IT Support - Accessing Email from the Internet
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Facility Orientation/
Annual Mandatory Education
ORGANIZATION STRUCTURE
• The Mission
• The PACE Benefit
• An overview of Adult Day Care Program
• Independent Living Philosophy and Consumer Control
• Conflict of Interest
• Provider Network (site specific)
QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT
• QAPI Overview
• Grievance/Appeal Policy
• Fraud Waste and Abuse
ENVIRONMENTAL SAFETY
• Bomb Threat
• Fire Safety
• Natural Disaster
• Equipment/Power/Water Failure
• Material Safety Data Sheet
• Oxygen Safety
• Smoking Policy
• Medical Emergency/ Emergency Care
• Body Mechanics and Back Safety Techniques
INFECTION CONTROL
• Exposure Control Plan for Blood-borne Pathogens
• Infectious Waste Handling (Blood spills, contaminated sharps, contaminated laundry)
• Hand Hygiene
• Tuberculosis
PSYCHOSOCIAL WELL-BEING
• Health Care Ethics
• Abuse and Neglect
• Member Rights
• Communication Techniques
• Behavior Management Techniques
• Restraints
• HIPAA Compliance
PERSONNEL
• Workplace harassment policy
THE ABOVE TOPICS HAVE BEEN REVIEWED WITH ME AND I HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS.
EMPLOYEE SIGNATURE: _________________________________ DATE: _____________
EDUCATION PROVIDED BY: ______________________________ DATE: ______________
•
Organization Structure
Mission Statement
THE MISSION OF SENIOR LIFE IS TO PARTNER WITH MEMBERS, FAMILY AND COMMUNITY TO ENABLE MEMBERS TO REMAIN AT HOME WHILE PRESERVING DIGNITY AND AUTONOMY. THE APPROACH IS MEMBER CENTERED AND ACCOMPLISHED BY PROMOTING OPEN COMMUNICATION AND ADVANCE CARE PLANNING THROUGH A SHARED DECISION MAKING PROCESS WITH SENIOR LIFE’S INTERDISCIPLINARY TEAM.
An Overview of Adult Day Care Programs
ADULT DAY CARE CENTERS PROVIDE COMMUNITY-BASED PROGRAMS TO MEET THE NEEDS OF ADULTS WHO ARE FUNCTIONALLY IMPAIRED AND/OR MENTALLY CONFUSED. THESE STRUCTURED, COMPREHENSIVE PROGRAMS PROVIDE A VARIETY OF HEALTH, SOCIAL, AND RELATED SUPPORT SERVICES FOR PEOPLE WITH ALZHEIMER’S DISEASE AND RELATED DEMENTIA, CHRONIC ILLNESSES, TRAUMATIC BRAIN INJURIES, DEVELOPMENTAL DISABILITIES, AND OTHER PROBLEMS THAT INCREASE THEIR CARE NEEDS.
The roles and responsibilities of the Adult Day Care Center staff includes: ADL assistance, health monitoring and health related services, medication management, social services, transportation, health education, and professional therapy services.
The ultimate goal of adult day care is to maximize the quality of life
and promote successful living for the participants.
The PACE Benefit
WHAT IS PACE?
Many older persons with chronic illness prefer to spend their last years at home. However research has shown that this is too often not the case. Instead, many frail elderly end up in nursing homes because they are unable to care for themselves or are unable to coordinate the services and payers needed for them to stay at home. Programs of All-Inclusive Care for the Elderly (PACE) address this issue by providing access and coordination for all needed medical and supportive services.
The centerpiece of PACE is a special type of daycare center, where older adults receive primary health care, rehabilitative therapies, meals, social work, and other services. As needed, PACE also arranges for hospital care, medications, medical specialist care, home care, and nursing home care. The goal, however, is to maintain participants at home.
Who is Eligible to Enroll in PACE?
PACE is exclusively for persons 55 years of age or older who live in a defined catchment area and are certified as eligible for nursing home care. Because of these requirements, PACE enrollees closely resemble typical nursing home patients. The average PACE enrollee is elderly, has 8 separate medical conditions, and is unable to perform three activities of daily living. Additionally, almost half of PACE participants have some degree of dementia.
Financing PACE?
Funds to establish a PACE program are generally provided by a combination of private contributions, grants, and collaborations with local healthcare organizations. Once operational, PACE centers receive monthly capitated payments from Medicare, Medicaid, and, in fewer instances, individuals. Most participants are dually certified by Medicare and Medicaid, and the PACE program receives a single monthly fee for each enrollee. The capitated reimbursement structure of PACE provides an incentive to support activities and programs that keep participants healthy.
Research has shown that PACE Improves Outcomes
▪ PACE participants are more likely to maintain their physical function.
▪ PACE participants have lower rates of nursing home admission, and spend fewer days in hospitals and nursing homes.
▪ PACE enrollees are over three times as likely to have advance directives as the general population.
▪ In the first 12 months after enrollment, mortality is decreased by 32%.
▪ Overall, PACE participants have lower mortality rates, compared to similar nursing home patients.
▪ PACE participants at the end of life are able to die at home more than twice as often as others nationally.
▪
Independent Living Philosophy and Consumer Control
INDEPENDENT LIVING MEANS HAVING CONTROL OVER YOUR OWN LIFE AND BEING ABLE TO MAKE DECISIONS ABOUT LIFE WORK AND PLAY IN THE SAME WAYS THAT PEOPLE WITHOUT DISABILITIES DO. THIS IS EXACTLY WHAT "INDEPENDENT LIVING" MEANS.
One of the primary principles of the independent living philosophy is "consumer control." "Consumer control" is at the heart of independent living in every way. The individual with a disability must have control over his or her life and all decision-making.
"Consumer control" is defined as: significant representation, power, authority, and influence of individuals with varying disabilities in all aspects of an organization that provides services to enhance independence and that seeks to change the political, social, and economic environment and quality of life possible for all disabled persons.
The concept of consumer control is based on the premise that people who use our services know best what they should be, how they should be structured and delivered.
CONFLICT OF INTEREST
CONFLICT OF INTEREST CAN BE DEFINED AS ANY SITUATION IN WHICH AN INDIVIDUAL OR CORPORATION IS IN A POSITION TO EXPLOIT A PROFESSIONAL OR OFFICIAL CAPACITY IN SOME WAY FOR THEIR PERSONAL OR CORPORATE BENEFIT.
Examples of the most common forms of conflicts of interest:
▪ Outside employment, in which the interests of one job contradict another (Rob moonlighting with AAA as an assessor while continuing his role at SL.)
▪ Self –dealing, in which public and private interests collide (Natalie’s husband owns and operates a DME company. Natalie goes to the members of SL and persuades them to request their new wheelchairs from her husband’s company.)
Remember, the best way to handle a conflict of interest is to avoid them entirely. If this is not possible, the next step is disclosure and recusal.
Disclosure is when you disclose information that is an actual or a potential conflict of interest.
Recusal is when those with a conflict of interest are expected to recuse themselves from decisions where such a conflict exists.
Quality Assurance
and
Performance Improvement
Quality Assurance and Performance
Improvement Plan Overview
PURPOSE:
The Quality Assurance Performance Improvement (QAPI) program at SeniorLIFE is designed and organized to support the mission, values, and goals of SeniorLIFE and the Program of All Inclusive Care for the Elderly (PACE). To this end, all employees are expected to consistently make improvements, minimize errors, and strive to do the following:
▪ Develop and support a therapeutic clinical environment in which every member’s capability is maximized;
▪ Develop an environment in which each discipline of the Interdisciplinary Team plays an integral part in the improvement process;
▪ Promote an environment of open communication;
▪ Progressively improve all services;
▪ Create an atmosphere that promotes and encourages innovation and creativity; and
▪ Seek and utilize input from members, caregivers, staff, and interested members of the community to enhance services.
The QAPI Program is based on the following principles:
▪ Effective operation of SeniorLIFE depends upon the performance of program staff, the operation of internal and external systems, the performance of contractors working for the program, and cooperative teamwork among the members, caregivers, families, interested members of the community and SeniorLIFE staff.
▪ Central to the effectiveness of the PACE program is the Interdisciplinary Team, which assesses each member individually, develops and implements individualized plans of care, monitors member progress, and modifies the plan of care as necessary.
▪ The program maintains a customer-first orientation with the needs, preferences, and values of internal and external customers driving quality goals. As part of this principle, member and caregiver involvement in the QAPI process is sought.
▪ The program implements and maintains a strategic planning process, which includes support for continuing QAPI.
▪ SeniorLIFE leaders show full support in the total QAPI process and communicate the importance of this process to every associate.
▪ QAPI education and training are integral parts of staff development activities.
▪ All disciplines and contract providers are interdependent and share responsibility for evaluating and improving the quality of member care and services.
▪ All SeniorLIFE providers maintain the confidentiality of medical information, written and otherwise, and show respect for members’ beliefs, values, expectations, and attitudes about health, illness,
health care, and quality of life.
▪ To the greatest extent possible, QAPI activities will utilize objective, quantifiable measures, statistically valid analysis techniques, and meaningful comparison data.
▪ All domains of service, including structure, process, and outcomes are addressed by the QAPI Program.
Goal:
The goal of the QAPI program is to improve future performance through effective improvement activities driven by identifying key, objective performance measures, tracking them and reliably reporting them to decision-making and care-giving staff.
Objectives:
Specific objectives of the QAPI Plan are to:
▪ Assure effective, timely and safe delivery of care
▪ Identify core and critical processes that most affect member outcomes as a focus of process standardization and performance improvement.
▪ Ensure all team members, staff and contract providers, are involved in the development of and implementation of the quality assessment and performance improvement activities and are aware
of the results of these activities.
Responsibilities:
The QAPI plan applies to all services provided by medical staff, employees, volunteers, contractors and others affiliated with SeniorLIFE.
Responsibility for quality assessment and performance improvement ultimately rests with the organization’s governing body, the Pennsylvania PACE, Inc. This governing body has the final authority to ensure that adequate resources are committed and a culture is created that allows QAPI efforts to flourish. The governing body, directly or through delegation to the SeniorLIFE Board of Directors, will:
▪ Lead the organization toward continually improving the quality of member care and services through the oversight of the organization’s mission and operation;
▪ Incorporate findings from quality assessment and improvement activities in strategic, program, and resource planning;
▪ Provide guidance toward continuing education concerning the approach, methods, tools, and application of continuous quality improvement;
▪ Establish broad guidelines for quality improvement activities in conjunction with the Director and Medical Staff leaders;
▪ Guide process analysis and improvement;
▪ Provide for and review an annual evaluation of the performance of the QAPI Plan.
The SeniorLIFE Management Team provides oversight of all QAPI activities at SeniorLIFE. The SeniorLIFE QI Coordinator is responsible for ensuring that quality data is collected from all appropriate sources, that the data is examined and that results are shared with all appropriate staff and/or committee members for follow-up action.
An annual Quality Management Summary (QMS) is composed by the QIC and reviewed with Management Team, passed up to the SeniorLIFE Board of Directors via the Program Director and the Medical Director. A copy of the QA annual report will be provided to DPW during their annual review. As applicable, contracted staff will also be sent a summarization of the annual QA report.
Grievance Procedure
POLICY:
It is the policy of SeniorLIFE (SL) to assure that all members understand and have access to the established grievance system should a concern/complaint about their care arise. All grievances are reviewed on a routine basis by the Executive Director. The QAPI Coordinator maintains a log of this information in order to foster an environment of continuous improvement. In addition, grievance information is made available for review by CMS and/or the PA DPW upon request. There shall be no discrimination against a member on the grounds that he/she has filed a grievance.
Purpose:
To provide members/family/representatives a process for expressing dissatisfaction with the services provided by SL. All SL members/family/representatives will have the opportunity to express their concerns or dissatisfactions with the services of SL or any of its providers without the fear of reprisal.
The grievance process also provides SL with opportunities to improve on their service delivery system. SL recognizes that grievances may be the first indication that a problem exists. The grievance policy is outlined in the Member Handbook and is reviewed with the member/representative at the time of enrollment and annually via the newsletter at the minimum. In addition, the grievance policy and procedure will be made available to the member/family upon their request and when a grievance is filed.
Definition:
A grievance is defined as a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished.
Filing a Grievance:
1. A grievance may be expressed to any staff member at any time. Any incoming grievances via telephone or in person given to a SL staff member will be documented on a Grievance Form by the staff receiving the complaint. This is then forwarded to the immediate supervisor of the person receiving the grievance.
2. If during non-center operational hours the member/family/representative wishes to file a grievance, the nurse on-call will be responsible for receiving the complaint and completing the form. The form will be forwarded to the appropriate personnel the next business day.
3. A written acknowledgement of receipt of the grievance will be provided to the person filing the grievance.
Documentation of a Grievance:
1. An investigation of the grievance is completed and documented on the Grievance Investigation Form by the staff that was assigned.
2. It is also written on the Grievance Log and maintained at the facility. Trends and patterns are identified by the QA Coordinator and reported to the QI Committee. The QI Committee is responsible for determining the need for and initiating an improvement plan. Identified trends and action plans are reported back to the Interdisciplinary Team on at least a quarterly basis.
Resolution:
Staff will report the grievance at the next IDT meeting or within a period of five working days (whichever is sooner).
If a solution is found and agreed to by the member within five working days of when the grievance if filed, the grievance is resolved.
All efforts are made by the team to pursue a resolution to its utmost ability so that problems with service delivery do not go unresolved.
Dissatisfaction:
If a solution is not found by the staff within five working days or agreed to by the member, the staff shall develop a written report regarding the nature of the grievance.
The written report shall be sent to the Executive Director, or if the grievance involves medical care, to the Medical Director for final action.
The Executive Director or Medical Director will immediately review and approve or disapprove the staff’s written report, and forward a copy of the approved report to the member within five working days. The report is considered final disposition to the grievance. The report is accompanied by a notice that contains a statement that if the member is not satisfied with this action, he/she has 30 days to request a review by the Plan Advisory Committee.
If the member is not satisfied with the action taken as a result of their grievance, he/she may ask for a review by the Plan Advisory Committee within 30 days of the receipt of the final disposition of their grievance.
The Plan Advisory Committee will send written acknowledgement of the receipt of the grievance within five working days to the member. The Plan Advisory Committee will then investigate and find a solution, and take appropriate actions subject to approval of the Board of Directors.
The committee will send to the member a copy of a report containing a description of the grievance,
the actions taken to resolve the grievance, and the basis for such action. The committee has 30 working days from the day the grievance is filed with the committee to complete its report and send it to the member.
