Assisted Living Policy and Procedure ManualNoticeWhen using th.docx

Assisted Living Policy and Procedure ManualNotice
When using this manual, please consider the following
important points:

1. The policies and procedures outlined in the manual will never
supersede current regulation. To the best of our knowledge,
these guidelines reflect current regulation; nevertheless, they
cannot be considered universal recommendations. For individual
application, all recommendations must be considered in light of
the resident’s condition. The authors and publishers disclaim
responsibility for any adverse effects resulting directly or
indirectly from the suggested procedures, from any undetected
errors, or from the reader’s misunderstanding of the text or
video content.

2. Regulations and interpretations will change and it is your
responsibility to ensure that the assisted living or residential
care community is operated under the guidelines outlined in
current regulation. Review regulations, policy, procedures and
instructions to ensure compatibility with the regulations your
community is obligated to abide by.

3. The guidelines outlined in this manual will never supersede a
state regulatory agency’s directive, physician order, or direction
from a licensed medical professional.

4. Hands-on resident care of any kind should always be in
accordance with physician orders. The interventions in this
manual are not intended to be personalized plans of care.

Copyright ( 2009 by Care and Compliance Group, Inc.
All rights reserved. Permission is granted to photocopy written
materials, certificates and quizzes for internal use within the

purchasing organization. Otherwise this publication may not be
reproduced, stored in a retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without prior written permission from
the publisher. Table of Contents

8General Policies
9Personal Property/Theft and Loss
12Abuse, Fraud, and Wrongdoing
14Personal Care Attendants
15Home Health Agencies
16Motorized Mobility Devices
17Resident Transportation
18Resident Independent Departure Assessment
19Sign-In/Sign-Out
20Firearms
21Personal Rights
23Dignity
24Corporal Punishment and Restraints
25Complaints
26Staffing
27Staffing Introduction
28Staff Training
30Job Description: Administrator
31Job Description: Assistant Administrator
33Job Description: Resident Care Coordinator
35Job Description: Medication Aide
37Job Description: Caregiver
39Volunteers
41Admissions and Move-In
42Resident Pre-Admission Appraisal
44Allowable Health Conditions
46Day of Admission/Move-In
47Change in Condition
50Ongoing Resident Appraisals

52Activity Assessments
53Admission Agreements
54Service Plans
56Resident Care Conference
59Move-Out
60Resident Care
61Basic Care Services
64Use of Assistive Devices and Ambulatory Aids
66Hygiene and Grooming
67Dressing
68Sleep and Rest
70Incontinence
72Nutrition and Weights
73Podiatry and Nail Care
74Caregiver Daily Schedule
78Sexual Expression
79Medication Management
80Medication Storage
81Medication Records
82Telephone Orders
83Medication Labels
84Resident Arrives with a Medication
85Medication Refills
86Medications are Permanently Discontinued
87Hold Orders
88Expired Medications
89Medications Left Behind by a Resident
90Medication Refusal and/or Missed Doses
91Crushing Medications
92Transferring Medications for Home Visits and Outings
93Sample Medications
94Use of Emergency Medications
95Injections
97Over-the-Counter (OTC) Medications
98Psychotropic Medications
99Warfarin and Other Anticoagulants

100Narcotics, Controlled Substances, and Preventing Drug
Diversion
102Emergencies and Medical Needs
103Physician and Other Medical Appointments
104Labs and Outside Medical Services
105Licensure of Nursing Personnel
106Medical Emergencies
108Psychiatric Emergencies
109Falls
110Death of a Resident
112Elopement/Missing Resident
115Advance Directives
117Documentation and Forms
118Confidentiality
119Narrative Charting Entries
120Incident Reports
120Procedure
121Abbreviations
122Approved Abbreviations
Terminology
Various terms related to resident care are used throughout this
manual. While most of these terms are commonly accepted in
the industry, there is some variation from state to state, and
within different organizations. To clarify these terms and to
improve your understanding of how they are used in this
manual, a brief explanation is provided below:

Administrator
This is the person responsible for the day-to-day operations of
the assisted living or residential care community. Some state
regulations specify other terms for this individual, such as
manager, and many organizations will refer to this person as the
"executive director."

Assisted Living
The specific terms used to describe assisted living vary from

state to state, but in this manual we refer to assisted living as a
homelike care setting that providers direct care and supervision
24 hours a day, 7 days a week, in addition to room, board, and
other services. Other common terms include residential care.

Community
The care setting is referred to as an assisted living or residential
care community. Although the term "facility" is often used in
state regulations and by some in the industry, we feel it is
important to distinguish an assisted living or residential care
residence as a home, rather than strictly a clinical facility.

When the word "community" is used in this manual it is
referring to the care setting, not the community at large.
Clarification will be provided if necessary. In some cases, such
as when quoting from regulations, the term facility will be used.

Caregiver
This is the person providing care. Although there are
exceptions, typically this person is not a licensed medical
professional.
Designated
Many of the policies in this manual will refer to the "designated

Representative
representative." It is recommended that you replace this title
with the specific title of the individual(s) within your
community that are responsible for the policy or procedure
being described.

Licensee
This is the person or organization that has obtained a license to
operate the assisted living or residential care community from
the appropriate state agency. In some cases the administrator
and licensee is the same person.

Nurses
Some policies and procedures in this manual refer to a nurse, if
your community does not utilize nurses, modify the policies and
procedures accordingly.
Physician
Many policies in this manual recommend obtaining a "physician
order" or prescription. In many states and situations the order
or prescription can also be written by a Nurse Practitioner (NP)
or Physician's Assistant (PA).

Resident
The resident is the individual receiving care. In other
healthcare settings the term "patient" or "client" are more
common, but to foster a homelike atmosphere the term resident
is used in the assisted living and residential care industries.
Responsible
Most residents living in assisted living or residential care

Party
communities will have a responsible party. This may be a
family member with power of attorney, conservator, or another
individual or agency that is legally authorized to make decisions
on behalf of the resident.
If any of these terms conflict with those used by your
organization you can use the electronic version of the manual
on the accompanying CD-ROM to make necessary changes.

Assisted Living

Policy and Procedure Manual

General Policies
POLICY:
Personal Property/Theft and Loss
This Theft and Loss Policy and Procedure program will be
reviewed twice a year by all staff.

Personal Property

1. General

a. Residents will be encouraged to keep no more than $50.00
cash at any time.

b. Residents will be requested to keep fine jewelry and other
items of value in a safe deposit box at their banking institution.
c. No items of value will be entrusted to the community for safe
keeping and no cash or other moneys will be entrusted to the
community.
d. The community does not have a safe on the premises to allow
for safe keeping of residents’ valuables. Residents are
encouraged to use their own private banking institution to
provide this service. The community provides all rooms with
either a lockable door to which the resident has a key, and/or a
lockable cabinet to which the resident has a key.

2. Inventory

a. The community maintains a current inventory of all personal
property identified by residents, unless the resident is able to
secure his/her room or refuses the inventory and the refusal XE
"Refusal" is documented.
b. When the inventory is complete, copies will be distributed to
and kept by the community, the resident, and the resident’s
responsible party.

c. The resident and responsible party are asked to notify the
community of any additions to, or removal of, personal property
inventory. The community will document XE "Documentation"
appropriately.

d. In the event of a resident’s discharge or a resident’s death XE

"Death" , the inventory list will be verified and the personal
items will be packed. When the items are returned to the
resident’s responsible party the list will be re-verified and
signed in receipt of belongings.
3. Identification

a. Upon admission XE "Admission" , all residents will be
requested to appropriately label all clothing and personal items.
b. All clothing will be labeled in an inconspicuous area (such as
the clothing tag) with permanent laundry markers to clearly
identify which resident they belong to.
c. All personal belongings that can be marked with permanent
pen will be marked in discreet locations.
d. In cases where the item or items cannot be safely labeled
with a non-erasable marker an electric pencil will be used to
engrave the resident’s name in a discreet place on the items, if
the resident agrees.

Theft and Loss

1. The community documents and appropriately investigates XE
"Documentation" all alleged and actual theft and loss of
personal property.
2. Residents are encouraged to notify staff immediately if they
notice a personal item is missing.
a. Staff will conduct a thorough search for the missing item(s).
b. If the personal belongings cannot be found, an estimate of
their value will be assessed. The estimate will be the original
purchase price plus or minus any appreciation or depreciation
that has occurred.
c. If the theft exceeds $100.00 or more, a report shall be filed
with the appropriate local law enforcement agency.
d. All appropriate documentation of the incident will be given
to the responsible parties.

i. The community will maintain the records on file for a

minimum of three (3) years after the theft.
Notification

1. The community notified all appropriate parties about the theft
and loss prevention program and provides them with copies of
applicable laws.
2. The community posts the policy and procedures for
safeguarding the residents’ property in a common area
accessible to all residents and visitors.

3. Upon moving into the community, the resident and
appropriate parties will be notified verbally and given a copy of
the theft and loss policy.

4. Copies of these procedures and applicable laws are available
to anyone upon request.

POLICY:
Abuse, Fraud, and Wrongdoing
The community takes all reasonable steps to prevent resident
abuse and neglect.
Residents, their responsible parties, personnel, health
professionals and all relevant stakeholders are encouraged to
report in good faith any activity, policy or practice, fraud, abuse
and any other wrongdoing that he/she believes violates
professional standards of practice or is against the law, or poses
a substantial risk to the health, safety, welfare or rights of a
resident.

Residents, their responsible parties, personnel, health
professionals and all relevant stakeholders may report such
activities, policies or practices without fear of restraint,
interference, coercion, discrimination or reprisal. Reasonable
efforts are made to maintain the confidentiality of the resident,
their family, personnel, healthcare professional or relevant
stakeholders.

The Administrator will investigate any reports of abuse, fraud,
or other wrongdoing.

Procedure

1. All staff will receive training on elder abuse incidence, signs
and symptoms, and reporting requirements.
2. Residents, their responsible parties, personnel, health
professionals and all relevant stakeholders are encouraged to
report any suspected incidence of abuse, fraud, or other
wrongdoing.
3. If a report of abuse, fraud, or other wrongdoing is received:

a. The Administrator is notified immediately

b. Any urgent medical or safety issues are addressed
immediately.

c. The Administrator or other designated representative initiates
and investigation.
d. The resident's responsible party is notified.

4. If the suspected abuse, fraud, or other wrongdoing is
substantiated a written report is made to the appropriate
licensing/regulatory agency, the responsible party XE
"Family/Responsible Party" , the Ombudsman, and Adult
Protective Services.
5. All appropriate parties are notified of the outcome of the
investigation.
6. Appropriate disciplinary actions will be made if community
staff participated in substantiated abuse, fraud, or other
wrongdoing.
POLICY:
Personal Care Attendants
Residents who desire to use a personal care attendant for

extended periods of time may do so with the prior approval of
the administrator XE "Administrator" .

Procedure

1. Resident needs may require a personal attendant, but must
not require 24 hour skilled nursing care.

2. Personal Care Attendants from outside agencies may be used
if approved by the Administrator XE "Administrator" . The
agency shall ensure a criminal clearance on all staff, health
screening, appropriate insurance including liability and
worker’s compensation, proof of appropriate employer tax
obligations, including but not limited to withholding of state
and federal taxes, payment of disability and unemployment
insurance. All appropriate labor laws are to be followed and
the Personal Care Attendant supervised by an agency
Administrator familiar with this assisted living community
operations.

3. All Personal Care Attendants from outside agencies are to be
fully trained in all necessary care giving skills by the agency
prior to coming in the assisted living community to serve a
resident.

4. Personal Care Attendants may not perform any act not
allowed by regulation or law.

5. The Personal Care Attendant, if employed by an agency, is
expected to notify his/her supervisor and community staff of
any change in resident status.

6. The Personal Care Attendants, if employed by an agency, are
not to provide care at any time to any other resident in the
community.

7. It is the responsibility of the agency to ensure proper training
of the Personal Care Attendant employed by the agency in
emergency procedures such as fire evacuation, disaster
preparedness, etc.

POLICY:
Home Health Agencies
Residents may receive services from a Home Health Agency.
Services will be coordinated by the community Administrator or
designated representative.

Procedure

1. Verify appropriate physician orders for the use of a Home
Health Agency.
2. The Administrator XE "Administrator" provides clarification
of the scope of practice in an assisted living community (e.g.
prohibited conditions, etc.), as well as community policies
regarding privacy, sign-in/sign-out, reporting suspected abuse,
etc.
3. The community Administrator, resident, and other
appropriate parties will be involved in the development of the
Home Health Agency plan of care.
4. Home Health Agency staff are expected to check-in with the
Administrator XE "Administrator" when arriving at the
community and when leaving.

5. The Home Health nurse XE "Administrator" should notify
the Administrator of any significant change in a resident's
condition/services to provide continuity of care and to allow for
monitoring of prohibited or restricted conditions.

6. The Administrator XE "Administrator" shall make the Home
Health Agency aware of all new orders, medication XE
"Medications" changes and response to interventions performed
by community staff.

7. The home health agency is expected to give notice to the
resident of the time of the visit.

8. A home health agency shall not provide training nor expect a
non-licensed XE "Unlicensed Staff" care giver to perform any
prohibited act/service in the community. Examples of prohibited
acts include, but are not limited to:
a. Non-licensed XE "Unlicensed Staff" staff filling insulin
syringes.

b. Dressing changes.

c. Wound irrigation.
POLICY:
Motorized Mobility Devices
Residents using motorized mobility devices, also known as
scooters, are asked to ensure the safety of all by observing the
following rules.

Procedure

1. Written physician approval/authorization shall be received
for each resident using a motorized mobility device.

2. Carts are to be parked in the resident room or patio when not
in use.

3. Carts are to be driven on the right side of hallways whenever
possible.

4. Extreme caution is to be used when pulling out around blind
turns, corners, etc..

5. Carts are to be kept a safe distance behind all pedestrians,
following the manufacturer's guidelines for safe stopping

distances.

6. Utmost courtesy is used to prevent rushing other residents on
foot, in wheelchairs or using other types of mobility aids.

7. Never drive carts when under the influence of alcohol or
medications XE "Medications" that could pose a safety hazard,
anywhere on the premises.

8. Caregivers will assist residents into any areas not safely
accessible by carts

9. In community rooms, carts should enter first and be the last
to exit, unless otherwise instructed for resident safety.

