Hendricks Community Hospital

Honor the resident's right to organize and participate in resident/family groups in the facility.

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

Allow residents to self-administer drugs if determined clinically appropriate.

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

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

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

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

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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.

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.

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

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

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

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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’s drug regimen must be free from unnecessary drugs.

Provide and implement an infection prevention and control program.

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.

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

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

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Provide safe and appropriate respiratory care for a resident when needed.

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…

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.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Have a Compliance and Ethics Program.