NJ Facility Certificate of Need: Advisory for Resident Activities & Care Plans, Slides of Nursing

Download NJ Facility Certificate of Need: Advisory for Resident Activities & Care Plans and more Slides Nursing in PDF only on Docsity! AAS-55 JUL 14 Page 1 of 12 Pages. New Jersey Department of Health Division of Health Facility Survey and Field Operations DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Please print information.) Facility Name (as it appears on the license): Street Address: City: , NJ Zip Code: County: Facility ID # (use MDS#): This facility is (check one) For Profit Not for Profit Number of Licensed Long-Term Care Beds: I, (print name) , Administrator of the aforementioned facility, hereby certify the facility’s compliance with the advisory standards checked below. (All identifiers refer to the number of the advisory standard contained in Chapter 8:39 of the New Jersey Administrative Code.) The Department will issue a “Statement of Compliance with Advisory Standards” report to a facility where at least 90% of the reviewed advisory standards are confirmed as met. The report will recognize compliance with advisory subchapters where at least 65% of all advisory standards are met in the subchapter. Facilities receiving a deficiency of level “E” and above are ineligible for an Advisory Survey. PLEASE CHECK OFF ONLY THE ADVISORY STANDARDS, WHICH YOU BELIEVE ARE MET BY THE FACILITY. Use the blank space below the checked standards to describe proof of compliance (for example, “in activities portion of all medical records,” or “sign in lobby”). Where supporting documentation is required or useful, attach the documentation to this form, labeled clearly with the number(s) of the standard(s) which it supports. THIS COMPLETED FORM AND ALL SUPPORTING DOCUMENTATION SHOULD BE GIVEN TO THE SURVEY TEAM ON THE FIRST DAY OF THE ANNUAL SURVEY. (Signature of Administrator) (Title) (Date) The surveyor will randomly select a total of 30 advisory standards for review by randomly selecting a standard as a starting point and selecting every fifth standard until thirty have been selected. If less than 30 standards have been checked by the facility, all of the checked standards will be evaluated by the surveyors. In the surveyor column next to each selected standard the surveyor will write “Yes” if their evaluation shows that the standard has been met and “No” if their evaluation shows that the standard has not been met. When evaluating advisory subchapter 46 (Alzheimer/Dementia), all 19 standards are to be checked for compliance. Team Leader: Team #: Survey Date(s): (Print Name) Supervisor: (Print Name) Ineligible – Scope and Severity level “E” and above New Number of standards checked by team: ____________ Continuation Number of checked standards not met: ____________ No longer participating DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 2 of 12 Pages. SUBCHAPTER 3. COMPLIANCE WITH MANDATORY RULES AND ADVISORY STANDARDS 8:39-3.1 Mandatory Rules (a) Mandatory rules contain minimum and essential requirements of care provided by a facility. (b) Failure to comply with any mandatory rules contained in this chapter shall constitute a deficiency for which the Department may take any or all of the enforcement actions set forth in N.J.A.C. 8:43E. 8:39-3.2 Advisory Standards (a) Advisory standards contain benchmarks of excellence or superior attainment in providing care of high quality. (b) Facilities are strongly encouraged to use advisory standards in striving to provide the highest quality of care possible. (c) Failure to comply with any or all advisory standards shall not constitute a deficiency or result directly or indirectly in any enforcement action by the Department. (d) Compliance with advisory standards shall not be used as an indication of whether the facility is in compliance with mandatory rules or whether a facility should be made subject to a penalty or other action to protect residents. 