Assisted Living Compliance Putting it all Together

Transcription

1 Assisted Living Compliance Putting it all Together State of Iowa Assisted Living Codes Read, teach & understand the State of Iowa codes: 231C 481 Chapters 67 & 69 (Updated & effective on April 20, 2016) Chapter 6: Nurse Practice Act 1

2 Where to Start? Hire the Right person in the Right role Detailed, compassionate, team oriented, experienced Nurse & department heads Compassionate, experienced, customer focused Support Staff Don t ever hire just a warm body offer job shadowing after interview Hired - Now What? Train them until competent Get to know them retention Check in with the co-worker that is doing much of the training Do NOT put them on the floor until Director, Nurse and new employee agrees they are ready Re-train as needed Perform a 90 day evaluation 2

3 Follow Your Policies Write, Teach and Follow Your Program s Policies & Medication (MARS) & Narcotic policies Incident Reporting policies Emergency, fire, weather, bomb, etc. Staffing policies Follow Criteria for Occupancy, Always! Service Plan policy H.R. Hiring policies Nurse on call Staff s Lifeline Maintenance on call (If available, and if not, then what do staff do if issues occur on Sunday?) Administrator/Director on call Cross train staff (i.e. maintenance how to s, activities, up & coming events, office staff & dining) Shift Communication book, Housekeeping/Cook s book, Maintenance book Support staff when reporting any issue 3

4 Trained, Knowledgeable, Caring, Confident, Dedicated Staff will Result in a Successful AL Program, Happy Tenants, Staff & Successful State Surveys Common Deficiencies Reported from State of Iowa DIA Surveys 4

5 PRE-Hire Deficiencies Human Resources MUST: Perform a criminal background check using SING or do a check with the Dept. of Public Safety PRIOR to hiring a new employee. Human Resources MUST perform an adult dependent abuse check PRIOR to hire through DHS. Must perform a child abuse check PRIOR To hire through DHS. Training Skills Roster Use a skills roster when training ALL new staff. List tasks & Nurse delegation training. New employee & Nurse signs & dates. List policies & procedures. Employee & the teaching staff will sign and date form. If you do NOT have a special computerized training program (Healthstream), be sure to document, date & sign. Nursing, Nutrition, Maintenance, Director, Activities, & Nursing staff ALL do training 5

6 Staff Training Deficiencies 67.9(4) If AL program hires a New Nurse, within 60 days, Nurse must document and review to ensure staff are sufficiently trained and competent in all tasks assigned or delegated. Staff Training Deficiencies If care giving staff are NOT CNA s, R.N. must train & document (i.e. bathing, ted hose) If CNA, Nurse should check their competency & document on training skills roster (i.e. return demo.) 6

7 Nurse Task Delegation Deficiencies Only a Registered Nurse can train staff on personal care & Nurse tasks. Support staff or CNA s CANNOT train staff to perform these tasks: Ted hose, oxygen, bathing, med administration, nebulizers, tens unit use, how to apply/remove ted hose or a leg brace, wound care, etc.) Remind care giving staff & inform new employees Staff Training Deficiencies Within 30 days, ALL Non-certified & certified staff must be trained in activities of daily living and service plan tasks assigned by the Nurse (i.e. wound care, nebulizer, leg brace, oxygen, tens unit, etc.) 7

8 Staff Training Deficiencies Nutrition Department IAC(69.28)5 Initial training on sanitation & safe food handling prior to handling food. Have staff sign off on the training. Annual in-service on food protection -can do in-house with Licensed Dietician One person directly responsible for food preparation shall have successfully completed a state approved food protection program IAC 69.28(5)a.1-3 Staff Training Deficiencies Nutrition Department IAC 69.28(5) Common deficiency is that staff have not had safe food handling training prior to handling food or they are not demonstrating safe handling. (i.e. Must pass out foods that are ready to eat, like cookies, while wearing gloves or using tongs or napkin). IAC 69.28(6) Defines when you don t have to be licensed to serve food 8

