DON Training Resources

Regulatory References & Clinical Guidelines

Nursing Documentation Guide for Thrive EMR
Comprehensive guide addressing documentation expectations for daily care, admissions, discharges, transfers, falls, and incidents in Thrive EMR.

📋 What's Included:

  • • Daily documentation requirements (Flow Chart, Shift Assessments, Comprehensive Notes)
  • • Change in condition documentation and notification protocols
  • • PRN pain medication documentation standards
  • • Wound assessment and documentation guidelines
  • • Admission documentation checklist and requirements
  • • Discharge documentation and location maintenance procedures
  • • Falls and incidents documentation protocols
  • • Hospital transfer documentation and required paperwork
  • • AI Copilot usage instructions for note generation
  • • Best practices and common errors to avoid
Comprehensive Resource Library
This resource library provides direct links to all regulatory requirements, interpretive guidelines, and clinical best practices referenced throughout the DON training program.

Federal Regulations

CMS Conditions of Participation (42 CFR Part 482) and interpretive guidelines

Louisiana Requirements

State-specific hospital licensing standards and regulations

Clinical Guidelines

Evidence-based best practices for patient safety and quality care

42 CFR Part 482 - Conditions of Participation for Hospitals
Complete federal regulations for hospital conditions of participation, including general hospital requirements applicable to IRFs.
regulationCMS Regulations
42 CFR 412.604 - Conditions for Payment Under IRF PPS
IRF-specific conditions of participation including admission requirements, rehabilitation physician supervision, interdisciplinary team requirements, and compliance with hospital CoPs.
regulationCMS Regulations
42 CFR 482.23 - Nursing Services CoP
Federal requirements for nursing services organization, staffing, and delivery in hospitals and IRFs.
regulationCMS Regulations
42 CFR 482.13 - Patient Rights CoP
Federal requirements for patient rights including informed consent, grievances, and restraint/seclusion.
regulationCMS Regulations
42 CFR 482.21 - Quality Assessment and Performance Improvement (QAPI)
Federal requirements for hospital QAPI programs, data collection, and performance improvement projects.
regulationCMS Regulations
42 CFR 482.42 - Infection Prevention and Control
Federal requirements for infection prevention and control programs, including antibiotic stewardship.
regulationCMS Regulations
State Operations Manual (SOM) Appendix A - Survey Protocol for Hospitals
CMS interpretive guidelines for hospital conditions of participation, including detailed survey procedures and compliance expectations.
guidelineCMS Interpretive Guidelines
State Operations Manual (SOM) Appendix PP - Guidance for IRFs
CMS guidance specific to Inpatient Rehabilitation Facilities including interpretive guidelines for 42 CFR 412.604 and hospital CoPs.
guidelineCMS Interpretive Guidelines
CMS Restraint and Seclusion Interpretive Guidelines
Detailed interpretive guidelines for patient rights related to restraint and seclusion (42 CFR 482.13(e)).
guidelineCMS Interpretive Guidelines
CMS Nursing Services Interpretive Guidelines
Interpretive guidelines for nursing services CoP including staffing effectiveness, competency, and supervision requirements.
guidelineCMS Interpretive Guidelines
IRF Quality Reporting Program (IRF QRP)
Overview of IRF quality measures, reporting requirements, and payment impact.
referenceIRF Quality Reporting
IRF QRP Quality Measures Specifications
Technical specifications for IRF quality measures including functional outcomes and patient safety indicators.
referenceIRF Quality Reporting
Section GG Functional Assessment Training
CMS training materials for IRF Section GG functional assessment including scoring guidelines, web-based courses, and video tutorials.
toolIRF Quality Reporting
Louisiana Department of Health - Health Standards Section
Official LDH website for health facility licensing, regulations, and compliance resources.
referenceLouisiana Regulations
Louisiana Hospital Licensing Standards (LAC 48:I.Chapter 77)
Louisiana Administrative Code requirements for hospital licensure including IRF-specific standards.
regulationLouisiana Regulations
Minimum Standards for Hospitals in Louisiana
State-specific minimum standards for hospital operations, staffing, and patient care in Louisiana.
regulationLouisiana Regulations
Louisiana Infection Prevention and Control Requirements
State requirements for infection prevention and control programs in healthcare facilities.
regulationLouisiana Regulations
Louisiana Nurse Staffing Requirements
State regulations for nursing staffing ratios, qualifications, and supervision in hospitals.
regulationLouisiana Regulations
IRF-PAI Manual - Section GG Chapter
Direct link to Section GG: Functional Abilities and Goals chapter in the IRF-PAI Training Manual with item-by-item coding instructions.
referenceIRF Quality Reporting
IRF Prospective Payment System (IRF PPS)
Overview of Medicare payment methodology for IRFs including CMG classification and payment rates.
referenceMedicare Payment
IRF 60% Rule Compliance
CMS guidance on the 60% Rule including qualifying conditions and compliance calculation methodology.
guidelineMedicare Payment
IRF Patient Assessment Instrument (IRF-PAI) Manual
Complete manual for IRF-PAI completion including item definitions, coding guidelines, and submission requirements.
manualIRF Documentation
AHRQ Fall Prevention Toolkit
Evidence-based fall prevention strategies and tools for hospitals from the Agency for Healthcare Research and Quality.
toolClinical Best Practices
NPIAP Pressure Injury Prevention Guidelines
National Pressure Injury Advisory Panel clinical practice guidelines for pressure injury prevention and treatment.
guidelineClinical Best Practices
CDC Healthcare-Associated Infection Prevention Guidelines
CDC guidelines for preventing CAUTI, CLABSI, SSI, and other healthcare-associated infections.
guidelineClinical Best Practices
OIG Compliance Program Guidance for Hospitals
Office of Inspector General guidance for hospital compliance programs including fraud prevention and reporting.
guidelineCompliance
Anti-Kickback Statute Overview
OIG guidance on the Anti-Kickback Statute and safe harbors for healthcare providers.
referenceCompliance
HIPAA Privacy Rule
HHS guidance on HIPAA Privacy Rule requirements for protected health information.
regulationCompliance
HIPAA Security Rule
HHS guidance on HIPAA Security Rule requirements for electronic protected health information.
regulationCompliance
CMS Emergency Preparedness Rule
Federal requirements for healthcare facility emergency preparedness including planning, training, and testing.
regulationEmergency Preparedness
Medicare Medical Necessity Documentation Guidelines
CMS guidance on documenting medical necessity for IRF admission and continued stay.
guidelineIRF Documentation
Quick Reference: Key Regulations
Most frequently referenced regulations for DON role

42 CFR 482.23 - Nursing Services

Primary CoP for nursing organization, staffing, and medication administration

42 CFR 482.60 - IRF Requirements

IRF-specific requirements for admission, supervision, and therapy

CMS State Operations Manual

Interpretive guidelines for hospital CoPs including survey procedures

LA Hospital Licensing

Louisiana Department of Health hospital licensing and certification