Oklahoma’s top assisted living consultant and the LTC Director of Survey at the Oklahoma State Department of Health jointly tackled issues, questions, and survey complaints at the March 2015 LeadingAge Oklahoma State Conference. This captivating presentation snapshots administrator’s frequently asked questions and give answers in a united format. link: http://www.achievisseniorliving.com/wp-content/uploads/2015/03/Assisted-Living-Reg-Compliance-Presentation-at-LeadingAge-Oklahoma-by-Achievis-and-OSDH.pdf Joyce Clark Achievis Senior Living Associates Oklahoma City, OK Email: joyce@achievisseniorliving.com Website: www.achievisseniorliving.com Specializing in Senior Housing & Long-Term Care Development, Marketing, & Management

1. UNITED VOICES
PROVIDER & OSDH ADDRESS
COMPLIANCE QUESTIONS

2. JOYCE CLARK
 CEO of Achievis Senior Living Associates
 Developed 7 Assisted Living & Memory
Care Communities in Oklahoma
 Management, Marketing, &
Development
 Ranging from Mock Surveys & Interim
Management to Turn-Key New Build

3. MARY FLEMING
 Director of Survey at Oklahoma State
Department of Health
 25 Years of Experience
 Bachelors in Nursing Science. Masters in
Human Resources Management.
 Project Officer for Development of AL
Rules & Survey Protocol.

4. LET’S START WITH
MOST FREQUENT
CITATIONS…

5. MISSING ITEMS IN
RESIDENT CONTRACT
Licensure acceptance does not
necessarily mean all required items
are in contract.
Modifications change original
contract compliance & need OSDH
approval.

6. SUGGEST THESE ITEMS
BE BOLD OR
UNDERLINED
310:663-13-2
Center Name & Address
Admission Criteria
Services Provided
Discharge Criteria
Dispute Resolution & Grievance Procedures
Charges for Services
Agreement Includes Marketing Materials & Regulations
Term, Renewal, & Cancellation
Conformity with State Law
Provision for 5 Day Transfer

7. MISSING “I” OR “P”
PIG method not followed.
Person preparing dose does not
GIVE it. Leaves in apt. or on table
for resident to take later.
Forgot to initial.

8. OUT OF STOCK
MEDICATIONS
 Especially crucial if for prevention of
seizures or for severe infection.
 Failure to follow physician orders.
 Suggest fee to provide emergency back-
up meds plus cost. Fee terms must be in
contract.

9. ASSESSMENTS
Not Signed / Coordinated by RN in Timely
Manner.
Documentation of Personal Interview
Between Resident or Resident’s
Representative & Person Completing Form.
Appropriate Assessment Was Not
Performed.

10.  Braden Scale
 Mini-Mental
 Fall Risk
 AIMS
 Admission Criteria Verification
 Evacuation Capability
 Comprehensive Evaluation of Needs and Preferences (2 years)
 Pain
 Elopement Risk
 Skin Evaluation
 Medication Review
 Self-Medication Assessment
 Quarterly RN Wellness Reviews – Not Required But Helpful Process
COMPLETE APPROPRIATE
ASSESSMENT TO DETERMINE
IF RESIDENT HAS NURSING
NEEDS. EXAMPLES:

11. USE ASSESSMENT(S) TO
DEVELOP SERVICE PLAN
Address resident need staff is to accommodate.
Once potential problem / need is known,
comprehensive care plan should have preventive
measures outlined.
Clinical Nursing Skills is good guideline.
What do you do if resident has pressure
ulcer? If sits or lays a lot?

12. “SPECIFIC INTERVENTIONS ON RESIDENT’S CARE
PLAN TO PROMOTE HEALING & PREVENT
DEVELOPMENT OF POTENTIAL PRESSURE SORES”
Skin assessments for prevention of re-occurring redness and/or sores
to the buttocks and skin.
Use and maintenance of pressure relieving devices.
Institution and DOCUMENTATION of a position change schedule q 2
hours to avoid prolonged pressure in one area.
Implementation of measures for the protection of the resident’s skin
from excess moisture to prevent maceration.
Evaluation and possible institution of 2000 – 3000 calories / day of
fluid to provide calories, protein, and fluids necessary for fluid repair.
Instructions related to interventions for direct care staff for the
promotion and prevention of actual and potential pressure sores /
skin breakdown.

