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Sample Policies: California Policy and Procedure Manual


Medication Administration

Reference: CCR Title 22, Division 3, Chapter 5, 54319, 54323, Division 5, Chapter 10, 78313, 78317

Policy:

Participants who are unable to self-administer their own medications shall be assisted by the nursing staff to ensure that medications are taken as indicated by physician when they are prescribed to be taken while participant is at the center.

Staff Responsible:

Registered Nurse

Form:

Medication Administration Record

Procedure:

  1. Medication shall only be administered to a participant if the name, dosage and frequency of administration of the drug and the name of the prescriber is recorded in that participant’s chart.
  2. Medications not self-administered shall be administered only by licensed medical or licensed nursing personnel.
  3. Medications administered by the center’s nursing staff shall be labeled in conformance with state and federal laws and regulations. PRN drug orders shall include an indication for use.
  4. Medications may not be dispensed by the center’s licensed nursing staff from a participant’s medi-set, or any other container that is not specifically labeled according to state and federal laws and regulations.
  5. Center personnel, except those lawfully authorized to do so, shall not dispense, repackage or label drugs or transfer drugs between containers.
  6. Medication shall be given only on the prescriber’s order.
  7. Participants shall be identified prior to the administration of a medication by checking the participant’s name tag as well as confirming name verbally with the participant (if able).
  8. A record of each dose is maintained in the participant’s chart. The record shall include the date and time the medication was taken, the dosage taken, and, if a PRN medication, the participant’s response. This is recorded on the “Medication Administration Record” form.
  9. Administration of medication does not include forcing a participant to take medications, hiding or camouflaging medications in other substances without the participant’s knowledge and consent, or otherwise infringing upon a participant’s right to refuse to take a medication.
  10. If a participant, who is unable to make his or her own decisions, chooses to not take his or her medication, when offered by the nursing staff, the nursing staff will document the choice in the participant’s chart and report this to the participant’s family member or representative by phone or email within fifteen minutes of refusal.

Center Environment & Space Requirements

Reference: CCR Title 22, Division 5, Chapter 10, 78505, California Medi-Cal 2020 Demonstration, SOP (D).

Policy:

Generic ADHC/CBAS is designed, equipped and maintained to provide a safe and healthy environment.

Staff Responsible:

Program Director

Procedure:

  1. Space shall comply with state and local building requirements and codes.
  2. Space shall be maintained in conformity with the regulations adopted by the State Fire Marshall.
  3. Space shall be available to accommodate both indoor and outdoor activities and for storage of equipment and supplies.
  4. There shall be a multipurpose room large enough for all participants to get together for large group activities and meals.
  5. Office space shall be available at the center for private interviews conducted by staff.
  6. A secluded area that is set aside for participants who require bed rest and privacy during medical treatments or social service interventions shall be made available.
  7. Appropriate office or other space shall be provided for administrative and admission activities, for a reception area and for a telephone, desk and file cabinets.
  8. General and specialized storage space shall be maintained to meet the needs of participants and for efficient operation of the center.

Activity Services

Reference: CCR Title 22, Division 3, Chapter 5, 54339, Division 5,  Chapter 10, 78341, California Medi-Cal 2020 Demonstration, SOP B, STC 45

 Policy:

Generic ADHC/CBAS shall provide planned and structured activities which utilize the participant’s skills to the highest extent possible, respond to the participant’s interests, capabilities, and needs and minimize any impairments in capacity to engage in those activities, resume self-care and normal activities and/or prevent further deterioration.

 Staff Responsible:

Program Director

Activity Coordinator

Procedure:

  1. Activities at Generic ADHC/CBAS shall encourage and stimulate each participant to interact with others and seek to establish, maintain or improve the participant’s sense of usefulness to self and to others, the desire to use his or her physical and mental capabilities to the fullest extent and his or her sense of self-respect.
  2. Activities shall be therapeutic and/or recreational in nature.
  3. Activities shall include, but are not limited to:
    1. Social; activities that require group interaction if the participant has indicated a desire for this activity;
    2. Daily living skills, including grooming, personal hygiene, social skills, cooking and simple homemaking tasks, and opportunities to learn about the community;
    3. Physical activities, including but not limited to games, sports and exercise, unless contraindicated;
    4. Creative endeavors;
    5. Leisure time to pursue personal interests;
    6. Educational programs;
    7. Cultural awareness opportunities and activities; and
    8. Service involvement, opportunities for increasing sense of purpose.
  4. Activities shall be encouraged through provision of space, equipment and supplies;
  5. Activities shall be designed to meet the participant’s specific needs and interests, as determined by the IPC and the participant’s choice;
  6. Activities shall be planned by the activity coordinator, or program aides allowing input from participants, care providers, or volunteers;
  7. All program activities shall be supervised by the activity staff; and
  8. Provisions shall be made for participant rest periods which are required based on the medical assessment or as desired by the participant.

Discharge Plan

Reference: CCR Title 22, Division 3, Chapter 5, 54321, Division 5, Chapter 10, 78345, California Medi-Cal 2020 Demonstration SOP H, STC 47

Policy:

Each participant shall have a discharge plan which is completed within the first six-months following admission, and updated during each subsequent six-month reassessment periods.

Staff Responsible:

Social Worker

Multidisciplinary Team

Form:

Discharge Planning Form

Procedure:

  1. Each participant shall have a plan of discharge developed by the social worker with input from the multidisciplinary team.
  2. This plan shall be reviewed and updated at the time of each reassessment.
  3. This plan shall be completed by the time of the first reassessment.
  4. The plan shall include the possible referrals that may need to be made if the participant is discharged. These referrals may be for services that may be needed if the participant’s health improves to such a level that ADHC/CBAS services are no longer needed as well as referrals that may be needed if participant’s health declines to such an extent that his or her needs may no longer be served by the ADHC/CBAS center.
  5. The multidisciplinary team shall sign the participant’s discharge plan, this includes the participant and or participant representative.



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