216-RICR-40-10-1
216-RICR-40-10-1. Licensing of Nursing Facilities (version Periodic Refile, 01/02/2002 to 08/04/2002)
RULES AND REGULATIONS
FOR LICENSING OF
NURSING FACILITIES
(R23-17-NF)
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DEPARTMENT OF HEALTH
February 1977
As Amended:
December 1978
July 1992 (E)
November 1979
December 1992
March 1980
September 1993 (E)
December 1980
January 1994
February 1984 (E)
January 1994 (E)
May 1984 (E)
May 1994
February 1985
May 1994 (E)
January 1987
September 1994
May 1987
February 1996
September 1987
May 1998
October 1988
September 1998 (E)
July 1989
January 1999 (E)
July 1989 (E)
March 1999
March 1990
May 1999 (E)
August 1990
July 1999 (E)
July 1991
September 1999 (E)
March 1992
September 1999
January 2000
January 2002 (re-filing in
accordance with the provisions of
section 42-35-4.1 of the Rhode
Island General Laws, as amended)
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INTRODUCTION
These Rules and Regulations for Licensing of Nursing Facilities (R23-17-NF) are
promulgated pursuant to the authority conferred under Section 23-17-10 of the General Laws of Rhode
Island, as amended, and are established for the purpose of adopting minimum requirements for the licensure
of nursing facilities in this state.
Pursuant to the provisions of section 42-35-3(c) of the General Laws of Rhode Island, as
amended, consideration was given to the following: (1) alternative approaches to the regulations; (2)
duplication or overlap with other state regulations; and (3) significant economic impact placed on facilities
through these regulations. Based on available information, no alternative approach, duplication or overlap
was identified. The health and safety of the public overrides and economic impact. These rules and
regulations are adopted in the best interest of the public health, safety and welfare.
These rules and regulations shall supersede all previous Rules and Regulations For the
Licensing of Nursing Facilities (R23-17-NF) promulgated by the Rhode Island Department of Health and
filed with the Secretary of State.
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TABLE OF CONTENTS
Page
PART I:
LICENSING PROCEDURES & DEFINITIONS
1
1.0
Definitions
7.0
Change of Ownership, Operation and/or Location
2.0
Certificate of Need Requirements
8.0
Inspections
3.0
General Requirements
9.0
Denial, Suspension, Revocation of License
4.0
Application for License
or Curtailment of Activities and Sanctions
5.0
Issuance and Renewal of License
6.0
Capacity and Classifications
PART II: ORGANIZATION & MANAGEMENT
12
10.0
Governing Body or Other Legal Authority
15.0
Medical Records
10.6
Medical Director
16.0
Transfer Agreements, Contracts, or Agreements
11.0
Administrator
17.0
Rights of Residents
12.0
Personnel
17.21
Uniform Reporting System
13.0
Handling of Resident Fund
14.0
Reporting of Resident Abuse or Neglect, Accidents and Death
PART III: RESIDENT CARE SERVICES
26
18.0
Resident Care Policies
27.0
Dental Services
19.0
Infection Control
28.0
Laboratory and Radiologic Services
20.0
Physician Services
29.0
Social Services
21.0
Nursing Service Management
30.0
Specialized Rehabilitative Services
22.0
Nursing Facilities Staff
31.0
Resident Activities
23.0
Selected Nursing Care Procedures
32.0
Equipment
24.0
Special Care Units
25.0
Dietetic Services
26.0
Pharmaceutical Services
PART IV:
ENVIRONMENTAL & MAINTENANCE SERVICES
42
33.0
Housekeeping
35.0
Disaster Preparedness
34.0
Laundry Service
PART V:PHYSICAL PLANT
45
36.0
New Construction, Addition or
42.0
Resident Rooms and Toilet Facilities
Modification
43.0
Special Care Unit
37.0
General Provisions -Physical Environment
44.0
Dining and Resident Activities Rooms
38.0
Fire and Safety (Existing Facilities)
45.0
Plumbing
39.0
Emergency Power
46.0
Waste Disposal
40.0
Facility Requirements for the Physically 47.0
Water Supply
Handicapped
48.0
Waste Water Disposal Systems
41.0
Nursing Unit
49.0
Maintenance
50.0
Other Provisions
PART VI:
VARIANCE & APPEAL PROCEDURE
51
51.0
Confidentiality
52.0
Variance Procedure
53.0
Deficiencies and Plans of Corrections
PART VII:
EXCEPTION & SEVERABILITY
53
54.0
Exception
55.0
Rules Governing Practices and Procedures
56.0
Severability
REFERENCES 54
APPENDIX I 57
1
PART I
LICENSING PROCEDURES & DEFINITIONS
Section 1.0 Definitions
Wherever used in these rules and regulations the following terms shall be construed as follows:
1.1
"Abuse" means any assault as defined in Chapter 11-5, including, but not limited to hitting,
kicking, pinching, slapping or the pulling of hair, provided however, unless such is required as
an element of offense, it shall not be necessary to prove that the patient or resident was injured
thereby, or any assault as defined in Chapter 11-37, or any offense under Chapter 11-10 of the
General Laws; or
o
any conduct which harms or is likely to physically harm the resident except where the conduct is
a part of the care and treatment, and in furtherance of the health and safety of the resident; or
o
intentionally engaging in a pattern of harassing conduct which causes or is likely to cause
emotional or psychological harm to the resident, including but not limited to ridiculing or
demeaning a patient or resident, making derogatory remarks to a patient or resident or cursing
directed towards a patient or resident, or threatening to inflict physical or emotional harm on a
patient.
1.2
"Alzheimer's Special Care Unit" means any nursing facility that locks, secures, segregates or
provides a special program or special unit for residents with a diagnosis of probable Alzheimer's
or a related disorder, to prevent or limit access by a resident outside the designated or separated
area; ad that advertises or markets the facility as providing specialized Alzheimer/dementia care
services.
1.3
"The capacity of a facility" refers to the maximum potential number of beds which may be
accommodated within a facility according to the dimensional limitations of section 42.0 herein.
1.4
"Change in operator" means a transfer by the governing body or operator of a nursing facility
to any other person (excluding delegations of authority to the medical or administrative staff of
the facility) of the governing body's authority to:
a)
hire or fire the chief executive officer of the nursing facility;
b)
maintain and control the books and records of the nursing facility;
c)
dispose of assets and incur liabilities on behalf of the nursing facility; or
d)
adopt and enforce policies regarding operation of the nursing facility.
(This definition is not applicable to circumstances wherein the governing body of a
nursing facility retains the immediate authority and jurisdiction over the activities
enumerated in subsections (a) through (d) herein.)
1.5
"Change in owner" means:
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(1)
in the case of a nursing facility which is a partnership, the removal, addition or substitution
of a partner which results in a new partner acquiring a controlling interest in such partnership;
(2)
in the case of a nursing facility which is an unincorporated solo proprietorship, the transfer
of the title and property to another person;
(3)
in the case of a nursing facility which is a corporation;
a)
a sale, lease, exchange or other disposition of all, or substantially all of the property
and assets of the corporation; or
b)
a merger of the corporation into another corporation; or
c)
the consolidation of two or more corporations, resulting in the creation of a new
corporation; or
d)
in the case of a nursing facility which is a business corporation, any transfer of
corporate stock which results in a new person acquiring a controlling interest in such
corporation; or
e)
in the case of a nursing facility which is a non-business corporation, any change in
membership which results in a new person acquiring a controlling vote in such
corporation.
1.6
"Drug administration" means an act in which a single dose of a prescribed drug or biological is
given to a resident by an authorized person in accordance with the regulations herein.
1.7
“Equity” means non-debt funds contributed towards the capital costs related to a change in owner or
change in operator of a nursing facility which funds are free and clear of any repayment or liens
against the assets of the proposed owner and/or licensee and that result in a like reduction in the
portion of the capital cost that is required to be financed or mortgaged.
1.8
“Health care provider” means any person licensed by this state to provide or otherwise lawfully
providing health care services, including, but not limited to, a physician, hospital, intermediate care
facility or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist,
psychiatric social worker, pharmacist, or psychologist, and any officer, employee or agent of that
provider acting in the course and scope of his or her employment or agency related to or supportive
of health services.
1.9
"High managerial agent" means an officer of a facility, the administrator and assistant administrator
of the facility, the director and assistant director of nursing services, or any other agent in a position
of comparable authority with respect to the formulation of policies of the facility or the supervision
in a managerial capacity of subordinate employees.
1.10 "The licensed capacity of a facility" refers to the number of beds a facility is licensed to operate.
1.11 "Licensing agency" means the Rhode Island Department of Health.
1.12 "Mistreatment" means the inappropriate use of medications, isolation, or use of physical or chemical
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restraints as punishment, for staff convenience, as a substitute for treatment or care, in conflict with
a physician's order, or in quantities which inhibit effective care or treatment, which harms or is likely
to harm the patient or resident.
1.13 "Neglect" means the intentional failure to provide treatment, care, goods and services necessary to
maintain the health and safety of the patient or resident, or the intentional failure to carry out a plan
of treatment or care prescribed by the physician of the patient or resident, or the intentional failure
to report patient or resident health problems or changes in health conditions to an immediate
supervisor or nurse, or the intentional lack of attention to the physical needs of a patient or resident
including, but not limited to toileting, bathing, meals and safety. Provided, however, no person shall
be considered to be neglected for the sole reason that he or she relies or is being furnished treatment
in accordance with the tenets and teachings of a well recognized church or denomination by a duly-
accredited practitioner thereof.
1.14 "Nursing facility" means a place, however named, or an identifiable unit or distinct part thereof that
provides 24 hour inresident nursing, therapeutic, restorative or preventive and supportive nursing
care services for two (2) or more residents unrelated by blood or marriage whose condition requires
continuous nursing care and supervision.
1.15 "Nursing service" means a service organized, staffed and equipped to provide nursing care to
residents on a continuous basis.
1.16 "Nursing unit" means a self-contained section of a facility such as a wing, ward or floor, housing
no more than 60 beds.
1.17 "The occupancy level of a facility" refers to the number of beds a facility has in actual use, equal to
or less than the licensed capacity.
1.18 "Person" means any individual, trust or estate, partnership, corporation (including associations, joint
stock companies), limited liability company, state or political subdivision or instrumentality of a
state.
1.19 "Physician" means a person licensed to practice allopathic or osteopathic medicine in this state,
pursuant to the provisions of Chapter 5-37 of the General Laws of Rhode Island, as amended.
Section 2.0 Certificate of Need Requirements
2.1
Any person individually or jointly with any other person(s) who proposes to undertake any substantial
construction shall be subject to the Rhode Island Department of Health, rules and regulations for
construction of nursing or personal care homes.
2.2
A certificate of need is required as a precondition to the establishment of a new nursing facility in
accordance with reference 5.
2.3
Any facility which has received a certificate of need as evidence by written approval of the Director
of Health after review by the Health Services Council, shall submit plans and specifications for
review, prior to signing a construction contract, to the Division of Facilities Regulation, Rhode Island
Department of Health, to the Division of Fire Safety, Executive Department, and to the Division of
Food Protection and Sanitation of the Rhode Island Department of Health in accordance with
reference 6.
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Section 3.0 General Requirements for Licensure
3.1
No person or governmental unit acting severally or jointly with any other person or governmental unit shall
conduct, maintain or operate a or hold itself out as a nursing facility without a license in accordance with
the requirements of reference 1.
3.2
The provisions of the rules and regulations herein, in addition to the provisions of reference 1, shall apply
to all nursing facilities and to all residents housed therein, except that persons caring exclusively for
relatives shall be exempted from the provisions of reference 1 and of the rules and regulations herein.
3.3
Facilities meeting the definition of nursing facilities by virtue of the residence therein of persons who are
mentally, physically and/or emotionally dependent on others for fulfilling the requirements of daily life
but which do not include primary medical and nursing components shall not be subject to the rules and
regulations herein but shall be subject to the requirements of Chapter 23-17.4 of the General Laws of
Rhode Island, as amended (see reference 3), and to the Rules and Regulations For Licensing Residential
Care & Assisted Living Facilities (R23-17.4-SCF) (see reference 4).
Section 4.0 Application for License or for Changes in Owner, Operator, or Lessee
4.1
Application for a license to conduct, maintain or operate a nursing facility shall be made in writing and
submitted on forms provided by the licensing agency prior to the expiration date for license renewal or
prior to the opening date for a new facility.
4.2
A notarized listing of names and addresses of direct and indirect owners whether individual, partnership,
or corporation, with percentages of ownership designated, shall be provided with the application for
licensure and shall be updated annually. If a corporation, the list shall include all officers, directors and
other persons or any subsidiary corporation owning stock.
4.3
Application for changes in the owner, operator, or lessee of a nursing facility shall be made on forms
provided by the licensing agency and shall contain but not be limited to information pertinent to the
statutory purpose expressed in section 23-17-3 of Chapter 23-17 or to the considerations enumerated in
section 5.6 herein. Twenty-five (25) copies of such applications are required to be provided.
4.3.1
Each application filed pursuant the provisions of this section shall be accompanied by an
application fee, made payable to the Rhode Island General Treasurer, as follows: applicants
shall submit a fee equal to one tenth of one percent (0.1%) of the projected annual facility net
operating revenue contained in the application; provided, however, that the minimum fee shall
be five hundred dollars ($500) and the maximum fee shall not exceed ten thousand dollars
($10,000).
Section 5.0 Issuance and Renewal of License
5.1
The licensing agency shall issue a license or renewal thereof for a period of no longer than one (1) year.
Said license, unless sooner suspended or revoked, shall expire by limitation on the 31st day of December
following its issuance and may be renewed from year to year after inspection, and approval by the
licensing agency, provided the applicant meets the appropriate requirements of reference 1 and the rules
and regulations herein.
5.2
A license shall be issued to a specific licensee for a specific location and shall not be transferable. The
5
license shall be issued to the individual owner, operator or lessee, or to the corporate entity responsible
for its governance.
5.2.1
Any change in owner, operator, or lessee of a licensed nursing facility shall require prior review
by the Health Services Council and approval of the licensing agency as provided in section 5.5
and section 5.6 as a condition precedent to the transfer, assignment or issuance of a new license.
5.3
A license issued hereunder shall be the property of the state and loaned to such licensee, and it shall be
kept posted in a conspicuous place on the licensed premises.
