LINCOLN COUNTY NURSING & REHAB

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Have a plan that describes the process for conducting QAPI and QAA activities.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Ensure the activities program is directed by a qualified professional.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Provide and implement an infection prevention and control program.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Honor the resident's right to organize and participate in resident/family groups in the facility.

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Assess the resident when there is a significant change in condition

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Ensure services provided by the nursing facility meet professional standards of quality.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide activities to meet all resident's needs.

Provide appropriate foot care.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Observe each nurse aide's job performance and give regular training.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Implement a program that monitors antibiotic use.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Respond appropriately to all alleged violations.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Ensure each resident receives an accurate assessment.

Ensure that residents are free from significant medication errors.

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Provide safe and appropriate respiratory care for a resident when needed.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Post nurse staffing information every day.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.