216-RICR-40-10-1
216-RICR-40-10-1. Licensing of Nursing Facilities (version Amendment, 12/10/2012 to 08/01/2013)
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
May 1998
November 1979
September 1998 (E)
March 1980
January 1999 (E)
December 1980
March 1999
February 1984 (E)
May 1999 (E)
May 1984 (E)
July 1999 (E)
February 1985
September 1999 (E)
January 1987
September 1999
May 1987
January 2000
September 1987
January 2002 (re-filing in
accordance with the provisions of
section 42-35-4.1 of the Rhode
Island General laws, as amended)
October 1988
July 2002
July 1989
April 2003
July 1989 (E)
March 2005
March 1990
October 2006
August 1990
January 2007 (re-filing in
accordance with the provisions of
section 42-35-4.1 of the Rhode Island
General laws, as amended)
July 1991
January 2012 (re-filing in
accordance with the provisions of
section 42-35-4.1 of the Rhode Island
General laws, as amended)
March 1992
September 2012
July 1992 (E)
December 1992
September 1993 (E)
January 1994
January 1994 (E)
May 1994
May 1994 (E)
September 1994
February 1996
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INTRODUCTION
These Rules and Regulations for Licensing of Nursing Facilities (R23-17-NF) are promulgated
pursuant to the authority conferred under section 23-17-10 of the General Laws of Rhode Island, as
amended, and are established for the purpose of adopting minimum requirements for the licensure of
nursing facilities in this state.
Pursuant to the provisions of section 42-35-3(c) of the General Laws of Rhode Island, as
amended, consideration was given to the following: (1) alternative approaches to the regulations; and
(2) duplication or overlap with other state regulations. Based on available information, no alternative
approach, duplication or overlap was identified. The health and safety of the public overrides and
economic impact. These rules and regulations are adopted in the best interest of the public health,
safety and welfare.
These rules and regulations shall supersede all previous Rules and Regulations For the
Licensing of Nursing Facilities (R23-17-NF) promulgated by the Rhode Island Department of Health
and filed with the Secretary of State.
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TABLE OF CONTENTS
Page
PART I:
LICENSING PROCEDURES and DEFINITIONS
1
1.0
Definitions
1
2.0
Certificate of Need Requirements
5
3.0
General Requirements
6
4.0
Application for License
7
5.0
Issuance and Renewal of License
8
6.0
Capacity and Classifications
13
7.0
Change of Ownership, Operation and/or Location
13
8.0
Inspections
14
9.0
Denial, Suspension, Revocation of License or Curtailment of Activities and Sanctions
15
PART II:
ORGANIZATION and MANAGEMENT
19
10.0
Governing Body or Other Legal Authority
19
11.0
Quality Improvement
20
12.0
Administrator
21
13.0
Medical Director and Attending Physicians
22
14.0
Personnel
23
15.0
Handling of Resident Fund
26
16.0
Reporting of Resident Abuse or Neglect, Accidents and Death
26
17.0
Medical Records
27
18.0
Transfer Agreements, Contracts, or Agreements
29
19.0
Rights of Residents
31
20.0
Uniform Reporting System
37
PART III:
RESIDENT CARE SERVICES
39
21.0
Resident Care Policies
39
22.0
Infection Control
40
23.0
Physician Services
43
24.0
Nursing Service
44
25.0
Selected Nursing Care Procedures
47
26.0
Special Care Units or Programs
49
27.0
Dietetic Services
50
28.0
Pharmaceutical Services
53
29.0
Dental Services
55
30.0
Laboratory and Radiologic Services
55
31.0
Social Services
56
32.0
Specialized Rehabilitative Services
56
33.0
Resident Activities
57
34.0
Equipment
57
PART IV:
ENVIRONMENTAL and MAINTENANCE SERVICES
59
35.0
Housekeeping
59
36.0
Laundry Service
59
37.0
Disaster Preparedness
60
PART V:
PHYSICAL PLANT
62
38.0
New Construction, Addition or Modification
62
39.0
General Provisions -Physical Environment
63
40.0
Fire and Safety
63
41.0
Emergency Power
63
42.0
Facility Requirements for the Physically Handicapped
63
iv
Table of Contents (Continued)
43.0
Residential Area
64
44.0
Resident Rooms and Toilet Facilities
64
45.0
Special Care Unit
66
46.0
Dining and Resident Activities Rooms
66
47.0
Plumbing
66
48.0
Waste Disposal
66
49.0
Water Supply
67
50.0
Waste Disposal Systems
67
51.0
Maintenance
67
52.0
Other Provisions
68
PART VI:
VARIANCE and APPEAL PROCEDURE
69
53.0
Confidentiality
69
54.0
Variance Procedure
69
55.0
Deficiencies and Plans of Corrections
69
PART VII:
EXCEPTION and SEVERABILITY
71
56.0
Exception
71
57.0
Rules Governing Practices and Procedures
71
58.0
Severability
71
REFERENCES
72
Appendix “A”
75
Appendix “B”
76
Appendix “C”
78
Appendix “D”
79
Appendix “E”
80
Appendix “F”
81
1
PART I Licensing Procedures and 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 44.0 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.)
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1.5
"Change in owner" means:
(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
"Controlling person" means any person or entity in control of a nursing facility directly or
indirectly, including:
a)
in the case of a corporation or a limited liability company, or limited liability
partnership, a person having a beneficial ownership interest of five percent (5%) or
more in the corporation, limited liability company or limited liability partnership to
which the facility is licensed;
b)
in the case of a general partnership or limited partnership, any general partner;
c)
in the case of a limited liability company, or limited liability partnership any
member;
d)
a legal entity that operates or contracts with another person for the operation of a
nursing facility or an owner thereof;
e)
each of the president, vice president, secretary and treasurer of a corporation that is
not exempt from taxation under section 501(a) of the United States Internal Revenue
Code as an organization described in section 501(c)(3) of such code; and
f)
such other ownership interest or relationship as may be determined by the Director.
1.7
“Credentialing” means the administrative process for reviewing, verifying, and evaluating the
qualifications and credentials of licensed physicians in accordance with criteria established by
the nursing facility for the purpose of granting clinical privileges at the nursing facility.
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1.8
"Department" means the Department of Health.
1.9
“Direct care nursing staff” means registered nurses, licensed practical nurses, and nursing
assistants who are assigned to provide direct nursing care to residents.
1.10 “Director” means the Director of the Rhode Island Department of Health.
1.11 "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.
1.12 "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.
1.13 “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.
1.14 “Family council” means an organized group of the family members, friends, or representatives of
facility residents who may meet in private without the presence of facility staff.
1.15 “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.
1.16 "High managerial agent" means an officer of a facility, the administrator and assistant
administrator of the facility, the director and assistant director of nursing services, or any other
agent in a position of comparable authority with respect to the formulation of policies of the
facility or the supervision in a managerial capacity of subordinate employees.
1.17 "Immediate jeopardy" means a situation in which the nursing facility's noncompliance or alleged
noncompliance with one or more state or federal requirements or conditions has caused, or is
likely to cause serious injury, harm, impairment or death to a resident; or shall be defined in
accordance with 42 CFR 489 or any subsequent applicable federal regulations.
1.18 "The licensed capacity of a facility" refers to the number of beds a facility is licensed to operate.
1.19 "Licensing agency" means the Rhode Island Department of Health.
1.20
"Lift team" means health care facility employees specially trained to perform patient lifts,
transfers, and repositioning in accordance with safe patient handling policy.
1.21 "Long-term care facility or facility" shall mean a health care facility as defined in Chapter 23-17,
which provides long term health care.
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1.22 “Medication technician”, as used herein, means selected unlicensed personnel who have
satisfactorily completed a state-approved course in drug administration who may administer oral or
topical drugs (with the exception of Schedule II drugs) in accordance with the requirements of
section 25.9 herein.
1.23 "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.
1.24 "Musculoskeletal disorders" means conditions that involve the nerves, tendons, muscles, and
supporting structures of the body.
1.25 "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.
1.26 "Net operating revenue" means net patient revenue plus other operating revenue.
1.27 "Nourishing snack" means a verbal offering of items, single or in combination, from the basic
food groups.
1.28 "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.
1.29 "Nursing service" means a service organized, staffed and equipped to provide nursing care to
residents on a continuous basis.
1.30 "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.
1.31 "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.
1.32 "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.
1.33
"Resident" means a person who resides in a nursing facility as defined in Chapter 17 of Title
23 and the regulations contained herein.
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1.34
“Resident attendant” means an individual who is trained to assist residents in a nursing home
with the activities of eating and drinking. A resident attendant shall not include an individual
who:
a)
is a licensed health professional, including but not limited to a nursing assistant,
registered dietitian; or
b)
volunteers without monetary compensation as authorized by the resident, or the
resident’s appropriate legal representative.
1.35
“Residential area” means a distinct living environment within a nursing facility that includes no
more than 60 beds.
1.36
“Safe patient handling" means the use of engineering controls, transfer aids, or assistive devices
whenever feasible and appropriate instead of manual lifting to perform the acts of lifting,
transferring, and/or repositioning health care patients and residents.
