeRequirementsBeforeTransfer/Discharge
483.15(c)(3)-(6)(8)
483.15Admission,Transfer,andDischarge
F203 483.15(c)(3)-(6)(8)
F624 PreparationforSafe/OrderlyTransfer/Discharge
483.15(c)(7)
483.15Admission,Transfer,andDischarge
F204 483.15(c)(7)
F625 NoticeofBedHoldPolicyBefore/UponTransfer 483.15(d)(1)(2)
483.15Admission,Transfer,andDischarge
F205 483.15(d)(1)(i)-(iv)(2)
F626 PermittingResidentstoReturntoFacility
483.15(e)(1)(2)
483.15Admission,Transfer,andDischarge
F206 483.15(e)(1)(2)
F621 EqualPracticesRegardlessofPaymentSource
483.15(b)(1)-(3)(c)(9)
483.15Admission,Transfer,andDischarge
F207 483.15(b)(1)-(3)(c)(9)
F620 AdmissionsPolicy 483.15(a)(1)-(7)
483.15Admission,Transfer,andDischarge
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)
483.10ResidentRights483.12FreedomfromAbuse,Neglect,andExploitation
F222483.10(e)(1),483.12(a)(2)
F605 X RighttobeFreefromChemicalRestraints
483.10(e)(1)483.12(a)(2)
483.10ResidentRights483.12FreedomfromAbuse,Neglect,andExploitation
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
483.12FreedomfromAbuse,Neglect,andExploitation
F223 483.12
F603 XFreefromInvoluntarySeclusion 483.12(a)(1)
483.12FreedomfromAbuse,Neglect,andExploitation
F223 483.12(a)(1)
F602 XFreefromMisappropriation/Exploitation
483.12
483.12FreedomfromAbuse,Neglect,andExploitation
F224 483.12
F606 X NotEmploy/EngageStaffwithAdverseActions 483.12(a)(3)(4)
483.12FreedomfromAbuse,Neglect,andExploitation
F225 483.12(a)(3)(4)
F609 XReportingofAllegedViolations 483.12(c)(1)(4)
483.12FreedomfromAbuse,Neglect,andExploitation
F225 483.12(c)(1)(4)
F610 X Investigate/Prevent/CorrectAllegedViolation 483.12(c)(2)-(4)
483.12FreedomfromAbuse,Neglect,andExploitation
F225 483.12(c)(2)-(4)
F607 XDevelop/ImplementAbuse/Neglect,etc.Policies
483.12(b)(1)-(4)
483.12FreedomfromAbuse,Neglect,andExploitation
(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)
483.10ResidentRights
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)
483.10ResidentRights
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)
F584 XSafe/Clean/Comfortable/HomelikeEnvironment 483.10(i)(1)-(7)
483.10ResidentRights F258 483.10(i)(7)
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)
F636 ComprehensiveAssessments&Timing
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)
F636 ComprehensiveAssessments&Timing
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)
483.21ComprehensiveResidentCenteredCarePlans
F280 483.21(b)(2)(i)-(iii)
F658 ServicesProvidedMeetProfessionalStandards
483.21(b)(3)(i)
483.21ComprehensiveResidentCenteredCarePlans
F281 483.21(b)(3)(i)
F659 QualifiedPersons 483.21(b)(3)(ii)(iii)
483.21ComprehensiveResidentCenteredCarePlans
(b)(iii)-Phase3WillnotbeinASPENuntilPhase3
F282 483.21(b)(3)(ii)
F661 DischargeSummary 483.21(c)(2)(i)-(iv)
483.21ComprehensiveResidentCenteredCarePlans
F283 483.21(c)(2)(i)-(iii)
F660 DischargePlanningProcess 483.21(c)(1)(i)-(ix)
483.21ComprehensiveResidentCenteredCarePlans
F284 483.21(c)(1)(i)-(ix)
F661 DischargeSummary 483.21(c)(2)(i)-(iv)
483.21ComprehensiveResidentCenteredCarePlans
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
483.40(b)(1)483.40BehavioralHealthServices
F319 483.40(b)(1)
F743 XNoPatternofBehavioralDifficultiesUnlessUnavoidable
483.40(b)(2)483.40BehavioralHealthServices
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)
483.45PharmacyServices
F428 483.45(c)(1)(2)(4)(5)
F758 XFreefromUnnecPsychotropicMeds/PRNUse
483.45(c)(3)(e)(1)-(5)
483.45PharmacyServices
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)
F584 XSafe/Clean/Comfortable/HomelikeEnvironment 483.10(i)(1)-(7)
483.10ResidentRights F461 483.10(i)(4)
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
483.90(i)(3) 483.90PhysicalEnvironment
F468 483.90(i)(3)
F925 MaintainsEffectivePestControlProgram
483.90(i)(4) 483.90PhysicalEnvironment
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)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F502 483.50(a)(1)
