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COVID-19 Webinars

Throughout this pandemic we've held multiple webinars to assist you, the provider, with the basics of a pandemic program, adjusting to the "new normal", reporting requirements, documentation control, and other important topics. You can watch a replay of these webinars by clicking on the links below. 

COVID-19 October 20 Q&A Webinar replay

COVID-19 June 25 Q&A Webinar replay

COVID-19 May 5 Q&A Webinar replay

COVID-19 March 26 Q&A Webinar replay 

COVID-19: Not If, But When - Define the Elements of a Pandemic Plan

Administration Resources

  • Admission Process/Opening Up COVID-19 v3 (Revised 7/16/20)
    Policy and Procedure to follow for New Admissions during the COVID-19 Pandemic.
  • Admission Process/Opening Up COVID-19 - Spanish v3 (Revised 7/16/20)
    Policy and Procedure to follow for New Admissions during the COVID-19 Pandemic. (Spanish version)
  • Adult Cardiac Arrest Algorithm for Suspected or Confirmed COVID-19 Patients
    An algorithm from the American Heart Association for treating cardiac arrest patients with suspected or confirmed COVID-19
  • AHCA/NCAL Statement on Phase 3 COVID-19 Provider Relief Funding Payments (Released 12/16/20)
    AHCA/NCAL CEO Mark Parkinson speaks on Provider Relief Funding.
  • APIC COVID-19 Infection Prevention Survey Results (Released 12/21/20)
    APIC conducted an online survey of its 11,922 U.S.-based infection preventionist members October 22–November 5, 2020. Results shown are based on responses from 1,083 infection preventionists located throughout the United States.
  • Care Efficiency Bundling Tasks v1 (Released 5/26/20)
    Consolidate services to limit the number of times we enter a resident's room.
  • Care Efficiency Bundling Tasks - Spanish v1 (Released 5/26/20)
    Consolidate services to limit the number of times we enter a resident's room. (Spanish version)
  • CDC Considerations for Retirement Communities v1 (Released 11/18/20)
    Guidance on the CDC offings for ways in which administrators of retirement communities and independent living facilities can help protect residents, workers, visitors, and communities and slow the spread of COVID-19.
  • CMS Counseling Checklist v1 (Released 8/18/20)
    People who have COVID-19 or were exposed to COVID-19 need to separate themselves from others until there is little risk of spreading (transmitting) the infection to others. CMS has provided a checklist to assist providers when communicating with patients.
  • CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (Dated 12/1/20)
    CMS is empowered to take proactive steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Social Security Act (the Act) and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are in effect, with a retroactive effective date of March 1, 2020 through the end of the emergency declaration.

Other Helpful COVID Information

Documentation Resources

  • COVID-19 Care Plan Toolkit - Spanish v2 (Updated 7/15/20)
    The Nursing Home Reform Act of 1987 says that nursing homes "must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident in accordance with a written plan of care". This toolkit was developed to assist you in updating your current care plans to address the COVID-19 pandemic. Facilities across the country are being cited for not having updated, comprehensive care plans to address the risks associated with the virus, isolation, decline in ADLs, etc. This toolkit will give you some examples and is not intended to be the end-all but rather the beginning! (Spanish version)
  • COVID-19 Care Plan Toolkit v2 (Updated 7/15/20)
    The Nursing Home Reform Act of 1987 says that nursing homes "must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident in accordance with a written plan of care". This toolkit was developed to assist you in updating your current care plans to address the COVID-19 pandemic. Facilities across the country are being cited for not having updated, comprehensive care plans to address the risks associated with the virus, isolation, decline in ADLs, etc. This toolkit will give you some examples and is not intended to be the end-all but rather the beginning!
  • Documentation Guidance During COVID-19 v1 (Released 5/6/20)
    Thorough documentation is critical to the facility’s success to support proper assessment and care and services were provided to the resident. Here is some guidance to guide you.
  • Documentation Guidance During COVID-19 - Spanish v1 (Released 5/6/20)
    Thorough documentation is critical to the facility’s success to support proper assessment and care and services were provided to the resident. Here is some guidance to guide you. (Spanish version)
  • Documentation Keys: COVID-19 Guidance v1 (Released 6/21/20)
    Items to record and/or copy and put in COVID-19 Response File. This will enable you to best demonstrate the actions you have taken (and continue to take) in response to the pandemic.
  • Documentation Keys: COVID-19 Guidance - Spanish v1 (Released 6/24/20)
    Items to record and/or copy and put in COVID-19 Response File. This will enable you to best demonstrate the actions you have taken (and continue to take) in response to the pandemic. (Spanish version)

