216 R.I. Code R. § 216-RICR-40-10-1.16 - Resident Care Services

1.16.1 Resident Care Policies

A. Each nursing facility shall have written resident care policies to govern the continuing nursing care and related medical or other services provided.

1. Care practices shall be person-centered in their implementation and resident-directed in their development whenever possible, and

2. The nursing facility shall provide care and services to all residents in accordance with the prevailing community standard of care.

B. Each nursing facility licensed under the provision of R.I. Gen. Laws Chapter 23-17 shall have a written plan for preventing the hazards of resident wandering from the nursing facility. Said plan shall be on file in the nursing facility and available to the licensing agency upon request.

C. As part of the initial resident admission and assessment process, the nursing facility shall review and consider any notice provided to the facility as required in R.I. Gen. Laws § 42-56-10(23) concerning the resident's or prospective resident's status on parole and recommendations, if any, from the Department of Corrections regarding safety and security measures.

D. Resident care policies and procedures shall be developed and reviewed annually, and revised as necessary, in all nursing facilities by a group of professional personnel including one (1) or more physicians, a registered nurse, representatives of self-directed work teams, and other professional personnel as deemed necessary (e.g., social workers, physical therapists, registered nursing assistants, universal workers, etc.). Documentation of this annual review shall be made available to the licensing agency upon request.

E. Resident care policies shall be available for review by all residents, physicians, community agencies, relatives and personnel and shall include provisions for at least the following:

1. Meeting the total medical and psychosocial needs of residents;

2. The establishment of written plans of care for each resident for medical, nursing and other related services provided;

3. The range of services available and provided to residents and constraints imposed by limitations of services, physicians, facilities, staff coverage, payment mechanism or other;

4. The frequency of physician visits shall be at a minimum of ninety (90) days;

5. The protection of residents' personal and property rights;

6. Types of clinical conditions acceptable for admission to specific levels of care and appropriate services;

7. Emergency admissions or discharges and emergency care of residents;

8. Requirements for informed consent by resident, parent, guardian or legal representative for treatment;

9. Notification of next of kin, attending physician or responsible agency of any transfer or discharge;

10. Notification of next of kin, attending physician or responsible agency of any change of condition;

11. Opportunity for resident, resident family, and/or Family Council comment or complaint;

12. Transfer of medical information in accordance with R.I. Gen. Laws Chapter 5-37.3;

13. Discharge and termination of services; and

14. Provision for continuity of resident care as related to discharge planning, which shall include a mechanism for recording, transmitting and receiving information essential to the continuity of resident care. Such information shall contain no less than the following:

a. Resident identification data; such as name, address, age, gender, name of next of kin, health insurance coverage, etc.;

b. Diagnosis and prognosis, medical status of resident, brief description of current illness, medical and nursing plans of care including such information as medications, treatments, dietary needs, baseline laboratory data;

c. Functional status;

d. Special services such as physical therapy, occupational therapy, speech therapy and such other;

e. Psychosocial needs;

f. Bed-hold policy and readmission in accordance with § 1.15.4(S)(3)(c) of this Part; and

g. Such other information pertinent to ensure continuity of resident care.

F. There shall be documented evidence of the designation of responsibility to a physician, or to a nurse or to the medical staff for the execution and implementation of resident care policies.

1. When a nurse is designated as the responsible agent for a day-to-day execution of resident care policies, a physician shall be available to provide necessary medical guidance.

1.16.2 Infection Prevention and Control

A. The nursing facility shall be responsible for no less than the following:

1. Establishing and maintaining a nursing facility-wide infection surveillance program;

2. Developing and implementing written policies and procedures for the surveillance, prevention, and control of infections in all nursing facility departments/services;

3. Establishing policies and practices governing the admission and isolation of residents with known or suspected infectious diseases;

4. Developing, evaluating and revising on a continuing basis infection prevention and control policies, procedures and techniques for all appropriate areas of nursing facility operation and services;

5. Developing and implementing a system for evaluating and recording the occurrences of all infections among residents and communicable diseases among personnel; such records shall be made available to the licensing agency upon request;

6. Assuring that all resident care support departments have adequate direction, training, staffing and facilities to perform required infection prevention and control functions;

B. Infection prevention and control policies and procedures shall be established for the mutual protection of residents, employees, and the public.

C. A continuing education program on infection prevention and control shall be established and conducted for all staff.

1.16.3 Reporting of Communicable Diseases

A. Each nursing facility shall report promptly to the Rhode Island Department of Health, Division of Emergency Preparedness and Infectious Disease cases of communicable diseases designated as "reportable diseases" when such cases are diagnosed in the facility in accordance with Part 30-05-1 of this Title, Reporting and Testing of Infectious, Environmental, and Occupational Diseases.

