Facility Policies

Section 340 Section 340.1300  Facility Policies a)         The facility shall have written policies and procedures governing all services provided by the facility.  The written policies and procedures shall be formulated with the involvement of the administrator.  The policies shall comply with the Act and this Part.  The written policies shall be followed in operating the facility and shall be reviewed at least annually by the facility's advising physician or the medical advisory committee, as evidenced by a dated signature. b)         An advisory physician, or a medical advisory committee composed of physicians, shall be responsible for advising the administrator on the overall medical management of the residents and the staff of the facility. c)         All of the information contained in the policies shall be available to the public, staff and residents, and for review by the Department. d)         The written policies shall include, at a minimum, the following provisions: 1)         Admission, transfer, and discharge of residents, including the types of services offered by the facility that would cause residents to be admitted, transferred or discharged, and transfers within the facility from one room to another; 2)         Resident care services, including physician services, emergency services, personal care and nursing services, restorative services, activity services, pharmaceutical services, dietary services, social services, clinical records, dental services, and diagnostic services (including laboratory and x-ray); 3)         A policy prohibiting blood transfusions, unless the facility is hospital based and appropriate services are available in case of an adverse reaction to the transfusions; and 4) A policy to identify, assess, and develop strategies to control risk of injury to residents and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident.  The policy shall establish a process that, at a minimum, includes all of the following: A) Analysis of the risk of injury to residents and nurses and other health care workers taking into account the resident handling needs of the resident populations served by the facility and the physical environment in which the resident handling and movement occurs. B) Education of nurses in the identification, assessment, and control of risks of injury to residents and nurses and other health care workers during resident handling. C) Evaluation of alternative ways to reduce risks associated with resident handling, including evaluation of equipment and the environment. D) Restriction, to the extent feasible with existing equipment and aids, of manual resident handling or movement of all or most of a resident's weight, except for emergency, life-threatening, or otherwise exceptional circumstances. E) Procedures for a nurse to refuse to perform or be involved in resident handling or movement that the nurse, in good faith, believes will expose a resident or nurse or other health care worker to an unacceptable risk of injury. F) Development of strategies to control risk of injury to residents and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident. G) Consideration of the feasibility of incorporating resident handling equipment or the physical space and construction design needed to incorporate that equipment when developing architectural plans for construction or remodeling of a facility or unit of a facility in which resident handling and movement occurs. (Section 3-206.05 of the Act) e)         For the purposes of subsection (d)(4): 1)         " Health care worker" means an individual providing direct resident care services who may be required to lift, transfer, reposition, or move a resident. 2) "Nurse" means an advanced practice nurse, a registered nurse, or a licensed practical nurse licensed under the Nurse Practice Act. (Section 3-206.05 of the Act) f)         The facility shall have a written agreement with one or more hospitals to provide diagnostic, emergency and routine acute care hospital services.  The Department will waive this requirement if the facility can document  that it is unable to meet the requirement because of its remote location or refusal of local hospitals to enter an agreement. g)         The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in a facility. These medical emergencies include, but are not limited to: 1)         Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure or arrest); 2)         Cardiac emergencies (for example, ischemic pain, cardiac failure or cardiac arrest); 3)         Traumatic injuries (for example, fractures, burns or lacerations); 4)         Toxicologic emergencies (for example, untoward drug reactions or overdoses); and 5)         Other medical emergencies (for example, convulsions or shock). h)         The facility shall maintain in a suitable location the equipment to be used during the emergencies detailed in subsection (g) of this Section. This equipment shall include, at a minimum, a portable oxygen kit, including a face mask or cannula, an airway, and a bag-valve-mask manual ventilating device.