ST JOSEPH OF THE PINES HEALTH CENTER

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

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

Post nurse staffing information every day.

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

Provide care and assistance to perform activities of daily living for any resident who is unable.

Reasonably accommodate the needs and preferences of each resident.

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Ensure each resident receives an accurate assessment.

Ensure services provided by the nursing facility meet professional standards of quality.

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

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Provide and implement an infection prevention and control program.

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

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

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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

Ensure each resident receives an accurate assessment.

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.

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.

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 to prevent abuse, neglect, and theft.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Ensure medication error rates are not 5 percent or greater.

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

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.

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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.

Ensure each resident receives an accurate assessment.

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.

Ensure services provided by the nursing facility meet professional standards of quality.

Provide care and assistance to perform activities of daily living for any resident who is unable.

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

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

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.

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

Implement a program that monitors antibiotic use.

Establish and follow a written policy that permits a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Ensure each resident receives an accurate assessment by a qualified health professional.

Allow residents the right to participate in the planning or revision of care and treatment.

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

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.

Store, cook, and serve food in a safe and clean way.

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

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