5.4
A distinct part of a nursing facility which is designed, maintained and primarily devoted to the provision
of residential care and assisted living in accordance with section 1.21 of reference 3 shall obtain a
separate license in accordance with the regulatory and statutory requirements of references 3 and 4.
5.5
Reviews of applications for changes in the owner, operator, or lessee of licensed nursing facilities shall
be conducted according to the following procedures:
a)
Within ten (10) working days of receipt, in acceptable form, of an application for a license in
connection with a change in the owner, operator or lessee of an existing facility, the licensing
agency will notify and afford the public thirty (30) days to comment on such application.
b)
The decision of the licensing agency will be rendered within ninety (90) days from acceptance of
the application for license.
c)
The decision of the licensing agency shall be based upon the findings and recommendations of the
Health Services Council unless the licensing agency shall afford written justification for variance
therefrom.
d)
All applications reviewed by the licensing agency and all written materials pertinent to the
licensing agency review, including minutes of all Health Services Council meetings, shall be
accessible to the public upon request.
5.6
Except as otherwise provided in Chapter 23-17 of the General Laws of Rhode Island, as amended, a
review by the Health Services Council of an application for a license in the case of a proposed change
in the owner, operator, or lessee of a licensed nursing facility may not be made subject to any criterion
unless the criterion directly relates to the statutory purpose expressed in section 23-17-3 of the General
Laws. In conducting reviews of such applications the Health Services Council shall specifically consider
and it shall be the applicant’s burden of proof to demonstrate:
5.6.1
The character, commitment, competence, and standing in the community of the proposed owners,
operators or directors of the facility as evidenced by:
(A)
In cases where the proposed owners, operators, or directors of the health care facility
currently own, operate, or direct a health care facility, or in the past five years owned,
operated or directed a health care facility, whether within or outside Rhode Island, the
demonstrated commitment and record of that (those) person(s):
(i)
in providing safe and adequate treatment to the individuals receiving the health
care facility's services;
6
(ii)
in encouraging, promoting and effecting quality improvement in all aspects of
health care facility services; and
(iii)
in providing appropriate access to health care facility services;
(B)
A complete disclosure of all individuals and entities comprising the applicant; and
(C)
The applicant’s proposed and demonstrated financial commitment to the health care
facility.
5.6.2
The extent to which the facility will continue, without material effect on its viability at the time
of change of owner, operator, or lessee, to provide safe and adequate treatment for individuals
receiving the facility's services as evidenced by:
(A) The immediate and long term financial feasibility of the proposed financing plan;
(i)
The proposed amount and sources of owner's equity to be provided by the
applicant;
(ii)
The proposed financial plan for operating and capital expenses and income
for the period immediately prior to, during and after the implementation of
the change in owner, operator or lessee of the health care facility;
(iii)
The relative availability of funds for capital and operating needs;
(iv)
The applicant's demonstrated financial capability;
(v)
Such other financial indicators as may be requested by the state agency;
5.6.3
The extent to which the facility will continue to provide safe and adequate treatment for
individuals receiving the facility's services and the extent to which the facility will encourage
quality improvement in all aspects of the operation of the health care facility as evidenced
by:
(A)
The applicant’s demonstrated record in providing safe and adequate treatment to
individuals receiving services at facilities owned, operated, or directed by the
applicant; and
(B)
the credibility and demonstrated or potential effectiveness of the applicant’s proposed
quality assurance programs;
5.6.4
The extent to which the facility will continue to provide appropriate access with respect to
traditionally underserved populations and in consideration of the proposed continuance or
termination of health care services by the facility as evidenced by:
(A)
In cases where the proposed owners, operators, or directors of the health care facility
currently own, operate, or direct a health care facility, or in the past five years owned,
operated or directed a health care facility, both within and outside of Rhode Island, the
demonstrated record of that person(s) with respect to access of traditionally underserved
populations to its health care facilities; and
7
(B)
The proposed immediate and long term plans of the applicant to ensure adequate and
appropriate access to the programs and health care services to be provided by the health
care facility;
5.6.5
In consideration of the proposed continuation or termination of health care services by the facility:
(A)
The effect(s) of such continuation or termination on access to safe and adequate treatment
of individuals, including but not limited to traditionally underserved populations;
5.6.6
And, in cases where the application involves a merger, consolidation or otherwise legal affiliation
of two or more health care facilities, the proposed immediate and long term plans of such health
care facilities with respect to the health care programs to be offered and health care services to
be provided by such health care facilities as a result of the merger, consolidation or otherwise
legal affiliation.
5.7
Subsequent to reviews conducted under sections 5.5 and 5.6 of these regulations, the issuance of a license
by the licensing agency may be made subject to any condition, provided that no condition may be made
unless it directly relates to the statutory purpose expressed in section 23-17-3 of the Rhode Island General
Laws, as amended, or to the review criteria set forth in section 5.6 herein. This shall not limit the
authority of the licensing agency to require correction of conditions or defects which existed prior to the
proposed change of owner, operator, or lessee and of which notice had been given to the nursing facility
by the licensing agency.
Moratorium on New Initial Nursing Facility Licensed Beds and on Increases to the Licensed Capacity of
Existing Nursing Facility Licenses
5.8 Pursuant to section 23-17-44 of the Rhode Island General Laws, as amended, the licensing agency shall
issue no new initial licenses for nursing facilities prior to July 1, 2004; provided, however, that: (a) any
person holding a previously issued and valid certificate of need as of the date of passage of that section
shall be permitted to effect such prior certificate from the licensing agency consistent with such other
statutory and regulatory provisions which may further apply; (b) any person holding a nursing facility
license may undertake activities to construct and operate a replacement nursing facility with the same or
lower bed capacity as is presently licensed provided that such replacement facility may only be licensed
upon the otherwise unconditional cessation of operation of the previously licensed nursing facility; and (c)
any certificate of need application under active review before the state agency as of January 10, 1996 which
application seeks approval of a proposal to establish a new nursing facility or seeks to increase the
licensed bed capacity of an existing nursing facility shall continue to be reviewed under all the statutory
and regulatory requirements in effect at the time such application was accepted for review by the state
agency; and (d) any residential care/assist living facility licensed as of July 1, 1999 pursuant to Chapter
23-17.4 of the Rhode Island General Laws, as amended, may establish a licensed nursing facility through
the conversion of residential care/assisted living space within its existing physical plant, provided that (1)
the number of nursing facility beds so licensed shall not exceed the lesser of twenty (20) beds or ten percent
(10%) of the licensed bed capacity of such residential care/assisted living facility as of July 1, 1999; (2)
the total capital expenditures associated with the implementation of such nursing facility shall not exceed
five hundred thousand dollars ($500,000); (3) that such nursing facility shall be limited to admitting as
residents those persons who are transferring from residency at such resident care/assisted living facility;
(4) that such nursing facility shall participate in the Medicaid program; (5) that such residential
care/assisted living facility shall have submitted a certificate of need application to the Department of
Health in a form and content acceptable to the Department of Health no later than 4:30 p.m. on October 1,
8
1999; (6) that such residential care/assisted living facility shall have been granted a certificate of need by
the Department of Health; and (7) that such nursing facility shall comply with all of the requirements of the
Health Care Certificate of Need Act (Chapter 15 of Title 23) and of the Licensing of Health Care Facilities
Act (Chapter 17 of Title 23). All certificate of need applications submitted pursuant to this subsection (d)
to the Department of Health in a form and content acceptable to the Department of Health no later than 4:30
p.m. on October 1, 1999 shall be batched and reviewed in the same review cycle.
5.9 Prior to July 1, 2001, the licensing agency shall not increase the licensed bed capacity of any existing
licensed nursing facility, including any nursing facility approved for change in ownership, pursuant to
section 23-17-14 of the Rhode Island General Laws, as amended, except for the greater of ten (10) beds
or ten percent (10%) of the facility’s licensed capacity; provided, however, that any person holding a
previously issued and valid certificate of need as of the date of passage of section 23-17-44 (2) or who
shall subsequently be granted a certificate of need pursuant to section 5.8 above shall be permitted to effect
such prior certificate from the licensing agency consistent with such other statutory and regulatory
provisions which may further apply.
Section 6.0 Capacity & Classifications
6.1
Each license shall specify the licensed bed capacity of the facility. No facility shall have more residents
than the number of beds for which it is licensed.
6.2
Proposed changes in bed capacity within a facility shall be submitted to the licensing agency in writing
and shall be subject to the approval of the licensing agency in accordance with the provisions of reference
5.
6.3
On or after January 1, 1994, any nursing facility which offers to provide or provides care for patients or
residents with Alzheimer's disease or other dementia by means of an Alzheimer's Special Care Unit shall
be required to disclose the form of care and treatment provided, in addition to that care and treatment
required by the rules and regulations for the licensing of nursing facilities in a format described in section
24.0.
6.3.1
After the initial filing of the disclosure, any significant changes in the information provided by the
nursing facility must be reported to the licensing agency at the time the changes are made.
6.4
On or after January 1, 1995, any nursing facility which offers to provide or provides care for patients or
residents by means of a Rehabilitation Special Care Unit or Subacute Special Care Unit shall be required
to disclose the form of treatment or treatment provided, in addition to that care and treatment provided,
in addition to that care and treatment required by the rules and regulations for the licensing of nursing
facilities on a standard disclosure form provided by the Department.
6.4.1
After the initial filing of the disclosure, any significant changes in the information provided by the
nursing facility must be reported to the licensing agency at the time the changes are made.
Section 7.0 Change of Ownership, Operation and/or Location
7.1
When a change of ownership, as defined in the rules and regulations pursuant to reference 5, or in
operation or location of a facility or when discontinuation of services is contemplated the owner and/or
operator shall notify the licensing agency in writing no later than six (6) weeks prior to the proposed
action.
9
7.2
A license shall immediately become void and shall be returned to the licensing agency when operation
of the facility is discontinued, or when any changes in ownership occur in accordance with appropriate
certificate of need rules and regulations.
a)
When there is a change in ownership as defined in the certificate of need rules and regulations or
in the operation or control of an existing facility, the licensing agency reserves the right to extend
the expiration date of such license, allowing the facility to operate under the same conditions
which applied to the prior operator, for such time as shall be required for the processing of a new
application or for transfer of residents, not to exceed six (6) weeks.
7.3
Thirty (30) days prior to voluntary cessation of any facility license, the Department of Health shall be
notified and provided with a plan for orderly closure, and transfer of residents and records.
Section 8.0 Inspections
8.1
The licensing agency shall make such inspections and investigations as deemed necessary and in
accordance with references 1 and 5 and the regulations herein. Such inspections shall apply to all nursing
facilities licensed under 23-17 and shall apply to all residents housed therein without regard to source of
payment.
8.2
A duly authorized representative of the licensing agency shall have the right to enter without prior notice
to inspect the entire premises and services, including all records of any facility for which an application
has been received or for which a license has been issued. Any application shall constitute permission for
and willingness to comply with such inspections. The duly authorized representative shall provide
necessary identification information and shall sign the log or journal of the nursing facility provided in
accordance with reference 7.
8.3
Refusal to permit inspections shall constitute a valid ground for license revocation.
8.4
Every nursing facility shall be given prompt notice by the licensing agency of all deficiencies reported
as a result of an inspection or investigation and in accordance with the procedures incorporated in
references 1 and 6.
8.5
Written reports and recommendations of inspections and inspection logs or journals shall be maintained
on file in each facility for a period of no less than three years.
8.6
Effective January 1, 2000, any nursing care facility which is cited for substandard care by the licensing
agency shall be inspected on a bimonthly basis for the twelve (12) month period immediately following
any citation. The licensing agency shall, on an annual basis, cause no less than ten percent (10%) of all
nursing care facility surveys to be conducted in whole or in part, on nights and/or on weekends.
Section 9.0 Denial, Suspension, Revocation of License or Curtailment of Activities & Sanctions
9.1
The licensing agency is authorized to deny, suspend or revoke the license of any nursing facility which:
(1) has failed to comply with the rules and regulations pertaining to licensing of nursing facilities; (2) has
aided, abetted or permitted any illegal act or conduct adverse to the health, welfare and safety of residents
or of the general public; or (3) has failed to comply with municipal, state or federal law.
a)
Lists of deficiencies noted in inspections conducted in accordance with section 8.0 herein shall
be maintained on file in the licensing agency, and shall be considered by the licensing agency in
10
rendering determinations to deny, suspend or revoke the license of a nursing facility or to curtail
its activities.
9.2
In those instances wherein the licensing agency determines that a nursing facility licensed in accordance
with reference 1 is not being operated in conformity with all of the requirements established thereby, the
licensing agency may (in lieu of suspension or revocation) curtail activities of the home in accordance
with reference 1. Such action may be taken only when the licensing agency determines that operation of
the home shall not result in undue hardship to residents.
a)
Notice of an order to curtail any or all activities of a nursing facility in accordance with section
9.2 herein shall be made in writing by certified mail and shall state the reason thereof, the action
to be taken by the licensee and the time within which said action shall be taken.
9.3
Where, however, the licensing agency deems that operation of a nursing facility results in undue hardship
to residents as a result of deficiencies enumerated in the notice of deficiencies, the licensing agency is
authorized to deny licensure to facilities not previously licensed, or to suspend the license for a stipulated
period of time or to revoke the license of a facility already licensed.
9.4
Whenever an action shall be proposed to deny, suspend or revoke the license or curtail activities of a
licensee, the licensing agency shall notify the nursing facility by certified mail (or may be hand delivered),
setting forth reasons for the proposed action, and the applicant or licensee shall be given an opportunity
for a prompt and fair hearing in accordance with reference 20.
a)
However, if the licensing agency finds that public health, safety, or welfare, including the health
and safety of residents, imperatively requires emergency action and incorporates a finding to that
effect in its order, the licensing agency may order summary suspension of license pending
proceedings for revocation or other action.
9.5
The appropriate state and federal placement and reimbursement agencies shall be notified of any action
taken by the licensing agency pertaining to either denial, suspension or revocation of license or curtailment
of activities of any facility.