1.37 "Safe patient handling policy" means protocols established to implement safe patient handling.
1.38
"Standing orders" means orders to be automatically implemented for a class of patients without
physician direction for an individual patient within the class.
1.39
"Substantial evening meal" means an offering of three (3) or more menu items at one time,
one (1) of which includes a high-quality protein such as meat, fish, eggs, or cheese. The meal
should represent no less than 20 percent (20%) of the day's total nutritional requirements.
1.40
“Turnover rate” means the total number of terminations in a given calendar year divided by the
average number of personnel employed for the same calendar year and multiplied by 100 (for
the percentage). (See calculation set forth in Appendix “F” herein).
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 Office of Facilities
Regulation, Rhode Island Department of Health, to the Division of Fire Safety, Executive
Department, and to the Office 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
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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.
3.5
The nursing facility shall maintain sufficient financial resources to provide adequate staffing and
supplies to care for the residents.
Safe Resident Handling
3.6
Each licensed nursing facility shall comply with the following as a condition of licensure:
3.6.1 Each licensed nursing facility shall establish a safe patient handling committee, which
shall be chaired by a professional nurse or other appropriate licensed health care
professional. A nursing facility may utilize any appropriately configured committee to
perform the responsibilities of this section. At least half of the members of the
committee shall be hourly, non-managerial employees who provide direct resident care.
3.6.2 By July 1, 2007, each licensed nursing facility shall develop a written safe patient
handling program, with input from the safe patient handling committee, to prevent
musculoskeletal disorders among health care workers and injuries to residents. As part
of this program, each licensed nursing facility shall:
3.6.3 By July 1, 2008, implement a safe resident handling policy for all shifts and units of the
facility that will achieve the maximum reasonable reduction of manual lifting,
transferring, and repositioning of all or most of a resident's weight, except in
emergency, life-threatening, or otherwise exceptional circumstances;
a)
Conduct a resident handling hazard assessment. This assessment should
consider such variables as patient-handling tasks, types of nursing units, resident
populations, and the physical environment of resident care areas;
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b)
Develop a process to identify the appropriate use of the safe resident t handling
policy based on the resident’s physical and mental condition, the resident's
choice, and the availability of lifting equipment or lift teams. The policy shall
include a means to address circumstances under which it would be medically
contraindicated to use lifting or transfer aids or assistive devices for particular
residents;
c)
Designate and train a registered nurse or other appropriate licensed health care
professional to serve as an expert resource, and train all clinical staff on safe
resident handling policies, equipment, and devices before implementation, and
at least annually or as changes are made to the safe patient handling policies,
equipment and/or devices being used;
d)
Conduct an annual performance evaluation of the safe resident handling with the
results of the evaluation reported to the safe resident handling committee or other
appropriately designated committee. The evaluation shall determine the extent to
which implementation of the program has resulted in a reduction in
musculoskeletal disorder claims and days of lost work attributable to
musculoskeletal disorder caused by resident handling, and include
recommendations to increase the program's effectiveness; and
e)
Submit an annual report to the safe resident handling committee of the facility,
which shall be made available to the public upon request, on activities related to
the identification, assessment, development, and evaluation of strategies to
control risk of injury to patients, nurses, and other health care workers associated
with the lifting, transferring, repositioning, or movement of a resident.
3.6.4 Nothing in this section precludes lift team members from performing other duties as
assigned during their shift.
3.6.5 An employee may, in accordance with established facility protocols, report to the
committee, as soon as possible, after being required to perform a resident handling
activity that he/she believes in good faith exposed the resident and/or employee to an
unacceptable risk of injury. Such employee reporting shall not be cause for discipline or
be subject to other adverse consequences by his/her employer. These reportable
incidents shall be included in the facility's annual performance evaluation.
Section 4.0 Application for License or for Changes in Owner, Operator, or Lessee
4.1
Application for a license to conduct, maintain or operate a nursing facility shall be made in writing
and submitted on forms provided by the licensing agency prior to the expiration date for license
renewal or prior to the opening date for a new facility.
4.2
A notarized listing of names and addresses of direct and indirect owners whether individual,
partnership, or corporation, with percentages of ownership designated, shall be provided with the
application for licensure and shall be updated annually. If a corporation, the list shall include all
officers, directors and other persons or any subsidiary corporation owning stock.
8
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, as set forth in the Rules and Regulations
Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services
Provided by the Department of Health.
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 initial licensure or 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 initial licensure or changes in the owner, operator, or lessee of
licensed nursing facilities shall be conducted according to the following procedures:
a)
Applicants for initial licensure or a change in effective control of a nursing facility shall
submit all required information as contained in the application provided by the
Department.
b)
Within ten (10) working days of receipt, in acceptable form, of an application for a license
in connection with an initial licensure or 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.
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c)
The decision of the licensing agency will be rendered within ninety (90) days from
acceptance of the application for license.
d)
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.
e)
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 an initial
licensure or 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;
10
(ii)
The proposed financial plan for operating and capital expenses and income
for the period immediately prior to, during and after the implementation of
the change in owner, operator or lessee of the health care facility;
(iii)
The relative availability of funds for capital and operating needs;
(iv)
The applicant's demonstrated financial capability;
(v)
Such other financial indicators as may be requested by the state agency;
5.6.3 The extent to which the facility will continue to provide safe and adequate treatment for
individuals receiving the facility's services and the extent to which the facility will
encourage quality improvement in all aspects of the operation of the health care facility as
evidenced by:
(A)
The applicant’s demonstrated record in providing safe and adequate treatment to
individuals receiving services at facilities owned, operated, or directed by the
applicant; and
(B)
the credibility and demonstrated or potential effectiveness of the applicant’s
proposed quality assurance programs;
5.6.4 The extent to which the facility will continue to provide appropriate access with respect to
traditionally underserved populations and in consideration of the proposed continuance or
termination of health care services by the facility as evidenced by:
(A)
In cases where the proposed owners, operators, or directors of the health care
facility currently own, operate, or direct a health care facility, or in the past five
years owned, operated or directed a health care facility, both within and outside of
Rhode Island, the demonstrated record of that person(s) with respect to access of
traditionally underserved populations to its health care facilities; and
(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.
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5.7
Subsequent to reviews conducted under sections 5.5 and 5.6 of these regulations, the issuance
of a license by the licensing agency may be made subject to any condition, provided that no
condition may be made unless it directly relates to the statutory purpose expressed in section
23-17-3 of the Rhode Island General Laws, as amended, or to the review criteria set forth in
section 5.6 herein. This shall not limit the authority of the licensing agency to require
correction of conditions or defects which existed prior to the proposed change of owner,
operator, or lessee and of which notice had been given to the nursing facility by the licensing
agency.
Background and Qualifications of the Applicant or Proposed License Holder
5.8
For purposes of this section, applicants must meet a financial threshold that shall include, as a
minimum, that the applicant or proposed license holder shall have sufficient resources to
operate the nursing facility at licensed capacity for thirty (30) days, evidenced by an
unencumbered line of credit, a joint escrow account established with the Department, or a
performance bond secured in favor of the state or a similar form of security satisfactory to the
Department.
5.9
The Department may also require background information to be submitted relating to any
partner, officer, director, manager or member (if member-managed) of the applicant or
proposed license holder, or information relating to each person having a beneficial ownership
interest of five percent (5%) or more in the applicant or proposed license holder.
5.10
In reviewing information required by sections 5.8 and 5.9 (above), the Department may require
the applicant or proposed license holder to file a sworn affidavit substantiating the validity of
any submitted information as required by the Department to substantiate a satisfactory
compliance history relating to each state or other jurisdiction in which the applicant, proposed
license holder or any other person described by sections 5.8 and 5.9 (above) operated a nursing
facility at any time during the five-year period preceding the date on which the application is
made. The Department shall determine what constitutes a satisfactory compliance history.
5.11
The Department may also require the applicant or proposed license holder to file information
relating to the current financial condition of the applicant, proposed license holder or any other
person described by sections 5.8 and 5.9 (above) and the history of the financial condition of the
applicant, proposed license holder or any other person described by sections 5.8 and 5.9 (above)
with respect to a facility operated in another state or jurisdiction at any time during the five-year
period preceding the date on which the application is made.
5.12
In addition to the information required to be provided in sections 5.8—5.11 above, the
Department shall gather information from state departments and agencies relating to the
background and qualifications of the applicant, proposed license holder, or any person having a
five percent (5%) or more beneficial ownership interest.
Moratorium on New Initial Nursing Facility Licensed Beds and on Increases to the Licensed
Capacity of Existing Nursing Facility Licenses
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5.13
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, 2009; 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.
5.14
Prior to July 1, 2009, 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 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.
5.15
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.
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5.15.1
"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.
5.15.2
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.
5.15.3
Beds taken out of service shall reduce a nursing facility's licensed bed capacity by the
number of beds taken out of service.
