CHAPTER 1
Administration
There are licensing requirements and certifications needed to run a skilled nursing facility. There is an operating certificate for the number of Medicaid certified beds, the Class 3A. There is a license for controlled substances, Schedule II, III, IV, and V. The local county has a permit for Hazardous or toxic material, there is a Clinical Laboratory Improvement Amendment certificate, and local state approval for Certified Ventilator Services beds.
There is a book by the American College of Health Care Administrator called "Standards of Practice for Long-Term Care Administrator". This gives Administrators a background for what they do.
The nursing home has an organizational chart for the facility. Facility and departmental staffing classification as to what is full time, part time, per diem and supplemental status can be analyzed. Nursing care hours can be calculated. It is determined by the number of staff times the hours worked divided by the number of residents. Resident acuity or sickness determines the amount of staff needed. A review of the Department of Nursing staffing plan should be conducted.
A review of the budget including salaries, operating expenses, and capital versus non-capital expenses should be conducted annually. The Collective Bargaining Agreement between the nursing home and nursing home workers Union should be reviewed annually.
The nursing home as well as each department should have a book of policy and procedure. This guides the operation of each department as well as the nursing home.
Each profession at the nursing home should have a job description with competency. The knowledge, skills, and abilities must match the job description. Performance evaluation is based on the tasks performed.
The role of the Ombudsman is to be an impartial advocate to the patient/resident.
The local State as well as Federal survey should be reviewed. Survey deficiencies should be analyzed, and a plan of correction drawn up. The Survey Profile Summary is placed by the front door lobby for the public's viewing. The JCAHO survey should be reviewed by the Administrator and Director of Nursing as well as any other department head involved.
There are Federal, State, and County laws and regulations to be reviewed as they relate to operating a Nursing Home. Policies and procedures have been developed over the years and continue to be developed so that compliance is achieved. I personally looked at the Official Compilation of Codes, Rules and Regulations of the State of New York.
Meetings should be conducted of the Safety Committee, Infection Control Committee, and the Quality Action Team. Their common goal is to improve performance in a planned, systematic, collaborative and continuous manner. Quality Improvement is an organization wide approach to increasing the performance and deliverance of healthcare.
New York State has an Abuse Law, and the New York State Department of Health has a policy on the reporting of alleged violations involving mistreatment, neglect, or abuse. The nursing home should have a form for complaints. Residents have a Bill of Rights which gives them certain protections under the law.
Advanced Directives for each resident such as a Healthcare Proxy, giving a loved one the decision-making responsibility should the patient/resident become incapacitated, and the Living Will should the patient/resident become brain dead or suffer a terminal illness and not want to be resuscitated. These are now covered by the MOLST form that an attorney goes over with their client.
The nursing home should establish relationships with community agencies and transfer agreements with local hospitals. Having Red Cross or Senior Citizen meetings in the nursing home's classroom or Board room extends a welcoming hand to the community. Having contracts with transportation companies to take patient/residents for dialysis and other needs or in the case of a disaster to move the patients to safety quickly.
It is important for the Administrator to view written grievances by employees. A criminal background check is performed on all employees being hired.
As far as interpersonal relationships go, there must be a respect that union and non-union employees must have for one another in order to work together as a team, instead of having discord. There is a union contract and guide lines for labor management meetings. To see if there are grounds for valid grievance one must compare the list of union complaints to the body of knowledge in the union contract. Participating in a Labor-Management Committee meeting differences and issues are discussed. Agreements are made and hopefully everyone goes home happy at the end of the day.
Long range planning of two and one half to five years is important in order to carry out strategic goals, and therefore have success with an organization. Often the current financial health of the facility is indicative of what the organization will be able to do with their current resources in order to use them to create and carryout a project for the future. An outcome that will be profitable for the organization is most desirable. As the old saying goes, "Those who fail to plan, plan to fail!"
Using effective leadership knowledge, skills, and abilities the administrator controls and coordinates the utilization of resources in the nursing home. Financial, material, and human resources are recognized and used to the fullest potential to serve the needs of the residents and to provide quality medical care in the long-term care setting. Human and intellectual capital are the greatest asset an administrator can have in the people who work for him or her and the nursing home. Today's nursing shortage is proof of that!
An executive secretary who assists in the coordination and provision of general office management is worth their weight in gold. This makes the job of administrator easier. An administrator would have an impossible job if it were not for neat retrievable files and a good office set up.