9.6
SANCTIONS: The licensing agency may take appropriate action from within the following array for
dealing with violations of references 1 and 5 or of the rules and regulations herein.
a)
As a result of denial, the rights and privileges attendant upon licensure will not accrue to a facility.
b)
As a result of an order to curtail any or all activities of a nursing facility, a licensee may be
ordered to admit no additional persons to said home, and/or transfer to other suitable
accommodations all or some of the residents residing in said home, and/or take any other
corrective action necessary to secure compliance with the requirements established by reference
1 and the rules and regulations herein.
c)
As a result of suspension, a facility shall be restrained from admitting any residents during the
period of suspension and shall be required to transfer all residents to another facility during the
period of suspension. The difference between suspension and revocation of license is essentially
a temporal one, such that the sanctions imposed as a result of suspension are so imposed until such
time as the deficiency is corrected or until such other time as the licensing agency determines,
whereas the sanctions imposed as a result of revocation are considered to be permanent and re-
application for license would be necessary.
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d)
As a result of license revocation, a facility loses all rights and privileges related to licensure and
will be required to transfer all residents, will be restrained from admitting any residents and will
be subject to prosecution for operation without a license if the foregoing actions are not
accomplished.
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PART II ORGANIZATION & MANAGEMENT
Section 10.0 Governing Body or Other Legal Authority
10.1 Each facility shall have an organized governing body or other legal authority, responsible for:
a)
the management and control of the operation and maintenance of the facility; and
b)
the conformity of the facility with all federal, state and local rules and regulations relating to fire,
safety, sanitation, communicable and reportable diseases, smoking policies and other relevant
health and safety requirements and with all rules and regulations herein.
c)
the administration of a policy of non-discrimination in the provision of services to residents and
the employment of persons without regard to race, color, creed, national origin, gender, religion,
sexual orientation, age handicapping condition or degree of handicap, in accordance with Title
VI of the Civil Rights Act of 1964; U.S. Executive Order #11246 entitled “Equal Employment
Opportunity”, U.S. Department of Labor regulations; Title V of the Rehabilitation Act of 1973, as
amended; the Rhode Island Fair Employment Practices Act, Rhode Island General Laws Chapter
28-5-1 et seq.; the Americans with Disabilities Act; and any other federal or state laws relating
to discriminatory practices.
10.2 The governing body or other legal authority shall provide facilities, personnel and other resources
necessary to meet resident and program needs.
10.3 The governing body or other legal authority shall designate a licensed administrator in accordance with
reference 8 and shall establish by-laws or policies to govern the organization of the facility, to establish
authority and responsibility and to identify program goals.
10.4 The governing body or other legal authority shall adopt a written policy statement relating to conflict of
interest on the part of members of the governing body receiving financial gain from ownership, medical
staff and employees who may influence corporate decisions.
10.5 The governing body or other legal authority, through the administrator, shall be responsible for the
procurement of a sufficient number of trained, experienced and competent personnel to provide
appropriate care and supervision for all residents and to ensure that their personal needs are met.
Medical Director and Attending Physicians
10.6 The governing body or other legal authority shall designate a physician to serve as medical director. The
medical director shall be responsible for implementation of resident care policies and for the coordination
of medical care in the facility. The medical director shall be a physician licensed to practice in Rhode
Island in accordance with the provisions cited in reference 28 herein.
10.7 Each nursing facility shall maintain an active file of all physicians attending residents for whatever
reason(s), including their phone numbers and addresses, an emergency phone number, their current
medical license numbers, and their preferred hospital admitting privileges. This file of physicians shall
be revised and updated, as needed, but no less than annually.
10.8 The governing body or other legal authority shall make available to each physician attending residents in
the facility the policies governing resident care management and services.
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Section 11.0 Administrator
11.1 Every facility shall have a full-time administrator licensed in accordance with reference 8, who shall be
directly responsible to the governing body or other legal authority for its management and operation, and
shall provide liaison between the governing body, medical and nursing staffs and other professional
supervisory staff.
a)
When the administrator does not spend full-time in the facility, a substitute shall be designated only
with the approval of the licensing agency.
b)
In the absence of the administrator, a person shall be designated or authorized in writing, as a
substitute on an interim basis.
c)
A substitute must be licensed in Rhode Island as a nursing home administrator.
11.2 The administrator shall be responsible to ensure that services required by residents shall be available on
a regular basis and provided in an appropriate environment in accordance with established policies.
11.3 The administrator shall be responsible for maintaining accurate time records on all personnel and for
posting the work schedule of all direct resident care personnel on a weekly basis. Time records shall be
retained by the facility for no less than three years.
11.4 Health care facilities shall provide the licensing agency with prompt notice of pending and actual labor
disputes/actions which would impact delivery of patient care services including, but not limited to, strikes,
walk-outs, and strike notices. Health care facilities shall provide a plan, acceptable to the Director, for
continued operation of the facility, suspension of operations, or closure in the event of such actual or
potential labor dispute/action.
11.5 The licensing agency shall be notified of any change of the administrator of a facility.
Section 12.0 Personnel
12.1 Criminal Records Check
12.1.1 Pursuant to section 23-17-34 of the General Laws, any person seeking employment in a nursing
facility, hired after July 21, 1992, and having routine contact with a resident without the presence
of other employees, shall be subject to a criminal background check, prior to, or within one week
of employment.
12.1.2 Said employee through the employer shall apply to the bureau of criminal identification of the state
or local police department for a statewide criminal records check. Fingerprinting shall not be
required as part of this check.
12.1.3 In those situations in which no disqualifying information has been found, the bureau of criminal
identification (BCI) of the state or local police shall inform the applicant and the employer in
writing.
12.1.4 Any disqualifying information as defined in these regulations, according to the provisions of
section 23-17-34 of the General Laws, will be conveyed to the applicant in writing, by the
bureau of criminal identification. The employer shall also be notified that disqualifying
14
information has been discovered, but shall not be informed of the nature of the disqualifying
information.
12.1.5 The employer shall maintain on file, subject to inspection by the Department of Health, evidence
that criminal records checks have been initiated on all employees seeking employment after July
21, 1992 as well as the results of said check. Failure to maintain this evidence shall be grounds
to revoke the license or registration of the employer.
12.1.6 If an applicant has undergone a statewide criminal records check within eighteen (18) months of
an application for employment, then an employer may request from the bureau a letter indicating
if any disqualifying information was discovered. The bureau will respond without disclosing the
nature of the disqualifying information. This letter may be maintained on file to satisfy the
requirements of Chapter 23-17-34.
12.1.7 An employee against whom disqualifying information has been found may request that a copy of
the criminal background report be sent to the employer who shall make a judgement regarding the
continued employment of the employee.
12.2 Each nursing facility shall maintain and implement written personnel policies and procedures supporting
sound resident care and personnel practices. Such policies shall be reviewed annually and updated as
necessary.
12.3 Various categories of personnel working in resident care areas shall be clearly identifiable to residents
and the public.
12.3.1 All personnel shall wear an identification badge, which includes the employee's name and title,
written in easily readable type.
12.4 There shall be a job description for each classification of position which delineates qualifications, duties,
authority and responsibilities inherent in each position.
a)
For those selected non-licensed personnel authorized to administer drugs in accordance with
section 23.7 herein, a job description delineating qualifications, duties and responsibilities shall
be provided.
Health Screening
12.5 Each facility shall implement policies and procedures for employee and non-employee staff, including
active medical staff , screening for the infectious diseases described below. These health screening
requirements do not apply to either transient employees not involved in direct resident care or outside
contractors not involved in direct resident care.
12.6 Upon hire and prior to delivering services, employment health examinations shall be required for each
employee involved in direct resident care and shall include a physician's certification (i.e., documented
evidence) which shall include but not be limited to the diseases listed below. If documented evidence
is provided by the employee that said health examination, including the required screenings, has been
performed during the most recent six (6) months prior to hire, the requirements of this section shall be
met.
a)
Tuberculosis: Evidence that the employee is free of active tuberculosis based upon the results of
15
a negative two-step tuberculin skin test shall be required.
i.
If the Mantoux (PPD) test done at the time of employment is positive, or a previous one
is known to have been positive, the physician's certification shall be based on
documentation of adequate chemotherapy for tuberculosis or on a chest x-ray taken not
more than six (6) months prior to the physician's certification;
ii.
Any positive reaction shall be recorded in millimeters in the personnel record.
b)
Rubella: In accordance with the current guidelines of The Red Book: Report on the Committee
for Infectious Diseases and the Advisory Council on Immunization Practices (ACIP), evidence
of immunity is required (with the exception of individuals who are not fit subjects for
immunization for documented medical reasons) of all health care workers through:
i.
Documented record of rubella immunization; or
ii.
Serologic evidence of naturally acquired immunity.
c)
Measles: In accordance with the current guidelines of The Red Book: Report on the
Committee for Infectious Diseases and the Advisory Council on Immunization Practices
(ACIP), evidence of immunity is required (with the exception of individuals who are not fit
subjects for immunization for documented medical reasons) of all health care workers
through:
1)
Proof of physician-documented illness; or
2)
Positive serologic test for antibody; or
3)
Documented receipt of either one (1) dose of measles-containing vaccine (for persons
born on or before 31 December 1956) or two (2) doses of live-virus measles vaccine
(for persons born on or after 01 January 1957). All documented receipt of vaccines
must have occurred after the first birthday.
d)
Influenza: Each facility shall offer annual vaccination against influenza to all persons
involved in direct resident care, including employees and volunteers. The facility shall be
responsible for documenting: 1) the number of persons who are eligible for said vaccination;
2) the number of persons who accept said vaccination and 3) the number of persons who are
exempted from vaccination based on medical reasons. Further, the facility shall be
responsible for providing, on an annual basis, staff education on the nature of influenza and
the role of vaccination in controlling its spread to those persons having direct resident
contact.
e)
Blood Borne pathogens:
Health care facilities must adhere to the OSHA Blood borne Pathogens Standard (29 CFR 1910-
1030), including the offering of hepatitis B vaccination along with all recommendations for
infection control training and provision of protective equipment to those employees at risk.
An exposure control plan shall be in place in all health care facilities licensed by the Department
of Health, pursuant to the provisions of Chapter 23-17 of the Rhode Island General Laws, as
16
amended.
f)
Such other appropriate test(s) to control communicable diseases as may be prescribed by the
Director of Health.
Personnel Records
12.7
Personnel records shall be maintained for each employee, shall be available at all times for inspection
and shall include no less than the following:
a)
current and background information covering qualifications for employment;
b)
records of completion of required training and educational programs;
c)
records of all required health examinations which shall be kept confidential and in accordance
with reference 17;
d)
evidence of current registration, certification or licensure of personnel subject to statutory
regulation;
e)
annual work performance evaluation records; and
f)
evidence of authorization to administer drugs for selected non-licensed personnel in accordance
with section 23.7 herein.
In-Service Education
12.8
An in-service educational program shall be conducted on an ongoing basis, which shall include an
orientation program for new personnel and a program for the development and improvement of skills of
all personnel. The in-service program shall be geared to the needs of the aged, prevention and control
of infection, food services and sanitation, fire prevention and safety, confidentiality of resident
information, rights of residents and any other area related to resident care.
12.8.1
Provision shall be made for written documentation of programs, including attendance. Flexible
program schedules shall be formulated at least two (2) months in advance.
Photo Identification
12.9
A health care facility shall require all persons, including students, who examine, observe, or treat a
patient or resident of such facility to wear a photo identification badge which states, in a reasonably
legible manner, the first name, licensure/registration status, if any, and staff position of such person.
Section 13.0 Handling of Resident Fund
13.1 Any assignment of residents' property either by contractual agreement or by transfer of real estate, bank
accounts or insurance benefits, must be reported together with the terms of the assignment to the residents'
guardian, next of kin, sponsoring agency(ies) or representative payor and to the licensing agency.
17
13.2 Each operator of a nursing facility acting or intending to act as fiduciary agent for a resident is required
to have written revocable authorization from any resident so served. The certification will attest to the
resident's understanding of the significance of his action and will be required to be on file for inspection
by authorized surveyors of the licensing agency.
13.3 The operator shall maintain adequate safeguards and accurate records of each resident's monies and
valuables and shall provide at least quarterly, and on request, accounting in accordance with section 17.15
herein. Such records shall be available for inspection.
13.4 In addition to requirements of section 13.1 through 13.3 above, each facility shall conform to the standards
of reference 13 in relation to Title XIX residents.
Section 14.0 Reporting of Resident Abuse or Neglect, Accidents & Death
14.1 Any physician, nurse or other employee of a nursing facility who has reasonable cause to believe that a
resident has been abused, exploited, or neglected shall within 24 hours of the receipt of said information,
transfer such to the Director of the Department of Health. Any person required to make a report pursuant
to this section shall be deemed to have complied with these requirements if a report is made to a high
managerial agent. Once notified, the administrator or the director of nursing services shall be required
to meet the above reporting requirements.
a)
Upon receipt of such information or allegation, the Director of Health or his designee, shall
forthwith conduct such investigation as may be necessary and submit a report of findings of the
investigation(s) to the Attorney General of the State of Rhode Island.
14.2 Accidents resulting in hospitalization or death of any resident shall be reported in writing to the licensing
agency before the end of the next working day. A copy of each report shall be retained by the facility for
review during subsequent surveys.
14.3 The death of any resident of a nursing facility occurring within 24 hours of admission or prior to the
performance of a physical examination in accordance with section 20.3 (c) herein, shall be reported to
the Office of the State Medical Examiners.
14.4 In addition, all resident deaths occurring within a nursing facility which are sudden or unexpected,
suspicious or unnatural, the result of trauma, remote or otherwise or when unattended by a physician shall
be reported to the Office of the State Medical Examiners in accordance with Title 23, Chapter 4 of the
General Laws of Rhode Island, as amended.
14.5 Reporting requirements, pursuant to Chapter 23-17.8 of the General Laws must be posted.
Section 15.0 Medical Records
15.1 A medical record shall be established and maintained for every person admitted to a facility in accordance
with accepted professional standards and practices. The administrator shall have ultimate responsibility
for the maintenance of medical records; such responsibility may be delegated in writing to a staff member.
15.2 Entries in the medical record relating to treatment, medication, diagnostic tests and other similar services
rendered shall be made by the responsible persons at the time of administration. Only physicians shall
enter or authenticate medical opinions or judgement.
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a)
All accidents, whether resulting in an injury or not, shall be immediately recorded in the resident's
record.
b)
Detailed descriptions of all decubiti, or skin lesions indicating potential decubiti, shall be
recorded in the resident's record.