10. Always keep carts in good repair to ensure safety.

11. Appropriate insurance is to be carried by all cart
drivers/owners with minimum coverage in the amount
designated by community.

12. Carts are to be driven on the lowest possible speed at all
times when indoors.

POLICY:
Resident Transportation
Resident transportation needs will be met.

Procedure

1. Before Transporting

a. Post notices of scheduled transportation in a clear, easy to
read format. Explain schedules to visually or other disabled
residents.

b. Ensure special arrangements are made for residents with
special needs.

c. Resident’s families are asked to place transportation requests
a minimum of 36 hours prior to the appointed time.

2. For Resident Safety

a. Residents are to have the cognitive and physical ability to be
transported without assistance. This is to be verified by a
physician XE "Physician" statement. Otherwise, residents are
not allowed to be transported without assistance.

b. Should a resident require accompaniment/assistance of any
kind, the Administrator XE "Administrator" arranges such
assistance prior to transportation of the resident.

c. Community vehicle drivers are to be notified verbally and in
writing of all residents who are not safe to leave the building
without an escort.

3. All community drivers are to be appropriately licensed, in
good health, drug free and safe to operate a motor vehicle.

4. A safety check of the vehicle is to be performed by the driver
before operating the vehicle.

POLICY:
Resident Independent Departure Assessment
Residents will be appraised for the ability to depart the
community independently.

Procedure

1. Each resident will have a physician XE "Physician"
verification of the ability to leave unescorted.

2. Should a physician XE "Physician" not concur that the
resident is able to leave without an escort the resident will be
encouraged to have staff accompaniment on outings.
a. This is documented in the resident's record, and the
responsible party if notified.
3. Eviction will be considered for residents who are not safe to
leave without supervision, yet insist on leaving independently.

POLICY:
Sign-In/Sign-Out
Residents are asked to sign-in and out when arriving at and
leaving the community.
Dementia XE "Dementia" Note: Should the community serve
residents with dementia a more appropriate policy would be
necessary.

Procedure

1. Residents are asked to sign out when leaving the community.
The person accompanying the resident is noted as well as the
time.

2. Residents may not be required to disclose their destination.
However, for safety purposes the resident’s destination may be
recorded if it is voluntarily disclosed.

3. Residents leaving for extended periods should notify the
front desk.

4. If residents are out during meal time, it is requested that staff
be notified that the resident will be out.

5. Upon returning to the community, resident or staff may sign
them in.

POLICY:
Firearms
To ensure the safety of residents and staff firearms and
ammunition are not permitted within any part of the community.

Procedure
1. Prior to admission, residents will be informed of the
prohibition of any firearm or ammunition within any part of the
community.

2. On admission the resident and or responsible party, as
appropriate will be asked if any firearm is being brought into
the building.

3. Should a staff member suspect or identify a firearm or
ammunition is present in the community, their immediate
supervisor is to be notified immediately.

a. The Administrator will be notified by the supervisor and
appropriate steps will be taken to remove the firearm.

b. If the resident refuses to allow the firearm to be removed, or
at anytime staff or resident safety is in danger, the police or
sheriff will be notified immediately by calling 9-1-1.

POLICY:
Personal Rights
Staff will observe and respect the personal rights of all
residents residing in the community.

Procedure

Staff respects each resident’s personal rights, which include,
but are not limited to, the right:

1. To be accorded dignity in his/her personal relationships with

staff, residents, and other persons.

2. To be free from corporal or unusual punishment, humiliation,
intimidation, mental abuse, or other actions of a punitive nature,
such as withholding of monetary allowances or interfering with
daily living functions such as eating or sleeping patterns or
elimination.

3. Leave or depart the community at any time and to not be
locked into any room, building, or on community premises by
day or night.

4. To visit the community prior to residence along with his/her
family XE "Family/Responsible Party" and responsible persons.

5. To have his/her family XE "Family/Responsible Party" or
responsible persons regularly informed by the community of
activities XE "Activity" related to his care or services
including ongoing evaluations, as appropriate to the resident's
needs.

6. To have communications to the community from his/her
family XE "Family/Responsible Party" and responsible persons
answered promptly and appropriately.

7. To be informed of the community's policy concerning family
XE "Family/Responsible Party" visits and other
communications with residents.

8. To have his/her visitors XE "Visitors" , including
ombudspersons and advocacy representatives permitted to visit
privately during reasonable hours and without prior notice,
provided that the rights of other residents are not infringed
upon.

9. To wear his/her own clothes; to keep and use his/her own

personal possessions, including his/her toilet articles; and to
keep and be allowed to spend his/her own money.

10. To have access to individual storage space for private use.

11. To have reasonable access to telephones XE "Telephone" ,
to both make and receive confidential calls. The licensee may
require reimbursement for long distance calls.

12. To mail and receive unopened correspondence in a prompt
manner.

13. To receive or reject medical care, or other services.
14. To receive assistance in exercising the right to vote.
15. To move from the community.

16. To have the freedom of attending religious services or
activities XE "Activity" of his/her choice and to have visits
from the spiritual advisor of his/her choice.

POLICY:
Dignity
Each resident has the personal right to be accorded dignity in
his/her personal relationships with staff, residents, and other
persons.

Procedure

1. Staff are respectful and courteous in all interactions with
residents.

2. Staff refer to residents by proper name (e.g. Mr. Smith or
Mrs. Jones), unless requested to use another name by the
resident or responsible party XE "Family/Responsible Party" .

3. When addressing personal care needs (e.g. bathing), staff will

speak with residents in a private location.
4. Privacy is provided to avoid creating a sense of humiliation
or embarrassment for a resident.
POLICY:
Corporal Punishment and Restraints
Each resident has the personal right to be free from corporal or
unusual punishment, humiliation, intimidation, mental abuse, or
other actions of a punitive nature, such as withholding of
monetary allowances or interfering with daily living functions
such as eating or sleeping patterns or elimination.

Procedure

1. Corporal or unusual punishment, humiliation, intimidation,
mental abuse, or other actions of a punitive nature are never
used in caring for a resident.
2. Physical or chemical restraints of any kind are never used in
this community.
POLICY:
Complaints
Each resident has the personal right to be informed by the
administrator XE "Administrator" (or a designated
representative) of provisions of law regarding complaints and of
procedures to confidentially register complaints, including, but
not limited to, the address and telephone XE "Telephone"
number of the complaint receiving unit of the licensing agency.

Procedure

1. At the time of admission XE "Admission" the administrator
XE "Administrator" (or a designated representative) informs
the resident and his/her responsible party of the internal
community complaint policy and procedure.

2. At the time of admission XE "Admission" the administrator
XE "Administrator" (or a designated representative) informs

the resident and his/her responsible party XE
"Family/Responsible Party" of the desire by the community and
all community to accommodate resident requests, needs,
complaints, and concerns.

3. At the time of admission XE "Admission" the administrator
XE "Administrator" (or a designated representative) provides
the resident and his/her responsible party XE
"Family/Responsible Party" a method of contacting the
Ombudsman.

4. At the time of admission XE "Admission" the administrator
XE "Administrator" (or a designated representative) informs
the resident and his/her responsible party XE
"Family/Responsible Party" of provision for registering
complaints with the state licensing agency. This includes, at a
minimum, the address and telephone XE "Telephone" number
of the complaint-receiving unit of the licensing agency.

5. Caregivers bring all resident requests, concerns, and/or
complaints to the attention of his/her immediate supervisor or
the administrator XE "Administrator" .

6. The administrator XE "Administrator" (or designated
representative) investigates all complaints and discusses his/her
findings with the resident and his/her responsible party XE
"Family/Responsible Party" .

7. The administrator XE "Administrator" (or a designated
representative) reports all substantiated serious or repeated
complaints to the local state licensing agency (as required by
state regulation).
Assisted Living

Policy and Procedure Manual

Staffing

Staffing Introduction
This section includes sample staff position titles, job
descriptions, duty schedules and forms used for communication
with and between employees.

The manual uses the title Resident Care Coordinator for a
supervisory position for the Caregivers. Other titles commonly
used for this position include:

· Assisted Living Director

· Director of Resident Services
· Director of Assisted Living
· Supervisor of Personal Care

· Shift Supervisors

This manual refers to the direct care providers in the assisted
living community as Caregiver. Again, there are other common
names also used within this industry such as:

Care Givers

Care Aids

Resident Aids

Personal Care Assistants

Resident Attendants

Certified Nurses Aids (only with proper certification)

Choose what fits your community best and make necessary

changes to this manual.
In this employee section there exists some “universal staffing,”
in that you will see Caregivers performing some housekeeping
duties. The idea of cross training may be greatly extended in
your community or you may prefer a more narrowly defined job
role than what is described within these pages. There exists
tremendous flexibility within the assisted living and residential
care industry to staff in a manner which reflects the best
standard of care based on your resident population, size of
community, and other factors. When working within an assisted
living community, the staffing patterns should reflect the needs
of your senior population.

This section is not intended as an exhaustive human resources
reference, but rather focuses on resident care issues and the
providers of the direct care services. In your community you
will likely have addendum support staff in other departments for
such services as housekeeping, food services, groundskeepers,
maintenance, financial operations, etc.
POLICY:
Staff Training
Direct care staff will Residents will receive initial orientation
and ongoing inservice training based on state regulations and
the needs of the residents being served in the community.

Implementation
1. Training on the following topics is included during caregiver
orientation training and ongoing inservices.

a. Professional and ethical conduct, confidentiality, and
reporting requirements.

b. Promoting resident dignity, independence, privacy, self-
determination, choice and resident rights.

c. Abuse, neglect, exploitation and reporting requirements.

d. Fire, safety and emergency procedures, including
identification of unsafe environmental factors.
e. Infection control and Standard Precautions.
f. Emergencies, evacuations, disasters, incident reporting,
g. Advanced directives and Do-Not-Resuscitate Orders.
h. Psychosocial care and social, recreational activities.
i. Diversity: cultural, age, gender, sexual orientation, spiritual
beliefs, socioeconomic status, language, ethnicity, racial issues,
etc.

j. End of life care and ethical issues.
k. Special care needs, aging issues, age-related limitations.
l. Providing physical care, assisting with ADLs, encouraging
independence, lifting and transferring techniques, use of care
equipment (e.g. lifts).
m. Nutritional issues.
n. Documentation and recordkeeping.
o. Service plans, assessments, appraisals, resident summaries,
person-centered care, and end of shift reports.
p. Dementia care, managing behavioral challenges, wandering
and elopement (as applicable).

q. First Aid and CPR (as applicable).
r. Medication management (as applicable).
2. All training will be documented. Copies of documentation
will be retained in the employee record.
POLICY:
Job Description: Administrator
Department: Administrative

Reports to: Licensee

Description of Position:

The Administrator XE "Administrator" is fully responsible for

community operations and quality of care. Financial stability of
the community, staffing practices and day to day operations are
coordinated by the Administrator to fall XE "Falls" within the
operational guidelines of governmental agencies. The
Administrator structures the environment which will produce
the highest standards of non-medical care.

Responsibilities of the Administrator XE "Administrator" :

1. Identify and develop community standards of care congruent
with the population seeking placement.

2. Project and develop a sound operating budget for the
community.

3. Standardize operations of each department.

4. Maintain the community in compliance with regulatory
agencies.

5. Develop sound policy and procedure for resident care.

a. Utilize a system of sound management which monitors
quality standards on an ongoing basis in all departments.

6. Develop and carry out a successful marketing program which
maintains > 95% occupancy.

7. Approve all admissions XE "Admission" .

8. Hire new staff and/or terminating of unsatisfactory staff.

9. Investigate theft/loss in the community.

10. Carry out the operating policy of the licensee.
POLICY:

Job Description: Assistant Administrator
Department: Administrative

Reports Directly to: Administrator XE "Administrator"
Description of Position:

Provides direct supervision of department heads. Works with
the community, ensuring that the community is a positive choice
for seniors in the area. Coordinates all departments to promote
outstanding community operations in alignment with goals,
budget guidelines and resident needs. Assumes responsibilities
of the administrator XE "Administrator" in his or her absence,
following community guidelines. Supervises operations to
conform to regulatory guidelines.

Responsibilities of the Assistant Administrator XE
"Administrator" :

1. Supervise all department heads to ensure community is
operating according to standards and in compliance with
regulatory guidelines.

2. Implement department budget and approve or deny
expenditures based on the allocations set by the Administrator
XE "Administrator" .

3. Work within the community to place residents in need of a
higher level of care.

4. Market the community to prospective placements. Schedule
and plan all community outreach projects.

5. Coordinate move-ins with other department heads.

6. Assume full responsibility all regulatory guidelines forms
and documentation XE "Documentation" for residents and

employees and ensure that administrative operation is up to date
and complete at all times. Secure all admission XE "Admission"
paperwork prior to move-in.

7. Organize monthly resident and family XE
"Family/Responsible Party" council meetings as well as family
conferences.

8. Prepare all licensing requests for exceptions XE "Exception"
, waivers XE "Waiver" and exemptions for Administrators
review and signature.

9. Monthly review of vendor performance.

10. Initial screening for all new job applicants. Verify
qualifications.

11. Criminal clearances and coordination of pre-employment
documentation XE "Documentation" .

12. Coordinate employee performance reviews.

13. Investigate complaints, document XE "Documentation" and
review with administrator XE "Administrator" .

14. Terminate unsatisfactory staff with approval from
administrator XE "Administrator" .

15. Other duties as assigned.

POLICY:
Job Description: Resident Care Coordinator
Department: Resident Care Services

Reports to: Administrator XE "Administrator"
Description of Position:

The Resident Care Coordinator works as a liaison between
residents, resident families, and staff. The Personal Care
Coordinator’s duties also include problem solving resident
concerns and coordinating care with the Caregivers. The
Personal Care Coordinator may be an RN or LVN when
necessary.
Staffing Pattern:

The community has one Personal Care Coordinator position, on
days only. This is the chief supervisory position for the
Caregivers who provide primary care to their resident
assignment.

Responsibilities of the Personal Care Coordinator:

1. Caregiver scheduling and resident assignments, working
within the department allowances.

2. Coordinate admissions XE "Admission" with assistant
administrator XE "Administrator" including supervising move-
ins to be sure accommodations are as desired and care is
immediately implemented.

3. Family XE "Family/Responsible Party" /resident admission
XE "Admission" interviews.

4. Immediately bring prohibited conditions or at-risk residents
in need of a higher level of care to the attention of the assistant
administrator XE "Administrator" .

