216-RICR-40-10-1. Licensing of Nursing Facilities (version Amendment, 05/01/2003 to 04/07/2005)

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) July 2002 April 2003 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. ii TABLE OF CONTENTS Page PART I: LICENSING PROCEDURES & DEFINITIONS 1 1.0 Definitions 1 2.0 Certificate of Need Requirements 4 3.0 General Requirements 4 4.0 Application for License 4 5.0 Issuance and Renewal of License 5 6.0 Capacity and Classifications 9 7.0 Change of Ownership, Operation and/or Location 9 8.0 Inspections 10 9.0 Denial, Suspension, Revocation of License or Curtailment of Activities and Sanctions 11 PART II: ORGANIZATION & MANAGEMENT 13 10.0 Governing Body or Other Legal Authority 13 10.6 Quality Improvement 13 11.0 Administrator 14 12.0 Medical Director and Attending Physicians 15 13.0 Personnel 15 14.0 Handling of Resident Fund 19 15.0 Reporting of Resident Abuse or Neglect, Accidents and Death 19 16.0 Medical Records 20 17.0 Transfer Agreements, Contracts, or Agreements 22 18.0 Rights of Residents 23 18.25 Uniform Reporting System 28 PART III: RESIDENT CARE SERVICES 30 19.0 Resident Care Policies 30 20.0 Infection Control 31 21.0 Physician Services 34 22.0 Nursing Service 35 23.0 Selected Nursing Care Procedures 37 24.0 Alzheimer and Other Dementias Special Care Units or Programs 38 25.0 Dietetic Services 40 26.0 Pharmaceutical Services 42 27.0 Dental Services 44 28.0 Laboratory and Radiologic Services 44 29.0 Social Services 45 30.0 Specialized Rehabilitative Services 45 31.0 Resident Activities 46 32.0 Equipment 47 PART IV: ENVIRONMENTAL & MAINTENANCE SERVICES 48 33.0 Housekeeping 48 34.0 Laundry Service 48 35.0 Disaster Preparedness 49 PART V: PHYSICAL PLANT 51 36.0 New Construction, Addition or Modification 51 37.0 General Provisions -Physical Environment 52 38.0 Fire and Safety (Existing Facilities) 52 39.0 Emergency Power 52 40.0 Facility Requirements for the Physically Handicapped 52 iii Table of Contents (Continued) 41.0 Nursing Unit 53 42.0 Resident Rooms and Toilet Facilities 53 43.0 Special Care Unit 55 44.0 Dining and Resident Activities Rooms 55 45.0 Plumbing 55 46.0 Waste Disposal 55 47.0 Water Supply 56 48.0 Waste Disposal Systems 57 49.0 Maintenance 57 50.0 Other Provisions 57 PART VI: VARIANCE & APPEAL PROCEDURE 58 51.0 Confidentiality 58 52.0 Variance Procedure 58 53.0 Deficiencies and Plans of Corrections 58 PART VII: EXCEPTION & SEVERABILITY 60 54.0 Exception 60 55.0 Rules Governing Practices and Procedures 60 56.0 Severability 60 REFERENCES 61 APPENDIX I 64 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 1.1.1 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 1.1.2 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 Dementia Special Care Unit or Program" means a distinct living environment within a nursing facility that has been physically adapted to accommodate the particular needs and behaviors of those with dementia. Such unit provides increased staffing, therapeutic activities designed specifically for those with dementia and trains its staff on an ongoing basis on the effective management of the physical and behavioral problems of those with dementia. The residents of such a unit/program have had a standard medical diagnostic evaluation and have been determined to have a diagnosis of Alzheimer dementia or another dementia. 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: 2 (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 "Department" means the Department of Health. 1.7 "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. 1.8 "Employee" means an individual employed, whether directly, by the contract with another entity or as an independent contractor, by a long-term care nursing facility on a part-time or full-time basis. 1.9 “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. 1.10 “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. 1.11 "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. 3 1.12 "The licensed capacity of a facility" refers to the number of beds a facility is licensed to operate. 1.13 "Licensing agency" means the Rhode Island Department of Health. 1.14 "Long-term care facility or facility" shall mean a health care facility as defined in Chapter 23-17, which provides long term health care. 1.15 "Mistreatment" means the inappropriate use of medications, isolation, or use of physical or chemical 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. 1.16 "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. 1.17 "Net operating revenue" means net patient revenue plus other operating revenue. 1.18 "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. 1.19 "Nursing service" means a service organized, staffed and equipped to provide nursing care to residents on a continuous basis. 1.20 "Nursing unit" means a self-contained section of a facility such as a wing, ward or floor, housing no more than 60 beds. 1.21 "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. 1.22 "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. 1.23 "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. 1.24 "Standing orders" means orders to be automatically implemented for a class of patients without physician direction for an individual patient within the class. 4 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. 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 Assisted Living Residences (R23-17.4-ALR) (see reference 4). 3.4 Any nursing facility that utilizes latex gloves shall do so in accordance with the provisions of the Rules and Regulations Pertaining to the Use of Latex Gloves by Health Care Workers, in Licensed Health Care Facilities, and by Other Persons, Firms, or Corporations Licensed or Registered by the Department promulgated by the Department of Health. 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 5 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 a non-returnable, non-refundable 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 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 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. 