8:39-3.3 Reporting Compliance with Advisory Standards (a) Compliance with advisory standards shall be calculated in accordance with the following: 1. The Department shall verify that at least 90 percent of no more than 30 advisory standards randomly selected from the total number of advisory standards which the facility claims to have met are in fact met; and 2, If the compliance rate determined at (a)1 above is 90 percent or greater, then, for any advisory subchapter in which the facility has claimed to meet 65 percent or more of the standards in the subchapter, recognition for meeting the entire subchapter shall be given. (b) If a facility applies for a certificate of need, compliance with six or more of the following advisory subchapters at the time of the most recent survey of the facility shall be taken into consideration: access to care (N.J.A.C. 8:39-6), resident assessment and care plans (N.J.A.C. 8:39-12), pharmacy (N.J.A.C. 8:39-30), infection control and sanitation (N.J.A.C. 8:39-20), resident activities (N.J.A.C. 8:39-8), dietary services (N.J.A.C. 8:39-18), medical services (N.J.A.C. 8:39-24), nurse staffing (N.J.A.C. 8:39-26), physical environment (N.J.A.C. 8:39-32), and quality assessment and/or quality improvement (N.J.A.C. 8:39-34). (c) If a facility can demonstrate that it has a system in place to meet the requirement, even though it is not applicable at the time of the survey, the surveyors may deem that, in their judgment, the standard is met. DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 5 of 12 Pages. NJDOH USE ______ _____ (c) Provision is made for residents to retain membership, join, and/or participate in community activities. These should include organizations, community projects, holiday observances, or charitable events. ______ _____ (d) A facility newsletter is provided to residents and families at least quarterly. ______ _____ (e) Each staff member wears an easily readable name tag. 8:39-14.2 Advisory staff education and training for communication ______ _____ (a) Periodic meetings are held with each service to discuss ways to improve care to all residents. ______ _____ (b) Education and training of staff includes an accredited program in cardiopulmonary resuscitation (CPR) which offers staff an opportunity to be recertified on an annual basis. ______ _____ (c) Each service establishes and implements education or training programs for members of other services on diverse topics. ______ _____ (d) Education or training sessions are offered which address new concepts and directions in cultural and interpersonal concepts. SUBCHAPTER 16. ADVISORY DENTAL SERVICES 2 (1) 8:39-16.1 Advisory resident dental services ______ _____ (a) The facility provides in-house dental services, including treatment and prophylactic care. ______ _____ (b) The facility follows established protocols for providing all residents with regularly scheduled routine prophylactic dental services and treatments when indicated, delivered by a dentist or a dental hygienist, except for residents whose medical records contain an explanation of why such services would not benefit the resident. SUBCHAPTER 18. ADVISORY DIETARY SERVICES 11 (7) 8:39-18.1 Advisory structural organization for dietary services ______ _____ A registered dietitian performs the resident dietary assessment and participates in the interdisciplinary plan of care. 8:39-18.2 Advisory staff qualifications for dietary services ______ _____ The director of dietary services or the dietitian is registered by the Commission on Dietetic Registration of the American Dietetic Association (R.D.) 8:39-18.3 Advisory staffing amounts and availability for dietary services ______ _____ The dietitian spends an average of 20 minutes per resident each month providing dietary services in the facility. (This is an average. It is equal to one full-time equivalent dietitian for every 520 residents.) 8:39-18.4 Advisory resident dietary services ______ _____ (a) There are dietary observances for national and/or religious holidays. ______ _____ (b) Fresh fruits and vegetables are served in season on a daily basis. ______ _____ (c) The facility utilizes a dining room/area, other than day rooms, for residents with special needs. ______ _____ (d) Residents have access to a refrigerator or snack bar. ______ _____ (e) Residents are offered a selective menu consisting of at least three main entrees at each meal. DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 6 of 12 Pages. NJDOH USE ______ _____ (f) A menu committee composed of residents participates in meal planning. ______ _____ (g) The facility sponsors a guest meal program. 8:39-18.5 Supplies and equipment ______ _____ The facility provides cloth table covers and cloth napkins at least once a day. SUBCHAPTER 20. ADVISORY INFECTION CONTROL AND SANITATION 7 (5) 8:39-20.1 Advisory policies and procedures for infection control ______ _____ (a) The facility routinely offers Hepatitis B vaccine to all employees, regardless of risk status or duties, without charge. ______ _____ (b) Employees undergo periodic or annual health screening. ______ _____ (c) The facility maintains records documenting contagious diseases contracted by employees during employment. 