5. Coordinate care planning with home health agencies on site,
working within community policy.

6. Arrange for transportation as desired by the resident.

7. Arrange for resident special needs involving other
departments, verifying follow through.

8. Function as a liaison with families ensuring special
needs/requests/complaints are addressed. Inform assistant
administrator XE "Administrator" , in writing and verbally, of
all family XE "Family/Responsible Party" or resident
complaints.

9. Monitor staff performance, providing or arranging assistance
as needed.

10. Read all communication notes regarding the community
between the Caregiver shifts.

11. Coordinate staff training and in-service schedules with the
Assistant Administrator XE "Administrator"
12. Supervise the medication XE "Medications" room and
orders, working with and supervising Medication Aides and
Caregivers.

13. Other duties as assigned.

POLICY:
Job Description: Medication Aide
Department: Resident Care Services
Reports to: Personal Care Coordinator

Description of Position:

Coordinates resident care related to medications by working
with all departments, the medical community, families and
administrative staff to provide for resident needs with
continuity and an adherence to the scope of practice and
licensure for the community. Provides complete supervision of
the medication XE "Medications" room, pass techniques,

documentation XE "Documentation" and supervision and
provision of care related to medication in the community.

Staffing Pattern:

The community has one Medication XE "Medications" Aide on
each shift.

Responsibilities of the Medication XE "Medications" Aide:

1. Resident charts. Keeping documentation XE "Documentation"
current (Community forms, licensing documentation, physician
XE "Physician" orders, incident reports., etc.)

2. Communicate resident status changes XE "Administrator" .

3. Ensure all medication XE "Medications" documentation XE
"Documentation" is current and correct, including medication
administration forms, physician XE "Physician" orders, change
of dosages, written orders to confirm telephone XE "Telephone"
orders, etc.

4. Ensure medication XE "Medications" room is completely
stocked with all required continuous, PRN XE
"Medications:PRN" , Over-the-Counter (OTC), and other XE
"Medications:Over-The-Counter" medications as ordered by the
physician XE "Physician" .

5. Coordinate medication orders and deliveries with pharmacies
6. Communicate with physicians and other healthcare providers
as needed.
7. Monitor Psychotropic med use is congruent with physician
XE "Physician" orders and ensuring resident behaviors actually
warrant the use of medication XE "Medications" .

8. Control medication XE "Medications" room access and key

assignment.

9. Pour, pass, and assist with administration of medications in
accordance with state regulations XE "Medications" .

10. Coordinate physician XE "Physician" and other medical
appointments.

11. Read all communication notes regarding the community
between the Caregiver shifts.

12. Other duties as assigned.

POLICY:
Job Description: Caregiver
Department: Resident Care Services

Reports Directly to: Personal Care Coordinator

Description of Position:

Provides direct personal care and supervision to the residents at
the community. Promotes resident well being and satisfaction
through support with activities XE "Activity" of daily living
XE "Activities of Daily Living" . Communicates with other
departments to ensure resident needs are met.

Staffing Pattern:

The Resident Care Services department at this assisted living
community staffs through a primary care structure. Each
Caregiver will be charged with all of the personal care duties of
their resident assignment. Whenever possible each Caregiver
will be assigned to the same resident group each day to promote
continuity of care.

Responsibilities of the Caregiver:
1. Assist with activities XE "Activity" of daily living XE
"Activities of Daily Living" , including passing medication XE
"Medications" as assigned, following community protocol,
licensing regulation and guidelines for both resident and
employee safety.

2. Follow safety guidelines in the community, including proper
lifting technique and universal precautions when providing care
to the residents.

3. Follow the schedule of duties for the Caregiver, as well as
the individual plan of care for each resident.

4. Function as a team, assisting coworkers as the need arises.

5. Monitor resident activity XE "Activity" , food intake,
functional status, psychosocial XE "Psychosocial" status,
taking action as required to promote resident well being.

6. Report status change immediately to the supervisor.

7. Act immediately on any resident crisis XE "Crisis" ,
following protocol and basic first aid training.

8. Document XE "Documentation" resident status change,
including but not limited to, physical change, reaction to
medication XE "Medications" , psychosocial XE "Psychosocial"
status change.

9. In the event all assigned duties cannot be completed, ask for
assistance and report to the personal care coordinator.

10. Any other assignments made by your direct supervisor or
administrator XE "Administrator" .

11. Promote open communication between health care
professionals, families, residents and staff.

12. Adhere to guidelines in the employee handbook including
dress code, conduct, scheduling, etc.
13. Other duties as assigned.
POLICY:
Volunteers
Students and/or volunteers will be utilized as appropriate.
Procedures will ensure the safe, competent and mutually
beneficial performance of volunteers.

Implementation
1. Signed Agreement

a. All volunteers will sign a written volunteer agreement.

2. Job Functions

a. Volunteers work under the direct supervision of the Director
of Activities.

b. Job functions will be specified by the Director of Activities
for each volunteer.

c. Job functions may include: assisting with activity programs,
assisting during activity outings, organizing activity supplies,
arranging for outings and special events.

d. All job functions will adhere to state-specific regulations.

3. Scope of Responsibility

a. Volunteers will not be assigned responsibility to supervise
community staff, caregivers, nurses, etc.

b. Volunteers are responsible for ensuring the safety, well-being
and personal rights of residents involved in their activities.

4. Criteria for Use/Supervision

a. Use of volunteers will adhere to state-specific regulations.

b. Volunteers are under the direct supervision of the Director of
Activities.

5. Orientation and Training

a. Volunteers will receive necessary orientation and training
from the Director of Activities.

b. Orientation and training will address:

i. Introduction to program and philosophy.

ii. Volunteer responsibility.

iii. Attendance.

iv. Reporting.

v. Safety.

vi. Delayed egress and/or alarm systems (if applicable).

vii. Confidentiality.

viii. Abuse reporting.

ix. Overview of resident-specific care or health issues.

6. Dismissal

a. Volunteering is at the mutual consent of the community and
the volunteer. Either party may terminate the relationship at
any time, with or without cause and with or without advance
notice.

7. Confidentiality

a. Volunteers will respect and ensure the confidentiality of all
resident, staff and community information.

Assisted Living

Policy and Procedure Manual

Admissions and Move-In XE "Admission"
POLICY:
Resident Pre-Admission XE "Admission" Appraisal XE
"Appraisals"
The Administrator XE "Administrator" will gather data on each
potential resident to determine the need and type of services to
be provided.

Procedure

1. The Administrator XE "Administrator" meets with the
resident and responsible party XE "Family/Responsible Party"
prior to admission.

2. The Resident Appraisal XE "Appraisals" is completed by the
Administrator.
3. The Administrator XE "Administrator" begins the pre-
placement meeting with proper introductions and explanations
to promote a milieu of trust, comfort, and honesty. Open-ended
questions are encouraged. Consent is obtained for the appraisal
XE "Appraisals" .

4. The purpose of the appraisal XE "Appraisals" is explained:
to determine the level and type of services/care needed by the
resident and that will be available for the resident at the time of
move-in, as well as to meet state licensing requirements. The
resident and/or family XE "Family/Responsible Party" is
assured by the Administrator that honesty and detail regarding
care needs is in the best interest of the resident.

5. Communicate acceptance by use of proper body posture, nods
of understanding and allowing the resident ample opportunity to
answer questions.

6. The Administrator XE "Administrator" reviews the Physician
XE "Physician" Report for any prohibited conditions or
communicable illness.

7. Absence of TB XE "Tuberculosis" must be evidenced by a
physician report or chest x-ray within the last six months.

8. The resident and/or responsible party XE
"Family/Responsible Party" are questioned about skin XE
"Skin" breakdown XE "Physician" .

9. A medication XE "Medications" review will include the
following:

a. Review of all medications on hand or reported.
i. NOTE: A physician XE "Physician" order is to be obtained
prior to admission XE "Admission" day, verifying medications
XE "Medications" and dosing schedule.

b. Specifically ask about the use of OTC XE
"Medications:Over-The-Counter" (Over-The-Counter)
medications and complimentary or alternative medicines XE
"Medications" . Note any preferred OTC medications to ensure

physician XE "Physician" orders are secured prior to admission
XE "Admission" .

i. NOTE: This is an opportunity for resident teaching regarding
the storage and use of OTCs, related to regulatory guidelines.

c. Should a resident desire to retain his/her OTC XE
"Medications:Over-The-Counter" medications XE
"Medications" , a physician XE "Physician" order is obtained
indicating the resident may self-store and self-administer
medications.

d. When OTC XE "Medications:Over-The-Counter"
medications XE "Medications" are centrally stored, a physician
XE "Physician" order is required for all routine medications
prior to assisting with the medication.

e. When the OTC XE "Medications:Over-The-Counter" is a
PRN XE "Medications:PRN" and centrally stored, the following
must be included in the physician XE "Physician" order:

i. Name of drug

ii. Strength of drug

iii. Dosage

iv. Exact time frames between doses

v. Maximum dose in a 24 hour period

vi. Symptoms for which the medication XE "Medications" is
used

10. Information regarding alcohol consumption is obtained.

11. Prohibited health conditions XE "Health
condition:Prohibited" and/or residents significantly at risk are
identified. See the policy on prohibited health conditions for
more information.
POLICY:
Allowable Health Conditions
The community will admit and retain stable residents with
health conditions that can be safely cared for by community
staff and are in compliance with state licensing agency
guidelines.

Procedure

1. A physician's XE "Physician" report XE "Physician’s
Report" is reviewed prior to placement to verify diagnoses and
health conditions.

2. The Physician XE "Physician" Visit form is used to monitor
health status changes after the resident is admitted.

3. The following are examples of health conditions/needs that
may be managed in the community.

a. Use of oxygen XE "Oxygen" when blood gases are stable and
the resident is capable of self-administration.

b. Colostomy, when the resident is able to manage all aspects of
the condition XE "Ostomy: Colostomy" .

c. Ileostomy, when the resident is able to manage all aspects of
the condition XE "Ostomy: Colostomy"

XE "Ostomy: Ileostomy" .

d. Incontinence XE "Incontinence" (both bowel XE "Bowel"
and bladder XE "Bladder" ).

e. Stage I and II decubitus XE "Skin:Breakdown" ulcers.

f. Post-surgical wounds when the wound is well approximated.

g. Diabetes, including insulin-dependent, providing the resident
has reasonable stability, and is able to self-test and self-inject.

h. Inhalation therapies.

i. Hospice XE "Hospice" , providing a Medicare certified
hospice agency, contracted by the resident/responsible party XE
"Family/Responsible Party" , is coordinating the care.
i. CALIFORNIA: A waiver XE "Waiver" must be obtained
prior to providing care to residents receiving hospice services.
Community Care Licensing XE "Community Care Licensing"
must be notified in writing, within 5 days of the initiation of
hospice services for any resident.

4. Mild to advanced dementia XE "Dementia" , providing the
community is appropriately licensed.
5. Before accepting or retaining a resident with any of the above
allowable health condition, an assessment/evaluation of the
resident XE "Health condition:Allowable" must be completed
to confirm:

a. Resident's ability for self-care.

b. Compliance with the care routine to maintain medical
stability and consent to additional services whether by the
community staff or outside contracting agencies.

POLICY:
Day of Admission/Move-In
The resident’s needs are addressed during the move-in process.

Procedure

1. The Administrator XE "Administrator" coordinates the
following on move-in day to ensure appropriate resident care.

a. All preadmission documentation XE "Documentation" is
complete and in the resident’s chart.
i. The chart is appropriately labeled and organized.

b. The service plan XE "Service plan" is completed.

c. All physician XE "Physician" admission XE "Admission"
orders are received.
d. Medications

i. All new prescriptions are sent to the pharmacy for same day
delivery, or if using existing fills, medications XE
"Medications" are verified.
ii. The medication XE "Medications" cart/storage area is
labeled and organized.
iii. The MAR XE "Medications:Medication Administration
Record" (Medication XE "Medications" Assistance Record) is
set up, including resident photograph in place.

e. Caregivers are assigned to assist the resident to put
belongings away and settle into his/her room.
i. The assigned caregiver checks with the newly placed resident
every 4-6 hours for the first 24 hours of placement, unless
otherwise requested by the resident.

5. The Administrator XE "Administrator" meets with the
resident at the time of move-in for a brief safety survey of the
room and to verify that the resident is stable.

6. The Administrator XE "Administrator" orients caregivers
about the needs of the newly admitted resident on each shift.

POLICY:
Change in Condition
When a resident exhibits a change in condition, action will be
taken to coordinate appropriate care.

Procedure

1. When a resident displays a change in condition, caregivers
notify the Administrator XE "Administrator" .
2. If a change in status progresses to an emergency at anytime,
call 911 XE "911" .
3. Examples of change in condition may include, but not be
limited to:
a. Refusal XE "Refusal" of meals
b. Decreased mobility/range of motion XE "Range of Motion"
c. Change in patterns of elimination
d. Weakness
e. Decreased coordination
f. Change in level of consciousness XE "Consciousness"
g. Decreased communication/response
h. Decreased ability to communicate signs
i. Decline in cognitive function
j. Motor agitation or retardation
k. Hallucinations or other unusual behavior
l. Nausea
m. Vomiting
n. Elevated or subnormal temperature XE "Vital
Signs:Temperature"
o. Wheezing
p. Shortness of breath or exertion
q. Complaints of pain XE "Pain" or discomfort
r. Edema or swelling
s. Change in usual range of vital signs XE "Vital Signs"
t. Reaction/side effect to medications XE "Medications"
u. Weight loss

v. Depressive behaviors
w. Falls

4. If there is an actual change in condition the resident’s
physician XE "Physician" is notified. Always have the
resident’s complete chart, list of meds, current vital signs XE
"Vital Signs" (if available), and concise list of problems
available when calling the physician.
5. If this is part of an ongoing problem and home health or
hospice are following the resident, contact the home health or
hospice nurse and explain the situation at hand.
6. Document XE "Documentation" the date and time of
contacts, and with whom you spoke. Clearly document any new
orders and repeat back to the physician XE "Physician" .
7. Immediately enter the new orders on the resident’s service
plan XE "Service plan" and/or medication XE "Medications"
administration record XE "Medications:Medication
Administration Record" if the order pertained to medications.
8. Notify the resident’s responsible person of the change in
status and action taken.
9. Keep the Administrator XE "Administrator" abreast of the
resident’s response to the new orders.
10. Report the status change and new physician XE "Physician"
orders to each shift.

