Basic Services

(1) Performance Improvement. (a) The nursing home must ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization. (b) The performance improvement program must be ongoing and have a written plan of implementation which assures that: 1. All organized services related to resident care, including services furnished by a contractor, are evaluated; STANDARDS FOR NURSING HOMES CHAPTER 0720-18 2. Nosocomial infections and medication therapy are evaluated; 3. All services performed in the facility are evaluated as to the appropriateness of diagnosis and treatment; and 4. The facility shall develop and implement a system for measuring improvements in adherence to the hand hygiene program and influenza vaccination program. (c) The nursing home must have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its residents. (d) The facility must develop and implement plans for improvement to address deficiencies identified by the performance improvement program and must document the outcome of the remedial action. (e) Performance improvement program records are not disclosable, except when such disclosure is required to demonstrate compliance with this section. (f) Good faith attempts by the performance improvement program committee to identify and correct deficiencies will not be used as a basis for sanctions. (2) Physician Services. (a) Policies and procedures concerning services provided by the nursing home shall be available for the admitting physicians. (b) Residents shall be aided in receiving dental care as deemed necessary. (c) Each nursing home shall retain by written agreement a physician to serve as a Medical Director. (d) The Medical Director shall be responsible for the medical care in the nursing home. The Medical Director shall: 1. Delineate the responsibilities of and communicate with attending physicians to ensure that each resident receives medical care; 2. Ensure the delivery of emergency and medical care when the resident’s attending physician or his/her designated alternate is unavailable; 3. Review reports of all accidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator; 4. Make periodic visits to the nursing home to evaluate the existing conditions and make recommendations for improvements; 5. Review and take appropriate action on reports from the Director of Nursing regarding significant clinical developments; 6. Monitor the health status of nursing home personnel to ensure that no health conditions exist which would adversely affect residents; and, STANDARDS FOR NURSING HOMES CHAPTER 0720-18 7. Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control. (3) Infection Control. (a) The nursing home must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. (b) The physical environment shall be maintained in such a manner to assure the safety and well being of the residents. 1. Any condition on the nursing home site conducive to the harboring or breeding of insects, rodents or other vermin shall be prohibited. Chemical substances of a poisonous nature used to control or eliminate vermin shall be properly identified. Such substances shall not be stored with or near food or medications. 2. Cats, dogs or other animals shall not be allowed in any part of the facility except for specially trained animals for the handicapped and except as addressed by facility policy for pet therapy programs. The facility shall designate in its policies and procedures those areas where animals will be excluded. The areas designated shall be determined based upon an assessment of the facility performed by medically trained personnel. 3. Telephones shall be readily accessible and at least one (1) shall be equipped with sound amplification and shall be accessible to wheelchair residents. 4. Equipment and supplies for physical examination and emergency treatment of residents shall be available. 5. A bed complete with mattress and pillow shall be provided. In addition, resident units shall be provided with at least one chair, a bedside table, an over bed tray and adequate storage space for toilet articles, clothing and personal belongings. 6. Individual wash cloths, towels and bed linens must be provided for each resident. Linen shall not be interchanged from resident to resident until it has been properly laundered. 7. Bath basin water service, emesis basin, bedpan and urinal shall be individually provided. 8. Water pitchers, glasses, thermometers, emesis basins, douche apparatus, enema apparatus, urinals, mouthwash cups, bedpans and similar items of equipment coming into intimate contact with residents shall be disinfected or sterilized after each use unless individual equipment for each is provided and then sterilized or disinfected between residents and as often as necessary to maintain them in a clean and sanitary condition. Single use, resident disposable items are acceptable but shall not be reused. 