F770 LaboratoryServices 483.50(a)(1)(i)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F503 483.50(a)(i)
F771 BloodBlankandTransfusionServices 483.50(a)(1)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F503 483.50(a)(ii)
F772 LabServicesNotProvidedOn-Site
483.50(a)(1)(iv)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F503 483.50(a)(iv)
F773 LabSvsPhysicianOrder/NotifyofResults
483.50(a)(2)(i)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F504 483.50(a)(2)(i)
F773 LabSvsPhysicianOrder/NotifyofResults
483.50(a)(2)(i)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F505 483.50(a)(2)(ii)
F774 AssistwithTransportArrangementstoLabSvcs
483.50(a)(2)(iii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F506 483.50(a)(2)(iii)
F775 LabReportsinRecord-LabName/Address
483.50(a)(2)(iv)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F507 483.50(a)(2)(iv)
F776 Radiology/OtherDiagnosticServices 483.50(b)(1)(i)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F508 483.50(b)(1)
F776 Radiology/OtherDiagnosticServices
483.50(b)(1)(i)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F509 483.50(b)(i)(ii)
F777 Radiology/Diag.SvcsOrdered/NotifyResults 483.50(b)(2)(i)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F510 483.50(b(2)(i)
F777 Radiology/Diag.SvcsOrdered/NotifyResults
483.50(b)(2)(i)(ii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F511 483.50(b)(2)(ii)
F778 AssistwithTransportArrangementstoRadiology
483.50(b)(2)(iii)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F512 483.50(b)(2)(iii)
F779 X-Ray/DiagnosticReportinRecord-Sign/Dated
483.50(b)(2)(iv)
483.50Laboratory,Radiology,andOtherDiagnosticServices
F513 483.50(b)(2)(iv)
F842 ResidentRecords-IdentifiableInformation
483.20(f)(5)483.70(i)(1)-(5)
483.20ResidentAssessments483.70Administration
F514 483.70(i)1)(5)
F842 ResidentRecords-IdentifiableInformation
483.20(f)(5)483.70(i)(1)-(5)
483.20ResidentAssessments483.70Administration
F515 483.70(i)(4)(i)-(iii)
F842 ResidentRecords-IdentifiableInformation
483.20(f)(5)483.70(i)(1)-(5)
483.20ResidentAssessments483.70Administration
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)
483.75QualityAssuranceandPerformanceImprovement
Entiretag-Phase3WillnotbeinASPENuntilPhase3
F520 483.75(c)(1)-(4)
F867 QAPI/QAAImprovementActivities
483.75(d)(1)(2)(e)(1)-(3)(g)(2)
483.75QualityAssuranceandPerformanceImprovement
(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)
483.75QualityAssuranceandPerformanceImprovement
(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)
483.12FreedomfromAbuse,Neglect,andExploitation
NoAssociatedTag
F655 BaselineCarePlan 483.21(a)(1)-(3)
483.21ComprehensiveResidentCenteredCarePlans
NoAssociatedTag
F699 X TraumaInformedCare 483.25(m) 483.25QualityofCare
Entiretag-Phase3WillnotbeinASPENuntilPhase3
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
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F895 ComplianceandEthicsProgram
483.85(a)-(e)483.85ComplianceandEthicsProgram
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F926 SmokingPolicies 483.90(i)(5)483.90PhysicalEnvironment NoAssociatedTag
F940 TrainingRequirements-General 483.95 483.95Training
Requirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F941 CommunicationTraining 483.95(a) 483.95TrainingRequirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F942 Resident’sRightsTraining 483.95(b)483.95TrainingRequirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F944 QAPITraining 483.95(d) 483.95TrainingRequirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F945 InfectionControlTraining 483.95(e)483.95TrainingRequirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F946 ComplianceandEthicsTraining 483.95(f)(1)(2) 483.95Training
Requirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
F949 BehavioralHealthTraining
483.95(i) 483.95TrainingRequirements
Entiretag-Phase3WillnotbeinASPENuntilPhase3
NoAssociatedTag
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.
