Section
1. Definitions.
(1) "Active
treatment" means daily participation, in accordance with an individual plan of
care and service, in activities, experiences, or therapy which are part of a
professionally developed and supervised program of health, social and/or
habilitative services offered by or procured by contract or other written
agreement by the institution for its residents.
(2) "Administrator" means a person who is
licensed as a nursing home administrator pursuant to
KRS
216A.080.
(3) "Aversive stimuli" means things or events
that the resident finds unpleasant or painful that are used to immediately
discourage undesired behavior.
(4)
"Developmental disability" means a severe chronic disability which is
attributable to a mental or physical impairment or combination of mental and
physical impairments manifested before the person attains the age of twenty-two
(22) and is likely to continue indefinitely. This disability results in
substantial limitations in three (3) or more areas of major life activity
including self-care, receptive and expressive language, learning, self
direction, mobility, capacity for independent living and economic sufficiency
and requires individually planned and coordinated services of a lifelong or
extended duration.
(5)
"Developmental nursing services" means treatment of a person's developmental
needs by designing interventions to modify the rate and/or direction of the
individual's development especially in the areas of self-help skills, personal
hygiene, and sex education while also meeting his physical and medical
needs.
(6) "Facility" means an
intermediate care facility for the mentally retarded and the developmentally
disabled (MR/DD).
(7) "Induration"
means a firm area in the skin which develops as a reaction to injected
tuberculosis proteins when a person has tuberculosis infection. The diameter of
the firm area is measured to the nearest millimeter to gauge the degree of
reaction. A reaction of ten (10) millimeters or more of induration is
considered highly indicative of tuberculosis infection.
(8) "Interdisciplinary team" means the group
of persons responsible for the diagnosis, evaluation and individualized program
planning and service implementation for the resident. The team is composed of
relevant professionals, and may include the resident, the resident's family, or
the guardian.
(9) "License" means
an authorization issued by the cabinet for the purpose of offering intermediate
care MR/DD services.
(10) "MR/DD"
means the mentally retarded and the developmentally disabled persons.
(11) "Normalization principle" is the
utilization of means which are as culturally normative as possible in order to
establish and maintain personal behavior and characteristics which are as
culturally normative as possible.
(12) "Qualified dietician or nutritionist"
means:
(a) A person who has a bachelor of
science degree in foods and nutrition, food service management, institutional
management or related services and has successfully completed a dietetic
internship or coordinated undergraduate program accredited by the American
Dietetic Association (ADA) and is a member of the ADA or is registered as a
dietician by ADA; or
(b) A person
who has a masters degree in nutrition and is a member of the ADA or is eligible
for registration by ADA; or
(c) A
person who has a bachelor of science degree in home economics and three (3)
years of work experience with a registered dietician.
(13) "Qualified occupational therapist" means
a graduate of a program of occupational therapy approved by the Council on
Medical Education of the American Medical Association and licensed in the
state, if required.
(14) "Qualified
speech pathologist or audiologist" means a person who is licensed pursuant to
KRS Chapter 334A who has been granted a certificate of clinical competence in
the American Speech and Hearing Association or who has completed the equivalent
education and experimental requirements for such a certificate.
(15) "Qualified social worker" means a person
who is licensed or exempt from licensure pursuant to KRS Chapter 335 with
bachelor's degree in social work from an accredited program or a bachelor's
degree in a field other than social work and at least three (3) years of social
work experience under the supervision of a qualified social worker.
(16) "A qualified mental retardation
professional" means a person who has specialized training or one (1) year of
experience in treating or working with the mentally retarded and/or
developmental disabilities and is one (1) of the following:
(a) A psychologist with a master's degree
from an accredited program;
(b) A
licensed physician;
(c) A educator
with a degree in education from an accredited program;
(d) A social worker who is licensed or exempt
from licensure pursuant to KRS Chapter 335 with a bachelor's degree in:
1. Social work from an accredited program;
or
2. A field other than social
work and at least three (3) years of social work experience under the
supervision of a qualified social workers;
(e) A physical or occupational therapist who
is a graduate of a program of physical or occupational therapy approved by the
Council on Medical Education of the American Medical Association.
(f) A speech pathologist or audiologist who
is licensed pursuant to KRS Chapter 334A who has been granted a certificate of
clinical competence in the American Speech and Hearing Association or who has
completed the equivalent educational and experimental requirements for such a
certificate;
(g) A registered
nurse;
(h) A therapeutic recreation
specialist who is graduate of an accredited program and is licensed in the
state, if required, or who has:
1. A
bachelor's degree in recreation, or in a specialty area, such as art, music, or
physical education; or
2. An
associate degree in recreation and one (1) year of experience in recreation;
or
3. A high school diploma, or an
equivalency certificate; and
a. Two (2) years
of experience in recreation; or
b.
One (1) year of experience in recreation plus completion of comprehensive
in-service training in recreation; or
4. Demonstrated proficiency and experience in
conducting activities in one (1) or more recreation program areas; or
(i) A "rehabilitation/counselor"
who is certified by the Committee on Rehabilitation Counselor
Certification.
(17)
"Restraint" means any chemical agent or any physical or mechanical device used
to restrict the movement of an individual or the movement or normal function of
a portion of the individual's body, excluding only those devices used to
provide support for the achievement of functional body position or proper
balance (such as positioning chairs) and devices used for specific medical and
surgical (as distinguished from behavioral) treatment.
(18) "Seclusion" means the retention of a
resident alone in a locked room.
