W. Va. Code R. § 64-2-8 - Participant Services

8.1. Admission and Discharge.

8.1.a. The licensee shall not admit to the medical adult day care center individuals requiring ongoing or extensive nursing care and shall not admit or retain individuals requiring a level of service that the center is not licensed to provide or does not provide.

8.1.b. The licensee shall seek immediate treatment for a participant or may refuse to admit or retain a participant if there is reason to believe that the participant may suffer serious harm, or is likely to cause serious harm to himself, herself or to others, if appropriate interventions are not provided in a timely manner.

8.1.c. If a participant has care needs that exceed the level of care for which the center is licensed or can provide, the licensee shall inform the participant, or his or her legal representative, of the need for discharge from the center.

8.2. Participant Records.

8.2.a. The licensee shall retain participants' records in a secure area in the center and shall make the records available for inspection by the Secretary.

8.2.b. Upon a participant's admission, the licensee shall start a record for him or her that includes:

8.2.b.1. The participant's name, social security number, date of birth, gender, marital status, and religious preference, if any;

8.2.b.2. The names, addresses and telephone numbers of the following, if applicable: the participant's physician, legal representative, person or agency responsible for the participant's payments, next of kin or person to be notified in case of an emergency, and any case management or service agency involved in the participant's care; and

8.2.b.3. Advanced directives, allergies, all contacts by the center's staff with the participant's physician and observations by licensed nurses, physicians and others authorized to care for the participant as related to care and services provided to the participant by the center.

8.2.c. The licensee shall keep in each participant's record current documentation regarding the participant's health status, any changes in health status and staff responses to the changes including but not limited to:

8.2.c.1. An initial and annual health assessment;

8.2.c.2. A functional needs assessment;

8.2.c.3. A service plan;

8.2.c.4. A daily record of attendance;

8.2.c.5. A daily record of medications, treatments and services provided;

8.2.c.6. Physician's orders for medications and treatments;

8.2.c.7. An activity assessment;

8.2.c.8. Specialty evaluations;

8.2.c.9. Progress notes, signed and dated by relevant staff; and,

8.2.c.10. A current photograph.

8.2.d. The licensee shall keep participant records in safe storage for at least five (5) years from the date of discharge of the participant. If the center ceases to operate, the licensee shall procure a holding area for the participant records that will ensure the confidentiality and safety of the records from loss, destruction or unauthorized use.

8.3. Health Assessments and Service Plans.

8.3.a. The center's director or the registered professional nurse shall conduct a pre-admission interview with the individual and his or her family if applicable, to determine eligibility for participation in the medical adult day care program.

8.3.b. An initial health assessment shall be obtained for each participant. The initial health assessment shall be in writing, signed and dated by a physician or other licensed health care professional, authorized under state law to perform this assessment, not more than sixty (60) days prior to the participant's admission, or no more than five (5) working days following admission. This assessment shall be completed at least annually thereafter. The admission and annual health assessment shall include a tuberculosis skin test (purified protein derivative PPD) or chest x-ray as indicated by exposure, prevalence or risk according to current medical practice in settings serving vulnerable populations as indicated by the Secretary. Thereafter, a tuberculosis screening shall be completed annually.

8.3.c. A licensed health care professional employed by the center shall complete an individualized functional needs assessment for each participant in writing within seven (7) attendance days. At a minimum, the participant's assessment shall include a review of health status and functional, psycho-social, activity and dietary needs.

8.3.d. The registered professional nurse shall complete an initial service plan on the participant's first day of attendance to direct the provision of treatment and services until the regular service plan is developed by the multi-disciplinary treatment team.

8.3.e. The multi-disciplinary treatment team shall develop a service plan for each participant within fourteen (14) attendance days of admission. Development of the service plan shall be coordinated by the registered professional nurse and shall:

8.3.e.1. Be available to staff to use as a guide for providing participant care;

8.3.e.2. Be based upon the participant's functional needs assessment and individual needs;

8.3.e.3. Include, at a minimum, the type of assistance needed from staff to provide personal care services, to administer prescribed medications and treatments, to follow any planned diet, rest or activity regimen, to engage in activities and programs appropriate to the individual's level of functioning, and to use equipment such as hearing aides, glasses, canes, wheelchairs, and other assistive devices; and

8.3.e.4. Specify the hours to be spent by the participant at the center.

8.3.f. The licensee shall ensure that the assessment and service plans reflect the participant's current needs and are updated periodically.