6 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; (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 7 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 (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 8 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 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, 1999; (5) that such residential care/assisted living facility shall have been granted a certificate of need by the Department of Health; and (6) 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, 2004, 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, to greater than the level of the facility's licensed bed capacity as of August 21, 1996 plus the 9 greater of ten (10) beds or ten percent (10%) of such licensed bed capacity. 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. 5.10 Notwithstanding any other provision of the law to the contrary, including any moratorium on increasing bed capacity in nursing facilities that may otherwise apply, a nursing facility may take out of service any or all beds of its licensed capacity without impediment to its right to place back into service such beds at a future date under the same terms and conditions as applied at the time of taking them out of service. 5.10.1 "Take out of service", as used in this section, means an action by a nursing facility to leave a bed(s) unutilized as a nursing facility bed for a specified period of time. Specified periods of time shall be in six-month increments, at a minimum. 5.10.2 The nursing facility shall inform the licensing agency in writing no less than ten (10) days prior to taking bed(s) out of service and shall describe the alteration of physical space (if any) resulting from taking such bed(s) out of service. 5.10.3 Beds taken out of service shall reduce a nursing facility's licensed bed capacity by the number of beds taken out of service. 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. 6.1.1 The facility shall identify to the licensing agency the location of licensed beds and shall maintain proper space and furnishings for such locations. 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. 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. 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 10 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 resident, his/her guardian or decision-maker, and the Department of Health shall be notified. The facility shall provide the Department with a plan for orderly closure, and transfer of residents and records. 7.3.1 In the event that a facility seeks a variance from the required thirty (30) day notice of closure of the facility, reasonable advance notice of the hearing for the variance shall be given by the facility to the resident, his or her guardian, or relative so appointed or elected to be his or her decision-maker, and an opportunity to be present at the hearing shall be granted to the person so designated. 7.3.2 In the event of the voluntary closure of a facility, which closure is the result of a variance from the required thirty (30) day notice of closure, granted by the Director, reasonable advance notice of the closure shall be given by the facility to the resident, his or her guardian, or relative so appointed or elected to be his or her decision-maker. 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 at any time 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. Section 9.0 Denial, Suspension, Revocation of License or Curtailment of Activities & Sanctions 9.1 The licensing agency is authorized to deny, suspend, revoke the license, or curtail the activities 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. 11 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 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 When 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. 12 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. 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. 13 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, 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. Quality Improvement 10.6 The governing body shall ensure that there is an effective, ongoing, facility-wide quality improvement program to evaluate the provision of resident care. 10.7 The organized facility-wide quality improvement program shall be ongoing and shall have a written plan of implementation. The written quality improvement plan shall include at least the following: a) program objectives; 14 b) oversight responsibility (e.g., reports to the governing body); c) facility-wide scope, including quarterly quality improvement meetings on topics relevant to quality improvement; Minutes and attendance records of these meetings shall maintained on file. d) program administration and coordination; e) involvement of all resident care disciplines/services; f) methodology for monitoring and evaluating quality of care; g) priority setting and problem resolution; h) documentation of the quality improvement plan review. 10.8 All resident care services, including services rendered by a contractor, shall be evaluated. 10.9 The facility shall take and document appropriate remedial action to address problems identified through the quality improvement program. The outcome(s) of the remedial action shall be documented and submitted to the governing body for their consideration. 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 staff and other professional 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, 15 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 Medical Director and Attending Physicians 12.1 The governing body or other legal authority shall designate a physician to serve as medical director. The medical director shall be a physician licensed to practice in Rhode Island in accordance with the provisions of reference 27 herein. Upon appointment, the name of the medical director shall be submitted to the Department. Each time a new medical director is appointed, the name of said physician shall be reported promptly to the Department. The medical director's Rhode Island medical license number, medical office address, telephone number, emergency telephone number, hospital affiliation and other credentialing information shall be maintained on file at the facility and updated as needed. Responsibilities of the medical director shall include, but not be limited to, implementation of resident care policies, coordination of medical care in the facility, ensuring completion of employee health screening and immunization requirements contained in sections 13.11 and 13.12 herein. 12.2 The administrator shall notify the medical director immediately when any enforcement order as described in section 9.0 herein is issued by the Department or when the administrator is notified of any Medicare/Medicaid certification enforcement action. The administrator shall provide copies of all statements of deficiencies and related plans of correction to the medical director in a timely fashion. 