11. If the resident status change results in a prohibited health
condition XE "Health condition:Prohibited" , a conference will
take place with the administrator XE "Administrator" to
determine the resident’s suitability for retention. The
administrator will file for an exception XE "Exception" if
required.
12. If the resident requires skilled monitoring due to the status
change, the Administrator XE "Administrator" consults with
the physician XE "Physician" to obtain an order for home
health.
13. The Administrator XE "Administrator" documents XE

"Documentation" , schedules and follows through with any
continuing physician XE "Physician" appointments and medical
care.
14. If the resident status change is more than a transient
problem, a resident care conference is arranged.
15. If the change in status involves a change in ambulatory
status, the resident will be retained in a nonambulatory-
approved room.

POLICY:
Ongoing Resident Appraisals
Residents are assessed/evaluated on an ongoing basis.

Procedure

1. Daily Evaluations

a. All staff members are encouraged to informally monitor
residents on a regular basis throughout the course of normal
daily activities, and to report any changes in condition that are
identified.

2. One-Month Resident Appraisal

a. Resident will be formally assessed thirty days after admission
XE "Admission" .

b. The Administrator XE "Administrator" meets with the
resident and/or responsible party XE "Family/Responsible
Party" to verify the resident’s needs are met.

c. The Administrator XE "Administrator" consults with other
caregivers and staff to ensure the resident’s needs are met.
d. The service plan XE "Service plan" is updated as necessary.

3. Quarterly Resident Appraisal

a. Residents are formally assessed on a quarterly basis.
b. The service plan XE "Service plan" is updated as needed.

c. Rates are adjusted, congruent with care delivered, and in
accordance with the terms of the admission agreement.
d. The Administrator XE "Administrator" consults with other
caregivers and staff to ensure the resident’s needs are met.
4. Stakeholders

a. The following key stakeholders are encouraged to participant
in resident appraisals and service plan updates:

i. The resident

ii. The Administrator

iii. The resident's responsible party

iv. Selected members of the community's care staff

v. Appropriate healthcare professionals (e.g., home health
nurse, physical therapy, etc.)

vi. The resident's physician

POLICY:
Activity Assessments
The activity preferences of each resident will be determined to
aid in the development of a resident-centered activity plan.
Procedure

1. The Administrator or a designated representative interviews
the resident and his/her responsible party XE
"Family/Responsible Party" regarding the resident’s personal
activity XE "Activity" history and preferences.

2. The following domains should be addressed during the
interview:
a. Gross motor activities
b. Daily living skills
c. Self-care activities
d. Crafts
e. Interest in social programs, games, music
f. Interest in large and small group participation
g. Social events
h. Community activities
i. Sensory enhancement, tactile stimulation
j. Outdoor activities, field trips
k. Family events

3. Use the Resident Activity XE "Activity" Assessment XE
"Assessments" form to document the assessment.
4. Information from the assessment is used to develop a
resident-centered activity plan and schedule.
POLICY:
Admission Agreements
Each resident (or responsible party) signs an admission XE
"Admission" agreement prior to admission.
Procedure

1. The resident and his/her responsible party is provided a copy
of the admission agreement prior to admission.

2. Prior to admission XE "Admission" , the administrator XE
"Administrator" meets with the resident and responsible party
XE "Family/Responsible Party" to discuss the agreement as
well as all fees and the plan of care.

3. The admission XE "Admission" agreement must be signed
prior to admission.

4. Resident are given thirty days notice of any subsequent

changes to the agreement.

POLICY:
Service Plans
A resident-centered service plan is created and maintained for
every resident. The purpose of the service plan is to provide a
centralized coordination of the services that will be provided to
each resident, based on his or her individual needs, abilities,
and preferences.

Procedure

1. The Administrator XE "Administrator" , or a designated
representative, develops a service plan XE "Service plan" for
each resident prior to admission XE "Admission" .
2. The service plan is developed with assistance and review
from:

a. The resident.
b. Family/significant other or responsible party.

c. The Administrator (or designee).

d. A registered or licensed nurse, if the resident is receiving
nursing services, medication assistance, or is unable to direct
self-care.

e. The resident’s case manager (if applicable).

f. The team may also include (at resident’s or responsible
party’s request): community personnel, his/her physician, and
other persons as requested.

3. The service plan should address, but is not limited to, the
following:

a. Activities of Daily Living (ADLs).
b. Medication management and/or assistance required.

c. Physical needs related to illness/chronic disease management.

d. Psychosocial needs including activities

e. Behavioral challenges/needs

f. Spiritual needs.

g. Fall history and/or risk.
h. Nutritional needs such as help with eating or special diet.
i. Skin integrity issues.
j. Any need identified by the family or resident.

k. Activities.
l. Transportation needs.
4. A copy of the service plan is available to all staff for review.
5. A current copy of the service plan, signed by the resident
and/or responsible party is retained in the resident’s record.
6. All direct care staff are encouraged to give input on service
plan changes.
7. Formal review takes place:

a. Thirty days after admission XE "Admission" .

b. Quarterly.

c. Annually.

d. Upon significant change in resident status/condition.

POLICY:
Resident Care Conference
The resident care conference is intended to encourage a

multidisciplinary approach to resident care planning that
involves input from all relevant stakeholders.
Procedure

1. Purpose of Resident Care Conferences:

a. To identify individual resident needs.

b. To collaborate with all stakeholders in the coordination of
optimal resident care, ensuring clear communication of the plan
of care.

c. To evaluate effectiveness of previous interventions and
current resident status.

d. To develop resident-centered interventions and methods of
care for the individual resident.

e. To coordinate discharges/evictions for those residents at risk
for transfer trauma XE "Trauma" .

2. Indications for Resident Care Conference:

a. Upon admission XE "Admission" of a new resident.

b. Upon readmission of a resident if there has been a change in
status or previous functional abilities.
c. Resident is at risk of move-out or discharge.

d. Change in resident status or condition.
e. Annual resident appraisal and service plan review.

3. Attendees at the resident care conference may include, but
are not limited to:
a. Administrator XE "Administrator"
b. Assistant administrator XE "Administrator"

c. Appropriate department heads.
d. The resident
e. The resident's responsible party XE "Family/Responsible
Party"
f. Home health nurse
g. Other health care providers as appropriate (e.g., hospice,
physical therapy, etc.)

4. Documentation XE "Documentation" /Information
a. Conferences are to be resident focused at all times. It is the
responsibility of the administrator XE "Administrator" to have
all of the following information available at the conference:
i. Resident’s history.
ii. A copy of the entire resident charting XE
"Documentation:Charting" for the last 60 days.
iii. List of current medications XE "Medications" .
iv. Significant health history.
v. Incident reports.
vi. Current service plan.
vii. All other relevant history and information.
viii. Current MD XE "Physician" orders.
5. Suggest Conference Agenda
a. The conference general agenda is as follows:
i. Identify the resident.
ii. State purpose of conference (at risk, status change, etc.)
iii. Brief history.
iv. Current medications XE "Medications" & Physician XE
"Physician" orders.
v. State chief problems/concerns.
vi. Discussion/identification of needs.
vii. Review/critique of previous interventions and plan of care.
viii. Discussion, revision and formulation of current plan of
action.
ix. Interventions.
x. Identification of individuals to carry out each intervention.
xi. Schedule of follow up conference date (as necessary) to

evaluate status and interventions.

POLICY:
Move-Out
Residents may move out of the community for a variety of
reasons, such as increased need for healthcare services, a
change in condition, or family/personal reasons. A move-out of
the community (discharge) is conducted in a dignified manner
to limit transfer trauma and to ensure that resident needs are
met XE "Trauma" .
Procedure

1. The Administrator XE "Administrator" coordinates the
timing of the move-out with the responsible party XE
"Family/Responsible Party" and receiving community or new
residence.

2. If ambulance transportation is necessary, it is arranged by the
Administrator XE "Administrator" .

3. The Administrator XE "Administrator" assigns a staff
member to assist resident with collecting and packing
belongings, as needed.

4. The resident is dressed in appropriate street clothing if going
by car. Gown, pajamas, etc., may be worn if going by
ambulance.

5. The caregiver assigned to the resident ensures hearing aid,
dentures XE "Dentures" , etc., are in place and appropriately
accounted for.

6. The resident’s medications XE "Medications" are counted
and packaged appropriately for transportation. The person
receiving the medications upon transfer signs for their receipt,
accepting and acknowledging responsibility for safekeeping.

7. All treatments and medication XE "Medications" given
within the last 24 hours are indicated, and passed on to the new
community.
8. A resident move-out summary is completed in the resident's
record.

9. The resident's record is archived.
Assisted Living

Policy and Procedure Manual

Resident Care

POLICY:
Basic Care Services
Personal care will be provided to all residents on an individual
basis according to findings from admission XE "Admission"
appraisals XE "Appraisals" and subsequent re-appraisals.
All resident care is planned and delivered in a resident-centered
manner, and personal service plans XE "Service plan" should
address any individual resident needs.

Procedure

1. At the beginning of each shift, staff should familiarize
themselves with resident status. Clear communication with
staff from the previous shift, using the shift report and verbal
exchange, ensures quality care.

2. Each resident is monitored on a routine basis. Check on
residents every two hours, unless indicated otherwise on the
resident’s service plan XE "Service plan" .

a. NOTE: Residents with confusion or a diagnosis of dementia
XE "Dementia" should be checked on an on-going basis.

3. Incontinent care is given as necessary to residents requiring
assistance every two hours. This includes nighttime hours,
unless the physician XE "Physician" orders indicate otherwise.

4. Medications XE "Medications" are to be given according to
physician orders and when possible according to the following
general medication pass schedule.

a. Morning medication XE "Medications" pass: 7:30 A.M.

b. Mid-day medication XE "Medications" pass: 11:30 A.M.

c. Evening medication XE "Medications" pass: 4:30 P.M.

d. Bedtime medication XE "Medications" pass: 8:30 P.M.

e. A "two-hour window" ensures appropriate delivery of
medications. Medications XE "Medications" may be passed
one hour earlier or one hour later unless indicated otherwise by
the physician or authorized prescriber XE "Physician" .

5. PRN XE "Medications:PRN" medications XE "Medications"
are administered according to physician XE "Physician" orders,
resident requests, and state regulations.
6. Residents are assisted with morning care as needed, which
may include but is not limited to the following XE "Activity" :

a. Clothing selection.
b. Dressing.
c. Oral care.
d. Assistive devices, such as eye glasses, hearing aids, etc.

e. Shaving.
f. Cosmetics.
g. Hair care.

7. Residents are to have a full shower/bath according to their
needs and preferences, and at least twice per week.

8. Residents needing a reminder or assistance with ambulation
or escorts are to receive assistance to the dining room as needed
for all three meals and snacks as necessary.

9. Each resident is to have his or her room tidied and bed XE
"Bed" made each day if unable to do so independently.
Complete cleaning of their quarters is performed by
housekeeping staff on a weekly basis.

10. Residents are encouraged to select and attend activities. It
is the responsibility of the Caregiver to remind the resident of
upcoming activities throughout the day.

11. Residents receive assistance with bedtime/evening care as
needed, which includes, but is not limited to the following:

a. Oral care.
b. Dentures XE "Dentures" in a labeled cup.
c. Assistance into night clothes.
d. Toileting.
e. Incontinence XE "Incontinence" care.
f. Safety check of the room.
g. Remove physical obstacles to the bathroom, and leave a low
light on in the bathroom.
h. Room set to a temperature desired by/comfortable for the
resident.
i. Monitor noise level. XE "Lighting"
12. Any unusual incident will be reported and documented. All
pertinent information on the resident will also be documented
and passed on to the following shift.

13. Resident status changes will be reported to the physician XE
"Physician" and resident's responsible party XE

"Family/Responsible Party" , in accordance with the policy on
Change in Condition.
POLICY:
Use of Assistive Devices and Ambulatory Aids
The community promotes resident safety by allowing and
encouraging the use of resident assistive devices and mobility
aids.

Implementation

1. The physician report and any pre-admission documentation
will be reviewed prior to placement, identifying resident need
for assistive devices or mobility aids.

2. The resident and responsible party are interviewed regarding
resident need for assistive devices or mobility aids.

3. Upon admission, the resident’s assistive devices and mobility
aids are labeled with name and room number.

4. Upon admission, residents are instructed about use of
devices/aids within the community:
a. Use in dining room.

b. Storage of devices for safety.

5. When a resident receives a new order for a mobility aid, the
physician is contacted to request a physical therapy consult for
resident teaching.

6. In the dining room or common areas where an activity may
cause some congestion, resident’s mobility aids are moved to a
designated area, once the resident is seated safely. Staff will
return the device to the resident upon request, when the resident
is ready to ambulate.

7. Any resident using a motorized scooter must demonstrate safe
operation of the device to the Administrator. The Resident Care
Coordinator also obtains a written order verifying the ability for
safe operation from the resident’s physician. The resident must
be re-evaluated for safety should any impaired operation take
place.

8. Safe use of mobility aids and assistive devices is included in
staff orientation.

POLICY:
Hygiene and Grooming
The resident’s hygiene and grooming needs are met while
addressing the resident’s personal preferences and daily routine.

Implementation

1. The Resident and responsible party are interviewed prior to
move-in to determine the resident’s preferences for the
provision of hygiene and grooming care.

2. The resident’s physician report and appraisal are reviewed to
identify resident needs and preferences.

3. Special care needs are addressed in the resident’s service
plan.

4. Residents are showered daily if desired, and at a minimum
twice a week. Exceptions are allowed for residents with special
conditions or needs, such as skin disorders or certain disease
processes.

5. Bed baths are given upon evidence of need. The Resident
Care Coordinator approves bed baths to be given on a regular
basis.

6. Refusal of necessary hygiene and grooming is reported by
Caregivers to the Resident Care Coordinator and/or
Administrator. Continued refusal of hygiene and grooming is
noted in the narrative charting section of the resident’s chart,
and the Administrator is notified for further action.

7. Resident autonomy is encouraged. Residents are not
encouraged to accept services when there is evidence they are
capable of providing self-care adequately.

8. Assistance is scheduled as indicated in the service plan.

POLICY:
Dressing
The resident’s need for assistance with dressing is met in
accordance with the resident’s personal preferences.