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:
Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.
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:
Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.
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:
Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.
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:
Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.
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:
Itisthepolicyofthefacilitytoprovidecareandservicesinsuchamannertoacknowledgeandrespectresidentrights.Exercisingrightsmeansthatresidentshaveautonomyandchoice,tothemaximumextentpossible,abouthowtheywishtolivetheireverydaylivesandreceivecare,subjecttothefacility’srules,aslongasthoserulesdonotviolatearegulatoryrequirement.
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:
Itisthepolicyofthefacilitytoinformitsresidentsandresidentinsuchamannertoacknowledgeandrespectresidentrights.
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:
Itisthepolicyofthefacilitytoinformitsresidentsandresidentinsuchamannertoacknowledgeandrespectresidentrights.
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.
POLICY/PROCEDURE
SUBJECT:FreedomfromAbuse,Neglect,andExploitation
DATE:
INTENT:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
PROCEDURE:
Thispolicywillinclude:
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:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
PROCEDURE:
1. Theresidenthastherighttobefreefromabuse,neglect,misappropriationofresidentproperty,andexploitationasdefinedinthissubpart.Thisincludesbutisnotlimitedtofreedomfromcorporalpunishment,involuntaryseclusionandanyphysicalorchemicalrestraintnotrequiredtreatingtheresident’smedicalsymptoms.
2. Thefacilitywillnotuseverbal,mental,sexual,orphysicalabuse,corporalpunishment,orinvoluntaryseclusion.
POLICY/PROCEDURE
SUBJECT:FreedomfromPhysicalandChemicalRestraints
DATE:
INTENT:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
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:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
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:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
PROCEDURE:
1. Thefacilitywilldevelopandimplementwrittenpoliciesandproceduresthat:
a. Prohibitandpreventabuse,neglect,andexploitationofresidentsandmisappropriationofresidentproperty,
b. Establishpoliciesandprocedurestoinvestigateanysuchallegations,andc. Includetraining.
POLICY/PROCEDURE
SUBJECT:ReportingofReasonableSuspicionofaCrime&AllegedViolations
DATE:
INTENT:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
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:
Thefacilitywilldevelopandoperationalizepoliciesandproceduresforscreeningandtrainingemployees,protectionofresidentsandfortheprevention,identification,investigation,andreportingofabuse,neglect,mistreatment,andmisappropriationofproperty;toincludetheuseofphysicalandorchemicalrestraints.Thepurposeistoassurethatthefacilityisdoingallthatiswithinitscontroltopreventoccurrences.
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.
POLICY/PROCEDURE
SUBJECT:Admission,Transfer&Discharge
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoAdmissions,TransfersandDischargesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:ResidentAssessment
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoResidentAssessment/InstrumentandProcessinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:ComprehensiveResidentCenteredCarePlans
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoComprehensiveResidentCenteredCarePlansinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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).
POLICY/PROCEDURE
SUBJECT:QualityofLife
DATE:
INTENT:
Itisthepolicyofthefacilitytospecifytheresponsibilitytocreateandsustainanenvironmentthathumanizesandindividualizeseachresident’squalityoflifebyensuringallstaff,acrossallshiftsanddepartments,understandtheprinciplesofqualityoflife,andhonorandsupporttheseprinciplesforeachresident;andthatthecareandservicesprovidedareperson-centered,andhonorandsupporteachresident’spreferences,choices,valuesandbeliefs.
PROCEDURE:
Thispolicywillinclude:
1. QualityofLife
2. ActivitiesofDailyLiving(ADLs)/MaintainAbilities
3. ADLCareProvidedforDependentResidents
4. Cardio-PulmonaryResuscitation(CPR)
5. ActivitiesMeetInterest/NeedsofEachResident
6. QualificationsofActivityProfessional
POLICY/PROCEDURE
SUBJECT:QualityofLife
DATE:
INTENT:
Itisthepolicyofthefacilitytospecifytheresponsibilitytocreateandsustainanenvironmentthathumanizesandindividualizeseachresident’squalityoflifebyensuringallstaff,acrossallshiftsanddepartments,understandtheprinciplesofqualityoflife,andhonorandsupporttheseprinciplesforeachresident;andthatthecareandservicesprovidedareperson-centered,andhonorandsupporteachresident’spreferences,choices,valuesandbeliefs.