B. When infectious diseases present a potential hazard to residents or personnel, these shall be reported to the Rhode Island Department of Health, Division of Emergency Preparedness and Infectious Disease even if not designated as "reportable diseases."

C. When outbreaks of food-borne illness are suspected, such occurrences shall be reported immediately to the Rhode Island Department of Health, Division of Emergency Preparedness and Infectious Disease, or to the Division of Environmental Health, Center for Food Protection.

D. Nursing Facilities must comply with the provisions of R.I. Gen. Laws § 23-28.36-3, which requires notification of fire fighters, police officers and Emergency Medical Technicians after exposure to infectious diseases.

1.16.4 Resident Immunization Policies/Practices

A. Every nursing facility in Rhode Island shall request that residents be immunized for influenza virus and pneumococcal disease in accordance with R.I. Gen. Laws Chapter 23-17.19.

B. Influenza, pneumococcal, and other adult vaccination policies and protocols (such as physician's standing orders) for nursing facility residents shall be developed and implemented by the nursing facility in accordance with the provisions of R.I. Gen. Laws §§ 23-17.19-4 (a) through (c).

C. Vaccinations must be provided in accordance with the Centers for Disease Control and Prevention (CDC) Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (November 2011) https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.

1. Exceptions: No resident shall be required to receive either the influenza or pneumococcal vaccine in accordance with exceptions listed in R.I. Gen. Laws § 23-17.19-6.

1.16.5 Physician Service

A. All residents shall remain or be under the care of a physician of his or her choice, subject to the physician's concurrence.

1. All physician assistant services shall be in accordance with the provisions of R.I. Gen. Laws Chapter 5-54.

2. All nurse practitioner services shall be in accordance with the provisions of R.I. Gen. Laws Chapter 5-34.

B. No less than the following resident care information shall be made available to facilities by the referring source prior to or upon admission and provided only in accordance with the requirements of R.I. Gen. Laws Chapter 5-37.3:

1. Current medical findings;

2. Summary of pre-admission treatment and care; and

3. Diagnosis and medical orders by the physician, physician assistant, or advanced practice registered nurse for immediate resident care.

C. Each nursing facility shall establish and comply with policies governing medical care supervision. Such policies shall include no less than the following:

1. That every resident be under the continued medical supervision of a physician of his or her choice;

2. That a prescribed medical care plan be established for each resident by the attending physician, or physician assistant or advanced practice registered nurse in collaboration with the attending physician. Accordingly, recommendations or orders from consultants shall be approved by the attending physician, or physician assistant or advanced practice registered nurse in collaboration with the attending physician prior to implementation of the order.

3. That the medical care plan be based on a physical examination done within forty-eight (48) hours of admission unless such was performed within five (5) days prior to admission;

4. That each resident be seen by an attending physician, or physician assistant or advanced practice registered nurse in collaboration with the attending physician and the medical care plan be renewed or revised in accordance with the needs of the resident at least every ninety (90) days;

5. That arrangements be made for physician coverage in the absence of the attending physician; and, and progress notes be written and signed by the physician at the time of each visit.

6. Any physician's, physician assistant's, or advanced practice registered nurse's verbal order for drugs, and biologicals shall be given in accordance with the provisions of § 1.16.9(B) of this Part.

D. Written policies and procedures pertaining to emergency medical care including a listing of physician coverage, shall be established and maintained in each residential area. The nursing facility must provide or arrange for physician's services twenty-four (24) hours a day in case of an emergency.

E. Standing orders shall not be permitted. All orders shall be recorded in the resident's medical record and shall be properly signed. However, a physician's, physician assistant's, or advanced practice registered nurse's order for an individual resident may refer to treatments described in a written protocol adopted by the nursing facility. An exception to the requirements of § 1.16.5 of this Part shall be made for the administration of influenza and pneumococcal immunizations as provided in § 1.16.4 of this Part and the administration of Naloxone (Narcan) in accordance with Part 20-20-5 of this Title, Opioid Overdose Prevention and Reporting.

1.16.6 Nursing Service and Minimum Staffing

A. Each nursing facility shall have a formally organized nursing service with an organization chart reflecting the lines of communication. The authority, responsibilities and duties for each nursing service position and/or category shall be clearly delineated in writing through job descriptions.