9. The facility shall have written policies and procedures governing care of residents during the failure of the air conditioning, heating or ventilation system, including plans for hypothermia and hyperthermia. When the temperature of any resident area falls below 65°F or exceeds 85°F, or is reasonably expected to do so, the facility shall be alerted to the potential danger, and the department shall be notified. STANDARDS FOR NURSING HOMES CHAPTER 0720-18 (c) The administrator shall assure that an infection control program including members of the medical staff, nursing staff and administrative staff develop guidelines and techniques for the prevention, surveillance, control and reporting of facility infections. Duties of the program shall include the establishment of: 1. Written infection control policies; 2. Techniques and systems for identifying, reporting, investigating and controlling infections in the facility; 3. Written procedures governing the use of aseptic techniques and procedures in the facility; 4. Written procedures concerning food handling, laundry practices, disposal of environmental and resident wastes, traffic control and visiting rules, sources of air pollution, and routine culturing of autoclaves and sterilizers; 5. A log of incidents related to infectious and communicable diseases; 6. Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques such as handwashing, proper grooming, masking, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of resident care equipment and supplies; and, 7. Continuing education for all facility personnel on the cause, effect, transmission, prevention, and elimination of infections. (d) The administrator, the medical staff and director of nursing services must ensure that the facility-wide performance improvement program and training programs address problems identified by the infection control program and must be responsible for the implementation of successful corrective action plans in affected problem areas. (e) The facility shall develop policies and procedures for testing a resident’s blood for the presence of the hepatitis B virus and the HIV virus in the event that an employee of the facility, a student studying at the facility, or other health care provider rendering services at the facility is exposed to a resident’s blood or other body fluid. The testing shall be performed at no charge to the resident, and the test results shall be confidential. (f) The facility and its employees shall adopt and utilize standard precautions (per CDC) for preventing transmission of infections, HIV, and communicable diseases, including adherence to a hand hygiene program which shall include: 1. Use of alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and water before and after each patient contact if hands are not visibly soiled; 2. Use of gloves during each patient contact with blood or where other potentially infectious materials, mucous membranes, and non-intact skin could occur and gloves changed before and after each patient contact; 3. Use of either a non-antimicrobial soap and water or an antimicrobial soap and water for visibly soiled hands; and 4. Health care worker education programs which may include: STANDARDS FOR NURSING HOMES CHAPTER 0720-18 (i) Types of patient care activities that can result in hand contamination; (ii) Advantages and disadvantages of various methods used to clean hands; (iii) Potential risks of health care workers’ colonization or infection caused by organisms acquired from patients; and (iv) Morbidity, mortality, and costs associated with health care associated infections. (g) All nursing homes shall adopt appropriate policies regarding the testing of residents and staff for HIV and any other identified causative agent of acquired immune deficiency syndrome. (h) The facility shall document evidence of annual vaccination against influenza for each resident, in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control most recent to the time of the vaccine. Influenza vaccination is medically contraindicated or the resident has refused the vaccine. Influenza vaccination for all residents accepting the vaccine shall be completed by November 30 of each year or within ten (10) days of the vaccine becoming available. Residents admitted after this date during the flu season and up to February 1, shall as medically appropriate, receive influenza vaccination prior to or on admission unless refused by the resident. The facility shall document evidence of vaccination against pneumococcal disease for all residents who are 65 years of age or older, in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control at the time of vaccination, unless such vaccination is medically contraindicated or the resident has refused offer of the vaccine. The facility shall provide or arrange the pneumococcal vaccination of residents who have not received this immunization prior to or on admission unless the resident refuses offer of the vaccine. (i) A nursing home shall have an annual influenza vaccination program which shall include at least: 1. The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The nursing home will encourage all staff and independent practitioners to obtain an influenza vaccination; 2. A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider); 3. Education of all employees about the following: (i) Flu vaccination, (ii) Non-vaccine control measures, and (iii) The diagnosis, transmission, and potential impact of influenza; 4. An annual evaluation of the influenza vaccination program and reasons for non- participation; and STANDARDS FOR NURSING HOMES CHAPTER 0720-18 5. A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee. (j) Precautions shall be taken to prevent the contamination of sterile supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents. Decontamination and preparation areas shall be separated. (k) Space and facilities for housekeeping equipment and supply storage shall be provided in each service area. Storage for bulk supplies and equipment shall be located away from patient care areas. The building shall be kept in good repair, clean, sanitary and safe at all