Additional Information Required of all Nursing Facilities
5.16
Effective January 1, 2006, any nursing facility applying for initial licensure or renewal of its
license that contracts with a management company to assist with the facility's operation shall
file a copy of the management contract with the Department including the management fee and,
if the management company is a corporation or limited liability company, shall identify every
person having an ownership interest of five percent (5%) or more in such corporation or limited
liability company and, if the management company is a general partnership or limited
partnership, shall identify all general or limited partners of such general partnership or limited
partnership.
Section 6.0 Capacity and 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
reserves the right to extend the expiration date of such license, allowing the facility to operate under the
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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.
7.4
Any nursing facility with any significant changes in its management contract shall submit a
copy of the revised management contract to the Department within thirty (30) days of the
effective date of the new contract provisions.
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
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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.
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 facility, order the licensee to be placed on probationary status and set
conditions with which the licensee must comply within a set period of time, order the licensee
to admit no additional persons to the facility, to provide health services to no additional persons
through the facility, to transfer all or some of the persons occupying the facility to other suitable
accommodations, or to take any other corrective action necessary to secure compliance with the
requirements established under the Act. Notice of the order and any subsequent hearing that
may be scheduled shall comply with the requirements of procedural due process stipulated in
section 23-17-8 of the Rhode Island General Laws, as amended. 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.
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9.6
SANCTIONS: The licensing agency may take appropriate action from within the following
array for dealing with violations of references 1 and 5 or of the rules and regulations herein.
a)
As a result of denial, the rights and privileges attendant upon licensure will not accrue to a
facility.
b)
As a result of an order to curtail any or all activities of a nursing facility, a licensee may be
ordered to admit no additional persons to said home, and/or transfer to other suitable
accommodations all or some of the residents residing in said home, and/or take any other
corrective action necessary to secure compliance with the requirements established by
reference 1 and the rules and regulations herein.
c)
As a result of suspension, a facility shall be restrained from admitting any residents during
the period of suspension and shall be required to transfer all residents to another facility
during the period of suspension. The difference between suspension and revocation of
license is essentially a temporal one, such that the sanctions imposed as a result of
suspension are so imposed until such time as the deficiency is corrected or until such other
time as the licensing agency determines, whereas the sanctions imposed as a result of
revocation are considered to be permanent and re-application for license would be
necessary.
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.
9.7
In accordance with the requirements of section 23-17-12.3 of the Rhode Island General Laws,
as amended, every person including a controlling person, or corporation who shall willfully and
continually violate the provisions of sections 23-17-12 -- 23-17-12.2 of the Rhode Island
General Laws, as amended, will be subject to a fine up to three hundred dollars ($300) for each
violation of these sections.
Adverse Change in Financial Condition
9.8
Whenever the Department, or the Department in consultation with the Rhode Island Department
of Human Services, determines that a nursing facility's financial status is of concern and
determines, through inspection of the facility or investigation of a complaint, that incident(s),
event(s) or patterns of care exist that harm or have the potential to result in harm or danger to the
residents of a facility, the Departments, acting jointly, shall convene a meeting, as soon as
possible but in no event later than ten (10) days after the finding(s) cited above, with the license
holder to communicate the state's concerns with respect to the operation of the facility. The
license holder shall be given the opportunity to respond to the state's concerns and to offer
explanation as to why the concerns are not valid or accurate.
9.9
In the event that the explanation provided by the license holder is not found by the Department to
be adequate or otherwise satisfactory, the Department shall direct the license holder to prepare
and submit, within ten (10) days of the meeting cited above, or for good cause shown no later
than twenty (20) days after said meeting, a plan of correction and remediation for the
Department's review and approval, including, but not limited to, the following elements:
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1)
Specific targeted improvements;
2)
Definite deadlines for accomplishing those targeted improvements;
3)
Measurable standards that will be used to judge whether the targeted improvements
have been accomplished;
4)
A spending plan that supports all costs associated with accomplishment of the targeted
improvements;
5)
Monthly reporting of cash availability, the status of vendor payments and employee
payrolls, and staffing levels, as metrics concerning financial status and quality of care;
and
6)
With regard to concerns regarding resident care, and if directed by the Department, a
proposal to engage an independent quality monitor or independent quality consultant, to
work, in consultation with the facility administrator and medical director, the
implementation of the plan of correction and remediation, and to provide progress
updates to the Department of Health.
9.10
Whenever a facility's financial status is determined to be marginal, the Department shall cause
such a facility to be inspected in order to determine if financial problems are causing the facility
to be out of compliance with nursing facility regulatory standards.
9.11
Whenever a facility is determined to be having severe financial difficulties, the Department
shall cause the facility to have more frequent inspections and the Director may, at the facility's
expense:
1)
Appoint an independent consultant to review the facility's management and financial
status and make recommendations to improve the facility's financial status; or
2)
Require the hiring of a temporary manager of the facility's operations.
9.12
With the exception of the plan of correction and remediation, as allowed in section 9.13 below,
the information obtained by the Department under this section is confidential and is not subject
to disclosure under § 38-2-2 of the Rhode Island General Laws, as amended, “Access to Public
Records.” However, upon request, the Department shall release the information to the following
who shall treat the information as confidential:
1)
The facility;
2)
A person other than the facility if the facility consents in writing to the disclosure;
3)
The state Medicaid agency responsible for rate setting of nursing facilities;
4)
The state long-term care ombudsman; or
5)
The Department of Attorney General.
9.13
Within ten (10) days, or twenty (20) days for good cause shown, of the submission of the plan
of correction and remediation by the facility, the Department shall either:
a)
Accept the plan, at which time it shall be considered to be a public record, and the
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facility shall make it, and all reports that follow and are related to it, available for public
inspection, and shall provide a written summary of the plan to each resident of the
facility or his or her legal representative, and each resident's family representative;
b)
Conditionally accept the plan with modifications made by the Department, at which
time the plan shall be considered to be a public record and the facility shall make it, and
all reports that follow and are related to it, available in accordance with subsection a)
above; or
c)
Reject the plan, at which time all records acquired in accordance with this section that
do not violate resident confidentiality shall be considered to be a public record, and a
notice of said plan rejection shall be sent, along with directions on obtaining the
complete record to each resident of the facility or his or her legal representative and
each resident's family representative.
9.14
The provisions in section 9.11 herein relating to the confidentiality of records do not apply:
1)
To a facility whose license has been revoked or suspended;
2)
To the use of the information in an administrative proceeding initiated by the
Department, including implementing enforcement actions, and in judicial proceedings
relating thereto.
9.15 These regulations adopt by reference the regulations that incorporate the criteria to measure
financial status as shall be promulgated by the Department of Human Services pursuant to § 40-8-
19.1 of the Rhode Island General Laws, as amended.
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PART II Organization and 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 fiduciary 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, resident quality of care
and quality of life, 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 and also:
a)
describe the structure of the facility’s governing body, including functional and staff
organizational charts;
b) provide names and affiliations of members of the facility’s governing body;
c)
provide a copy of the organization’s charter, constitution and/or by-laws.
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, to identify program goals, and to
provide for an annual evaluation of administrator performance.
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.
Section 11.0 Quality Improvement Program
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11.1
Pursuant to section 23-17-12.11 of the Rhode Island General Laws, as amended, each licensed
nursing facility shall develop and implement a quality improvement program and establish a
quality improvement committee. The governing body shall ensure that this program is effective,
ongoing, facility-wide and shall have a written plan of implementation.
11.2
Each licensed nursing facility shall designate a qualified individual, who shall be determined by
the facility’s administrator, to coordinate and manage the nursing facility’s quality improvement
program.
11.3
The nursing facility’s quality improvement committee shall include at least the following
members:
The nursing facility administrator;
The director of nursing;
The medical director;
A social worker; and
A representative of dietary services.
11.4
The quality improvement committee shall meet at least quarterly; shall maintain records of all
quality improvement activities; and shall keep records of committee meetings that shall be
available to the Department during any on-site visit.
11.5
The quality improvement committee for a nursing facility shall annually review and approve the
quality improvement plan for the nursing facility. Said plan shall be available to the public upon
request.
11.6
Each nursing facility shall establish a written quality improvement plan that shall be reviewed by
the Department during the facility’s annual survey and that includes:
a) program objectives;
b) oversight responsibility (e.g., reports to the governing body);
c) facility-wide scope;
d) involvement of all resident care disciplines/services; and
e) provides criteria to monitor nursing care, including medication administration;
f) prevention and treatment of decubitus ulcers;
g) dehydration, and nutritional status and weight loss or gain;
h) accidents and injuries;
i) unexpected deaths;
j) changes in mental or psychological status; and
k) any other data necessary to monitor quality of care;
l) and includes methods to identify, evaluate, and correct problems.
11.7
All resident care services, including services rendered by a contractor, shall be evaluated.
11.8
The facility shall take and document appropriate remedial action to address problems identified
through the quality improvement program. The nursing facility administrator shall take
appropriate remedial actions based on the recommendations of the nursing facility’s quality
improvement committee. The outcome(s) of the remedial action shall be documented and
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submitted to the governing body for their consideration.
11.9 The Director may not require the quality improvement committee to disclose the records and the
reports prepared by the committee except as necessary to assure compliance with the
requirements of this section.
11.10 Good faith attempts by the quality improvement committee to identify and correct quality
deficiencies will not be used as a basis for sanctions.