B. The nursing service shall be under the direction of a Director of Nurses who shall be a registered nurse and employed full-time. A relief registered nurse shall be employed to ensure full-time coverage in the absence (including vacation, sick time, days off, or other) of the designated registered nurse.

1. The Director of Nurses shall not be the administrator nor the assistant administrator and shall:

a. Have at least two (2) years' experience in nursing supervision or, by training and experience, shall have demonstrated competency in nursing service management;

b. Be employed by only one (1) facility in said capacity; and

c. Be responsible for the total nursing service which shall include no less than:

(1) Development, maintenance and evaluation of standards of nursing practice;

(2) Development and periodic revision of nursing policies and procedure manuals;

(3) Recommendation to the nursing facility's administration of the number and categories of nursing personnel required to provide resident care;

(4) Training, assignment, supervision and evaluation of personnel;

(5) Coordination of nursing care services with other services, e.g., medical, nutrition, etc.; and

(6) All other functions and activities related to nursing service management.

C. Each facility shall have a registered nurse on the premises twenty-four (24) hours a day. In addition, the necessary nursing service personnel (licensed and nonlicensed) shall be in sufficient numbers on a twenty-four (24) hour basis, to assess the needs of resident, to develop and implement resident care plans, to provide direct resident care services, and to perform other related activities to maintain the health, safety and welfare of residents.

1. There shall be a master plan of the staffing pattern for providing twenty-four (24) hour direct care nursing service; for the distribution of direct care nursing personnel for each floor and/or residential area; for the replacement of direct care nursing personnel; and for forecasting future needs. The staffing pattern shall include provisions for registered nurses, licensed practical nurses, nursing assistants, medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, physical therapist assistants and other personnel as required.

2. Each nursing facility shall include direct caregivers, including at least one (1) nursing assistant, in the process to create the master plan of the staffing pattern and the federally mandated facility assessment. If the nursing assistants in the nursing facility are represented under a collective bargaining agreement, the bargaining unit shall coordinate voting to allow the nursing assistants to select their representative.

3. The number and type of nursing personnel shall be based on resident care needs and classifications as determined for each residential area. Each nursing facility shall be responsible to have sufficient qualified staff to meet the needs of the residents.

4. At least two (2) individuals who are certified in Basic Life Support must be available twenty-four (24) hours a day within the nursing facility. One (1) of these individuals must be a licensed nurse.

5. Commencing on January 1, 2022, nursing facilities shall provide a quarterly minimum average specified in R.I. Gen. Laws § 23-17.5-32(c)(i).

6. Commencing on January 1, 2023, nursing facilities shall provide a quarterly minimum average specified in R.I. Gen. Laws § 23-17.5-32(c)(ii).

a. In accordance with R.I. Gen. Laws § 23-17.5-32(d), Director of Nursing hours and nursing staff hours spent on administrative duties or non-direct care giving tasks are excluded and may not be counted toward compliance with the minimum staffing hours requirement in §§ 1.16.6(C)(5) and (6) of this Part.

b. Nursing facilities that are certified by the Federal Centers for Medicare and Medicaid Services (CMS) shall access and report data using CMS' payroll-based journal database in accordance with R.I. Gen. Laws § 23-17.5-33(a)(2).

c. Nursing facilities that are not certified by CMS (State licensure only) shall report data to the licensing agency in a form and manner as prescribed by the Director.

7. In accordance with R.I. Gen. Laws § 23-17.5-32(e), the requirements of §§ 16.6.(C)(5) and (6) of this Part are minimum standards only. Nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant State and Federal staffing requirements.

8. Compliance and enforcement for § 1.16.6 of this Part shall be done in accordance with R.I. Gen. Laws § 23-17.5-33.

1.16.7 Nursing Staff Posting Requirements

A. Each nursing facility shall post its daily direct care nurse staff levels by shift in a public place within the nursing facility that is readily accessible to and visible by residents, employees, and visitors. The posting shall be accurate to the actual number of direct care nursing staff on duty for each shift per day. The posting shall be in a format prescribed by the Director, to include:

1. The number of registered nurses, licensed practical nurses, nursing assistants, medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, and physical therapy assistants;

2. The number of temporary, outside agency nursing staff;

3. The resident census as of 12:00 a.m.

4. Documentation of the use of unpaid eating assistants (if utilized by the nursing facility on that date).

5. The minimum number of nursing facility direct caregiver staff per shift that is required to comply with the minimum staffing level requirements contained in § 1.16.6 of this Part; and

6. The telephone number or internet website that a resident, employee or visitor of the nursing facility may use to report a suspected violation by the nursing facility of a regulatory requirement concerning staffing levels and direct patient care.