7. If the decision is wholly or partially adverse to the member, a copy of the report shall be forwarded immediately to DPW and the ombudsman
8. The member will continue to receive all required services during the grievance process.
9. The QA Coordinator is responsible for maintaining, aggregating, and analyzing information on grievance proceedings. By analyzing the number and types of grievances, SL can develop activities that will monitor and improve the grievance resolution process, as well as identify and make improvements or modifications in areas of care. This information will, in turn, be reported to the Management Team, and ultimately, the governing board.
Appeal Process
POLICY:
It is the policy of SL to assure that all members understand the appeal process and have access to the established appeal system if needed.
Definition:
An appeal is defined as action taken on behalf of a member with respect to the provider’s non-coverage of or non-payment for a service; denial of a request for services; reduction, termination or suspension for a service; untimely provision of services; denial of enrollment; or involuntary disenrollment of the member from the program.
Procedure:
1. An appeal may be filed to any member of the IDT.
2. Confirmation that the appeal was received will be sent to the member within 24 hours of receipt of the request.
3. An impartial third party will be appointed to review the appeal which will be scheduled and completed as expeditiously as possible or within 30 days at the latest. SL ensures that the individual(s) who make the decision on the medical necessity are health care professionals who have the appropriate clinical expertise.
4. Ten business days advanced written notice will be provided to the member filing the appeal where feasible but as expeditiously as possible based on scheduling and confirmation by independent third party reviewers. The notice will inform them of the opportunity to present evidence related to the dispute in person and in writing as well as the right for the members/representative to examine pertinent documents and records.
5. The continuation of disputed services must occur until a final determination if made through all appeal channels if:
a. SL is proposing to terminate or reduce currently furnished services, and
b. The member understands they may be liable for the costs if the determination is not made in their favor. SL may not suspend or discontinue any services under dispute during the entirety of the appeals process.
c. A written report of the third party review will be provided to the member. The report will include the date of the appeal, the description of the appeal, actions taken by SL to address the issues, the outcome of the third party review, and additional appeal rights through Medicare and Medicaid if the outcome is wholly or partially adverse to member. This will occur as expeditiously as the member’s health condition requires, but no later than 30 calendar days of receipt of the request. A possible extension of up to 14 additional calendar days can be requested if the member or SL requests an extension, or justifies (to the State agency upon request) a need for additional information and how the extension is in the member’s best interest.
d. The services will be provided as expeditiously as possible if determination is made in favor of the member by SL or State fair hearing officer.
e. A copy of third party report and copy of notification to member will be forwarded to CMS, Department and local ombudsman if outcome is wholly or partially adverse to the member within 30 calendar days of receipt of the request. .
f. Expedited appeal process can be filed for situations in which the member believes that his or her life, health or ability to regain or maintain maximum function would be seriously jeopardized absent the services. SL will comply with any requests for an expedited appeal. The SL must respond to a request for an expedited appeal no later than 72 hours after receipt of the appeal unless the member requests an extension of up to 14 calendar days or SL justifies to Department that delay is in the best interests of the member. For any extension not requested by the member, SL must give the member written notice of the reason for the delay. In any case, SL must inform the member of the time available in which to present evidence. In addition to written notice, SL must make reasonable efforts to provide oral notice of resolution.
g. All appeals will be tracked by the QI Coordinator on the appeal log.
h. All appeal files will be audited and maintained by the QI Coordinator.
i. Appeals will be reviewed by the QI Committee on a quarterly basis.
j. The appeal process is outline in the Member Handbook and is reviewed with the member/representative at enrollment. On an annual basis a written copy of the appeal process is disseminated through the SL newsletter. Upon denial of services/payment, the member will also be provided with a written copy of the appeal process.
k. If the interdisciplinary team fails to provide the member with timely notice of the resolution of the request or does not furnish the services required by the revised plan of care, this failure constitutes an adverse decision, and the member’s request must be automatically processed by the organization as an appeal.
Executive and Manager Responsibilities
Purpose
• Explain our role as a Medicare Part D (prescription drug) plan sponsor
• Describe the Senior LIFE Fraud, Waste and Abuse Compliance Program
• Provide guidance on where to go and who to call to address compliance concerns
What is a Compliance Program?
• Prevention
➢ Sets rules of conduct
➢ Educates about rules of conduct
• Detection
➢ Audits and monitors to detect problems
➢ Encourages employees to report concerns
• Correction
Imposes discipline when appropriate
➢ Corrects problems
Medicare Part D
• Senior Life is considered a Part D plan sponsor, and most of the prescription drugs we provide our members are now paid for under Medicare Part D, Medicare’s prescription drug plan.
• All Part D plans are required to have a comprehensive program to prevent, detect, and correct fraud, waste and abuse in our prescription drug benefit program.
• The Medicare prescription drug benefit is high-profile and under much scrutiny; expects to see significant attention to fraud, waste, and abuse in the near future.
Terminology:
• Fraud - purposeful deception for the purpose of getting something of value (such as increased reimbursement from the government). Examples include enrolling fictitious individuals in a PACE program and pocketing the money provided. Waste -the careless or needless expenditure of funds that results in connection with a Part D plan. Examples include poor or inefficient record-keeping that results in increased costs to the government. Abuse -any kind of behavior inconsistent with sound fiscal, business or medical practices and that directly or indirectly results in higher costs to the government. Examples include issuing refills for a prescription that is not medically necessary.
• CMS - Centers for Medicare and Medicaid Services, the government agency responsible for administering the Medicare prescription drug benefit. MEDIC -Medicare Drug Integrity Contractor retained by CMS to assist with fraud prevention and detection.
Important Federal Laws:
• The False Claims Act (FCA) prohibits knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment or approval. Additionally, it prohibits knowingly making or using a false record or statement to get a false or fraudulent claim paid by the federal government.
Examples include:
➢ Submitting fabricated data to CMS in order to get higher payments
➢ Falsifying data in the RAPS or other systems in order to get a higher capitation or reimbursement rate plan.
➢ The Anti-Kickback Statute (AKS) prohibits the payment of a kickback or other remuneration in return for referring or recommending a service paid for by Medicare or Medicaid.
➢ A pharmaceutical company paying a fee to a physician for every prescription the physician writes for that company’s drugs
➢ A Part D plan paying a nursing home to influence all residents to sign up for that prescription drug plan. The Anti-Kickback Statute (AKS) prohibits the payment of a kickback or other remuneration in return for referring or recommending a service paid for by Medicare or Medicaid.
• The Compliance Officer (Executive Director) is responsible for the Senior LIFE compliance plan, including the Part D FWA Program. The Board of Directors is responsible for approving our compliance plan and the FWA Program, and receives reports from the Compliance Officer about ongoing compliance activities. Managers that interact with prescriptions and prescription drug data, as well as those involved in care management, will have specific responsibilities to monitor utilization patterns and other information for possible FWA. All employees and contractors are responsible for conducting themselves in an ethical manner and in accordance with our compliance program, and for reporting any suspected fraud, waste and abuse.
High Risk Areas:
•Member’s personal funds were utilized to pay for services or items that are covered under Medicare and Medicaid.
•Billing for items or services not rendered or provided as claimed.
•Submitting claims for equipment, medical supplies and services that are not medically necessary.
•Billing for medically unnecessary services, supplies and equipment.
•Billing for services or items which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of the malformed body member.
•Failure to maintain the highest practicable physical, mental, and psychosocial well-being of each member.
•Lack of clinical reviews prior to billing for services as a means to verify that members receive appropriate services.
•Inappropriate ancillary arrangements with an outside vendor who over-utilizes one service in return for lower pricing to the facility for another service.
•Submitting claims for members who are not eligible for the coverage.
•Knowingly billing for inadequate or substandard care.
•Misrepresenting a member’s Medicare Part A technical criteria in order to circumvent the program’s limitation for coverage or payment.
•Submission of claims for items or services not ordered.
•Duplicate billing of services either by the Program, its contracted vendor, or both.
•Billing for items or services that are included in the program’s reimbursement rate.
•Billing for a service or item that must remain bundled.
•Failure to identify and refund credit balances.
•Up coding the level of service provided.
•Altering documentation or forging a physician’s signature on documents to verify that services were ordered or provided.
•Failing to maintain sufficient documentation to support the diagnosis, justify treatment, document the course of treatment and results, and promote continuity of care.
•Submission of falsely prepared cost reports.
•Failure to comply with the Anti-Kickback Statute, Stark Physician Self-Referral Law, and other federal and state statutes which address acceptance of bribes, kickbacks, or other remuneration to induce business from entities that is reimbursable by federally funded health care programs.
•Routine write-off of coinsurance and deductible amounts due the facility without reasonable efforts for collection.
•Referral agreements for members.
•Acceptance of gifts from vendors or business associates that would be viewed as influencing an employee’s independent judgment.
•Arrangements with vendors that result in the nursing facility receiving non-covered items at below market price or no charge, provided the facility purchases Medicare or Medicaid reimbursed items.
Reporting and Investigations
• You can report compliance concerns:
➢ Call 1-866-290-8032
➢ Speak to the Chief Compliance Officer (Executive Director) at Senior LIFE
• Reporting and Investigation (cont.) The Compliance Officer is responsible for overseeing internal investigations (investigations that we perform).When the government or a government contractor such as a MEDIC conducts an investigation; it is the policy of Senior LIFE to cooperate in that investigation. You are not obligated to consent to an interview, and you may ask that someone else be present during any interview. Contact the Compliance Officer immediately if contacted by a law enforcement officer or government agent regarding Senior LIFE business, or upon receiving an OIG or Grand Jury subpoena or summons.
Monitoring and Auditing
• Senior LIFE engages in regular internal monitoring of our Part D plan, including monitoring for potential FWA.
• Senior LIFE monitors our pharmacy and other third parties that assist with our Part D plan.
• We review prescription drug event (PDE) and cost data that is submitted to CMS.
• We also need to monitor members and prescribers to identify any possible FWA.
• You’re Responsibilities:
➢ Reviewing the accuracy of data submitted to CMS is very important. You may be asked to help periodically monitor the following: Prescription Drug Event (PDE) data submitted to CMS: this data will need to be checked against actual claims data Diagnoses information reported through RAPS Deletion records (generated when a beneficiary fails to pick up a prescription)Enrollment and disenrollment data
Prohibitions on Kick Backs or False Claims
• If you have any reason to believe that: A staff member, prescriber or other individual is receiving improper kickbacks in return for actions related to prescription drugs, Or the organization’s prescription drug program is using false data or participants are not getting the drugs that have been prescribed for them, CONTACT THE COMPLIANCE OFFICER
Disciplinary Guidelines
• Compliance with our FWA Program and other compliance-related policies, and participation in training programs, is a condition of employment at Senior LIFE Serious or repeated misconduct, including failure to report violations, may result in termination of employment Compliance with the FWA Program and other compliance policies is a factor included in employee evaluations.
• Conflicts of Interest “conflict of interest” is any outside interest (financial, personal or organizational) of a PACE employee that could impair your ability to make independent judgments on the job. If you are involved in the Part D plan, you may be asked to complete a “conflicts of interest” statement annually.
General Staff Training for Employee and Contractors
Purpose
• Explain our role as a Medicare Part D (prescription drug) plan sponsor
• Describe the Senior LIFE Fraud, Waste and Abuse Compliance Program
• Provide guidance on where to go and who to call to address compliance concerns
What is a Compliance Program?
• Prevention
➢ Sets rules of conduct
➢ Educates about rules of conduct
• Detection
➢ Audits and monitors to detect problems
➢ Encourages employees to report concerns
• Correction
Imposes discipline when appropriate
➢ Corrects problems
Medicare Part D
• Senior Life is considered a Part D plan sponsor, and most of the prescription drugs we provide our members are now paid for under Medicare Part D, Medicare’s prescription drug plan.
• All Part D plans are required to have a comprehensive program to prevent, detect, and correct fraud, waste and abuse in our prescription drug benefit program.
• The Medicare prescription drug benefit is high-profile and under much scrutiny; expect to see significant attention to fraud, waste, and abuse in the near future.
Terminology:
• Fraud - purposeful deception for the purpose of getting something of value (such as increased reimbursement from the government). Examples include enrolling fictitious individuals in a PACE program and pocketing the money provided. Waste -the careless or needless expenditure of funds that results in connection with a Part D plan. Examples include poor or inefficient record-keeping that results in increased costs to the government. Abuse -any kind of behavior inconsistent with sound fiscal, business or medical practices and that directly or indirectly results in higher costs to the government. Examples include issuing refills for a prescription that is not medically necessary.
• CMS - Centers for Medicare and Medicaid Services, the government agency responsible for administering the Medicare prescription drug benefit. MEDIC -Medicare Drug Integrity Contractor retained by CMS to assist with fraud prevention and detection.
Important Federal Laws:
• The False Claims Act (FCA) prohibits knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment or approval. Additionally, it prohibits knowingly making or using a false record or statement to get a false or fraudulent claim paid by the federal government.
Examples include:
➢ Submitting fabricated data to CMS in order to get higher payments
➢ Falsifying data in the RAPS or other systems
➢ A pharmaceutical company paying a fee to a physician for every prescription the physician writes for that company’s drugs
➢ A Part D plan paying a nursing home to influence all residents to sign up for that prescription drug plan The Anti-Kickback Statute (AKS) prohibits the payment of a kickback or other remuneration in return for referring or recommending a service paid for by Medicare or Medicaid.
• The Compliance Officer (Executive Director) is responsible for the Senior LIFE compliance plan, including the Part D FWA Program. The Board of Directors is responsible for approving our compliance plan and the FWA Program, and receives reports from the Compliance Officer about ongoing compliance activities. Managers that interact with prescriptions and prescription drug data, as well as those involved in care management, will have specific responsibilities to monitor utilization patterns and other information for possible FWA. All employees and contractors are responsible for conducting themselves in an ethical manner and in accordance with our compliance program, and for reporting any suspected fraud, waste and abuse.
High Risk Areas High Risk Areas include:
•Member’s personal funds were utilized to pay for services or items that are covered under Medicare and Medicaid.
•Billing for items or services not rendered or provided as claimed.
•Submitting claims for equipment, medical supplies and services that are not medically necessary.
•Billing for medically unnecessary services, supplies and equipment.
•Billing for services or items which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of the malformed body member.
•Failure to maintain the highest practicable physical, mental, and psychosocial well-being of each member.