11.11 If the Department determines that a nursing facility is not implementing its quality improvement
program effectively and that quality improvement activities are inadequate, the Department may
impose sanctions on the nursing facility to improve quality of resident care including mandated
hiring of, directly or by contract, an independent quality consultant acceptable to the
Department.
Health Care Quality Program
11.12 All nursing facilities licensed under Chapter 23-17 of the Rhode Island General Laws, as
amended, shall meet all applicable requirements of the Rules and Regulations Related to the
Health Care Quality Program (R23-17.17-QUAL) promulgated by the Department.
Section 12.0 Administrator
12.1 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.
12.2
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.
12.3
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.
12.4
Health care facilities shall provide the licensing agency with prompt notice of pending and actual
labor disputes/actions which would impact delivery of patient care services including, but not
limited to, strikes, walk-outs, and strike notices. Health care facilities shall provide a plan,
acceptable to the Director, for continued operation of the facility, suspension of operations, or
closure in the event of such actual or potential labor dispute/action.
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12.5
The licensing agency shall be notified of any change of the administrator of a facility.
Section 13.0 Medical Director and Attending Physicians
13.1 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.
Duties and Responsibilities of the Medical Director
13.2
Responsibilities of the medical director shall include, but not be limited to:
a)
coordination of medical care in the facility,
b)
ensuring completion of employee health screening and immunization requirements
contained in sections 14.11 and 14.12 herein.
c)
the implementation of facility policies and procedures related to the medical care
delivered in the facility;
d)
physician and advanced practice practitioner credentialing;
e)
practitioner performance reviews;
f)
employee health including infection control measures;
g)
evaluation of health care delivery, including oversight of medical records and
participation in quality improvement;
h)
provision of staff education on medical issues;
i)
participation in state survey process, including the resolution of deficiencies, as needed.
13.3 The medical director, charged with the aforementioned duties and responsibilities for the delivery
of medical care in the nursing facility, shall be immune from civil or criminal prosecution for
reporting to the Board of Medical Licensure and Discipline the unprofessional conduct,
incompetence or negligence of a nursing facility physician or limited registrant; provided, that
the report, testimony, or other communication was made in good faith and while acting within the
scope of authority conferred by this section.
13.4 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.
13.5 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.
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13.6 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.
13.7 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 14.0 Personnel
Criminal Records Check
14.1 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.
14.2 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.
14.3 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.
14.4 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.
14.4.1 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.
14.5 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.
14.6 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
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of the disqualifying information. This letter may be maintained on file to satisfy the requirements
of Chapter 23-17-34.
14.7 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 judgment regarding the
continued employment of the employee.
Policies and Procedures
14.8 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
14.9 There shall be a job description for each classification of position which delineates qualifications,
duties, authority and responsibilities inherent in each position.
a) For those selected non-licensed personnel authorized to administer drugs in accordance with
section 25.9 herein, a job description delineating qualifications, duties and responsibilities shall
be provided.
Health Screening
14.10 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.
14.11 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 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
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his status for influenza determined by the facility, and, if found to be deficient, the facility
shall make available the necessary immunization.
iv. Exceptions: No employee shall be required to receive the influenza vaccine if any of the
following apply:
1)
The vaccine is contraindicated;
2)
It is against his/her religious beliefs; or
3)
The person refuses the vaccine after being fully informed of the health risks
of that action.
Personnel Records
14.12 Personnel records shall be maintained for each employee, shall be available at all times for
inspection and shall include no less than the following:
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 25.9 herein.
In-Service Education
14.13 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.
14.13.1 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
14.14 A health care facility shall require all persons, including students, and as directed by the nursing
facility, who examine, observe, treat or assist a patient or resident of such facility to wear a photo
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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
14.15 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 15.0 Handling of Resident Fund
15.1 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.
15.2 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.
15.3 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 19.16 herein. Such records shall be available for inspection.
15.4 In addition to requirements of sections 15.1 through 15.3 above, each facility shall conform to the
standards of reference 13 in relation to Title XIX residents.
Section 16.0 Reporting of Resident Abuse or Neglect, Accidents & Death
16.1 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 make within 24 hours or
by the end of the next business day of the receipt of said information, a report to the licensing
agency (Office of Facilities Regulation). 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)
All reports, as required herein, shall be provided to the licensing agency (Office of Facilities
Regulation) in writing via facsimile on the form supplied in Appendix “E” herein. A copy of
each report shall be retained by the facility for review during subsequent inspections by the
licensing agency.
b) 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. Appropriate corrective action shall be taken, as necessary.
The results of said investigation shall be reported to the licensing agency within five (5)
business days.
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16.2 Accidents resulting in:
1.
hospitalization; or
2.
death in the nursing facility; or
3.
death in the hospital following the accident;
of any resident shall be reported in writing to the licensing agency before the end of the next
working day or in a follow-up report in the event of item #3 (above). A copy of each report shall
be retained by the facility for review during subsequent surveys.
16.3 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 23.3 (c) herein, shall be
reported to the Office of the State Medical Examiners.
16.4 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.
16.5
Reporting requirements, pursuant to Chapter 23-17.8 of the General Laws must be posted.
Section 17.0 Medical Records
17.1 A medical record shall be established and maintained for every person admitted to a facility in
accordance with accepted professional standards and practices. The administrator shall have
ultimate responsibility for the maintenance of medical records; such responsibility may be
delegated in writing to a staff member.
17.2 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 judgment.
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.
17.3 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;
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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;
p)
diagnosis at time of discharge; and
q)
disposition and final summary notes.
17.4 At time of discharge, a discharge summary, summarizing the resident's stay, shall be completed
promptly and signed by the attending physician.
17.5 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.
17.6 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.
17.7 Provisions shall be made for the safe storage of medical records to safeguard them against loss,
destruction or unauthorized use.
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17.8 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.
17.9 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 19.15 (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 18.0 Transfer Agreements, Contracts, or Agreements
18.1 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;
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
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c) security and accountability for the resident's personal effects during transfer.
18.2 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.
18.3 If the facility does not employ full-time qualified professional personnel to render required
services, or obtains services from an outside source, arrangements for such services shall be made
through written agreements or contracts.
a)
The responsibilities, functions, objectives, terms of agreement, financial arrangements,
charges and other pertinent requirements shall be clearly delineated in the terms of any
contract negotiated by a facility.
b)
All contracts or agreements negotiated by a facility shall be consistent with the policies
established in accordance with section 10.4 concerning conflict of interest.
c)
Each consultant or outside source providing services to a facility shall submit monthly
reports as services are provided. Said reports and contracts shall be kept on file for
inspection for a period of no less than three (3) years.
Financial Interest Disclosure
18.4 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.
18.5 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, Office of Facilities Regulation
3 Capitol Hill, Room 306
Providence, RI 02908
401.222.2566
18.6 Non-compliance with sections 18.4 and 18.5 (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.
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Section 19.0 Rights of Residents
19.1 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.
19.2 Each resident shall be offered treatment without discrimination as to gender, age, race, color,
religion, national origin, handicap, or source of payment.
19.3 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.
19.4 Each resident shall have the right to choose his or her own physician subject to the physician's
concurrence.
19.5 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.
19.6 Each resident or responsible party shall be informed in writing, prior to, or at the time of
admission and during stay, of services available and of related charges including all charges not
covered either under federal and/or state programs by other third party payers or by the facility's
basic per diem rate.
19.7 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.
19.8 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.
19.9 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.
19.9.1 There shall be prompt efforts by the facility staff to resolve resident's grievances.
19.10 Residents shall not be subject to mental and physical abuse and shall be free from chemical and
(except in emergencies) physical restraints.
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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.
19.11 A resident shall not be required to perform services for the facility that are not included for
therapeutic purposes in his plan of care.
19.12 Residents may meet with and participate in activities of social, religious and community groups at
their discretion unless medically contraindicated per written medical order.
19.13 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.
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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.
19.14 Residents shall have the right to obtain personal services or to purchase needs outside of the
facility.
19.15 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.
19.16 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.
19.17 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.
19.18 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.
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19.18.1 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
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) Any nursing facility that accepts private payment for purposes of reserving a
bed in the facility for a resident who is transferred from the facility for
hospitalization or other institutional therapeutic leave, and that resident’s
medical and health care is being paid for by the state Medical Assistance
Program, shall not charge an amount per day for reserving a bed in the
facility that exceeds the facility’s current Medicaid daily rate; for a minimum
of the first five (5) days of said hospitalization or the institutional therapeutic
leave.
iv) 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.
19.19 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.
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19.19.1 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.
19.20 The resident shall have the right to have his or her pain assessed on a regular basis.
19.21 Notwithstanding any other provisions of this section, upon request, patients receiving care
through hospitals, nursing homes, assisted living residences and home health care providers,
shall have the right to receive information concerning hospice care, including the benefits of
hospice care, the cost, and how to enroll in hospice care.
19.22 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.
19.23 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.
19.24 All rights and responsibilities specified in sections 19.4, 19.8, 19.16, and 19.18 shall devolve, in
order of priority, to a resident's guardian, next of kin, sponsoring agency(ies) or representative
payor (except when the facility itself is the representative payor) for residents who are:
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.