Administrative record keeping is important. It is best to always keep a copy of all memos sent out of the administrators' office for clarification should it be needed at a future date. File retrieve-ability is an important function of any administration office filing system, especially when a certain file is needed a few years later.
There are social groups that are a special societal sub-set in long-term care. The "resident council" is a group of residents that meet to discuss and express the concerns of the residents in the nursing home. The Dept. of Health requires that all New York State nursing homes have a resident's council. A "family council" is a structural support for the families of residents. There can be residents who have spouses living with them in the nursing home, for them there is the "couple's council" to address their needs. These various groups take on a life of their own. A leader usually emerges and tends to be significant and effective.
Leadership and management styles tend to be either centralized or decentralized. Centralized administrators are authoritative and micromanage. Decentralized administrators teach their managers to be independent when it comes to decision making. This style of administrator has the manager report back to them only when needed and has an open-door policy. The truth is, it is probably a synthesis of the two styles that meet the challenges of everyday problems, and solves those problems effectively, that really works in today's long-term care setting.
Nursing Homes have complex social systems that require organizational coordination and conformity. The effective integration of staff attitudes and beliefs is crucial to the success of the organization. Relationships are after all a two-way street of giving and taking. Organizations that have staff composed of citizens highly committed to the goals of the organization are more likely to be effective than those that don't. The belief of employees in the philosophy, goals, and values of the organization may provide the group with a common effort that binds it together into a successful entity. The result is a lower level of staff turnover, sick time abuse, and tardiness, along with a greater pride of workmanship, and job satisfaction.
With the Health Insurance Portability and Accountability Act or HIPAA privacy rule, nursing homes must provide patients with a notice of their privacy practices and the individual privacy rights. The staff cannot talk about a patients' medical information in a public area where those not involved with the patient can over hear the medically sensitive private information. Written authorization must be obtained to use a patient's protected health information for marketing purposes.
CHAPTER 2
Nursing Department
The Nursing Department should have an organizational chart. It should have a list of job descriptions with the basic tasks performed, including education and licensing needed for each position. It should have a policy and procedures manual.
There is a book "The Long Term Care Survey" published by the American Healthcare Association. One should pay attention to the sections on resident abuse and neglect. The development and implementation of policies that include screening, training, prevention, identification, investigation, protection, and reporting/response have been and continue to be developed at the Nursing Home. The facility should have a "Statement of Residents Rights" and a "Complaints and Grievances" form for a resident's complaint.
The Inservice Coordinator conducts classes on Tube feeding, Pressure Sores, the Aging Process, and the Administering of Medicines. Tube feeders with weight loss may have pumps that are not being utilized to capacity. Quality care for pressure sores includes keeping the pressure sore clean and dry, increasing mobility of the resident possibly by turning every two hours, and supplying good nutrition with the proper amount of protein in the diet. The five rights of administering medications are making sure that you have 1) the right resident, 2) deliver the medicine through the right route, 3) with the right drug 4) with the right dose, and 5) with the right frequency. The Inservice Coordinator also assesses the nursing staff on its knowledge, skills and abilities with a Core Competency evaluation annually.
The Pressure Sore rounds committee consists of a Rehab Registered Nurse Coordinator, Dietician, a Rehab C.N.A., a Nurse Practitioner, a L.P.N., and a Physical Therapist. The team assesses a pressure sore by measuring the sore, looking at the lab report to see if the resident has a good level of protein building components in the blood, and making sure the wound is dry, clean and dressed. Also, to see if the resident needs Physical Therapy. Weekly documentation is recorded and analyzed on a Wound Status Flow Sheet until the wound is healed. This committee continually endeavors to improve the quality of life for all residents, and to prevent further disability, maintain existing abilities and to restore maximum levels of functioning so that the resident can live with dignity.
The Infection Control Committee conducts Environmental Rounds to inspect the various units to see if they are in conformance and kept clean. The Infection Control Nurse, Quality Improvement Nurse, Housekeeping Supervisor, and Nursing Care Coordinator are all on this Committee. The Infection Control Nurse must be American Professionals of Infection Control certified. There should be an Infection Control policy manual. The Infection Control Report is completed monthly, quarterly, and yearly by the Infection Control Nurse. It is a record of monthly, quarterly and yearly infection rates in the facility. Statistics on Infection Requiring Isolation is also monitored. A Monthly Infection Control Tracking Log is kept. A Resident Infection Report is to be completed by the Head Nurse and Infection Control Nurse. It identifies the diagnosis of infection, treatment, risk factors, and type and site of infection. These activities help prevent the development and transmission of infection.
