Phase 3: Operational Compliance & Resident Care Excellence
Once licensed, this phase focuses on establishing and maintaining robust operational systems, policies, and procedures to ensure high-quality resident care and ongoing compliance with Texas regulations.
Key Objective 1: Comprehensive Policies & Procedures Manual
Develop, implement, and maintain a detailed Policies and Procedures (P&P) manual covering all aspects of facility operation, as mandated by TAC §553.41(a).
- Cover areas such as resident admission/discharge, assessments, service planning, medication management, resident rights, staffing, training, emergency procedures, infection control, record keeping, etc.
- Ensure policies are specific to your facility type (A or B) and services offered (e.g., Alzheimer's care).
- Regularly review and update the manual to reflect changes in regulations or facility practices.
- Staff must be trained on all relevant policies and procedures.
Utilize our Policy Templates Toolkit as a starting point.
Key Objective 2: Resident Admission, Review, and Dismissal (ARD) Process
Implement a compliant and thorough ARD process (TAC §553.41(c), §553.43, §553.44).
- Pre-admission Screening: Ensure the facility can meet the prospective resident's needs.
- Admission Agreement: A comprehensive contract outlining services, fees, rights, and responsibilities.
- Initial Assessment: Conduct a thorough assessment of the resident's needs upon admission as per TAC §553.45.
- Individualized Service Plan (ISP): Develop a person-centered ISP based on the assessment, outlining care and services to be provided.
- Regular Reassessments and ISP Updates: Periodically review and update assessments and ISPs.
- Compliant Discharge/Transfer Procedures: Follow regulatory requirements for resident discharge or transfer.
Our Resident ARD Process Toolkit provides detailed guidance and forms.
Key Objective 3: Medication Management Compliance
Establish and follow strict medication management protocols according to TAC §553, Subchapter C, Division 4 (Medication Administration for Type B) or Division 3 (Assistance with Medication for Type A).
- Secure storage of medications.
- Accurate medication administration records (MARs).
- Proper disposal of unused/expired medications.
- Staff training and competency in medication assistance/administration.
- Protocols for medication errors and adverse drug reactions.
Key Objective 4: Staffing, Training, & Competency
Maintain adequate, qualified, and well-trained staff (TAC §553.61, §553.65, §553.66).
- Ensure sufficient staff are on duty 24/7 to meet resident needs.
- Provide initial orientation and ongoing training on topics like resident rights, abuse/neglect prevention, infection control, emergency procedures, and specific resident conditions (e.g., dementia care if applicable).
- Verify staff competencies for assigned tasks.
- Maintain complete personnel records, including training documentation and background checks.
Explore our Staff Training Curricula Toolkit.
Key Objective 5: Documentation, Record-Keeping, & Reporting
Maintain accurate and complete records as required by various TAC sections (e.g., TAC §553.41(l), §553.28).
- Resident records (assessments, ISPs, MARs, progress notes).
- Staff records (applications, background checks, training, competency evals).
- Operational records (menus, emergency drills, incident reports, maintenance logs).
- Ensure records are legible, current, and securely stored.
- Understand and comply with mandatory reporting requirements (e.g., incidents, abuse/neglect allegations to HHSC and other agencies).