(19) "Skin test" means a tuberculin skin test
utilizing the intradermal (Mantoux) technique using five (5) tuberculin units
of purified protein derivative (PPD). The results of the test must be read
forty-eight (48) to seventy-two (72) hours after injection and recorded in
terms of millimeters of induration.
(20) "Two (2) step skin testing" means a
series of two (2) tuberculin skin tests administered seven (7) to fourteen (14)
days apart.
(21) "Time out" means a
procedure which involves removing the person from a reinforcing situation, for
a period of time when the person engages in a specified inappropriate
behavior.
Section
3. Administration and Operation.
(1) Licensee. The licensee shall be legally
responsible for the facility and for compliance with federal, state and local
laws and regulations pertaining to the operation of the facility.
(2) Administrator. All facilities shall have
an administrator who is responsible for the operation of the facility and
delegating such responsibility in his absence. The administrator shall not be
the nursing services supervisor.
(3) Contracted services. The licensee shall
contract for professional and supportive services not available in the facility
as dictated by the needs of the residents. The contract shall be in
writing.
(4) Administrative
records.
(a) The facility shall maintain a
bound, permanent, chronological resident registry showing date of admission,
name of resident and date of discharge.
(b) The facility shall require and maintain
written recommendations or comments from consultants regarding the program and
its development on a per visit basis.
(c) Menu and food purchase records shall be
maintained.
(d) A written report of
any incident or accident involving a resident (including medication errors or
drug reactions), visitor or staff shall be made and signed by the administrator
or nursing services supervisor, and any staff member who witnessed the
incident. The report shall be filed in an incident file.
(5) Policies. The facility shall establish
written policies and procedures that govern all services provided by the
facility. The written policies shall include:
(a) Services including medical, nursing,
habilitation, pharmaceutical (including medication stop orders policy), and
residential services;
(b) Adult and
child protection. The facility shall have written policies which assure the
reporting of cases of abuse, neglect or exploitation of adults and children to
the Department for Human Resources pursuant to KRS Chapters 209 and
620;
(c) Use of restraints. The
facility shall have a written policy that defines the use of restraints and
supportive devices and a mechanism for monitoring and controlling their use;
and
(d) Missing resident
procedures. The facility shall have a written procedure to specify in a
step-bystep manner the actions which shall be taken by staff when a resident is
determined to be lost, unaccounted for or other unauthorized absence.
(6) Patient rights. Patient rights
shall be provided for pursuant to
KRS
216.510 to
216.525.
(7) Admission.
(a) Patients shall be admitted only upon the
approval of a physician. The facility shall admit only persons who have a
physical or mental condition which requires developmental nursing services and
a planned program of active treatment.
(b) The interdisciplinary team shall consist
of a physician, a psychologist, a registered nurse, a social worker and other
professionals, at least one of whom is a qualified mental retardation
professional. The interdisciplinary team shall:
1. Conduct a comprehensive evaluation of the
individual, not more than three (3) months before admission, covering physical,
emotional, social, and cognitive factors; and
2. Prior to admission define the need for
service without regard to availability of those services. The team shall review
all available and applicable programs of care, treatment, and training and
record its findings.
(c)
If admission is not the best plan but the individual must be admitted
nevertheless, the facility shall clearly acknowledge that the admission is
inappropriate and initiate plans to actively explore alternatives;
(d) Before admission, the resident and a
responsible member of his family or committee shall be informed in writing of
the established policies of the facility and fees, reimbursement, visitation
rights during serious illness, visiting hours, type of diets offered and
services offered; and
(e) The
facility shall provide and maintain a system for identifying each resident's
personal property and facilities for safekeeping of his declared valuables.
Each resident's clothing and other property shall be reserved for his own
use.
(8) Discharge
planning. Prior to discharge the facility shall have a postinstitutional plan
which identifies the residential setting and support services which would
enable the resident to live in a less restrictive alternative to the current
setting. Before a resident is released, the facility shall:
(a) Offer counseling to parents or guardians
who requests the release of a resident concerning the advantages and
disadvantages of the release;
(b)
Plan for release of the resident, to assure that appropriate services are
available in the resident's new environment, including protective supervision
and other follow-up services; and
(c) Prepare and place in the resident's
record a summary of findings, progress, and plans.
(9) Transfer procedures and agreements.
(a) The facility shall have written transfer
procedures and agreements for the transfer of residents to other health care
facilities which can provide a level of health care not provided by the
facility. Any facility which does not have a transfer agreement in effect but
which documents a good faith attempt to enter into an agreement shall be
considered to be in compliance with the licensure requirement. The transfer
procedures and agreements shall specify the responsibilities each institution
assumes in the transfer of resident, and shall establish responsibility for
notifying the other institution promptly of the impending transfer of a
resident and shall arrange for appropriate and safe transportation.
(b) When the resident's condition exceeds the
scope of services of the facility, the resident, upon physician's orders
(except in cases of emergency), shall be transferred promptly to a hospital or
a skilled nursing facility, or services shall be contracted for from another
community resource.
(c) When
changes and progress occur which would enable the resident to function in a
less structured and restrictive environment, and the less restrictive
environment cannot be offered at the facility, the facility shall offer
assistance in making arrangements for residents to be transferred to facilities
providing appropriate services.
(d)
Except in an emergency, the resident, his next of kin, or guardian, if any, and
the attending physician shall be consulted in advance of the transfer or
discharge of any resident.