9 New Tenant Admission Deficiencies Nurse performs cognitive, functional, health, (medical history) assessment prior to admission Nurse reviews medical records and meets with the team to approve or deny potential tenant Nurse reviews service plan with tenant and both parties sign. Occupancy agreement is reviewed and signed AFTER service plan is signed. Medication Deficiencies Nurse must follow Doctors orders Meds change throughout the month, use a form to put med changes on to ensure they get into the computer for the next month Missed initials are a med error do incident report Throughout the day/week staff and Nurse check med sheets. Staff that finds missed documentation should do incident report. 9

10 Medication Deficiencies If meds are delegated to the AL Program, Nurse must list the Delegated and Non-delegated meds either on the Service plan and/or on the Med sheet. We do the following: On the Service plan: Delegated & Nondelegated meds (if applicable) are listed on the Med sheets (MARS). On the Med Sheet: Use one sheet to list all NON-Delegated meds that are in the tenant s own possession. Incident Reporting Deficiencies Tenant reports missing money Investigate & if real, contact IA DIA, police, & do incident report (follow your policy if you have one) A negative outcome occurrence between two tenants or tenant and staff i.e. Tenant on scooter runs over another tenant s foot 10

11 Incident Reporting Deficiencies Bed bugs Do an initial incident report, call company to exterminate bugs, notify tenant & family (POA), follow up & document everything Accidents or unusual occurrences within the AL building or on the premises. Injury outside facility -For Medicaid Incident Reporting Deficiencies Tenant is out of building at med pass & meds were not sent with, do incident report Med is not available to give, (i.e. Rural community do what you can to obtain med), do incident report Staff in charge at time of incident, does report (1 st staff to arrive does incident report ) 11

12 Service Plan Deficiencies If staff need to assist tenant with any item that is NOT delegated to the AL Program, be sure to put on the service plan - i.e. Tenant has nitro stored in nightstand in bedroom, tenant may need staff assistance to read label and open bottle. List hospital stays & reason on service plan List special instructions on plan: -Bathing a Tenant in arm cast, document how to cover arm cast when showering Service Plan Deficiencies List any devices or braces that tenant needs assistance with and how often i.e. put on in morning, take off at bedtime. Use a personal care task form for staff to initial when service is performed or have staff circle initials & add reason for refusal. List specific needs of tenant; not boiler plate. List managed risk agreements on service plan. Follow-up ongoing 12

13 Service Plan Deficiencies List date and that an antibiotic was ordered by the Doctor on the Service plan i.e Cipro Antibiotic ordered for UTI for 10 days. If for 10 days is NOT written, you Must later discontinue the antibiotic on the service plan. Nurse to initial & date. Oxygen is a Doctor ordered medication, list it on the service plan along with liter setting. Put on MARS also. List P.T./O.T./Speech on plan. Service Plan Deficiencies List interventions for staff to use for a tenant s specific needs: For anxiety, offer warm bath for relaxation, can redirect tenant by watching old Shirley Temple movies she loves, can call daughter, Julie, to talk, can offer PRN anxiety med. Signs of UTI: Hides depends, low back pain, doesn t show up to activities or meals on time, tired more than usual. 13

14 Service Plan Deficiencies List Assistive devices on plan: Manual wheelchair and walker Electric wheelchair for long distances. List planned AND spontaneous activities on plan, esp. if cannot self - plan: Planned: Live music, Bingo, Euchre card game Spontaneous: Walk outside, watch old movies, play Solitaire Service Plan Deficiencies IAC69.26(2) ALL persons who develop a service plan and the tenant or tenant s legal representative, shall sign the plan. IAC 69.26(3) If a significant change triggers the review and update of the service plan, the updated plan shall be signed and dated by ALL parties involved. 14

15 Significant Change Deficiencies Use flow chart the State provides to determine if a tenant had a significant change or just needs a Nurse review completed. When in doubt, can call or the State DIA office. A significant change requires the Nurse to perform cognitive, functional, and health assessment, as well as service plan review. Nurse, other staff involved and Tenant sign & date the service plan. Significant Change Examples After hospital admission do same day they are discharged New change in condition resulting in fall, confusion, diagnosed UTI. Moved in with no dementia or mild dementia and now acting demented. Needs additional services or higher level of care. i.e. Low level of care, broke arm, needs additional services. 15