Angie's Blog

End of Life Resources

  • Advanced Directives Policy & Procedure v2 (Revised 7/16/20)
    Each resident has the right to formulate an advance directive, including the right to request, refuse and/or discontinue treatment. This sample policy can be modified to your facility.
  • Advanced Directives Policy & Procedure - Spanish v2 (Revised 7/16/20)
    Each resident has the right to formulate an advance directive, including the right to request, refuse and/or discontinue treatment. This sample policy can be modified to your facility. (Spanish version)
  • Cardiopulmonary Resuscitation (CPR) During COVID-19 v1 (Updated 4/22/20)
    Additional precautions are required when performing CPR during this pandemic, use this sample policy & procedure and customize for your facility.
  • Cardiopulmonary Resuscitation (CPR) During COVID-19 - Spanish v1 (Updated 4/22/20)
    Additional precautions are required when performing CPR during this pandemic, use this sample policy & procedure and customize for your facility. (Spanish version)
  • Handling the Body of Persons who Have Died from Suspected/Confirmed COVID-19 v1 (Released 4/15/20)
    To date, there is no evidence of persons having been infected from exposure to the body of persons who died from COVID-19. The dignity of the deceased, their cultural and religious traditions/beliefs, and their family will be respected and protected on an individual basis, balancing family wishes and the risk of exposure. The safety and well-being of caregivers who provide post-mortem care is a high priority.
  • Handling the Body of Persons who Have Died from Suspected/Confirmed COVID-19 - Spanish v1 (Released 4/17/20)
    To date, there is no evidence of persons having been infected from exposure to the body of persons who died from COVID-19. The dignity of the deceased, their cultural and religious traditions/beliefs, and their family will be respected and protected on an individual basis, balancing family wishes, and the risk of exposure. The safety and well-being of caregivers who provide post-mortem care is a high priority. (Spanish version)
  • Post Mortem Care Policy During COVID-19 v1 (Released 4/15/20)
    The dignity of a resident who has died including their cultural and religious traditions/beliefs and their family will be respected and protected while providing postmortem care to the extent possible during a pandemic. (Spanish version)
  • Post Mortem Care Policy During COVID-19 - Spanish v1 (Released 4/15/20)
    The dignity of a resident who has died including their cultural and religious traditions/beliefs and their family will be respected and protected while providing postmortem care to the extent possible during a pandemic. (Spanish version)
  • Things to Remember: End of Life v1 (Released 4/20/20)
    No one wants to think about end of life, but you should be prepared. Here are some things to remember at this time.
  • Things to Remember: End of Life - Spanish v1 (Released 4/23/20)
    No one wants to think about end of life, but you should be prepared. Here are some things to remember at this time. (Spanish version)