19.25 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;
36
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.
e)
the telephone number of the state Medicaid Fraud Unit: 401-222-2256 or 401-274-4400
x2269.
Resident and Family Notification
19.26
When directed to do so by the Department, the facility shall 1. notify the resident, or his or her
legal representative, the resident’s family representative, the resident’s attending physicians of
record and the nursing facility’s medical director, if that resident has been found to be in
immediate jeopardy to health and safety; and 2. in federally-certified facilities, notify all
facility residents, or their legal representatives, their family representatives, their attending
physicians and the nursing facility’s medical director, whenever a nursing facility is cited for
substandard quality of care as defined in 42 CFR 488.301or its successor regulation.
19.27
The facility shall provide for notification of changes regarding resident condition as provided
in federal regulation 42 CFR 483.10 or successor regulation.
19.28
In nursing facilities not federally certified, when directed to do so by the Department, the
facility shall notify all facility residents, or their legal representatives, their family
representatives, their attending physicians and the nursing facility’s medical director, whenever
a nursing facility is cited for substandard quality of care as determined by the Director.
19.29
A facility citation for substandard quality of care shall be considered to be a public record ten
(10) days following the citation, or upon Departmental approval of the corresponding plan of
correction, whichever is sooner.
Family Councils
19.30
Upon the admission of a resident, the nursing facility shall inform the resident and the
resident’s family members, in writing, of their right to form a family council, or if a family
council already exists, of the date, time, and location of scheduled meetings.
19.31
If a family council exists, its role shall be to address issues affecting residents generally at the
facility, not to pursue individual grievances.
19.32
The family council shall not be entitled to obtain information about individual residents or staff
members, or any other information deemed confidential under state or federal law.
19.33
No licensed nursing facility may prohibit the formation of a family council.
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19.34
When requested by a member of a resident’s family or a resident’s representative, a family
council shall be allowed to meet in a common meeting room of the nursing facility at least once
a month during mutually agreed upon hours.
19.35
The nursing facility administration shall notify the state long-term care ombudsman of the
existence or planned formation of a family council at that facility.
19.36
The family council may exclude members only for good cause shown, subject to appeal by the
excluded party to the state long-term care ombudsman. No member shall be excluded on the
basis of race or color, religion, gender, sexual orientation, disability, age, or country of ancestral
origin.
19.37
A facility shall provide its family council with adequate space in a prominent posting area for
the display of information pertaining to the family council.
19.38 Staff or visitors may attend family council meetings at the council’s invitation.
19.39 The nursing facility shall provide a designated staff person who, at the request of the council,
shall be responsible for providing assistance to the family council and for responding to
recommendations and requests made by the family council.
19.40 The nursing facility shall consider the recommendations of the family council concerning issues
and policies affecting resident care and life at the nursing facility.
19.41 A violation of the provisions of this section shall constitute a violation of the rights of nursing
home residents.
Section 20.0 Uniform Reporting System
20.1 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.
20.2 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.
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20.3 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.
20.4 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.
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PART III
Resident Care Services
Section 21.0 Resident Care Policies
21.1 Each facility shall have written resident care policies to govern the continuing nursing care and
related medical or other services provided.
21.2 Each nursing facility licensed under the provision of Chapter 23-17 of the Rhode Island General
Laws, as amended, shall have a written plan for preventing the hazards of resident wandering from
the facility. Said plan shall be on file in the nursing facility and available to the licensing agency
upon request.
21.3 As part of the initial resident admission and assessment process, the facility shall review and
consider any notice provided to the facility as required in subsection 42-56-10(23) of the Rhode
Island General Laws, as amended, concerning the resident's or prospective resident's status on
parole and recommendations, if any, from the Department of Corrections regarding safety and
security measures.
21.4 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.
21.5 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
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discharge;
j)
notification of next of kin, attending physician or responsible agency of any change of
condition;
k)
transfer of medical information in accordance with reference 17;
l)
discharge and termination of services; and
m)
provision for continuity of resident care as related to discharge planning, which shall
include a mechanism for recording, transmitting and receiving information essential to the
continuity of resident care.
Such information shall contain no less than the following:
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 19.18.1 c) herein; and
vii.
such other information pertinent to ensure continuity of resident care.
21.6 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 22.0 Infection Control
22.1
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;
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c)
establishing policies governing the admission and isolation of residents with known or
suspected infectious diseases;
d)
developing, evaluating and revising on a continuing basis infection control policies,
procedures and techniques for all appropriate areas of facility operation and services;
e)
developing and implementing a system for evaluating and recording the occurrences of
all infections relevant to employment (e.g., skin rash) among personnel and infections
among residents; such records shall be made available to the licensing agency upon
request;
f)
implementing a TB infection control program requiring risk assessment and development
of a TB infection control plan; early identification, treatment and isolation of strongly
suspected or confirmed infectious TB residents; effective engineering controls; an
appropriate respiratory protection program; health care worker TB training, education,
counseling and screening; and evaluation of the program's effectiveness, per guidelines
in reference 30.
i)
The TB infection control plan shall include, at a minimum, a provision that
residents shall be screened for TB, within fourteen (14) days of admission, and
found to be free of active tuberculosis based upon the results of a negative two-
step tuberculin skin test. If documented evidence is provided that the resident has
had a two-step tuberculin skin test, performed within the most recent twelve (12)
months prior to admission, that was negative, the requirements of this section
shall be met.
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.
22.2 Infection control provisions shall be established for the mutual protection of residents, employees,
and the public.
22.3 A continuing education program on infection control shall be conducted periodically for all staff.
22.4 Reporting of Communicable Diseases
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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.
Resident Immunization Policies/Practices
22.5 Long term care resident immunization: Except as provided in subsection 22.5 (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.
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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
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 23.0 Physician Service
23.1 All residents shall remain or be under the care of a physician of his or her choice, subject to the
physician's concurrence.
23.1.1 All physician assistant services shall be in accordance with the provisions of Chapter 5-
54 of the General Laws.
23.1.2 All nurse practitioner services shall be in accordance with the provisions of Chapter 5-34
of the General Laws.
23.2 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:
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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.
23.3 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.
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 25.8 (b) herein.
23.4 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.
23.5 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 22.5 herein.
Section 24.0 Nursing Service
24.1 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.
24.2 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.
45
a) The Director of Nurses employed full-time in accordance with section 24.2 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;
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.
24.3 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 residential area; 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 residential area. 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.
Nursing Staff Posting Requirements
24.4 Each facility shall post its daily direct care nurse staff levels by shift in a public place within the
facility. The posting shall be accurate to the actual number of direct care nursing staff on duty for
each shift per day. The posting shall be in a format similar to that found in Appendix “A” herein
to include:
a)
the number of registered nurses, licensed practical nurses, nursing assistants, and
medication technicians who are not also nursing assistants;
b)
the number of temporary, outside agency nursing staff;
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c)
the resident census as of 12:00 a.m.
d)
documentation of the use of unpaid eating assistants (if utilized by the facility on that date).
24.5 The posting information shall be maintained on file by the nursing facility for no less than three
(3) years and shall be made available to the public upon request.
24.6 The nursing facility shall prepare an annual report showing the average daily direct care nurse
staffing level for the facility by shift and by category of nurse to include registered nurses,
licensed practical nurses, nursing assistants and medication technicians; the use of nurse and
nursing assistant staff from temporary placement agencies; and the nurse and nurse assistant
turnover rates.
24.6.1 The annual report shall be submitted with the facility’s renewal application and provide
data for the previous twelve (12) months and ending no earlier than September 30th, for the
year preceding the license renewal year or for the partial year available for the 2007
renewal applications. Annual reports shall be submitted in a format similar to that found in
Appendix “F” herein.
24.7 The information on nurse staffing shall be reviewed as part of the nursing facility’s annual
licensing survey and shall be available to the public, both in printed form and on the
Department’s website, by facility.
24.8 The Director of Nurses may act as a charge nurse only when the facility is licensed for 30 beds or
less.
24.9 Whenever the licensing agency determines, in the course of inspecting a facility, that additional
staffing is necessary on any residential area 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.
24.10 No nursing staff of any facility shall be regularly scheduled for double shifts.
Section 25.0 Selected Nursing Care Procedures
25.1 Written resident care plans, including problems, measurable goals, interventions, and time frames,
47
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.
25.2 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.
25.3 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.
25.4 Every facility shall have an active program for rehabilitative nursing care.
25.5 Such supportive and restorative nursing care needed to maintain maximum functioning of the
resident shall be provided.
25.6 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.
25.7 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
25.8
Drugs shall be administered in accordance with written orders of the attending physician and
procedures established in accordance with sections 28.1 and 28.2 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
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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 Medication Technicians
25.9 Medication technicians 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 medication technicians are from temporary employment agencies, the
facility shall have onsite evidence of supervision in accordance with the state-approved protocol
in drug administration.
25.10 The director of nursing or his/her registered nurse designee shall conduct and document
quarterly evaluations of the medication technicians who are administering drugs. Copies of said
evaluations shall be placed in the medication technicians’ personnel records.
