Monthly Administrator and Director of Nurses Meetings

Monthly Administrator and Director of Nurses Meetings

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Goal

To ensure regular, structured communication between the Administrator and the Director of Nurses, addressing key operational and clinical issues, in compliance with public health code and CMS requirements.

Policy

The Administrator and Director of Nurses must meet formally on a monthly basis to discuss critical operational, clinical, and staffing issues to ensure the highest quality of care and compliance with regulatory standards.

Procedure

1. Meeting Schedule:

   • Meetings are scheduled monthly and minutes should be documented and placed in a binder for reference.

2. Agenda Items:

   • Department Reports:

     • Review weekly pressure sore reports and submit to corporate.
     • Review infection control data, including infection types and rates.
     • Review monthly clinical statistics report, ensuring it is computerized and emailed to corporate.

   • Recruitment Reports:

     • Review open slots/hours and new hires.
     • Assess and address pool hours.

   • Payroll:

     • Review weekly nursing payroll variance report and file with Administrator.
     • Discuss overage hours and manage within budget constraints.

   • Staffing Issues:

     • Discuss staff on leave of absence (LOA) and those out on light duty due to workman’s compensation.
     • Review employee accidents and incidents (A&I) and address resigned or terminated staff.

   • Accident & Incident Review:

     • Analyze trends and patterns from A&I reports.
     • Discuss falls, bruises, tears, lacerations, abrasions, medication errors, adverse reactions, assaultive actions, and elopements.
     • Implement measures to prevent A&I incidents and review existing prevention strategies.

   • Nursing Budget:

     • Review and file the nursing department budget with the Administrator.

   • Monthly Pharmacy Report Review:

     • Discuss the monthly pharmacy report and file it with the Director of Nursing Services (DNS).

   • Staff Development Issues:

     • Identify needs for in-service training and staff development.

   • Communication Sheets/Complaints:

     • Review and address communication sheets, complaints, and letters.

   • Physician/Vendor PPS Service Review:

     • Evaluate physician, vendor, and provider services.

3. Documentation:

   • Ensure meeting minutes are documented, signed by both the Director of Nurses and the Administrator, and stored in a designated binder.

Monthly Administrator & Director of Nurses Meeting

Date Held: _____________________________
(Review Month Previous)

Issues Reviewed:

• Department Reports:

  • Pressure sore report – completed weekly & submitted to corporate.
  • Infection Control – review infection types and rate.
  • Clinical Statistics Report – completed monthly, computerized, and emailed to corporate.

• Recruitment Reports (Completed Weekly, Filed with DNS):

  • Open slots/hours.
  • New hires.
  • Pool hours.

• Nursing Payroll Variance Report (Completed Weekly, Filed with Administrator):

  • Overage hours.

• Staffing Issues (Review Time Scheduled, Employee A&I Filed with Administrator Assistant):

  • Staff on LOA.
  • Staff out and/or light duty due to workman’s compensation.
  • Employee A&I review.
  • Resigned and/or terminated staff.

• Accident/Incident Review (Review A&I Log, Filed with DNS):

  • Trends & patterns reviewed for all A&I reports.
  • Falls.
  • Bruises, tears, lacerations, abrasions.
  • Medication errors, adverse reactions.
  • Assaultive actions.
  • Elopements.
  • Measures to prevent A&I incidents; review measures in place.

• Nursing Department Budget Review (Filed with Administrator).

• Monthly Pharmacy Report Review (Filed with DNS).

• Staff Development Issues/Need for In-servicing.

• Communication Sheets, Complaints, Letters, etc., Reviewed and Addressed.

• Physician, Vendor, Provider Services Reviewed.

• Other: ________________________________________________________________________

Signatures:

Director of Nurses Administrator

NSA: Revised [Current Date]

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]