Implementation

1. The resident’s physician report will be reviewed to determine
if assistance is required.

2. Resident and family/responsible party are interviewed prior
to move-in to determine the resident’s preferences for the
provision of hygiene and grooming care.

3. Residents requiring assistance with dressing are encouraged
to perform as much of the task as possible.

4. The resident is expected to select or participate in the
selection of his/her clothing.

5. Residents are dressed in “street clothes” when in common
areas of the community.

6. Residents are assisted with additional clothing changes

throughout the day as needed.
POLICY:
Sleep and Rest
Sleep disturbances will be addressed to promote appropriate
rest.

Procedure

1. Residents with insufficient or poor quality sleep are
monitored and/or interviewed for possible causative factors.
The Administrator XE "Administrator" and Caregivers monitor
for:

a. Bedtime and waking times

b. Bedtime rituals

c. Type of bedclothes

d. Frequency and duration of awake time

e. Activities XE "Activity" usually performed in the early
evening hours

f. Leisure activities XE "Activity"
g. Medications XE "Medications" taken

h. Perceived health status and satisfaction with life

i. Food or fluids consumed shortly before bedtime

j. Number of nightly trips to the bathroom

k. Frequency of need for pain XE "Pain" medications XE
"Medications" or for help with toileting

l. Time spent out of bed XE "Bed"
2. The Administrator XE "Administrator" initiates changes in
care to improve sleep, such as:

a. Maintain the same daily schedule for waking, resting, and
sleeping.

b. Get up at the usual time even if the sleep has been disturbed
or the bedtime change temporarily.

c. Establish a bedtime ritual and stick to it.

d. Exercise every day but avoid vigorous exercises at night.

e. Limit naps to one or two hours per day, at the same time each
day.

f. Take a warm bath in late afternoon or early evening.

g. Avoid caffeine-containing beverages and products.

h. Practice relaxation methods such as deep breathing, music,
rocking, massage, or reading calm materials.

i. Eat a light XE "Lighting" snack of carbohydrates and fat
before bed XE "Bed" .

j. If the resident is awake for longer than 30 minutes, get the
resident out of bed XE "Bed" and engage in a non-stimulating
activity XE "Activity" such as reading.

3. When other methods have failed, the Administrator XE
"Administrator" consults with the physician XE "Physician"
for possible use of temporary sleep aids or other medical
interventions or assessments XE "Assessments" .

POLICY:
Incontinence
Residents suffering with incontinence XE "Incontinence" will
receive care and management aimed towards restoring
continence whenever possible and preventing incontinence-
related complications.
Procedure

1. Should a resident have an episode of incontinence XE
"Incontinence" , the Administrator XE "Administrator" consults
with the physician XE "Physician" to investigate the following:

a. Problems with manual dexterity or mobility.

b. Problems or changes in the environment (access, distance to
toilets, etc.)

c. Problems with excessive fatigue.

d. Difficulty or painful voiding.

e. Problems with constipation/stool impaction.

f. Changes in diet, including increase in caffeine.

g. Changes in medications XE "Medications" , such as addition
of a diuretic.

h. Changes in behavior/affect.

i. Mental status.

2. The Administrator XE "Administrator" instructs caregivers
to track episodes of incontinence XE "Incontinence" . If the
resident is alert XE "Alert" , encourage the resident to track
episodes themselves.

3. The Administrator XE "Administrator" transmits the
information on episodes of incontinence XE "Incontinence" and
other pertinent information to the resident’s physician XE
"Physician" .

4. The Administrator XE "Administrator" establishes a toileting
schedule for staff to follow when appropriate.

5. The Administrator XE "Administrator" consults with the
physician XE "Physician" to develop interventions to correct
incontinence XE "Incontinence" whenever possible.

6. Should interventions fail and the resident is diagnosed with
chronic intractable incontinence XE "Incontinence" , the service
plan XE "Service plan" will include a skin XE "Skin"
management plan.
7. Unless contraindicated, residents receive incontinent care and
brief changes every two hours, or more often as needed, to keep
the resident clean and dry.

8. Caregivers are instructed to monitor for and report any signs
of skin breakdown.
POLICY:
Nutrition and Weights
The community monitors weights and provides modified diets as
ordered by the physician XE "Physician" .

Procedure

1. The Administrator XE "Administrator" assigns the task of
measuring resident weights to caregivers (after appropriate
training) on a monthly basis.
2. Weights are measured more often if ordered by the physician
XE "Physician" .
3. Weight measurements are recorded in the residents record on

the weight record form.
4. Weights are measured using the following guidelines:
a. Prior to breakfast, after first voiding, and with the same
amount of clothing each day.

5. A weight change of five pounds or 5% of body weight in a
30-day period, whichever is greater, is reported to the physician
XE "Physician" .

6. Nutritional supplements will be offered to the resident as
ordered by the physician XE "Physician" .

7. Modified diets will be provided as ordered by the physician
XE "Physician" .

POLICY:
Podiatry and Nail Care
The community will arrange for or make available foot and nail
care.

Procedure

1. Caregivers monitor the length and condition of the toe and
finger nails of residents receiving bathing, dressing, or
grooming services.

2. Caregivers note changes in residents’ nail or foot integrity.

3. Caregivers do not trim nails, smooth corns, calluses, etc.

4. The Administrator XE "Administrator" schedules a podiatry
appointment for foot and/or nail care, other than cleaning or
moisturizing.

5. The Administrator XE "Administrator" arranges for regular
(monthly preferred) onsite visits by a podiatrist, as needed and

as available.
POLICY:
Caregiver Daily Schedule
Caregivers are given assigned duties to ensure quality care.

This is only a basic policy and schedule. Always refer to the
resident’s individual plan of care for additional intervention.

11:00 pm - 7:30 am

1. Verify resident status changes with the previous shifts. Read
documentation XE "Documentation" .

2. Rounds every two hours.

3. Incontinent care every two hours as assigned, and as needed.

4. Housekeeping duties as assigned.

5. PRN XE "Medications:PRN" medications as needed (med
aides only).
6. Awaken first serving breakfast residents.

7. Assist with designated early morning baths.

8. Assist as needed with grooming: Resident morning grooming
(assist only as required)

a. Bathing (on designated days)

b. Incontinent care

c. Clothing selection

d. Dressing

e. Oral care

f. Assistive devices in place

g. Shave

h. Make-up

i. Hair care

j. Mini appraisal XE "Appraisals"
9. First serving residents to dining room.

10. Set-up and pass 7:30 am medications (medication aides
only).
11. Assist second serving residents with personal care.

12. Document XE "Documentation" resident status change or
incidents per community protocol.

13. Report off to next shift.

7:00 am - 3:30 pm STAFF DUTIES

1. Verify resident status changes with the previous shifts. Read
documentation XE "Documentation" .

2. Check schedule for resident physician XE "Physician" or
other scheduled appointments.

3. Designated resident baths.

4. Assist with resident grooming which was not completed by
the night shift.

a. Bathing ( on designated days )

b. Incontinent care

c. Clothing selection

d. Dressing

e. Oral care

f. Assistive devices in place

g. Shave

h. Make-up

i. Hair care

j. Mini appraisal XE "Appraisals"
5. Second service residents to dining room by 7:30 am.
6. Rounds every 2 hours.

7. Incontinent care every 2 hours as assigned.

8. Make beds.

9. Tidy rooms/housekeeping duties as assigned.

10. Pass am snacks.

11. Residents to 10:00 am activities XE "Activity" .

12. PRN XE "Medications:PRN" medications as needed (med
aides only).
13. Prepare and assist first serving residents to dining room for
lunch.

14. Prepare and pass 11:30 am medications (med aides only).
15. Prepare and assist second serving residents to dining room
for lunch.

16. Residents to early afternoon activities XE "Activity" .

17. Afternoon grooming/room check.

a. Clean clothing

b. Wash face and hands

c. Tidy room

18. Pass afternoon snacks.

19. Document XE "Documentation" status change/incidents per
protocol.

20. Report off to next shift.

21. Med staff only.

3:00 pm - 11:30 pm
1. Verify resident status changes with previous shifts. Check
documentation XE "Documentation" .

2. Rounds every 2 hours.

3. Incontinent care every 2 hours.

4. Housekeeping duties as assigned.

5. PRN XE "Medications:PRN" medications as needed (med
aides only).
6. Set-up and pass 4:30 pm medications (med aides only).

7. First serving residents to dining room at 4:30 pm. Second
serving residents to dining room at 5:30 pm.

8. Residents to pm activities XE "Activity" .

9. Set-up and pass 8:30 pm medications (med aides only).
10. Assist residents as needed with evening care.

a. Oral care

b. Dentures XE "Dentures" in labeled cup

c. Assist into night clothes

d. Toileting

e. Incontinent care

f. Remove soiled clothing and put in hamper

g. Remove assistive devices (hearing aids, etc.)

h. Safety check

i. Pathway clear to bathroom

j. Room a comfortable temperature XE "Vital
Signs:Temperature"
k. Extra blankets, etc.

11. Check lighting XE "Lighting" .

12. Outside doors secured. (from outside only)

13. Document XE "Documentation" status change/incidents per
protocol.

14. Report off to next shift.

POLICY:
Sexual Expression
The community respects the resident’s need for sexual
expression and intimacy.

Procedure

1. Resident privacy is observed by scheduling for private time,
knocking on doors before entering, etc.

2. Verify the resident’s ability to give consent by consulting
with the resident’s physician XE "Physician" for residents
interested in pursuing sexual relationships.

3. When a resident displays inappropriate sexual activity XE
"Activity" / exposure, have staff remind the resident of the
need for privacy and then move the resident to his or her room.

4. Discuss the resident’s sexual behavior with caregivers.
Reinforce the idea that sexual behavior is normal and that
acknowledging a resident’s sexuality is appropriate.

5. Educate families about resident rights related to sexuality and
the normalcy of sexual expression.

6. When a resident interacts or touches staff inappropriately, the
Administrator XE "Administrator" reinforces care techniques to
avoid such problems. For example:

a. Identify yourself when ready to provide care.

b. Stand at the side, rather than in front of the residents reach
when providing personal care.

c. Give the resident something to hold when providing personal
care.

Assisted Living

Policy and Procedure Manual

Medication XE "Medications" Management

POLICY:
Medication Storage
Medications XE "Medications" will be stored in a manner that
ensures maintenance of both the integrity of the medication and
the safety of all residents residing in the community.

Procedure

1. All medications XE "Medications" , including over-the-
counter XE "Medications:Over-The-Counter" , are kept in
locked storage at all times.

2. All medications XE "Medications" must be stored in
accordance with label instructions (refrigerate, room
temperature XE "Vital Signs:Temperature" , out of direct
sunlight, etc.).

3. Medication XE "Medications" requiring refrigeration are
stored in a separate, locked refrigerator that is used solely for
medication storage.

4. If resident is allowed to keep his/her own medications XE
"Medications" , the Administrator XE "Administrator" ensures:

a. Locked storage is maintained in the resident’s room to
prevent access by other residents.

b. Physician XE "Physician" orders are on file in the resident’s
chart indicating the resident is able to store and self-administer
his/her medications XE "Medications" .

c. Quarterly evaluation of the resident’s ability to safety store
and self-administer his/her medications XE "Medications" .

POLICY:
Medication Records
Records of medications XE "Medications" are maintained.

Procedure

1. A record of all medication XE "Medications" brought into
the community is maintained for three years.

2. A record of medications XE "Medications" that are disposed
of in the community is maintained for at least 3 years.

3. Written physician XE "Physician" orders for all medications
XE "Medications" are maintained in the resident’s chart in the
“Physician Orders” section.

4. Medication XE "Medications" Administration Record XE
"Medications:Medication Administration Record" s (MARs) are
maintained for all medications poured and/or passed by
community staff.

POLICY:
Telephone Orders
Telephone orders for medications are not permitted. Prescribers
will be asked to fax orders directly to the community.
Procedure

1. If a physician or other authorized prescriber attempts to give
a telephone order, he/she is asked to fax the order to the

community.
2. Community staff may write the order on the appropriate form
and fax it to the prescriber for a signature.

POLICY:
Medication Labels
Community staff does not alter prescription labels.
Procedure

1. Community staff does not alter prescription labels. In order
to maintain a label that matches the current physician XE
"Physician" ’s order, the designated staff person XE
"Administrator" :

a. Without obscuring the original label, flags the container with
a brightly colored sticker and writes on it “order changed,” with
the date, time, and his/her initials.

b. The designated staff person highlights the old order in the
MAR XE "Medications:Medication Administration Record" and
writes: “order changed,” with the date, time, and his/her
initials.

c. The designated staff person transcribes the new order in the
next available space in the resident’s MAR XE
"Medications:Medication Administration Record" .

2. The designated staff person discusses the change with
resident and/or responsible party XE "Family/Responsible
Party" .

3. The designated staff person ensures the new medication XE
"Medications" instructions are transmitted to the pharmacy so
consecutive refills are appropriately labeled.
POLICY:
Resident Arrives with a Medication

When a resident arrives at the community with a new
medication XE "Medications" , steps will be taken to ensure
proper storage and handling of the medication. Physician XE
"Physician" ’s orders will be verified for all medications.

Procedure

1. Each physician XE "Physician" is contacted to ensure that
the physician is aware of all medications XE "Medications"
currently taken by the resident.

2. Containers are inspected by a pharmacist to ensure the
labeling is accurate.

3. The Administrator XE "Administrator" discusses
medications XE "Medications" with the resident or the
responsible party XE "Family/Responsible Party" .

4. If the physician and administrator XE "Administrator" agree
that the resident is capable of self-storage and self-
administration of medication XE "Medications" , the resident’s
medications are stored in a locked compartment in his/her room.

5. The medications XE "Medications" are placed in the
medication room in an appropriately labeled drawer, bin, etc., if
central storage is required.

6. The medications XE "Medications" are appropriately listed
on the MAR XE "Medications:Medication Administration
Record" , verifying accuracy according to physician XE
"Physician" orders.

7. All medications XE "Medications" not self stored or self
administered by the resident are logged on to the Centrally
Stored Medication Record.

POLICY:
Medication Refills
Medication XE "Medications" refills will be obtained in a
timely manner to ensure residents have all physician XE
"Physician" ordered medication available.

