Governing body

1. The governing body is legally responsible for the quality of resident services; for resident health, safety, and security; and to ensure the overall operation of the facility is in compliance with all applicable federal, state, and local laws. 2. The governing body is responsible for approval and implementation of effective resident care and administrative policies and procedures for the operation of the facility. These policies and procedures must be in writing, signed, dated, reviewed annually, and revised as necessary, and shall address: a. All services provided by the facility to meet the needs of the residents, including admission, transfer, discharge, discharge planning, and referral services. b. Protocols developed by appropriately licensed professionals for use in the event of serious health-threatening conditions, emergencies, or temporary illnesses. These protocols must include provisions for: (1) Designation of a licensed health care practitioner for each resident and arrangements to secure the services of another licensed health care practitioner if the resident's designated licensed health care practitioner is not available. (2) Notification of an appropriately licensed professional in the event of an illness or injury of a resident. c. Provisions for pharmacy and medication services developed in consultation with a registered pharmacist, including: (1) Assisting residents in obtaining individually prescribed medications from a pharmacist of the resident's choice. (2) Disposing of medications that are no longer used or are outdated, consistent with applicable federal and state laws. (3) Allowing the resident to be totally responsible for the resident's own medication upon resident request and based on the assessment of the resident's capabilities with respect to this function by an appropriately licensed professional. d. Infection control practices, including provision of a sanitary environment and an active program for the prevention, investigation, management, and control of infections and communicable diseases in residents and staff members. e. Prohibition of resident abuse, neglect, and misappropriation of resident property, including investigation, reporting to the department, and followup action. f. Reporting a significant medication error to officials in accordance with state law. A significant medication error by a medication assistant I or II shall be reported to the department of health. g. A process for handling complaints made by residents or on behalf of residents. h. Resident rights which comply with North Dakota Century Code chapter 50-10.2. i. Personnel policies to include checking state registries and licensure boards prior to employment for findings of inappropriate conduct, employment, disciplinary actions, and termination. j. Personnel records to include job descriptions, verification of credentials where applicable, and records of training and education. 3. If the facility provides any clinical laboratory testing services to an individual, regardless of the frequency or the complexity of the testing the governing body is responsible to obtain and maintain compliance with the applicable parts of the clinical laboratory improvement amendments of 1988, 42 CFR part 493. 4. The governing body shall appoint an administrator to be in charge of the general administration of the facility. Provisions must be made for a staff member to be identified in writing to be responsible for the onsite operation of the facility in the absence of the administrator. 5. The governing body shall ensure sufficient trained and competent staff are employed to meet the residents' needs. Staff must be in the facility, awake and prepared to assist residents twenty-four hours a day.