13. OTHER CARE PLAN TIPS
 Pain Interventions Such as ROM, Exercise,
Heat, Cold, Topical Ointments,
Repositioning.
 Address Most Prevalent Needs.
 Update Plan As Needs Change.
 Create 1-Page Template Need Plans. Easy
to Use for Inservices. Individualize for
Resident Updates / Temporary Services.

14. RISK MANAGEMENT
DEFICIENCIES
“Right to Fall.” Residents have
“right to safety” and fall prevention
measures must be taken.
“Right to Drive.”

15. INCIDENT TIMELINE
If on Friday or weekend, the report
(ODH 283) does not get sent within
1 business day of discovery.
ODH Form 718 - Notification of
Nurse Aide Abuse, Neglect,
Mistreatment or Misappropriation
of Property (1 business day of
identifying alleged perpetrator).

16. NURSE AIDE REGISTRY SKILLS
PERFORMANCE CHECKLIST
INDICATES AIDES CAN NOT DO:
Change colostomy bags?? Factors like RN
staffing for scheduled assessments may make
this a delegable task. To be discussed more.
Perform neuro checks
Injury assessment or wound care
Picc line
Setting O2 flow

17. ON THE OTHER HAND…
SKILLS ON CHECKLIST
Perform Active and Passive Range
of Motion Exercises
Provide Indwelling Catheter Care

18. LET’S ANSWER
ADMINISTRATOR
QUESTIONS…

19. RECENT DEFICIENCIES CITE “PLAN OF
CARE DID NOT CONTAIN NURSING
INTERVENTIONS WITH MEASURABLE
GOALS AND OUTCOMES”. WHAT
REGULATION OR LAW SAYS ASSISTED
LIVING SERVICE PLANS MUST HAVE
“MEASURABLE GOALS AND OUTCOMES”?
This language was intended to clarify
care plan contents.

20. IF DOCTOR WRITES A MED
ORDER THAT WE KNOW
RESIDENT WON’T TAKE, DO WE
HAVE TO FILL IT?
YES. Must give (offer) medications
as ordered.
Have doctor clarify the order.

21. HOW DO I REPORT A HOME HEALTH
COMPANY THAT IS NOT ABIDING
REGULATIONS?Policy. Third party contract.
Admission criteria & assessment determines scope of
services.
Contact attending doctor & ask for change. Remind of
fraud liability.
OSDH Home Health Complaint Hotline.
Send 3 complaints to OSDH LTC.
Copy director of HH & resident’s physician.
Involve Attorney General & Oklahoma Health Care
Authority.

22. HOW CAN WE OFFER RESIDENT
CHOICE WHILE ALSO EFFECTIVELY
COORDINATING THIRD PARTY CARE?
CAN WE LIMIT HOME HEALTH /
HOSPICE CHOICE TO SHORT LIST OF
PROVIDERS WHO MEET FACILITY
STANDARDS?
Admission policy refers to recommended list of
providers.
Disclose prior to admission

23. IS A CNA
QUALIFIED TO PUT
TED HOSE ON A
RESIDENT?
YES
Oklahoma Nurse Aide
Registry Skills Performance
Checklist.
Applying Compression
Support Stockings is Part of
Training / Orientation.

24. DO DIETARY SUPPLEMENTS
NEED TO BE DOCUMENTED?
YES if supplement is administered as if
was a medication / on a schedule.
YES if part of care plan from dietician or
licensed professional.
Document on TAR.

25. WHEN ARE ADL’S
REQUIRED TO BE CHARTED?
ADL charting is not required. Per facility
policy.
Chart when care is performed or delegated by
licensed professional.
Meal / fluid intake if ordered.
Range of motion, hand splints.
Bowel movements if monitoring constipation.