Procedure

1. The Designated staff person XE "Administrator" contacts the
dispensing pharmacy to obtain a refill at least seven (7) days
prior to running out of a medication XE "Medications" , unless
medication is on a cycle refill with the pharmacy. When the
medication is ordered it is entered onto the Refill Roster. When
medications are received they are entered on the Refill Roster.

2. If necessary, the prescribing physician XE "Physician" is
contacted for a new order.

3. Medications XE "Medications" are never allowed to run out
unless directed to by the physician (obtain this direction in
writing) XE "Physician" .

4. Containers are inspected to ensure all information on the
label is correct.

5. Any changes in instructions and/or medication XE
"Medications" are noted; for example, change in dosage,
change to generic brand, etc.

6. Medications XE "Medications" are logged on the Centrally
Stored Medication Record when received.

7. The Designated staff person XE "Administrator" discusses
any changes in medications XE "Medications" with the
resident, responsible party XE "Family/Responsible Party" and
appropriate staff.

POLICY:
Medications are Permanently Discontinued
Permanently discontinued medication XE "Medications" will
not be retained in the community.

Procedure

1. The Designated staff person XE "Administrator" confirms
with physician XE "Physician" the order to permanently
discontinue the use of the medication XE "Medications" , and
obtains written documentation XE "Documentation" of the
discontinuance from the physician, prior to destroying.

2. The Designated staff person XE "Administrator" discusses
the discontinuance with the resident and/or responsible party
XE "Family/Responsible Party" .

3. To properly dispose of permanently discontinued medications
XE "Medications" the Designated staff person XE
"Administrator" and another adult witness who is not a
resident:

a. Returns the medication XE "Medications" to the dispensing
pharmacy for disposal; or

b. Disposes of the medication XE "Medications" in a medical
waste receptacle that is picked up at regular intervals by a
licensed medical waste company.

4. Medications XE "Medications" to be returned to the
pharmacy are held in a bin labeled “return to pharmacy” in the
medication room until the time of pick-up by the pharmacy.

5. The Designated staff person XE "Administrator" and witness
will document XE "Documentation" destruction on the

Centrally Stored Medication XE "Medications" Record.

POLICY:
Hold Orders
Temporarily discontinued ("dc") and/or “HOLD” medications
XE "Medications" will be held from use by the resident as
instructed by the physician XE "Physician" .

Procedure

1. The Designated staff person XE "Administrator" discusses
the change with the resident and/or responsible party XE
"Family/Responsible Party" .

2. The Designated staff person XE "Administrator" obtains a
written order from the physician XE "Physician" to HOLD the
medication XE "Medications" .

3. Without obscuring the label, the medication XE
"Medications" container is flagged with a brightly colored
sticker where the Designated staff person XE "Administrator"
writes: “HOLD,” the date, the time, and his/her initials.

4. The medication XE "Medications" is not given to the
resident until the date and/or time indicated in the physician XE
"Physician" ’s hold order.

5. The medication XE "Medications" is placed into a plastic bin
labeled “On Hold Medications” in the medication room.

POLICY:
Expired Medications
Expired medication XE "Medications" will be not be given to
any resident or responsible party XE "Family/Responsible
Party" , nor retained in the community.

Procedure

1. Expired medications XE "Medications" are not used.

2. The Designated staff person XE "Administrator" inspect
containers regularly for expiration dates.

3. The Designated staff person XE "Administrator"
communicates with physician XE "Physician" and pharmacy
promptly to obtain a refill.

4. To properly dispose of expired medications XE
"Medications" the Designated staff person XE "Administrator"
and another adult witness who is not a resident:

a. Returns the medication XE "Medications" to the dispensing
pharmacy for disposal; or

b. Disposes of the medication XE "Medications" in a medical
waste receptacle, which is picked up at regular intervals by a
licensed medical waste company.

5. The Designated staff person XE "Administrator" and witness
will document XE "Documentation" destruction on the
Centrally Stored Medication XE "Medications" Record.

POLICY:
Medications Left Behind by a Resident
When a resident moves out of the community, all medications
XE "Medications" , including over-the-counter XE
"Medications:Over-The-Counter" s, should go with resident
when possible.

Procedure

1. If the resident dies, prescription medications XE

"Medications" are to be destroyed.

2. To properly dispose of medications XE "Medications" left
behind by a resident, the Designated staff person XE
"Administrator" and another adult witness who is not a
resident:

a. Returns the medication XE "Medications" to the dispensing
pharmacy for disposal; or

b. Disposes of the medication XE "Medications" in a medical
waste receptacle, which is picked up at regular intervals by a
licensed medical waste company.

3. The Designated staff person XE "Administrator" and witness
will document XE "Documentation" destruction on the
Centrally Stored Medication XE "Medications" Record.

4. Document XE "Documentation" on Centrally Stored
Medication XE "Medications" Record when medication is
transferred with the resident. Obtain signature of person
accepting the medications (i.e., responsible party XE
"Family/Responsible Party" ) will be obtained, indicating
agreement with the quantity of each medication transferred out
of the community.

5. Medication XE "Medications" records are retained for at
least three years.

POLICY:
Medication Refusal and/or Missed Doses
No resident will be forced to take any medication XE
"Medications" . Steps will be taken to avoid missed or refused
doses of medications and related adverse reactions.

Procedure

1. Missed/refused medications XE "Medications" are
documented in the resident's medication record and the
prescribing physician XE "Physician" notified immediately or
according to physician parameters. Physician parameters must
be retained in writing and kept on file.

2. Physician XE "Physician" instructions regarding missed dose
are followed.

3. The Designated staff person XE "Administrator" re-appraises
the resident and contacts the physician XE "Physician" and
responsible party XE "Family/Responsible Party" if the
resident is continually refusing a medication XE "Medications"
(s). If unable to resolve continued refusal XE "Refusal" , the
resident’s relocation from the community may be necessary.

POLICY:
Crushing Medications
Medications XE "Medications" will be crushed in accordance
with physician XE "Physician" ’s orders and state regulations,
without infringing on the resident’s personal right to refuse
medications.
Procedure

1. The Designated staff person XE "Administrator" obtains a
physician XE "Physician" ’s order prior to crushing a resident’s
medications XE "Medications" .

2. The pharmacist is consulted to verify appropriate foods the
medication XE "Medications" may be mixed with. This phone
conversation is documented in the resident’s chart.

3. The physician XE "Physician" order and documentation XE
"Documentation" of the telephone XE "Telephone" consult is
maintained in the resident’s record XE "Community Care

Licensing" .

4. When crushing medications XE "Medications" :

a. A pill-crushing device is used.

b. The completely crushed medication XE "Medications" is
mixed with an appropriate soft food such as applesauce or
pudding, not a liquid.
5. The resident is clearly informed that he/she is receiving
medications.
POLICY:
Transferring Medications for Home Visits and Outings
Staff will assist resident to obtain/maintain necessary
medications XE "Medications" for use while not in the
community.

Procedure

1. When a resident leaves the community for a short period of
time during which only one dose of medication XE
"Medications" is needed, the Designated staff person XE
"Administrator" gives the medications to a responsible party
XE "Family/Responsible Party" in an envelope (or similar
container) labeled with the resident's name, name of
medication(s), and instructions for administering the dose.

2. If the resident is to be gone for more than one dosage period,
the Designated staff person XE "Administrator" may:

a. Give the full prescription container to the resident, or
responsible party XE "Family/Responsible Party" , or

b. Have the pharmacy fill a separate prescription or separate the
existing prescription into two bottles, or
c. Have the resident's family XE "Family/Responsible Party"

obtain a separate supply of the medication XE "Medications"
for use when the resident visits the family. If family maintains
a separate supply, the Designated staff person XE
"Administrator" supplies them with current physician XE
"Physician" orders prior to every outing or home visit.

4. The Designated staff person XE "Administrator" reviews the
resident’s physician XE "Physician" orders, appraisal XE
"Appraisals" and service plan XE "Service plan" to verify the
ability of the resident to store and self-administer medications
XE "Medications" while away from the community. If it is not
safe to give the medications to the resident, the medications are
entrusted to the person who is escorting the resident off the
community premises.

5. The person entrusted with the medications XE "Medications"
agrees in writing as to the amount of medication received on
behalf of the resident and the appropriate dosing amount and
schedule.

POLICY:
Sample Medications
Sample medications XE "Medications" may be used when
provided by the prescribing physician XE "Physician" . All
safety controls imposed on other medications will apply to
sample medications as well.

Procedure

1. The Designated staff person XE "Administrator" ensures that
all sample medications XE "Medications" received into the
community are provided by the prescribing physician XE
"Physician" .

2. Sample medications XE "Medications" will be labeled with
all the information required on any prescription label except

pharmacy name and prescription number.

3. Sample medications XE "Medications" are centrally stored,
documented and handled in the same manner as other
prescription medications.

POLICY:
Use of Emergency Medications
Residents who have a medical condition requiring the
immediate availability of emergency medication XE
"Medications" (i.e. nitroglycerine, inhaler, etc.) for life-saving
purposes may maintain the medication in his/her possession if
the safety the resident and other residents can be maintained
and state regulatory requirements are followed.

Procedure

1. A physician XE "Physician" order is received stating that the
resident is capable of determining the need for a dosage of the
medication XE "Medications" and has determined that
possession of the medication by the resident is safe.

2. This determination by the physician XE "Physician" is
maintained in the individual's file and available for inspection
by the state licensing agency.

3. The physician XE "Physician" 's determination clearly
indicates the dosage and quantity of medication XE
"Medications" that should be maintained by the resident.

4. Neither the community designated staff person XE
"Administrator" nor state licensing agency staff has determined
that the medications XE "Medications" must be centrally stored
in the community due to risks to others or other specified
reasons.

5. If the physician XE "Physician" has determined it is
necessary for a resident to have medication XE "Medications"
immediately available in an emergency but has also determined
that possession of the medication by the resident is dangerous,
then that resident may be inappropriately placed and may
require a higher level of care.

POLICY:
Injections
Injectable XE "Medications:Injectables" medications XE
"Medications" will be administered by authorized licensed
nurses or physicians, according to physician XE "Physician" ’s
orders and state regulatory requirements.

Procedure

1. Injections XE "Medications:Injectables" are administered
only by the resident themselves or by a licensed medical
professional. Licensed medical professional includes Doctors
of Medicine (MD XE "Physician" ), Registered Designated staff
persons (RN), and Licensed Practical/Vocational Nurses
(LPN/LVN).

2. Licensed medical professionals administer only medications
XE "Medications" /insulin that they have drawn up, or have
been predrawn by the pharmacy or the drug manufacturer.

3. If the resident administers his/her own injections XE
"Medications:Injectables" , physician XE "Physician"
verification of the resident's ability to do so is maintained in the
resident’s record.

4. The Designated staff person XE "Administrator" ensures
sufficient amounts of medications XE "Medications" , test
equipment, syringes, needles, and other supplies are maintained
in the community and stored properly.

5. Syringes and needles are disposed of in a "container for
sharps," and the container shall is kept inaccessible to residents.
The container shall be removed from the community by an
appropriate medical waste company.

6. Insulin and other injectable XE "Medications:Injectables"
medications XE "Medications" are kept in the original
containers until the prescribed single dose is measured into a
syringe for immediate injection.

7. Insulin or other injectable XE "Medications:Injectables"
medications XE "Medications" may be packaged in pre-
measured doses in individual syringes prepared by a pharmacist
or the manufacturer.

8. Syringes may be pre-filled under the following
circumstances:

a. Pre-filled syringes prepared by a registered nurse XE
"Administrator" , may be self-injected by residents who are able
and approved to self-inject.

b. The registered nurse (RN) must not set up insulin syringes
for more than seven days in advance. The pre-drawn insulin is
only for the resident to self-administer. An LVN may not pre-
draw insulin.

9. Injectable XE "Medications:Injectables" medications XE
"Medications" that require refrigeration must be kept
inaccessible to residents.

POLICY:
Over-the-Counter (OTC) Medications
A physician XE "Physician" order is required for all OTC XE
"Medications:Over-The-Counter" medications XE

"Medications" .

Procedure

1. OTC XE "Medications:Over-The-Counter" preparations are
centrally stored, documented and handled in the same manner as
prescription medications XE "Medications" .

2. The Designated staff person XE "Administrator" contacts the
physician XE "Physician" for prescriptions for OTC XE
"Medications:Over-The-Counter" preparations prior to their
use.

POLICY:
Psychotropic Medications
Psychotropic medications XE "Medications" are given in a safe
manner according to physician XE "Physician" orders. The
community minimizes the use of psychotropic medications when
possible.

Procedure

1. Behavioral and environmental interventions are attempted to
avoid over or unnecessary use of psychotropic medications XE
"Medications" .

2. Caregivers are educated on appropriate interventions for
anxiety, agitation, dementia XE "Dementia" -related behavioral
challenges, and potential adverse effects of psychotropic
medications XE "Medications" .

3. The Designated staff person XE "Administrator" encourages
caregivers to report adverse effects such as extrapyramidal
symptoms XE "Extrapyramidal Symptoms" and tardive
dyskinesia XE "Tardive Dyskinesia" .

POLICY:
Warfarin and Other Anticoagulants
Residents taking warfarin or other anticoagulants will receive
assistance with necessary monitoring and/or lab tests.

Procedure

1. Residents receiving Coumadin XE "Medications:Coumadin
(warfarin)" are instructed on signs and symptoms of
complications, and to report these immediately to their
physician XE "Physician" and to the Administrator XE
"Administrator" .

2. Staff are trained on monitoring residents receiving warfarin
(Coumadin XE "Medications:Coumadin (warfarin)" ) or other
anticoagulants.

3. The Administrator XE "Administrator" makes arrangements
for transportation to lab appointments as required.
4. Lab results are reported directly to the prescribing physician.
5. The Medication XE "Medications" Administration Record
XE "Medications:Medication Administration Record" is
updated immediately upon receiving the Coumadin XE
"Medications:Coumadin (warfarin)" dosing change from the
prescribing physician XE "Physician" .

POLICY:
Narcotics, Controlled Substances, and Preventing Drug
Diversion
All medications are stored in a secure manner, as outlined in
other policies. Special storage and security procedures will be
followed to protect controlled substances (narcotics, etc) and to
help prevent drug diversion.
Procedure

1. All medications XE "Medications" , including over-the-

counter medications XE "Medications:Over-The-Counter" , are
kept in locked storage at all times.
a. Only authorized staff members are given keys to the
medication storage area.

b. Staff members do not take keys home or otherwise off
community premises.