•Lack of clinical reviews prior to billing for services as a means to verify that members receive appropriate services.
•Manipulation of the Minimum Data Set (MDS) which scores the resident in a higher category than the medical documentation can support.
•Inappropriate ancillary arrangements with an outside vendor who over-utilizes one service in return for lower pricing to the facility for another service.
•Submitting claims for residents who are not eligible for the coverage.
•Knowingly billing for inadequate or substandard care.
•Misrepresenting a member’s Medicare Part A technical criteria in order to circumvent the program’s limitation for coverage or payment.
•Submission of claims for items or services not ordered.
•Providing misleading information about a member’s medical condition on the MDS or providing inaccurate information used to determine the Resource Utilization Group (RUG) category assigned to the member.
•Failure to identify and refund credit balances.
•Duplicate billing of services either by the Center, its contracted vendor, or both.
•Up coding the level of service provided.
•Billing for items or services that are included in the facility’s reimbursement rate.
•Billing for a service or item that must remain bundled.
•Altering documentation or forging a physician’s signature on documents to verify that services were ordered or provided.
•Failing to maintain sufficient documentation to support the diagnosis, justify treatment, document the course of treatment and results, and promote continuity of care.
•Submission of falsely prepared cost reports.
•Failure to comply with the Anti-Kickback Statute, Stark Physician Self-Referral Law, and other federal and state statutes which address acceptance of bribes, kickbacks, or other remuneration to induce business from entities that is reimbursable by federally funded health care programs.
•Routine write-off of coinsurance and deductible amounts due the facility without reasonable efforts for collection.
•Referral agreements for members.
•Acceptance of gifts from vendors or business associates that would be viewed as influencing an employee’s independent judgment.
•Arrangements with vendors that result in the nursing facility receiving non-covered items at below market price or no charge provided the facility purchases Medicare or Medicaid reimbursed items.
Reporting and Investigations:
• You can report compliance concerns by: Call 1-800-HHS-TIPSSpeak to your supervisor or the Executive Director at Senior LIFE for other methods for reporting
• Employees and contractors are encouraged to ask questions and report suspected non-compliance. It is your responsibility to make these reports. Reports can be made anonymously, and Senior LIFE will make all reasonable attempts to protect confidentiality. The Compliance Officer will review the available information and take appropriate actions.
• You will not be punished or retaliated against for reporting compliance concerns, including concerns of suspected FWA in Part D. You are prohibited from retaliating against anyone in response to such reports. If you believe you have been disciplined or retaliated against for reporting a compliance concern, you should tell the Compliance Officer.
• Reporting and Investigation (cont.) The Compliance Officer is responsible for overseeing internal investigations (investigations that we perform).When the government or a government contractor such as a MEDIC conducts an investigation; it is the policy of Senior LIFE to cooperate in that investigation. You are not obligated to consent to an interview, and you may ask that someone else be present during any interview. Tell the Compliance Officer immediately if contacted by a law enforcement officer or government agent regarding Senior LIFE business, or upon receiving an OIG or Grand Jury subpoena or summons.
Monitoring and Auditing
• Senior LIFE engages in regular internal monitoring of our Part D plan, including monitoring for potential FWA.
• Senior LIFE monitors our pharmacy and other third parties that assist with our Part D plan.
• We review prescription drug event (PDE) and cost data that is submitted to CMS.
• We also need to monitor members and prescribers to identify any possible FWA.
• Report to an interdisciplinary team member: Any instances of improper drug-seeking behavior on the part of the members, or any incidents suggesting that member’s families may be improperly obtaining prescription drugs from the member. Any incidents suggesting improper over utilization of prescription drugs on the part of a member or their family.
Prohibitions on Kick Backs or False Claims:
• If you have any reason to believe that:
➢ A PACE staff member, prescriber or other individual is receiving improper kickbacks in return for actions related to prescription drugs,
➢ The organization’s prescription drug program is using false data or participants are not getting the drugs that have been prescribed for them; CONTACT THE COMPLIANCE OFFICER
Disciplinary Guidelines
• Compliance with our FWA Program and other compliance-related policies, and participation in training programs, is a condition of employment at Senior LIFE Serious or repeated misconduct, including failure to report violations, may result in termination of employment Compliance with the FWA Program and other compliance policies is a factor included in employee evaluations.
Environmental Safety
14.
Bomb Threat
POLICY:
To provide safe orderly evacuation of members, visitors, and employees in the event of a bomb threat directly to the center.
Procedure:
1. In the event of a bomb threat directly to the center, the recipient of the threat is to prolong the conversation as long as possible. The recipient shall be alert for distinguishing voice characteristics and background noises such as music, voices and church bells etc.
2. The recipient of the call will summon help. The first available person will announce overhead “a Code Black” and activate 911.
3. Emergency evacuation procedures shall be followed unless otherwise directed by the local emergency authorities.
4. This procedure is presented to all new employees on orientation and annually as part of emergency preparedness education.
FIRE SAFETY
Policy:
To provide safety for members, visitors, and employees in the event of a fire.
Procedure:
1. In response to a fire alarm The Receptionist will check the nearest fire alarm panel for location of fire.
2. The Receptionist will announce the fire location overhead by utilizing the overhead paging system. The announcement will be announced as a “CODE RED” followed by the location of the fire. The Receptionist will then place a call to the 911 center to verify that they received the alarm. The Receptionist will secure the daily attendance logs and proceed to the nearest evacuation route.
3. Designated staff will proceed to the location of the fire with fire extinguishers.
4. Medical personnel from clinic are responsible to bring electronic medical member information to the evacuation location.
5. All other staff are to begin evacuating members through the nearest exit away from the fire and take any available wheelchairs to the evacuation exit to assist members.
6. The Center Manager and/or the Executive Director will be in charge of directing staff and the evacuation until the fire company arrives.
7. After evacuating via the nearest exit, all members and staff should report to the designated meeting place (please refer to center-specific location for designated meeting place and emergency shelter). Additional instructions will be given at that time. Members will be transported to a pre-established emergency shelter the event of a facility fire and members are unable to be transported home.
8. The Transportation Coordinator will facilitate movement of the vans to provide shelter and method for transport home if necessary.
9. Fire extinguishers are available throughout the facility. Fire extinguishers are inspected and approved annually. The date of the inspection is on the extinguisher. SeniorLIFE will follow the PASS procedure for fire extinguisher use:
P- Pull the pin
A- Aim the nozzle
S- Squeeze the handle
S- Sweep at the base of the fire
10. SeniorLIFE will utilize the RACE acronym to ensure that the staff will know what to do if they discover a fire or smoke and the alarm has not yet been activated:
R- Remove any member away from the fire without endangering yourself.
A- Activate the alarm-Yell for help and direct the first person who arrives to assist to pull the nearest fire alarm. The Receptionist will check the fire panel and announce location of fire overhead.
C- Contain the fire- Office staff, Housekeeping staff, and dietary staff will report to the location of fire with fire extinguishers to attempt containment and extinguish.
E- Evacuate - All other employees will begin evacuation of members out the nearest exit.
11. Fire Safety Inspection:
a. The center shall have an annual on-site fire safety inspection by the local fire department.
b. Documentation of the fire safety inspection shall be kept in the Facility Manager’s Office.
12. Fire Alarm:
a. There is an operable fire alarm system that is audible throughout the building.
b. The fire alarm system is equipped with a visual alarm device for the deaf or hearing impaired.
c. If the fire alarm is inoperative, repairs will be made by the maintenance department within two working days of the time the fire alarm was found to be out of service.
d. If the fire alarm is inoperable, staff and members will be made aware that there is a fire by the overhead paging system.
1) Program Director is responsible to activate a monitoring system.
2) Staff will be instructed to check for signs of smoke/fire every 30 minutes during operating hours
13. Fire Drills:
a. A fire drill will be held at a minimum of every six months and will be coordinated by the Facility Manager.
b. The Facility Manager will keep written drill record on site and a copy will be forwarded to the Quality Assurance Coordinator.
c. Fire Drills will be held on different days of the week and at different times of the day.
14. Fire safety training for members and staff is conducted on enrollment/hire and quarterly thereafter.
NATURAL DISASTER
IT IS THE POLICY OF SENIORLIFE TO ASSESS FOR PROBABLE DISASTERS THAT MAY AFFECT SENIORLIFE BASED ON EXPOSURE RISKS OR GEOGRAPHICAL LOCATION. THE PURPOSE IS TO ASSURE MEMBER AND STAFF SAFETY. SPECIFIC PROCEDURES TO ADDRESS PROBABLE SCENARIOS WILL BE OUTLINED. STAFF WILL BE TRAINED UPON HIRE AND ANNUALLY THEREAFTER. STAFF WILL PARTICIPATE IN DISASTER DRILLS ACCORDING TO REGULATIONS AND AS NEEDED TO ASSURE COMPETENCE.
The probable disasters specific to SeniorLIFE in this geographic region are identified as the following:
• Severe weather including snow, sleet, freezing rain, and heavy fog
• Bomb threat
• Fire
• Tornado
• Hurricane effects
• Chemical spill
• Power outages
• Equipment failure
• Water failure
A Natural Disaster will be defined as a tornado or hurricane effects as these are the weather events that have the potential to occur in the geographical region served by SeniorLIFE.
Policy:
It is the policy of SL to ensure member and employee safety during a natural disaster.
Procedure:
Utilizing the overhead paging system, the receptionist will announce 3 times “Code Brown”.
1. Upon hearing the disaster announcement, staff will proceed with the following protocol:
• Staff will evacuate members to the shower area, clinic area, and therapy room, away from all windows and glass doors. Check all restrooms for members. Do so in an orderly and quiet manner to minimize confusion and allow for instructions to be heard. The last person evacuating rooms will close the doors behind them.
• Designated staff from administration and housekeeping will close all the blinds on the windows and the front desk receptionist will lock the front doors, put the phone in night mode, and bring the daily rosters to the “safe” areas.
• Medical personnel from clinic are responsible to bring electronic medical member information to the evacuation location
• Dietary and housekeeping will shut down all electrical and gas appliances that are running. Dietary will bring bottled water to the “safe” areas.
• Remain in the “safe” areas until it is announced that the disaster is over. A pre- established location will be utilized as emergency back-up shelter in the event that evacuation is necessary and members are unable to be transported home.
2. Natural disaster drills will be held annually.
3. Natural disaster education for members and staff is completed on enrollment/hire and quarterly thereafter.
EQUIPMENT, POWER, AND WATER FAILURE
Policy:
SeniorLIFE will assure the safety of both members and staff in the event of equipment, power, or water failure at the LIFE Center. All staff are trained on the procedures as outlined below at the time of hire and annually thereafter.
Procedure:
If equipment, power, or water failures occur in the center the following procedures will be implemented:
1. Remove members and staff from immediate dangers.
2. Center Manager or designee will call and notify the appropriate agency.
3. If outages are anticipated to be less than one hour and member needs can be safely met, then the center will remain open. Flashlights will be available throughout the facility. Alternative power sources are available in designated areas.
4. In the event of water failure, an emergency 3 day supply will be maintained at the center. For an extended emergency situation, a local supplier for a water buffalo will be contacted or the local fire department as necessary.
5. The Center Manager or designee will ascertain if each member can be transported home at that time.
6. The appropriate agencies will be notified as necessary.
MATERIAL SAFETY DATA SHEET
Policy:
It is the policy of SeniorLIFE (SL) to provide personnel with an easy reference to identify precautions necessary when handling, disposing of, or otherwise come in contact with chemicals.
Procedure:
1. The product name and the MSDS will be located in the MSDS manual
2. The MSDS will include:
• Manufacturer’s name and demographic information
• Information regarding the identity of the substance
• Physical chemical characteristics and the conditions of temperature (including boiling point, vapor pressure, vapor density, melting point, evaporation rate, water solubility, flash point, appearance/odor under normal condition)
• The fire hazards of the substance and any condition that could result in a fire or explosion
• Reactivity data – how reactive the substance is with other chemicals and the conditions to be avoided with its use
• Information about the health hazards of the chemical
• Precautions for safe handling and steps to be taken in case material is released or spilled. Describes precautions to be taken in storing, waste disposal methods, or other precautions.
• Description of personal protection equipment and ventilation requirements for the chemical
3. MSDS training will occur at orientation and annually.
4. The MSDS Manual is kept at the nurse’s station. The Facility Manager will be responsible for adding and maintaining the MSDS.
OXYGEN SAFETY
Policy:
To define safe handling and storage for oxygen cylinders.
Procedure:
1. At all times oxygen cylinders will be firmly secured in racks, approved transport carts, or chained to the wall.
2. Cylinders will be kept out of high traffic areas.
3. Every effort will be made to prevent a cylinder from falling or being hit. However, if a cylinder should fall or a valve is hit, the main cylinder valve and regulator should be examined for damage and leaks. If damage has occurred the tank should be taken out of service immediately, plainly marked damaged, and returned to the supplier. Never use broken or corroded regulators. Proper regulating devices should be used at all times.
4. Cylinder Transport and Storage:
a. All compressed oxygen cylinders have a designated area for storage free from combustible materials.
b. Never permit oil, grease, or other readily flammable materials to come in contact with oxygen valves, regulators, gauges, or fittings.
c. When tanks are transported in a vehicle, the tank will be firmly secured.
5. Oxygen safety is reviewed with pertinent employees on hire during job specific orientation.
SMOKING POLICY
Policy:
Smoking, or use of any other tobacco products, by both members and employees is prohibited in the facility and on facility property.
This policy includes electronic cigarettes (or e-cigarettes), electronic vaping device, personal vaporizer (PV), electronic nicotine delivery system (ENDS) or any battery-powered device which simulates tobacco smoking.
Procedure:
1. Appropriate “No Smoking” sign shall be posted at the entrance of the LIFE Center.
2. The smoking policy is reviewed with members on enrollment and with staff upon hire.
Emergency Care
EMERGENCY CARE: A MEDICAL CONDITION MANIFESTING ITSELF BY ACUTE SYMPTOMS OF SUFFICIENT SEVERITY SUCH THAT A PRUDENT LAYPERSON, WHO POSSESSES AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE, COULD REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO RESULT IN PLACING THE HEALTH OF THE INDIVIDUAL IN SERIOUS JEOPARDY. EMERGENCY MEDICAL CARE CAN BE RENDERED IN AN INPATIENT OR OUTPATIENT SETTING THAT IS FURNISHED IN OR OUT OF THE PROVIDER’S SERVICE AREA BY A SOURCE OTHER THAN THE PROVIDER OR ITS CONTRACT PROVIDERS. SUCH SERVICES SHALL INCLUDE TRANSPORTATION TO AND FROM A PROVIDER OF EMERGENCY SERVICES AND MEDICATIONS ADMINISTERED IN THE COURSE OF RENDERING EMERGENCY SERVICES.