15.3 Each medical record shall contain sufficient information to identify the resident and to justify diagnosis,
treatment, care and documented results and shall include as deemed appropriate:
a)
identification data;
b)
pre-admission screening including mental status;
c)
medical history;
d)
plan of care and services provided;
e)
physical examination reports;
f)
admitting diagnosis;
g)
diagnostic and therapeutic orders;
h)
consent forms;
i)
physicians' progress notes and observations;
j)
nursing notes;
k)
medication and treatment records;
l)
laboratory reports, X-ray reports, or other clinical findings;
m)
consultation reports;
n)
documentation of all care and services rendered (e.g., dental reports, physical and occupational
therapy reports, social service summaries, podiatry reports, inhalation therapy reports, etc.);
o)
resident referral forms;
p)
diagnosis at time of discharge; and
q)
disposition and final summary notes.
15.4 At time of discharge, a discharge summary shall be completed promptly and signed by the attending
physician.
15.5 Medical records of discharged residents shall be completed within a reasonable period of time (not to
exceed sixty (60) days) with all clinical information pertaining to the resident's stay made part of the
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resident's medical record.
15.6 Confidentiality of medical records shall be governed by the provisions of reference 17 and the following;
a)
Only authorized personnel shall have access to the records.
b)
The facility shall release resident's medical information only with the written consent of the
resident, parent, guardian or legal representative in accordance with reference 17.
15.7 Provisions shall be made for the safe storage of medical records to safeguard them against loss,
destruction or unauthorized use.
15.8 All medical records, either original or accurately reproduced, shall be preserved for a minimum of five
(5) years following discharge or death of the resident in accordance with reference 9.
a)
Medical records of minors, however, shall be kept for at least five (5) years after such minor
would have reached the age of eighteen (18) years.
15.9 The medical records of all residents shall be opened for inspection to duly authorized representatives of
the licensing agency whose duty it is to enforce the regulations herein consistent with section 17.14 (a)
herein.
a)
Information contained in medical records gathered and collected for the purpose of enforcing these
regulations is confidential in nature and shall not be publicly disclosed by any person obtaining
such information by virtue of his office, unless by court order or as otherwise required by law.
Section 16.0 Transfer Agreements, Contracts, or Agreements
16.1 The facility shall have in effect transfer agreements with one or more hospitals for the provision of
hospital care or other hospital services to be made available promptly to the residents of the facility, as
needed. The written transfer agreement shall ensure:
a)
timely (within 24 hours) transfer or admission of residents between the hospital and the facility,
whenever deemed medically appropriate in writing by a physician;
b)
interchange of medical and other information necessary or useful in the care and treatment of
residents transferred or to determine the kind of care the resident requires that includes, but is not
limited to the following:
i.
clear statement of the reason(s) resident is being transferred to the hospital or for
consultation;
ii.
name of resident, address, insurance status;
iii.
name of attending physician and his/her telephone number;
iv.
resident’s next-of-kin and his/her telephone number;
v.
name of contact staff person at the facility;
20
vi.
list of all diagnoses and complaints;
vii.
list of all current medications;
viii.
recent x-ray reports and laboratory reports, as applicable;
ix.
existence of any advance directives;
x.
any additional information as cited in the “Continuity of Care” form available from the
Department; and
c)
security and accountability for the resident's personal effects during transfer.
16.2 Designated nursing facility personnel shall complete the “Continuity of Care” form approved by the
Department for each resident who is discharged to another health care facility, such as a hospital,
or who is discharged home with follow-up home care required. Said form shall be provided to the
receiving facility or agency prior to or upon transfer of the resident.
16.3 If the facility does not employ full-time qualified professional personnel to render required services, or
obtains services from an outside source, arrangements for such services shall be made through written
agreements or contracts.
a)
The responsibilities, functions, objectives, terms of agreement, financial arrangements, charges
and other pertinent requirements shall be clearly delineated in the terms of any contract negotiated
by a facility.
b)
All contracts or agreements negotiated by a facility shall be consistent with the policies
established in accordance with section 10.4 concerning conflict of interest.
c)
Each consultant or outside source providing services to a facility shall submit monthly reports as
services are provided. Said reports and contracts shall be kept on file for inspection for a period
of no less than three (3) years.
Financial Interest Disclosure
16.4 Any health care facility licensed pursuant to Chapter 23-17 of the Rhode Island General Laws, as
amended, which refers clients/residents to another such licensed health care facility or to a residential
care/assisted living facility licensed pursuant to Chapter 23-17.4 of the Rhode Island General Laws, as
amended, or to a certified adult day care program in which the referring entity has a financial interest
shall, at the time a referral is made, disclose in writing the following information to the client/resident:
(1) that the referring entity has a financial interest in the facility or provider to which the referral is being
made; (2) that the client/resident has the option of seeking care from a different facility or provider which
is also licensed and/or certified by the state to provide similar services to the client/resident.
16.5 The referring entity shall also offer the client/resident a written list prepared by the Department of Health
of all such alternative licensed and/or certified facilities or providers. Said written list may be obtained
by contacting:
Rhode Island Department of Health, Division of Facilities Regulation
3 Capitol Hill, Room 306
21
Providence, RI 02908
401.222.2566
16.6 Non-compliance with sections 16.4 and 16.5 (above) shall constitute grounds to revoke, suspend or
otherwise discipline the licensee or to deny an application for licensure by the Director, or may result in
imposition of an administrative penalty in accordance with Chapter 23-17.10 of the Rhode Island General
Laws, as amended.
Section 17.0 Rights of Residents
As part of the procedure for admission of a resident to a nursing facility a written contract shall be entered into
between the said resident or his next of kin or legal representative and the nursing facility and the following rules
shall be observed in accordance with reference 25.
17.1 Each resident shall be offered treatment without discrimination as to sex, age, race, color, religion,
national origin handicap, diagnosis of Alzheimer's Disease, or related dementia, or source of payment.
17.2 Each resident shall be treated and cared for with consideration, respect and dignity and shall be afforded
his right to privacy to the extent consistent with providing adequate medical care and with efficient
administration.
17.3 Each resident shall have the right to choose his or her own physician subject to the physician's
concurrence.
17.4 Each resident shall be fully informed, as evidenced by the resident's written acknowledgment, prior to or
at the time of admission or during stay, of all rules and regulations and policies pertaining to rights of
residents and governing resident conduct and responsibilities.
17.5 Each resident shall be informed in writing, prior to, or at the time of admission and during stay, of services
available and of related charges including all charges not covered either under federal and/or state
programs by other third party payers or by the facility's basic per diem rate.
17.6 Each resident admitted to a facility shall be and remain under the care of a physician as specified in
policies adopted by the governing body.
a)
Each resident shall be informed by a physician of his medical condition unless medically
contraindicated, (as documented by a physician in his medical record), and shall participate in the
planning and selection of his medical treatment and care.
17.7 If it is proposed that a resident be used in any human experimentation project, the resident shall first be
thoroughly informed in writing of such proposal and shall be offered the right to refuse to participate in
such project. A resident who, after being thoroughly informed, wishes to participate must execute a
written statement of informed consent. The informed consent documentation shall be maintained on file
in the facility.
17.8 Residents shall be encouraged and assisted to voice their grievances through a documented grievance
mechanism established by the facility, involving residents, staff and relatives of residents, which will
insure resident's freedom from restraints, interference, coercion, discrimination or reprisal.
17.8.1 There shall be prompt efforts by the facility staff to resolve resident's grievances.
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17.9 Residents shall not be subject to mental and physical abuse and shall be free from chemical and (except
in emergencies) physical restraints.
a)
Restraining devices are generally prohibited. A controlling device to be used for the protection
of the resident may be utilized only as prescribed in writing and signed by a physician. The length
of time, the purpose and the kind of restraint shall be specified in the physician's order.
b)
If after a trial of less restrictive measures, the facility decides that a physical restraint would
enable and promote greater functional independence, then the use of the restraining device must
first be explained to the resident, family member, or legal representative, and if the resident,
family member or legal representative agrees to this treatment alternative, then the restraining
device may be used for the specific periods for which the restraint has been determined to serve
the purpose defined above. This does not allow the use of restraints for convenience sake.
c)
The restraining device must be authorized by the physician for use for specific periods for which
the restraint has been determined to serve the purpose defined in paragraph b) above. This does
not allow the use of restraints for convenience sake.
17.10 A resident shall not be required to perform services for the facility that are not included for therapeutic
purposes in his plan of care.
17.11 Residents may meet with and participate in activities of social, religious and community groups at their
discretion unless medically contraindicated per written medical order.
17.12 Residents may associate and communicate privately with persons of their choice and shall be allowed
freedom and privacy in sending and receiving mail.
a)
Posted reasonable visiting hours must be maintained in each home, with a minimum of four hours
daily. The facility must provide immediate access to residents by properly identified appropriate
government personnel, family members and relatives. However, the resident reserves the right
to refuse visitation by any of the aforementioned.
b)
i.
All health care providers, as licensed under the provisions of Chapter 29 or 37 of Title
5 and all health care facilities, as defined in section 23-17-2(5) of the Rhode Island
General Laws, as amended, shall be required to note in their residents’ permanent medical
records, the name of individual(s) not legally related by blood or marriage to the resident,
who the resident wishes to be considered as immediate family member(s), for the purpose
of granting extended visitation rights to said individual(s), so said individual(s) may visit
the resident while he or she is receiving inpatient health care services in a health care
facility.
ii.
A resident choosing to designate said individual(s) as immediate family members for the
purpose of extending visitation rights may choose up to five (5) individuals and do so
either verbally or in writing. This designation shall be made only by the resident and can
be initiated and/or rescinded by the resident at any time, either prior to, during, or
subsequent to an inpatient stay at the health care facility.
iii.
The full names of individual(s) so designated, along with their relationship to the resident,
shall be recorded in the resident’s permanent medical records, both at the inpatient health
23
care facility and with the resident’s primary care physician.
iv.
In the event the resident has not had the opportunity to have said designation recorded in
his or her medical records, a signed statement in the resident’s own handwriting attesting
to the designation of said individual(s) as an immediate family member for the purpose of
extending visitation right during the provision of health care services in an inpatient health
care facility, along with their relationship to said individual(s) shall meet all the
requirements of this section. The resident’s signature on said signed statement shall be
witnessed by two individuals, neither of whom can be the designated individual(s). In the
event such signed statement is not available, those designated as agents on a durable
power of attorney for health care form shall be allowed visitation privileges.
v.
This section shall not be construed to prohibit legally recognized members of the
resident’s family from visiting the resident if they have not been so designated through
the provisions of this section. No resident shall be required to designate individual(s)
under the provisions of this section.
17.13 Residents shall have the right to obtain personal services or to purchase needs outside of the facility.
17.14 The resident's right to privacy and confidentiality shall extend to all records pertaining to the resident.
Release of any records shall be subject to the resident's approval except as otherwise provided by law.
a)
The right to privacy and confidentiality relates to the public dissemination of specific information
contained within resident records and to the identification of specific individuals, but does not
abrogate the responsibility of the licensing agency to review all resident records.
17.15 A resident shall have the right to manage his or her own personal financial affairs. The resident may
delegate the management of his or her financial affairs to the facility by means of a formal written request.
The written request should specify the period of time for which transfer of financial responsibility is
desired. If the facility agrees to accept such responsibility, it shall convey acknowledgment of acceptance
to the patient in writing. The facility shall have the obligation to conduct the patient's affairs in
conformity with state laws and to provide a written accounting statement at least quarterly or at any time
upon demand of the patient.
17.16 If married, residents shall be assured privacy for visits by the spouse; if both are in residence in the
facility they may share a room unless medically contraindicated per written order of the physician and
subject to the availability of such accommodations within the facility.
17.17 Before transferring a resident to another facility or level of care within a facility, the resident shall be
informed of the need for such a transfer and of any alternatives to such a transfer.
a)
A resident shall be transferred or discharged only for medical reasons, or for his welfare or that
of other residents or for nonpayment of his stay.
b)
Reasonable advance notice for transfers to health care facilities other than hospitals shall be given
to ensure orderly transfer or discharge and such actions shall be documented in the medical
record.
17.17.1 Bed-Hold and Readmission: A nursing facility must provide written information
pertaining to bed-hold and readmission for residents transferred for hospitalization or
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therapeutic leave as follows:
a)
Notice before transfer: Before a resident of a nursing facility is transferred for
hospitalization or therapeutic leave, a nursing facility must provide written
information to the resident and a family member or legal representative
concerning:
i)
the provisions of the medical assistance program state plan regarding the
period (if any) during which the resident will be permitted under the state
plan to return and resume residence in the facility; and
ii)
the policies of the facility regarding such a period, which policies must be
consistent with section b) hereunder;
b)
Notice upon transfer: At the time of the transfer of a resident to a hospital or for
therapeutic leave, a nursing facility must provide written notice to the resident and
a family member or legal representative of the duration of any period described
in section c) hereunder; except in an emergency, said notice must be given within
24 hours of the transfer.
c)
Permitting resident to return: A nursing facility must establish and follow a
written policy under which a resident:
i)
who is transferred from the facility for hospitalization or therapeutic leave;
and
ii)
whose hospitalization or therapeutic leave exceeds a period paid for under
the state plan for the holding of a bed in the facility for the resident, will
be readmitted to the facility immediately upon the first availability of a bed
of appropriate level of care in a semi-private room in the facility if at time
of readmission, the resident requires the services provided by the facility;
iii)
the departments of human services and health shall receive, on a monthly
basis, the names from each nursing home of those persons awaiting
readmission under these provisions.
17.18 A resident shall have the right to live in a tobacco smoke-free environment. It shall be prohibited for any
person other than a nursing facility resident to smoke in a nursing facility.
17.18.1
Nursing facility residents who smoke may do so only in private or semi-private rooms
where both patients smoke, or rooms designated by the administration of the facility.
a)
A designated smoking area shall be a room or rooms other than the largest living or
assembly room or lounge.
b)
A designated smoking area shall be ventilated in such a way that the air therefrom shall
not enter other parts of the nursing facility.