8.3.f.1. The participant's health assessment shall be updated annually by a physician or other licensed health care professional, authorized under state law or as indicated by a significant change in the participant's condition;

8.3.f.2. The nurse and therapists, if applicable, shall independently review and re-evaluate the service plan and shall update the plan to reflect any changes in the participant's treatment or condition; and

8.3.f.3. The service plan shall be reviewed quarterly by the full multi-disciplinary treatment team and updated to reflect any changes in the participant's treatment or condition.

8.4. Medications and Treatments.

8.4.a. The licensee shall ensure that all participant care and treatment is provided by appropriate individuals as required by state and federal law.

8.4.b. The licensee shall provide all participant care, treatment and services in accordance with current standards of practice using appropriate infection control techniques.

8.4.c. A prescription, written or verbal order from a professional authorized by state law to prescribe medications is required for altering, discontinuing and administering or self-administering prescription and over-the counter medications, treatments, and therapies. The licensee shall keep copies of the prescriptions or written orders in the participant's record.

8.4.d. A licensed health care professional shall determine whether or not a participant is capable of self-administration of medications or requires supervision of self administration of medications in accordance with Subsection 3.39 of this rule and shall document it in the participant's medical record prior to the participant self administering medications.

8.4.e. The prescribing health care professional who gives a verbal order shall review and sign the order within thirty (30) working days of the original order date.

8.4.f. The attending physician or prescribing health care professional shall review the medication regimen of each participant at least annually. The participant's record shall contain documentation of this review.

8.4.g. The licensee shall keep a record of all medications given to each participant indicating each dose given. The record shall include the participant 's name; the name of the medication; the dosage to be administered and route of administration; the time or intervals at which the medication is to be administered; the date the medication is to begin and end; the printed name, initials and signature of the individual who administered the medication; and any special instructions for handling or administering the medication, including instructions for maintaining aseptic conditions and appropriate storage.

8.4.h. The licensee shall keep medications in a locked room, cabinet or other storage receptacle, accessible only to the appropriately licensed staff responsible for medications. If a participant is capable of self administration of medication, the licensee shall provide him or her resources to store medications in a manner to be inaccessible to other participants.

8.4.i. The licensee shall store all medications in their original containers, legally dispensed and labeled in accordance with the rules of the West Virginia board of pharmacy, for the participant for whom it has been prescribed, including the name and strength of the medication, the manufacturer's name, its lot number, and expiration date. Only a licensed pharmacist shall re-label medications. If the prescribing health care provider changes medication directions, the licensee shall have a written signed and dated order for the change in the participant's record.

8.4.j. If refrigeration of medication is required, the licensee shall provide: a refrigerator in a locked room; a locked refrigerator; or a locked box within the refrigerator for storage. A thermometer is required in a refrigerator storing medications. The licensee shall store refrigerated medications within the recommended temperature range on the medication package.

8.4.k. If Schedule II drugs of the Uniform Controlled Substances Act W. Va. Code § 60A-1-101 et seq. are administered, these drugs shall be stored in a manner so that they are securely protected by two (2) locks. The key to the separately locked Schedule II drugs shall not be the same key that is used to gain access to non-scheduled drugs.

8.4.l. When a participant requires oxygen, the licensee shall assure there is an appropriate storage area for extra tanks. The licensee shall post no smoking signs conspicuously and prohibit smoking in any location when oxygen is in use.

8.4.m. The licensee may provide or coordinate restorative services for participants as ordered by their physician, including occupational, physical and speech therapy. If restorative services are provided, documentation must be maintained in the participant record about the participant progress and the service provider shall be included as a member of the participant's multi-disciplinary treatment team responsible for development and review of the participant's service plan.

8.5. Accident, Illness and Major Incident Procedures.

8.5.a. The licensee shall have readily available at all times a standard first-aid kit, or its equivalent, to provide emergency aid for commonly occurring household injuries.

8.5.b. When a participant has an illness or accident that results in an injury or a participant complaint, the nurse shall assess the severity and cause of the illness or accident, advise staff of the treatment needed related to the accident or illness, and record actions taken in the participant's record. If the participant needs emergency assistance, the staff on duty shall first obtain the necessary assistance.

8.5.c. Staff shall monitor and document the participant's condition at least once every two (2) hours while at the center following the accident or the onset of the illness or more frequently if specified by the registered nurse or other licensed health care professional.

8.5.d. When a major incident or any significant change in the participant's condition occurs, the staff shall promptly notify the participant's responsible party or next of kin, and document this notification in the participant's record.

8.5.e. If an epidemic occurs or a reportable disease is diagnosed, the licensee shall comply with the recommendations of the local public health authority in handling and reporting it.

Notes

W. Va. Code R. § 64-2-8