MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE(2) by pptfiles

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									Facility Self-Checklist
on Items to Provide to the Surveyor for Record Keeping Review
This following checklist was developed by the Office of Health Care Quality as a guide to assist providers in the organization of the paperwork for assisted living facilities.  To further help organize the paperwork requirements of COMAR regulations 10.07.14.19 and 10.07.14.23, it is recommended that facility policies, resident records or logs, staff records, assisted living manager and alternate manager records be kept separately.  Loose-leaf binders are a good choice and will keep you organized in the day-to-day operation of your assisted program.  Please note that each resident must have a separate binder or record/log.

1). Policies/Procedures/Plans _____ a. Smoking policy _____ b. Policy to prohibit abuse, neglect and exploitation of residents _____ c. Documentation policy _____ d. Grievance/complaint procedure _____ e. Bed and room assignment, changes in accommodation, bed hold and transfer policy. (This will need to be in your resident agreement). _____ f. Admission and discharge policies. (This will need to be in your resident agreement). _____ g. Emergency Plan _____ h. Relocation Plan (This will need to be in your resident agreement). _____ i. Staffing Plan 2). Medications a. Delegating nurse for the on-site review is _____________________________________ (Name of the delegating registered nurse). His or her license number is _____________. Describe how the delegating nurse can be contacted: ____________________________. b. The following persons have taken the Medication Administration training course: Name ___________________________ Date course was taken ____________________ Course was given by ______________________________________________________ Name ___________________________ Date course was taken ____________________ Course was given by ______________________________________________________ Name ___________________________ Date course was taken ____________________ Course was given by ______________________________________________________ Name ___________________________ Date course was taken ____________________ Course was given by ______________________________________________________ 3). Advertising Material _____ Please have available any advertising material that you have for your facility such as brochures, business cards, etc.

Office of Health Care Quality (OHCQ). An optional form to help ALF providers to organize record keeping. As of October, 2007, the form is not distributed by OHCQ, but the website creators found it useful.

4). Resident Log (or Record) Contents _____ a. Health Care Practitioner’s Physical Assessment. _____ b. Functional Assessment (assisted living manager’s assessment). _____ c. Level of care scoring guide. _____ d. Care notes. _____ e. Service plan. _____ f. Emergency data sheet (include advance directives, guardianship orders, power of attorney, etc.) _____ g. Documentation of the resident’s representative, if any, such as guardian, power of attorney, representative payee, etc. who has legal authority. _____ h. Medical or physician orders and rehabilitation plans, if appropriate (e.g. physical therapy, occupational therapy, etc.). THE FOLLOWING MAY BE KEPT IN THE RESIDENT RECORD. These documents are documented or written evidence of regulation compliance (that you are following the rules). _____ i. Incident reports. This includes incident reports for medication errors. _____ j. Recording of burial arrangements. _____ k. MARs (Medication Administration Records) if the resident requires assistance with medications or is administered medications. 5). Assisted Living Manager Please provide written evidence of the following: _____ a. Proof of age. _____ b. High school diploma, GED or other appropriate education experience. _____ c. Documentation that the assisted living manager is free from active reportable communicable disease documented by a PPD (TB screening test) or chest x-ray if needed. _____ d. A physician’s written statement that the manager is free from any impairment which would hinder your assigned duties (you are healthy enough to be able to do the job of an assisted living manager). _____ e. Criminal background check or criminal history records check. _____ f. Three (3) letters of reference. In-Service Training/Knowledge _____ g. Health and psychosocial needs of the population you serve. _____ h. Resident assessment process. _____ i. Use of service plans. _____ j. Cueing, coaching and monitoring of residents who will administer medications, with or without assistance. The tape and training manual are available from DHMH. Call them if you would like a copy. The telephone number is 410-402-8217. There is a charge for the Assisted Living Medication training video program. _____ k. Providing assistance with ambulation, personal hygiene, dressing, toileting, and feeding.

Office of Health Care Quality (OHCQ). An optional form to help ALF providers to organize record keeping. As of October, 2007, the form is not distributed by OHCQ, but the website creators found it useful.