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Infection Control Resources

  • 3 Key Steps to Take While Waiting for Your COVID-19 Test Result from the CDC v1 (Released 8/14/20)
    To help stop the spread of COVID-19, take these 3 key steps NOW while waiting for your test results
  • 3 Key Steps to Take While Waiting for Your COVID-19 Test Result from the CDC - Spanish v1 (Released 8/14/20)
    To help stop the spread of COVID-19, take these 3 key steps NOW while waiting for your test results (Spanish version)
  • Admitting a Resident with COVID-19 v1 (Released 4/10/20)
    If you are accepting the admission of a resident with suspected or positive COVID, consider the tips outlined here.
  • Admitting a Resident with COVID-19 - Spanish v1 (Released 4/15/20)
    If you are accepting the admission of a resident with suspected or positive COVID, consider the tips outlined here. (Spanish version)
  • Admitting Residents from a Hospital Setting v1 (Released 4/16/20)
    Things to consider when admitting residents from a hospital setting during the COVID-19 Pandemic.
  • Admitting Residents from a Hospital Setting - Spanish v1 (Released 4/16/20)
    Things to consider when admitting residents from a hospital setting during the COVID-19 Pandemic. (Spanish version)
  • Aerosol-Generating Procedures During COVID-19 v2 (Revised 7/16/20)
    The COVID-19 virus is transmitted by respiratory droplets, so aerosol-generating procedures can be associated with a high risk of transmission. This is a policy you can use for residents with chronic conditions requiring aerosol-generating procedures
  • Aerosol-Generating Procedures During COVID-19- Spanish v2 (Revised 7/16/20)
    The COVID-19 virus is transmitted by respiratory droplets, so aerosol-generating procedures can be associated with a high risk of transmission. This is a policy you can use for residents with chronic conditions requiring aerosol-generating procedures (Spanish version)
  • Airborne Precautions Sign v1
    Sign displaying CDC-recommended airborne precautions everyone must take.
  • Airborne Precautions Sign Spanish v1
    Sign displaying CDC-recommended airborne precautions everyone must take (Spanish version).

PPE Resources

  • Capacity Strategies N95 CDC Update v1 (Released 12/16/20)
    Once personal protective equipment IPPE) supplies and availability return to normal, healthcare facilities should promptly resume conventional practices. Decisions to implement contingency and crisis strategies are based upon these assumptions.
  • CDC Surgical Masks & N95 Respirator - Understand the Difference
    Infographic outlining the differences between the two
  • Community Use of Cloth Masks Information v1 (Released 1/8/21)
    The CDC recommends community use of masks, specifically non-valved, multi-layer, cloth masks to prevent transmission of SARS-CoV-2.
  • Competency Checklist Donning PPE (Released 6/1/20)
    Steps to take when putting on PPE
  • Competency Checklist - Removing PPE #1 v1 (Released 7/6/20)
    Steps to take when removing PPE Sample #1
  • Competency Checklist - Removing PPE #1 - Spanish v1 (Released 7/6/20)
    Steps to take when removing PPE Sample #1 (Spanish version)
  • Competency Checklist - Removing PPE #2 v1 (Released 7/6/20)
    Steps to take when removing PPE Sample #2
  • Competency Checklist - Removing PPE #2 - Spanish v1 (Released 7/6/20)
    Steps to take when removing PPE Sample #2 (Spanish version)
  • COVID-19 PPE for Healthcare Personnel v2 (Updated 6/15/2020)
    This is a visual graphic from the CDC showing preferred PPE and acceptable alternative PPE that can be posted in your facility.
  • Daily PPE Tracking Log - COVID Unit v1 (Released 5/6/20)
    Tracking log you can use as a template for your facility to track the PPE provided to employees in the COVID-19 Care Area on a daily basis.