Assistance with Eating and Hydration
25.11 Nursing facilities may employ resident attendants to assist residents with activities of eating and
drinking. The resident attendant shall not be counted in the direct care staffing levels (see also
section 24.4 herein).
25.12 A nursing facility shall not use any individual on a paid or unpaid basis in the capacity of a
resident attendant, as defined herein, in the nursing home unless the individual:
a)
has satisfactorily completed a training program approved by the Director, as described in
section 25.14 of these regulations;
b)
continues to provide competent eating and hydration assistance as determined by the
facility’s professional nursing staff.
25.13
The facility shall ensure:
a)
the resident attendant works in congregate dining areas under the supervision of a
registered nurse (RN) or licensed practical nurse (LPN);
b)
the resident attendant wears a photo identification badge in accordance with section
14.14 of these regulations;
c)
the resident attendant only assists residents selected by the professional nursing staff,
49
based on the charge nurse’s assessment and the resident’s latest assessment and plan of
care;
d)
the resident attendant assists with eating and drinking for residents who have no
complicated eating/feeding problems, including but not limited to:
i.
Tube or parenteral/IV feedings;
ii.
Recurrent lung aspirations;
iii.
Difficulty swallowing;
iv.
Residents at risk of choking while eating or drinking;
v.
Residents with significant behavior management challenges while eating or
drinking;
vi.
Residents presenting other risk factors that may require emergency intervention.
e)
maintenance of records regarding individuals acting as resident attendants and the
training program attended.
Training Program for Resident Attendants
25.14
Resident attendants shall be required to have successfully completed a basic training program
approved by the Director consisting of eight (8) hours of classroom instruction, as stipulated in
Appendix B, and including no less than four (4) hours of practical experience supervised and
documented by a registered nurse.
Pain Assessment
25.15 All health care providers licensed by this state to provide health care services and all health care
facilities licensed under Chapter 23-17 of the Rhode Island General Laws, as amended, shall
assess patient pain in accordance with the requirements of the Rules and Regulations Related
to Pain Assessment (R5-37.6-PAIN) promulgated by the Department.
Section 26.0 Special Care Units
Alzheimer and Other Dementia Special Care Units or Programs:
26.1 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.
26.1.1
The information disclosed shall be on a form prescribed by the Department of
Health.
26.1.2
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.
50
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
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.
26.1.3 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:
26.2 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.
26.2.1
The information disclosed shall be on a form prescribed by the Department.
26.2.2
The facility shall provide care and services as described in the disclosure form, and
consistent with the rules and regulations herein.
26.2.3
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 27.0 Dietetic Services
27.1 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.
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27.2 When the dietary manager is not a qualified dietitian who is registered or eligible for registration
by the commission of dietetic registration and/or licensed by the State, the facility shall obtain per
written contractual arrangement adequate and regularly scheduled consultation from a qualified
dietitian.
27.3 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.
27.4 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.
27.5 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
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f)
ancillary dietary services, including food storage and preparation in satellite kitchens and
vending operations in accordance with reference 10; and
g)
a plan to include alternate methods and procedures for food preparation and service,
including provisions for potable water, to be used in emergencies.
27.6 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 hand washing shall be done prior to assisting in food distribution.
27.7 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.
27.8 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.
27.9 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.
27.10 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.
27.11 Each resident shall receive and the facility shall provide at least three (3) meals daily, at regular
times comparable to normal mealtimes based upon the individual preference of a resident or
group of residents in a residential area and/or at regular times comparable to normal mealtimes in the
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community.
a)
There shall be no more than fourteen (14) hours between a substantial evening meal and
breakfast the following day, except as provided in (c) below.
b)
The facility shall offer snacks at bedtime daily.
c)
When a nourishing snack is provided at bedtime, up to sixteen (16) hours may elapse
between a substantial evening meal and breakfast the following day if a resident, or
group of residents in a residential area agrees to this meal span, and a nourishing snack
is served.
27.12 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.
27.13 Food shall be attractively served on dinnerware of good quality, such as ceramic, plastic or other
materials that are durable and aesthetically pleasing.
27.14 A dining room shall be available for those residents or residents who wish to participate in group
dining in accordance with section 46.1 herein.
27.15 Self-help feeding devices shall be available to those residents who need them to maintain
maximum independence in the activities of daily living.
27.16 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 28.0 Pharmaceutical Services
28.1 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.
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28.2 There shall be written policies and procedures relating to the pharmaceutical service which shall
require no less than:
a)
the authority, responsibility and duties of the registered pharmacist;
b)
the selection, procurement, distribution, storage, dispensing or other disposition of drugs
and biologicals in accordance with appropriate federal and state laws and regulations;
c)
maintenance of records of all transactions, including recording of receipt and dispensing or
other disposition of all drugs and biologicals;
d)
inspection of all drug and biological storage and medication areas and documented
evidence of findings;
e)
automatic stop orders for drugs or biologicals;
f)
the use of only approved drugs and biologicals;
g)
control of medicines from any source;
h)
a monitoring program to identify adverse drug reactions, interactions and incompatibilities
and antibiotic antagonisms; and
i)
labeling of drugs and biologicals including name of resident, name of physician, drug
dosage, cautionary instructions, and expiration date.
28.3 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.
28.4 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.
28.5 An emergency medication kit, approved by the pharmaceutical service committee or its equivalent,
shall be kept at each nursing station.
28.6 Each residential area shall have adequate drug and biological preparation areas with provisions for
locked storage in accordance with federal and state laws and regulations.
28.7 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;
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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 28.2 herein; and
iv.
monitor the service.
b)
A registered pharmacist shall assist in developing, coordinating and supervising all pharmaceutical
services in conjunction with the pharmaceutical services committee. In addition, a registered
pharmacist shall:
i.
review the drug and biological regimen of each resident at least monthly;
ii.
report any irregularities to the attending physician and director of nurses. These reports
must show evidence of review and response; and
iii.
document in writing the performance of such review, which documentation shall be kept on
file by the facility and shall be made accessible to inspectors on request.
Section 29.0 Dental Services
29.1 Each facility shall provide or obtain from outside resources, dental services for routine and
emergency care.
29.1.1 Each resident shall have the right to receive dental services from a dentist of his/her choice.
29.2 A list of community dentists shall be maintained and available to all residents.
29.3 When necessary, arrangements shall be made by facilities for the transportation of residents to and
from the dental care office.
Section 30.0 Laboratory and Radiologic Services
30.1 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.
30.2 If the facility provides its own laboratory and x-ray services, these shall meet all applicable
statutory and regulatory requirements.
30.3 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.
30.4 Signed and dated reports of all findings shall become part of the resident's medical record.
Section 31.0 Social Services
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31.1 Every facility shall provide social services to attain or maintain the highest practicable physical,
mental and psychological well being of each resident. Social services must be provided either
directly by a qualified social worker or by arrangement with an appropriate health or social service
agency or through consultation with a qualified social worker who would supervise a social work
designee appointed by the administrator.
a)
Services shall pertain to no less than the following:
i.
identification of social and emotional needs of residents through a comprehensive
psychosocial assessment including a social history;
ii.
establishment of a plan of care based on residents' needs;
iii.
procedures for referral of residents, when indicated, to appropriate social agencies
and discharge planning as indicated
31.2
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 31.1 (a) above.
31.3
Notwithstanding any provisions in §§ 5-39.1-1 – 5-39.1-14 or any other general or public law to
the contrary, any nursing facility licensed under Chapter 17 of Title 23 that employs a social
worker or social worker designee who meets all of the criteria in section 31.4 below shall be
granted a variance to the "qualified social worker" provisions stated herein.
31.4
Such criteria shall be limited to: (1) meets the centers for Medicare and Medicaid requirements
for long-term care facilities under 42 CFR part 483, subpart B (or any successor regulation); (2)
is currently employed by a nursing facility licensed under Chapter 17 of Title 23; and (3) has
been continuously employed in a nursing facility licensed under Chapter 17 of Title 23
commencing on or before July 1, 2003.
31.5
Sufficient supportive personnel shall be available to meet resident needs.
31.6
Appropriate records shall be maintained of all social services rendered, including consultation
services, and reports shall be included in the resident's medical record.
31.7
Policies and procedures shall be established to assure confidentiality of all resident information
consistent with the requirements of reference 17.
Section 32.0 Specialized Rehabilitative Services
32.1
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.
32.2
The specialized rehabilitative services, which include physical therapy, speech pathology,
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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.
32.3
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.
32.4 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.
32.5 Entries of all rehabilitative or supportive services rendered, including evaluation of progress and
other pertinent information, shall be recorded in the resident's medical record and signed by
personnel rendering the service(s).
32.6 Safe and adequate space and equipment shall be available commensurate with the scope of
services provided.
Section 33.0 Resident Activities
33.1 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.
33.2 The activities program must be directed by a qualified professional as defined in reference 2.
33.3 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.
33.4 Adequate space, supplies and equipment shall be available to meet resident care needs in
accordance with the activities program and as stipulated in section 46.0 herein.