(e) When
a transfer is to another level of care within the same facility, the complete
medical record or a current summary thereof shall be transferred with the
resident.
(f) If the resident is
transferred to another health care facility or other community resource, a
transfer form shall accompany the resident. The transfer form shall include at
least: physician's orders (if available), current information relative to
diagnosis with a history of problems requiring special care, a summary of the
course of prior treatment, special supplies or equipment needed for resident
care, and pertinent social information on the resident and family.
(10) Medical records.
(a) The facility shall maintain a record for
each resident for:
1. Planning and continuous
evaluation of the resident's habilitation program;
2. Furnishing documentary evidence of each
resident's progress and response to his habilitation program; and
3. Protecting the rights of the residents,
the facility and the staff.
(b) All entries in the resident's record
shall be legible, dated and signed.
(c) At the time a resident is admitted, the
facility must enter in the individual's record the following information:
1. Name, date of admission, birth date and
place, citizenship status, marital status, and Social Security
number;
2. Father's name and
birthplace, mother's maiden name and birthplace, and parents' marital
status;
3. Name and address of
parents, legal guardian, and next of kin if needed;
4. Sex, race, height, weight, color of hair,
color of eyes, identifying marks, and recent photograph;
5. Reason for admission or referral
problem;
6. Type and legal status
of admission;
7. Legal competency
status;
8. Language spoken or
understood;
9. Sources of support,
including Social Security, veterans' benefits, and insurance;
10. Religious affiliation, if any;
11. Reports of the preadmission evaluations;
and
12. Reports of previous
histories and evaluations, if any.
(d) Within one (1) month after the admission
of each resident, the ICF/MR must enter the following in the resident's record:
1. A report of the review and updating of the
preadmission evaluation;
2. A
prognosis that can be used for programming and placement; and
3. A comprehensive evaluation and individual
program plan, designed by an interdisciplinary team.
(e) The facility must enter the following
information in a resident's record during his residence:
1. Reports of accidents, seizures, illnesses,
and treatments for these conditions;
2. Records of immunizations;
3. Records of all time periods that
restraints were used, with justification and authorization for each;
4. Reports of regular, at least annual,
review and evaluation of the program, developmental progress, and status of
each resident;
5. Observations of
the resident's response to his program to enable evaluation of its
effectiveness;
6. Records of
significant behavior incidents;
7.
Records of family visits and contacts;
8. Records of attendance and
absences;
9. Correspondence
pertaining to the resident;
10.
Periodic updates of the information recorded at the time of admission;
and
11. Appropriate authorizations
and consent.
(f) The
ICF/MR must enter a discharge summary in the resident's record at the time he
is discharged.
(11)
Personnel.
(a) Job descriptions. Written job
descriptions shall be developed for each category of personnel, to include
qualifications, lines of authority and specific duty assignments.
(b) Employee records. Current employee
records shall be maintained and shall include a resume of each employee's
training and experience, evidence of current licensure or registration where
required by law, health records, records of in-service training and ongoing
education, and the employee's name, address and Social Security
number.
(c) Staffing requirements.
The facility shall have adequate personnel to meet the needs of the residents
on a twenty-four (24) hour basis. The number and classification of personnel
required shall be based on the number of residents, the amount and the kind of
personal care, nursing care, supervision and program needed to meet the needs
of the resident as determined by the interdisciplinary team, and the services
required by this administrative regulation.
(d) The licensee shall have a qualified
mental retardation professional who is responsible for:
1. Supervising the delivery of each
resident's individual plan of care;
2. Supervising the delivery of training and
habilitation services;
3.
Integrating the various aspects of the facility program;
4. Recording each resident's progress;
and
5. Initiating a periodic review
of each individual plan of care for necessary changes.
(e) Each resident living unit, regardless of
organization or design, must have, as a minimum, overall staff-resident ratios
(allowing for a five (5) day work week plus holiday, vacation, and sick time)
as follows unless program needs justify otherwise:
1. For units serving children under the age
of six (6) years, severely and profoundly retarded, severely physically
handicapped, or residents who are aggressive, assaultive, or security risks, or
who manifest severely hyperactive or psychotic-like behavior, the overall ratio
is one (1) to two (2);
2. For units
serving moderately retarded residents requiring habit training, the overall
ratio is one (1) to two and five tenths (2.5); and
3. For units serving residents in vocational
training programs and adults who work in sheltered employment situations, the
overall ratio is one (1) to five (5).
(f) When the staff/resident ratio does not
meet the needs of the residents, the Division for Licensing and Regulation
shall determine and inform the administrator in writing how many additional
personnel are to be added and of what job classification and shall give the
basis for this determination.
(g) A
responsible staff member shall be on duty and awake at all times to assure
prompt, appropriate action in case of injury, illness, or fire or other
emergencies.
(h) Volunteers shall
not be counted to make up minimum staffing requirements.
(i) Supervision of nursing services shall be
by a registered nurse or licensed practical nurse employed on the day shift
seven (7) days per week. The supervisor shall have training and experience in
the field of developmental disabilities and mental retardation. When a licensed
practical nurse serves as the supervisor, consultation shall be provided by a
registered nurse preferably with a baccalaureate degree, at regular intervals,
not less than four (4) hours weekly. The responsibilities of the nursing
services supervisor shall include:
1.
Developing and maintaining nursing service objectives, standards of nursing
practice, nursing procedure manuals, and written job description for each level
of nursing personnel;
2. Nursing
service personnel at all levels of experience and competence shall be assigned
responsibilities in accordance with their qualifications, delegate authority
commensurate with their responsibility, and provide appropriate professional
nursing supervision; and
3.
