10- 144 C.M.R. ch. 110, § 5

Current through 2024-51, December 18, 2024

Section 144-110-5 - Facility Policies

5.A.Professional Policy Group

5.A.1.Requirements

Each facility shall have written policies which govern all areas of services provided and are developed with the advice of, and with provisions for, annual review by a group of professional personnel including the administrator, Director of Nurses, a physician, a registered pharmacist, and such other professional personnel as necessary.

5.A.2.Meetings

The professional policy group shall meet as necessary, but at least annually, to review written policies and reports of the Quality Assurance and other Committees. All members of the group should be present or have input and minutes of meetings shall be recorded and reflect the activities.

5.A.3. The professional policy group meetings may be incorporated within the Quality Assurance Committee.

5.B.Written Policies

5.B.1. The written policies of each facility shall be consistent with State licensing and Federal certification requirements and shall include:

a. Specific reference to indicate the person or persons responsible for the execution of such policies;

b. A written outline of the objectives of the facility;

c. Provision for these written policies to be available at all times to residents, families, admitting physicians, sponsoring agencies, staff, and the public;

d. Provision for implementation of policies and training of staff;

5.B.2. Policies shall address all areas of services provided and facility practices regarding:

a. Resident Rights, including advanced directives for care and treatment, and grievance procedures;

b. The types and extent of services that are available in the facility;

c. The extent of medical and nursing practices that may be provided by the facility;

d. The type of residents that the facility will accept, based on sex, mental status, source of referral, etc. Policies should also provide that residents will be accepted regardless of race, color, national origin, sexual orientation or reimbursement source;

e. The waiting list for facility admissions;

f. The Quality Assurance Committee;

g. Admissions, transfers and discharges:

1. Provision for prevention of resident transfer from one part of the facility to another, except from a private room, solely because of Medicaid status;

2. Provision for prevention of discharging a patient from a nursing facility solely because of Medicaid status;

3. A nursing facility must establish and follow written readmission policies which are consistent with all applicable regulations and statutes.

h. Physician services;

i. Emergencies;

j. Pharmaceutical services;

k. Dietary services;

l. Diagnostic and other services, including the tests which may be done within the facility;

m. Written agreements with outside resources;

n. Social services;

o. Independent and group activities;

p. Physical and chemical restraints;

q. Resident records;

r. Maintenance, laundry and housekeeping services;

s. Infection control and waste management;

t. Smoking restrictions;

u. Dental services;

v. Disaster preparedness;

w. Reporting of abuse, neglect and/or misappropriation of resident property;

x. Nursing services;

y. Staff orientation and in-service;

z. Rehabilitative services.

10- 144 C.M.R. ch. 110, § 5