26. DOES ACTIVITY DIRECTOR
NEED FOOD HANDLER’S
TRAINING IF WORKING WITH
EDIBLES FOR RESIDENTS?
YES. Part of Orientation.
Food Handler Training Documents and
Videos Online.
CODE 257

27. IS THE FOOD SERVICE
MANAGER REQUIRED TO
HAVE DIETARY MANAGER
CERTIFICATION?
 NO

28. WHEN CHANGING LICENSURE
FROM RES CARE TO ASSISTED
LIVING, DOES THE PHYSICIAN
NEED TO REDO REFERRAL, H&P, &
MEDICATION ORDERS?
 Not required but common practice is to get “Admit to
Assisted Living” on monthly order.
 Physician order form needs to include all required
items. Some items may not have been on Residential
Care orders.
 Existing history and physical is fine.

29. WHAT CHEMICALS / CLEANING
ITEMS ARE OK TO HAVE IN
RESIDENT APARTMENT? DO
THEY NEED TO BE LABELED?
 Assess resident to determine they can handle the
item safely.
 No other residents can access chemical.
 Cannot be “harmful or fatal if swallowed” if
dementia resident can access. (Nail polish remover,
dish detergent, deodorant, shampoo, perfume)

30. DO YOU HAVE ANY TIPS TO
IMPROVE OUR QA PROCESS?
 Invite pharmacist if medication administration is
reoccurring problem. (Involve right people)
 “Remind resident to use call light” as a fall
prevention measure is inappropriate if resident
is confused / forgetful.
 Quarterly customer satisfaction measures.
 Include survey plan of correction.

31. ARE LIFTS ALLOWED TO
ASSIST IN TRANSFERRING A
RESIDENT?
YES. Lifts are a medical device and
are not prohibited.
One-person assist.
Staff training required.

32. HOW ABOUT A TRAPESE OR
HALF BEDRAIL USED FOR
PULL-UP OR SELF-
POSITIONING?
Permissible medical device
No restraining bedrails allowed

33. WHAT OXYGEN
ADMINISTRATION TASKS ARE
NURSE AIDES ALLOWED TO DO?
Nurse must set flow as ordered.
Tanks must be secured in holder.
No rules provide clear guidance
on who can change tanks.

34. CAN A FACILITY PROVIDE TRAINING
FOR ACTIVITY DIRECTOR OR MUST
THEY GO TO SPECILIIZED CLASS FOR
CERTIFICATION?
310:663-9-5 (C0952) Each assisted living
center shall ensure that staff members
providing socialization, activity, and exercise
services are qualified by training.
Training must be documented.
Can be formal class or part of orientation.

35. HOW DO OTC’S IN
RESIDENT’S APARTMENT
NEED TO BE LABELED?
Keep box with directions.
First and last name.
Physician name and date opened not
required.

36. WHERE CAN I GET COPY OF
LIFE SAFETY CODES?
 Local, State, Fed Vary. Most Restrictive Applies.
 OAC 265:25-1-3 Supplement to LTC Emergency
Action Plan (Incorporated National Codes &
Standards). Examples:
 International Building Code, 2003 Edition
 International Fire Prevention Code, 2003 Edition
 NFPA #101 Life Safety Code, 2003 Edition

37. MISC TIPS:
Kitchen trash cans need lids.
Don’t forget Initial Skills Review and
Annual Performance Reviews.
RN supervision of inservices.
OSDH offers free Tai-Chi certification
for staff.

39. CONTACT INFO
JOYCE CLARK
CEO OF ACHIEVIS SENIOR LIVING ASSOCIATES
Phone: 405.812.9089
Email: joyce@achievisseniorliving.com
MARY FLEMING, BSN, MHR
DIRECTOR OF SURVEY
OKLAHOMA STATE DEPT. OF HEALTH
Phone: 405.271.6868
Email: maryf@health.ok.gov