Participate in the development and implementation of resident care
policies.
(j) The
facility shall retain a licensed pharmacist on a full-time, part-time or
consultant basis to direct pharmaceutical services.
(k) Each facility shall have a full-time
person designated by the administrator, responsible for the total food service
operation of the facility and on duty a minimum of thirty-five (35) hours each
week.
(l) Supportive personnel,
consultants, assistants and volunteers shall be supervised and shall function
within the policies and procedures of the facility.
(m) Health requirements. No employee
contracting an infectious disease shall appear at work until the infectious
disease can no longer be transmitted. The facility shall comply with the
following tuberculosis testing requirements:
1. The skin test status of all staff members
shall be documented in the employee's personnel record. A skin test shall be
initiated on all new staff members before or during the first week of
employment and the results shall be documented in the employee's personnel
record within the first month of employment. No skin testing is required at the
time of initial employment if the employee documents a prior skin test of ten
(10) or more millimeters of induration or if the employee is currently
receiving or has completed six (6) months of prophylactic therapy or a course
of multiple-drug chemotherapy for tuberculosis. Two (2) step skin testing is
required for new employees over age forty-five (45) whose initial test shows
less than ten (10) millimeters of induration, unless they can document that
they have had tuberculosis skin test within one (1) year prior to their current
employment. All staff who have never had a skin test of ten (10) or more
millimeters induration must be skin tested annually on or before the
anniversary of their last skin test.
2. All staff who are found to have a skin
test of ten (10) or more millimeters induration, on initial employment testing
or annual testing, must receive a chest x-ray unless a chest x-ray within the
previous two (2) months showed no evidence of tuberculosis or the individual
can document the previous completion of a course of prophylactic treatment with
isoniazid. Such employees shall be advised of the symptoms of the disease and
instructed to report to their employer and seek medical attention promptly, if
symptoms persist.
3. The
administrator shall be responsible for ensuring that all skin tests and chest
x-rays are done in accordance with paragraphs 1 and 2 of this subsection. All
skin testing dates and results and all chest x-ray reports shall be recorded as
a permanent part of the personnel record.
4. The following shall be reported by the
administrator to the local health department having jurisdiction immediately
upon becoming known: names of staff who convert from a skin test of less than
ten (10) to a skin test of ten (10) or more millimeters of induration; names of
staff who have a skin test of ten (10) millimeters or more induration at the
time of employment; and all chest x-rays suspicious for tuberculosis.
5. Any staff whose skin test status changes
on annual testing from less than ten (10) to ten (10) or more millimeters of
induration shall be considered to be recently infected with Mycobacterium
tuberculosis. Such recently infected persons who have no signs or symptoms of
tuberculosis disease on chest x-ray or medical history should be given
preventive therapy with isoniazid for six (6) months unless medically
contraindicated, as determined by a licensed physician. Medications shall be
administered to patients only upon the written order of a physician. If such
individual is unable to take isoniazid therapy, the individual shall be advised
of the clinical symptoms of the disease, and have an interval medical history
and a chest x-ray taken and evaluated for tuberculosis infection every six (6)
months during the two (2) years following conversion for a total of five (5)
chest x-rays.
6. Any staff who can
document completion of preventive treatment with isoniazid shall be exempt from
further screening requirements.
(n) The facility shall have a staff training
program adequate for the size and nature of the facility with a person
designated the responsibility for staff development and training. The program
shall include:
1. Orientation for each new
employee to acquaint him with the philosophy, organization, program, practices,
and goals of the facility;
2.
In-service training for any employee who has not achieved the desired level of
competence;
3. Continuing
in-service training for all employees to update and improve their skills;
and
4. Supervisory and management
training for each employee who is in, or a candidate for, a supervisory
position.
Section
4. Provision of Services.
(1)
The professional interdisciplinary team shall assure that the health needs of
the residents are met and that plans are developed for each resident which
include treatments, medications, dietary requirements, and other program
services. All activities shall reflect adherence to the normalization
principle. The active treatment program shall assure:
(a) An individual written plan of care that
sets forth measurable goals or objectives stated in terms of desirable behavior
and that prescribes an integrated program of activities, experiences or
therapies necessary for the individual to reach those goals or objectives. The
plan is to help the individual function at the greatest physical, intellectual,
social, or vocational level he can presently or potentially achieve.
(b) Regular participation, in accordance with
an individualized plan, in a program of activities that are designed to attain
the optimum physical, intellectual, social, and vocational functioning of which
a resident is capable.
(c)
Reevaluation medically, socially, and psychologically at least annually by the
staff involved in carrying out the resident's individual plan of care. This
must include review of the individual's progress toward meeting the plan
objectives, the appropriateness of the individualized plan of care, assessment
of his continuing need for institutional care, and consideration of alternate
methods of care.
(2)
Infection control and communicable diseases.
(a) There shall be written infection control
policies, which are consistent with the Centers for Disease Control guidelines
including:
1. Policies which address the
prevention of disease transmission to and from patients, visitors and
employees, including:
a. Universal blood and
body fluid precautions;
b.
Precautions for infections which can be transmitted by the airborne route;
and
c. Work restrictions for
employees with infectious diseases.
2. Policies which address the cleaning,
disinfection, and sterilization methods used for equipment and the
environment.
(b) The
facility shall provide in-service education programs on the cause, effect,
transmission, prevention and elimination of infections for all personnel
responsible for direct patient care.