B. The posting information shall be maintained on file by the nursing facility for no less than three (3) years and shall be made available to the public upon request.

C. The nursing facility shall prepare an annual report showing the average daily direct care nurse staffing level for the nursing facility by shift and by category of nurse to include registered nurses, licensed practical nurses, nursing assistants medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, and physical therapy assistants; the use of nurse and nursing assistant staff from temporary placement agencies; and the nurse and nursing assistant turnover rates.

1. The annual report shall be submitted with the nursing facility's renewal application and provide data for the previous twelve (12) months and ending no earlier than September 30th, for the year preceding the license renewal year. Annual reports shall be submitted in a format prescribed by the Director.

D. The information on nurse staffing shall be reviewed as part of the nursing facility's annual licensing survey and shall be available to the public, both in printed form and on the Department's website, by nursing facility.

E. The Director of Nurses may act as a charge nurse only when the nursing facility is licensed for thirty (30) beds or less.

F. Whenever the licensing agency determines, in the course of inspecting a nursing facility, that additional staffing is necessary on any residential area to provide adequate nursing care and treatment or to ensure the safety of residents, the licensing agency may require the nursing facility to provide such additional staffing and any or all of the following actions shall be taken to enforce compliance with the determination of the licensing agency.

1. The nursing facility shall be cited for a deficiency and shall be required to augment its staff within ten (10) days in accordance with the determination of the licensing agency.

2. If failure to augment staffing is cited, the nursing facility shall be required to curtail admission to the nursing facility.

3. If a continued failure to augment staffing is cited, the nursing facility shall be subjected to an immediate compliance order to increase the staffing, in accordance with R.I. Gen. Laws § 23-1-21.

4. The sequence and inclusion or non-inclusion of the specific sanctions enumerated in § 1.16.7(F) of this Part may be modified in accordance with the severity of the deficiency in terms of its impact on the quality of resident care.

G. No nursing staff of any nursing facility shall be regularly scheduled for double shifts.

1.16.8 Selected Nursing Care Procedures

A. Written resident care plans, including problems, measurable goals, interventions, and time frames, shall be developed and maintained for each resident consonant with the attending physician, physician assistant, or advanced practice registered nurse's plan of medical care.

1. Resident care plans shall be reviewed, evaluated and revised by professional staff no less than every three (3) months, or when there is a significant change in the resident's health status.

B. The personal hygiene of each resident shall be attended to. All residents shall receive person-centered care including care of skin, shampooing and grooming of hair, oral hygiene, shaving, cleaning and cutting of fingernails and toenails. Residents shall be kept free of offensive odors.

C. Residents shall be encouraged and/or assisted to function at their highest level of self-care and independence. Every effort shall be made to keep residents active and out of bed for reasonable periods of time except when contraindicated by physician, physician assistant, or advanced practice registered nurse orders.

D. Every nursing facility shall have an active program for rehabilitative nursing care.

E. Such supportive and restorative nursing care needed to maintain maximum functioning of the resident shall be provided.

F. Each resident shall be given care to prevent pressure ulcers, contractures and deformities, including:

1. Preventive skin care as appropriate;

2. Changing the position of bedfast and chair-fed residents;

3. Maintaining proper body alignment and joint movement to prevent contractures and deformities; and

4. Encouraging, assisting and training residents in self-care and activities of daily living.

G. Measures shall be taken to prevent and reduce incontinence for each resident which shall include no less than:

1. Written assessment by a registered nurse or physician assistant, within two (2) weeks of admission, of each incontinent resident's ability to participate in a bowel and/or bladder training program;

2. An individualized plan of care for each resident selected for training to be included in the resident's nursing care plan to restore as much normal bladder function as possible.

1.16.9 Administration of Drugs

A. Drugs shall be administered in accordance with written orders of the attending physician and procedures established in accordance with §§ 1.17.4(A) and (B) of this Part. Such procedures shall include measures to assure:

1. That drugs are checked against physicians', physician assistants', or advanced practice registered nurses' orders;

2. That the resident is identified prior to administration of a drug;

3. That each resident has an individual medication record; and

4. That the dose of drug administered to each resident is properly recorded therein by the person administering the drug.

B. Drugs not specifically limited as to time or number of doses when ordered shall be controlled by automatic stop orders or other methods in accordance with written policies.

