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. First, 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 New Jersey Department of Health 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 New Jersey DOH:
7.8.2.22 FACILITY REPORTS, RECORDS, RULES, POLICIES AND PROCEDURES:
- Reports and records. Each facility shall keep the following reports, records, policies and procedures on file at the facility and make them available for review upon request by the licensing authority, residents, potential residents or their surrogate decision makers:
(1) fire inspection report;
(2) zoning approval;
(3) building official approval (certificate of occupancy);
(4) a copy of the approved building plans;
(5) a copy of the most recent survey conducted by the licensing authority, to include adverse actions or appeals and complaints;
(6) for facilities with food establishments/kitchens that require a permit from the local health authority that has jurisdiction, a copy of the current inspection report in accordance with the applicable, municipal, or federal laws and regulations and pursuant to Subsection B of 7.6.2.8 NMAC, regarding kitchen and food management; if a facility is considered a licensed private home and not required to meet specific requirements by the local health authority, a copy of that determination must also be maintained;
(7) where necessary, a copy of the liquid waste disposal and treatment system permit from the local health authority that has jurisdiction;
(8) thirty (30) days of menus as planned, including snacks and thirty (30) days of menus as served, including snacks;
(9) record of monthly fire drills conducted at the facility and the fire safety evaluation system (FSES) rating, if applicable;
(10) written emergency plans, policies and procedures for medical emergencies, power failure, fire or natural disaster; plans shall include evacuation, persons to be notified, emergency equipment, evacuation routes, refuge areas and the responsibilities of personnel during emergencies; plans shall also include a list of transportation resources that are immediately available to transport the residents to another location in an emergency; the emergency preparedness plan shall address two types of emergencies:
(a) an emergency that affects just the facility; and
(b) a region/area wide emergency;
(11) a copy of this rule, Requirements for Assisted Living Facilities for Adults, 7.8.2 NMAC);
(12) for facilities with two or more residents (that are not related to the owner), a valid custodial drug permit issued by the NM board of pharmacy, that supervise administration and self-administration of medications or safeguards with regard to medications for the residents; and
(13) vaccination records for pets in the facility.
- Reports and records. Each facility shall keep the following reports, records, policies and procedures on file at the facility and make them available for review upon request by the licensing authority:
(1) a copy of the facility license;
(2) employee personnel records, including an application for employment, training records and personnel actions:
(a) caregiver criminal history screening documentation pursuant to 7.1.9 NMAC;
(b) employee abuse registry documentation pursuant to 7.1.12 NMAC; and
(3) a copy of all waivers or variances granted by the licensing authority.
- Rules. Prior to admission to a facility a prospective resident or his or her representative shall be given a copy of the facility rules. Each facility shall have written rules pertaining to resident’s rights and shall include the following:
(1) resident use of tobacco and alcohol;
(2) resident use of facility telephone or personal cell phone;
(3) resident use of television, radio, stereo and cd;
(4) the use and safekeeping of residents’ personal property;
(5) meal availability and times;
(6) resident use of common areas;
(7) accommodation of resident’s pets; and
(8) resident use of electric blankets and appliances.
- Policies and procedures. All facilities shall have written policies and procedures covering the following areas:
(1) actions to be taken in case of accidents or emergencies;
(2) policy and procedure for updating and consolidating the resident’s current physician or PCP orders, treatments and diet plans every six (6) months or when a significant change occurs, such as a hospital admission;
(3) policy for medication errors;
(4) method of staying informed when residents are away from the facility (e.g., sign-out sheets or other record indicating where the resident will be, cell phone contact, etc.);
(5) the handling of resident’s funds, if the facility provides such services;
(6) reporting of incidents, including abuse, neglect and misappropriation of property, injuries of unknown cause, environmental hazards and law enforcement interventions in accordance with 7.1.13 NMAC;
(7) reporting and investigating internal complaints;
(8) reporting and investigating complaints to the incident management bureau;
(9) staff and resident fire and safety training;
(10) smoking policy for staff, residents and visitors;
(11) the facility’s bed hold policy;
(12) admission agreement;
(13) admission records;
(14) resident records including maintenance and record retention if the facility closes;
(15) program narrative;
(16) resident’s rights with regard to making health care decisions and the formulation of advance directives;
(17) personnel policies;
(18) identifying and safeguarding resident possessions;
(19) securing medical assistance if a resident’s own physician is not available;
(20) staff training appropriate to staff responsibilities;
(21) staff training for employees who provide assistance to residents with boarding or alighting from motor vehicles and safe operation of motor vehicles to transport residents;
(22) witnessed destruction of unused, outdated or recalled medication by the facility administrator with the consulting pharmacist present; and
(23) mealtimes, daily snacks, menus, special diets, resident’s personal preference for eating alone or in the dining room setting.
Top Takeaways:
- (10) written emergency plans, policies and procedures for medical emergencies, power failure, fire or natural disaster; plans shall include evacuation, persons to be notified, emergency equipment, evacuation routes, refuge areas and the responsibilities of personnel during emergencies; plans shall also include a list of transportation resources that are immediately available to transport the residents to another location in an emergency; the emergency preparedness plan shall address two types of emergencies:
(a) an emergency that affects just the facility; and
(b) a region/area wide emergency;
When operating an assisted living residence, it is imperative to operate by the rule of the 5 ‘P’s; Proper Preparation Prevents Poor Performance. This could be no truer than when discussing emergency preparedness for disasters. Make sure you and your team are well versed in the emergency preparedness plan and how to respond with each given emergency. This plan is required to be on file for easy access to the DOH.
- Policies and procedures.All facilities shall have written policies and procedures covering the following areas: (6) reporting of incidents, including abuse, neglect and misappropriation of property, injuries of unknown cause, environmental hazards and law enforcement interventions in accordance with 7.1.13 NMAC;
If a resident has reported an abuse allegation you must take it seriously! Immediately contact the staff member in question of abuse and interview them regarding their side of the situation. I also highly suggest suspending this employee pending investigation in order to remove them from the situation while you gather facts and continue the reporting process.