Regulatory Resources

  • Focused Infection Control Toolkit v1 (Released 6/23/20)
    On Friday, March 13, 2020, the President declared a national emergency which triggered the Secretary’s ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act, CMS is prioritizing surveys, including infection control surveys for nursing homes. This toolkit includes the survey preparation checklist, entrance conference guide and several policies related to containing the spread of COVID-19 to assist you in preparing for a focused survey.
  • Focused Infection Control Toolkit - Spanish v1 (Released 6/23/20)
    On Friday, March 13, 2020, the President declared a national emergency which triggered the Secretary’s ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act, CMS is prioritizing surveys, including infection control surveys for nursing homes. This toolkit includes the survey preparation checklist, entrance conference guide and several policies related to containing the spread of COVID-19 to assist you in preparing for a focused survey. (Spanish version)
  • Liability Sign On Letter v1 (Posted 6/15/20)
    Letter requesting that Congress act to provide reasonable liability protections during this health crisis by expanding the protections in section 3215 of the CARES Act to all health care professionals and front-line facilities.
  • Notification Toolkit v2
    CMS has new guidance requiring nursing homes to report COVID-19 related data to the CDC/NHSN database weekly which is in addition to any state and local reporting currently being done. This requirement is effective May 17, 2020, with public reporting of facility numbers of COVID cases, both resident and staff. Effective May 8, 2020, additional reporting requires that with any new case of COVID-19 or when 3 or more staff or residents are symptomatic within a 72-hour period, residents, representatives, and families are notified by 5:00 pm the following day. This is in addition to the requirement of notifying representatives/families of a resident’s change of condition. The notification process must be done in a way that protects the privacy of our staff and residents (HIPAA). This toolkit provides several sample documents for your consideration. There are two “initial” letter samples that may be used to notify residents, families, and staff of the new CMS requirements. The third sample letter is considered an “update letter” and may be used to post the required data on your website, send via email or USPS, depending on your individual situation.
  • Notification Toolkit - Spanish v2
    CMS has new guidance requiring nursing homes to report COVID-19 related data to the CDC/NHSN database weekly which is in addition to any state and local reporting currently being done. This requirement is effective May 17, 2020, with public reporting of facility numbers of COVID cases, both resident and staff. Effective May 8, 2020, additional reporting requires that with any new case of COVID-19 or when 3 or more staff or residents are symptomatic within a 72-hour period, residents, representatives, and families are notified by 5:00 pm the following day. This is in addition to the requirement of notifying representatives/families of a resident’s change of condition. The notification process must be done in a way that protects the privacy of our staff and residents (HIPAA). This toolkit provides several sample documents for your consideration. There are two “initial” letter samples that may be used to notify residents, families, and staff of the new CMS requirements. The third sample letter is considered an “update letter” and may be used to post the required data on your website, send via email or USPS, depending on your individual situation. (Spanish version)

Reopening Resources

  • Compassionate Care Visits Policy & Procedure v1 (Released 8/18/20)
    A policy & procedure that follows CDC and CMS guidelines regarding Compassionate Care Visitation.
  • Compassionate Care Visits Policy & Procedure - Spanish v1 (Released 8/24/20)
    A policy & procedure that follows CDC and CMS guidelines regarding Compassionate Care Visitation. (Spanish version)
  • Early Progressive Mobility Program v1 (Released 8/24/20)
    Sarcopenia, a loss of muscle mass, can begin after only 2 days of bed rest, decreasing muscle strength by 1%-3% per day. One week of bed rest can result in a 20% decrease in muscle strength and an additional 20% muscle strength loss for each week on bed rest! The purpose of this program is to introduce a mobility program designed to maintain baseline mobility and functional capacity, decrease the incidence of delirium, and decrease the length of stay in hospitalized patients.
  • Early Progressive Mobility Program - Spanish v1 (Released 8/27/20)
    Sarcopenia, a loss of muscle mass, can begin after only 2 days of bed rest, decreasing muscle strength by 1%-3% per day. One week of bed rest can result in a 20% decrease in muscle strength and an additional 20% muscle strength loss for each week on bed rest! The purpose of this program is to introduce a mobility program designed to maintain baseline mobility and functional capacity, decrease the incidence of delirium, and decrease the length of stay in hospitalized patients. (Spanish version)
  • Outdoor Visitation Reopening Policy & Procedure v1 (Released 8/18/20)
    A policy & procedure that follows CDC and CMS guidelines and best practices for outdoor visitation.
  • Outdoor Visitation Reopening Policy & Procedure - Spanish v1 (Released 8/24/20)
    A policy & procedure that follows CDC and CMS guidelines and best practices for outdoor visitation. (Spanish version)
  • Reopening Group Activities v1 (Released 8/18/20)
    A policy & procedure that follows CDC and CMS guidelines regarding reopening and group activities.
  • Reopening Group Activities - Spanish v1 (Released 8/24/20)
    A policy & procedure that follows CDC and CMS guidelines regarding reopening and group activities. (Spanish version)