C. Physicians', physician assistants', or advanced practice registered nurses' verbal orders for drugs and biologicals shall be given only to a licensed nurse, a registered pharmacist or to a physician and shall be immediately recorded and signed by the person receiving the order. Such orders shall be countersigned by the attending physician within fifteen (15) days.

1.16.10 Administration of Drugs by Medication Technicians

A. Medication aides or technicians who have satisfactorily completed a State-approved course in drug administration and have demonstrated competency in accordance with the State-approved protocol in drug administration may administer oral or topical drugs, with the exception of all Schedule II drugs, with supervision in accordance with the State-approved protocol in drug administration. If such medication technicians are from temporary employment agencies, the nursing facility shall have onsite evidence of supervision in accordance with the Rhode Island-approved protocol in drug administration.

B. The director of nursing or his or her registered nurse designee shall conduct and document quarterly evaluations of the medication technicians who are administering drugs. Copies of said evaluations shall be placed in the medication technicians' personnel records.

1.16.11 Assistance with Eating and Hydration

A. Nursing facilities may employ resident attendants to assist residents with activities of eating and drinking. The resident attendant shall not be counted in the direct care staffing levels (see also § 1.16.7(A) of this Part).

B. A nursing facility shall not use any individual on a paid or unpaid basis in the capacity of a resident attendant, as defined in this Part, in the nursing facility unless the individual:

1. Has satisfactorily completed a training program approved by the Director, as described in § 1.16.12 of this Part;

2. Continues to provide competent eating and hydration assistance as determined by the facility's professional nursing staff.

C. The nursing facility shall ensure:

1. The resident attendant works in congregate dining areas under the supervision of a registered nurse (RN) or licensed practical nurse (LPN);

2. The resident attendant wears a photo identification badge in accordance with § 1.14.7 of this Part;

3. The resident attendant only assists residents selected by the professional nursing staff, based on the charge nurse's assessment and the resident's latest assessment and plan of care;

4. The resident attendant assists with eating and drinking for residents who have no complicated eating or eating assistance problems, including but not limited to:

a. Tube or parenteral/enteral nutrition;

b. Recurrent lung aspirations;

c. Difficulty swallowing;

d. Residents at risk of choking while eating or drinking;

e. Residents with significant behavior management challenges while eating or drinking;

f. Residents presenting other risk factors that may require emergency intervention.

5. Maintenance of records regarding individuals acting as resident attendants and the training program attended.

1.16.12 Training Program for Resident Attendants

A. Resident attendants shall be required to have successfully completed a basic training program approved by the Director to provide safe and proper eating and hydration assistance to nursing residents with no complicated eating or drinking problems. The program requirements shall include, but are not limited to, the following:

1. The training program shall be conducted by a registered nurse, and may include the assistance of a registered dietitian;

2. The training shall provide a minimum of eight (8) hours of classroom instruction, and participants shall demonstrate an understanding of topics that includes but is not limited to:

a. Eating techniques;

b. Physical mechanics of:

c. Breathing and swallowing;

d. Aspiration;

e. Choking

f. Assistance with eating and hydration (drinking);

g. Infection control;

h. Resident rights;

i. Communication and interpersonal skills;

j. Appropriate responses to resident behavior;

k. Safety and emergency procedures, including the Heimlich maneuver;

3. The training shall provide, either directly or through arrangements with a nursing facility, a minimum of four (4) hours of documented practical experience supervised by a registered nurse.

4. Certificate of classroom completion shall be signed by registered nurse trainer, bear the Department program approval certification number and include an area for documentation of satisfactory completion of practical experience.

5. Organizations or facilities interested in providing a resident attendant eating assistance program should submit a letter of intent to:

HEALTH Center for Health Facilities Regulation

c/o Eating Assistance Program

3 Capitol Hill

Providence, RI 02908

a. The request must include:

(1) An outline of the structure and format for the program;

(2) Resume/curriculum vita for the registered nurse trainer and other trainers;

(3) Curriculum/program outline to be utilized;

(4) Method of ensuring participants' successful demonstration of competencies;

(5) Program contact information.

6. Following review by HEALTH, numbered program approvals will be provided.

1.16.13 Pain Assessment

A. All health care providers licensed by Rhode Island to provide health care services and all health care facilities licensed under R.I. Gen. Laws Chapter 23-17 shall assess patient pain in accordance with the requirements of Part 20-15-2 of this Title, Pain Assessment.

Notes

216 R.I. Code R. § 216-RICR-40-10-1.16

Amended effective 7/3/2022
Amended effective 8/25/2022
Amended effective 10/2/2023, exp. 1/30/2024(Emergency)
Amended effective 3/7/2024