Building your policies and procedures
Having a thorough set of policies and procedures for how their facility operates can certainly keep them out of hot water in many different circumstances. Firstly, when you have a clear P&P for how things are supposed to go your staff will be much more prepared for their job which will ultimately lead to providing better care for residents. When team members understand expectations, it can lead to much happier and efficient employees who to perform. In addition to the benefits your staff and residents will see from having clearly defined P&Ps you can also guarantee The Community Residence Facilities Branch, Child and Residential Care Facilities Division, Health Regulation Administration will require to see your policies on the regulations they are inspecting. For more information on what you need to develop in your policies and procedures check out the following regulation provided by DC CRF/CRCFD/HRA:
10110 REQUIRED POLICIES AND PROCEDURES
10110.1 An ALR shall develop and implement dated, written policies and procedures concerning its operation which shall be consistent with the Act, this chapter, and all other applicable District or federal law.
10110.2 Policies developed and implemented pursuant to § 10110.01 shall include, but not be limited to the following, which shall meet the approval of the Director:
(a) Medication management, administration of medication, medication administration errors, and medication storage;
(b) Developing, reviewing, and revising a resident’s ISP, including policies on addressing a resident’s (or surrogate’s) disagreement with an ISP in part or whole and using a shared responsibility agreement (SRA) to resolve remaining discrepancies between the individual resident’s right to independence and the ALR’s concerns for the safety and wellbeing of the resident and others;
(c) Private duty nurses, aides, and other healthcare professionals;
(d) Companions;
(e) Admission, transfer, and discharge, including guidelines on accommodating a resident’s needs prior to an admission, transfer, or discharge;
(f) Complaints and grievances, including policies for use of the mechanism through which a resident may have complaints and grievances addressed, and for review of submitted complaints and grievances;
(g) Protecting residents from the threat of retaliation for expressing complaints and grievances;
(h) Preventing, investigating, reporting, and remediating abuse, neglect, and exploitation of residents;
(i) Criteria to determine the care needs required by each resident upon initial assessment and throughout the duration of the resident’s stay, including how staffing, emergency triage, and fees assessed to residents are impacted by the level of care needs assigned to a resident;
(j) Alcohol, tobacco, and marijuana use;
(k) Infection control, sanitation, and universal precautions;
(l) Emergency preparedness, which shall meet the same standards for emergency preparedness as those set for long term care facilities by the Centers for Medicare and Medicaid Services, at 42 CFR § 483.73;
(m) Use of audio-visual monitoring systems to monitor the non-private areas of the ALR’s internal and external premises, including length of retention and the destruction of recordings;
(n) Resident’s right to visitation, and visitor conduct;
(o) Monitoring of independent contractors performing work on the ALR’s premises on behalf of the ALR or resident;
(p) Availability of the ALA to the ALR staff;
(q) Contacting the ALR’s registered nurse;
(r) Determining when an ambulance or emergency medical services are contacted during a health emergency;
(s) Resident falls; and
(t) Notification system to inform residents in the event of emergencies such as utility outages, environmental hazards, and other events that pose a substantial threat to the safety of the general ALR community.
10110.3 Procedures developed and implemented in connection with the policies in § 10110.2 shall meet the approval of the Director.
10110.4 An ALR shall train its staff in the proper implementation of its procedures.
10110.5 A resident shall be permitted to view a copy of any policy required under § 10110.2 at his or her request.
10110.6 A resident shall be permitted, at his or her request, to view a copy of the ALR procedures developed in connection with the policies identified in paragraphs (b) and (f) of § 10110.2.
Top Takeaways:
- 2 Policies developed and implemented pursuant to § 10110.01 shall include, but not be limited to the following, which shall meet the approval of the Director:
- Medication management, administration of medication, medication administration errors, and medication storage;
One of the most important policies you will have in the facility is the policy for medication management and all aspects of the medication procedure. This is the backbone for your success at being compliant when you are due for inspection. The survey team will audit your medication pass and if they see your policies are being followed you will be in the clear.
- 2 Policies developed and implemented pursuant to § 10110.01 shall include, but not be limited to the following, which shall meet the approval of the Director:
(k) Infection control, sanitation, and universal precautions;
At the time of writing this article, America is facing a pandemic like we have never seen before. COVID-19 has been responsible for over 500,000 deaths in the United States alone. Many administrators and directors of nursing had never imagined Infection Control would be at the forefront of our daily planning. Having an effective infection control policy should safe guard you against many potentially deadly illnesses and avoid being tagged by the inspection team.