AHMC SETON MEDICAL CENTER

Provide and implement an infection prevention and control program.

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

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

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

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

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

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

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

Ensure each resident receives an accurate assessment.

Assess the resident when there is a significant change in condition

Respond appropriately to all alleged violations.

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

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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

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.

Put firmly secured handrails on each side of hallways.

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Keep all essential equipment working safely.

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 and implement policies and procedures for flu and pneumonia vaccinations.

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

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

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.

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

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.

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

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

Ensure each resident receives an accurate assessment.

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.

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 be treated with respect and dignity and to retain and use personal possessions.