Assisted Living Policy and Procedure Manual

Notice

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

8 General Policies

9 Personal Property/Theft and Loss

12 Abuse, Fraud, and Wrongdoing

14 Personal Care Attendants

15 Home Health Agencies

16 Motorized Mobility Devices

17 Resident Transportation

18 Resident Independent Departure Assessment

19 Sign-In/Sign-Out

20 Firearms

21 Personal Rights

23 Dignity

24 Corporal Punishment and Restraints

25 Complaints

26 Staffing

27 Staffing Introduction

28 Staff Training

30 Job Description: Administrator

31 Job Description: Assistant Administrator

33 Job Description: Resident Care Coordinator

35 Job Description: Medication Aide

37 Job Description: Caregiver

39 Volunteers

41 Admissions and Move-In

42 Resident Pre-Admission Appraisal

44 Allowable Health Conditions

46 Day of Admission/Move-In

47 Change in Condition

50 Ongoing Resident Appraisals

52 Activity Assessments

53 Admission Agreements

54 Service Plans

56 Resident Care Conference

59 Move-Out

60 Resident Care

61 Basic Care Services

64 Use of Assistive Devices and Ambulatory Aids

66 Hygiene and Grooming

67 Dressing

68 Sleep and Rest

70 Incontinence

72 Nutrition and Weights

73 Podiatry and Nail Care

74 Caregiver Daily Schedule

78 Sexual Expression

79 Medication Management

80 Medication Storage

81 Medication Records

82 Telephone Orders

83 Medication Labels

84 Resident Arrives with a Medication

85 Medication Refills

86 Medications are Permanently Discontinued

87 Hold Orders

88 Expired Medications

89 Medications Left Behind by a Resident

90 Medication Refusal and/or Missed Doses

91 Crushing Medications

92 Transferring Medications for Home Visits and Outings

93 Sample Medications

94 Use of Emergency Medications

95 Injections

97 Over-the-Counter (OTC) Medications

98 Psychotropic Medications

99 Warfarin and Other Anticoagulants

100 Narcotics, Controlled Substances, and Preventing Drug Diversion

102 Emergencies and Medical Needs

103Physician and Other Medical Appointments

104Labs and Outside Medical Services

105 Licensure of Nursing Personnel

106 Medical Emergencies

108 Psychiatric Emergencies

109 Falls

110 Death of a Resident

112 Elopement/Missing Resident

115 Advance Directives

117 Documentation and Forms

118 Confidentiality

119 Narrative Charting Entries

120 Incident Reports

120 Procedure

121 Abbreviations

122 Approved 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.