Nursing
This staff member must be present for 24/7 supervision of patient care
Registered Nurse
Monitors and evaluates the quality and appropriateness of social services furnished.
Director of Social Services
Inform each patient, or representative of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible.
Notice of Rights
Must be retained in their original or legally reproduced form for a period of at least 5 years
Medical Records
Labs must meet this regulatory standard for clinical accuracy
CLIA
This nursing leader must hold a master's degree in nursing/related field or have ongoing supervision
Chief Nursing Officer (CNO)
Performing and documenting nutritional assessments and evaluating patient tolerance to therapeutic diets when appropriate
Dietician
Hospitals must provide/obtain this if a patient lacks capacity to consent
Advanced Directive
Must include a recapitulation of the patient's visit
Discharge Summary
Monitoring patterns of hospital-acquired infections
Infection Survelliance
Must be reviewed and revised as necessary to meet the patient care needs
Staffing
Must meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry
Clinical/medical Director
Dictates the circumstances under which the patient was admitted and/or is being treated - i.e., voluntary, involuntary, committed by court
Legal Status
Must be completed by a trained RN or provider within one hour of a seclusion or restraint
Face-to-Face Assessment
A committee that evaluates necessity and length of stays
Utilization Review Committee
Reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs.
Evaluate an individual's cognitive, emotional, and behavioral functioning in a structured and objective manner. Part of the medical staff.
Psychologist
Must be obtained prior to treatment, Includes explanation of the risk, benefits and alternatives to treatment
Informed Consent
Must be completed and documented no more than 30 days before or 24 hours after admission or registration
History and Physical
As part of its quality assessment and performance improvement program, the hospital must conduct this activity
Performance Improvement Projects
Hospitals are expected to regularly reassess staff to provide periodic training needed to keep staff skills up to date
Staff Competency
Focus upon the development and maintenance of adaptive skills that will improve the patient’s functioning. Can be an Occupational Therapist.
Activity Therapy
This process captures patient dissatisfaction and responses.
Complaint and Grievance Process
Completed by a provider; reflects the current clinical status of the patient
Progress Note
This group must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement)
Governing Body