Social Services/Activities Resources

  • Beauty and Care of Residents v1 (Released 4/9/20)
    Here are some helpful suggestions to implement at your facility to assist in pampering your residents during this challenging time
  • Beauty and Care of Residents - Spanish v1 (Released 4/14/20)
    Here are some helpful suggestions to implement at your facility to assist in pampering your residents during this challenging time (Spanish version)
  • Dementia Activities Toolkit v1 (Released 8/4/20)
    Just like those of us without dementia, residents living with dementia have different personality types. We've put together a toolkit of activities based on personality type. You can try these to keep your residents active and engaged.
  • Dementia Activities Toolkit - Spanish v1 (Released 8/4/20)
    Just like those of us without dementia, residents living with dementia have different personality types. We've put together a toolkit of activities based on personality type. You can try these to keep your residents active and engaged. (Spanish version)
  • Hair Salons and Services Guidelines during COVID-19 v1 (Released 10/28/20)
    When it is determined by state and local health departments that beautician and barber services may resume, this center will provide these services following the guidelines from the CDC and state and local health departments.
  • Heart-to-Heart Engagement Recipe Book v1
    We've reached out to our members and collected the best ideas for the engagement of our residents during isolation. We've put them all together in a "recipe" book that you can follow!
  • Individualized Dementia Care Activities v1 (Released 4/9/20)
    Activity ideas for residents with dementia based on their personality type.
  • Individualized Dementia Care Activities - Spanish v1 (Released 4/14/20)
    Activity ideas for residents with dementia based on their personality type. (Spanish version)

Staffing Resources

  • Asymptomatic Employees Algorithm v1 (Updated 4/14/20)
    Process for dealing with asymptomatic staff who may be exposed to coronavirus
  • Asymptomatic Employees Algorithm - Spanish v1 (Updated 4/14/20)
    Process for dealing with asymptomatic staff who may be exposed to coronavirus. (Spanish version)
  • COVID-19 Staffing Considerations v1 (Released 5/20/20)
    Here are some staff considerations during the COVID-19 pandemic:
  • Employee Safety and Rights: HIPAA/ADA v1 - (Released 4/21/20)
    Guidance to help employers seek information about an employee’s health that would typically be limited by the ADA, in order to help prevent the spread of COVID-19.
  • Employee Safety and Rights: HIPAA/ADA - Spanish v1 (Released 4/21/20)
    Guidance to help employers seek information about an employee’s health that would typically be limited by the ADA, in order to help prevent the spread of COVID-19. (Spanish version)
  • Employee Sign In Sign Out Log & Policy v7 (Revised 7/23/20)
    Policy for screening anyone who enters the facility, plus an employee sign-in log.
  • Employee Sign In Sign Out Log & Policy - Spanish v7 (Revised 7/23/20)
    Policy for screening anyone who enters the facility, plus an employee sign-in log. (Spanish version)
  • Household Plan of Action Infographic v1 (Released 5/20/20)
    It's important to follow safety guidelines, not just in our work environment but at home too. Here are some guidelines we can share with our family members.
  • Isolation After Community Exposure v1 (Updated 4/22/20)
    When to start and end home isolation for healthcare providers and public health officials managing persons with coronavirus disease 2019 (COVID-19)
  • Isolation After Community Exposure - Spanish v1 (Updated 4/22/20)
    When to start and end home isolation for healthcare providers and public health officials managing persons with coronavirus disease 2019 (COVID-19) (Spanish version)