33.5 Each resident must have an activities plan, and all pertinent observations and information must be
recorded in the medical record.
Section 34.0 Equipment
34.1 Each facility shall maintain sufficient and appropriate types of equipment consistent with resident
needs and sufficient to meet emergency situations.
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34.2 All equipment to meet the needs of the residents shall be maintained in safe and good operational
condition.
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PART IV Environmental and Maintenance Services
Section 35.0 Housekeeping
35.1 A full-time employee of the facility shall be designated responsible for housekeeping services,
supervision and training of housekeeping personnel.
35.2 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 hand
washing should be done prior to assisting in food distribution.
35.3 Written housekeeping policies and procedures shall be established in accordance with section 22.1
herein on Infection Control, for the operation of housekeeping services throughout the facility.
Copies shall be available for all housekeeping personnel.
35.4 All parts of the home and its premises shall be kept clean, neat and free of litter and rubbish and
offensive odors.
35.5 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.
35.6 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.
35.7 Cleaning shall be performed in a manner which will minimize the development and spread of
pathogenic organisms in the home environment.
35.8 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.
35.9 Facilities contracting with outside resources for housekeeping services shall require conformity
with existing regulations.
35.10 Each facility shall be maintained free from insects and rodents through the operation of a pest
control program.
Section 36.0 Laundry Services
36.1 Each facility shall make provisions for the cleaning of all linens and other washable goods.
36.2 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.
36.3 Written policies and procedures for the operation of the laundry service including special
60
procedures for the handling and processing of contaminated linens, shall be established in
accordance with section 22.0 herein on Infection Control.
36.4 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.
36.5
All soiled linen shall be placed in closed containers prior to transportation.
36.6
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.
36.7
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.
36.8
Facilities contracting for services with an outside resource in accordance with section 18.3
herein shall require conformity with these regulations.
Section 37.0 Disaster Preparedness
37.1 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 shall include
provisions for evacuation of the facility in the event of a natural disaster. 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.
37.2 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;
61
i)
handling of drugs and biologicals;
j)
missing residents;
k)
back-up or contingency plans to address possible internal systems (e.g., food, power,
water, sewage disposal) and/or equipment failures; and
l)
any other essentials as required by the local emergency management agency.
37.3
A copy of the plan shall be available at every nursing unit.
37.4
Emergency steps of action shall be clearly outlined and posted in conspicuous locations
throughout the facility.
37.5
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.
37.6
All personnel shall receive training in disaster preparedness as part of their employment
orientation.
37.7
The administrator of the facility shall notify the licensing agency (Office of Facilities
Regulation) immediately by telephone of any unscheduled implementation of any part of the
facility’s disaster preparedness plan and shall provide a follow-up report in writing within three
(3) business days using the form supplied in Appendix “E” herein.
37.8
Each nursing facility shall agree to enter into a memorandum of agreement with the licensing
agency and the local municipality in which the nursing facility is geographically located to
participate in a statewide distribution plan for medications and/or vaccines in the event of a
public health emergency or disease outbreak.
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PART V Physical Plant
Section 38.0 New Construction, Addition or Modification
38.1
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.
38.2
All plans for new construction or the renovation, alteration, extension, modification or
conversion of an existing facility that may affect compliance with sections 41.0, 43.0, 44.0, 45.0,
46.0, and 52.0 herein, and reference 15, shall be reviewed by a Rhode Island licensed architect.
Said architect shall certify that the plans conform to the construction requirements of sections
41.0, 43.0, 44.0, 45.0, 46.0, and 52.0 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.
38.2.1 In the event of non-conformance for which the facility seeks a variance, the general
procedures outlined in section 54.0 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.
38.2.2 If variances are granted, a licensed architect shall certify that the plans conform to all
construction requirements of sections 41.0, 43.0, 44.0, 45.0, 46.0, and 52.0 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.
38.3 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 39.0 General Provisions - Physical Environment
63
39.1 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.
39.2 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.
39.3 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.
39.4 Grounds surrounding the facility shall be accessible to and usable by residents and shall be
maintained in an orderly and well-kept manner.
Section 40.0 Fire and Safety
40.1 Each facility shall meet the provisions of reference 16.
40.2 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 41.0 Emergency Power
41.1 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 42.0 Facility Requirements for the Physically Handicapped
42.1
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.
42.2
Blind, non-ambulatory, physically handicapped or residents with mobility disabilities which
limit self-preservation capability shall not be housed above the street level floor unless the
facility is equipped with an elevator and meets other requirements of reference 19. Further, the
facility must meet one of the following as defined in the N.F.P.A. Standards No. 220:
a)
is of fire resistive construction, one (1) hour protected non-combustible construction; or
b)
is fully sprinklered one (1) hour protected ordinary construction; or
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c)
is fully sprinklered one (1) hour protected wood frame construction.
Section 43.0 Residential Area
43.1 Each residential area, as defined in section 1.35 herein, shall have at least the following:
a)
a nurses' station with adjacent hand washing 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.
43.2
In addition, each residential area 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 44.0 Resident Rooms and Toilet Facilities
44.1 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.
44.2
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.
44.3
The size of each window shall be no less than 2'6" wide by 4'5" high, double hung or an
approved equivalent.
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44.4
Each room shall have direct access to a corridor and outside exposure with the window at or
above grade level.
44.5
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.
44.6
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 38.0
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.
44.7 Separate lavatory and toilet facilities shall be provided for employees and the general public
commensurate with the needs of the facility.
44.8 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 residential area.
44.9 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.
44.10 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.
44.11 Each resident must be provided with a bed of proper size and height for the convenience of the
resident, with a clean, comfortable mattress, bedside stand, 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.
44.12 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.
Section 45.0 Special Care Unit
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45.1 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 hand washing
facilities, and shall conform to other requirements established for the control of infection in
accordance with section 22.0 herein.
Section 46.0 Dining & Resident Activities Rooms
46.1 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 47.0 Plumbing
47.1 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.
47.2 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 48.0 Waste Disposal
48.1 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.
48.2 Other Waste:
Wastes which are not classified as infectious waste, hazardous wastes or which are not otherwise
regulated by law or rule may be disposed in dumpsters or load packers provided the following
precautions are maintained:
a) Dumpsters shall be tightly covered, leak proof, inaccessible to rodents and animals, and
placed on concrete slabs preferably graded to a drain. Water supply shall be available within
easy accessibility for washing down of the area. In addition, the pick-up schedule shall be
67
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 49.0 Water Supply
49.1 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 residential area 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 50.0 Waste Disposal Systems
50.1 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 51.0 Maintenance
51.1 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 52.0 Other Provisions
52.1 Facilities shall make provisions to ensure that the following are maintained:
68
a)
adequate and comfortable lighting levels in all areas in accordance with Appendix D;
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 70F 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.
69
PART VI Confidentiality - Variance and Appeal Procedure
Section 53.0 Confidentiality
53.1 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 54.0 Variance Procedure
54.1 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,
16.0, 19.0, 22.0, 24.0, 25.0, 27.11, 48.0, 49.0, 51.0, and 53.0.
54.2 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.
54.3 At a hearing held in furtherance of an appeal from a denial for a variance in accordance with
section 54.2 (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.
54.4 Nursing facilities that provide care in accordance with alternative service delivery models may be
eligible for a variance in accordance with the requirements contained herein.
Section 55.0 Deficiencies and Plans of Correction
55.1 The procedures of this section are exclusive of those required in accordance with section 24.5
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.
55.2 The licensing agency shall notify the governing body or other legal authority of a facility of
violations of individual standards through a notice of deficiencies which shall be forwarded to the
facility within fifteen (15) days of inspection of the facility unless the director determines that
immediate action is necessary to protect the health, welfare, or safety of the public or any member
thereof through the issuance of an immediate compliance order in accordance with section 23-1-21
of the General Laws of Rhode Island, as amended.
70
55.3 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.
55.4 The licensing agency will be required to approve or reject the plan of corrections submitted by a
facility in accordance with section 55.3 above within fifteen (15) days of receipt of the plan of
corrections.
55.4.1 To be deemed acceptable by the licensing agency, a plan of correction shall:
a) Address how corrective action will be accomplished for those residents found to have been
affected by the deficient practice(s);
b) Address how the facility will identify other residents having the potential to be affected by
the same deficient practice(s);
c) Address what measures will be put into place or systemic changes made to ensure that the
deficient practice(s) will not recur;
d)
Indicate how the facility plans to monitor its performance to ensure that solutions are
sustained;
e) Include dates when corrective action will be completed; and
f)
Include any additional components deemed necessary by the licensing agency.
55.4.2
The facility shall develop a plan for ensuring that correction is achieved and sustained.
This plan shall be implemented and the corrective action(s) evaluated for effectiveness.
The plan of correction shall be integrated into the quality assurance system.
55.4.3
All deficiencies shall be fully and wholly corrected within thirty (30) days of the date of
notice of the deficiencies, unless an extension is granted for good cause shown, but in no
case shall an extension exceed fifteen (15) days.
55.5 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 55.3 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.
55.6 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.
