Section 340.1300  Facility Policies

a)         The facility shall have written policies and procedures governing all services provided by the facility, which shall be formulated with the involvement of the administrator.  These policies shall be in compliance with the Act and this Part.  These written policies shall be followed in operating the facility and shall be reviewed at least annually, as evidenced by a dated signature.

b)         There shall be an advisory physician, or a medical advisory committee composed of physicians, who shall be responsible for advising the administrator on the overall medical management of the residents and the staff of the facility. If the facility employs a house physician, the house physician may be the advisory physician.

c)         All the information contained in the policies shall be available to the public, staff, residents, and for review by Department personnel.

d)         These written policies shall include, at a minimum, the following provisions:

1)         Admission, transfer, and discharge of residents including the types of services offered by the facility that would cause residents to be admitted, transferred or discharged, and transfers within the facility from one room to another.

2)         Resident care services including physician services, emergency services, personal care and nursing services, restorative services, activity services, pharmaceutical services, dietary services, social services, clinical records, dental services, and diagnostic service (including laboratory and x-ray).

3)         Prohibition against blood transfusions, unless the facility is hospital based and appropriate services are available in case of an adverse reaction to the transfusions.

e)         The facility shall have a written agreement with one or more hospitals, which indicates the hospital or hospitals will provide diagnostic, emergency and routine acute care hospital services. (This requirement may be waived when the facility can document to the satisfaction of the Department that by reason of remote location or refusal of local hospitals to enter an agreement, it is unable to effect such an agreement.)

f)          The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in a facility. These medical emergencies include, but are not limited to, such things as:

1)         Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest).

2)         Cardiac emergencies (for example, ischemic pain, cardiac failure, or cardiac arrest).

3)         Traumatic injuries (for example, fractures, burns, or lacerations).

4)         Toxicologic emergencies (for example, untoward drug reactions or overdoses).

5)         Other medical emergencies (for example, convulsions or shock).

g)         The facility shall maintain in a suitable location the equipment to be used during the emergencies detailed in subsection (f) of this Section. This equipment shall include, at a minimum, a portable oxygen kit, including a face mask or cannula, an airway, and a bag valve mask manual ventilating device.