12.3 The medical director shall attend the quarterly quality assurance/improvement meetings, as required in section 10.7 (d) herein. The administrator, or his/her designee, shall provide the medical director with adequate notice of the quarterly quality assurance/improvement meeting. 12.4 Each nursing facility shall maintain an active file of all physicians attending residents for any reason(s), including their phone numbers and addresses, an emergency phone number, their current medical license numbers, and the physician's preferred admitting hospital. This file of physicians shall be revised and updated, as needed, but no less than annually. 12.5 The governing body or other legal authority shall make available to each physician attending residents in the facility all of the policies governing resident care management and services. Section 13.0 Personnel Criminal Records Check 13.1 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, to be initiated prior to, or within one week of employment. 13.2 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. 16 13.3 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. 13.4 Any disqualifying information, as defined below, 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 information has been discovered, but shall not be informed by the BCI of the nature of the disqualifying information. 13.4.1 Disqualifying information, as defined in Chapter 23-17-37 of the Rhode Island General Laws, as amended, means information produced by a criminal records review pertaining to conviction, for the following crimes will result in a letter to the employee and employer disqualifying the applicant from said employment: murder, voluntary manslaughter, involuntary manslaughter, first degree sexual assault, second degree sexual assault, third degree sexual assault, assault on persons sixty (60) years of age or older, child abuse, assault with intent to commit specified felonies (murder, robbery, rape, burglary, or the abominable and detestable crime against nature), felony assault, patient abuse, neglect or mistreatment of patients, burglary, first degree arson, robbery, felony drug offenses, larceny or felony banking law violations. 13.5 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. 13.6 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. 13.7 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. Policies and Procedures 13.8 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. Job Descriptions 13.9 There shall be a job description for each classification of position which delineates qualifications, duties, authority and responsibilities inherent in each position. 17 a) For those selected non-licensed personnel authorized to administer drugs in accordance with section 23.9 herein, a job description delineating qualifications, duties and responsibilities shall be provided. Health Screening 13.10 Upon hire and prior to delivering services, a pre-employment health screening shall be required for each individual who has or may have direct contact with a resident in the nursing facility. Such health screening shall be conducted in accordance with the Rules and Regulations Pertaining to Immunization, Testing, and Health Screening for Health Care Workers (R23-17- HCW) promulgated by the Department of Health. 13.11 Influenza: Long term care employee immunization: Except as provided in subsection v (below), every facility in this state shall request that employees receive yearly immunization for influenza virus and at least a single immunization for pneumococcal disease in accordance with Chapter 23-17.19 of the Rhode Island General Laws, as amended. Employee Immunization i. Notice to employees: Every facility shall notify every employee of the immunization requirements of the provisions of Chapter 23-17.19 of the Rhode Island General Laws, as amended, and request that the employee agree to be immunized against influenza virus. ii. Records and immunizations: The facility shall require documentation of annual immunization against influenza virus for each employee, which includes written evidence from a health care provider indicating the date and location the vaccine was administered. Upon finding that an employee is lacking such immunization or the facility or individual is unable to provide documentation that the individual has received the appropriate immunization, the facility shall make available the immunization. iii. Other immunizations: An individual who is newly employed as an employee shall have his status for influenza determined by the facility, and, if found to be deficient, the facility shall make available the necessary immunization. iv. Immunization authorized: Nothing in this section shall prohibit the immunization against pneumococcal disease to employees. v. Exceptions: No employee shall be required to receive either the influenza or pneumococcal vaccine if any of the following apply: 1) the vaccine is contraindicated; or 2) it is against his religious beliefs. Personnel Records 13.12 Personnel records shall be maintained for each employee, shall be available at all times for inspection and shall include no less than the following: 18 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 23.9 herein. In-Service Education 13.13 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 and shall include annual programs on 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. 13.13.1 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 13.14 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. This badge shall be worn in a manner that makes the badge easily seen and read by the resident or visitor. Licensure Verification 13.15 For every person employed by the nursing facility who is licensed, certified, or registered by the Department, a mechanism shall be in place to electronically verify such licensure via the Department's licensure database. Section 14.0 Handling of Resident Fund 14.1 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. 19 14.2 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. 14.3 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 18.16 herein. Such records shall be available for inspection. 