Pathway Health Services, Inc

Director of Nursing Manual For Health Care Facilities

Section 1. The Leader of the Nursing Department

The Leader of the Nursing Department Morning Meeting Morning IDT Stand How Not To Get Burned Out Overview of Registered Nurse Functions in Long Term Care DON Checklist- Know Your Facility Six Steps to Operational Excellence Administration Criteria for Development of a Cohesive Team Communication Strategies that Work Meeting Strategies that work Holding an Effective Meeting Time Management Qualities of the Effective DON Ten Ways to Bring the Best Out in People

Section 2. Staying on Top of Resident Acuity and Condition

Procedures for Making Rounds Daily Rounds Tool Assessment Guide for UTI’s Assessment for Change in Neuro Status Assessment for Changes in Respiratory Status Change of Condition Reporting Form Documentation Basics Documentation-Assessment Schedule Follow-Up Charting Log Using SBAR Communications with MD Nursing Report Shift to Shift Report Resident Status Change Notification Form

Section 3. Resident Safety, Investigation, and Reporting

Record Destruction Policy Resident Right to Confidential Communications Minimum Necessary Uses and Disclosures Workforce identified to apply to minimum necessary uses and disclosures Use of Computer for Documentation Preadmission Date Collection Preadmission Dementia Investigation of Injury of Unknown Origin

Allegations of Rape or Sexual Assault Check List Safe Medical Device Reporting Guidelines Health Information Summary of State and Federal Regulations Program Statement CMS Definitions Components of Abuse Program Accident Incident Process and Reporting Policy The Investigation and the Investigative Report Incident Report Guide Incident- Accident Investigative File Check List The Interview and Investigative Process With a Resident Incident Investigation Witness Interview Form Witness Statement Check Off List Landscape Incident Investigation Witness Interview Form Occurrence Investigation Review Log Resident to Resident Altercation Policy and Procedure Monitoring of Staff Burn Out Caregiver Pledge F323 Accidents and Supervision at a Glance

Section 4. Customer Relations and Marketing

Marketing Tips for Customer Relations Customer Satisfaction Survey Blank Family Survey Impressions Program Resident and Family Satisfaction and Quality

Section 5. Recruitment, Retention, and Staffing

Keys to Successful Staffing Nursing Staffing Policies Booklet Staff to Resident Ration Goals Staffing Template- Daily Hours by Shift Template for Staff Posting Per CMS

Section 6. Control Panel: Quality Improvement, Infection Control, and Ergonomics Infection Control Program Surveillance Guidelines for Nursing Home Ergonomics OSHA Basics OSHA References for Long Term Care

Section 6. Continued: Control Panel: Quality Improvement, Infection Control, and Ergonomics Workplace Safety Survey Flagged Area Quality Improvement Analysis Policy and Procedure QI Analysis Form Quality Indication Reference Guide Mid-month Operations Report Comprehensive Chart Review Key Indicator Report

Section 7. The Human Resource Basics, Leadership and Culture Change

Equal Employment Opportunities and Antidiscrimination Sexual and Other Unlawful Harassment Substance Abuse Policy Whistleblower Procedure Six Rules of People Management Behavior Based Interviewing Employee Exit Interview Employee Attendance Record Holding Employees Accountable Corrective Action Notice Understanding your team- Leadership and Temperament CMS Artifacts of Culture Change Tool Learning Circles Envisioning the possibilities- Group Exercise Leadership Temperament Activities HR File Checklist

Section 8. The Role of the Medical Director

The Role of the Medical Director Policy Statements Physician Guidelines CMS Regulations Communication with MD/NP Using SBAR

Section 9. Pharmacy Services

Expectations of the Pharmacy Consultant Inappropriate Medications Medication Pass Guidelines Controlled Substances Anticoagulant Flow Sheet

Section 9. Continued: Pharmacy Services

Coumadin Flow Sheet F329 Unnecessary Drugs Fact Sheet Liquid Narcotic Medication Audit Medication Incident Policy and Procedure Med Room Inspection Narcotic Count Psychoactive Medication Audit Psychoactive Medication Reference Guide Psychotherapeutic Drug Assessment Psychotropic Medication Informed Consent Form Use of Psychotherapeutic Medications Quick Guide to Dosage Calculations

Section 10. Special Medical Insurance: Medicare / Medicaid

Basics of Medicare Medicare Criteria Medicare Checklist Checklist for Determining Medicare Coverage Documentation Medical Necessity for Therapy Difference Between Medicare and Medicaid Denial-Appeal-Demand Log Policy and Procedure Denial-Appeal-Demand Log

Section 11. Education Employee Development Lesson Plans Creating an In-service Program Nurse aide checklist Licensed nurse skills checklist Communication with MD using SBAR

Section 12. Quality Management

Quality Management Policy with Root Cause Analysis Regulation Overview Quality Improvement Focus Area Plan QA Worksheet Cares Checklist Incident Review Worksheet LSC Checklist

Section 12. Continued: Quality Management

Life Safety Code Survey Checklist Med Room Inspection Medication Administration Audit Comprehensive Chart Review Worksheet for Testing Change Aim Worksheet PDSA Worksheet Using the Three Questions CMS QIS QAA Audit Tool

Section 13. Survey Management / Preparation

Success Tips that Lead to a Goof Proof Survey How to Survive a Survey Survey Book Procedure CMS QIS Survey Process Facility Information Survey Book Sections F323 Environmental Audit for Safety CMS 672 CMS 802 CMS 802 Instructions CMS SOM Family Review CMS SOM Resident Review CMS QIS Survey Resident Interview CMS QIS Survey Family Interview QIS Survey Info How To Write Correction Orders Regulatory Action Plan- Blank DON Worksheet, POC Grid QIS Survey Facility Entrance Form Staff Emergency Preparedness General Observation CLIA Waiver Checklist Website information for QIS Survey

Section 14. The Nursing Budget

MDS Submission and Penalty Timeframes How to Write a Nursing Budget Case Mix Audit Policy and Procedure Case Mix Audit Tool MDS Completion Audit

Section 15. Resources for the Director of Nursing Office

DON Office Website Addresses Culture Transformation Resources