times. (l) The facility shall appoint a housekeeping supervisor who shall be responsible for: 1. Organizing and coordinating the facility’s housekeeping service; 2. Acquiring and storing sufficient housekeeping supplies and equipment for facility maintenance; and, 3. Assuring the clean and sanitary condition of the facility to provide a safe and hygienic environment for residents and staff. Cleaning shall be accomplished in accordance with the infection control rules herein and facility policy. (m) Laundry facilities located in the nursing home shall: 1. Be equipped with an area for receiving, processing, storing and distributing clean linen; 2. Be located in an area that does not require transportation for storage of soiled or contaminated linen through food preparation, storage or dining areas; 3. Provide space for storage of clean linen within nursing units and for bulk storage within clean areas of the facility; and, 4. Provide carts, bags or other acceptable containers appropriately marked to identify those used for soiled linen and those used for clean linen to prevent dual utilization of the equipment and cross contamination. (n) The facility shall name an individual who is responsible for laundry service. This individual shall be responsible for: 1. Establishing a laundry service, either within the nursing home or by contract, that provides the facility with sufficient clean, sanitary linen at all times; 2. Knowing and enforcing infection control rules and regulations for the laundry service; 3. Assuring the collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules and procedures; and, 4. Assuring that a contract laundry service complies with all applicable infection control rules and procedures. (4) Nursing Services. STANDARDS FOR NURSING HOMES CHAPTER 0720-18 (a) Each nursing home must have an organized nursing service that provides twenty-four (24) hour nursing services furnished or supervised by a registered nurse. Each home shall have a licensed practical nurse or registered nurse on duty at all times and at least two (2) nursing personnel on duty each shift. (b) The facility must have a well-organized nursing service with a plan of administrative authority and delineation of responsibilities for resident care. The Director of Nursing (DON) must be a licensed registered nurse who has no current disciplinary actions against his/her license. The DON is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the facility. (c) The Director of Nursing shall have the following responsibilities: 1. Develop, maintain and periodically update: (i) Nursing service objectives and standards of practice; (ii) Nursing service policy and procedure manuals; (iii) Written job descriptions for each level of nursing personnel; (iv) Methods for coordination of nursing service with other resident services; and, (v) Mechanisms for monitoring quality of nursing care, including the periodic review of medical records. 2. Participate in selecting prospective residents in terms of the nursing services they need and nursing competencies available. 3. Make daily rounds to see residents. 4. Notify the resident’s physician when medically indicated. 5. Review each resident’s medications periodically and notify the physician where changes are indicated. 6. Supervise the administration of medications. 7. Supervise assignments of the nursing staff for the direct care of all residents. 8. Plan, develop and conduct monthly in-service education programs for nursing personnel and other employees of the nursing home where indicated. An organized orientation program shall be developed and implemented for all nursing personnel. 9. Supervise and coordinate the feeding of all residents who need assistance. 10. Coordinate the dietary requirements of residents with the staff responsible for the dietary service. 11. Coordinate housekeeping personnel. 12. Assure that discharge planning is initiated in a timely manner. STANDARDS FOR NURSING HOMES CHAPTER 0720-18 13. Assure that residents, along with their necessary medical information, are transferred or referred to appropriate facilities, agencies or outpatient services, as needed, for follow-up or ancillary care. (d) The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and certified nurse aides to provide nursing care to all residents as needed. Nursing homes shall provide a minimum of two (2) hours of direct care to each resident every day including 0.4 hours of licensed nursing personnel time. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the availability of a licensed nurse for bedside care of any resident. (e) A registered nurse must supervise and evaluate the nursing care for each resident. (f) The facility must ensure that an appropriate individualized plan of care is prepared for each resident with input from appropriate disciplines, the resident and/or the resident’s family or the resident’s representative. (g) A registered nurse must assign the nursing care of each resident to other nursing personnel in accordance with the resident’s needs and the specialized qualifications and competence of the nursing staff available. (h) Non-employee licensed nurses who are working in the nursing home must adhere to the policies and procedures of the facility. The director of the nursing service must provide for the adequate supervision and evaluation of the clinical activities of non- employee nursing personnel which occur within the responsibility of the nursing service. (i) All drugs, devices and related