Post Stabilization Care: Services provided subsequent to an emergency that a treating Physician views as medically necessary after an emergency medical condition has been stabilized. They are not emergency services, which providers are obligated to cover. Rather, they are non-emergency services that the provider should approve before they are provided outside the service area.
Urgent Care: Care provided to a member who is out of the PACE service area, and who believes there illness or injury is too sever to postpone treatment until they return to the service area, but their life or function is not in severe jeopardy.
Emergency Care Plan: An Emergency care plan is established at enrollment and reviewed as needed.
The members and or representative are educated on when and how to get access to e emergency services and that no prior authorization is needed.
• Includes information on how and when to contact the LIFE center and appropriate emergency responders.
• Is located in a confidential folder in the member’s home.
• The members and or representative are educated on when and how to get access to emergency services and that no prior authorization is needed.
Emergency/Urgent Care After Hours
SL provides 24 hour medical support to the members via a call line.
Procedure:
A physician will be available on-call whenever the center is closed. A single number will allow access to the on-call nurse and the number is provided to all members at enrollment. Outside center hours, the on-call physician will be contacted for all emergency problems. In those cases where it calls for EMS activation, the on-call physician will be contacted after EMS; in all other cases he/she should be contacted before other action is taken. The on-call physician will then obtain sufficient information to triage the problem, and formulate a response plan to meet the established need.
Medical Emergency in LIFE Center During Regular Center Hours:
Procedure:
1. Upon entering the LIFE Center each day the members will receive a name tag for identification. If the member is a DNR there will be a black dot on the back of their name tag. If the member is a FULL CODE there will be a blue dot on the back of their name tag.
2. If the physician is present in the center, she/he will have primary responsibility for identifying life-threatening conditions and directing subsequent care.
3. When the physician is not present, qualified staff will identify life-threatening or unstable situations and respond appropriately:
Member is a Full Code:
• Call 911 and then the physician.
• An Automatic Electronic Defibrillator will be located in the clinic. Staff trained in Basic Life Support is trained to use the AED and will implement usage as needed.
Member is a Do Not Resuscitate (DNR):
▪ Notify the Physician
▪ Provide appropriate medical care as needed.
▪ This may include calling 911 in some situations, in which case they should be informed of the wishes not to be resuscitated.
BODY MECHANICS AND BACK SAFETY TECHNIQUES
ANATOMY OF THE SPINE
Vertebrae
The healthy spine is made up of 24 vertebrae.
Curves
The 24 vertebrae are aligned in three natural curves:
• cervical curve of the neck,
• thoracic curve of the middle back,
• lumbar curve of the lower back.
When the three natural curves are maintained in their anatomical alignment, the body’s weight is evenly distributed throughout the vertebrae and discs, which makes the back least vulnerable to injury.
Discs
The discs are located between the vertebral bodies and allow flexible movement of the spine. They are often referred to as “shock absorbers”
Nerves
The spinal column is actually the flexible, protective housing for thousands of nerves that run through it. The nerves that run through the spinal column make up the spinal cord which is basically the information highway of the body.
Muscles and Ligaments
The support structures of the spine are the muscles and ligaments that attach and allow fluid movement of the body.
Factors Attributing to Back Pain
Cumulative Trauma
Back pain is not typically due to an isolated incident but rather the culmination of chronic injury which occurs with a lifetime of poor habits. In other words, pain is the result of “the straw that broke the camel’s back.”
Poor Posture
When standing upright, the lumbar region must support the weight for the entire upper body and bear most of the load when in motion. Sitting produces the highest intervertebral pressures; therefore it is important to maintain proper posture in the sitting position, i.e., avoid slouching. Poor posture places our musculoskeletal system at a biomechanical disadvantage which increases risk of injury.
Muscle Imbalance
Muscle imbalance goes hand in hand with poor posture--this occurs when the body has faulty postural alignment. When you have sustained misalignment, it results in some muscles becoming shortened while the opposing muscles develop a constant over-stretch. Likewise, when certain muscles are worked more frequently they may become stronger and tighter while the underutilized opposing muscles become weaker, e.g. forward head posture.
Proper Posture
Proper posture is achieved by maintaining the three natural curves of the spine. Your three curves are correctly aligned when you can draw a straight line from the middle of your ear lobe through the middle of the shoulder, the hip, the knee, and slightly in front of the ankle.
Improper Lifting
Improper lifting techniques and poor body mechanics increase the risk of back injury. Proper lifting technique utilizes the lower body as the primary source of motion through bending at the knees, thus eliminating the strain produced in the lumbar region that occurs from bending over at the waist.
Poor Physical Fitness
Poor physical fitness and a sedentary lifestyle have a direct correlation to back related problems. It also has a negative impact on the body’s ability to heal quickly and the entire healing process in the event of injury or pain.
Smoking
Smoking has a correlation to vasoconstriction and decreased circulation which effects nutrient and oxygen supply to your body, contributing to lower back pain and degenerative disorders of the intervertebral discs. Smoking also induces chronic coughing which elevates the intradiscal pressure increasing the risk of protrusion or prolapse of the lumbar discs.
Body Weight
Body mass in excess of the recommended ranges per height and weight places additional unnecessary strain on the back, and can be a contributing factor in the mechanism of injury to the back.
Stress
Both conscious and unconscious tension causes changes to the body’s nervous system, such as constriction of blood vessels and reduction of blood flow to soft tissues. This causes a decrease in oxygen to the area and a buildup of biochemical waste products in the muscles which results in muscle tension, spasm, and ultimately back pain
Prevention of back pain
The following can help prevent the occurrence, reoccurrence, and severity of back injury or pain:
• Stretching Exercises: Performing stretching exercise intermittently throughout the day will help avoid injury. Because most of our work puts our bodies in a forward flexed position, stretches should focus on extension.
• Strengthening Exercises: Strong, healthy muscles promote improved posture and muscle balance.
• Minimizing Risk Factors
• Education/Knowledge
• Proper Lifting--Assess environment/lift to be performed
▪ What is the load?
▪ Where is it going?
▪ Test the weight
• STOP
S = Stance (shoulder width apart for a strong base of support)
T = Turn, twist, torque (never twist, move your feet and turn)
O = Object (keep object close to center of gravity. A 2 pound object carried at your center of gravity puts 2 pounds of force on the low back, carried away from the body can increase the force up to 200 pounds )
P = Pace (Take your time, get help if needed)
Infection control
Exposure Control Plan for Bloodborne Pathogens
EXPOSURE CONTROL PLAN
Introduction:
In December 1991, the Occupational Safety and Health Administration (OSHA) issued a revised final bloodborne pathogen standard which mandates the use of Universal Precautions for the prevention of bloodborne infections in the health care workers. These regulations are based on the premise that any patient may be unknowingly infected with bloodborne pathogens. Consequently, barriers such as gloves, goggles, masks, and gowns must be used when the potential for exposure to infectious material is anticipated. It covers all employees who could be “reasonably anticipated” as a result of the requirements of their job duties to have contact with blood and other potentially infectious materials.
The standard also mandates that Hepatitis B Vaccine be offered at no cost to all employees who have risk of occupational exposure during the course of performing their duties, and that there be a plan in the event of exposure for post-exposure evaluation and follow-up.
Senior LIFE recognizes that health care workers face a significant health risk as a result of occupational exposure to bloodborne pathogens and has developed this Bloodborne Pathogens Occupational Exposure Control Plan accordingly to prevent the transmission of potential bloodborne infection to all personnel by using appropriate precautions on ALL members at ALL times. Components of the plan include:
▪ Occupational Exposure Determination
▪ Methods of Compliance
▪ Post-exposure Evaluation and Follow-up
▪ Education and Training
Definitions
The following definitions are provided to clarify terminology as it relates to this plan.
Occupational Exposure defined as reasonable anticipated skin, eye, mucous membrane non-intact skin or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.
Bloodborne Pathogens means disease producing microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).
Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of exposure to the employee.
Parenteral means piercing mucous membranes of the skin surface through such events as needle-sticks, human bites, cuts and abrasions.
Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping).
Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood and other potentially infectious materials that result from the performance of an employee’s duties.
Contaminated means the presence or the reasonably anticipated presence of blood and other potentially infectious materials on an item or surface.
Significant Exposure is the direct contact with blood or body fluids of a patient in a manner which (CDC definition), is capable of transmitting human immunodeficiency virus, including, but not limited to, a percutaneous injury contact of mucous membranes, or contact of skin (i.e. when exposed skin is chapped, abraded or afflicted with dermatitis), or if the contact is prolonged or involves an extensive area.
Potentially Infectious Materials includes blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pericardial fluid, peritoneal fluid, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.
Hazardous Trash/Materials Definitions References (Pennsylvania Code, March 21, 1998- Environmental Protection)
Infectious Agent an organism, such as a virus or bacteria that is capable of being communicated by invasion and multiplication in body tissues and capable of causing disease or adverse health impacts on humans.
Isolation wastes are biological wastes and waste contaminated with blood, excretion, exudates or secretions from humans who are insulated to protect others from highly virulent diseases.
Regulated Waste-No universal definition of medical waste; various organizations and agencies use different criteria to identify what substances fit into this category. However, regulated medical waste (as defined by the federal government) originates from a resident’s care, treatment, or immunization.
The following list provides the Environmental Protection Agency’s classification for regulated medical waste:
Pathological Waste-Human pathological wastes include any tissue or fluids (and their containers) from residents.
Human Blood and Body Products are liquid waste-human blood, blood products, items saturated and/or dripping with human blood, and previously saturated items that are now caked with dried human blood. These divisions include serum, plasma, and other blood components and their containers that were used or intended for use in resident care, intravenous bags are also included.
Sharps-Sharps that have been used in member care or treatment, including hypodermic needles, syringes (with and without attached needle), blood vials, and needles with attached tubing. Also included are the other types of broken and unbroken glassware that were in contact with infectious agents, such as cover slips.
Isolation Wastes-Biological waste and discarded materials contaminated with blood, excretion, exudates, or secretions from humans who are isolated to protect others from certain highly communicable diseases.
Unused Sharps-Unused hypodermic needles, suture needles, and syringes that have been discarded.
These most directly involve member care. Other forms of biomedical waste are not infectious. Some of these are soiled dressings, sponges, disposable gloves, and so forth, also do not need to be classified as infectious waste unless generated in the care of an exposed resident.
Occupation Risk Determination
The following list includes job classifications in which all employees in that classification perform tasks which put them at risk of occupational exposure:
Registered Nurse Licensed Practical Nurse
Member Assistants Occupational Therapist
Speech Pathologist Facility Personnel
Housekeepers Physical Therapist
Laundry Personnel Dietary Staff
Transportation Personnel Physicians
Methods of Compliance
Standard Precautions:
It is the policy of SeniorLIFE that the Standard Precautions be utilized at all times. The purpose of these practices is to prevent exposure to blood or other potentially infectious materials and to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. All blood, body fluids, secretions, visible blood, non-intact skin and mucous membranes are considered potentially infectious.
Engineering and Work Practice Controls:
Engineering controls are one of the first line defenses against exposure to blood or other potentially infectious materials. These controls significantly reduce the risk of occupational exposure. In addition, personal protective equipment and specific work practices are instituted to further reduce the risk of exposure. It is the responsibility of each department manager to ensure that these engineering controls are utilized as appropriate. If the manager determines at any time that these controls are in any way ineffective, he/she must report such to the Center Manager.
The following engineering and work practice controls are currently utilized at this facility.
Sharps disposal containers- Sharps disposal containers are provided throughout the facility in locations convenient to generation of contaminated sharps for the purpose of isolating or removing bloodborne pathogen hazards from the workplace. Although a variety of containers may be used in the facility, each is plastic, leak proof, puncture-proof, and labeled and/or colored to communicate to employees that contents are biohazard materials. Sharps containers are replaced when full. The nursing staff is responsible for evaluating when sharps containers need replaced.
Needleless I.V. System- The facility uses needleless I.V. access equipment for maintaining venous access and delivering intravenous fluids and medications. Special injection caps are used in conjunction with a blunt stylet at the connecting end of the delivery line. The use of this system eliminates the risk of exposure to contaminated needles during I.V. line management. Special adapter caps are available for use with multiple dose vials to maintain needleless compatibility.
Safety vacutainer holders- are provided by the laboratory to SeniorLIFE. Use of this device reduces the risk of injury associated with recapping and untwisting contaminated needles from vacutainer holders.
Recapping Needles- Facility policy prohibits the recapping of needles. Contaminated needles and other contaminated sharps are never to be bent, cut, broken or clipped.
Regulated Waste Management- Regulated (biohazard) waste will be properly contained and disposed of, so as not to become a source of transmission of disease to employees. Only those transport containers
provided by the facility’s regulated waste hauler will be used to package the facility’s regulated waste. These containers meet the OSHA and PADEP (Pennsylvania Department of Environmental Protection) guidelines.
Hand washing availability – Hand washing facilities are provided throughout the facility. They are conveniently located for employee use in the workplace and nearby restrooms. Employees are instructed that hand washing is the simplest, most effective method of preventing the spread of infection.
Ingestion and splash guidelines- Eating, drinking, smoking, applying cosmetics and contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
Eye wash stations are located in the assessment room and the kitchen. They provide easy access for eye flushing after a body fluid splash. All employees are oriented on the location of the eyewash stations.
Food and drinks are prohibited from refrigerators, freezers, shelves, cabinets, countertops where blood or other potentially infectious materials are stored or processed
Procedures involving the handling and processing of blood or other potentially infectious materials are performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances.
Specimen Transportation- Specimens of blood or other potentially infectious materials are placed in a container which prevents leakage during collection, handling, processing, storing, transporting, or shipping.
All laboratory specimens are handled as if they are infectious. Universal Precautions are followed when processing specimens for transport to outside laboratories.
All lab specimens being sent out of the facility for analysis are placed in “ziploc” plastic bags that are labeled with the appropriate Biohazard label. Blood tube surfaces contaminated with visible blood are wiped with a disinfectant before packaging for transport. If the primary container is leaking, “double-bagging” is performed to contain the specimen and the outer bag is marked as contaminated.