14.4 In addition to requirements of sections 14.1 through 14.3 above, each facility shall conform to the standards of reference 13 in relation to Title XIX residents. Section 15.0 Reporting of Resident Abuse or Neglect, Accidents & Death 15.1 Any physician, nurse or other employee of a nursing facility who has reasonable cause to believe that a resident has been abused, exploited, mistreated, 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) The facility shall maintain evidence that all allegations of abuse, neglect, and/or mistreatment have been thoroughly investigated and that further potential abuse has been prevented while the investigation is in progress. The results of said investigation shall be reported to the Department. Appropriate corrective action shall be taken, as necessary. 15.2 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. 15.3 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 21.3 (c) herein, shall be reported to the Office of the State Medical Examiners. 15.4 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 facility medical director and to the Office of the State Medical Examiners in accordance with Title 23, Chapter 4 of the General Laws of Rhode Island, as amended. 15.5 Reporting requirements, pursuant to Chapter 23-17.8 of the General Laws must be posted. Section 16.0 Medical Records 16.1 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 20 ultimate responsibility for the maintenance of medical records; such responsibility may be delegated in writing to a staff member. 16.2 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. a) All accidents, including falls, whether resulting in an injury or not, shall be immediately recorded in the resident's record. b) Detailed descriptions of all pressure ulcers, or other skin lesions, shall be recorded in the resident's record. 16.3 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 {or PASARR (Pre-Admission Screening and Annual Resident Review), where appropriate}; 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, including any immunizations; 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; 21 p) diagnosis at time of discharge; and q) disposition and final summary notes. 16.4 At time of discharge, a discharge summary, summarizing the resident's stay, shall be completed promptly and signed by the attending physician. 16.5 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 resident's medical record. 16.6 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. 16.7 Provisions shall be made for the safe storage of medical records to safeguard them against loss, destruction or unauthorized use. 16.8 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. 16.9 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 18.15 (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 17.0 Transfer Agreements, Contracts, or Agreements 17.1 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 transfer or admission of residents between the hospital and the facility, whenever deemed medically appropriate in writing by a physician; 22 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; 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 ("Long Form") available from the Department; and c) security and accountability for the resident's personal effects during transfer. 17.2 Designated nursing facility personnel shall complete the “Continuity of Care” form ("Short 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. 17.3 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. 23 Financial Interest Disclosure 17.4 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. 17.5 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 Providence, RI 02908 401.222.2566 17.6 Non-compliance with sections 17.4 and 17.5 (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 18.0 Rights of Residents 18.1 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 24. 18.2 Each resident shall be offered treatment without discrimination as to gender, age, race, color, religion, national origin, handicap, or source of payment. 18.3 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. 18.4 Each resident shall have the right to choose his or her own physician subject to the physician's concurrence. 18.5 Each resident or responsible party 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. 18.6 Each resident or responsible party shall be informed in writing, prior to, or at the time of 24 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. 18.7 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. 18.8 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. 18.9 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. 18.9.1 There shall be prompt efforts by the facility staff to resolve resident's grievances. 18.10 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. 18.11 A resident shall not be required to perform services for the facility that are not included for therapeutic purposes in his plan of care. 18.12 Residents may meet with and participate in activities of social, religious and community groups 25 at their discretion unless medically contraindicated per written medical order. 18.13 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, physicians, 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 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. 18.14 Residents shall have the right to obtain personal services or to purchase needs outside of the facility. 26 18.15 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. 18.16 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 residents in writing. The facility shall have the obligation to conduct the resident'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 resident. 18.17 Residents shall be assured privacy for visits by the spouse or other partner. If both are residents 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. 18.18 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. 18.18.1 Bed-Hold and Readmission: A nursing facility must provide written information pertaining to bed-hold and readmission for residents transferred for hospitalization or 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 27 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 of health shall receive, on a monthly basis, the names from each nursing home of those persons awaiting readmission under these provisions. 18.19 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. 18.19.1 Nursing facility residents who smoke may do so only in private or semi-private rooms where both residents 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. 