materials must be administered by, or under the supervision of, nursing or other personnel in accordance with federal and state laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. (j) There must be a facility procedure for reporting adverse drug reactions and errors in administration of drugs. (k) When non-employees are utilized as sitters or attendants, they shall be under the authority of the nursing service and their duties shall be set forth clearly in written nursing service policies. (l) Each resident shall be given proper personal attention and care of skin, feet, nails and oral hygiene in addition to the specific professional nursing care as ordered by the resident’s physician. (m) Medications, treatments, and diet shall be carried out as prescribed to safeguard the resident, to minimize discomfort and to attain the physician’s objective. (n) Residents shall have baths or showers at least two (2) times each week, or more often if requested by the resident. (o) Body position of residents in bed or chair bound shall be changed at least every two (2) hours, day and night, while maintaining good body alignment. Proper skin care shall be provided for bony prominences and weight bearing parts to prevent discomfort and the development of pressure areas, unless contraindicated by physician’s orders. STANDARDS FOR NURSING HOMES CHAPTER 0720-18 (p) Residents who are incontinent shall have partial baths each time the bed or bed clothing has been wet or soiled. The soiled or wet bed linen and the bed clothing shall be replaced with clean, dry linen and clothing immediately after being soiled. (q) Residents shall have shampoos, haircuts and shaves as needed, or desired. (r) Rehabilitation measures such as assisting patients with range of motion, prescribed exercises and bowel and bladder retraining programs shall be carried out according to the individual needs and abilities of the resident. (s) Residents shall be active and out of bed except when contraindicated by written physician’s orders. (t) Residents shall be encouraged to achieve independence in activities of daily living, self-care, and ambulation as a part of daily care. (u) Residents shall have clean clothing as needed and shall be kept free from odor. (v) Residents’ weights shall be taken and recorded at least monthly unless contraindicated by a physician’s order. (w) Physical restraints shall be checked every thirty (30) minutes and released every two (2) hours so the resident may be exercised and offered toilet access. (x) Restraints may be applied or administered to residents only on the signed order of a physician. The signed physician’s order must be for a specified and limited period of time and must document the necessity of the restraint. There shall be no standing orders for restraints. (y) When a resident’s safety or safety of others is in jeopardy, the nurse in charge shall use his/her judgment to use physical restraints if a physician’s order cannot be immediately obtained. A written order must be obtained as soon as possible. (z) Locked restraints are prohibited. (aa) Assistance with eating shall be given to the resident as needed in order for the resident to receive the diet for good health care. (bb) Abnormal food intake will be evaluated and recorded. (cc) A registered nurse may make the actual determination and pronouncement of death under the following circumstances: 1. The deceased was a resident of a nursing home; 2. The death was anticipated, and the attending physician or nursing home medical director has agreed in writing to sign the death certificate. Such agreement by the attending physician or nursing home medical director must be present with the deceased at the place of death; 3. The nurse is licensed by the state; and, 4. The nurse is employed by the nursing home in which the deceased resided. (5) Medical Records. STANDARDS FOR NURSING HOMES CHAPTER 0720-18 (a) The nursing home shall comply with the Tennessee Medical Records Act, T.C.A. §§ 68-11-301, et seq. (b) The nursing home must maintain a medical record for each resident. Medical records must be accurate, promptly completed, properly filed and retained, and accessible. The facility must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. (c) All medical records, in either written, electronic, graphic or otherwise acceptable form, must be retained in their original or legally reproduced form for a minimum period of at least ten (10) years after which such records may be destroyed. However, in cases of residents under mental disability or minority, their complete facility records shall be retained for the period of minority or known mental disability, plus one (1) year, or ten (10) years following the discharge of the resident, whichever is longer. Records destruction shall be accomplished by burning, shredding or other effective method in keeping with the confidential nature of the contents. The destruction of records must be made in the ordinary course of business, must be documented and in accordance with the facility’s policies and procedures, and no record may be destroyed on an individual basis. (d) When a nursing home closes with no plans of reopening, an authorized representative of the facility may request final storage or disposition of the facility’s medical records by the department. Upon transfer to the department, the facility relinquishes all control over final storage of the records and the files shall become property of the State of Tennessee. (e) The nursing home must have