PROCEDURE:
Qualityoflifeisafundamentalprinciplethatappliestoallcareandservicesprovidedtofacilityresidents.
Eachresidentwillreceiveandthefacilitywillprovidethenecessarycareandservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being,consistentwiththeresident’scomprehensiveassessmentandplanofcare.
POLICY/PROCEDURE
SUBJECT:ActivitiesofDailyLiving(ADLs)/MaintainAbilities
DATE:
INTENT:
Itisthepolicyofthefacilitytospecifytheresponsibilitytocreateandsustainanenvironmentthathumanizesandindividualizeseachresident’squalityoflifebyensuringallstaff,acrossallshiftsanddepartments,understandtheprinciplesofqualityoflife,andhonorandsupporttheseprinciplesforeachresident;andthatthecareandservicesprovidedareperson-centered,andhonorandsupporteachresident’spreferences,choices,valuesandbeliefs.
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:
Itisthepolicyofthefacilitytospecifytheresponsibilitytocreateandsustainanenvironmentthathumanizesandindividualizeseachresident’squalityoflifebyensuringallstaff,acrossallshiftsanddepartments,understandtheprinciplesofqualityoflife,andhonorandsupporttheseprinciplesforeachresident;andthatthecareandservicesprovidedareperson-centered,andhonorandsupporteachresident’spreferences,choices,valuesandbeliefs.
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.
POLICY/PROCEDURE
SUBJECT:QualityofCare
DATE:
INTENT:
Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.
PROCEDURE:
Thispolicywillinclude:
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:
Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.
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:
Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.
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.
13. Removeglovesandperformhandhygiene.
14. Putoncleangloves
15. Cleansewoundwithgauzeandprescribedcleaningsolutionusingsingleoutwardstrokes.Useseparategauzeforeachcleansingwipe.
16. Usedrygauzetopatthewounddry.
17. Removeglovesandpreformhandhygiene.
18. Putoncleangloves.
19. Applycleandressingasorderedandensurethedressingisdated.
20. Removeglovesandperformhandhygiene.
21. Repositiontheresidentandensurethecalllightisinplace.
22. Discardalldisposableitemsintotheappropriatereceptacle.
23. Cleanthebedsidestand/tablewithgermicidaldisposablecloth.
24. Removetrashfromresident’sroom.
25. Washanddryhandsthoroughly.
26. Documentthecompletionofdressingchangeonthetreatmentrecord.
PROCEDURE
SUBJECT:SkinPrepApplication
DATE:
PROCEDURE:
Thepurposeofthisprocedureistoprovideguidelinesfortheapplicationofskinprep.
1. Assembleequipmentandsuppliesneeded.
2. Identifytheresidentandexplaintheprocedure.
3. Placetheresident’strashcanwithineasyreach.
4. Positiontheresidentforcomfort.
5. Washanddryhandsthoroughly.
6. Putoncleangloves.
7. Removethebarrierwipefromwrappingandwipeoverarea(s)ofbonyprominenceand/orhighfriction.
8. Repositiontheresidentforcomfortasneeded.
9. Removeglovesandperformhandhygiene.
10. Documentandreportanychangestoresident’sskinintegrity.
POLICY/PROCEDURE
SUBJECT:FootCare
DATE:
INTENT:
Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.
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:
Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.
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:
Itisthepolicyofthefacilitytoensureitidentifiesandprovidesneededcareandservicesthatareresidentcentered,inaccordancewiththeresident’spreferences,goalsforcareandprofessionalstandardsofpracticethatwillmeeteachresident’sphysical,mental,andpsychosocialneeds.