18.20 The resident shall have the right to have his or her pain assessed on a regular basis. 18.21 The health care facility shall respond in a reasonable manner to the request of a resident's physician, certified nurse practitioner and/or a physician's assistant for medical services to the resident. The health care facility shall also respond in a reasonable manner to the resident's request for other services customarily rendered by the health care facility to the extent the services do not require the approval of the resident's physician, certified nurse practitioner and/or a physician's assistant or are not inconsistent with the resident's treatment. 18.22 Heat relief: Pursuant to section 23-17.5-27 of the Rhode Island General Laws, as amended, any nursing home facility which does not provide air conditioning in every patient room shall provide an air conditioned room or rooms in a residential section(s) of the facility to provide relief to patients when the outdoor temperature exceeds eighty (80) degrees Fahrenheit. 18.23 All rights and responsibilities specified in section 18.4, 18.8, 18.16 and 18.18 shall devolve, in order of priority, to a resident's guardian, next of kin, sponsoring agency(ies) or representative 28 payor (except when the facility itself is the representative payor) for residents who are: 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. 18.24 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. d) the telephone number of the state long-term care ombudsman: 401-785-3340. 18.25 Uniform 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. 18.26 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. 29 18.27 The 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. 18.28 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. 30 PART III RESIDENT CARE SERVICES Section 19.0 Resident Care Policies 19.1 Each facility shall have written resident care policies to govern the continuing nursing care and related medical or other services provided. 19.2 Resident care policies and procedures shall be developed and reviewed annually, and revised as necessary, 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.). Documentation of this annual review shall be made available to the licensing agency upon request. 19.3 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 31 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: 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 18.18.1 c) herein; and vii. such other information pertinent to ensure continuity of resident care. 19.4 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. Section 20.0 Infection Control 20.1 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; 32 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 30. 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 32. (See also reference 31 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), vancomycin resistant enterococci (VRE), 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. 20.2 Infection control provisions shall be established for the mutual protection of residents, employees, and the public. 20.3 A continuing education program on infection control shall be conducted periodically for all staff. 20.4 Reporting of Communicable Diseases a) Each facility shall report promptly to the Rhode Island Department of Health, Division of Disease Prevention & 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 Prevention & 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 Prevention & Control or to the Office 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. 33 Immunization Policies/Practices 20.5 Long term care resident immunization: Except as provided in subsection 20.5(e) (below), every facility in this state shall request that residents be immunized for influenza virus and pneumococcal disease in accordance with Chapter 23-17.19 of the Rhode Island General Laws, as amended. 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) Notice to resident: In accordance with the provisions of section 23-17.19-4 of the Rhode Island General Laws, as amended, upon admission, the facility shall notify the resident and legal guardian of the immunization requirements of Chapter 23-17.19 of the Rhode Island General Laws, as amended, and request that the resident agree to be immunized against influenza virus and pneumococcal disease. b) Records and immunizations: Every facility shall document the annual immunization against influenza virus and immunization against pneumococcal disease for each resident which includes written evidence from a health care provider indicating the date and location the vaccine was administered. Upon finding that a resident is lacking such immunization or the facility or individual is unable to provide documentation that the individual has received the appropriate immunization, the facility shall make available the immunization. c) Other immunizations: An individual who becomes a resident shall have his status for influenza and pneumococcal immunization determined by the facility, and, if found to be deficient, the facility shall make available the necessary immunizations. d) Vaccinations must be provided in accordance with the most current ACIP (Advisory Council on Immunization Practices) guidelines for these vaccinations. e) Exceptions: No resident or employee shall be required to receive either the influenza or pneumococcal vaccine if any of the following apply: 1) the vaccine is contraindicated; 2) it is against his religious beliefs; or 3) the resident or the resident's legal guardian refuses the vaccine after being fully informed of the health risks of such action. f) 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) number of all eligible residents 65 years and older residing in or admitted to the facility from September 15th to March 31st of the next year and the number of influenza vaccinations administered in that period; ii) number of all eligible residents 64 years and younger residing in or admitted to the 34 facility from September 15th to March 31st of the next year 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; v) the number of outbreaks in the facility each year due to influenza virus and pneumococcal disease, if known; vi) the number of hospitalizations of facility residents each year due to influenza virus, pneumococcal disease and complications thereof; if known; and vii) other reports as may be required by the Director. Section 21.0 Physician Service 21.1 All residents shall remain or be under the care of a physician of his or her choice, subject to the physician's concurrence. 