a system of coding and indexing medical records. The system must allow for timely retrieval by diagnosis and procedure. (f) The nursing home must have a procedure for ensuring the confidentiality of resident records. Information from or copies of records may be released only to authorized individuals, and the facility must ensure that unauthorized individuals cannot gain access to or alter resident records. Original medical records must be released by the facility only in accordance with federal and state laws, court orders or subpoenas. (g) The medical record must contain information to justify admission, support the diagnosis, and describe the resident’s progress and response to medications and services. (h) All entries must be legible, complete, dated and authenticated according to facility policy. (i) All records must document the following: 1. Evidence of a physical examination, including a health history, performed no more than thirty (30) days prior to admission or within forty-eight (48) hours following admission; 2. Admitting diagnosis; 3. A dietary history as part of each resident’s admission record; 4. Results of all consultative evaluations of the resident and appropriate findings by clinical and other staff involved in the care of the resident; STANDARDS FOR NURSING HOMES CHAPTER 0720-18 5. Documentation of complications, facility acquired infections, and unfavorable reactions to drugs; 6. Properly executed informed consent forms for procedures and treatments specified by facility policy, or by federal or state law if applicable, as requiring written resident consent; 7. All practitioners’ orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the resident’s condition; 8. Discharge summary with disposition of case and plan for follow-up care; and, 9. Final diagnosis with completion of medical records within thirty (30) days following discharge. (j) Electronic and computer-generated records and signature entries are acceptable. (6) Pharmaceutical Services. (a) The nursing home shall have pharmaceutical services that meet the needs of the residents and are in accordance with the Tennessee Board of Pharmacy statutes and rules. The medical staff is responsible for developing policies and procedures that minimize drug errors. (b) All internal and external medications and preparations intended for human use shall be stored separately. They shall be properly stored in medicine compartments, including cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept securely locked when not in use, and the key must be in the possession of the supervising nurse or other authorized persons. Poisons or external medications shall not be stored in the same compartment and shall be labeled as such. (c) Schedule II drugs must be stored behind two (2) separately locked doors at all times and accessible only to persons in charge of administering medication. (d) Every nursing home shall comply with all state and federal regulations governing Schedule II drugs. (e) A notation shall be made in a Schedule II drug book and in the resident’s nursing notes each time a Schedule II drug is given. The notation shall include the name of the resident receiving the drug, name of the drug, the dosage given, the method of administration, the date and time given and the name of the physician prescribing the drug. (f) All oral orders shall be immediately recorded, designated as such and signed by the person receiving them and countersigned by the physician within ten (10) days. (g) All orders for drugs, devices and related materials must be in writing and signed by the practitioner or practitioners responsible for the care of the resident. Electronic and computer-generated records and signature entries are acceptable. When telephone or oral orders must be used, they shall be: 1. Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with federal and state law; and, STANDARDS FOR NURSING HOMES CHAPTER 0720-18 2. Signed or initialed by the prescribing practitioner according to nursing home policy. (h) Medications not specifically limited as to time or number of doses when ordered are controlled by automatic stop orders or other methods in accordance with written policies. No Schedule II drug shall be given or continued beyond seventy-two (72) hours without a written order by the physician. (i) Medication administration records (MAR) shall be checked against the physician’s orders. Each dose shall be properly recorded in the clinical record after it has been administered. (j) Preparation of doses for more than one scheduled administration time shall not be permitted. (k) Medication shall be administered only by licensed medical or licensed nursing personnel or other licensed health professionals acting within the scope of their licenses. (l) Unless the unit dose package system is used, individual prescriptions of drugs shall be kept in the original container with the original label intact showing the name of the resident, the drug, the physician, the prescription number and the date dispensed. (m) Legend drugs shall be dispensed by a licensed pharmacist. (n) Nursing homes may participate in drug donation repository programs as defined in Title 63, Chapter 10 and may use such programs for drug disposal services. The facility’s participation in a drug donation repository program shall be outlined in the facility’s policies and procedures. (o) Alternatively, if a nursing home declines to participate in the drug donation repository program or in the case of drugs not acceptable under the program, any unused portions of prescription drugs shall be turned over to the resident only on a written order by the physician. If not turned over to the resident, such unused drugs left in a nursing home must be destroyed on the premises by a licensed nurse and a witness. The facility’s policies and procedures shall outline person(s) who may serve as a witness and methodology. The facility’s policies and procedures must be in compliance with applicable DEA regulations. (7) Radiology Services. The nursing home must maintain or have available diagnostic radiologic services according to the needs of the residents. