**§52.120 Quality of care.**

Each participant must receive, and the program management must provide,
the necessary care and services to attain or maintain the highest
practicable physical, mental, and psychosocial well-being, in accordance
with the comprehensive assessment and plan of care.

\(a\) *Reporting of sentinel events*.

\(1\) Definition. A *sentinel event* is an adverse event that results in
the loss of life or limb or permanent loss of function.

\(2\) Examples of sentinel events are as follows:

> \(i\) Any participant death, paralysis, coma or other major permanent
> loss of function associated with a medication error; or
>
> \(ii\) Any suicide or attempted suicide of a participant, including
> suicides following elopement (unauthorized departure) from the
> program; or
>
> \(iii\) Any elopement of a participant from the program resulting in a
> death or a major permanent loss of function; or
>
> \(iv\) Any procedure or clinical intervention, including restraints,
> that result in death or a major permanent loss of function; or
>
> \(v\) Assault, homicide or other crime resulting in a participant's
> death or major permanent loss of function; or
>
> \(vi\) A participant's fall that results in death or major permanent
> loss of function as a direct result of the injuries sustained in the
> fall; or
>
> \(vii\) A serious injury requiring hospitalization.

\(3\) The program management must report sentinel events to the director
of the VA medical center of jurisdiction within 24 hours of
identification. The director of the VA medical center of jurisdiction
must report sentinel events to the VA Network Director (10N1-22),
Assistant Deputy Under Secretary for Health (10N), and Chief Consultant,
Geriatrics and Extended Care Strategic Healthcare Group (114), within 24
hours of identification and/or notification by the State home.

\(4\) The program management must establish a mechanism to review and
analyze a sentinel event resulting in a written report no later than 10
working days following the event. The purpose of the review and analysis
of a sentinel event in an adult day health care program is to prevent
future injuries to residents, visitors, and personnel.

\(b\) *Activities of daily living*. Based on the comprehensive
assessment of a resident, the program management must ensure that:

\(1\) A participant's abilities in activities of daily living do not
diminish unless circumstances of the individual's clinical condition
demonstrate that diminution was unavoidable. This includes the
participant's ability to:

\(i\) Bathe, dress, and groom;

\(ii\) Transfer and ambulate;

\(iii\) Toilet; and

\(iv\) Eat.

\(2\) A participant is given the appropriate treatment and services to
maintain or improve his or her abilities specified in paragraph (b)(1)
of this section.

\(3\) A participant who is unable to carry out activities of daily
living receives the necessary services to maintain good nutrition,
hydration, grooming, personal and oral hygiene, mobility, and bladder
and bowel elimination.

\(c\) *Vision and hearing*. To ensure that participants receive proper
treatment and assistive devices to maintain vision and hearing
abilities, the program management must, if necessary, assist the
participant and family:

\(1\) In making appointments; and

\(2\) Arranging for transportation to and from the office of a
practitioner specializing in the treatment of vision or hearing
impairment or the office of a professional specializing in the provision
of vision or hearing assistive devices.

\(d\) *Pressure ulcers*. Based on the comprehensive assessment of a
participant, the program management must ensure that:

\(1\) A participant who enters the program without pressure ulcers does
not develop pressure ulcers unless the individual's clinical condition
demonstrates that they were unavoidable; and

\(2\) A participant having pressure ulcers receives necessary treatment
and services to promote healing, prevent infection and prevent new
ulcers from developing.

\(e\) *Urinary and fecal incontinence*. Based on the participant's
comprehensive assessment, the program management must ensure that:

\(1\) A participant who enters the program without an indwelling
catheter is not catheterized unless the participant's clinical condition
demonstrates that catheterization was necessary;

\(2\) A participant who is incontinent of urine receives appropriate
treatment and services to prevent urinary tract infections and to
restore as much normal bladder function as possible; and

\(3\) A participant who has persistent fecal incontinence receives
appropriate treatment and services to treat reversible causes and to
restore as much normal bowel function as possible.

\(f\) *Range of motion*. Based on the comprehensive assessment of a
participant, the program management must ensure that:

\(1\) A participant who enters the program without a limited range of
motion does not experience reduction in range of motion unless the
participant's clinical condition demonstrates that a reduction in range
of motion is unavoidable; and

\(2\) A participant with a limited range of motion receives appropriate
treatment and services to increase range of motion and/or to prevent
further decrease in range of motion.

\(g\) *Mental and psychosocial functioning*. Based on the comprehensive
assessment of a participant, the program management must ensure that a
participant who displays mental or psychosocial adjustment difficulty,
receives appropriate treatment and services to correct the assessed
problem.

\(h\) *Accidents*. The program management must ensure that:

\(1\) The participant environment remains as free of accident hazards as
is possible; and

\(2\) Each participant receives adequate supervision and assistance
devices to prevent accidents.

\(i\) *Nutrition*. Based on a participant's comprehensive assessment,
the program management must ensure, by working with the family, that a
participant:

\(1\) Maintains acceptable parameters of nutritional status, such as
body weight and protein levels, unless the participant's clinical
condition demonstrates that this is not possible; and

\(2\) Receives a therapeutic diet when a nutritional deficiency is
identified.

\(j\) *Hydration*. The program management must provide each participant
with sufficient fluid intake during the day to maintain proper hydration
and health.

\(k\) *Unnecessary drugs*.

\(1\) *General*. Each participant's drug regimen must be free from
unnecessary drugs. An unnecessary drug is any drug when used:

> \(i\) In excessive dose (including duplicate drug therapy); or
>
> \(ii\) For excessive duration; or
>
> \(iii\) Without adequate monitoring; or
>
> \(iv\) Without adequate indications for its use; or
>
> \(v\) In the presence of adverse consequences which indicate the dose
> should be reduced or discontinued; or
>
> \(vi\) Any combinations of the reasons in paragraphs (k)(1)(i) through
> (v) of this section.

\(2\) *Antipsychotic drugs*. Based on a comprehensive assessment of a
participant, the program management must ensure that:

\(i\) Participants who have not used antipsychotic drugs are not given
these drugs unless antipsychotic drug therapy is necessary to treat a
specific condition as diagnosed by the primary physician and documented
in the clinical record; and

\(ii\) Participants who use antipsychotic drugs receive gradual dose
reductions, and behavioral interventions, unless clinically
contraindicated, in an effort to discontinue these drugs.

\(l\) *Medication errors*. The program management must ensure that:

\(1\) Medication errors are identified and reviewed on a timely basis;
and

\(2\) Strategies for preventing medication errors and adverse reactions
are implemented. (Authority: 38 U.S.C. 101, 501, 1741-1743)

(The Office of Management and Budget has approved the information
collection requirements in this paragraph under control number
2900-0160.)

*Next Section is §52.130*