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Corporate Policies and Procedures

April 04 , 2018

From the office of Jon Popowich, Chief Quality & Privacy Officer

New Corporate Continuing Care Policies and Procedures

  • Dysphagia (Swallowing Disorder) and Eating Concerns
  • Enteral Nutrition
  • Nutrition and Hydration
  • Oral Health
  • Palliative and End of Life Care
  • Standardized Assessment, Care Planning and Care Conferences

Revised Corporate Policies/Procedures

  • Move-Out (Continuing Care)
  • Bladder Scanning Using Non-Ionizing Radiation

PLEASE NOTE: You can view the policies/procedures (with the changes highlighted) on the Medical Staff Portal under "New/Updated Corporate Policies".

VII-C-80, Dysphagia (Swallowing Disorder) and Eating Concerns - Continuing Care

  • Health care providers shall notify the resident's care manager/designate of any symptoms of dysphagia or eating difficulties.
  • Residents who have symptoms of dysphagia or eating concerns shall be referred for assessment to the appropriate health care professional (speech language pathologist [SLP], registered dietitian [RD], and/or occupational therapst [OT]}.

VII-C-100, Enteral Nutrition - Continuing Care

  • This policy provides best practice guidelines to reduce the risk of adverse events/complications and to improve safety for the resident receiving enteral nutrition.
  • When administering enteral nutrition, health care professionals shall also adhere to citeria identified in the A.S.P,E,N Enteral Nutrition Handbook and identified Infection Control standards.

VII-C-105. Nutrition and Hydration - Continuing Care

  • Ensures that residents have their nutritional needs assessed and receive appropriate referral for dietetic consultation.
  • Nutrition and hydriation needs will be assessed as part of the Move-in assessments and diet orders including therapeutic diets and enteral nutrition schedules will be ordered on move-in.
  • Hydration will be encourage and aupported by all health care providers in accordance with the resident fluid order.

VII-C-110, Oral Health - Continung Care

  • Oral hygeine shall be offered at minimum twice a day and documented in the resident's care plan.
  • Residents have choice in the type and frequency of oral hygeine they desire and will be supported to perform self-care.
  • Oral cavity assessments (mucosa, teeth, gums, tongue and lips) shall be performed by a health care professional to monitor the resident for oral hygiene and oral health.
  • When the assessment indicates the need consultation, health professional or AHS Case Manager shall be responsible for initiating discussion with resident and/or family regarding referral to dental health care professionals, as appropriate.

VII-C-10, Standardized Assessment, Care Planning and Care Conferences (previously titled "Care Planning") - Continung Care

  • Care plans will be created based on the resident's goals, preferences, health status (including mental and physicial health), assessment of capabilities and needs, and will focus on prevention of disease and injury.
  • Assessments will be done by the interdisciplinary team, be based on the individualized resident need; and be completed on Move-in, and when there is a significant change in health status.
  • Care conferences will be held regularly (in accordance with provincial standards) to facilitate communication and care planning among the interdisciplinary team and the resident/family.

VII-C_65, Move-Out - Continuing Care

    • This policy has been revised to meet Accommodation Standard 23.3 and it has been edited to provide the option of immediate termination of the Move In Agreement if the resident's behavior is dangerous or threatening to self orĀ others in the Home.
  • The Move in Agreement form has also been updated.

NOTE: These new and revised corporate continuing care policies and procedures supersede and replace any previous site or corporate policies on this topic.

INFO: If you have any questions specific to this policy and procedure, please contact Jane Graff, Policy Lead Continuing Care. P: 780.418.5037, Email

VII=C=115, Palliative and End of Life Care - Continuing Care

  • This policy provides direction to health care providers to guide them in the provision of palliative and end of life care services in alignment with the Continuing Care Health Services Standards.
  • Continuing Care staff will ensure appropriate Palliative and End-of-Life Care services are provided and/or made available to all persons with a life limiting illness, and their family(ies).

NOTE: This new corporate continuing care document replaces any previous site policies/procedures.

INFO: If you have any questions specific to this policy and procedure, please contact Lisa Weisgerber, Clinical Nurse Education, Palliative Institute. P: 780.735.9635, Email

VII-B-425. Bladder Scanning Using Non-Ionizing Radiation - applicable to all Covenant Health Facilities

  • Bladder scanner using non-ionizing radiation may only be performed by authorized health care professionals who have the competency to perform this restricted activity.
  • Registered psychiatric nurses are not authorized under the Health Professions Act to perform this restrictec activity.
  • LPNs who are competent in knowledge, skill and judgement, may perform bladder scanning under the supervision of a physician (refer to policy for definition of "supervision').

NOTE: This revised corporate policy replaces any previous versions.

INFO: If you have any questions specific to this policy and procedure, please contact Professional Practice at 780.735.2508.

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