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. (8) Laboratory Services. The nursing home must maintain or have available, either directly or through a contractual agreement, adequate laboratory services to meet the needs of the residents. The nursing home must ensure that all laboratory services provided to its residents are performed in a facility licensed in accordance with the Tennessee Medical Laboratory Act (TMLA). All technical laboratory staff shall be licensed in accordance with the TMLA and shall be qualified by education, training and experience for the type of services rendered. (9) Food and Dietetic Services. (a) The nursing home must have organized dietary services that are directed and staffed by adequate qualified personnel. A facility may contract with an outside food management company if the company has a dietitian who serves the facility on a full- STANDARDS FOR NURSING HOMES CHAPTER 0720-18 time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this paragraph and provides for constant liaison with the facility medical staff for recommendations on dietetic policies affecting resident treatment. If an outside contract is utilized for management of its dietary services, the facility shall designate a full-time employee to be responsible for the overall management of the services. (b) The nursing home must designate a person, either directly or by contractual agreement, to serve as the food and dietetic services director with responsibility for the daily management of the dietary services. The food and dietetic services director shall be: 1. A qualified dietitian; or, 2. A graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the American Dietetic Association; or, 3. An individual who has successfully completed in-person or online coursework that provided ninety (90) or more hours of classroom instruction in food service supervision. If the course has not been completed, this person shall be enrolled in a course and making satisfactory progress for completion within the time limit specified by the course requirement; or, 4. An individual who is a certified dietary manager (CDM), or certified food protection professional (CFPP); or, 5. A current or former member of the U.S. military who has graduated from an approved military dietary manager training program. (c) There must be a qualified dietitian, full-time, part-time, or on a consultant basis, who is responsible for the development and implementation of a nutrition care process to meet the needs of residents for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. Medical nutrition therapy includes assessment of the nutritional status of the resident and treatment through diet therapy, counseling and/or use of specialized nutrition supplements. (d) Menus must meet the needs of the residents. 1. Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the residents and must be prepared and served as prescribed. 2. Special diets shall be prepared and served as ordered. 3. Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the residents. 4. A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. (e) Education programs, including orientation, on-the-job training, inservice education, and continuing education shall be offered to dietetic services personnel on a regular basis. STANDARDS FOR NURSING HOMES CHAPTER 0720-18 Programs shall include instruction in the use of equipment, personal hygiene, proper inspection, and the handling, preparing and serving of food. (f) A minimum of three (3) meals in each twenty-four (24) hour period shall be served. A supplemental night meal shall be served if more than fourteen (14) hours lapse between supper and breakfast. Additional nourishments shall be provided to patients with special dietary needs. A minimum of three (3) days supply of food shall be on hand. (g) Menus shall be prepared at least one week in advance. A dietitian shall be consulted to help write and plan the menus. If any change in the actual food served is necessary, the change shall be made on the menu to designate the foods actually served to the residents. Menus of food served shall be kept on file for a thirty (30) day period. (h) The dietitian or designee shall have a conference, dated on the medical chart, with each resident and/or family within two (2) weeks of admission to discuss the diet plan indicated by the physician. The resident’s dietary preferences shall be recorded and utilized in planning his/her daily menu. (i) Food shall be protected from dust, flies, rodents, unnecessary handling, droplet infection, overhead leakage and other sources of contamination whether in storage or while being prepared and served and/or transported through hallways. (j) Perishable food shall not be allowed to stand at room temperature except during necessary periods of preparation or serving. Prepared foods shall be kept hot (140°F or