16 Significant Change Flow Chart License Deficiencies Nutrition Department Only provide nutrition services up to what is allowed by your license. Therapeutic diets (i.e. ground up food) requires a Licensed Dietician to be responsible for the menu, review of procedures for food prep & service for therapeutic diets, IAC 69.28(4) effective

17 New AL Code April 20, 2016 Criteria for Admission Retention of Tenants IAC (231C) Tenant under the age of 18 cannot be admitted. Despite intervention, tenant chronically urinates or defecates in places that are not considered acceptable according to societal norms, such as on the floor or in a potted plant. New AL Code April 20, 2016 Evaluation of Tenant IAC (231C) Prior to occupancy, if tenant s cognitive evaluation indicates moderate decline and risk, if tenant subsequently returns to their mildly cognitive state, the AL Program may discontinue use of GDS and revert to a scored cognitive screening tool (minimental exam) 17

18 New AL Code April 20, 2016 Tenant Documents IAC (231C) When Tenant is unable to advocate on their own behalf, OR has multiple service providers (hospice), accurate documentation of completion of routine personal/healthcare is required on tasks sheets. If tasks are Doctor ordered tasks shall be part of the MARS (med record). New AL Code April 20, 2016 Service Plans IAC (231C) If a significant change does not exist, the AL Program may, after nurse review, add minor discretionary changes to the service plan without comprehensive evaluation & without obtaining signatures on the service plan. IAC 69.26(3)b. 18

19 New AL Code April 20, 2016 Service Plans IAC (231C) If a significant change relates to a recurring or chronic condition, a previous evaluation and service plan of the recurring condition may be used without new signatures being obtained. i.e. Chronic exacerbation of UTI - Nurse Review is adequate. IAC 69.26(3)c. New AL Code April 20, 2016 Activities IAC (231C) Shall reflect individual differences in age, health status, sensory deficits, lifestyle, ethnic & cultural beliefs, religious beliefs, values, experiences, needs, interests, abilities & skills by providing opportunities for a variety of types & levels of involvement. IAC 69.34(1) 19

20 New AL Code April 20, 2016 New Policies IAC 481 Policy related to head injuries IAC 69.4(7) Policy addressing sexual relationships between staff and tenant IAC 69.4(20) Policy addressing sexual relationships between tenants with dementia with a score greater than 5 on the GDS scale. New AL Code April 20, 2016 Adult Dependent Abuse Policy & Procedures to include 67.2(2): Reporting requirements for staff & employees (new employees sign within 30 days) Requirement that victim and alleged abuser be separated 20

21 New AL Code April 20, 2016 Tenant Rights 67.3(1) (9): To be free from Restraints Restraints is defined as, any chemical or manual method which restricts freedom of movement or normal access to one s body or any physical or manual device, material or equipment which is attached or adjacent to the tenant s body that the tenant cannot remove easily & which restricts freedom of movement or normal access to one s body. New AL Code April 20, 2016 Medications (2) -Tenant can self-administer unless: Tenant or legal rep delegates any portion of meds to AL Program Tenant delegates med setup to someone other than the AL Program. AL Program assumes partial control of med set up at direction of tenant. The AL Program s R.N. must deem plan appropriate. Note: 67.9(4) AL Program s R.N. must agree to the medication plan. 21

22 Forms & Resources Tool Forms Resource Guide for R.N. s Scheduling program for organizing ALL your nursing assessments Triggers for tenant re-assessments Nurse Delegation form AL Program State reported incidents tool/guide & all State Codes Medicaid elderly waiver forms & lists Getting ready for state inspection/ survey & recertification guide 22

23 State of Iowa Assisted Living Codes If you have questions on the State code, you can contact Rose Boccella, MS, Adult Service Bureau Program Coordinator at the IA Dept. of Inspections & Appeals at Questions? Thank you. 23