Guam Memorial Hospital Authority

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

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.

Ensure each resident receives an accurate assessment.

PASARR screening for Mental disorders or Intellectual Disabilities

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

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

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Post nurse staffing information every day.

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.

Provide routine and 24-hour emergency dental care for each resident.

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

Provide and implement an infection prevention and control program.

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

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

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

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

Plan the resident's discharge to meet the resident's goals and needs.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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

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

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

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Provide and implement an infection prevention and control program.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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

Honor the resident's right to choose his or her attending physician.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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

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.

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.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

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

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

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.

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.

Provide routine and 24-hour emergency dental care for each resident.

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

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Provide and implement an infection prevention and control program.

Report COVID19 data to residents and families.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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

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.

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

Provide and implement an infection prevention and control program.

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

Keep residents' personal and medical records private and confidential.

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.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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

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 that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Post nurse staffing information every day.

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

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.

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

Dispose of garbage and refuse properly.

Provide and implement an infection prevention and control program.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Provide housekeeping and maintenance services.

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

Provide necessary care and services to maintain or improve the highest well being of each resident .

Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Have a program that investigates, controls and keeps infection from spreading.

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Provide activities to meet the interests and needs of each resident.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

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

Maintain 15 months of resident assessments in the resident's active clinical record.

Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.

Ensure residents maintain acceptable nutritional status.

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Use a registered nurse at least 8 hours a day, 7 days a week.

Hire a qualified dietician.

Have a program that investigates, controls and keeps infection from spreading.

Keep all essential equipment working safely.

Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility

Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.

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