Personal Protective Equipment (PPE):
PPE is available for employee use for instances of actual or anticipated occupational exposure to blood or other potentially infectious material. All equipment is located in areas convenient to where tasks are performed. Appropriate equipment approved for use at the facility prevents blood or other potentially infectious materials from passing through to reach the employee’s clothing, skin, eyes or mucous membranes under normal conditions.
Personal protective equipment provided for employee use includes, but is not limited to:
• Gloves
• Eye shields
• Gowns
• Face masks
Nursing staff are instructed to use Standard Precautions during all member care. Personal Protective Equipment (PPE) should be selected on an individual basis dependent on the degree of risk anticipated. Eye shields and face shields protect conjunctiva, oral, and nasal mucous membranes from splashed body substances. Gowns protect your clothing from potentially infectious material.
Nursing Department- The Clinic Staff is responsible for assuring that PPE is available. Resuscitation masks are available in designated areas throughout the facility.
Other Departments- Each Department is responsible for providing for PPE in quantities appropriate to the exposure risks of their respective areas, and in a location that is convenient to areas where risk occurs. Gloves are provided in all departments that perform tasks associated with potential blood exposure.
• All PPE supplies can be obtained through the Housekeeping Department.
• All articles of PPE are disposable.
If a garment of protective equipment is penetrated by blood or other potentially infectious material during use, or become torn, the garment is removed immediately or as soon as feasible. PPE is to be removed after exposure related tasks have been completed and prior to leaving the work area. Articles of PPE are removed and placed in appropriate areas and containers for disposal.
Employees will wash their hands after removing and disposing garments of protective equipment.
Wearing Guidelines for PPE
Gloves:
▪ Must be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes and non-intact skin.
▪ Must be worn when handling or touching contaminated items or surfaces.
▪ Must be worn when performing vascular access procedures.
▪ Powderless latex and vinyl gloves are available by request. Employees allergic to the normally supplied gloves may request hypoallergenic gloves.
Face Shields/Mask with Eye Shield/Gowns:
▪ A face shield must be used whenever splashes, spray, splatter or droplets of blood or other potentially infectious materials may be generated, and eye, nose or mouth contamination can be reasonably anticipated.
▪ Appropriate protective clothing such as gowns, are worn when the employee can reasonably anticipate exposure to their clothing, or body areas in addition to their clothing, or body areas in addition to their face and hands.
Housekeeping:
Departmental and Facility cleaning and disinfection responsibilities are reviewed and approved by the Facility Manager on an annual basis.
All equipment and surfaces are cleaned and disinfected in accordance with the following schedule after contact with blood or other potentially infectious materials:
▪ after the completion of medical procedures
▪ immediately, or as soon as feasible, when surfaces are visibly contaminated
▪ at the end of the work day if the surface may have been contaminated
▪ after any spill of blood or infectious materials.
All pails, bins, cans and other receptacles intended for waste containment or disposal are visually inspected when emptied for evidence of contamination. Containers are cleaned and disinfected as necessary when visibly soiled or odorous.
Potentially contaminated broken glassware is picked up using mechanical means, such as dustpan and brush, and must not be picked up directly with the hand.
Laundry:
Facility Linens- All soiled linen is considered infectious and handled using Standard Precautions.
▪ All soiled/contaminated linen is handled as little as possible and with a minimum of agitation.
▪ Sorting of linen is prohibited. EXCEPTION: The clothing is considered as an activity of daily living during therapeutic programming or in the member’s personal laundry area for member/family use.
▪ All soiled linen is placed into leak proof bags or containers at the site of generation.
▪ Laundry containers are cleaned and disinfected by the housekeeping department as necessary when visibly soiled or odorous.
Labels and Signs:
Labels and signs are used throughout the Center to identify containers of regulated wastes that are collected and processed. Labels contain a biologic hazard symbol and the word “BIOHAZARD.”
Blood or other potentially infectious specimens going to the contract laboratory service, are not individually labeled with the biohazard label, but are carried in a biohazard labeled container to the laboratory facility.
Bio-hazard trash is stored in covered labeled containers for transport to the processing area.
Hepatitis B Vaccine:
Hepatitis B Vaccination is offered at no cost to all employees of SL. Occupational exposure is defined
as reasonably anticipated skin, eye, mucous membrane or contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.
Procedure for Offering Hepatitis B Vaccine:
1. Hepatitis B Vaccine is offered to all employees of SLJ upon hire.
2. Previously vaccinated employees are requested to provide documentation of vaccine dates and/or antibody testing results if possible. Employees whose vaccine status is uncertain or unknown will be handled on an individual basis.
3. When the first dose of the series is given the timetable of the rest of the series is explained.
4. One to two months after the third dose is given, the employee will be requested to get a blood test for Hepatitis B surface antibody (Hbsab).
5. Employees who do not respond to the primary series with a positive Hbsab will be offered the vaccination series and antibody testing again. Non responders will be evaluated by the Center
or private Physician. Employee medical records are confidential. Employee health records are kept intact throughout the employment period.
Method of Administering Vaccine:
1. Hepatitis B Vaccine is an intramuscular injection. The deltoid muscle is the preferred site in adults. The buttock should be avoided.
2. Contraindications for vaccine:
a. Hepatitis B Vaccine will not be given to persons with yeast allergies.
b. Immune-deficiency or those receiving immunosuppressive therapy require larger vaccine doses and respond less well than do healthy individuals.
c. Those who develop symptoms suggestive of hypersensitivity after an injection should not receive further injections.
d. Pregnant employees will not be given the vaccine without written permission from their OB Physician.
3. Pre-vaccination serologic screening for susceptibility will not be done routinely.
4. Hepatitis B Vaccine produces immunity on more than 90% of healthy persons if given in the deltoid muscle.
Post-Exposure Evaluation and Follow-up:
When an employee sustains an exposure, the following procedure will be followed:
1. An Incident Report Form will be generated by the employee.
2. The Incident Report Form must then be given to the employee’s supervisor to complete and the employee is sent for an evaluation as appropriate. (The Incident Report should accompany the employee.)
3. If the employee requests source testing, the source will be counseled and asked to consent to baseline testing. The request for source testing will be documented on the source member’s chart along with all pretest education/counseling.
4. A good faith effort must be made to notify the source member or family of the exposure, and seek consent for HIV related testing. If consent for testing has not been obtained, this should b
documented on the members’ medical record. Test results and education will be given to the member or the family and documented on the chart.
If the source member or family refuses consent for HIV related testing after counseling and education, and the laboratory is not in possession of source member’s blood, no HIV related testing can be done. This must be documented on the member’s chart.
5. A confidential evaluation and follow-up will be provided immediately following the exposure incident.
a. An evaluation of the exposure incident.
b. Collection and testing of employee’s blood for HIV and HBV status if the employee consents.
c. Review of source individual’s status.
d. Informing employee of results the source member’s testing.
6. All occupational bloodborne pathogen exposure incidents will be recorded on an Incident Report Form and forwarded to the QA Coordinator. Additionally, a Sharps Injury Log is maintained in the center.
7. All occupational exposures will be reviewed by the Infection Control Committee and reported to the QI Committee. If patterns are found in the way the injuries occurred a QI plan will be initiated.
8. Employee training including information on the actions to be taken following an exposure incident, the reporting method, and the availability of medical follow-up, will take place on hire and yearly.
INFECTIOUS WASTE HANDLING
PURPOSE:
To provide an infectious waste plan in accordance with regulatory agencies that reduces the risk of occupational exposure and disease transmission from infectious waste.
Policy:
Infectious waste is waste that is or may be contaminated by disease producing microorganism or material that may harm or threaten human health. This waste must be disposed, stored, collected, and transported according to local, state, and federal regulations.
Facility infectious waste – includes, but is not limited to, the following items:
▪ Filled sharps disposable containers
▪ Used blood vials
▪ Wound dressing containing blood
▪ Waste items contaminated by infectious organisms from members in isolation precautions
▪ Used hypodermic needles, syringes, scalpel blades and instruments, IV access devices, razors, and broken glass that have been in contact with pathogens.
▪ Glucose monitoring lancets
▪ Urinary or ostomy with visible blood
▪ Disposable equipment, material or device contaminated with visible blood or other potentially infectious material
Gloves must be worn at all times when handling infectious waste.
Education – All employees receive education on proper management of infectious waste at orientation and annually.
BLOOD SPILL (BIOLOGIC SPILL) MANAGEMENT
Purpose:
To provide an effective method to manage hazardous biologic spills and reduce the risk of occupational exposure to bloodborne pathogens and other potential sources of infection.
Policy:
Personnel will follow the biologic spill protocol for effective management of a biologic spill (blood or body fluid with or without signs of blood).
Biologic spill clean-up protocol
1. Notify housekeeping personnel immediately to initiate clean up. Assist with traffic control as needed until area is completely disinfected.
2. Use a fluid control solidifier according to manufacturer’s directions.
3. Wear gloves during the entire cleaning and decontamination process.
4. If splashing is anticipated, wear protective eyewear and a gown.
5. Remove visible material with cardboard or paper towels after the spill has solidified. Place in the red isolation bag that is provided in the spill kit.
6. Disinfect area with appropriate germicide using a disposable towel.
7. Discard all items in the red isolation bag.
8. Wash hands and dispose of the red isolation bag in the red infectious waste container.
Contaminated Sharps – Handling/Disposal
PURPOSE:
To reduce the risk of occupational exposure to blood and other potentially infectious material from the handling of used sharp items.
Policy:
Recapping or manipulation of used needles is strictly prohibited.
Sharps with engineered sharp injury protection systems are used.
▪ Sharps are defined as any object that can penetrate the skin, including needles, scalpels, and broken capillary tubes.
▪ Used sharps are discarded immediately in containers that are:
- Closeable
- Puncture resistant
- Leak-proof on sides and bottom
- Color coded/labeled in accordance with OSHA requirements
▪ Contaminated sharps containers are maintained in an upright position.
▪ Sharps containers are never overfilled, with items protruding, and are routinely replaced.
▪ Contaminated sharps containers are securely sealed prior to replacement, transport, storage, and shipping.
▪ Sealed sharps containers are packed for shipping by the facility manager or designee.
▪ NEVER attempt to retrieve anything from a contaminated sharps container.
CARE OF ISOLATION AND CONTAMINATED LAUNDRY
PURPOSE:
To prevent the transmission of infectious microorganisms from contact with linen.
Policy:
1. All soiled linen is regarded as contaminated.
2. Soiled linen is bagged in a clear plastic bag.
3. The bagged linen is then taken and placed into one of the contaminated/soiled linen containers or the soiled utility room.
4. Personnel wash their hands after handling any soiled linen.
Hand hygiene
ALL PERSONNEL ARE REQUIRED TO PERFORM HAND HYGIENE AFTER EACH DIRECT OR INDIRECT MEMBER CONTACT FOR WHICH HAND HYGIENE IS INDICATED BY ACCEPTED PROFESSIONAL PRACTICE. HAND HYGIENE POLICY AND PROCEDURES WILL BE PART OF EACH EMPLOYEE’S INITIAL ORIENTATION AND REVIEWED ANNUALLY.
Procedures:
All staff are required to abide by the following hand-washing protocol:
A. Indications for hand hygiene (whether or not gloves have been worn)
1. Wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids or after using the toilet.
2. If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of Clostridium difficile, hand washing with soap and water is the preferred method.
3. Use a facility approved soapless hand rub as the preferred means for routine hand antisepsis in all other clinical situations described in D below, if hands are not visibly soiled. If a soapless product is not available, wash hands with soap and water.
4. Perform hand hygiene:
a. before and after touching a member;
b. before and after performing invasive procedures or handling an invasive device for care regardless of whether or not gloves are used;
c. before and after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings;
d. if moving from a contaminated body site to another body site during care of the same member;
e. after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the member;
f. after removing sterile or non-sterile gloves;
g. before handling medication, preparing food or assisting members with eating;
h. before and after eating, drinking, or smoking;
i. before and after going to the bathroom
j. any time hands are dirty from any source
B. Recommended hand hygiene agents
Approved soap and hand hygiene products are available throughout the facility.
C. Hand-hygiene with soap and water
Duration of the entire procedure: 40 - 60 seconds
1. Wet hands with warm water (figure 0)
2. Apply enough soap to cover all hand surfaces (figure 1)
3. Rub hands together:
a. palm to palm (figure 2);
b. palm over left dorsum with interlaced fingers and vice versa (figure 3);
c. palm to palm with fingers interlaced(figure 4);
d. backs of fingers to opposing palms with fingers interlocked (figure 5);
e. rotational rubbing of left thumb clasped in right palm and vice versa (figure 6);
f. rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa (figure 7);
4. Rinse hands with water (figure 8)
5. Dry hands thoroughly with a single use towel (figure 9)
6. Use towel to turn off faucet (figure 10). Your hands are now safe.
*Follow these steps on Figure 11.2 on the following page.
D. Hand-hygiene with alcohol based formulation
Duration of the entire procedure: 20 - 30 seconds
1. Apply a palmful of the product in a cupped hand, covering all surfaces.
(figures 1a-1b).
2. Rub hands together:
a. palm to palm (figure 2);
b. palm over left dorsum with interlaced fingers and vice versa (figure 3);
c. palm to palm with fingers interlaced(figure 4);
d. backs of fingers to opposing palms with fingers interlocked (figure 5);
e. rotational rubbing of left thumb clasped in right palm and vice versa (figure 6);
f. rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa (figure 7);
3. Once dry, your hands are safe (figure 8). Follow these steps on Figure 11.1 on the following page.
[pic]
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Tuberculosis
CAUSE:
Tuberculosis or TB is caused by the bacterium, Mycobacterium tuberculosis, also referred to as the tubercle bacillus. TB usually affects the lungs but can also affect other body sites.
Transmission:
Transmission of the tubercle bacillus occurs when a susceptible person inhales droplet nuclei containing the organisms which are suspended in the air. Droplet nuclei are produced when a person with active pulmonary or laryngeal TB coughs, sings, sneezes, shouts, or performs other activities which could aerosolize the TB organisms.
Note:
▪ Usually, people who do not cough do not produce droplet nuclei and are therefore, not infectious.
▪ People who cover their mouth with a tissue when they cough do not produce droplet nuclei.
▪ Good ventilation dilutes the concentration of droplet nuclei and reduces the risk of infection in the area.
▪ TB is contagious, but not extremely so. The average new infection occurs after contact lasting six months or eight hours a day. In a household of an active TB case, about 30% of family members will become infected over time.