21.1.1 All physician assistant services shall be in accordance with the provisions of Chapter 5- 54 of the General Laws. 21.1.2 All nurse practitioner services shall be in accordance with the provisions of Chapter 5-34 of the General Laws. 21.2 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. 21.3 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. Accordingly, recommendations or orders from consultants shall be approved by the attending physician prior to implementation of the order. 35 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; 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 23.8 (b) herein. 21.4 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. 21.5 Standing orders shall not be permitted. All orders shall be recorded in the resident's medical record and shall be properly signed. However, a physician's order for an individual resident may refer to treatments described in a written protocol adopted by the facility. An exception to the requirements of this section shall be made for the administration of influenza and pneumococcal immunizations as provided in section 20.5 herein. Section 22.0 Nursing Service 22.1 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. 22.2 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 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 22.2 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; 36 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. 22.3 Each facility shall have a registered nurse on the premises twenty-four (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. Each nursing facility shall be responsible to have sufficient qualified staff to meet the needs of the residents. 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. 22.4 The Director of Nurses may act as a charge nurse only when the facility is licensed for 30 beds or less. 22.5 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, the licensing agency may require the facility to provide such additional staffing and 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. 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. 37 22.6 No nursing staff of any facility shall be regularly scheduled for double shifts. Section 23.0 Selected Nursing Care Procedures 23.1 Written resident care plans, including problems, measurable goals, interventions, and time frames, 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, or when there is a significant change in the resident's health status. 23.2 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. 23.3 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. 23.4 Every facility shall have an active program for rehabilitative nursing care. 23.5 Such supportive and restorative nursing care needed to maintain maximum functioning of the resident shall be provided. 23.6 Each resident shall be given care to prevent pressure ulcers, 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. 23.7 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. Administration of Drugs 38 23.8 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 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. Administration of Drugs by Non-Licensed Personnel 23.9 Selected non-licensed personnel who have satisfactorily completed a State Approved Course in Drug Administration and have demonstrated competency in accordance with the state-approved protocol in drug administration may administer oral or topical drugs, with the exception of all Schedule II drugs, with supervision in accordance with the state-approved protocol in drug administration. If such unlicensed personnel are from temporary employment agencies, the facility shall have onsite evidence of supervision in accordance with the state-approved protocol in drug administration. Section 24.0 Special Care Units 24.1 Alzheimers and Other Dementia Special Care Units or Programs: Any facility that provides or offers to provide 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 and Other Dementia Special Care Unit/Program the form of specialized care and treatment provided that is in addition to the care and treatment required in the regulations herein. 24.1.1 The information disclosed shall be on a form prescribed by the Department of Health. 24.1.2 The facility shall provide care and services as described in the disclosure form, and consistent with the rules and regulations herein. The information disclosed shall explain the additional care provided in each of the following areas: a) Philosophy - The special care unit/program’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 and criteria for placement (which shall include a diagnosis of dementia), 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 39 plan of care evolves and is responsive to changes in condition. d) Staffing Patterns and Training - Staff patterns and training and continuing education programs, which shall emphasize the effective management of the physical and behavioral problems of those with dementia. e) Physical Environment - The physical environment and design features shall be appropriate to support the functioning and safety of cognitively impaired adult residents. f) Therapeutic Activities - The frequency and types of resident activities. Therapeutic activities shall be designed specifically for those with dementia. g) Family Role in Care – The facility shall provide for the involvement of families and family support program. h) Program Costs - The cost of care and any additional fees. 24.1.3 Any significant changes in the information provided by the nursing facility will be reported to the licensing agency at the time the changes are made. Rehabilitation Special Care Unit and Subacute Special Care Unit: 24.2 Any facility that provides or offers to provide care for patients or residents by means of a Rehabilitation Special Care Unit or a Subacute Special Care Unit shall be required to disclose to the licensing agency and to any person seeking placement in a Rehabilitation Special Care Unit or a Special Care Unit of a nursing facility the form of specialized care and treatment provided that is in addition to the care and treatment required in the regulations herein. 24.2.1 The information disclosed shall be on a form prescribed by the Department. 