Behavior management of the resident is monitored daily and is recorded as such on the Daily Behavior Monitoring form. Complaints and/or Grievances are recorded on the form named as such. An investigation is to be conducted and corrective action taken. The completed form is forwarded to Social Service and Administration. A Behavior Weekly Assessment Evaluation is performed and kept in the patient's chart.
The Fall Risk Assessment Form is completed within three days of admission, with a change in condition, quarterly and when the resident sustains an accident and/or fall. If the resident receives a high score, they will be considered a high risk and a prevention protocol will be initiated immediately and documented on the care plan. A Resident Accident/Incident report is filled out by the charge nurse or supervisor when there is an accident or incident. The Occurrence Risk Factor Investigative Tool is filled out by the charge nurse to determine the cause of the event. The CNA fills out an Accident/Incident Investigative Form to better describe the event. Finally, an Accident/ Incident Investigation Report is completed by the Nursing Supervisor, DNS, and Safety Committee. The Quality Improvement Nurse tracks occurrences with an Accident/Incident QA Audit tool. These six forms fully investigate and statistically track these unfortunate occurrences.
Upon admission the resident is assessed with the Nursing Admission Assessment/Plan of Care form. This form records personal data, medical history, Activities of Daily Living (ADL), and identifies anatomical and physiological characteristics of the resident. The Minimum Data Set is completed upon admission or within five days later. It is also done quarterly, and whenever there is a significant change in the resident's status. This leads to the Resident Assessment Protocol (RAP) trigger which leads to the RAP key, which leads to the RAP guidelines, which leads to the RAP summary, then the ADL supplement, then to the RAP worksheet, which leads to the Comprehensive Care Plan.
The Comprehensive Care Plan (CCP) is completed quarterly by a committee that consists of members from each healthcare discipline involved in the residents' healthcare process. The CCP shows the problem or need of the resident, the goal or target date for remedy of the problem or need, the approach to the problem or need, and the disciplines involved in the process. The Progress Notes indicates if goal objectives are, or are not, being met. Progress towards the objectives or lack thereof must be addressed.
The Patient Review Instrument (PRI) is completed quarterly. At six months intervals, the PRI is done on every resident in the facility. New admissions and discharges are picked up quarterly, and at the time of discharge to their home or another nursing home or assisted living program. The PRI is to be completed by someone who has obtained a PRI number. The PRI number is obtained by attending a seminar conducted by PSRC of America. The PRI systematically categorizes a residents financial and medical information.
All nursing homes must have an Anti-Biotic Stewardship program. As germs have evolved to grow resistant to modern anti-biotics, the smart use of these pharmaceuticals is of the utmost importance. We do not want to see the day when germs have become immune to every anti-biotic we have to fight them. An Anti-Biotic Stewardship Officer over sees that the smart use and not the overuse of today's anti-biotics does not occur in a nursing home.
CHAPTER 3
Nutritional Services
This department provides each resident with a nourishing, palatable, and well-balanced diet that meets the daily nutritional and special dietary needs of each resident. They properly maintain their cold food temperatures below 40 degrees Fahrenheit, and above 140 degrees Fahrenheit for cooked foods. Frozen foods are kept below 0 degrees Fahrenheit. Thermometers are kept in all refrigerators, and freezers and are checked and recorded twice on every shift to ensure proper food safety. Metal plate heaters are used to ensure that the resident's hot foods are delivered to the floors above 140 degrees Fahrenheit. Dry pots are required for storage in the Pot room so that no microbial life can grow in the moisture. The kitchen is clean at the beginning of the shift, and it should be that way at the end of the shift. The staff is taught: "you clean as you work!".
The Director is a Registered Dietitian. Registered Dietitians analyze the residents' dietary program. On the other side of the department, you have the Food Service Supervisor and workers, including the cooks, who are responsible for preparing the meals. The facility should employ enough support staff to carry out the tasks of the department.
The resident's menu is on a three-week cycle where the same selections are not served until three weeks later. Large print menus are used. The menu meets the nutritional needs of residents in accordance with the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, which is part of the National Academy of Sciences. There is no more than 14 hours between dinner and breakfast. If a nourishing snack, consisting of a protein and starch, is provided to the resident, a sixteen-hour period may elapse between dinner, and breakfast of the following day, if the resident agrees to such. Food is delivered on time to the residents on the unit. It is delivered on hot plates to maintain a hot food temperature. The food is tasty and appealing to the eyes. The time that the food leaves the kitchen and arrives on the unit is recorded to ensure a timely delivery.
