A facility with well-defined policies and procedures can rest assured they will be successful in many areas, especially when it comes to being involved with a facility inspection from ADHS. See the following regulation for what needs to be included in your policies:
504 PERSONNEL AND GENERAL POLICIES AND PROCEDURES
504.1 Required Policies and Procedures Governing General Administration of the Facility
The facility must develop, maintain, and make available for public inspection the following policies and procedures.
- Resident policies and procedures as set forth in Section 505;
- Admission policies as set forth in Section 601;
- Discharge and transfer policies as set forth in Section 602;
- Incident reporting policies and procedures as set forth in Section 507, including procedures for reporting suspected abuse or neglect.
- Policies and procedures for the management of resident personal allowance account as set forth in Section 505.1 and Section 603.1(3)(N);
- Residents’ Rights policies and procedures as set forth in Section 603.1;
- Fire safety standards as set forth in Section 504.1.1(i) and Section 906;
- Smoking policies for residents and facility personnel as set forth in Section 504.1.1(j) and Section 906;
- Policy and procedures regarding visitors, mail, and associates as set forth in Section 603.1(3)(K), (L), and (M);
- Policy and procedures regarding emergency treatment plans as set forth in Section 505(l);
- Policy and procedures for the relocation of residents in cases of emergencies (e.g., natural disasters, or utility outages) 20 Assisted Living Facilities Level I R. 08/01/11
- Failure of a facility to meet the requirements of this subsection shall be a violation pursuant to Ark. Code Ann. § 20-10-205, et seq. 504.1.1
Each facility must have written employment and personnel policies and procedures.
Personnel records shall include, as a minimum, the following:
- Employment applications for each employee.
- Written functional job descriptions for each employee that is signed and dated by the employee. Personnel records for each employee shall be maintained and shall include, as a minimum:
- description of responsibilities and work to be performed, and which shall be updated as they change;
- minimal qualifications, to include educational qualifications;
- evidence of credentials, including current professional licensure or certification;
- written statements of reference or documentation of verbal reference check – verbal check documentation must include the name and title of the person giving the reference, the substance of any statements made, the date and time of the call, and the name of the facility employee who is making the call;
- documentation of education, documentation of continuing training, including orientation training and continuing education units (CEUs) related to administration certification, personal care, food management, etc. CEU documentation must include copies of the documentary evidence of the award of hours by the certifying organization; 6. documentation of attendance at in-service or on-the-job training, and orientation as required by the job description;
- employee’s signed acknowledgment that he or she has received and read a copy of the Residents’ Bill of Rights;
- results of the criminal record check required by law or regulation. c. Verification that employee is at least 18 years of age;
- Documentation that employees with communicable diseases, or with infected skin lesions, are prohibited from direct contact with residents or with residents’ food, if direct contact will transmit the disease;
- Verification that employee has not been convicted or does not have a substantiated report of abusing or neglecting residents or misappropriating resident property. The facility shall, at a minimum, prior to employing any individual or for any individuals working in the facility through a contract with a third party, make an inquiry to the Employment Clearance Registry of the Office of Long Term Care and the Adult Abuse Register maintained by the Department of Human Services, Division of Aging and Adult Services, and shall conduct re-checks of all employees every five (5) years. Inquires to the Adult Abuse Registry shall be made by submitting a Request for Information form found in the Appendix, addressed to Adult Protective Services Central Registry, P. O. Box 1437, Slot S540, Little Rock, AR 72203;
- Documentation that all employees and other applicable individuals utilized by the facility as staff have successfully completed a criminal background check pursuant to Ark. Code Ann. § 20-33- 201, et seq. and in accordance with the Rules and Regulations for Conducting Criminal Record Checks for Employees of Long Term Care Facilities;
- A copy of a current health card issued by the Arkansas Department of Health or other entities as provided by law;
- Documentation that the employee has been provided a copy of all personnel policies and procedures. A copy of all personnel policies and procedures must be made available to OLTC personnel or any other Department;
- Documentation that policies and procedures developed for personnel about fire safety standards and evacuation of the building have been provided to the employee;
- Documentation that policies and procedures developed for tobacco use have been provided to the employee; Failure to comply with the provisions of this subsection or violation of any policies or procedures developed pursuant to this subsection shall be a violation pursuant to Ark. Code Ann. § 20-10-205, and Ark. Code Ann. § 20-10-206, or may constitute a deficiency finding against the facility
The facility shall meet all regulations issued by the Arkansas Department of Health regarding communicable diseases. Further, the facility must prohibit employees with a communicable disease, or with infected skin lesions, from direct contact with residents or with residents’ food, if direct contact will transmit the disease.
Top Takeaway:
- Policies regarding the hiring and orientation practices of your facility are one of the most common deficiencies cited by state surveyors. Ensure this process is up to date and covers all necessary areas.