▪ Extrapulmonary TB is not contagious since droplet nuclei are not usually produced.
▪ Treatment usually renders the individual non-contagious after several weeks of effective therapy.
People at Risk:
People at risk of exposure to TB are those who come in contact with a person with active TB disease. Risk of infection is influenced by the number of TB organisms in the droplets, number of droplets in the air, air circulation at the site of exposure, and susceptibility of the person being exposed.
Persons at risk of being infected are persons with HIV infection, close contacts of known TB cases, persons with other medical risk factors, foreign-born persons from high prevalence countries (e.g. Asia, Africa, the Caribbean, and Latin America), medically under-served low income populations, alcoholics, IV-drug users, and LTCF residents. Risk of infection progressing to active disease is increased in HIV infection, silicosis, fibrotic chest lesions, diabetes, prolonged corticosteroid or immunosuppressive therapy, leukemia, Hodgkin’s disease, end stage renal disease, surgery, chronic malabsorption syndromes, cancer, or being under weight.
Stages of TB Disease:
1. Infection: when a person exposed to the TB organism acquires and continues to harbor the organism but develops no signs or symptoms of active disease, the person is considered infected with TB. The tuberculin skin test (PPD or Mantoux skin test) usually becomes positive within a few weeks of acquiring the infection.
2. Primary Disease: when the infection develops into active TB disease within one year of infection, the disease is referred to as “primary TB disease”. About 5% of newly infected people with normal immunity will develop primary TB.
3. Latent Disease: when an exposed and infected person continues to harbor the organisms usually is skin test positive, has no active disease, and is not contagious, the person is said to have “latent TB disease”. Ninety percent of people with normal immunity who become infected with TB will never get sick. Preventive treatment reduces the risk of disease development in the future.
4. Reactivation TB: if the immune system of a person with latent TB should weaken, the bacteria can “break out” and cause active disease years or even decades after the original infection. Five percent of people with normal immunity who become infected will eventually develop reactivation TB, and may become contagious. Active disease will usually be first treated with 3 or 4 oral antibiotics. If drug susceptibilities indicate the organism is susceptible, the number of drugs can be reduced to two (INH and rifampin). The usual length of treatment is 6-12 months.
REMEMBER: TB is a curable disease.
Symptoms and Consequences
Symptoms: include low grade fevers, night sweats, loss of appetite, weight loss, fatigue, coughing up blood, in addition to a persistent cough lasting 3 or more weeks.
Consequences of Untreated TB: include lowering of quality of life, disability, threat to life, loss of work, and increased risk of transmission to household.
Who Should Be Isolated?
▪ A person in whom active, infectious TB is suspected.
▪ A person diagnosed with active pulmonary TB (AFB smear-positive) until the person:
- Has three consecutive sputums for AFB that are smear-negative.
- Has received at least 2-3 weeks of appropriate medication.
- Shows clear clinical improvement, such as reduced cough and fever.
- Continues under medical supervision.
What Does TB Isolation Require?
▪ A private room with special ventilation system.
▪ The door to the room must be kept closed so the air is ventilated to the outside.
▪ Caregivers should use high efficiency, closely-fitted mask (N-95) filtration mask.
▪ The resident must stay in the room and healthcare procedures done in the room.
▪ If the resident is taken out of the room, the resident must be fitted with a surgical mask.
▪ This Center does not admit or treat active infectious cases of tuberculosis.
TB in Immunocompromised People:
▪ The risk of active disease, either primary or reactivation, is much higher in such people.
▪ They may have a rapid course of the disease.
▪ They may be more difficult to diagnose since they may have unusual chest x-ray findings and/or a negative TB skin test.
▪ They can have TB and other respiratory disease at the same time.
▪ They may have an undiagnosed active TB disease.
Multi-Drug Resistant TB (MDR-TB):
The frequency of TB caused by drug-resistant organisms is on the rise. Drug resistant TB is very difficult to treat. The appearance of MDR-TB is usually the result of incomplete treatment. Ways to combat this problem include:
▪ Instructing individuals that it is critical they take their medications consistently and for as long as directed. If they don’t, the TB organism may reappear as MDR-TB. It will then be difficult to treat and they can then transmit resistant TB organisms to others.
▪ If you are infected with TB, take all medication as long as prescribed. A person exposed to MDR-TB strain has the same chance of developing an active case of TB as with drug susceptible strains, but it will be more difficult to treat successfully.
Preventing Transmission of TB:
1. Identify, and diagnose people with active TB.
2. Comply with facility screening programs.
3. Restrict members with active TB from attending the Center.
Preventing Exposure to TB:
The employer is responsible for the prevention of employee exposure to infectious TB by developing an exposure control plan, assuring compliance with infectious TB by developing an exposure control plan, assuring compliance with the plan, providing training to employees upon employment and annually thereafter. The employee is responsible for prevention of self-exposure to infectious TB while at work by getting trained, understanding, and following policies and procedures.
The main exposure control method for this facility is to prevent a person who is suspect or a confirmed case of TB from admittance to the Center. If a suspect case is found, it is important to adhere to restricting the member until active TB is ruled out.
Identification of TB and Follow Up:
1. Skin Testing
The purpose of skin testing is to identify persons who are infected with TB. The TB skin test (TST) shows that the person might be infected with TB. False negatives occur in immunosuppressed persons (such as persons with HIV infection), persons with febrile disease or measles, during live virus vaccination, during steroid therapy, and in the presence of overwhelming active TB disease. False positives can also occur. Persons with a positive test are encouraged to be tested for HIV.
You should also be aware of the “booster phenomenon.” The booster phenomenon is seen when the first PPD is negative and is followed by a second test 1-3 weeks later that is positive. The phenomenon may occur due to old inactive TB infection, cross-reaction with TS-related organisms, or other reasons. The physician will decide how to interpret a booster phenomenon.
Persons who have had a previous positive PPD will have a chest x-ray to determine TB status. Persons who are immunocompromised such as people with HIV infection may be unable to generate an immune response to the PPD and will have a chest x-ray to determine TB status if they are anergic.
2. Preventive Therapy
Preventive therapy usually prevents TB infection from progressing to TB disease. Preventive therapy requires monitoring for drug toxicity, side effects, and compliance in taking the medication. Persons infected with TB that will receive preventive treatment include persons younger than 35, persons with HIV, close contacts of contagious cases, recent TST converters, persons with fibrotic chest lesions, IV drug users, and other persons with increased risk of developing TB disease.
The TB Exposure Control Plan of the LIFE Center:
The TB Exposure Control Plan is kept in the Infection Control Manual. You are encouraged to read the plan for a better understanding of how to prevent TB. Please feel free to ask questions during and after your training about any aspect of the TB Exposure Control Plan.
Psychosocial Well-Being
HealthCare Ethics
WHAT IS HEALTHCARE ETHICS?
Did you know that healthcare professionals are also a practicing philosopher? That's right; every healthcare professional studies medical ethics--nursing ethics in particular, a set of moral and practical guidelines that influences decisions big and small.
In essence, ethics is a set of shared values or principles that govern the way healthcare professionals interact with patients, a patient's family, and doctors and nurses.
What Kind Of Ethical Issues Do Healthcare Professionals Face?
Slight nuances set general medical ethics apart from ethics. Where doctors are concerned with treating the disease and finding a cure, nurses and other professionals are dedicated to treating the person and easing suffering. That difference in perspective defines ethics from various standpoints.
Some of the broader ethics issues today include questions about end-of-life care. Ethical issues on a day-to-day basis often involve patient communication and advocacy. Healthcare professionals are often the ones working closest with a patient while administering ongoing care. Patients may express desires, questions, and fears with their nurse, and those sentiments need to be shared with the rest of the health care team.
From working with unbiased compassion to standing up for patients' rights, a healthcare professional hold a wide range of responsibilities in addition to the actual physical work of caring for patients. You should always:
• Practice with compassion and respect for "the inherent dignity, worth and uniqueness of every individual"
• Advocate and strive to protect the health, safety, and rights of the patient
Why Ethics Is Important
Having a code of ethics helps guide healthcare professionals through tricky situations. But the primary goal of ethics is to protect patients. Veering from the code of ethics can lead to a breakdown in team communication and physical consequences for a patient.
Ethics Committee
The Ethics Committee advises SeniorLIFE staff on individual member matters involving ethical dilemmas encountered by the staff during their provision of care to members and their caregivers. The committee may also serve as a consultative resource in grievance issues raised by SeniorLIFE members and their families. It advises the program on policy development related to ethical decision making.
The Ethics Committee is composed of representatives of the SeniorLIFE staff, the local medical, legal, and religious communities, as well as community service agencies.
The committee meets on an as-needed basis.
ABUSE AND NEGLECT
POLICY:
It is the policy of SeniorLIFE to ensure that all members will be free from verbal, physical, sexual, mental abuse, neglect, and exploitation.
Procedure:
1. All employees will undergo a criminal background check prior to hire.
2. During employee orientation the following will be reviewed:
a. The definitions of the different types of abuse and neglect and how to recognize signs.
b. How to identify which members are at a higher risk of being abused.
c. The policy on reporting abuse/neglect and the investigation of abuse/neglect.
d. Techniques for abuse/neglect prevention.
3. Continuing education on abuse will occur at least annually and throughout the year as needed.
4. If abuse or neglect is suspected concerns will be reported immediately to the Center Manager.
5. The MSW and designee will then be notified to intervene. The Area Agency on Aging will be notified when/if appropriate. Necessary staff will work closely to assure optimum safety of the member.
6. If necessary SL will pursue immediate alternative placement within resources of the program to assure the safety of the member.
7. Continued program participation will be contingent upon individual member need.
8. Appropriate documentation will be maintained in the medical record.
9. Any employee under investigation of abuse charges will be suspended pending investigation.
10. Any staff member found guilty of abuse by a court of law will have their name entered into the state nurse aid registry or appropriate licensing authority, if applicable. The employee will also be terminated immediately.
Warning Signs, Risk Factors, Prevention, and Help
Every year, tens of thousands of elderly Americans are abused in their own homes, in relatives’ homes, and even in facilities responsible for their care. You may suspect that an elderly person you know is being harmed physically or emotionally by a neglectful or overwhelmed caregiver or being preyed upon financially. By learning the signs and symptoms of elder abuse and how to act on behalf of an elderly person who is being abused, you’ll not only be helping someone else but strengthening your own defenses against elder abuse in the future.
What is Elder Abuse?
There’s an elderly neighbor you’ve chatted with at civic meetings and block parties for years. When you see her coming to get her mail as you walk up the street, you slow down and greet her at the mailbox. She says hello but seems wary, as if she doesn’t quite recognize you. You ask her about a nasty bruise on her forearm. Oh, just an accident, she explains; the car door closed on it. She says goodbye quickly and returns to the house. Something isn’t quite right about her. You think about the bruise, her skittish behavior. Well, she’s getting pretty old, you think; maybe her mind is getting fuzzy. But there’s something else — something isn’t right.
As elders become more physically frail, they’re less able to stand up to bullying and or fight back if attacked. They may not see or hear as well or think as clearly as they used to, leaving openings for unscrupulous people to take advantage of them. Mental or physical ailments may make them more trying companions for the people who live with them.
Tens of thousands of seniors across the United States are being abused: harmed in some substantial way often people who are directly responsible for their care
More than half a million reports of abuse against elderly Americans reach authorities every year, and millions more cases go unreported.
Where Does Elder Abuse Take Place?
Elder abuse tends to take place where the senior lives: most often in the home where abusers are apt to be adult children; other family members such as grandchildren; or spouses/partners of elders. Institutional settings especially long-term care facilities can also be sources of elder abuse.
The Different Types of Elder Abuse:
Abuse of elders takes many different forms, some involving intimidation or threats against the elderly, some involving neglect, and others involving financial chicanery. The most common are defined below.
1. Physical Abuse
Physical elder abuse is non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.
2. Emotional Abuse
In emotional or psychological senior abuse, people speak to or treat elderly persons in ways that cause emotional pain or distress.
Verbal forms of emotional elder abuse include:
▪ intimidation through yelling or threats
▪ humiliation and ridicule
▪ habitual blaming or scapegoating.
Nonverbal psychological elder abuse can take the form of:
▪ ignoring the elderly person
▪ isolating an elder from friends or activities
▪ terrorizing or menacing the elderly person
3. Sexual Abuse
Sexual elder abuse is contact with an elderly person without the elder’s consent. Such contact can involve physical sex acts, but activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.
4. Neglect or Abandonment by Caregivers
Elder neglect, failure to fulfill a caretaking obligation, constitutes more than half of all reported cases of elder abuse. It can be active (intentional) or passive (unintentional, based on factors such as ignorance or denial that an elderly charge needs as much care as he or she does).
5. Financial Exploitation
This involves unauthorized use of an elderly person’s funds or property, either by a caregiver or an outside scam artist.
An unscrupulous caregiver might:
▪ misuse an elder’s personal checks, credit cards, or accounts
▪ steal cash, income checks, or household goods
▪ forge the elder’s signature
▪ engage in identity theft
Typical rackets that target elders include:
▪ announcements of a “prize” that the elderly person has won but must pay money to claim
▪ phony charities
▪ investment fraud
6. Healthcare Fraud and Abuse
Carried out by unethical doctors, nurses, hospital personnel, and other professional care providers, examples of healthcare fraud and abuse regarding elders include:
▪ Not providing healthcare, but charging for it
▪ Overcharging or double-billing for medical care or services
▪ Getting kickbacks for referrals to other providers or for prescribing certain drugs
▪ Overmedicating or under-medicating
▪ Recommending fraudulent remedies for illnesses or other medical conditions
▪ Medicaid fraud
Signs and symptoms of elder abuse
At first, you might not recognize or take seriously signs of elder abuse. They may appear to be symptoms of dementia or signs of the elderly person’s frailty — or caregivers may explain them to you that way. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that doesn’t mean you should dismiss them on the caregiver’s say-so.