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
4. Placeyoursuppliesonacleanoverbedtable/bedsidestandandarrangesotheycanbeeasilyreached.
5. Positionheadofbedat30-45degreesunlessmedicallycontraindicated.
6. Washhandsanddrythoroughly
7. Donnegloves
8. Attachtheenteraltubingtothepumpandprimethetubing
9. Verifyplacementofthetubeusingthefacility’sprocedure.
10. Checkgastricresidualvolumeusingthefacility’sprocedure.
11. Iftheplacementispositiveandgastricresidualvolumeiswithintheamountacceptableforthatresident,proceedtoinitiatingtheenteralfeeding.
12. Clamptheenteraltubeandremovetheplug.
13. Connecttheprimedfeedingpumpsettotheenteraltube(G-Tube,NGT,Jejunostomytube)andunclampthetube.Setrateandpressstartforcontinuousfeeding
14. Discarddisposablesuppliesinthedesignatedcontainers.
15. Cleanreusableequipment.
16. Cleanoverbedtableandreturntoproperposition.
17. Maketheresidentcomfortable
18. Placecalllightineasyreachforresident
19. Removeglovesandwashhands
20. Documentontheresident’smedicalrecordtoincludeanycomplicationandnotifythephysicianasneeded.
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.
3. Placeyoursuppliesonacleanoverbedtable/bedsidestandandarrangesotheycanbeeasilyreached.
4. Maintainheadofbedat30-45degreesunlessmedicallycontraindicated.
5. Preformhandhygiene.
6. Donnegloves.
7. Providebarriertoprotectresident’sclothing.
8. Verifyplacementofthetubeusingthefacility’sprocedure.
9. Checkgastricresidualvolumeusingthefacility’sprocedure.
10. Iftheplacementispositiveandgastricresidualvolumeiswithintheamountacceptableforthatresident,proceedtoinitiatingtheenteralfeeding.
11. Pourprescribedamountofenteralfeedingintoenteralfeedingbagandprimetubing.Clamptubing.
12. Removetheplugfromtheenteralfeedingtubeandflushasorder.
13. HangenteralfeedingbagonIVpoleapproximatelyeighteen(18)inchesaboveresident’shead.Connecttoenteraltubeandallowfeedingtoflowbygravity.
14. Followfeedingwithprescribedflushorder.
15. Whenflushcompleted,disconnectbagfromenteraltube
16. Instructtheresidenttoremainuprightorleaveheadofbedelevatedforapproximatelyone(1)hourtopreventaspiration.
17. Discarddisposablesuppliesinthedesignatedcontainers.
18. Cleanreusableequipment.
19. Cleanoverbedtableandreturntoproperposition.
20. Maketheresidentcomfortable.
21. Placecalllightineasyreachforresident.
22. Removeglovesandwashhands.
23. Documentontheresident’smedicalrecordtoincludeanycomplicationandnotifythephysicianasneeded.
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.
2. Placeyoursuppliesonacleanoverbedtable/bedsidestandandarrangesotheycanbeeasilyreached.
3. Positionheadofbedat30-45degreesunlessmedicallycontraindicated.
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.
10. Discarddisposablesuppliesinthedesignatedcontainers.
11. Cleanreusableequipment.
12. Cleanoverbedtableandreturntoproperposition.
13. Maketheresidentcomfortable
14. Placecalllightineasyreachforresident
15. Removeglovesandwashhands
16. Documentontheresident’smedicalrecordtoincludeanycomplicationandnotifythephysicianasneeded.
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.
POLICY/PROCEDURE
SUBJECT:PhysicianServices
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoPhysicianServicesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:NursingServices,General
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoNursingServicesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:BehavioralHealthServices
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovideMentalHealthServicesinaccordancetoStateandFederalregulations.
PROCEDURE:
Thispolicywillinclude:
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
POLICY/PROCEDURE
SUBJECT:PharmacyServices
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoPharmacyServicesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
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.
POLICY/PROCEDURE
SUBJECT:Dental
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoDentalServicesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:FoodandNutritionServices
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoDietaryServicesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:SpecializedRehabServices
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoSpecializedRehabServicesinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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.
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:
Thispolicywillinclude:
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.
POLICY/PROCEDURE
SUBJECT:QualityAssuranceandPerformanceImprovement
DATE:
INTENT:
ThesepoliciesareintendedtoensurethefacilitydevelopsaplanthatdescribestheprocessforconductingQAPI/QAAactivities,suchasidentifyingandcorrectingqualitydeficienciesaswellasopportunitiesforimprovement,whichwillleadtoimprovementinthelivesofnursinghomeresidents,throughcontinuousattentiontoqualityofcare,qualityoflife,andresidentsafety.