17.19 All rights and responsibilities specified in section 17.3, 17.7, 17.15 and 17.17 shall devolve, in order of
priority, to a resident's guardian, next of kin, sponsoring agency(ies) or representative payor (except when
the facility itself is the representative payor) for residents who are:
25
a)
adjudicated incompetent in accordance with state law; or
b)
found by the physician to be medically incapable of understanding their rights; or
c)
found to exhibit a communication barrier. If however, the communication barrier is one of
speaking a language other than English, then an attempt shall be made to find an interpreter to
allow the resident to knowingly exercise his or her rights.
17.20 Posting a Copy of Rights of Residents: Each nursing facility shall provide each resident or his/her
representative upon admission, a copy of the provisions of section 23-17.5-4, entitled "Rights of Nursing
Home Patients", and shall display in a conspicuous place, in the facility a copy of the "Rights of
Residents" herein and related information. At a minimum the display must include the following:
a)
A summary of the major provisions of the Rights of Residents as set forth herein;
b)
The address and telephone number of: Health Facilities Regulation, Rhode Island Department of
Health, Three Capitol Hill, Providence, R.I. 02908 (Telephone Number: 401-222-2566), the
agency which will accept complaints or notice of violations of the provisions herein.
c)
The results of the most recent state and federal licensing and certification surveys of nursing homes
must be posted.
17.21Uniform Reporting System: Each nursing facility shall establish and maintain records and data in such
a manner as to make uniform the system of periodic reporting. The manner in which the requirements of
this regulation may be met shall be prescribed from time to time in directives promulgated by the Director
with the advice of the Health Services Council.
17.22 Each nursing facility shall report to the licensing agency detailed financial and statistical data pertaining
to its operations, services, and facilities. Such reports shall be made at such intervals and by such dates
as determined by the Director and shall include but not be limited to the following:
a)
utilization of nursing services;
b)
unit cost of nursing services;
c)
charges for rooms and services;
d)
financial condition of the facility; and
e)
quality of care.
17.23The licensing agency is authorized to make the reported data available to any state agency concerned with
or exercising jurisdiction over the reimbursement or utilization of nursing facilities.
17.24 The directives promulgated by the Director pursuant to these regulations shall be sent to each facility to
which they apply. Such directives shall prescribe the form and manner in which the financial and
statistical data required shall be furnished to the licensing agency.
26
PART III RESIDENT CARE SERVICES
Section 18.0 Resident Care Policies
18.1 Each facility shall have written resident care policies to govern the continuing nursing care and related
medical or other services provided.
18.2 Resident care policies and procedures shall be developed and reviewed annually in all facilities by a
group of professional personnel including one or more physicians, a registered nurse, and other
professional personnel as deemed necessary (e.g., social workers, physical therapists, etc.)
18.3 Resident care policies shall be available for review by all residents, physicians, community agencies,
relatives and personnel and shall include provisions for at least the following:
a)
meeting the total medical and psychosocial needs of residents;
b)
the establishment of written plans of care for each resident for medical, nursing and other related
services provided;
c)
the range of services available and provided to residents and constraints imposed by limitations
of services, physicians, facilities, staff coverage, payment mechanism or other;
d)
the frequency of physician visits shall be at a minimum of 90 days;
e)
the protection of residents' personal and property rights;
f)
types of clinical conditions acceptable for admission to specific levels of care and appropriate
services;
g)
emergency admissions or discharges and emergency care of residents;
h)
requirements for informed consent by resident, parent, guardian or legal representative for
treatment;
i)
notification of next of kin, attending physician or responsible agency of any transfer or discharge;
j)
notification of next of kin, attending physician or responsible agency of any change of condition;
k)
transfer of medical information in accordance with reference 17;
l)
discharge and termination of services; and
m)
provision for continuity of resident care as related to discharge planning, which shall include a
mechanism for recording, transmitting and receiving information essential to the continuity of
resident care.
Such information shall contain no less than the following:
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i.
resident identification data; such as name, address, age, gender, name of next of kin, health
insurance coverage, etc.;
ii.
diagnosis and prognosis, medical status of resident, brief description of current illness, medical
and nursing plans of care including such information as medications, treatments, dietary needs,
baseline laboratory data;
iii.
functional status;
iv.
special services such as physical therapy, occupational therapy, speech therapy and such other;
v.
psychosocial needs;
vi.
bed-hold policy and readmission in accordance with section 17.17.1 c) herein; and
vii.
such other information pertinent to ensure continuity of resident care.
18.4 There shall be documented evidence of the designation of responsibility to a physician, or to a nurse or to
the medical staff for the execution and implementation of resident care policies.
a)
When a nurse is designated as the responsible agent for a day-to-day execution of resident care
policies, a physician shall be available to provide necessary medical guidance.
18.5 Resident care policies shall be reviewed annually and shall be revised when necessary.
Section 19.0 Infection Control
19.1
The facility shall be responsible for no less than the following:
a)
establishing and maintaining a facility-wide infection surveillance program;
b)
developing and implementing written policies and procedures for the surveillance, prevention,
and control of infections in all resident care departments/services;
c)
establishing policies governing the admission and isolation of residents with known or suspected
infectious diseases;
d)
developing, evaluating and revising on a continuing basis infection control policies, procedures
and techniques for all appropriate areas of facility operation and services;
e)
developing and implementing a system for evaluating and recording the occurrences of all
infections relevant to employment (e.g., skin rash) among personnel and infections among
residents; such records shall be made available to the licensing agency upon request;
f)
implementing a TB infection control program requiring risk assessment and development of
a TB infection control plan; early identification, treatment and isolation of strongly suspected
or confirmed infectious TB residents; effective engineering controls; an appropriate respiratory
protection program; health care worker TB training, education, counseling and screening; and
evaluation of the program's effectiveness, per guidelines in reference 31.
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g) developing and implementing an institution-specific strategic plan for the prevention and control
of vancomycin resistance, with a special focus on vancomycin-resistant enterococci, per
guidelines in reference 33. (See also reference 32 herein for additional information on this
issue).
h) developing and implementing protocols for: 1) discharge planning to home that include full
instruction to the family or caregivers regarding necessary infection control measures; and 2)
hospital transfer of residents with infectious diseases which may present the risk of continuing
transmission. Examples of such diseases include, but are not limited to, tuberculosis (TB),
Methicillin resistant staphylococcus aureus (MRSA), and clostridium difficile.
i)
assuring that all resident care staff are available in order to assist in the prevention and control
of infectious diseases and are provided with adequate direction, training, staffing and facilities
to perform all required infection surveillance, prevention and control functions.
19.2
Infection control provisions shall be established for the mutual protection of residents, employees, and
the public.
19.3
A continuing education program on infection control shall be conducted periodically for all staff.
19.4 Reporting of Communicable Diseases
a)
Each facility shall report promptly to the Rhode Island Department of Health, Division of Disease
Control, cases of communicable diseases designated as "reportable diseases" when such cases
are diagnosed in the facility in accordance with reference 11.
b)
When infectious diseases present a potential hazard to residents or personnel, these shall be
reported to the Rhode Island Department of Health, Division of Disease Control even if not
designated as "reportable diseases."
c)
When outbreaks of food-borne illness are suspected, such occurrences shall be reported
immediately to the Rhode Island Department of Health, Division of Disease Control or to the
Division of Food Protection and Sanitation.
d)
Facilities must comply with the provisions of section 23-28.36-3, which requires notification of
Fire Fighters, Police Officers and Emergency Medical Technicians after exposure to infectious
diseases.
19.5
Influenza, pneumococcal, and other adult vaccination policies and protocols (such as physician’s
standing orders) for facility residents shall be developed and implemented by the facility and shall
contain no less than the following provisions:
a)
Each facility must offer annual vaccination against influenza to all residents. Vaccinations
must be provided in accordance with the most current ACIP (Advisory Council on
Immunization Practices) guidelines for these vaccinations.
b)
Each facility must offer a pneumococcal vaccination to all residents 65 years and older, if
not previously vaccinated. Vaccinations must be provided in accordance with the most
current ACIP (Advisory Council on Immunization Practices) guidelines for these vaccinations.
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c)
Reports of vaccination rates shall be submitted annually (by July 1st of each year) to the
Department. Such reports shall include, at a minimum:
i)
average facility census for the preceding twelve (12) months of residents 65 years and
older and the number of influenza vaccinations administered in that period;
ii)
average facility census for the preceding twelve (12) months of residents 64 years and
younger and the number of influenza vaccinations administered in that period;
iii)
percentage of current residents 65 years and older vaccinated with pneumococcal vaccine;
iv)
the number of residents who are exempted from influenza and/or pneumococcal
vaccination for medical reasons; and
v)
other reports as may be required by the Director.
Section 20.0 Physician Service
20.1 All residents shall remain or be under the care of a physician of his or her choice, subject to the
physician's concurrence.
20.1.1 All Physician Assistant Services shall be in accordance with the provisions of Chapter 5-54 of
the General Laws.
20.1.2 All Nurse Practitioner services shall be in accordance with the provisions of Chapter 5-34 of the
General Laws.
20.2 No less than the following resident care information shall be made available to facilities by the referring
source prior to or upon admission and provided only in accordance with the requirements of reference
17:
a)
current medical findings;
b)
summary of pre-admission treatment and care; and
c)
diagnosis and medical orders by the physician for immediate resident care.
20.3 Each facility shall establish and comply with policies governing medical care supervision. Such policies
shall include no less than the following:
a)
that every resident be under the continued medical supervision of a physician of his or her choice;
b)
that a prescribed medical care plan be established for each resident by the attending physician;
c)
that the medical care plan be based on a physical examination done within 48 hours of admission
unless such was performed within 5 days prior to admission;
d)
that each resident be seen by an attending physician and the medical care plan be renewed or
revised in accordance with the needs of the resident at least every 90 days;
30
e)
that arrangements be made for physician coverage in the absence of the attending physician; and,
and progress notes be written and signed by the physician at the time of each visit.
f)
any physician's verbal order for drugs, and biologicals shall be given in accordance with the
provisions of section 23.6(b) herein.
20.4 Written policies and procedures pertaining to emergency medical care including a listing of physician
coverage, shall be established and maintained at each nursing station. The facility must provide or arrange
for physician's services 24 hours a day in case of an emergency.
Section 21.0 Nursing Service Management
21.1 Each facility shall have a formally organized nursing service with an organization chart reflecting the lines
of communication. The authority, responsibilities and duties for each nursing service position and/or
category shall be clearly delineated in writing through job descriptions.
21.2 Each facility shall have a registered nurse on duty 24 hours a day. In addition, the necessary nursing
service personnel (licensed and non-licensed) shall be in sufficient numbers on a 24 hour basis, to assess
the needs of resident, to develop and implement resident care plans, to provide direct resident care
services, and to perform other related activities to maintain the health, safety and welfare of residents.
a)
There shall be a master plan of the staffing pattern for providing 24 hour nursing service; for the
distribution of nursing personnel for each floor and/or nursing unit; for the replacement of nursing
personnel; and for forecasting future needs. The staffing pattern shall include provisions for
nurses, aides, orderlies and other personnel as required.
b)
The number and type of nursing personnel shall be based on resident care needs and classifications
as determined for each nursing unit.
c)
At least one individual who is certified in Basic Life Support must be available twenty-four hours
a day (24 hrs./day) within the facility.
21.3 Whenever the licensing agency determines that additional staffing is needed to provide adequate nursing
care and treatment or to ensure the safety of the residents, the licensing agency may require the facility to
provide such additional staffing.
21.4 No nursing staff of any facility shall be regularly scheduled for double shifts.
21.5 Every facility shall have an active program for rehabilitative nursing care.
21.6 Written resident care plans shall be developed and maintained for each resident consonant with the
attending physician's plan of medical care.
a)
Resident care plans shall be reviewed, evaluated and revised by professional staff no less than
every three months.
Section 22.0 Nursing Facility Staff
22.1 In nursing facilities, the nursing service shall be under the direction of a Director of Nurses who shall be
a registered nurse employed full-time. A relief registered nurse shall be employed to insure full-time
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coverage in the absence (including vacation, sick time, days off, or other) of the designated registered
nurse.
a)
The Director of Nurses employed full-time in accordance with section 22.1 above shall not be the
administrator nor the assistant administrator and shall: (1) have at least two years' experience in
nursing supervision or, by training and experience, shall have demonstrated competency in nursing
service management; (2) be employed by only one facility in said capacity; and (3) be responsible
for the total nursing service which shall include no less than:
i.
development, maintenance and evaluation of standards of nursing practice;
ii.
development and periodic revision of nursing policies and procedure manuals;
iii.
recommendation to the facility's administration of the number and categories of nursing
personnel required to provide resident care;
iv.
training, assignment, supervision and evaluation of personnel;
v.
coordination of nursing care services with other services, e.g., medical, nutrition, etc.; and
vi.
all other functions and activities related to nursing service management.
22.2 The Director of Nurses may act as a charge nurse only when the facility is licensed for 30 beds or under.
a)
the planning, supervision and evaluation of nursing care of each resident;
b)
the formulation and implementation of resident care plans;
c)
assignment of resident care on the basis of level of preparation and competency of staff;
d)
supervision and evaluation of staff assignments and performance; and
e)
provision of direct and indirect resident care as needed.
22.3 Each nursing facility shall be responsible to have sufficient qualified staff to meet the needs of the
residents.
22.4 Staffing Deficiencies
Whenever the licensing agency determines, in the course of inspecting a facility, that additional staffing is
necessary on any nursing unit to provide adequate nursing care and treatment or to ensure the safety of residents,
any or all of the following actions shall be taken to enforce compliance with the determination of the licensing
agency.
a)
The facility shall be cited for a deficiency and shall be required to augment its staff within 10 days
in accordance with the determination of the licensing agency.
b)
If failure to augment staffing is cited, the facility shall be required to curtail admission to the
facility.
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c)
If a continued failure to augment staffing is cited, the facility shall be subjected to an immediate
compliance order to increase the staffing, in accordance with section 23-1-21 of the General Laws
of Rhode Island of as amended.
d)
The sequence and inclusion or non-inclusion of the specific sanctions enumerated in sections
above may be modified in accordance with the severity of the deficiency in terms of its impact on
the quality of resident care.
Section 23.0 Selected Nursing Care Procedures
23.1 The personal hygiene of each resident shall be attended to. All residents shall receive care including care
of skin, shampooing and grooming of hair, oral hygiene, shaving, cleaning and cutting of fingernails and
toenails. Residents shall be kept free of offensive odors.