24.2.2 The facility shall provide care and services as described in the disclosure form, and consistent with the rules and regulations herein. 24.2.3 Any significant changes in the information provided by the nursing facility shall be reported to the licensing agency at the time the changes are made. 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 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 40 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 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 41 g) a plan to include alternate methods and procedures for food preparation and service, including provisions for potable water, 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. 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 42 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 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. Such services shall be provided in accordance with the requirements of references 25 and 34 herein. 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; 43 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 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 44 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/her 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. 28.3 All services shall be provided only per order of the attending physician who shall be promptly notified of the findings in accordance with a protocol established by the facility. Such a protocol shall describe which laboratory values mandate a call to the resident’s attending physician. 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. 45 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. 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 46 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 types of equipment consistent with resident needs and sufficient to meet emergency situations. 32.2 All equipment to meet the needs of the residents shall be maintained in safe and good operational condition. 47 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 20.1 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. 34.3 Written policies and procedures for the operation of the laundry service including special 48 procedures for the handling and processing of contaminated linens, shall be established in accordance with section 20.0 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 including the set of linen which is actually in use shall be available and in good repair at all times. 34.8 Facilities contracting for services with an outside resource in accordance with section 17.3 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 that shall include plans and procedures to be followed in case of fire or other emergencies. The plan and procedures shall be developed with the assistance of qualified safety, emergency management, and/or other appropriate experts and shall be coordinated with the local emergency management agency. 35.2 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; h) feeding of residents; 49 i) handling of drugs and biologicals; j) missing residents; and k) any other essentials as required by the local emergency management agency. 35.3 A copy of the plan shall be available at every nursing unit. 35.4 Emergency steps of action shall be clearly outlined and posted in conspicuous locations throughout the facility. 35.5 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. 35.6 All personnel shall receive training in disaster preparedness as part of their employment orientation. 50 PART V PHYSICAL PLANT Section 36.0 New Construction, Addition or Modification 36.1 All new construction, alterations, extensions or modifications of an existing facility, 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 (AIA Construction Guidelines) Reference 16 (State Fire Code) Reference 18 (Sewage regulations) Reference 19 (ANSI Code) Reference 23 (State Building Code) Reference 28 (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 new construction or the renovation, alteration, extension, modification or conversion of an existing facility that may affect compliance with sections 39.0, 41.0, 42.0, 43.0, 44.0 and 50.0 herein, and reference 15, shall be reviewed by a licensed architect, acceptable to the Director. Said architect shall certify that the plans conform to the construction requirements of sections 39.0, 41.0, 42.0, 43.0, 44.0 and 50.0 herein, and reference 15, prior to construction. The facility shall maintain a copy of the plans reviewed and the architect’s signed certification, for review by the Department of Health upon request. 36.2.1 In the event of non-conformance for which the facility seeks a variance, the general procedures outlined in section 52 shall be followed. Variance requests shall include a written description of the entire project, details of the non-conformance for which the variance is sought and alternate provisions made, as well as detailing the basis upon which the request is made. The Department may request additional information while evaluating variance requests. 36.2.2 If variances are granted, a licensed architect shall certify that the plans conform to all construction requirements of sections 39.0, 41.0, 42.0, 43.0, 44.0 and 50.0 herein, and reference 15, except those for which variances were granted, prior to construction. The facility shall maintain a copy of the plans reviewed, the variance(s) granted and the architect’s signed certification, for review by the Department upon request. 36.3 Upon completion of construction, the facility shall provide written notification to the Department describing the project, and a copy of the architect's certification. The facility shall obtain authorization from the Department prior to occupying/re-occupying the area. At the discretion of the Department, an on-site visit may be required Section 37.0 General Provisions - Physical Environment 51 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 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 52 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 1.20 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 clean and soiled 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 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. At least five percent (5%) of the total beds (per unit or per facility) shall be located in single-bed rooms, each with a private bathing facility and toilet. 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. In new construction, single bedrooms shall be no less than 120 square feet in area. 