General signs of abuse:
The following are warning signs of some kind of elder abuse:
▪ Frequent arguments or tension between the caregiver and the elderly person
▪ Changes in personality or behavior in the elder
Signs and symptoms of specific types of abuse
If you suspect elderly abuse, but aren't sure, look for clusters of the following physical and behavioral signs:
|Physical Abuse: |Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two side |
| |of the body |
| |Broken bones, sprains, or dislocations |
| |Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it|
| |should) |
| |Broken eyeglasses or frames |
| |Signs of being restrained, such as rope marks on wrists |
| |Caregiver’s refusal to allow you to see the elder alone |
|Emotional Abuse: |In addition to the general signs above, indications of emotional elder abuse include: |
| |Threatening, belittling, or controlling caregiver behavior that you witness |
| |Behavior from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself |
|Sexual Abuse: |Bruises around breasts or genitals |
| |Unexplained venereal disease or genital infections |
| |Unexplained vaginal or anal bleeding |
| |Torn, stained, or bloody underclothing |
Risk factors for elder abuse:
It’s difficult to take care of a senior when he or she has many different needs, and it’s difficult to be elderly when age brings with it infirmities and dependence. Both the demands of care giving and the needs of the elder can create situations in which abuse is more likely to occur.
Risk factors among caregivers:
Among caregivers, significant risk factors for elder abuse are
▪ inability to cope with stress (lack of resilience)
▪ depression, which is common among caregivers
▪ lack of support from other potential caregivers
▪ the caregiver’s perception that taking care of the elder is burdensome and without psychological reward
▪ substance abuse
Even caregivers in institutional settings can experience stress at levels that lead to elder abuse. Nursing home staff may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to caregiving, or work under poor conditions.
The elder’s condition and history:
Several factors concerning elders themselves, while they don’t excuse abuse, influence whether they are at greater risk for abuse:
▪ The intensity of an elderly person’s illness or dementia
▪ Social isolation; i.e., the elder and caregiver are alone together almost all the time
▪ The elder’s role, at an earlier time, as an abusive parent or spouse
▪ A history of domestic violence in the home
▪ The elder’s own tendency toward verbal or physical aggression
In many cases, elder abuse, though real, is unintentional. Caregivers pushed beyond their capabilities or psychological resources may not mean to yell at, strike, or ignore the needs of the elders in their care.
Reporting elder abuse:
If you are an elder who is being abused, neglected, or exploited, tell at least one person. Tell your doctor, a friend, or a family member whom you trust. Other people care and can help you.
You can also call Eldercare Locator at 1-800-677-1116.
The person who answers the phone will refer you to a local agency that can help. The Eldercare Locator answers the phone Monday through Friday, 9 am to 8 pm, Eastern Time.
How do I report suspected elder abuse?
The 500,000 to 1,000,000 reports of elder abuse recorded by authorities every year (the vast majority of which are proven to be true) are only the tip of the iceberg; according to data from different states, for every case of elder abuse reported, another 12 or 13 are not. Accordingly there’s a great need for people to report suspected abuse. In every state, physical, sexual, and financial abuses targeting elders that violate laws against assault, rape, theft, and other offenses are punishable as crimes. With some variation among states, certain types of emotional elder abuse and elder neglect are subject to criminal prosecution, depending on the perpetrators' conduct and intent and the consequences for the victim. States differ on who is required to report suspected elder abuse (there’s no federal standard), though the categories of mandatory reporters are expanding. Typically, medical personnel, nursing home workers, peace officers, emergency personnel, public officials, social workers, counselors, and clergy are listed as mandatory reporters, and that responsibility is spreading to financial institutions and other entities that work with seniors.
While it’s important for elders to seek refuge from abuse, either by calling a local agency or telling a doctor or trusted friend, many seniors don't report the abuse they face even if they’re able. Many fear retaliation from the abuser, while others believe that if they turn in their abusers, no one else will take care of them. When the caregivers are their children, they may be ashamed that their children are behaving abusively or blame themselves: “If I’d been a better parent when they were younger, this wouldn’t be happening.” Or they just may not want children they love to get into trouble with the law.
Mandatory Reporting
Employees and administrators of nursing homes, personal care homes, domiciliary care homes, adult day care centers and home health care are mandated by Act 13 of 1997 to immediately report any suspected abuse of a recipient of care to the Area Agency on Aging. If the abuse involves serious injury, sexual abuse or suspicious death, reporters must also call police and the Pennsylvania Department of Aging at (717) 265-7887. In addition, the reporter may also call the Pennsylvania Department of Health Nursing Home Complaint Line at 1-800-254-5164.
Failure to report as required by Act 13-1997 can result in administrative or criminal penalties.
The Older Adults Protective Services Act (OAPSA), mandatory abuse reporting requirements have been amended. Effective February 9, 2003, facilities that provide services to individuals with mental retardation in residences licensed by the Pennsylvania Department of Public Welfare (DPW) or that are funded through a County Mental Retardation (MR) program shall not be required to report abuse if the recipient is under the age of 60 years. Specifically this includes:
1. Community residential rehabilitation services;
2. Community homes and family living homes for individuals with mental retardation;
3. Intermediate care facilities for individuals with mental retardation, including State and non-State operated facilities and homes; and,
4. State mental hospitals
Member Bill of Rights
SeniorLIFE is committed to providing the highest quality of care that promotes the autonomy of the individual member and instills a level of cooperation between the member, the family, and the program.
To achieve those means, a Bill of Rights has been developed in accordance with DPW licensing regulations and CMS regulatory requirements, which both focus on the members rights as an enrollee of SL.
The Member's Bill of Rights:
1. All treatment options will be fully discussed and explained in a language you understand.
2. To be fully informed in writing in a language you understand, prior to and at the time of enrollment (as well as during participation) of the services available at the Center and in the program.
3. To not be required to perform services for SL.
4. To be fully informed of rights and responsibilities as a member in SL and to exercise your rights as a member. This may include voicing grievances and recommending changes in policies and services to center staff and outside representatives of your choice. There will be no restraint, interference, coercion, discrimination or reprisal by the Center or its staff.
5. To be fully informed of the appeal process, and be provided, by SL staff, any assistance needed to file an appeal, as outlines in SL appeal process.
6. To be fully informed by the health team of your health and functional status.
7. To participate in the development and implementation of your service plan designed to promote your functional ability to the optimal level and to encourage your independence. The health team must agree upon these services.
8. To choose your health care provider from SL’s contracted network.
9. To request a qualified specialist for women’s health.
10. To access emergency services without prior approval.
11. To request reassessment by the health team.
12. To be given advance notice, in writing, of any transfer to another treatment setting.
13. To receive information on advance directives and assistance in completing forms to carry out your wishes.
14. To receive treatment and rehabilitation services.
15. To be treated with dignity and respect, and be afforded privacy, confidentiality.
16. To receive services in a culturally competent manner even if you have a limited English language skills and a diverse cultural and ethnic background.
17. To be free from harm, corporal punishment, unnecessary physical or chemical restraints, involuntary seclusion, physical or mental abuse or neglect.
18. To be free from hazardous procedures.
19. To have reasonable access to telephones.
20. To be assured of confidential treatment of all information contained in your health record, including information contained in any automated data bank. We will require your written consent or authorization for the release of information to persons not otherwise authorized under law to receive it. Your may provide written consent or authorization, which limits the degree of information and the persons to whom information may be given.
21. To review your own records and receive a copy of your medical records and to request that they be amended or corrected.
22. To refuse treatment and be informed of the consequences of such refusal.
23. To receive competent, considerate, respectful care from SL staff and contractors without regard to race, religion, color, age, sex, source of payment, national origin, sexual orientation or disability.
24. To receive comprehensive health care in a safe and clean environment and in an accessible manner.
25. To be able to examine the results of the most recent review of SL conducted by the state and federal government.
26. To end your participation in SL at any time subject to the terms of this agreement.
Violation of Rights
.
If a violation of rights is suspected, concerns will be brought to the attention of the Center Manager or designee. The Center Manager or designee will investigate the incident in a timely manner.
Family will be notified as the investigation warrants. Other persons to be notified, if indicated, include the Executive Director and/or outside agencies. Violation of member rights by volunteers and providers under contract with SL will be referred to the QAPI Coordinator.
Effective Communication Techniques
LISTEN ACTIVELY:
▪ Be attentive - concentrate on what is being said.
▪ Be impartial - don't form an opinion, just listen.
▪ Reflect back - restating what has been said helps the speaker know that you understand.
▪ Summarize - pull together the important messages so that you and the speaker recognize what was important during the conversation.
Nonverbal Message:
▪ Posture - let your body show that you are interested by sitting up and leaning toward the speaker.
▪ Equal positioning - if the speaker is standing, you stand. If the speaker is sitting, you sit as well.
▪ Facial expression - remember that feelings are reflected in facial expressions.
▪ Gestures - your body language reveals a lot about how you interpret a message, so be aware of when you send signals that might cause the speaker to believe that you are angry, in a hurry, bored, etc.
Express Thoughts and Feelings:
▪ Be open and honest - collaboration between parents and professionals begins with the understanding that you trust each other with all information.
▪ Speak clearly - don't mumble and don't talk too quietly. If you don't know the word for something, describe what you mean so that you and the speaker can have a shared understanding of your concern or question.
Communicate Without Being Adversarial:
▪ Express concerns non-judgmentally - talk about your questions or concerns without blaming other people. For example, you might be angry that your child is not receiving enough speech therapy. Rather than talk about the speech therapist not doing his/her job, discuss your idea of how often your child should receive this service.
▪ Use "I" messages. Rather than say, "You didn't explain that very well," say, "I didn't understand what you just said. Please explain it again."
Behavior Management Techniques
PEOPLE WHO HAVE ALZHEIMER’S DISEASE OFTEN POSE SEVER BEHAVIOR MANAGEMENT PROBLEMS FOR THOSE WHO PROVIDE CARE. SINCE ALZHEIMER’S DISEASE AND OTHER DEMENTIAS ATTACK THE BRAIN IN DIFFERENT PLACES AND AT DIFFERENT RATES OF SPEED, YOU WILL FIND THAT EACH PERSON’S BEHAVIOR IS DIFFERENT. BUT OVERALL, WHEN CARING FOR DEMENTIA PATIENTS, YOU WILL SEE CERTAIN TYPES OF BEHAVIOR PROBLEMS. YOU CAN LEARN TECHNIQUES TO CHANGE BEHAVIORS THAT MAY BE MAKING YOUR JOB DIFFICULT. MOST IMPORTANTLY THOUGH, THESE TECHNIQUES WILL HELP YOU OBSERVE AND MANAGE PATIENT BEHAVIORS AS THEY CHANGE OVER TIME, AND WILL ALLOW YOU TO ADAPT AND CHANGE YOUR INTERACTIONS FOR THE BEST RESULTS.
Demented patients show a variety of different behavioral problems, including (but not limited to) anger, agitation, depression, suspiciousness, paranoia, wandering, sexual inappropriateness, hallucinations, and delusions. All of these behaviors can pose serious difficulties for the person trying to provide care.
What is meant by the term “behavior?” Behavior is an action that you can see and describe. While a behavior might result from an emotion, this section will not be exclusively concerned with emotions, but will concentrate on behavior, or on what you see happening. Because you can see behavior, you can get information about it such as how often does it happen, or, who is around the patient when it happens?
Why Work with Behaviors?
Although you can’t yet change the course of the patient’s disease or how it will damage the brain, you can change behaviors. Behavior affects the quality of both of your lives. By changing an unpleasant behavior you can increase the quality of life for the patient and make caregiving easier on yourself.
Changing behavior involves the following steps:
1. Learning to observe and define problem behaviors
2. Developing a plan to change the behavior.
3. Evaluating your plan’s effectiveness in changing behaviors.
4. Changing your plan and re-evaluating to make your plan more effective.
Before starting to work with difficult behaviors, be sure that the person’s medications or medical conditions are not causing or contributing to their problems. Be alert for sudden illness, effects of new medication or change in dosage, or any other recent changes in the patient’s life or surroundings.
Defining a “Problem” Behavior:
A behavior can be considered a “problem” if for some reason it is not suitable or acceptable to your or others. This could mean that the behavior is dangerous to someone (like striking someone), or it damages something (like breaking objects), or it is unpleasant to experience (like arguing or yelling). Sometimes several behavior problems occur at once (the patient yells and strikes out.)
Observing Behavior:
Behavior always occurs in three parts. These parts we call A, B, and C.
A is a triggering event or cause, or an antecedent.
B is the behavior itself.
C is the consequence of the behavior (what happens because of the behavior.)
As you observe (see and pay attention to) a behavior, you will learn to look for these three parts and they will be your key to changing the behavior. Think about the problem and gather information:
First define the behavior (B). What is the current behavior? What is happening? What did the person do? Describe the action, for example, the patient yelled, the patient struck out, the patient paced, the patient asked the same question ten times, or the patient pinched the nurse’s aide. Also notice when, where, and how often the behavior occurs.
Next, look for prior events that may have triggered the behavior (the antecedent (A)). Did anyone or anything trigger the behavior? What was happening before the behavior started? Look for clues, like somebody demanding too much, being angry at the person, or for disturbing noise or activity around the person. Were there any changes in the environment beforehand?
Lastly, what is the consequence (C) of the behavior? What happens as a result of the behavior? What changes occurred in the environment or in the behavior of other people because of the patient’s behavior?
Observe and write down your observations about the behavior. It’s easiest to work with one behavior at a time, so target just one to watch. Behavior, even in a confused person, results from a cause. Understanding the causes can help you figure out what to do to help.
Identity Theft Detection and Prevention
Red Flags Rule Compliance Policy
IT IS THE POLICY OF SENIORLIFE (SL) TO FOLLOW ALL FEDERAL AND STATE LAWS AND REPORTING REQUIREMENTS REGARDING IDENTITY THEFT. SPECIFICALLY, THIS POLICY OUTLINES HOW SL WILL IDENTIFY, DETECT, AND RESPOND TO “RED FLAGS.” A RED FLAG AS DEFINED BY THIS POLICY INCLUDES A PATTERN, PRACTICE, OR SPECIFIC ACCOUNT OR RECORD ACTIVITY THAT INDICATES POSSIBLE IDENTITY THEFT.
1. Identify Red Flags: In the course of caring for members, SL may encounter inconsistent or suspicious documents, information, or activity that may signal identity theft. SL identifies the following as potential red flags, and this policy includes procedures describing how to detect and respond to these red flags below:
▪ A complaint or question from a member based on the member’s receipt of:
▪ A bill for another individual;
▪ A bill for a product or service that the member denies receiving;
▪ A bill from a health care provider that the member never patronized; or
▪ A notice of insurance benefits (or explanation of benefits) for health care services never received.
2. Records showing medical treatment that is inconsistent with a physical examination or with a medical history as reported by the member.
3. A complaint or question from a member about the receipt of a collection notice from a bill collector.
4. A patient or health insurer report that coverage for legitimate hospital stays is denied because insurance benefits have been depleted or a lifetime cap has been reached.