23.2 Residents shall be encouraged and/or assisted to function at their highest level of self-care and
independence. Every effort shall be made to keep residents active and out of bed for reasonable periods
of time except when contraindicated by physician orders.
23.3 Such supportive and restorative nursing care needed to maintain maximum functioning of the resident shall
be provided.
23.4 Each resident shall be given care to prevent decubiti, contractures and deformities, including:
a)
preventive skin care as appropriate;
b)
changing the position of bedfast and chair-fed residents;
c)
maintaining proper body alignment and joint movement to prevent contractures and deformities;
and
d)
encouraging, assisting and training residents in self-care and activities of daily living.
23.5 Measures shall be taken to prevent and reduce incontinence for each resident which shall include no less
than:
a)
written assessment by a registered nurse, within two (2) weeks of admission, of each incontinent
resident's ability to participate in a bowel and/or bladder training program;
b)
an individualized plan of care for each resident selected for training to be included in the resident's
nursing care plan to restore as much normal bladder function as possible.
23.6 Administration of Drugs
Drugs shall be administered in accordance with written orders of the attending physician and procedures
established in accordance with sections 26.1 and 26.2 herein. Such procedures shall include measures to assure:
(1) that drugs are checked against physicians' orders; (2) that the resident is "identified" prior to administration
of a drug; (3) that each resident has an individual medication record; and (4) that the dose of drug administered
to each resident is properly recorded therein by the person administering the drug.
a)
Drugs not specifically limited as to time or number of doses when ordered shall be controlled by
33
automatic stop orders or other methods in accordance with written policies.
b)
Physicians' verbal orders for drugs and biologicals shall be given only to a licensed nurse, a
registered pharmacist or to a physician and shall be immediately recorded and signed by the
person receiving the order. Such orders shall be countersigned by the attending physician within
fifteen (15) days.
23.7 Administration of Drugs by Non-Licensed Personnel
Selected non-licensed personnel with demonstrated competency, who have satisfactorily completed a State
Approved Training Program in Drug Administration may administer oral or topical drugs, if adequate medical
and nursing supervision is provided in accordance with reference 23.
Section 24.0 Special Care Units
24.1 Alzheimer's Special Care Units:
Any facility that offers to provide or provides care or services for residents in a manner as defined in section
1.2 herein shall disclose to the licensing agency and any person seeking placement in such Alzheimer's Special
Care Unit the form of the care and treatment provided, in addition to that care and treatment required in
regulation herein.
24.1.1 The information disclosed shall be on a form prescribed by the Department of Health.
24.1.2 The information disclosed shall explain the additional care provided in each of the following
areas:
a)
Philosophy - The Alzheimer's special care unit's written statement of its overall
philosophy and mission which reflects the needs of residents afflicted with dementia.
b)
Pre-Admission, Admission and Discharge - The process criteria for placement, transfer
or discharge from the unit.
c)
Assessment, Care Planning and Implementation -The process used for assessment and
establishing the plan of care and its implementation, including the method by which the
plan of care evolves and is responsive to changes in condition.
d)
Staffing Patterns and Training Ratios - Staff training and continuing education practices.
e)
Physical Environment - The physical environment and design features appropriate to
support the functioning of cognitively impaired adult residents.
f)
Residents Activities - The frequency and types of resident activities.
g)
Family Role in Care - The involvement of families and family support program.
h)
Program Costs - The cost of care and any additional fees.
i)
The licensing agency shall develop a standard disclosure form and shall review the
information provided on the disclosure form by the nursing facility to verify the accuracy
of the information reported on it. Any significant changes in the information provided by
34
the nursing facility will be reported to the licensing agency at the time the changes are
made.
24.2 Special Care Units:
Rehabilitation Special Care Unit and Subacute Special Care Unit:
Any facility that offers to provide or provides care for patients or residents by means of a Rehabilitation Special
Care Unit or a Subacute Special Care Unit shall be required to disclose the form of care or treatment provided,
in addition to that care and treatment required by the rules and regulations for the licensing of nursing facilities.
The information disclosed shall be made to:
a)
The licensing agency on a standard disclosure form developed by the licensing agency; and
b)
To any person seeking placement in a Rehabilitation Special Care Unit or a Special Care Unit of
a nursing facility.
Section 25.0 Dietetic Services
25.1 Each facility shall maintain a dietetic service under the supervision of a full-time person who, as a
minimum, is a graduate of a State approved course that provided 90 or more hours of classroom
instruction in food service supervision and nutrition and has experience in the organization and
management of food service.
a)
When the dietary manager is absent, a responsible person shall be assigned to supervise dietetic
service personnel and food service operations.
25.2 When the dietary manager is not a qualified dietitian who is registered or eligible for registration by the
commission of dietetic registration and/or licensed by the State, the facility shall obtain per written
contractual arrangement adequate and regularly scheduled consultation from a qualified dietitian.
25.3 The responsibilities of the qualified dietitian shall include but not be limited to:
a)
advising the administration and the supervisor of dietetic services on all nutritional aspects of
resident care, food service and preparation;
b)
reviewing food service policies, procedures and menus to insure the nutritional needs of all
residents are met in accordance with reference 12;
c)
serving as liaison with medical and nursing staff on nutritional aspects of resident care;
d)
advising on resident care policies pertaining to dietetic services;
e)
providing dietary counseling to residents when necessary;
f)
planning and conducting regularly scheduled in-service education programs which shall include
training in food service sanitation;
g)
preparing reports which shall include date and time of consultation and services rendered, which
35
reports shall be signed and kept on file in the facility; and
h)
recording observations and information pertinent to dietetic treatment in the resident's medical
record;
i)
input in care plan development.
25.4 Adequate space, equipment and supplies shall be provided for the efficient, safe and sanitary receiving,
storage, refrigeration, preparation and service of food and other related aspects of the food service
operation in accordance with reference 10.
25.5 Policies and procedures shall be established for the dietetic service, pertaining to but not limited to the
following:
a)
responsibilities and functions of personnel;
b)
standards for nutritional care in accordance with reference 12;
c)
alterations or modifications to diet orders or schedules;
d)
food purchasing storage, preparation and service;
e)
safety and sanitation relative to personnel and equipment in accordance with reference 10; and
f)
ancillary dietary services, including food storage and preparation in satellite kitchens and vending
operations in accordance with reference 10; and
g)
a plan to include alternate methods and procedures for food preparation and service to be used
in emergencies.
25.6 All facilities shall provide sufficient and adequately trained supportive personnel, competent to carry out
the functions of the dietetic services.
a)
The dietetic services shall have employees on duty over a period of 12 or more hours per day,
seven days per week.
b)
Those employees involved in direct preparation of food (as opposed to distribution of food,
dishwashing, etc.) shall not be involved in resident care.
c)
Housekeeping and nursing personnel may assist in food distribution, but not food preparation.
Careful handwashing shall be done prior to assisting in food distribution.
25.7 The facility's food service operation shall comply with all appropriate standards of reference 10.
a)
Diet kitchens, nourishment stations, and any other related areas shall be the responsibility of the
dietetic service.
25.8 All menus including alternate choices shall be planned at least one week in advance, to meet the standards
for nutritional care in accordance with reference 12 and to provide for a variety of foods, adjusted for
seasonal changes, and reflecting the dietary preferences of residents.
36
a)
Menus shall indicate nourishments offered to residents between evening meal and bedtime.
b)
Menus shall be posted in a conspicuous place in the dietary department and in resident areas.
c)
Records of menus actually served shall be retained for thirty (30) days.
25.9 All diets shall be ordered in writing by the attending physician.
a)
All diets shall be planned, prepared and served to conform to the physician's orders and to meet
the standards of reference 12 to the extent medically possible.
b)
Diet orders shall be reviewed by the attending physician on same schedule as other physician
orders.
25.10 There shall be a diet manual, approved by the dietitian and available to all dietetic and nursing services
personnel. Diets served to residents shall comply with the principles set forth in the diet manual.
25.11 At least three meals (or their equivalent as ordered by the physician) are to be served daily at regular
hours, with not more than a 14-hour span between a substantial evening meal and breakfast the next day.
a)
Breakfast shall not be served before 7:00 A.M. nor later than 8:30 A.M. Lunch shall not be served
before 11:00 A.M. nor later than 1:00 P.M. Supper shall not be served before 5:00 P.M. nor later
than 6:00 P.M.
b)
Between evening meal and bedtime, nourishments shall be offered to all residents, unless
medically contraindicated.
25.12 Foods shall be prepared by methods that conserve nutritive value, flavor and appearance, and shall be
prepared and served at proper temperatures and in a form to meet individual needs. Food substitutes of
similar nutritive value shall be offered when residents refuse foods served for good reason.
a)
A file of tested recipes, adjusted to appropriate yield, shall be maintained and utilized
corresponding to items on the menu.
b)
House diets shall be appropriately seasoned.
c)
There shall be a supply of staple foods for a minimum of seven (7) days and of perishable foods
for a minimum of two days in the facility.
25.13 Food shall be attractively served on dinnerware of good quality, such as ceramic, plastic or other
materials that are durable and aesthetically pleasing.
25.14 A dining room shall be available for those residents or residents who wish to participate in group dining
in accordance with section 44.1 herein.
25.15 Self-help feeding devices shall be available to those residents who need them to maintain maximum
independence in the activities of daily living.
25.16 A facility contracting for food service shall require as part of the contract, that the contractor comply with
37
the provisions of the regulations herein.
Section 26.0 Pharmaceutical Services
26.1 Each facility shall provide pharmaceutical services either directly within the facility or per contractual
arrangement.
a)
In either instance, appropriate methods and procedures for the procurement and the dispensing of
drugs and biologicals shall be established in accordance with appropriate federal and state laws
and regulations.
26.2 There shall be written policies and procedures relating to the pharmaceutical service which shall require
no less than:
a)
the authority, responsibility and duties of the registered pharmacist;
b)
the selection, procurement, distribution, storage, dispensing or other disposition of drugs and
biologicals in accordance with appropriate federal and state laws and regulations;
c)
maintenance of records of all transactions, including recording of receipt and dispensing or other
disposition of all drugs and biologicals;
d)
inspection of all drug and biological storage and medication areas and documented evidence of
findings;
e)
automatic stop orders for drugs or biologicals;
f)
the use of only approved drugs and biologicals;
g)
control of medicines from any source;
h)
a monitoring program to identify adverse drug reactions, interactions and incompatibilities and
antibiotic antagonisms; and
i)
labeling of drugs and biologicals including name of resident, name of physician, drug dosage,
cautionary instructions, and expiration date.
26.3 Adequate space, equipment, supplies and locked storage areas shall be provided for the storage of drugs
and biologicals based on the scope of services provided. Refrigerated food storage units shall not be
utilized for storage of drugs and/or biologicals except:
a)
In facilities of 30 beds or less, a refrigerated food storage unit may be used for drugs and
biologicals provided they are locked in an appropriate container.
26.4 Drugs may be administered to residents from bulk inventories of non-legend and non-controlled substance
items such as aspirin, milk of magnesia, etc. as ordered by a licensed physician.
26.5 An emergency medication kit, approved by the pharmaceutical service committee or its equivalent, shall
be kept at each nursing station.
26.6 Each nursing unit shall have adequate drug and biological preparation areas with provisions for locked
38
storage in accordance with federal and state laws and regulations.
26.7 In Nursing Facilities
a)
The pharmaceutical service committee or its equivalent, consisting of not less than a registered
pharmacist, a registered nurse, a physician and the administrator, shall:
i.
serve as an advisory body on all matters pertaining to pharmaceutical services;
ii.
establish a program of accountability for all drugs and biologicals;
iii.
develop and review periodically all policies and procedures for safe and effective drug
therapy in accordance with section 26.2 herein; and
iv.
monitor the service.
b)
A registered pharmacist shall assist in developing, coordinating and supervising all
pharmaceutical services in conjunction with the pharmaceutical services committee. In addition,
a registered pharmacist shall:
i.
review the drug and biological regimen of each resident at least monthly;
ii.
report any irregularities to the attending physician and director of nurses. These reports
must show evidence of review and response; and
iii.
document in writing the performance of such review, which documentation shall be kept
on file by the facility and shall be made accessible to inspectors on request.
Section 27.0 Dental Services
27.1 Each facility shall provide or obtain from outside resources, dental services for routine and emergency
care.
27.1.1 Each resident shall have the right to receive dental services from a dentist of his choice.
27.2 A list of community dentists shall be maintained and available to all residents.
27.3 When necessary, arrangements shall be made by facilities for the transportation of residents to and from
the dental care office.
Section 28.0 Laboratory & Radiologic Services
28.1 All nursing facilities shall make provisions for laboratory, x-ray and other services to be provided either
directly by the facility or per contractual arrangements with an outside provider.
28.2 If the facility provides its own laboratory and x-ray services, these shall meet all applicable statutory and
regulatory requirements.
39
28.3 All services shall be provided only per order of the attending physician who shall be promptly notified
of the findings.
28.4 Signed and dated reports of all findings shall become part of the resident's medical record.
Section 29.0 Social Services
29.1 Every facility shall provide social services to attain or maintain the highest practicable physical, mental
and psychological well being of each resident. Social services must be provided either directly by a
qualified social worker or by arrangement with an appropriate health or social service agency or through
consultation with a qualified social worker who would supervise a social work designee appointed by
the administrator.
a)
Services shall pertain to no less than the following:
i.
identification of social and emotional needs of residents through a comprehensive
psychosocial assessment including a social history;
ii.
establishment of a plan of care based on residents' needs;
iii.
procedures for referral of residents, when indicated, to appropriate social agencies and
discharge planning as indicated
29.2 A qualified social worker is defined as an individual with a minimum of a BSW from an accredited
School of Social Work. A social work designee is defined as a staff member appointed by the
administrator who is suited by training or experience to implement plans and procedures enumerated in
accordance with section 29.1 (a) above.
29.3 Sufficient supportive personnel shall be available to meet resident needs.
29.4 Appropriate records shall be maintained of all social services rendered, including consultation services,
and reports shall be included in the resident's medical record.
29.5 Policies and procedures shall be established to assure confidentiality of all resident information consistent
with the requirements of reference 17.
