F W HUSTON MEDICAL CENTER

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Observe each nurse aide's job performance and give regular training.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Provide enough food/fluids to maintain a resident's health.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Assess the resident when there is a significant change in condition

Implement a program that monitors antibiotic use.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.