5. A complaint or question from a patient about information added to a credit report by a health care provider or health insurer.
6. A dispute of a bill by a member who claims to be the victim of any type of identity theft.
7. A member who has an insurance number but never produces and insurance cared or other physical documentation of insurance.
8. A notice or inquiry from an insurance fraud investigator for a private health insurer or a law enforcement agency, including but not limited to a Medicare or Medicaid fraud agency.
Detect Red Flags: SL staff will be alert for discrepancies in documents and member information that suggest risk of identity theft or fraud. SL will verify patient identity, address, and insurance coverage at the time of member enrollment.
1. When a member enrolls into the program, they will be asked to bring information.
2. Staff should be alert for the possibility of identity theft in the following situations:
▪ The photograph on a driver’s license, or other photo ID submitted by the member does not resemble the member.
▪ The member submits a driver’s license, insurance card, or other identifying information that appears to be altered or forged.
▪ Information on one form of identification the member submitted is inconsistent with information on another form of identification, or with information already in the medical records.
▪ An address or telephone number is discovered to be incorrect, non-existent, or fictitious.
▪ The member fails to provide identifying information or documents.
▪ The member’s signature does not match a signature in the program records.
▪ The Social Security number or other identifying information in the program records provided
by another individual, or Social Security number is invalid.
Respond to Red Flags: If an employee of SL detects fraudulent activity or if a member claims to be a victim of identity theft, SL will respond to and investigate the situation. If the fraudulent activity involves protected health information covered under HIPA security standards, SL will also apply its existing HIPAA security policies and procedures to the response.
If potentially fraudulent activity is detected by an employee of SL:
1. The employee should gather all documentation and report the incident to his or her immediate supervisor.
2. The supervisor and or the designated compliance officer/privacy official will determine whether the activity is fraudulent or authentic.
3. If the activity is determined to be fraudulent, SL will take immediate action. Actions may include:
▪ Cancellation of any transactions
▪ Notification of appropriate law enforcement
▪ Notification of affected patient
▪ Notification of others affected
▪ Assess impact to program
If a member claims to be a victim of identity theft:
1. The member should be encouraged to file a police report for identity theft if he/she has not done so.
2. The member should be encouraged to complete the ID Theft Affidavit developed by the FTC, along with supporting documentation.
3. SL will compare the member’s documentation with personal information in the program records.
4. If, following the investigation, it appears that the patient has been a victim of identity theft, SL will promptly consider what further remedial acts/notifications may be needed under the circumstances. The physician will review the affected member medical record to confirm whether documentation was made in the member’s medical record that resulted in inaccurate information in the record. If inaccuracies due to identity theft exist, a notation will be made in the record to indicate such theft.
5. A program designee will determine whether any other records and or ancillary service providers are linked to the inaccurate information. Any additional files contain information relevant to identity theft will be removed and appropriate action taken.
6. If following investigation, it does not appear that the member has been a victim of identity theft; SL will take whatever action is deemed appropriate.
RESTRAINTS
While SeniorLIFE (SL) will make every effort to minimize restraint use, both physical and chemical, it is our organization’s philosophy that there are circumstances where restraints are necessary to treat certain medical and psychosocial conditions or to provide added safety. In these instances, every effort will be made to use the least-restrictive device possible.
According to Centers for Medicare and Medicaid Services. “If the multidisciplinary team determines that a restraint is needed to ensure the member’s physical safety or the safety of others, the use must meet the following conditions: (1) be imposed for a defined, limited period of time, based upon the assessed need of the member; (2) be imposed in accordance with safe and appropriate restraining techniques; (3) be imposed only when other less restrictive measures have been found to be ineffective to protect the member or others from harm; (4) be removed or ended at the earliest possible time; (5) the condition of the restrained member must be continually assessed, monitored, and reevaluated.”
CMS states members have “...the right to be free from harm, including physical or chemical restraints...the use of restraints must be limited to those situations with adequate, appropriate clinical justification...The less restrictive and most effective method available must be utilized and it must conform to the member’s plan of care. Restraints may only be used as a last resort.
CMS does not believe that restraints of any kind should ever be used as a preferred approach to care and we at CMS expect PACE organizations to ensure that their programs are ‘restraint free’ to the greatest extent possible.”
1. A physical restraint is any manual method or physical or mechanical device, materials, or equipment attached or adjacent to the member’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body. Examples of a physical restraint include special types of vests, chairs with lap trays, lap belts, and enclosed walkers.
1. A chemical restraint is a medication used to control behavior or to restrict the member’s freedom of movement and is not a standard treatment for the member’s medical or psychiatric condition. Chemical restraint will be limited to the least restrictive and most effective method available. Examples of chemical restraints that may be used are haloperidol, clonazepam, alprazolam, and olanzapine.
2. A positioning device is any device used to align the member’s body in order to treat a specific medical condition or to meet a specific functional need that does not meet the definition of physical restraint. If a positioning device is recommended, no MD order is required. An enabling device is a device that supports any of four major functional categories: bed mobility, transfers, ambulation, and wheelchair locomotion
3. Environmental adaptations are manipulations of the environment that reduce member agitation, wandering, or other behaviors as well as fall risk that might have historically resulted in the use of physical restraints. Examples include: sound reduction, use of “soft” lighting, painting of hall handrails and doorways with sharp, contrasting colors, “fooling/blinding” cognitively-impaired members to reduce wandering, furniture height adjustment, etc.
4. Staff interventions are behaviors in which staff provide restorative nursing, meaningful activities such as assisting with non-laborious tasks and skilled therapy services to reduce the need for restraints or discontinue their use altogether for members. Note: Every staff member has the ability and the responsibility to respect members’ dignity while creating the safest possible functional environment.
5. Restraint release shall be defined as removal of a restraint from a member with assistance and offer of one or more of the following interventions as appropriate: toileting and incontinent care, range of motion, ambulation, repositioning, oral hydration, or provision of oral nutrition. Restraint removal will be monitored at the LIFE Center utilizing the Restraint Removal Record.
HIPAA: Confidentiality and Privacy
The HIPAA privacy rule guarantees patients access to their medical records, gives them more control over how their protected health information is used and disclosed, and provides recourse if their medical privacy is compromised. The rule also protects the confidentiality of medical records.
Health care providers need to understand their responsibilities and rights under the federal privacy regulation to implement new policies and procedures without interfering with access to quality care.
This guide summarizes the HIPAA privacy rule, its implication, and steps to take to ensure compliance.
The HIPAA Privacy Rule
The privacy rule creates national standards to protect individuals’ medical records and other
personal health information. The rule:
• Gives patients more control over their health information
• Sets boundaries on the use and release of health records.
• Establishes appropriate safeguards that health care providers and others must achieve to protect the privacy of health information.
• Holds violators accountable with civil and criminal penalties that can be imposed if
they violate patients’ privacy rights.
• Takes into account public responsibility to disclose some forms of data to protect
public health
Who Is Covered By the Privacy Rule?
Providers who conduct electronic transactions, health plans, and clearinghouses are covered.
If business associates receive or create protected health information to perform some function, contracts must declare that those business associates will use the information only for the purposes that they were hired to perform, will safeguard the information form misuse and will help the covered entity comply with its HIPAA obligations. They are prohibited from using information in any way that would violate HIPAA.
Protected Health Information (PHI))
• HIPAA protections extend to any identifiable information related to the "past,
present or future physical or mental health condition" of a person
• In any form or medium
• Information that contains no direct identifiers
• It would be virtually impossible to identify from the indirect one that remain
Examples of protected health information include: zip codes, telephone numbers, fax numbers, e-mail addresses, pictures, dates of service, patient history, discharge summary, phone notes, inpatient progress notes, outpatients progress notes, census and
allergies.
The Minimum Necessary Standard states that when using or disclosing protected health information or when requesting protected health information from another covered entity, the provider must make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.
Incidental disclosures are not a violation of the privacy rule.
Who is authorized to see protected health information?
Healthcare providers who are directly involved in providing treatment, payment, or involved with health operations (TPO) are authorized to see access patient information.
What is required of providers to ensure privacy of patients?
Provide information to patients about their privacy rights and how their information may be used.
• Secure patient records containing individually identifiable health information so
that they are not readily available to those who do not need them.
• Comply with the minimum necessary information requirements.
• Provider responsibilities
• Ensure that patient information is not disclosed improperly.
• Allow patients access to examine their records.
• Allow patients to suggest changes to those records.
• Educate patients on privacy policies (how their data will be used).
• Give patients the right to revoke permission to use data.
• Notify patients of anyone who has seen their records.
• Provide a formal complaint process for patients.
• Allow patients to determine where communications are sent.
• Mitigate damage from inappropriate uses or disclosure.
• Respond within reasonable time and costs to patient requests.
• Maintain a permanent copy of the record and appropriately
manage it.
Provider Rights
• Use patient information for treatment, payment, and health care operations.
• Disclose information for treatment, payment, and operations by other covered entities.
• Withhold part of the record if disclosure would result in patient harm.
• Disclose information to family members or other patient representatives, if patients
cannot speak for themselves.
Fines and Penalties for Violating HIPAA Standards
• Civil and criminal penalties for noncompliance include fines up to $250,000 and/or imprisonment up to 10 years for knowing misuse of individually identifiable health
information.
Authorization for Use or Disclosure of Protected Health Information (PHI)
Authorization is not required for use or disclosure of PHI for treatment, payment
and health care operations (TPO).
Individual authorization required from patient for:
• Marketing and fund-raising.
• Research-related treatment (unless waived by a n institutional review board).
• Psychotherapy notes.
• Employment determinations.
• State laws impact that may provide authorization for an individual.
Disclosures Not Requiring Authorization from Patient
These disclosures can occur without patient permission:
Health oversight
• Medical devices reporting for injuries, breakdown or malfunction
• To report child abuse, neglect, domestic violence
• For law enforcement investigations
• For judicial or administrative proceedings
• To avert a serious, immediate threat to public safety
Ways to Safeguard Protected Health Information (PHI)
• Reasonable efforts for implementation of administrative, technical and physical safeguards are required:
• Verbal conversations precautions: Close doors when discussing treatments and administering procedures.
• Close curtains and speak softly in semi-private rooms when discussing treatments and administering procedures.
• Avoid discussion about patients in public areas such as elevators and cafeteria lines.
• Do not leave messaged on answering machine regarding patient conditions or test results.
• Avoid paging patients using information that could reveal their health problems.
• Secure storage and transportation or patient information.
• Display precautions (e.g., computer screens displayed away from public access)
• Posted or written patient information i.e., whiteboards kept away from public access areas
• Log off computers when away from workstation.
• Telephone and facsimile precautions: When given patient information regarding condition on the phone limit responses to basic responses stable or critical.
• Verify the doctor is working on the patient’s case; send to a registered fax number on record. Send fax only when someone is there to receive it- do not leave in the fax machine for long periods of time.
• Shredding and disposal of PHI. PHI should be placed in closed receptacles, burned, or shredded- never leave in open garbage bins.
• Records are kept locked, only people with a need to see information about patients have access to them.
WORKPLACE HARASSMENT
Purpose:
To educate employees in the recognition and prevention of illegal workplace harassment and to provide an effective means of eliminating such harassment from the workplace.
DEFINITIONS
Workplace Harassment:
Any unwelcome verbal, written or physical conduct that either denigrates or shows hostility or aversion towards a person on the basis of race, sex, color, national origin, religion, sexual orientation, age, or disability, that: (1) has the purpose or effect of creating an intimidating, hostile or offensive work environment; (2) has the purpose or effect of unreasonably interfering with an employee’s work performance; or (3) affects an employee’s employment opportunities or compensation.
Retaliation:
Overt or covert acts of reprisal, interference, restraint, penalty, discrimination, intimidation, or harassment against an individual or group exercising rights under this policy.
PROHIBITED CONDUCT
Harassment:
The Company strictly forbids harassment of any employee, applicant for employment, vendor, contractor, or volunteer, on the basis of an individual’s race, sex, color, national origin, religion, sexual orientation, age, or disability. Examples of harassment that may violate the law and will violate this policy include:
• Oral or written communications that contain offensive name-calling, jokes, slurs, negative stereotyping, or threats.
• Nonverbal conduct, such as staring, leering, and giving inappropriate gifts.
• Physical conduct, such as assault or unwanted touching.
• Visual images, such as derogatory or offensive pictures, cartoons, drawings, or gestures. Such prohibited images include those in hard copy or electronic form.
Retaliation:
The Company will not tolerate any form of retaliation directed against an employee or third party who either complains about harassment or who participates in any investigation concerning harassment.
HARASSMENT COMPLAINT PROCEDURE
• Employees and third parties should report incidents of work- place harassment as soon as possible after the incident occurs.
• Employees should report workplace harassment to the Executive Director. Under no circumstances shall the individual alleging harassment be required to file a complaint with the alleged harasser.
Assurance Against Retaliation:
Employees and third parties who make complaints of work-place harassment, or provide information related to such complaints, will be protected against retaliation. If retaliation occurs, the employee(s) should report the retaliation through the harassment complaint procedure.
POLICY VIOLATIONS
Engaging In Harassment:
Any employee who engages in conduct determined to be harassment, or who encourages such conduct by others, shall be subject to disciplinary action up to and including discharge from employment.
Allowing Harassment to Continue/Failure to Respond:
Managers and/or supervisors who knowingly allow work-place harassment to continue or fail to take appropriate corrective action upon becoming aware of the harassment shall be subject to disciplinary action, up to and including discharge.
Performance Feedback Is Not Harassment:
Effective leadership requires that managers talk with their employees about their job performance. Constructive criticism and supervisory actions regarding performance deficiencies or other workplace issues when done in a professional and respectful manner are not harassment or retaliation.
TRAINING
The Company will communicate this policy to their employees at orientation and at regular intervals, including:
• Educating their employees about the types of behavior that can be considered workplace harassment, and
• Explaining procedures established for filing workplace harassment complaints.
RESPONSE
Managers and supervisors will:
• Stop any workplace harassment of which they are aware, whether or not a complaint has been made;
• Express strong disapproval of all forms of workplace harassment;
• Stop any acts that they see that may be considered workplace harassment, and take appropriate steps to intervene;
• Take immediate action to prevent retaliation towards the complaining party or any participant in an investigation; and
• Take immediate action to eliminate any hostile work environment where there has been a complaint of workplace harassment.
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Documenting Within a Guideline
Revised 2009
EMR User Guide
Psychosocial Well-Being
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