Section 30.0 Specialized Rehabilitative Services
30.1 Each facility shall provide directly or per written agreement with outside providers specialized
rehabilitative and supportive services as needed by residents to improve, restore or maintain functioning.
a)
Residents shall not be admitted or retained in a facility not providing either directly or per
contractual arrangement, those rehabilitative or other specialized services required to meet
individual medical care needs of residents.
30.2 The specialized rehabilitative services, which include physical therapy, speech pathology, audiology and
occupational therapy shall be provided per written order of the attending physician and in accordance with
accepted professional practice by licensed therapists or assistants.
40
30.3 Written administrative and resident care policies and procedures shall be developed for rehabilitative
services by appropriate therapists and representatives of the medical, administrative and professional
staff.
30.4 Rehabilitative services shall be provided under a written plan of care initiated by the attending physician
and developed in consultation with appropriate therapist(s) and nursing personnel.
30.5 Entries of all rehabilitative or supportive services rendered, including evaluation of progress and other
pertinent information, shall be recorded in the resident's medical record and signed by personnel rendering
the service(s).
30.6 Safe and adequate space and equipment shall be available commensurate with the scope of services
provided.
Section 31.0 Resident Activities
31.1 Each facility shall provide for an ongoing activities program, appropriate to the needs and interests of each
resident, to encourage self-care, resumption of normal activities and maintenance of an optimal level of
psychosocial functioning.
31.2 The activities program must be directed by a qualified professional as defined in reference 2.
31.3 The ongoing activities program shall make provisions to:
a)
promote opportunities for engaging in normal pursuits including religious activities of the
resident's choice;
b)
promote the physical, social and mental well-being of each resident;
c)
promote independent as well as group activities; and
d)
harmonize with each resident's needs and medical treatment plan, subject to approval by the
resident's attending physician.
31.4 Adequate space, supplies and equipment shall be available to meet resident care needs in accordance with
the activities program and as stipulated in section 44.0 herein.
31.5 Each resident must have an activities plan, and all pertinent observations and information must be recorded
in the medical record.
Section 32.0 Equipment
32.1 Each facility shall maintain sufficient and appropriate type equipment consistent with resident needs.
32.2 Such equipment shall consist of no less than the following:
41
a)
oxygen;
b)
emergency kit(s);
c)
I.P.P.B. machine (if residents requiring it are admitted);
d)
intravenous set ups;
e)
gastrostomy feeding equipment;
f)
air pressure and/or water pressure mattresses;
g)
clysis, catheterization and irrigation sets;
h)
suction machines; and
i)
wheelchairs and walkers;
j)
cardiac chairs.
32.3 All equipment shall be maintained in safe and good operational condition.
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PART IV ENVIRONMENTAL & MAINTENANCE SERVICES
Section 33.0 Housekeeping
33.1 A full-time employee of the facility shall be designated responsible for housekeeping services, supervision
and training of housekeeping personnel.
33.2 Sufficient housekeeping and maintenance personnel shall be employed to maintain a comfortable, safe,
clean, sanitary and orderly environment in the facility.
a)
Housekeeping personnel may assist in food distribution but not food preparation. Careful
handwashing should be done prior to assisting in food distribution.
33.3 Written housekeeping policies and procedures shall be established in accordance with section 19.1 herein
on Infection Control, for the operation of housekeeping services throughout the facility. Copies shall be
available for all housekeeping personnel.
33.4 All parts of the home and its premises shall be kept clean, neat and free of litter and rubbish and offensive
odors.
33.5 Equipment and supplies shall be provided for cleaning of all surfaces. Such equipment shall be
maintained in a safe, sanitary condition and shall be properly stored.
33.6 Hazardous cleaning solutions, compounds, and substances shall be labeled, stored in a safe place, and kept
in an enclosed section separate from other cleaning materials.
33.7 Cleaning shall be performed in a manner which will minimize the development and spread of pathogenic
organisms in the home environment.
33.8 Exhaust ducts from kitchens and other cooking areas shall be equipped with proper filters and cleaned at
regular intervals. The ducts shall be cleaned as often as necessary and inspected by the facility no less
than twice a year.
33.9 Facilities contracting with outside resources for housekeeping services shall require conformity with
existing regulations.
33.10 Each facility shall be maintained free from insects and rodents through the operation of a pest control
program.
Section 34.0 Laundry Services
34.1 Each facility shall make provisions for the cleaning of all linens and other washable goods.
34.2 Facilities providing laundry service shall have adequate space and equipment for the safe and effective
operation of laundry service and, in unsewered areas, shall obtain approval of the sewage system by the
licensing agency to ensure its adequacy.
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34.3 Written policies and procedures for the operation of the laundry service including special procedures for
the handling and processing of contaminated linens, shall be established in accordance with section 19.0
herein on Infection Control.
34.4 There shall be distinct areas for the separate storage and handling of clean and soiled linens.
a)
The soiled linen area and the washing area shall be negatively pressurized or otherwise protected
to prevent introduction of airborne contaminants.
b)
The clean linen area and the drying area shall be physically divorced from the soiled linen area
and the washing area.
34.5 All soiled linen shall be placed in closed containers prior to transportation.
34.6 To safeguard clean linens from cross-contamination they shall be transported in containers used
exclusively for clean linens which shall be kept covered at all times while in transit and stored in areas
designated exclusively for this purpose.
34.7 A quantity of linen equivalent to three times the number of beds shall be available and in good repair at
all times including the set of linen which is actually in use.
34.8 Facilities contracting for services with an outside resource in accordance with section 16.2 herein shall
require conformity with these regulations.
Section 35.0 Disaster Preparedness
35.1 Each facility shall develop and maintain a written disaster preparedness plan based on the guidelines of
reference 22 which shall include plans and procedures to be followed in case of fire or other emergencies.
35.2 The plan and procedures shall be developed with the assistance of qualified safety, emergency
management, and/or other appropriate experts.
35.3 The plan shall include procedures to be followed pertaining to no less than the following:
a)
fire, explosion, severe weather, loss of power and/or water, flooding, failure of internal systems
and/or equipment, and other calamities;
b)
transfer of casualties;
c)
transfer of records;
d)
location and use of alarm systems, signals and fire fighting equipment;
e)
containment of fire;
f)
notification of appropriate persons;
g)
relocations of residents and evacuation routes;
44
h)
feeding of residents;
i)
handling of drugs and biologicals;
j)
missing residents; and
k)
any other essentials in accordance with reference 22.
35.4 A copy of the plan shall be available at every nursing unit.
35.5 Emergency steps of action shall be clearly outlined and posted in conspicuous locations throughout
the facility.
35.6 Simulated drills testing the effectiveness of the plan shall be conducted for all shifts at least quarterly.
Written reports and evaluation of all drills shall be maintained by the facility.
35.7 All personnel shall receive training in disaster preparedness as part of their employment orientation.
35.8
All facilities shall develop a plan, approved and adopted by the governing board and consistent with
the requirements of this section, to address the year 2000 computer/chip problem (“Y2K”) by
September 30, 1999 and must test such plan by October 30, 1999.
35.8.1 The plan shall include, at a minimum, facility identification of potential problem areas,
remediation of identified problems, and testing for functionality, and shall also include
consideration of vendor and supplier compliance.
45
PART V PHYSICAL PLANT
Section 36.0 New Construction, Addition or Modification
36.1 All construction, as defined in rules and regulations pursuant to reference 5, shall be subject to the
following provisions:
Reference 5 (Certificate of Need)
Reference 6 (Department of Health)
Reference 10 (Food Code)
Reference 15 (HEW Construction R&R)
Reference 16 (State Fire Code)
Reference 18 (R&R for Sewage)
Reference 19 (ANSI Code)
Reference 24 (State Building Code)
Reference 29 (Americans with Disabilities Act)
In addition, any other applicable state and local laws, codes and regulations shall apply. Where there is a
difference between codes, the code having the higher standard shall apply.
36.2 All plans for construction or renovation not requiring review pursuant to reference 5 must be reviewed
by the Department of Health prior to construction.
Section 37.0 General Provisions - Physical Environment
37.1 Each facility shall be constructed, equipped and maintained to protect the health and safety of residents,
personnel and the public. All equipment and furnishings shall be maintained in good condition, properly
functioning and replaced when necessary.
37.2 All steps, stairs and corridors shall be suitably lighted, both day and night. Stairs used by residents shall
have banisters, handrails or other types of support. All stair treads shall be well maintained to prevent
hazards.
37.3 All rooms utilized by residents shall have proper ventilation and shall have outside openings with
satisfactory screens. Shades or Venetian blinds and draperies shall be provided for each window.
37.4 Grounds surrounding the facility shall be accessible to and usable by residents and shall be maintained
in an orderly and well-kept manner.
Section 38.0 Fire & Safety (Existing Facilities)
38.1 Each facility shall meet the provisions of reference 16.
38.2 Each facility shall establish a monitoring program for the internal enforcement of all applicable fire and
safety laws and regulations. Such a program shall include written procedures for the implementation of
said rules and regulations and logs shall be maintained.
Section 39.0 Emergency Power
46
39.1 The facility shall provide an emergency source of electrical power necessary to protect the health and
safety of residents in the event the normal electrical supply is interrupted.
a)
Such emergency power system shall supply power adequate at least for: (1) lighting all means of
egress; (2) equipment to maintain detection, alarm and extinguishing systems; and (3) life support
systems, where applicable.
b)
Where life support systems are used, emergency electrical service shall be provided by an
emergency generator located on the premises.
Section 40.0 Facility Requirements for the Physically Handicapped
40.1 Each facility shall be accessible to, and functional for, residents, personnel and the public. All necessary
accommodations shall be made to meet the needs of persons with mobility disabilities, or sight, hearing
and coordination or perception disabilities in accordance with reference 19.
40.2 Blind, non-ambulatory, physically handicapped or residents with mobility disabilities which limit
self-preservation capability shall not be housed above the street level floor unless the facility is equipped
with an elevator and meets other requirements of reference 19. Further, the facility must meet one of the
following as defined in the N.F.P.A. Standards No. 220:
a)
is of fire resistive construction, one (1) hour protected non-combustible construction; or
b)
is fully sprinklered one (1) hour protected ordinary construction; or
c)
is fully sprinklered one (1) hour protected wood frame construction.
Section 41.0 Nursing Unit
41.1 Each nursing unit, as defined in section 1.16 herein, shall have at least the following:
a)
a nurses' station with adjacent handwashing facility;
b)
storage and preparation area(s) for drugs and biologicals;
c)
storage rooms for walkers, wheelchairs and other equipment;
d)
appropriate utility space; and
e)
a telephone with outside line.
41.2 In addition, each nursing unit shall be equipped with a communication system which, as a minimum, shall
be:
a)
electrically activated;
b)
operated from the bedside of each occupant and from all areas used by occupants, including
multipurpose rooms, toilet and bathing facilities; and
47
c)
capable of alerting the responsible person or persons on duty 24 hours a day, wherever their
station may be.
Section 42.0 Resident Rooms & Toilet Facilities
42.1 Resident rooms shall be designed with a personalized, homelike environment, and equipped for adequate
nursing care, comfort and privacy of residents with no more than two (2) beds per room.
a)
Single bedrooms shall be no less than 100 square feet in area and no less than eight feet wide
exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules.
b)
Multi-bedrooms shall be no less than 160 square feet in area and no less than ten feet wide,
exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules.
c)
New construction must comply with the requirements of section 36.0 herein.
42.2 Each room shall have a window which can be easily opened. The window sill shall not be higher than
3'0" above the floor and shall be above grade level.
42.3 The size of each window shall be no less than 2'6" wide by 4'5" high, double hung or an approved
equivalent.
42.4 Each room shall have direct access to a corridor and outside exposure with the window at or above grade
level.
42.5 Lavatories and bathing areas to be used by the handicapped shall be equipped with grab-bars for the safety
of the residents and shall meet the requirements of reference 15.
42.6 All facilities constructed after the 20th of March 1977 shall have as a minimum, connecting lavettes
between residents' rooms in accordance with the requirements of section 36.0 herein.
a)
However, in facilities constructed prior to 20 March 1977, there shall be no less than one bath per
12 beds and one toilet per eight beds or fraction thereof on each floor where resident rooms are
located and which are not otherwise served by bathing facilities within resident rooms.
42.7 Separate lavatory and toilet facilities shall be provided for employees and the general public
commensurate with the needs of the facility.
42.8 At least one bathtub shall be provided in each nursing unit. Additional bathing fixtures may include
showers.
42.9 Each bathtub or shower shall be in an individual room or enclosure which provides space for the private
use of the bathing fixture, for drying and dressing and for a wheelchair and an attendant.
42.10
Complete privacy shall be provided to each resident in semi-private rooms by the use of overhead
type fire resistive screens and/or cubicle fire resistive curtains suspended by inset overhead tracks
in accordance with reference 16.
48
a)
When overhead type screens and/or cubicle curtains are not provided, each semi-private room
shall be equipped with a fire resistive portable screen.
42.11
Each resident must be provided with bed of proper size and height for the convenience of the
resident, spring and clean, comfortable mattress, bedside stand, straight-back chair, comfortable
chair, dresser and individual closet space for clothing with clothes racks and shelves accessible
to residents in each room, and a reading lamp equipped with bulb of adequate candlepower.
a)
Bedding including bedspread, shall be seasonally appropriate.
42.12
Bedside rails shall be utilized for the protection of residents as determined by the condition of
the resident.
42.13
In all situations where physical configuration is not comfortable to adequate nursing care, comfort
or privacy in the application of the above standards, the licensing agency shall be the ultimate
authority in determining standards to be applied.
Section 43.0 Special Care Unit
43.1 A resident room shall be designated for isolation purposes. Such room shall be properly identified with
precautionary signs, shall have outside ventilation, private toilet and handwashing facilities, and shall
conform to other requirements established for the control of infection in accordance with section 11.0
herein.
Section 44.0 Dining & Resident Activities Rooms
44.1 The facility shall provide one or more clean, orderly, appropriately furnished and easily accessible
room(s) of adequate size designed for resident dining and resident activities.
a)
These areas shall be appropriately lighted and ventilated with non-smoking areas identified.
b)
If a multipurpose room is used, there must be sufficient space to accommodate dining and resident
activities and prevent interference with each other.
c)
The total area set aside for these purposes shall be not less than 30 square feet per bed for the first
100 beds and 27 square feet per bed for all beds in excess of 100.
d)
Storage shall be provided for recreational equipment and supplies.
