MOUNTAIN CITY REHAB CENTER

Have a plan that describes the process for conducting QAPI and QAA activities.

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

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure each resident receives an accurate assessment.

Respond appropriately to all alleged violations.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Make sure that a working call system is available in each resident's bathroom and bathing area.

Keep all essential equipment working safely.

Provide and implement an infection prevention and control program.

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

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 residents are free from significant medication errors.

Ensure medication error rates are not 5 percent or greater.

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.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Provide safe, appropriate pain management for a resident who requires such services.

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

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.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide activities to meet all resident's needs.

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

Ensure residents do not lose the ability to perform activities of daily living unless there is 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.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Ensure each resident receives an accurate assessment.

Assess the resident when there is a significant change in condition

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

Respond appropriately to all alleged violations.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Reasonably accommodate the needs and preferences of each resident.

Keep all essential equipment working safely.

Provide and implement an infection prevention and control program.

Ensure medication error rates are not 5 percent or greater.

Prepare residents for a safe transfer or discharge from the nursing home.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Ensure residents have reasonable access to and privacy in their use of communication methods.

Provide and implement an infection prevention and control program.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 medication error rates are not 5 percent or greater.

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

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Post nurse staffing information every day.

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

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

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Ensure each resident receives an accurate assessment.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

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

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.