8:39-20.2 Advisory staff qualifications ______ _____ (a) The infection control coordinator is certified in Infection Control (CIC) by the National Board of Infection Control, P. O. Box 14661, Lenexa, KS 66286-4661. ______ _____ (b) The infection control coordinator is an active member of the National Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), 1275 K Street, NW, Suite 1000, Washington, DC 20005-4006. ______ _____ (c) The infection control coordinator has completed an APIC Basic Training Course or has received at least 25 hours of training in infection control, and receives an additional six hours of training annually. 8:39-20.3 Advisory staff education and training for infection control ______ _____ At least four education or training programs on infection control are held every year so that all staff members are fully informed about infection control requirements that apply to them. SUBCHAPTER 24. ADVISORY MEDICAL SERVICES 3 (2) 8:39-24.1 Advisory medical staff qualifications ______ _____ The medical director is board-certified in a primary care specialty, such as family medicine, gerontology, or general internal medicine. 8:39-24.2 Advisory resident medical services ______ _____ (a) The facility arranges for physician *or advanced practice nurse* visits in the facility on a scheduled appointment basis in an office provided for that purpose. ______ _____ (b) The facility has a staff or consultant psychiatrist with admitting privileges to the inpatient psychiatric unit at a hospital. SUBCHAPTER 26. ADVISORY NURSE STAFFING 12 (8) 8:39-26.1 Advisory structural organization for nurse staffing ______ _____ Facilities with more than 200 licensed beds employ at least one full-time equivalent staff educator; facilities with between 100 and 200 licensed beds employ at least a half-time staff educator; or facilities with fewer than 100 licensed beds employ a staff educator at least one-fifth time. DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 7 of 12 Pages. NJDOH USE 8:39-26.2 Advisory policies and procedures for nurse staffing ______ _____ (a) The facility establishes and implements a system for assigning nursing personnel on the basis of a classification system involving resident acuity. ______ _____ (b) The facility uses a primary system in which nurse aides are assigned on a regular basis to specific residents to provide continuity of care. 8:39-26.3 Advisory nurse staffing amounts and availability ______ _____ (a) A registered professional nurse is on duty at all times in facilities with fewer than 100 licensed beds; two registered professional nurses are on duty at all times in facilities with 100 to 200 licensed beds; and three registered nurses are on duty at all times in facilities with more than 300 beds. ______ _____ (b) The facility provides direct nursing services pursuant to N.J.A.C. 8:39-25.2(b) of this chapter which are increased by at least ten percent. ______ _____ (c) At least 50 minutes per resident per day of resident care is provided by licensed nurses, that is, registered professional nurses and licensed practical nurses. (This is an average. It is equal to one full-time equivalent nurse for every ten residents.) ______ _____ (d) All nurse aides working in the facility have completed a training and orientation program to all services of at least two weeks full-time duration within the facility prior to their permanent assignment in the facility. ______ _____ (e) Each resident care unit in the facility meets the nurse staffing requirements mandated in N.J.A.C. 8:39- 25.2(b). 8:39-26.4 Advisory qualifications for nurse staffing ______ _____ (a) The director of nursing has a baccalaureate or master’s degree in nursing or a health-related field. ______ _____ (b) An advanced practice nurse who is board-certified in family, adult, or geriatric practice is available on staff or under contract with the facility to perform assessments and to provide consultation to other staff members. ______ _____ (c) The facility employs an advanced practice nurse certified in gerontology or psychiatric nursing on at least a half time basis. ______ _____ (d) A nurse who holds certification in gerontological nursing, rehabilitation nursing, or a related field of nursing from the American Nurses Credentialing Center of the American Nurses Association, is available on staff or under contract with the facility. SUBCHAPTER 28. ADVISORY QUALITY OF CARE 7 (5) 8:39-28.1 Advisory policies and procedures for resident care ______ _____ (a) The facility conducts scheduled interdisciplinary staff discussions, and discussions with residents and families, about the right of residents to die with dignity. ______ _____ (b) The facility develops and provides individualized non-restrictive equipment meeting