_____ l. Resident’s rights. _____ m. Fire and life safety. _____ n. Infection control, including standard precautions. _____ o. Basic food safety. _____ p. Basic first aid training. _____ q. Current CPR (cardiopulmonary resuscitation) card. _____ r. Emergency disaster plans. _____ s. Specific training in the management, assessment, and programming for the resident with cognitive impairment. (Alzheimer’s/Dementia training). _____ t. Instruction in the use of fire extinguishers. Provide a copy of a job description for your staff (What are their responsibilities in your facility?). 6). Alternate Assisted Living Manager (COMAR 10.07.14.16) Please identify by name: __________________________________________________ Please provide written evidence of the following: _____ a. Proof of age _____ b. High school diploma, GED or other appropriate education experience. _____ c. Documentation that the assisted living manager is free from active reportable communicable disease documented by a PPD (TB screening test) or chest x-ray if needed. _____ d. A doctor’s written statement that the assistant is free from any impairment which would hinder their assigned duties (you must be healthy enough to be able to do the job of an alternate assisted living manager). _____ e. Criminal background check or criminal history records check. _____ f. Three (3) letters of reference. In-Service Training/Knowledge _____ g. Health and psychosocial needs of the population you serve. _____ h. Resident assessment process. _____ i. Use of service plans. _____ j. Cueing, coaching and monitoring of residents who self-administer medications, with or without assistance. The tape and training manual are available from DHMH. Call them if you would like a copy. Their telephone number is 410-402-8217. There is a charge for the Assisted Living Medication training video program. _____ k. Providing assistance with ambulation, personal hygiene, dressing, toileting, & feeding. _____ l. Resident’s rights. _____ m. Fire and life safety _____ n. Infection control, including standard precautions. _____ o. Basic food safety. _____ p. Basic first aid training. _____ q. Current CPR (cardiopulmonary resuscitation) card. _____ r. Emergency disaster plans

Office of Health Care Quality (OHCQ). An optional form to help ALF providers to organize record keeping. As of October, 2007, the form is not distributed by OHCQ, but the website creators found it useful.

_____ s. Specific training in the management, assessment, and to programming for the resident with cognitive impairment. (Alzheimer’s/Dementia training). _____ t. Instruction in the use of fire extinguishers. 7). Staff Staff must be 21 years of age unless supervised at all times by another person who is 21 years of age. The other person who is 21 years of age must be present in the facility and have all the training and documentation (medical, background checks, etc.) that is required by the regulations. Please provide written evidence of the following: _____ a. Age. _____ b. Free from active reportable communicable disease. PPD (TB screening test) or a chest-x-ray if needed or a doctor’s statement. _____ c. A doctor’s written statement that the person is free from any impairment, which would, hinder assigned duties (he or she is healthy enough to be able to do his or her tasks). _____ d. Criminal background check. All staff must participate in an orientation and on-going training. e. Training must include: 1. Fire and life safety. 2. Infection control, including standard precautions. 3. Basic food safety. 4. Basic first aid. 5. Emergency disaster plans. If the staff is new, this training must be done within 24 hours of when they start to work. 6. Current CPR training card. (It is required that at least one person trained currently in CPR is in the facility 24-hours a day and 7 days a week (COMAR 10.07.14.17)). 7. Training in Dementia/Alzheimer’s Disease 8. Instruction in the use of fire extinguishers 9. Medication administration training and updates if applicable to the individual staff person(s) who administers medications to the residents. Proof of knowledge or training in: _____10. The health and psychosocial needs of the population of the facility. _____11. The resident assessment process. _____12. The use of service plans. _____13. Resident rights. _____ f. Staff job description or individual job requirements (they need to be given a job description of what the person is expected to do in writing and explained their duties). _____ g. A copy of the staff person’s license or certification as required by law (e.g. nurse’s assistant training. L.P.N. or R.N. license), if applicable.

Office of Health Care Quality (OHCQ). An optional form to help ALF providers to organize record keeping. As of October, 2007, the form is not distributed by OHCQ, but the website creators found it useful.

_____ h. Proof that the person has knowledge or training in cueing, coaching and providing assistance with activities of daily living if that person’s duties involve giving personal care services. 8). Resident Agreement _____ a. Signed resident agreements for all residents in your facility. _____ b. A blank resident agreement if you have no residents. 9). Plan for Relocation and Continuous Provision of Services to Residents in the Event of a Permanent or Temporary Closure of the Assisted Living Program. You should have a contract or transfer agreement with the relocation party. 10). If you received a letter asking to submit paperwork that should have been received by this Office when your application for an assisted living program was submitted, please respond to that letter if you have not already responded. If a letter was not sent to you by this Office at the time that you sent in your application, disregard number 10.

Office of Health Care Quality (OHCQ). An optional form to help ALF providers to organize record keeping. As of October, 2007, the form is not distributed by OHCQ, but the website creators found it useful.


								
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