2. A Narcotic Count Sheet will be maintained for all narcotic
medications.
a. When a narcotic is received in the community, it is counted
by two staff members and added to the narcotic sheet with the
current medication count reflected in the amount on hand.

b. Each time a resident receives assistance with self-
administration of a narcotic, this is documented and the amount
of medication on hand is updated on the Narcotic Count Sheet.

c. At the end of each shift, the staff member responsible for
medication completing his/her shift, and the staff member
responsible for medications who is starting his/her shift, count
all narcotic medications and confirm that the amount on hand
matches was it listed on the Narcotic Count Sheet for each
medication. Both staff members will sign a Narcotic
Reconciliation Sheet confirm the accurate count of narcotics on
hand.
d. Any discrepancies are immediately reported to the
Administrator.

3. When medications are to be destroyed, the destruction must
be witnessed by the staff member responsible for medications
and a pharmacist. The destruction is documented, including the
amount of medication destroyed and a signature from both
witnesses.

4. Staff members will be trained to identify drug diversion and

encouraged to report suspected drug diversion to the
Administrator for proper investigation.

a. Any drug diversion will be reported to the state licensing
agency, law enforcement, and any other agencies as required.
Assisted Living

Policy and Procedure Manual

Emergencies and Medical Needs
POLICY:
Physician and Other Medical Appointments
The resident will receive assistance in obtaining necessary
medical care.

Procedure

1. Residents and responsible parties are informed to notify the
Administrator XE "Administrator" of pending physician XE
"Physician" or other medical appointments.

2. The scheduled physician XE "Physician" visits are entered
on the physician appointment calendar.

3. The following accompanies the resident on all physician XE
"Physician" visits:

a. Physician XE "Physician" Visit form.

b. Photocopy of current MAR XE "Medications:Medication
Administration Record" (originals are never sent).

c. Any other requested documentation XE "Documentation"
(daily glucose reading, etc.).

d. The Physician XE "Physician" Visit form is returned to the

community and all orders transcribed by the licensed
Administrator XE "Administrator" or supervisor on duty.

4. Family XE "Family/Responsible Party" /responsible party
may transport XE "Transport" the resident to appointments.
The Administrator XE "Administrator" instructs caregivers to
have the resident appropriately dressed and ready for transport.

5. Should the resident not have transportation, the
Administrator XE "Administrator" arranges for necessary
transportation.

6. If a resident is unsafe to be left without an escort, the
Administrator XE "Administrator" arranges for a staff member
to accompany the resident.

7. Should the Administrator XE "Administrator" determine a
resident is not stable, safe, or comfortable enough for van/car
transportation, arrangements are made for ambulance transport
XE "Transport" .

8. It will be disclosed to the resident/responsible party XE
"Family/Responsible Party" upon admission XE "Admission" ,
that off-hour, unscheduled, or ambulance transportation is the
financial responsibility of the resident.

POLICY:
Labs and Outside Medical Services
The resident will receive assistance with arrangements for
outside medical services.

Procedure

1. Residents and responsible parties are informed to notify the
Administrator XE "Administrator" of any pending outside
medical services.

2. The scheduled service is calendared.

3. Should the resident not have transportation, the
Administrator XE "Administrator" arranges for a staff member
to accompany the resident.

4. If the resident is unable to be left without an escort, the
Administrator XE "Administrator" arranges for a staff member
to accompany the resident.

5. It is disclosed to the resident and responsible party XE
"Family/Responsible Party" upon admission XE "Admission" ,
that off hour unscheduled or ambulance transportation is the
financial responsibility of the resident.

6. The Administrator XE "Administrator" instructs all labs
reporting or transmitting values to directly transmit to the
physician XE "Physician" . Unlicensed XE "Unlicensed Staff"
caregivers may not take verbal lab values.

POLICY:
Licensure of Nursing Personnel
Nursing personnel must present verification of such license XE
"License" prior to or upon employment.

Procedure

1. At the time of employment, nursing personnel who require a
license XE "License" or registration present verification of
such license to the administrator XE "Administrator" .

2. A copy of the current license XE "License" and registration
number is filed in the employee’s personnel record.

3. A copy of the annual renewal (as applicable) is presented to

the administrator XE "Administrator" .

4. If the validity or standing of a license XE "License" is in
question, the administrator XE "Administrator" will contact the
appropriate board for verification.

5. Until the license XE "License" is verified, the nurse will not
perform any duties requiring licensure.

POLICY:
Medical Emergencies
The resident will receive emergency medical care when needed
to prevent further injury XE "Injury" or illness.

Procedure

1. Caregivers immediately summon the community
Administrator XE "Administrator" should a resident exhibit
signs and symptoms of a medical emergency.

2. The Administrator XE "Administrator" makes a
determination as to the severity of the situation.

3. The community summons emergency medical services by
calling 911 XE "911" ), when the resident exhibits signs and
systems of distress and/or emergency condition. Examples
include, but are not limited to:

a. New onset of chest pain XE "Pain" ;

b. Recurrent chest pain XE "Pain" , unrelieved in 15 minutes by
previously ordered nitroglycerin XE
"Medications:Nitroglycerin" given as ordered;

c. Unconsciousness;

d. Fall with deformity, severe pain XE "Pain" or head injury
XE "Injury" ;

e. Uncontrolled bleeding XE "Bleeding" ;

f. First time seizure XE "Seizure" ;

g. Recurring seizure XE "Seizure" which last for more than 1
minute;

h. Sudden onset severe pain XE "Pain" ;

i. Shortness of breath;

j. Sudden lack of muscle control, ability to communicate,
drooping facial expression or other signs of stroke XE "Stroke"
;

k. Low blood sugar (according to physician XE "Physician"
order parameters, usually <60);

l. Excessively high blood sugar, according to physician XE
"Physician" order parameters;

m. Poisoning;

n. Fever XE "Fever" which is not lowering despite
interventions and fever reducing agents;

o. Choking;

p. Psychiatric XE "Psychiatric" crisis XE "Crisis" .

4. A non-emergency transport XE "Transport" is only used
when the resident needs urgent but non-emergency medical
care, such as stitches, controlled bleeding XE "Bleeding" , etc.

5. The Administrator XE "Administrator" contacts the
family/responsible party XE "Family/Responsible Party" , as
quickly as possible, once the resident is safely under the care of
the paramedics XE "Paramedics" . Unless instructed otherwise
by the family/responsible party, this includes anytime, 24-hours
a day.

6. The Administrator XE "Administrator" or caregivers are not
required to obtain permission from the family/responsible party
XE "Family/Responsible Party" before summoning emergency
medical services.

7. A staff member remains with the resident until paramedics
XE "Paramedics" transport XE "Transport" out of the
community.

8. A copy of the current MAR XE "Medications:Medication
Administration Record" is given to the paramedics XE
"Paramedics" , along with the Emergency Identification Form.

9. The actual medications XE "Medications" are retained in the
community.

10. The staff person observing the transport XE "Transport" out
of the community will note what belongings are going with the
resident, such as jewelry, dentures XE "Dentures" , prosthetic
devices, etc.

11. A narrative chart entry is made in the resident’s chart
regarding the circumstances which led up to the call (Data),
what care was provided by the staff, including any first aid
(Action), as well as the resident’s response to the action
(Response).

12. An Incident Report is completed.

POLICY:
Psychiatric Emergencies
Appropriate care will be arranged for should a resident be in
psychiatric XE "Psychiatric" crisis XE "Crisis" .

Procedure

1. Caregivers immediately report to the Administrator XE
"Administrator" any significant change in resident affect,
personality, or behavior.

2. Any verbalization of suicidal ideation are taken seriously by
caregivers and reported to the Administrator XE
"Administrator" .

1. NOTE:
Should an Administrator not be on duty, suicidal ideations
would be reported to the immediate supervisor or medical
professional XE "Administrator" .

2. Should a resident show evidence of violence (e.g. throwing
objects, attempting to strike another resident, etc.) other
residents are immediately removed from the area and assistance
is summoned. Objects that could be used as a weapon are
removed from the area.

3. Physical force is not used to subdue a resident.

4. If the severe behavior continues, call 911 XE "911" .
Monitor the resident until assistance arrives.

5. An Incident Report is completed for all psychiatric XE
"Psychiatric" crises and given to the administrator XE
"Administrator" .

6. All psychiatric XE "Psychiatric" crises are reported to the

resident’s responsible party XE "Family/Responsible Party" .

POLICY:
Falls
Should a resident experience a fall XE "Falls" , staff will
provide or arrange for necessary emergency care, and will
follow up with necessary service plan XE "Service plan"
updates.

Procedure

1. Should the resident have trauma XE "Trauma" resulting in
deformity, exhibit any change in level of consciousness XE
"Consciousness" , received obvious head or significant trauma
the Administrator XE "Administrator" or caregivers summon
emergency medical services (call 911 XE "911" ).

2. When a resident falls XE "Falls" caregivers are instructed to
summon immediate assistance from the Administrator XE
"Administrator" or another caregiver.
3. Caregivers do not move the resident, except to protect against
further injury XE "Injury" , as in the case of a dangerous
environment.

4. The physician XE "Physician" is contacted for further
instructions if the head was not involved in the fall XE "Falls"
and the resident is able to move all extremities.

a. The Administrator XE "Administrator" instructs caregivers
to provide appropriate care and frequent resident checks. Any
change in status is reported to the Administrator.

5. An incident report is completed XE "Administrator"

XE "Community Care Licensing" .

6. The Administrator XE "Administrator" informs the physician
XE "Physician" of subsequent falls XE "Falls" and instability.
Medical intervention, physical therapy, and/or gait analysis is
arranged when residents remain a significant risk for falls.
7. Ongoing falls may require relocation from the community.
POLICY:
Death of a Resident
The community will take appropriate action in the event of the
death XE "Death" of a resident.

Procedure

1. Call 911 XE "911" . Emergency Medical Services must be
summoned to determine death XE "Death" , unless a hospice XE
"Hospice" nurse XE "Administrator" is present at the bedside.

2. Do not move the body. The body may not be moved until
there is either coroner XE "Coroner" release of the body or the
police or sheriff on-site gives direct explicit permission to move
the body. Staff should remain with the body at all times until
paramedics XE "Paramedics" arrive.

3. Notify the resident’s primary physician XE "Physician" .

4. Notify the administrator XE "Administrator" .

5. The coroner XE "Coroner" must be contacted. Once
paramedics XE "Paramedics" have pronounced the body (via
communication with the physician XE "Physician" or coroner
XE "Coroner" ), coroner release of the body must be obtained,
allowing for transport XE "Transport" to the funeral home of
the resident or family XE "Family/Responsible Party" ’s choice.

6. Notify the family XE "Family/Responsible Party" . Once the
body has been pronounced the family XE "Family/Responsible
Party" may be told of the death XE "Death" . Frequently the

physician XE "Physician" will make this phone call.
Otherwise, the administrator XE "Administrator" or the
Administrator will notify the family.

7. Prepare the room for visitors XE "Visitors" if required.
Occasionally family XE "Family/Responsible Party" or
significant other will want to spend a few moments with the
resident prior to transport XE "Transport" out of the
community. In consideration, tidy the room, remove linens,
etc., with objectionable odors and put a chair near the bed XE
"Bed" . Lights XE "Lighting" should be turned on to a
comfortable level. Insert the resident’s dentures XE "Dentures"
(if applicable), close the resident’s mouth and eyes.

8. Contact the funeral home. Once coroner XE "Coroner"
release has been obtained, the resident may be removed from
the community. Call the funeral home designated. The resident
should remain no longer than two hours in the community, if
possible.

9. Document XE "Documentation" appropriately.

10. Submit a death XE "Death" report to the state licensing
agency.
POLICY:
Elopement/Missing Resident
Elopement precautions and response procedures are carried out
for resident safety.
Procedure

1. ELOPEMENT DRILLS

a. Elopement drills are conducted a minimum of twice per year
and documented accordingly.
2. MISSING PERSON – GENERAL PROCEDURE

a. Local contact numbers of bus, rail, cab or other modes of
transportation will be maintained for possible contact in
emergency search.
b. Staff shall remain alert and follow re-direction techniques if
a wandering resident gains access to any exit areas.

c. Staff shall request help if wandering resident cannot be
redirected easily.
d. In house transportation staff will be notified of potential
elopers possibly seeking rides and advised to be observant for
wandering confused residents.
e. Staff will be routinely alerted by the Administrator of
residents identified to be at risk

f. Service plans will reflect interventions for resident safety

g. Routine safety checks will be made by staff.
h. Flashlights and emergency first aid kits will be included in
emergency supplies to accommodate searches outside

i. Walkie-talkie and cell phones are made available during
outside searches

3. MISSING RESIDENT

a. Staff alerts immediate supervisor to begin a thorough search
of entire community area. This includes searching bathroom
areas, bedroom closets, under beds and window areas to ensure
windows were not used as exit.
b. Administrator is immediately notified.
c. The Administrator or designee alerts other departments to
ensure entire community is on alert.
d. A thorough re-search of building including stairwells, roofs,
basements and outdoor area is expanded with ancillary staff and
any volunteers.
e. Automobile searches by staff & volunteers are conducted in

surrounding neighborhood.
f. All search staff call or report back to community regarding
status within 15 minutes.
4. IF RESIDENT IS STILL MISSING

a. Notify sheriff /police department by calling 911 .
b. Provide local law enforcement with the following:
i. Resident full bodied photo

ii. Description of current clothing he/she was wearing

iii. Any other physically identifying information

iv. Information in regard to current medication/treatment needs

v. Information in regard to resident’s nickname or typical
behavior

c. Notify the resident's responsible party.
d. Continue search efforts per direction of law enforcement.
5. MISSING PERSON – IF RESIDENT IS FOUND

a. Notify all searching parties.
b. Conduct assessment to identify possible injuries.
c. Transfer to hospital for further medical evaluation.
d. Notify physician.
e. Notify the resident's responsible party.
f. Complete an incident report and notify licensing agency per
licensing requirement.
6. MISSING PERSON – WHEN RESIDENT RETURNS TO
COMMUNITY

a. Obtain updated medical evaluation from hospital or doctors
office. Initiate any new orders.
b. Establish private duty care for resident oversight until
resident re-assessment indicates there is no longer a need.

c. Maintain resident behavior monitoring for identification of
any triggers.
d. Complete resident record documentation.
e. Update service plan and resident summary to reflect potential
elopement.
f. Inservice care staff and any relevant staff members.
g. Evaluate the community’s continued ability to meet the
resident’s needs

i. Responsible party will be kept informed and assisted with
alternative placement if determined to be necessary.
POLICY:
Advance Directives
Residents may have Advance Directives and/or Do-Not-
Resuscitate (DNR) orders. The community staff will take steps
to ensure, as best as possible, that a resident's wishes are
honored.
Procedure

1. A Do-Not-Resuscitate order does not direct health
professionals working in the community or any staff member to
withhold all emergency care. The resident should receive all
medications XE "Medications" , treatments and any other care
as ordered by the physician XE "Physician" , as well as all
emergency first aid care as necessary. Any necessary transfer
to a higher level of care (acute hospitalization) should take
place as necessary.

