Boost Quality Assurance with QA Audit Forms

Get the most from your Quality Assurance department by using facility program audit forms.

An Admission Documentation audit is a fast and efficient way to make sure every essential assessment is completed and documented at admission.

A Facility Fall Prevention Program audit quickly assesses if your facility has everything in place to prevent and monitor resident falls and improve facility practices and procedures.

Keep track of unnecessary medications and adverse consequences with a Facility Medication audit.

Quality Assurance audit forms help the Director of Nursing and Administrator view the overall performance and consistency of facility practices and to pinpoint problematical areas of performance.

Debra Collins, RN, RAC-CT

As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term careand home health care federal regulatory changes.

She has written and published manuals for long term care and home health care documentation on nursing care plans, restorative nursing care plans,social service care plans, activities care plans, home health nursing care plans, home health nursing inservices, MDS 3.o forms for the MDS Coordinator, resources for theDirector of Nursing in long term care, nursing policy for long term care, long term care inservices, infection control for long term care, and Medicare/Medicaid documentation. The books are used by over one third of long term care facilities in the United States.

Debra has over 25 years experience in long term care and home health care. She worked as an MDS Consultant for many years, and is certified as a Resident Assessment Coordinator by AANAC, the American Association of Nurse Assessment Coordinators.

She is a member of the Bloomington Indiana Chamber of Commerce, National Nurses in Business Association, National Association for Female Executives, American Business Women’s Association, andLadies Who Launch.

Amazon Author Page Debra Collins, RN, RAC-CT

Good Nursing Policies and Procedures are the Blueprint for Quality Care

A long term care facility’s Nursing department policy and procedure manual should outline administrative policies and standards of care for basic nursing care procedures and all basic clinical practices.

It is the Director of Nursing’sresponsibility to review and update the manual at least annually to assure it is comprehensive and accurate. Updates must also be made when applicable due to changes in regulations or nursing standards of practice.

The master copy should be kept in the Director of Nursing’s office, and one copy placed at each nurses’ station so when policy or procedure is in doubt, staff can refer to the manual for clarity. To make it easier for staff to find subjects, it’s best if the manual includes a table of contents and an alphabetized cross-index.

The standard format for a procedure includes:

Statement giving objective goal of policy or procedure

Equipment and material needed

Staff the policy applies to, staff authorized to perform procedure

Documentation guidelines

Some facilities include in the policy and procedure manualmaster copies of long term care nursing forms. This helps to ensure uniform documentation throughout the facility.

Examples of policy and procedure manual topics:

Admissions and discharges

Blood sugar monitoring

Dressing changes

Feeding Tube

Isolation protocols

Lifts and transfers

Medication Errors

Post-fall protocol

Range of motion

Restraints

Standard precautions

Tracheostomy care

Urinary catheter insertion and care

Read more about topics of interest to the DON in long term care in the book Nursing Policy for Long Term Care and in the book  Director of Nursing Book .

Skilled Charting Guidelines Increase Reimbursement

Check out this free sample Skilled Charting Guideline for Tube Feeding.

Federal regulations for long term care facility Medicare reimbursement are very specific about exactly what must be charted in nurses notes and in nursing care plans to justify payment for skilled nursing services.

With high turnover in nursing staff, having clear and handy instructions can vastly improve quality of care, documentation, and Medicare reimbursement.

Find out more about PPS reimbursement, MDS 3.0, and MDS Coordinator resources in the book MDS Coordinator Book.

Care Plan Books

Make Nursing Care Plans and Forms resident and facility specific in one click with care plans in the books and on the CDs.
Geriatric, long term care, and home health care books for every nursing diagnosis are up to date with all the latest changes in federal regulations and surveyor guidelines.
Templates are in the most popular format, with nursing diagnoses, goals, and interventions based on the language of MDS 3.0.
Resources for the MDS Coordinator, Director of Nursing,Social Services department, and Activities department.
View and print sample nursing care plans and view the table of contents with complete care plan and form list for every book.
Order now and receive a free manual with every book.

Care Plan Books

The Ten Most Common Nursing Home Violations

ProPublica analyzed 262,500 deficiencies with its u Nursing Home Inspect tool, which includes deficiencies identified by government regulators and the U.S. Centers for Medicare and Medicaid Services over the past three years.
Since releasing this information on its website this summer, has added details of historical violations found in nursing homes. The agency now releases narrative reports of these problems from a home’s last three inspection cycles — or about three years.
Here is their list of the 10 regulations most commonly violated by nursing homes:
Facility is Free of Accident Hazards: 17,331
Facility Establishes Infection Control Program: 14,186
Provide Necessary Care for Highest Practicable Well-Being: 13,401
Store/Prepare/ Distribute Food Under Sanitary Conditions: 11,746
Develop Comprehensive Care Plans: 9,070
Services Provided Meet Professional Standards: 8,986
Clinical Records Meet Professional Standards: 7,962
Not Employ Persons Guilty of Abuse: 7,288
Drug Regimen is Free from Unnecessary Drugs: 7,040
Dignity: 6,605

The Ten Most Common Nursing Home Violations

The Latest MDS 3.0 Updates

The latest changes to the MDS Users Manual and the MDS 3.0 form will not require any changes to care plans. AANAC has a good summary article on the changes for coding the form.

How to Write Nursing Care Plans

Nursing care plans are blueprints for residents entire care needs, and direct the actions of all health care team members. Written nursing care plans are usually arranged into the three parts of Care Plan Problem, Care Plan Goal, and Care Plan Interventions.

Read more on the LTCS Books page: Sample Nursing Care Plans