(c) Sharp wastes.
1. Sharp wastes, including needles, scalpels,
razors, or other sharp instruments used for patient care procedures, shall be
segregated from other wastes and placed in puncture resistant containers
immediately after use.
2. Needles
shall not be recapped by hand, purposely bent or broken, or otherwise
manipulated by hand.
3. The
containers of sharp wastes shall either be incinerated on or off site, or be
rendered non-hazardous by a technology of equal or superior efficacy, which is
approved by both the Cabinet for Human Resources and the Natural Resources and
Environmental Protection Cabinet.
(d) Disposable waste.
1. All disposable waste shall be placed in
suitable bags or closed containers so as to prevent leakage or spillage, and
shall be handled, stored, and disposed of in such a way as to minimize direct
exposure of personnel to waste materials.
2. The facility shall establish specific
written policies regarding handling and disposal of all wastes.
3. The following wastes shall be disposed of
by incineration, autoclaved before disposal, or carefully poured down a drain
connected to a sanitary sewer: blood, blood specimens, used blood tubes, or
blood products.
4. Any wastes
conveyed to a sanitary sewer shall comply with applicable federal, state, and
local pretreatment regulations pursuant to 40 CFR
403 and 401 KAR
5:055,
Section 9.
(e) Patients
infected with the following diseases shall not be admitted to the facility:
anthrax, cam-pylobacteriosis, cholera, diphtheria, hepatitis A, measles,
pertussis, plague, poliomyelitis, rabies (human), rubella, salmonellosis,
shigellosis, typhoid fever, yersiniosis, brucellosis, giardiasis, leprosy,
psittacosis, Q fever, tularemia, and typhus.
(f) A facility may admit a (noninfectious)
tuberculosis patient under continuing medical supervision for his tuberculosis
disease.
(g) Patients with active
tuberculosis may be admitted to the facility whose isolation facilities and
procedures have been specifically approved by the cabinet.
(3) Use of control and discipline of
residents.
(a) The facility must have written
policies and procedures for the control and discipline of residents that are
available in each living unit and to parents and guardians.
(b) The facility shall not allow:
1. Corporal punishment of a
resident;
2. A resident to
discipline another resident, unless it is done as part of an organized
self-government program conducted in accordance with written policy;
or
3. Seclusion of a
resident.
(c) On orders
of a physician, or in the case of an emergency until a physician is contacted,
the facility may allow the use of physical restraint on a resident only if
absolutely necessary to protect the resident from injuring himself or others
but may not use physical restraint as punishment, for the convenience of the
staff, or as a substitute for activities or treatment.
(d) The facility must have a written policy
that specifies how and when physical restraint may be used, the staff members
who must authorize its use, and the method for monitoring and controlling its
use.
(e) An order for physical
restraint may not be in effect longer than twelve (12) hours. Appropriately
trained staff must check a resident placed in a physical restraint at least
every thirty (30) minutes and keep a record of these checks. A resident who is
in a physical restraint must be given an opportunity for motion and exercise
for a period of not less than ten (10) minutes during each two (2) hours of
restraint. Mechanical devices used for physical restraint must be designed and
used in a way that causes the resident no physical injury and the least
possible physical discomfort. Restraints that require lock and key shall not be
used.
(f) Mechanical supports used
as protective devices must be designed and applied under the supervision of a
qualified professional, and in accordance with principles of good body
alignment, concern for circulation, and allowance for change of
position.
(g) The facility may not
use chemical restraint excessively, as punishment, for the convenience of the
staff, as a substitute for activities or treatment, or in quantities that
interfere with a resident's habilitation program.
(h) Behavior modification programs involving
the use of aversive stimuli or time-out devices shall be:
1. Reviewed and approved by the facility's
human rights committee or a qualified mental retardation
professional;
2. Conducted only
with the consent of the affected resident's parents or legal guardian;
and
3. Described in written plans
that are kept on file in the ICF/MR.
(i) A physical restraint used as a time-out
device may be applied only during behavior modification exercises and only in
the presence of the trainer.
(j)
Time-out devices and aversive stimuli may not be used for longer than one (1)
hour, and then only during the behavior modification program and only under the
supervision of the trainer.
(4) Medical supervision of residents. The
facility shall maintain policies and procedures to assure that each resident
shall be under the medical supervision of a physician.
(a) The resident (or his guardian) shall be
permitted his choice of physician.
(b) The physician shall visit the residents
as often as necessary and in no case less often than every sixty (60) days,
unless justified and documented by the attending physician.
(c) A complete medical evaluation to include
social, physical, emotional, and cognitive factors shall be made of the person
desiring or requiring institutionalization prior to, but not to exceed three
(3) months before admission.
(d)
Medical reevaluation at least annually shall be made by the resident's
physician, a physician provided by a community service, or a registered
visiting nurse, according to the resources for the community and the apparent
needs of the resident receiving intermediate care.
(e) Formal arrangements shall be made to
provide for medical emergencies on a twenty-four (24) hour, seven (7) days a
week basis. This shall be the responsibility of the facility providing
care.
(5) Health
services. Health services shall include:
(a)
The establishment of a nursing care plan as part of the total habilitation
program for each resident. Each plan shall be reviewed and modified as
necessary, or at least quarterly. Each plan shall include goals, and nursing
care needs;
(b) Nursing care to
achieve and maintain the highest degree of function, self-care and independence
with those procedures requiring medical approval ordered by the attending
physician. Nursing care shall include:
1.