71
PART VII Exception and Severability
Section 56.0 Exception
56.1 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 57.0 Rules Governing Practices and Procedures
57.1 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 58.0 Severability
58.1 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.
72
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.
73
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
Settings, 2005, U.S. Department of Health & Human Services, Public Health Service, Centers for
Disease Control & Prevention, MMWR 2005; 54 (No. RR-17, 1-141).
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.
74
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.
37.
Rules and Regulations Related to Pain Assessment (R5-37.6-PAIN), Rhode Island Department
of Health.
NursingFacilities_Final_Sept2012.doc
Monday, 17 September 2012
75
Appendix “A”
Todays Date:
Resident Census (12:01 a.m.):
A.M/Day Shift Hours
2
(List hours)
P.M/Day Shift Hours
(List hours)
Night Shift Hours
(List hours)
Facility Nursing:
Direct Care Positions
# Staff
# Hours this
shift
# Staff
# Hours this shift
# Staff
# Hours this
shift
Registered Nurse (RN)
Lic. Practical Nurse
(LPN)
Nurse Assistant (NA)
Medication Technician
Agency/contract Nursing:
Direct Care Positions
# Staff
# Hours this
shift
# Staff
# Hours this
shift
# Staff
# Hours this
shift
Registered Nurse (RN)
Lic. Practical Nurse
(LPN)
Nurse Assistant (NA)
Medication Technician
Resident attendants for meal assistance are/is provided for the following meal times:
Footnotes:
1RIGL 23-17-12.8 Posting of nursing staff levels in nursing facilities. Facilities are required to post actual on-site direct care nursing staff
levels by shift in a public place within the facility.
2For alternative work schedules or cross-over shifts, the staff FTE and hours worked must be split over the appropriate work shifts.
76
Appendix B
Nursing Home Resident Attendant Training Program Protocol
Version 7-07
Scope:
To provide training to individuals who will provide safe and proper eating and hydration assistance to
nursing home residents with no complicated eating or drinking problems.
Program Criteria:
The training program shall be conducted by a registered nurse, and may include the assistance of a
registered dietitian;
The training shall provide a minimum of eight (8) hours of classroom instruction, and participants
shall demonstrate an understanding of topics that includes but is not limited to:
o
Eating techniques;
o
Physical mechanics of:
Breathing and swallowing;
Aspiration;
Choking
o
Assistance with eating and hydration (drinking);
o
Infection control;
o
Resident rights;
o
Communication and interpersonal skills;
o
Appropriate responses to resident behavior;
o
Safety and emergency procedures, including the Heimlich maneuver;
The training shall provide, either directly or through arrangements with a nursing facility, a minimum
of four (4) hours of practical experience supervised by a registered nurse.
Classroom Demonstration:
Completion of eight (8) hours of classroom instruction and demonstration of topic competency to
the satisfaction of the registered nurse trainer.
Practical Demonstration:
Completion of four (4) hours of practical experience supervised by a registered nurse.
Certificate of Completion:
Certificate of classroom completion signed by registered nurse trainer and bearing the Department
program approval certification number and including an area for documentation of satisfactory
completion of practical experience, similar to Appendix C.
Program Approval:
Organizations or facilities interested in providing a resident attendant eating assistance program should
submit a letter of intent to HEALTH, Office of Facilities Regulation, c/o Eating Assistance Program, 3
77
Capital Hill, Providence, RI 02908. The request must include:
An outline of the structure and format for the program;
Resume/curriculum vita for the registered nurse trainer and other trainers;
Curriculum/program outline to be utilized;
Method of ensuring participants’ successful demonstration of competencies;
Program contact information.
Following review by HEALTH, numbered program approvals will be provided.
78
Appendix C
Nursing Home Resident Attendant Training Program
Jane Doe
Has completed the classroom portion of a nursing home resident attendant training program and
demonstrated her knowledge and understanding of the following core competencies:
Eating techniques;
Physical mechanics of:
o Breathing and swallowing;
o Aspiration;
o Choking
Assistance with eating and hydration (drinking);
Infection control;
Resident rights;
Communication and interpersonal skills;
Appropriate responses to resident behavior;
Safety and emergency procedures, including the Heimlich maneuver;
(List any additional or supplemental competencies provided)
Successfully demonstrated to me on this date:
{Month, day, Year}
Registered Nurse Trainer (Name)
License #
HEALTH Program Approval #
Four (4) hours of practical demonstration was completed on the following date(s):
#
Hours
Date
Registered Nurse
Signature
Facility Name
79
APPENDIX D
Recommended Lighting Levels for Areas Unique to Nursing Homes
Minimum Foot Candles on Tasks At Any Time1
Foot Candles
Administrative Spaces: General Office, Medical Records, Conference/interview
area/room(s)
50
Corridors – Nursing Areas:
Day:
Night:
20
10
Dietary
50
Elevators
15
Examination Rooms
50
Employee:
Lounge(s):
Locker Room(s):
50
20
Linens:
Sorting soiled linen:
Central clean linen supply:
Linen room(s)/closets
30
30
10
Stairways
15
Lobby area(s):
Receptionist:
General:
30
20
Physical therapy
30
Occupational therapy area(s):
Work benches/tables:
Work area – general:
50
30
Speech therapy
30
Resident Lounge(s):
Reading
General
30
15
Resident dining area(s)
30
Resident care area(s):
Room/bed/toilet/reading:
General:
30
15
Nursing station(s):
Desk, medication area, nourishment center:
General:
Corridors day/night (see “corridors” above):
50
30
20 - 10
Mechanical-electrical room/space:
30
Utility room:
Clean and soiled
30
Janitor’s closet
15
Storage – general
20
Toilet – bathing – shower facilities
30
Barber and beautician areas
50
Waiting area(s):
Reading
General
30
20
1 Source: Guidelines for Construction and Equipment of Hospital and Medical Facilities, The American Institute of Architects Press, Washington,
D.C., 1992--1993 edition.
80
Department of Health, Office of Facilities Regulation
Documentation of Required Reporting2
R23-17-NF - Appendix E
Statutory Reference:
Chapter 23-17,
Sections 16 & 37
Chapter 23-17.8-2
Reporting Facility:
Date of report:
Facility Address:
Reported by:
Title
Contact number:
Type of Report:
Allegation of Abuse, Neglect, or Mistreatment
3
Accident
Incident/Other
Select most appropriate reason for report:
Abuse, Neglect, or Mistreatment (as defined in §23-17.8-1)
Resident to Resident
Resident accident or incident resulting in hospitalization, death, or death following hospitalization;
Death within 24 hours or admission or prior to physical exam - see section 23.3(c)4;
Elopement:
Police notified:
Yes
No
Misappropriation or exploitation of resident property or resources, or
Unscheduled implementation of the facilities fire/evacuation/disaster plan impacting residents.
Resident(s) Information:
Last Name:
First:
Gender:
Female
Male
Last Name:
First:
Gender:
Female
Male
Incident Information:
Date of Incident:
Time:
Witness(s)
No
Yes (List
below)
Location of Incident:
Witness(s):
Alleged Perpetrator(s) Information (if applicable):
Last Name:
First:
Resident
Non-resident
Last Name:
First:
Resident
Non-resident
Victim or Abuser involved in previous
abuse?
Victim:
No
Yes
Abuser:
No
Yes
Description of incident and immediate action taken to ensure safety of resident(s) pending facility investigation.
CONTINUE ON ADDITIONAL PAGES AS NEEDED
FAX to:
Facilities Regulation: 222-3650,
and
RI LTC Ombudsman: 785-3391
2 Reports may be called in immediately to DOH-222-5200 with follow-up faxes of this form by the next business day.
3 Facility investigation reports required within five (5) business days.
4 Requires report to the State Medical Examiner in accordance with 23, Chapter 4 and notice to facility medical director.
81
Department of Health, Office of Facilities Regulation
Nursing Facility Licensed Staff Hours/Turnover
Annual Report
Statutory
Reference:
Chapter 23-
17-24.7
R23-17-NF - Appendix F
Facility Name:
License #:
Reporting Period
From:
To:
Month
Year
Month
Year
TABLE 1: Nursing Care Annual Turnover Rate
RN
LPN
NA
TOTAL # of Terminations this period:
AVERAGE # Employed
(Sum of each Mouth/12)
RN
LPN
NA
Staff Turnover Rate
(Terminations/Average Staff)
TABLE 2: Average Direct care Nursing Hours - Input average Census and staff data for this period
Average Resident Census this Period:
Average A.M./Day Hours
Per Resident
Average P.M./Evening Hours
Per Resident
Average Night Hours
Per Resident
Registered Nurse (RN)
Lic. Practical Nurse (LPN)
Licensed
Nurse Assistant (NA)
Sub-Total Facility Nursing Staff this
period:
Medication Technician
(unlicensed) .
Registered Nurse (RN)
Lic. Practical Nurse (LPN)
Licensed
Contract
Nurse Assistant (NA)
Sub-Total Contract Nursing Staff this
period:
Medication Technician
(unlicensed) .
Total Average Nursing Staff this Period -
Per resident/Per shift:
Comments:
Administrator Signature
Date Submitted