Hendricks Community Hospital

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.

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.

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

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

Provide and implement an infection prevention and control program.

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.

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.

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 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.

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

Have a Compliance and Ethics Program.

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

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

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

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

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.

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.

Provide and implement an infection prevention and control program.