Positioning and turning. Nursing personnel shall encourage and assist residents
in maintaining good body alignment while standing, sitting, or lying in bed to
prevent decubiti.
2. Exercises.
Nursing personnel shall assist residents in maintaining maximum range of
motion.
3. Bowel and bladder
training. Nursing personnel shall make every effort to train incontinent
residents to gain bowel and bladder control.
4. Training in habits of personal hygiene,
family life, and sex education that includes but is not limited to family
planning and venereal disease counseling.
5. Ambulation. Nursing personnel shall assist
and encourage residents with daily ambulation unless otherwise ordered by the
physician.
6. Administration of
medications and appropriate treatment.
7. Written monthly assessment of the
resident's general condition with any changes in the resident's condition,
actions, responses, attitudes, or appetite recorded in the resident's record by
licensed personnel.
(6) Pharmaceutical services.
(a) The facility shall provide appropriate
methods and procedures for obtaining, dispensing, and administering drugs and
biologicals, developed with the advice of a licensed pharmacist or a
pharmaceutical advisory committee which includes one (1) or more licensed
pharmacist.
(b) If the facility has
a pharmacy department, a licensed pharmacist shall be employed to administer
the pharmacy department.
(c) If the
facility does not have a pharmacy department, it shall have provision for
promptly obtaining prescribed drugs and biologicals from a community or
institutional pharmacy holding a valid pharmacy permit issued by the Kentucky
Board of Pharmacy, pursuant to
KRS
315.035.
(d) An emergency medication kit approved by
the facility's professional personnel shall be kept readily available. The
facility shall maintain a record of what drugs are in the kit and document how
the drugs are used.
(e) Medication
requirement and services.
1. Conformance with
physician's orders. All medications administered to residents shall be ordered
in writing. Oral orders shall be given only to a licensed nurse or pharmacist,
immediately reduced to writing, and signed. Medications not specifically
limited as to time or number of doses, when ordered, shall be automatically
stopped in accordance with the facility's written policy on stop orders. The
pharmacist or nurse shall review the resident's medication profile on a regular
basis. The resident's attending physician shall be notified of stop order
policies and contacted promptly for renewal of such orders so that continuity
of the resident's therapeutic regimen is not interrupted. Medications shall be
released to residents on discharge or visits only after being labeled
appropriately and on the written authorization of the physician.
2. Administration of medications. All
medications shall be administered by licensed nurses or personnel who have
completed a state approved training program, from a state approved training
provider. Each dose administered shall be recorded in the medical record.
Intramuscular injections shall be administered by a licensed nurse or a
physician. If intravenous injections are necessary they shall be administered
by a licensed physician or a registered nurse.
a. The nursing station shall have items
required for the proper administration of medication readily
available.
b. Medications
prescribed for one resident shall not be administered to any other
resident.
c. Self-administration of
medications by residents shall not be permitted except for drugs on special
order of the resident's physician and a predischarge program under the
supervision of a licensed nurse as a part of the resident's treatment
plan.
d. Medication errors and drug
reactions shall be immediately reported to the resident's physician and
pharmacist and an entry thereof made in the resident's medical record as well
as on an incident report.
3. The facility shall provide up-to-date
medication reference texts for use by the nursing staff (e.g., Physician's Desk
Reference).
4. Labeling and storing
medications. All medications shall be plainly labeled with the resident's name,
the name of the drug, strength, name of pharmacy, prescription number, date,
physician name, caution statements and directions for use except where accepted
modified unit dose systems conforming to federal and state laws are used. The
medications of each resident shall be kept and stored in their original
containers and transferring between containers shall be prohibited. All
medicines kept by the facility shall be kept in a locked place and the persons
in charge shall be responsible for giving the medicines and keeping them under
lock and key. Medications requiring refrigeration shall be kept in a separate
locked box of adequate size in the refrigerator in the medication area. Drugs
for external use shall be stored separately from those administered by mouth
injection. Provisions shall also be made for the locked separate storage of
medications of deceased and discharge resident until such medication is
surrendered or destroyed in accordance with federal and state laws and
regulations.
5. Controlled
substances. Controlled substances shall be kept under double lock, (i.e., in a
locked box in a locked cabinet). There shall be a controlled substances record,
in which is recorded the name of the resident, the date, time, kind, dosage,
balance remaining and method of administration of all controlled substances;
the name of the physician who administered it, or staff who supervised the
self-administration. In addition, there shall be a recorded and signed schedule
II controlled substances count daily, and schedule III, IV and V controlled
substances count once per week by those persons who have access to controlled
substances. All controlled substances which are left over after the discharge
or death of the patient shall be destroyed in accordance with
KRS
218A.230, or
21 CFR
1307.21, or sent via registered mail to the
Controlled Substances Enforcement Branch of the Kentucky Cabinet for Human
Resources.
(7)
Personal care services.
(a) Each resident
shall be trained to be as independent as possible to achieve and maintain good
personal hygiene including:
1. Bathing of the
body to maintain clean skin and freedom from offensive odors. In addition to
assistance with bathing, the facility shall provide soap, clean towels, and
wash cloths for each resident. Toilet articles such as brushes and combs shall
not be used in common.
2.
Shaving.
3. Cleaning and trimming
of fingernails and toenails.
4.
Cleaning of the mouth and teeth to maintain good oral hygiene as well as care
of the lips to prevent dryness and cracking. All residents shall be provided
with tooth brushes, a dentifrice, and denture containers, when
applicable.
