Using Federal Regulations to Support Culture Change in ICFs/MR (DD5) 9:30 AM – 11:30 AM October 10, 2007 Joyce L. Halling, QMRP, BA, LPN, LNHA Ann E. Lee, QMRP, MSW, SMQT Get on TRAC , Inc. Sandy, Utah. The surveyors wrote us out for that last year What about infection control?
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Culture Change in ICFs/MR (DD5)
9:30 AM – 11:30 AM
October 10, 2007
Joyce L. Halling, QMRP, BA, LPN, LNHA
Ann E. Lee, QMRP, MSW, SMQT
Get on TRAC, Inc.
What about infection control?
But the “W” tags say we have to do it this way
I can’t get it all done now, how do you expect me to do one more thing?
But we’ve always done it that way
We can’t make the clients do that, the rules say so
The client won’t be safe if we do that
The client’s family said “Nuh-Nuh”, “No way”, “Not in my life time”
The client has a right to refuse treatment/care
The doctor didn’t order thatHave you ever heard . . . ?
Do they confine you?
Do you use them?
Requirement must be met in the absolute sense in order to be certified (room size, HVAC)
Requirement must be complied with but how it is achieved is facility determined (IPP, IDT comprehensive assessment)
Requirement reflects the processes experienced by the client and may be negative or positive (active treatment)
If surveyors have found or have reason to believe that a Condition level deficiency exists in any of the four fundamental survey CoPs, an extended survey reviews all standards under the fundamental CoPs will be initiated
150 Bed facility, sample size 10%, 15 clients
Do you feel like the sign on the
psychiatric hospital that says:
“Please do not disturb
Get on TRAC, Inc.
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Ann E. = email@example.com