individual needs which fosters and supports a restraint-free environment for all residents. ______ _____ (c) The facility maintains an on-going and on-site program of preventative treatment and referral to mental health services which includes prevention, treatment, and referral directed by a qualified mental health professional. DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 10 of 12 Pages. NJDOH USE 8:39-36.3 Advisory staff qualifications for medical records ______ _____ (a) The facility utilizes the services of a medical record practitioner or consultant who is: 1. Certified or eligible for certification as a registered record administrator (RRA) or an accredited record technician (ART) by the American Medical Record Association (American Medical Record Association, 875 North Michigan Avenue, Suite 1850, John Hancock Center, Chicago, Illinois 60611); or 2. A graduate of a program in medical record science accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association in collaboration with the Council on Education of the American Medical Record Association (American Medical Record Association, 875 North Michigan Avenue, Suite 1850, John Hancock Center, Chicago, Illinois 60611). SUBCHAPTER 38. ADVISORY REHABILITATION 4 (3) 8:39-38.1 Advisory rehabilitation staff qualifications ______ _____ Speech therapy and audiology services are provided by individuals who hold a Certificate of Clinical Competence issued by the American Speech-Language-Hearing Association. 8:39-38.2 Advisory rehabilitation space and environment ______ _____ The facility has an examination and treatment room for rehabilitation therapy. 8:39-38.3 Advisory rehabilitation supplies and equipment ______ _____ (a) In addition to parallel bars and stairs, physical therapy equipment available to residents includes a whirlpool for hydrotherapy and ultrasound. ______ _____ (b) The occupational therapy program provides individually designed adaptive equipment as needed to enhance residents’ independence. SUBCHAPTER 40. ADVISORY SOCIAL WORK 11 (7) 8:39-40.1 Advisory staff qualifications for social work ______ _____ A social worker has a master’s degree in social work from an accredited university or education program. He or she should provide consultant services at least eight hours per month, or be on the facility’s staff. 8:39-40.2 Advisory staff amounts and availability for social work ______ _____ (a) A social worker is available to the facility on evenings and weekends at scheduled times or by previously arranged appointments for interaction with residents and families, and is available seven days a week in cases of emergency or serious need. ______ _____ (b) A social worker assists staff with problems and issues related to aging and illness. ______ _____ (c A social worker orients nurse aides to the social needs of new residents before the resident’s arrival in the facility. 8:39-40.3 Advisory resident social work services ______ _____ (a) A social worker meets with the resident on the day of admission. ______ _____ (b) A social worker conducts support groups for families. ______ _____ (c A social worker conducts group counseling sessions for residents and families. ______ _____ (d) A social worker participates in pre-admission planning with residents and families prior to their admission to the nursing home. DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 11 of 12 Pages. NJDOH USE ______ _____ (e) The social worker encourages and monitors a regular visiting pattern by families and provides outreach services to families where the visiting pattern has changed. 8:39-40.4 Advisory space and environment for social work ______ _____ Social workers are to be provided with a private office equipped with a telephone or, in facilities with 60 or fewer licensed beds, with access to a private office equipped with a telephone. 8:39-40.5 Advisory social work staff education and training ______ _____ The facility encourages the social worker to participate in community agency associations and other professional organizations. SUBCHAPTER 44A. ADVISORY STANDARD FOR RESPITE CARE SERVICES 1 (1) 8:39-44A.1 Advisory staffing ______ _____ A long-term care facility assigns specific staff members to an individual respite care resident to provide continuity of care during the resident’s stay in the facility. SUBCHAPTER 46. ALZHEIMER’S/DEMENTIA PROGRAMS - ADVISORY STANDARDS 19 (17) 8:39-46.1 Advisory Alzheimer’s/dementia program policies and procedures ______ _____ (a) The long-term care facility has written policies and procedures for the Alzheimer’s/dementia program that are retained by the administrative staff and available to all staff and to members of the public, including those participating in the program. ______ _____ (b) The facility has established criteria for admission to the program and criteria for discharge from the program when the resident’s needs can no longer be met, based upon an interdisciplinary assessment of the resident’s cognitive and functional status. 