LEFA SERAN SNF

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

Provide enough food/fluids to maintain a resident's health.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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

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

Provide and implement an infection prevention and control program.

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.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Provide training in compliance and ethics.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Ensure that residents are fully informed and understand their health status, care and treatments.

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.

Ensure each resident receives an accurate assessment.

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

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

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.

Ensure medication error rates are not 5 percent or greater.

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

Provide and implement an infection prevention and control program.

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.

Ensure that residents are fully informed and understand their health status, care and treatments.

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

Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide enough food/fluids to maintain a resident's health.

Provide safe, appropriate pain management for a resident who requires such services.

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.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

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

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.

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

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

Provide and implement an infection prevention and control program.

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Protect each resident from the wrongful use of the resident's belongings or money.

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

Ensure residents have reasonable access to and privacy in their use of communication methods.

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.

PASARR screening for Mental disorders or Intellectual Disabilities

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.

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.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Observe each nurse aide's job performance and give regular training.

Ensure medication error rates are not 5 percent or greater.

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.

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

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

Provide and implement an infection prevention and control program.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

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

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 basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Observe each nurse aide's job performance and give regular training.

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.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

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

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.

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.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

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.

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.

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Observe each nurse aide's job performance and give regular training.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

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

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Ensure that residents are fully informed and understand their health status, care and treatments.

Respond appropriately to all alleged violations.

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

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

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.

Provide written records when a resident is transferred or discharged.

Keep each resident free from physical restraints, unless needed for medical treatment.

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

Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay.

Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.

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

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

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

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.

Make sure that doctors visit residents regularly, as required.

Give or get specialized rehabilitative services per the patient's assessment or plan of care.

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

Make sure that a working call system is available in each resident's room or bathroom and bathing area.