Vaccines and Treatments Resources

  • AHCA/NCAL COVID-19 Facility Vaccine Clinic Checklist v1 (Created 12/14/20)
    AHCA/NCAL has created the checklist for use when administering vaccines.
  • AMDA Letter To Families COVID Vaccine (Released 12/23/20)
    The Society for Post-Acute and Long-Term Care Medicine have provided a letter that facilities can use to inform families about the safety of the COVID-19 vaccines.
  • AMDA - Q&A about the COVID-19 Vaccine for PALTC Patients Family Member and Staff Dec 1, 2020
    The Society for Post-Acute and Long-Term Care Medicine has released a Q&A about the COVID-19 vaccine.
  • Bamlanivimab EUA for COVID-19 v1 (Released 1/5/21)
    The investigational neutralizing IgG1 monoclonal antibody bamlanivimab (LY-CoV555; Lilly) has been granted an FDA Emergency Use Authorization (EUA) for treatment of recently diagnosed mild to moderate COVID-19 in patients who are ≥12 years old, weigh at least 40 kg, and are at high risk for progressing to severe disease and/or hospitalization. Eligibility for patients considered high risk.
  • CDC Advisory Committee on Immunization Practices v1 (Released 12/9/20)
    The Advisory Committee on Immunization Practices (ACIP) is a group of medical and public health experts that develops recommendations on how to use vaccines to control diseases in the United States. This document answers questions about the ACIP such as how it makes decisions about vaccine recommendations, what the ACIP considers in the vaccine recommendation process, and where you can find their vaccine recommendations.
  • CDC Facts about COVID-19 vaccines (Posted 1/8/21)
    A flyer from the CDC with facts about the COVID-19 vaccine
  • CDC Management of Anaphylaxis at COVID-19 Vaccination Site (Posted 12/28/20)
    Anaphylaxis is an acute and potentially life-threatening serious allergic reaction. Severe allergic reaction (e.g., anaphylaxis) to a previous dose of any COVID-19 vaccine or any component of the COVID-19 vaccine listed in the prescribing information is a contraindication to vaccination. A history of a severe allergic reaction to any other vaccine or injectable therapy is a precaution to vaccination.
  • CDC Pfizer COVID-19 Vaccine Standing Orders for Administering Vaccine (12/17/20)
    To reduce morbidity and mortality from coronavirus disease 2019 (COVID-19) by vaccinating persons who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP)
  • CDC Pre-Vaccination Screening Form (Posted 12/28/20)
    The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine on that particular day. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked.
  • CDC Product Information Guide for COVID-19 Vaccines v1 (Released 12/4/20)
    This guide provides specifications for COVID-19 vaccine and associated products. This is NOT a catalog from which you can order products. It provides key product information including product package dimensions and weight, minimum order quantities, product presentation, distribution method, storage information, and additional information. This guide will be updated as more products become available.

Visitors Resources

  • Connecting While Social Distancing v1 (Released 4/1/20)
    With the spread of the coronavirus, facilities must also devote time to ensure that their residents do not succumb to the negative effects of social isolation. With this in mind, staff may consider adopting the following practices to encourage communication with residents’ family and friends.
  • Connecting While Social Distancing - Spanish v1 (Released 4/6/20)
    With the spread of the coronavirus, facilities must also devote time to ensure that their residents do not succumb to the negative effects of social isolation. With this in mind, staff may consider adopting the following practices to encourage communication with residents’ family and friends. (Spanish version)
  • Core Principles of Indoor Visitation v1 (Released 11/16/20)
    Infographics/Signage with reminders of the core principles of Indoor Visitation
  • Core Principles of Indoor Visitation - Spanish v1 (Released 11/23/20)
    Infographics/Signage with reminders of the core principles of Indoor Visitation (Spanish version)
  • MDHHS Residential Care Visitation Order
    A safe plan for visitation, and continues necessary protections for residents and staff in facilities across the state fo Michigan
  • Visitor Informed Consent & Assumption of Risk v2 (Revised 7/14/20)
    Policy and acknowledgment form to inform visitors of the potential exposure and accept that they knowingly assume the risk of COVID-19 exposure
  • Visitor Informed Consent & Assumption of Risk - Spanish v2 (Revised 7/15/20)
    Policy and acknowledgment form to inform visitors of the potential exposure and accept that they knowingly assume the risk of COVID-19 exposure. (Spanish version)
  • Visitor Notice for Door v2 (Updated 6/15/20)
    Notification to post of your facility's door notifying visitors of isolation practices.
  • Visitor Notice for Door - Spanish v2 (Updated 6/23/20)
    Notification to post of your facility's door notifying visitors of isolation practices. (Spanish version)
  • Visitor Recommendations v1 (Released 3/17/20)
    CMS is recommending only those needed to provide care and keep the building operating should be admitted to a facility at this time. All others and anyone with fever or respiratory symptoms should be excluded.

Notice

These works are licensed under the Creative Commons Attribution-No Derivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nd/4.0/

These documents are not intended to replace the informed judgment of individual physicians, nurses or other clinicians nor are they intended as  statements of prevailing community standards or minimum standards of practice. They are suggested methods and techniques for achieving optimal health care, not minimum standards below which residents necessarily would be placed at risk.