Section 45.0 Plumbing
45.1 All plumbing shall be installed in such a manner as to prevent back siphonage or cross connections
between potable and non-potable water supplies in accordance with reference 24.
45.2 Fixtures from which grease is discharged may be served by a line in which a grease trap is installed in
accordance with standards of reference 24. The grease trap shall be cleaned sufficiently often to sustain
efficient operation.
Section 46.0 Waste Disposal
49
46.1 Medical Waste:
Medical waste as defined in the Rules and Regulations Governing the Generation, Transportation,
Storage, Treatment, Management & Disposal of Regulated Medical Waste in Rhode Island (DEM-
DAH-MW-01-92), Rhode Island Department of Environmental Management (June 1994), shall be
managed in accordance with the provisions of the aforementioned regulations.
46.2 Other Waste:
Wastes which are not classified as infectious waste, hazardous wastes or which are not otherwise
regulated by law or rule may be disposed in dumpsters or load packers provided the following
precautions are maintained:
a)
Dumpsters shall be tightly covered, leak proof, inaccessible to rodents and animals, and placed
on concrete slabs preferably graded to a drain. Water supply shall be available within easy
accessibility for washing down of the area. In addition, the pick-up schedule shall be maintained
with more frequent pick-ups when required. The dumping site of waste materials must be in
sanitary landfills approved by the Department of Environmental Management.
b)
Load packers must conform to the same restrictions required for dumpsters and in addition, load
packers shall be:
i.
high enough off the ground to facilitate the cleaning of the underneath areas of the stationary
equipment; and
ii.
the loading section shall be constructed and maintained to prevent rubbish from blowing
from said area site.
Section 47.0 Water Supply
47.1 Water shall be distributed to conveniently located taps and fixtures throughout the building and shall be
adequate in volume and pressure for all purposes including fire fighting.
a)
In resident areas, hot water temperatures shall not be less than 100 degrees Fahrenheit nor exceed
110 degrees Fahrenheit (plus or minus two degrees). Thermometers (accuracy of which can be
plus or minus two degrees) shall be provided in each nursing unit to check water temperature
periodically on that unit and at each site where residents are immersed or showered.
b)
Thermostatic or pressure balanced mixing valves are required at each site or fixture used for
immersion or showering of residents. Thermometers and tactical (skin sense) method shall be
used to verify the appropriateness of the water temperature prior to each use.
c)
After 1 July 1991, in addition to temperature regulating devices controlling the generation of
domestic hot water, hot water supply(ies) to resident care areas shall be regulated by anti-
scalding, water tempering or mixing valves (approved by the director or his/her designee) in order
to maintain the temperature standards of 47.1 a).
Section 48.0 Waste Disposal Systems
50
48.1 Any new facility shall be connected to a public sanitary sewer if available, or otherwise shall be subject
to the requirements of reference 18.
Section 49.0 Maintenance
49.1 All essential mechanical, electrical and resident care equipment shall be maintained in safe operating
condition and logs or records shall be maintained of required inspections.
Section 50.0 Other Provisions
50.1 Facilities shall make provisions to ensure that the following are maintained:
a)
adequate and comfortable lighting levels in all areas in accordance with Appendix I;
b)
limitation of sounds at comfort levels;
c)
comfortable temperature levels in all parts of resident occupied areas with a centralized heating
system to maintain a minimum of 75 degrees Fahrenheit during the coldest periods;
d)
adequate ventilation through windows or by mechanical means; and
e)
corridors equipped with firmly secured handrails on each side.
51
PART VI CONFIDENTIALITY - VARIANCE AND APPEAL PROCEDURE
Section 51.0 Confidentiality
51.1 Disclosure of any health care information relating to individuals shall be subject to all the statutory and
regulatory provisions pertaining to confidentiality including but not limited to the provisions of reference
17.
Section 52.0 Variance Procedure
52.1 The licensing agency may grant a variance from the provisions of a rule or regulation in a specific case
if it finds that a literal enforcement of such provision will result in unnecessary hardship to the applicant
and that such a variance will not be contrary to the public interest, public health and/or health and safety
of residents.
Variances shall not be granted for the provisions of these regulations found in sections 2.0, 9.0, 11.0, 14.0,
17.0, 19.0, 21.0, 23.0, 46.0, 47.0, 49.0, and 51.0.
52.2 A request for a variance shall be filed by an applicant in writing, setting forth in detail the basis upon
which the request is made.
a)
Upon the filing of each request for variance with the licensing agency, and within a reasonable time
thereafter, the licensing agency shall notify the applicant by certified mail of its approval or in the
case of a denial, a hearing date, time and place may be scheduled if the facility appeals the denial.
52.3 At a hearing held in furtherance of an appeal from a denial for a variance in accordance with section
52.2(a) above, the applicant shall present his case to the Director or his designee for quasi-judicial
matters, and shall have the burden of persuading the Director or his designee as aforesaid, through the
introduction of clear and convincing evidence, that a literal enforcement of the rules will result in
unnecessary hardship, and that a variance will not be contrary to the public interest, public health and/or
health and safety of residents.
Section 53.0 Deficiencies & Plans of Correction
53.1 The procedures of this section are exclusive of those required in accordance with section 23.4 herein and
of those procedures required to be performed as a result of inspections and investigations conducted in
accordance with Chapter 23-17 of the General Laws of Rhode Island, as amended.
53.2 The licensing agency shall notify the governing body or other legal authority of a facility of violations of
individual standards through a notice of deficiencies which shall be forwarded to the facility within fifteen
(15) days of inspection of the facility unless the director determines that immediate action is necessary
to protect the health, welfare, or safety of the public or any member thereof through the issuance of an
immediate compliance order in accordance with section 23-1-21 of the General Laws of Rhode Island,
as amended.
53.3 A facility which received a notice of deficiencies must submit a plan of corrections to the licensing agency
within fifteen (15) days of the date of the notice of deficiencies. The plan of corrections shall detail any
requests for variances as well as document the reasons therefor.
52
53.4 The licensing agency will be required to approve or reject the plan of corrections submitted by a facility
in accordance with section 3 above within fifteen (15) days of receipt of the plan of corrections.
53.5 If the licensing agency rejects the plan of corrections, or if the facility does not provide a plan of
corrections within the fifteen (15) day period stipulated in section 53.3 above, or if a facility whose plan
of corrections has been approved by the licensing agency fails to execute its plan within a reasonable time,
the licensing agency may invoke the sanctions enumerated in section 9.6 herein. If the facility is aggrieved
by the action of the licensing agency, the facility may appeal the decision and request a hearing in
accordance with reference 20.
53.6 The notice of the hearing to be given by the Department of Health shall comply in all respects with the
provisions of section 10 of reference 20. The hearing shall in all respects comply with sections 9, 10 and
12 of reference 20.
53
PART VII EXCEPTION AND SEVERABILITY
Section 54.0 Exception
Modification of any individual standard herein, for experimental or demonstration purposes, or as deemed
appropriate by the licensing agency, provided that such modification will not be contrary to the public interest
and the public health, or to the health and safety of residents, shall require advance written approval by the
licensing agency.
Section 55.0 Rules Governing Practices and Procedures
55.1 All hearings and reviews required under the provisions of Chapter 23-17 of the General Laws of Rhode
Island, as amended, shall be held in accordance with the provisions of the Rules and Regulations of the
Rhode Island Department of Health Regarding Practices and Procedures Before the Department of
Health and Access to Public Records of the Department of Health (R42-35-PP).
Section 56.0 Severability
56.1 If any provisions of these regulations or the application thereof to any facility or circumstances shall be
held invalid, such invalidity shall not affect the provisions or application of the regulations which can be
given effect, and to this end the provisions of the regulations are declared to be severable.
54
REFERENCES
1.
"Health Care Facility Licensing Act of Rhode Island", Chapter 23-17 of the General Laws of Rhode
Island, as amended.
2.
"Conditions of Participation for Long Term Care Facilities", CFR 42 Part 483, Subpart A; Health Care
Financing Administration, Department of Health Education and Welfare 1991 Edition.
3.
"Residential Care and Assisted Living Facility Licensing Act", Chapter 23-17.4, General Laws of Rhode
Island, as amended.
4.
Rules and Regulations for the Licensing of Residential Care and Assisted Living Facilities, Rhode
Island Department of Health.
5.
"Health Care Certificate of Need Act of Rhode Island", Chapter 23-15 of the General Laws of Rhode
Island, as amended.
6.
"Department of Health", Chapter 23-1 of the General Laws of Rhode Island, as amended.
7.
"Nursing or Personal Care Home Accountability", Chapter 23-17.2 of the General Laws of Rhode Island,
as amended.
8.
"Nursing Home Administrators", Chapter 5-45 of the General Laws of Rhode Island, as amended.
9.
"Vital Statistics", Section 23-3-26 of the General Laws of Rhode Island, as amended.
10.
Food Code (R23-1,21-27-FOOD), Rhode Island Department of Health.
11.
Rules and Regulations Pertaining to the Reporting of Communicable, Occupational, and Environmental
Diseases (R23-6, 10, 11, 24.6-CD/ERD), Rhode Island Department of Health.
12.
"Recommended Dietary Allowances", National Research Council, National Academy of Sciences, 2101
Constitution Avenue, Washington, D.C. 20418.
13.
"Uniform Accountability Procedures for Title XIX Patient Personal Needs Funds in Skilled Nursing and
Intermediate Care Facilities", Rhode Island Department of Social and Rehabilitative Services.
14.
"Linens in the Nursing Home", American Nursing Home Association, Washington, D.C.
15.
"Guidelines for Construction and Equipment of Hospital and Medical Facilities", 1987 Edition, American
Institute of Architects, Committee of Architecture for Health, 1735 New York Avenue, N.W., Washington,
DC 20006.
16.
"Rhode Island State Fire Safety Code", Chapter 23-28.1 of the General Laws of Rhode Island, as amended.
17.
"Confidentiality of Health Care Information", Chapter 5-37.2 of the General Laws or Rhode Island, as
amended.
55
18.
Rules and Regulations Establishing Minimum Standards Relating to Maintenance of Individual Sewage
Disposal Systems, Rhode Island Department of Environmental Management.
19.
"The American National Standard - Specifications for Making Buildings and Facilities Accessible to and
Usable by, the Physically Handicapped", American National Standards Institute, Inc., 1430 Broadway,
New York, New York 10013.
20.
"Administrative Procedures", Chapter 42-35 of the General Laws of Rhode Island of, as amended.
21.
Rules and Regulations for the Registration of Nursing Assistants, (R23-17, 9NA), Rhode Island
Department of Health.
22.
"Disaster Preparedness Guidelines for Nursing Homes", Rhode Island Defense Civil Preparedness
Agency.
23.
"Nurses", Chapter 5-34 of the General Laws of Rhode Island, as amended.
24.
"Rhode Island State Building Code", Chapter 23-27.3 of the General Laws of Rhode Island of, as
amended.
25.
"Rights of Nursing Home Patients", Chapter 23-17.5 of the General Laws of Rhode Island of, as amended.
26.
Rules and Regulations Governing the Generation, Transportation, Storage, Treatment, Management
and Disposal of Regulated Medical Waste in Rhode Island (DEM-DAH-MW-01-92), Rhode Island
Department of Environmental Management, April 1994.
27.
"Guidelines for Prevention of Tuberculosis Transmission in Hospitals", U.S. Department of Health and
Human Services, HHS Publication, No. (CDC) 82-8371, January 1982.
28.
Rules and Regulations for the Licensure & Discipline of Physicians (R5-37-MD/DO), Rhode Island
Department of Health.
29.
"The Americans with Disabilities Act," U.S. Code Title 42 Sections 12101--12213; Title 47
Sections 152, 221, 225, 611; Title 29 Section 706 effective July 21, 1990. Amendments effective
November 21, 1991: 105 Stat. 1077, 1095.
30.
Guidelines for Construction and Equipment of Hospital and Medical Facilities, The American Institute
of Architects Press, Washington, D.C., 1992--1993 edition.
31.
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities,
1994, U.S. Department of Health & Human Services, Public Health Service, Centers for Disease Control
& Prevention, October 28, 1994, vol. 43, no. RR-13.
32.
Recommendations for Preventing the Spread of Vancomycin Resistance: Recommendations of the
Hospital Infection Control Practices Advisory Committee (HICPAC), U.S. Public Health Service,
Centers for Disease Control, Morbidity & Mortality Weekly Report, September 22, 1995 (vol. 44, no.
RR 12).
56
33.
Guidelines for the Control of Vancomycin Resistant Enterococci (VRE) in Nursing Homes and Extended
Care Facilities, Rhode Island Department of Health, April 1996.
57
APPENDIX I
Recommended Lighting Levels for Areas Unique to Nursing Homes
Minimum Foot Candles on Tasks At Any Time
Areas
Foot Candles
Administrative Spaces: General Office
Medical Records
Conference/interview area/room
50
50
50
Corridors Nursing Areas--Day
Corridors Nursing Areas--Night
20
10
Dietary
50
Elevators
15
Examination Room
50
Employee Lounge
50
Employee Locker Room
20
Linens: Sorting soiled linen
Central (clean) linen supply
Linen rooms/closets
30
30
10
Stairways
15
Lobby areas, General
Lobby areas, Receptionist
20
30
Physical therapy
30
Occupational therapy: Work Area, General
Occupational therapy: Work benches/tables
30
50
Speech Therapy
30
58
Areas
Foot Candles
Resident Lounge: General
Resident Lounge: Reading
15
30
Resident Dining Area
30
Resident care unit (or room), general
Resident care room, reading/bed
Resident Room: Toilet
15
30
30
Nursing Station:
General
Desk
Medication Area
Nourishment Center
Corridors--Day
Corridors--Night
30
50
50
50
20
10
Mechanical/electrical room/space
30
Utility room, Clean and soiled
30
Janitor's closet
15
Storage, general
20
Toilet, bathing, and shower facilities
30
Barber and Beautician areas
50
Waiting Area, General
Waiting Area, Reading
20
30
Source:Guidelines for Construction and Equipment of Hospital and Medical Facilities, The American Institute of Architects Press, Washington, D.C., 1992--1993 edition.