8:39-46.2 Advisory staffing ______ _____ (a) Staffing levels are sufficient to provide care and programming, based upon resident census in the program and an interdisciplinary assessment of the cognitive and functional status of residents in the program. ______ _____ (b) The facility has established criteria for the determination of each staff member’s abilities and qualifications to provide care to residents in the program. ______ _____ (c) The facility provides an initial and ongoing educational, training and support program for each staff member which includes at least the causes and progression of dementias, the care and management of residents with dementias, and communication with dementia residents. ______ _____ (d) Each Alzheimer’s/dementia program has a full-time employee, with specialized training and/or experience in the care of residents with dementia, who has been designated as coordinator/director and whose duties include responsibility for the operation of the program. ______ _____ (e) A consultant gerontologist is available to residents and to the program, as needed, to address the medical needs of the resident. “Consultant gerontologist” means a physician, psychiatrist, or geriatric advanced practice nurse who has specialized training and/or experience in the care of residents with dementia. 8:39-46.3 Advisory environmental modification ______ _____ (a) The program includes appropriate facility modifications to ensure a safe environment which allows each Alzheimer’s/dementia resident to function with maximum independence and success. DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS (Continued) AAS-55 JUL 14 Page 12 of 12 Pages. NJDOH USE ______ _____ (b) The facility has developed safety policies and procedures and a security monitoring system which are specific to the program, based upon the physical location of the program as well as the individual needs of the Alzheimer’s/dementia residents. ______ _____ (c) The facility provides indoor and outdoor arrangements that allow residents freedom to ambulate in a controlled setting. ______ _____ (d) Doors are marked with items familiar to the individual resident, which enhance the resident’s ability to recognize his or her room, and bathrooms are specially marked and easily accessible. 8:39-46.4 Advisory activity programming ______ _____ The Alzheimer’s/dementia program provides a daily schedule of special activities, seven days a week and at least two evenings per week, designed to maintain residents’ dignity and personal identity, enhance socialization and success, and to accommodate the various cognitive and functional abilities of each resident. 8:39-46.5 Advisory nutrition ______ _____ (a) The Alzheimer’s/dementia program provides nutritional intervention as needed, based upon assessment of the eating behaviors and abilities of each resident. Interventions may include, but are not limited to, the following: 1. Verbal and non-verbal eating cues; 2. Modified cups, spoons, or other assistive devices; and 3. Simplified choices of foods or utensils. ______ _____ (b) The Alzheimer’s/dementia program provides a small dining room, separate room, or designated dining area furnished to meet the needs of the residents, with staff members or trained volunteers to assist. 8:39-46.6 Advisory social services ______ _____ (a) The facility provides individual and group counseling to residents if appropriate, utilizing techniques designed to reach the dementia resident and to maintain the resident’s maximum level of functioning. ______ _____ (b) Families are encouraged and provided with opportunities to participate in planning and providing resident care. ______ _____ (c) The facility provides individual and group counseling, support and education groups for families, and information and referral on bioethical and legal issues related to dementia, including competence, guardianship, conservatorship and advance directives. ______ _____ (d) Family members are referred to community Alzheimer’s Disease support groups or other family counseling agencies, as required. ______ _____ (e) Discharge care plans, including preparation for discharge from the unit, are discussed with the legal next of kin, and, if possible, with the resident at the time of admission to the program.