5. Washing, grooming,
and cutting of hair.
(b)
Each resident who does not eliminate appropriately and independently must be in
a regular, systematic toilet training program and a record must be kept of his
progress in the program.
(c) A
resident who is incontinent must be bathed or cleaned immediately upon voiding
or soiling, unless specifically contraindicated by the training program, and
all soiled items must be changed.
(d) The staff shall train and when necessary
assist the residents to dress in their own street clothing (unless otherwise
indicated by the physician).
(8) Dental services.
(a) Comprehensive dental services shall be
provided and if not available within the facility, arrangements with
specialists in the dental field will be made for such service.
1. Appropriate dental services shall be
provided through personal contact with all residents by dentists, dental
hygienists, and dental assistants under the supervision of the dentists, health
educators, and oral hygiene aids.
2. A dental professional shall participate,
as appropriate on the interdisciplinary team serving the facility.
3. There shall be sufficient supporting
personnel, equipment, and facilities available to the dental professional if
dental services are delivered within the facility.
(b) Dental records shall be part of each
resident's record.
(c) A dentist
shall be responsible for insuring that direct care staff are instructed in the
proper use of oral hygiene methods for residents.
(9) Social services.
(a) Social services shall be available either
on staff or by formal arrangement with community resources for all residents
and their families, including evaluation and counseling with referral to, and
use of, other planning for community placement, discharge and follow up
services rendered by or under the supervision of a social worker.
(b) The social worker of the intermediate
care facility, providing services for the mentally retarded and developmentally
disabled shall be under the supervision of a social worker who is a qualified
mental retardation professional.
(c) Social services shall be integrated with
other elements of the plan of care.
(d) A plan for such care shall be recorded in
the resident's record and periodically evaluated in conjunction with resident's
total plan of care.
(e) Social
services records shall be maintained as an integral part of case record
maintained on each resident.
(10) Recreation services. The facility shall
coordinate recreational services with other services and programs provided to
each resident and shall:
(a) Provide
recreation equipment and supplies in a quantity and variety that is sufficient
to carry out the stated objectives of the activities programs.
(b) Keep resident records that include
periodic surveys of the residents' recreation interests and the extent and
level of the residents' participation in the recreation program.
(c) Have enough qualified staff and support
personnel available to carry out the various recreation services with the
qualifications as defined in the definitions.
(11) Speech pathology and audiology services.
The facility shall provide speech pathology and audiology services as needed to
maximize the communication skills of residents needing such services. These
services shall be provided by, or under the supervision of, a certified speech
pathologist or audiologist who is a member of the interdisciplinary
team.
(12) Occupational therapy.
(a) Occupational therapy shall be provided by
or under the supervision of a qualified occupational therapist to residents as
required by the resident's needs.
(b) The occupational therapist shall act upon
the program designed by the professional interdisciplinary team of which the
therapist is a member.
(13) Physical therapy.
(a) Physical therapy shall be provided by or
under the supervision of a licensed physical therapist to residents as required
by the resident's needs.
(b) The
physical therapist shall act upon the program designed by the professional
interdisciplinary team of which the therapist is a member.
(14) Psychological services. Psychological
services as needed shall be provided by a licensed or certified psychologist
pursuant to KRS Chapter 319 who shall participate in the evaluation and
periodic review, individual treatment, and consultation and training of program
staff as a member of the interdisciplinary team.
(15) Transportation.
(a) If transportation of residents is
provided by the facility to community agencies or other activities, the
following shall apply:
1. Special provision
shall be made for residents who use wheelchairs.
2. An escort or assistant to the driver shall
be provided in transporting residents to and from the facility if necessary for
the resident's safety.
(b) The facility shall arrange for
appropriate transportation in case of medical emergencies.
(16) Residential care services. All
facilities shall provide residential care services to all residents including:
room accommodations, housekeeping and maintenances services, and dietary
services. All facilities shall meet the following requirements relating to the
provision of residential care services:
(a)
Room accommodations.
1. Each resident shall be
provided a standard size bed at least thirty-six (36) inches wide, equipped
with substantial spring, a clean comfortable mattress, a mattress cover, two
(2) sheets and a pillow, an such bed covering as is required to keep the
resident comfortable. Rubber or other impervious sheets shall be placed over
the mattress cover whenever necessary. Beds occupied by residents shall be
placed so that no resident may experience discomfort because of proximity to
radiators, heat outlets, or by exposure to drafts.
2. The facility shall provide window
coverings, bedside tables with reading lamps (if appropriate), comfortable
chairs, chests or dressers with mirrors, a night light, and storage space for
clothing and other possessions.
3.
Residents shall not be housed in unapproved rooms or unapproved detached
buildings.
4. Basement rooms shall
not be used for sleeping rooms for residents.
5. Residents may have personal items and
furniture when it is physically feasible.
6. Each living room or lounge area shall have
an adequate number of reading lamps, and tables and chairs or settees of sound
construction and satisfactory design.
7. Dining room furnishings shall be adequate
in number, well constructed, and of satisfactory design for the
residents.
8. Each resident shall
be permitted to have his own radio and television set in his room unless it
interferes with or is disturbing to other residents.
(b) Housekeeping and maintenance services.
1. The facility shall maintain a clean and
safe facility free of unpleasant odors. Odors shall be eliminated at their
source by prompt and thorough cleaning of commodes, urinals, bedpans and other
sources.
