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Organizational POLICIES AND PROCEDURES with
Impact on Activity Department
DISCUSSION FACILITATED BY:CHILES HEALTHCARE CONSULTING [email protected]
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Participants will:
• Investigate regulations and/or policies/procedures that may have impact on activity department
• Examine opportunities within the regulations that promote individualized care/services to promote the resident’s sense of well-being and worth
• Explore critical elements of an effective quality assurance/improvement program.
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Policies and Procedures
n Policy: a definite course or method of action; a high-level overall plan embracing the general goals and acceptable procedures. Often based on regulation.
n Procedure: a series of steps followed in a regular definite order. Often to spell out how a policy will be met
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Why do we have policy/procedures?
• To establish a philosophy / standard• To demonstrate rationale or purpose• To provide instruction• To promote consistency• To demonstrate best practice• To enhance compliance• To meet regulatory expectation
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Federal and State Regulations for NFsState Regulations for ALFs
• Nursing facilities are governed by both state and federal regulations• Federal regulations apply when NF is certified to
provide Medicare/Medicaid services• Regulations are enforced by VDH, Office of
Licensure and Certification and CMS• ALF have Virginia specific standards or regulations that
are enforced/monitored by Department of Social Services
• FOCUS – resident centered care and quality of life are primary focus for both NF and ALFs
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Policies and Procedures
What are some policies/procedures
in my facility that impact the work of
the Activity department / team?
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Advanced Directives
uPlanning for the futureuCode Status
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Access & Visitation Rights• Facilities must provide 24-hour access to other non-relative visitors who are visiting with the consent of the resident. These other visitors are subject to “reasonable restrictions” according to the regulatory language. “Reasonable restrictions” are those imposed by the facility that protect the security of all the facility’s residents, …..
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Facilities must be compliant with CDC and VDH guidelines for visitation during pandemic
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Married CouplesuThe resident has the right to share a
room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.
uThis regulation does not prohibit the facility from accommodating residents who wish to room with another nursing home resident of their choice.
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Restraints• The intent of this requirement is for
each person to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints
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Restraint Definition• Freedom of Movement” means any
change in place or position for the body or any part of the body that the person is physically able to control.
• “Remove Easily” means that the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff.
• NF discussion about use of position change alarms
• Greater focus on use of side rails
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Preventing / Investigating & Reporting Abuse or Neglect
• You are a mandated reporter• Elder Justice Act
Any allegation of abuse must be reported within 2 hours for NFs
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Dignity
• The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.
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Dignityu “Dignity” means that in their interactions
with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth. Examples might include:uGroominguDininguRespecting private space/belongingsuPrivacy, etc.
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Self Determination & Participation• The intent of this requirement is to specify
that the facility must create an environment that is respectful of the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.
• This includes actively seeking information from the resident regarding significant interests and preferences in order to provide necessary assistance to help residents fulfill their choices over aspects of their lives in the facility.
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Accommodation of Needsu “Reasonable accommodations of
individual needs and preferences,” means the facility’s efforts to individualize the resident’s physical environment. This includes the physical environment of the resident’s bedroom and bathroom, as well as individualizing as much as feasible the facility’s common living areas..
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Accommodation of Needs• The facility’s physical environment
and staff behaviors should be directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident’s own needs and preferences
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Activity Programu The intent of this requirement is that:u The facility identifies each resident's
interests and needs; u The facility involves the resident in an
ongoing program of activities that is designed to appeal to his or her interests and to enhance the resident's highest practicable level of physical, mental, and psychosocial well-being.
KEY Focus:Resident centered “Meaningful”
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Environment - Homelike
uA safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
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Environment - Homelikeu A “homelike environment” is one that
de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members.
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Environment - Lighting
• “Adequate lighting” means levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform.
• “Comfortable lighting” means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of illumination so that visually impaired residents can maintain or enhance independent functioning.
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Care Plans S = Specific
M = Measurable
A = Achievable
R = Realistic
T = Time Oriented
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Care Plans / ISP
• Activities are a way for individuals to establish meaning in their lives, and the need for enjoyable activities and pastimes does not change on admission to a nursing home.
• A lack of opportunity to engage in meaningful and enjoyable activities can result in boredom, depression, and behavior disturbances.
• Individuals vary in the activities they prefer, reflecting unique personalities, past interests, perceived environmental constraints, religious and cultural background, and changing physical and mental abilities.
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Quality of Care• Care of residents with special needs• Dialysis
• Hospice• Dementia
• Pain• Respiratory
• Behavioral
• Skin/Wound
• Nutrition / Hydration
• Others _______________
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Unnecessary MedicationsuNon-pharmacological interventions to minimize behaviorsuNon-pharmacological interventions to minimize painuMonitoring for behaviors and potential side effects
Resident engagement in meaningful activities can play a critical role in reducing use of unnecessary medications
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Food Sanitation
• Inadequate cooking or holding temperatures• Poor personal hygiene• Food storage• Contaminated equipment
Applies to all locations in which food is stored, prepared or distributed
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Infection Control Program
• The intent of this regulation is to assure that the facility has an infection control program which is effective for investigating, controlling, and preventing infections.
NEW Regulations for both NFs and ALFs
Impacts ALL departments
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Medical Record Documentation
uEnsures maintaining accurate, complete and organized clinical information about each resident that is readily accessible for resident care.
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Quality Assessment & Performance Improvement [QAPI]
• NF -- The intent of this requirement is that:• The facility has an ongoing quality assessment and assurance (QAA)
committee that includes designated key members and that meets at least quarterly; and
• The committee identifies quality deficiencies and develops and implements plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans.
• ALFs – not required by regulation but makes “good sense”
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“QUALITY IS NEVER AN ACCIDENT; IT IS ALWAYS THE RESULT OF HIGH INTENTION,
SINCERE EFFORT, INTELLIGENT DIRECTION AND
SKILLFUL EXECUTION; IT REPRESENTS THE WISE
CHOICE OF MANY ALTERNATIVES”
WILLA FOSTER
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In Summary
• Policies and procedures provide direction for consistent care / services
• Policies and procedures provide structure for accountability• YOUR documentation “tells the story if policy/procedures
were followed or not”• Proactive QA programs serve to validate that current policies,
procedures, protocols, and practices are achieving the expected outcome by residents, staff, regulators, clients, etc.
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If you have questions, we I gladly try to answer them or research them for you..
Chiles Healthcare Consulting, LLC804-690-5824
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