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. In new construction, multi-bedrooms shall be no less than 200 square feet in area. 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. 53 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 toilet rooms between residents' rooms in accordance with the requirements of section 36.0 herein. In all facilities constructed after 1 August 2001, patient toilet rooms shall be equipped with facilities for cleaning bedpans. a) However, in facilities constructed prior to 20 March 1977, there shall be no less than one toilet per eight beds or fraction thereof on each floor where resident rooms are located. 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 A minimum of one (1) bathtub or shower shall be provided for every twelve (12) residents, not otherwise served by bathing facilities in resident rooms. At least one bathtub shall be provided in each nursing unit. 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. 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 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. 54 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 20.0 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 23. 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 23. The grease trap shall be cleaned sufficiently often to sustain efficient operation. Section 46.0 Waste Disposal 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: 55 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. c) Recycleable waste: Containers for recyclable waste, including paper and cardboard, shall be tightly covered, leak proof, inaccessible to rodents and animals, and placed on concrete slabs preferably graded to a drain. In addition, the pick-up schedule shall be maintained with more frequent pick-ups when required. 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 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 56 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 periodic 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 for the residents in all parts of resident occupied areas with a centralized heating system to maintain a minimum of 70°F 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. f) Heat relief: Pursuant to section 23-17.5-27 of the Rhode Island General Laws, as amended, any nursing home facility which does not provide air conditioning in every patient room shall provide an air conditioned room or rooms in a residential section(s) of the facility to provide relief to patients when the outdoor temperature exceeds eighty (80) degrees Fahrenheit. 57 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, 15.0, 18.0, 20.0, 22.0, 23.0, 46.0, 47.0, 49.0, and 51.0. Effective June 30, 2004, variances shall not be granted for the provisions contained in section 29.1 herein. 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 22.5 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 58 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. 53.4 The licensing agency will be required to approve or reject the plan of corrections submitted by a facility in accordance with section 53.3 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. 59 PART VII EXCEPTION AND SEVERABILITY Section 54.0 Exception 54.1 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. 60 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 Assisted Living Residences, 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 (R23-10-DIS), 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 Design and Construction of Hospital and Health Care Facilities", 2001 Edition, American Institute of Architects Academy of Architecture for Health with Assistance from the U.S. Department of Health and Human Services, 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. 61 17. "Confidentiality of Health Care Information", Chapter 5-37.3 of the General Laws or Rhode Island, as amended. 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, (R23-17.9-NA), Rhode Island Department of Health. 22. "Nurses", Chapter 5-34 of the General Laws of Rhode Island, as amended. 23. "Rhode Island State Building Code", Chapter 23-27.3 of the General Laws of Rhode Island of, as amended. 24. "Rights of Nursing Home Patients", Chapter 23-17.5 of the General Laws of Rhode Island of, as amended. 25. 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. 26. "Guidelines for Prevention of Tuberculosis Transmission in Hospitals", U.S. Department of Health and Human Services, HHS Publication, No. (CDC) 82-8371, January 1982. 27. Rules and Regulations for the Licensure & Discipline of Physicians (R5-37-MD/DO), Rhode Island Department of Health. 28. "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. 29. 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. 30. 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). 31. Guidelines for the Control of Vancomycin Resistant Enterococci (VRE) in Nursing Homes and Extended Care Facilities, Rhode Island Department of Health, April 1996. 62 32. Rules and Regulations Pertaining to Immunization, Testing, and Health Screening for Health Care Workers (R23-17-HCW), Rhode Island Department of Health. 33. Rules and Regulations Pertaining to Pharmacists, Pharmacies & Manufacturers, Wholesalers & Distributors (R5-19-PHAR), Rhode Island Department of Health. 34. Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC), U.S. Public Health Service, Centers for Disease Control, Morbidity & Mortality Weekly Report, December 26, 1997 / 46(RR-18);1-42. Available online at: www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm 35. Policy and Procedures for Tuberculosis Screening of Health-Care Workers. Francis J. Curry National Tuberculosis Center, 3180 18th Street, Suite 101, San Francisco, CA 94110-2028 (telephone: 415-502-4600 facsimile: 415-502-4620) available online at: www.nationaltbcenter.edu 36. Rules and Regulations Pertaining to the Use of Latex Gloves by Health Care Workers, in Licensed Health Care Facilities, and by Other Persons, Firms, or Corporations Licensed or Registered by the Department (R23-73-LAT), Rhode Island Department of Health. Monday, March 31, 2003 nursingfacilities-final regs-april03.doc 63 APPENDIX I Recommended Lighting Levels for Areas Unique to Nursing Homes Minimum Foot Candles on Tasks At Any Time 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 64 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. 65