2. An adequate supply of
clean linen shall be on hand at all times. Soiled clothing and linens shall
receive immediate attention and shall not be allowed to accumulate. Clothing or
bedding used by one resident shall not be used by another until it has been
laundered or dry cleaned.
3. Soiled
linen shall be placed in washable or disposable containers, transported in a
sanitary manner and stored in separate, well-ventilated areas in a manner to
prevent contamination and odors. Equipment or areas used to transport or store
soiled linen shall not be used for handling or storing of clean
linen.
4. Soiled linen shall be
sorted and laundered in the soiled linen room in the laundry area. Hand-washing
facilities with hot and cold water, soap dispenser and paper towels shall be
provided in the laundry area.
5.
Clean linen shall be sorted, dried, ironed, folded, transported, stored and
distributed in a sanitary manner.
6. Clean linen shall be stored in clean linen
closets on each floor, close to the nurses' station.
7. Personal laundry of residents or staff
shall be collected, transported, sorted, washed and dried in a sanitary manner,
separate from bed linens.
8.
Resident's personal clothing shall be laundered by the facility as often as
necessary. Resident's personal clothing shall be laundered by the facility
unless the resident or the resident's family accepts this responsibility.
Residents capable of laundering their own personal clothing may be provided the
facilities to do so. Resident's personal clothing laundered by the facility
shall be marked to identify the resident owner and returned to the correct
resident.
9. Maintenance. The
premises shall be well kept and in good repair. Requirements shall include:
a. The facility shall insure that the grounds
are well kept and the exterior of the building, including the wide walks,
steps, porches, ramps and fences are in good repair.
b. The interior of the building including
walls, ceilings, floors, windows, window coverings, doors, plumbing and
electrical fixtures shall be in good repair. Windows and doors shall be
screened.
c. Garbage and trash
shall be stored in areas separate from those used for the preparation and
storage of food and shall be removed from the premises regularly. Containers
shall be cleaned regularly.
d. A
pest control program shall be in operation in the facility. Pest control
services shall be provided by maintenance personnel of the facility or by
contract with a pest control company. The compounds shall be stored under
lock.
(c)
Dietary services. The facility shall provide or contract for food service to
meet the dietary needs of the residents including modified diets or dietary
restrictions as prescribed by the attending physician. When a facility
contracts for food service with an outside food management company, the company
shall provide a qualified dietician on a full time, part time or consultant
basis to the facility. The qualified dietician shall have continuing liaison
with the medical and nursing staff of the facility for recommendations on
dietetic policies affecting resident care. The company shall comply with all of
the appropriate requirements for dietary services in this administrative
regulation.
1. Therapeutic diets. If the
designated person responsible for food service is not a qualified dietician or
nutritionist, consultation by a qualified dietician or qualified nutritionist
shall be provided.
2. Dietary
staffing. There shall be sufficient food service personnel employed and their
working hours, schedules of hours on duty, and days off shall be posted. If any
food service personnel are assigned duties outside the dietary department, the
duties shall not interfere with the sanitation, safety or time required from
regular dietary assignments.
3.
Menu planning.
a. Menus shall be planned,
written and rotated to avoid repetition. Nutrition needs shall be met in
accordance with the current recommended dietary allowances of the Food and
Nutrition Board of the National Research Council adjusted for age, sex and
activity, and in accordance with physician's orders.
b. Meals shall correspond with the posted
menu. Menus must be planned and posted one (1) week in advance. When changes in
the menu are necessary, substitutions shall provide equal nutritive value and
the changes shall be recorded on the menu and kept on file for thirty (30)
days.
c. The daily menu shall
include regular and all modified diets served within the facility based on a
currently approved diet manual. The manual shall be available in the dietary
department. The diet manual shall indicate nutritional deficiencies of any
diet. The dietician shall correlate and integrate the dietary aspects of the
resident's care with the resident and resident's chart through such methods as
resident instruction, recording diet histories and through participation in
rounds and conferences.
4. Food preparation and storage.
a. There shall be at least a three (3) day
supply of food to prepare well balanced palatable meals.
b. Food shall be prepared with consideration
for any individual dietary requirement. Modified diets, nutrient concentrates
and supplements shall be given only on the written orders of a
physician.
c. At least three (3)
meals per day shall be served with not more than a fifteen (15) hour span
between the substantial evening meal and breakfast. Between-meal snacks to
include an evening snack before bedtime shall be offered to all residents.
Adjustments shall be made when medically contraindicated.
d. Foods shall be prepared by methods that
conserve nutritive value, flavor and appearance and shall be attractively
served at the proper temperatures, and in a form to meet individual needs. (A
file of tested recipes, adjusted to appropriate yield shall be maintained.)
Food shall be cut, chopped or ground to meet individual needs. If a resident
refuses the food served, nutritious substitutions shall be offered.
e. All opened containers or leftover food
items shall be covered and dated when refrigerated.
5. Serving of food. When a resident cannot be
served in the dining room, trays shall be provided and shall rest on firm
supports. Sturdy tray stands of proper height shall be provided for residents
able to be out of bed.
a. Correct positioning
of the resident to receive his tray shall be the responsibility of the
direct-care staff. Residents requiring help in eating shall be assisted
according to their training plan.
b. Adaptive self-help devices shall be
provided to contribute to the resident's independence in eating, if assessments
deem necessary.
6.
Sanitation. All facilities shall comply with all applicable provisions of
KRS
219.011 to
KRS 219.081 and
902 KAR 45:005
(Kentucky's Food Service Establishment Act and Food Service
Code).