LAO
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08/24/2023

You Asked... We Answered

You Asked: 

Is a policy required for every type of care practice performed in a nursing home, such as tracheostomy cleaning, catheter care, IV care, etc.?

We Answered: 

A facility may have a resident care policy that refers staff to a clinical practice manual for specific care areas and some care policies may refer to the manufacturer guidelines. The Requirements of Participation state that a facility, in collaboration with the medical director, must develop and implement resident care policies that are consistent with current professional standards of practice. If a facility has a resident care policy that directs staff to refer to a clinical practice guideline manual, then the facility needs to ensure that the resource is up-to-date, widely accepted, or supported by recent clinical literature. Facilities should ensure staff are aware of the location of the resource during the orientation process. Staff competency on resident care practices should be monitored and evaluated for the awareness and use of the clinical practice manual. The facility should also ensure the resource is reviewed on a routine basis to ensure it is the most current version available.

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