2. This policy shall at all times be available for review by the
licensing agency and its representatives.

3. A resident requesting a Do-Not Resuscitate order be
implemented will be directed to obtain the directive from their
visiting home health nurse or physician XE "Physician" . No
agent or employee of the community shall sign, witness or be
legally recognized as a surrogate decision maker for the

resident’s Do-Not-Resuscitate order.

4. A copy of the Do-Not-Resuscitate order will be placed in the
resident’s file and in their room. Note: this is confidential
information and must not be posted in a conspicuous place for
visitors XE "Visitors" or other residents to see.

5. A list of all residents with a current valid Do-Not-Resuscitate
order will be available in the following locations:

a.
_____________________________________________________
_____
b.
_____________________________________________________
_____

c.
_____________________________________________________
_____

6. Should a resident desire, a medic-alert XE "Alert" bracelet
with a DNR medallion may be ordered and worn by the resident
with a current Do-Not-Resuscitate status.

7. In the event of a crisis XE "Crisis" , emergency medical
services should be immediately summoned for the resident.
When the emergency medical service personnel arrive they
should immediately be presented with the resident’s Do-Not-
Resuscitate order.
Assisted Living

Policy and Procedure Manual

Documentation XE "Documentation"
and Forms

POLICY:
Confidentiality
All resident data and information is treated as confidential.

Procedure

1. Resident charts, information, preadmission documentation
XE "Documentation" , etc., are kept inaccessible to visitors XE
"Visitors" and individuals not involved in the direct care and
admission XE "Admission" of the resident.

2. Care and administrative staff given access to resident related
documentation XE "Documentation" are trained during
orientation to maintain confidentiality.

3. Photocopying and removal of resident information is strictly
prohibited unless approved by the administrator XE
"Administrator" .

4. Release of resident health and personal information is made:

a. When requested by the competent resident.

b. When requested by the resident’s conservator as allowed
according to law.

c. After consent for release of information is signed by either
party above.

5. State regulatory personnel as allowed under regulation may
review resident information.

6. The ombudsman is provided the name of the resident, name
and address of the responsible party XE "Family/Responsible
Party" and room number of each resident upon request.

7. Medication XE "Medications" and other clinical information
are provided only upon release by the resident or conservator,
as appropriate.

POLICY:
Narrative Charting Entries
Narrative charting XE "Documentation:Charting" will be
maintained to promote clear communication regarding resident
care.

Procedure

1. The format for narrative charting XE
"Documentation:Charting" is:

a. D = Data
Enter all essential facts related to resident status.

b. A = Action
State the actions/interventions made in response to the data.

c. R = Response
Follow up and document XE "Documentation" the resident’s
response to the action taken.

2. A narrative entry is made upon admission XE "Admission" ,
noting the date and time of admission, and any pertinent data
regarding the resident’s response to their placement.

3. A narrative entry addressing current resident status is made
every shift (or more often if necessary) for 48 hours after a fall
XE "Falls" or sentinel event.

4. Except as stated in (2) and (3) above, staff utilize the
charting XE "Documentation:Charting" by exception XE

"Exception" related to resident status.

5. The Administrator XE "Administrator" reviews the narrative
charting XE "Documentation:Charting" from the previous shift,
for at risk residents.

POLICY:
Incident Reports
Injury XE "Injury" and unusual incidents will be reported in
compliance with state regulatory requirements.

Procedure

1. The Unusual Incident form is used to document XE
"Documentation" and report any incident which is a threat to a
resident’s health, safety, welfare, or rights. This includes, but
is not limited too occurrences such as:

a. Falls XE "Falls" .

b. Injury XE "Injury" .

c. Psychiatric XE "Psychiatric" crisis XE "Crisis" .

d. Unexplained absence.

e. Any violation of resident rights.

f. Any incident that threatens the health, welfare, or safety of
the resident.

2. Any incident which is a threat to a resident’s health, safety,
welfare, or right will be reported to the state licensing agency
within 7 days of the incident and a report made via telephone
XE "Telephone" within 24 hours of the incident.

3. The Administrator XE "Administrator" completes incident
reports.

4. Incidents are reported to the resident's responsible party XE
"Family/Responsible Party" . Document XE "Documentation"
the date and time the report was made to the family/responsible
party in the narrative charting XE "Documentation:Charting"
section.

5. All incidents related to physical abuse, neglect, sexual
assault, or exploitation are reported to the ombudsman, state
licensing agency, and in the case of assault (physical or sexual)
to law enforcement.

POLICY:
Abbreviations
Standardization of terms, definitions, abbreviations, acronyms,
and symbols will be used to promote clear communication and
accuracy of information.

Procedure

1. A standardized list of acceptable terms, abbreviations and
acronyms is posted in each community charting XE
"Documentation:Charting" area.

2. All staff are instructed to use only approved terms,
abbreviations, and acronyms on this list for all charting XE
"Documentation:Charting" .

3. Changes or additions to the list of acceptable terms are made
after approval from the Administrator and administrator XE
"Administrator" .

POLICY:
Approved Abbreviations

ALWAYS follow community policies regarding the use of
abbreviations. Never “invent” a new abbreviation.

Remember, it is best to write words out and avoid the use of
abbreviations. Medical professionals working with assisted
living communities should be encouraged to avoid the use of
abbreviations. Never guess at the meaning of an abbreviation;
verify the meaning with the author.

A
a
Before
ABD
Abdomen
AC
Before eating
AD
Right dear
ad lib
As desired
ADL
Activity of daily living
am
Morning
amb
Ambulate
AS
Left ear
ASAP
As soon as possible
AU
Both ears
B
BID
Twice a day
BKA

Below the knee amputation
BM
Bowel movement
BP or B/P
Blood pressure
BPM
Beats per minute
BS
Bowel or breath sounds
C
c
With
C
Celsius or centigrade
C&S
Culture and sensitivity
CA
Cancer
Ca
Calcium
CAD
Coronary artery disease
CAP
Capsule
CAT
Computerized axial tomography, as in "CAT scan"
CBC
Complete blood count
CBG
Capillary blood gas
CCU
Clean catch urine
CHF
Congestive heart failure
CNA
Certified nurses aide

CNS
Central nervous system
C/O
Complaining of
COPD
Chronic obstructive pulmonary disease
CPAP
Continuous positive airway pressure, as in "CPAP machine"
CPR
Cardiopulmonary resuscitation
CSF
Cerebrospinal fluid
CT
Computerized tomography, as in "CT scan"
CVA
Cerebrovascular accident, aka "stroke"
CXR
Chest X-ray
D
DAT
Diet as tolerated
DC
Discontinue or discharge
DM
Diabetes mellitus
DNR
Do not resuscitate
DME
Durable medical equipment
DOB
Date of birth
DPT
Diphtheria, pertussis, tetanus
DVT
Deep venous thrombosis or deep vein thrombosis
DX or Dx

Diagnosis
E
ECG
Electrocardiogram
ECT
Electroconvulsive therapy
ED
Executive director
EMS
Emergency medical services
ENT
Ears, nose, and throat
ETOH
Ethanol, often used in reference to alcohol use/abuse
F
F
Fahrenheit
FBS
Fasting blood sugar
Fe
Iron
FTT
Failure to thrive
FU
Follow-up
FWB
Full weight bearing
FWW
Front wheeled walker
Fx
Fracture
G
GI
Gastrointestinal
gr
Grain, 1 grain = 65 mg

gm
Gram
gt or gtt
Drops
GU
Genitourinary
H
H
Hour
H2O
Water
HA
Headache
HDL
High density lipoprotein
Hgb
Hemoglobin
HO
History of
HOB
Head of bead
HOH
Hard of hearing
HR
Heart rate
HS
At bedtime
HTN
Hypertension
Hx
History
I
I&O
Intake and output
ID
Identification

IDDM
Insulin dependent diabetes mellitus
IM
Intramuscular
INR
International Normalized Ratio
IPPB
Intermittent positive pressure breathing
IV
Intravenous
L
L
Left or Liter
LOC
Loss of consciousness or level of consciousness
LPN
Licensed practical nurse
LVN
Licensed vocational nurse, this term is used only in California
and Texas
M
mL
Milliliter
MRI
Magnetic resonance imaging
MRSA
Methicillin resistant staph aureus
MS
Multiple sclerosis
N
Na
Sodium
NAS
No added salt
NG
Nasogastric

NKA
No known allergies
NKDA
No known drug allergies
noc
Nighttime
NPO
Nothing by mouth
NS
Normal saline
NSAID
Non-steroidal anti-inflammatory drugs
NT
Nasotracheal
N/V
Nausea and vomiting
NVD
Nausea, vomiting, and diarrhea
O
OD
Right eye
OOB
Out of bed
OS
Left eye
OTC
Over-the-counter
OU
Both eyes
oz
Ounce
P
p
After
PC
After meals

PDR
Physicians' desk reference
pm
Afternoon
PO
By mouth
PRN
As needed
PT
Physical therapy or Prothrombin time
Q
Q
Every (e.g., Q6H = every 6 hours)
QD
Every day
QH
Every hour
Q4h, Q6H, etc...
Every 4 hours, every 6 hours, etc...
QID
Four times a day
QNS
Quantity not sufficient
QOD
Every other day
R
R
Right
RBC
Red blood cell
RDA
Recommended daily allowance
R/O
Rule out
ROM
Range of motion

RT
Respiratory therapy
Rx
Treatment
S
s
Without
SL
Sublingual
SNF
Skilled nursing facility
S/O
Significant other
SOB
Shortness of breath
STAT
Immediately
Subq or SQ
Subcutaneous
Sx
Symptoms
T
TB
Tuberculosis
Temp
Temperature
TIA
Transient ischemic attack
TID
Three times a day
TO
Telephone order
Tx
Treatment
U
UA

Urinalysis
URI
Upper respiratory infection
US
Ultrasound
UTI
Urinary tract infection
V W X Y Z
VO
Verbal order
VRE
Vancomycin-resistant enterococcus
WBC
White blood cell or count
W/C
Wheelchair
WNL
Within normal limits
YO
Years old
YTD
Year to date
Misc
>
Greater than
<
Less than
=
Equals
#
Number, pounds
"
Inch or second

Care and Compliance Group, Inc.

page 2

Facility:____________________________
Surveyor(s):____________________
Date:__________________

New Policies and Procedures Checklist

1.104 ORGANIZATION AND STAFFING
Policies and Procedures
_____ P0212, 1.104 (5)(c) Serious Illness, Injury, Death

Facility will notify an emergency contact when the resident’s
injury or illness
warrants medical treatment or face-to- face medical evaluation.
Upon ER visit or
unplanned hospitalization, the facility must notify the
emergency contact ASAP.

Resident Rights (new provisions)
_____ P0410, 1.106(1)(e) Right to be free from neglect
_____ P0434, 1.106(1)(q)(i)(ii) Exceptions to 30 day notice of
changes in services:

Services necessary to protect health/safety due to change in
medical acuity
Requests by resident or family for additional services to be
added to the care plan

_____ P0446, 1.106(1)(u) Right to receives services per care
plan and/or agreement

Discharge Policy (must address the following)
_____ P0224, 1.104(5)(g)(i)(A – D)
Grounds for involuntary transfer, discharge, or eviction
Explanation of notice requirements
Description of the relocation assistance offered by the facility
Right to call advocates/agencies

Investigation of Abuse/Neglect Allegations (must address the
following)
_____ P0252, 1.104(5)(j)(i – vii)
Reporting to appropriate agencies and facility administrator

Emergency contact notified within 24 hours of facility
becoming aware of
allegation

Process for investigating allegation
How facility will document the investigation process to provide
evidence that
required reporting and a thorough investigation was conducted
Procedure for resident protection during investigation
Corrective action upon confirmed abuse/neglect
Investigation findings available to the Department within 5
working days of the
allegation being lodged

Restrictive Egress Alert Devices (must address if used)

_____ P0262, 1.104(5)(k)(i) How the device will be used to
protect resident from
elopement, including which door alarms will be triggered

_____ P0264, 1.104(5)(k)(ii)(A and B)
Legal authority for admission
Assessment by qualified professional prior to use

_____ P0266, 1.104(5)(k)(iii) Response to alarm to prevent
elopement including:
System to alert staff of breached door
Staff responsible for responding and providing redirection
How staff will provide protective oversight to other residents

Restrictive Egress Alert Devices (cont.)
_____ P0268, 1.104(5)(k)(iv) How facility will provide access
to secure outdoor area
_____ P0270, 1.104(5)(k)(v) Documented monthly testing of
egress alert system

1.105 ADMINISTRATIVE FUNCTIONS
Resident Agreement
Agreement must specify the following:
_____ P0324, 1.105(2)(a)(iv – viii)
Bed hold policy and fees
Transportation fees
Therapeutic diets
Bed/bath linens and furnishings provided
Security deposit reimbursed for closure w/out notice

Addenda to agreement with following:
_____ P0326, 1.105(2)(b)(i)(ii) Care plan and house rules

Disclosures
_____ P0328, 1.105(2)(c)(i – v)
Facility’s policies and procedures

How staffing levels are determined, extent to which certified or
licensed health
care professionals are available onsite

Types of activities provided
Whether or not facility is sprinklered
Use of restrictive egress alert devices, the types of behaviors
exhibited by persons
that need such devices

Resident Records
Face Sheet must include:
_____ P0362, 1.105(5)(a)(i)(A)(IV, VI, VII)
Legal representative and/or emergency contact
Diagnoses at time of admission
Allergies

Path: G:\PCBH Forms \Surveyor Packet Forms \New Policies
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