POLICY:
Thispolicywillinclude:
1. QAPIProgram/Plan,Disclosure/GoodFaithAttempt
2. QAPI/QAAImprovementActivities
3. QAACommittee
POLICY/PROCEDURE
SUBJECT:QualityAssuranceandPerformanceImprovement
DATE:
INTENT:
ThesepoliciesareintendedtoensurethefacilitydevelopsaplanthatdescribestheprocessforconductingQAPI/QAAactivities,suchasidentifyingandcorrectingqualitydeficienciesaswellasopportunitiesforimprovement,whichwillleadtoimprovementinthelivesofnursinghomeresidents,throughcontinuousattentiontoqualityofcare,qualityoflife,andresidentsafety.
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:
ThesepoliciesareintendedtoensurethefacilitydevelopsaplanthatdescribestheprocessforconductingQAPI/QAAactivities,suchasidentifyingandcorrectingqualitydeficienciesaswellasopportunitiesforimprovement,whichwillleadtoimprovementinthelivesofnursinghomeresidents,throughcontinuousattentiontoqualityofcare,qualityoflife,andresidentsafety.
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.
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:
ItisthepolicyofthefacilitytoensurethatappropriateinfectionpreventionandcontrolmeasuresaretakentopreventthespreadofinfectioninaccordancewithStateandFederalRegulations,andnationalguidelines.
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.
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.
13. Removeglovesandperformhandhygiene.
14. Putoncleangloves
15. Cleansewoundwithgauzeandprescribedcleaningsolutionusingsingleoutwardstrokes.Useseparategauzeforeachcleansingwipe.
16. Usedrygauzetopatthewounddry.
17. Removeglovesandpreformhandhygiene.
18. Putoncleangloves.
19. Applycleandressingasorderedandensurethedressingisdated.
20. Removeglovesandperformhandhygiene.
21. Repositiontheresidentandensurethecalllightisinplace.
22. Discardalldisposableitemsintotheappropriatereceptacle.
23. Cleanthebedsidestand/tablewithgermicidaldisposablecloth.
24. Removetrashfromresident’sroom.
25. Washanddryhandsthoroughly.
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:
ItisthepolicyofthefacilitytoensurethatappropriateinfectionpreventionandcontrolmeasuresaretakentopreventthespreadofinfectioninaccordancewithStateandFederalRegulations,andnationalguidelines.
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:
ItisthepolicyofthefacilitytoensurethatappropriateinfectionpreventionandcontrolmeasuresaretakentopreventthespreadofinfectioninaccordancewithStateandFederalRegulations,andnationalguidelines.
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).
POLICY/PROCEDURE
SUBJECT:PhysicalEnvironment
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovidecareandservicesrelatedtoPhysicalEnvironmentinaccordancetoStateandFederalregulation.
PROCEDURE:
Thispolicywillinclude:
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
POLICY/PROCEDURE
SUBJECT:TrainingRequirements
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovideaStaffEducationPlaninaccordancewithStateandFederalregulations.
PROCEDURE:
Thispolicywillinclude:
1. AbuseNeglectandExploitationTraining
2. RequiredIn-ServiceTrainingforNurseAides
3. TrainingforFeedingAssistants
POLICY/PROCEDURE
SUBJECT:Abuse,NeglectandExploitationTraining
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovideaStaffEducationPlaninaccordancewithStateandFederalregulations.
PROCEDURE:
1. Thefacilitywilldevelop,implement,andmaintainaneffectivetrainingprogramforallnewandexistingstaff;individualsprovidingservicesunderacontractualarrangement;andvolunteers,consistentwiththeirexpectedroles.
2. Thefacilitywilldeterminetheamountandtypesoftrainingnecessarybasedonafacilityassessment.
POLICY/PROCEDURE
SUBJECT:RequiredIn-serviceTrainingforNurseAides
DATE:
INTENT:
ItisthepolicyofthefacilitytoprovideaStaffEducationPlaninaccordancewithStateandFederalregulations.
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:
ItisthepolicyofthefacilitytoprovideaStaffEducationPlaninaccordancewithStateandFederalregulations.
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.