above) or cold (45°F or less). Appropriate equipment for temperature maintenance, such as hot and cold serving units or insulated containers, shall be used. (k) All nursing homes shall have commercial automatic dishwashers approved by the National Sanitation Foundation. Dishwashing machines shall be used according to manufacturer specifications. (l) All dishes, glassware and utensils used in the preparation and serving of food and drink shall be cleaned and sanitized after each use. (m) The cleaning and sanitizing of handwashed dishes shall be accomplished by using a three-compartment sink according to the current “U.S. Public Health Service Sanitation Manual.” (n) The kitchen shall contain sufficient refrigeration equipment and space for the storage of perishable foods. (o) All refrigerators and freezers shall have thermometers. Refrigerators shall be kept at a temperature not to exceed 45°F. Freezers shall be kept at a temperature not to exceed 0°F. (p) Written policies and procedures shall be followed concerning the scope of food services in accordance with the current edition of the “U.S. Public Health Service Recommended Ordinance and Code Regulating Eating and Drinking Establishments” and the current “U.S. Public Health Service Sanitation Manual” should be used as a guide to food sanitation. (10) Social Work Services. (a) Social services must be available to the resident, the resident’s family and other persons significant to the resident, in order to facilitate adjustment of these individuals STANDARDS FOR NURSING HOMES CHAPTER 0720-18 to the impact of illness and to promote maximum benefits from the health care services provided. (b) Social work services shall include psychosocial assessment, counseling, coordination of discharge planning, community liaison services, financial assistance and consultation. (c) A resident’s social history shall be obtained within two (2) weeks of admission and shall be appropriately maintained. (d) Social work services shall be provided by a qualified social worker. (e) Facilities for social work services shall be readily accessible and shall permit privacy for interviews and counseling. (11) Physical, Occupational and Speech Therapy Services. (a) Physical therapy, occupational therapy and speech therapy shall be provided directly or through contractual agreement by individuals who meet the qualifications specified by nursing home policy, consistent with state law. (b) Speech therapy services shall be provided only by or under supervision of a qualified speech language pathologist in good standing, or by a person qualified as a Clinical Fellow subject to Tennessee Board of Communications Disorders and Sciences Rule 1370-01-.10. (c) A licensed physical therapist shall be in charge of the physical therapy service and a licensed occupational therapist shall be in charge of the occupational therapy service. (d) Direct contact shall exist between the resident and the therapist for those residents that require treatment ordered by a physician. (e) The physical therapist and occupational therapist, pursuant to a physician order, shall provide treatment and training designed to preserve and improve abilities for independent functions, such as: range of motion, strength, tolerance, coordination and activities of daily living. (f) Therapy services shall be coordinated with the nursing service and made a part of the resident care plan. (g) Sufficient staff shall be made available to provide the service offered. (12) Ventilator Services. A nursing home that provides ventilator services shall meet or exceed the following minimum standards by: (a) Ensuring a licensed respiratory care practitioner as defined by Tennessee Code Annotated Section 63-27-102(7), shall be physically present at the facility twenty four (24) hours per day, seven (7) days per week to provide: 1. Ventilator care; 2. Administration of medical gases; 3. Administration of aerosol medications; and 4. Diagnostic testing and monitoring of life support systems; STANDARDS FOR NURSING HOMES CHAPTER 0720-18 (b) Ensuring that an appropriate, individualized plan of care is prepared for each patient requiring ventilator services. The plan of care shall be developed with input and participation from a pulmonologist or a physician with experience in ventilator care; (c) Ensuring that admissions criteria is established to ensure the medical stability of ventilator-dependent patients prior to transfer from an acute care setting; (d) Ensuring that Arterial Blood Gas (ABG) is readily available in order to document the patient’s acid base status and/or End Tidal Carbon Dioxide (etCOs) and whether continuous pulse oximetry measurements should be performed in lieu of ABG studies; (e) Ensuring that an audible, redundant external alarm system is located outside of each ventilator-dependent patient’s room for the purpose of alerting caregivers of patient disconnection, ventilator disconnection or ventilator failure; (f) Ensuring that the nursing home is equipped with emergency suction equipment and an adequate number of Ambu bags for manual ventilation; (g) Ensuring that ventilator equipment is connected to electrical outlets connected to back- up generator power; (h) Ensuring that ventilators are equipped with battery back-up systems; (i) Ensuring that the nursing home is equipped to employ the use of current ventilator technology consistent with meeting patients’ needs for mobility and comfort; and (j) Ensuring that a back-up ventilator is available at all times.