Alabama Administrative Code
Title 420 - ALABAMA STATE BOARD OF HEALTH
Chapter 420-5-20 - SPECIALTY CARE ASSISTED LIVING FACILITIES
Section 420-5-20-.06 - Care Of Residents

(a) Designation of Attending Physician. Upon admission, each resident shall be asked to designate an attending physician of his or her choice. If the resident is unable to designate an attending physician, or does not wish to designate an attending physician, the facility shall assist the resident in identifying an attending physician who will serve the resident. A resident shall be permitted to change the designation of his or her attending physician at any time. Whenever a resident requires medical attention, an attempt shall first be made to contact the resident's attending physician, except in medical emergencies requiring activation of the local EMS system (911 or other emergency call).

(b) Back-up Physician Support. Each specialty care assisted living facility shall have an agreement with one or more duly licensed physicians to serve in those instances when a resident's own attending physician cannot be reached, and to provide temporary medical attention to any resident whose attending physician is temporarily not available. A nurse practitioner or physician's assistant shall not serve as the back-up physician in a specialty care assisted living facility.

(c) All physician orders shall be written in accordance with community standards. If verbal orders are used, they are to be used infrequently. A physician verbal order shall only be accepted by an R.N. or L.P.N. employed by the facility and authorized to do so by facility policy and procedures and state law. All verbal orders shall be reduced to writing on the physicians' order sheet by a licensed facility nurse and shall be dated and signed by the nurse receiving the order. All orders, including verbal orders, shall be dated, timed, and authenticated promptly by the ordering practitioner, or another practitioner who is responsible for the care of the resident and authorized to write orders by facility policy. All verbal orders must be authenticated within such time period as provided by facility policy, but in no case shall exceed 30 days following entry of the order.

(a) Initial Physical Examination. Not more than 30 days prior to admission of any resident to a specialty care assisted living facility, the resident or prospective resident shall be examined by a physician. For purposes of the initial physical examination, a physician currently licensed and in good standing with the Medical Licensure Commission of any state may complete this physical assessment. The physician shall report his or her findings in writing to the facility. This examination is not required for a resident of a facility dually licensed as an assisted living facility and as a specialty care assisted living facility in those cases when the resident is transferred from the assisted living unit to the specialty care assisted living unit in the same facility. In addition to any information otherwise required by the facility's policies and procedures and in addition to any other information the physician recommends or believes is pertinent, the initial physical examination record shall contain the following:

(b) Annual Physical Examination. In addition to the admission physical examination, each resident shall be examined annually by a physician, and findings from the annual physical examination shall be documented with a copy placed in the resident's medical examination record. In addition to any other items specified in the facility's policies and procedures, and in addition to any information deemed necessary, pertinent, or recommended by the resident's attending physician, the annual physical examination shall contain the following:

(c) Change of Condition Physical Examinations. Changes in the resident's condition that require a physician examination and result in a change in diagnoses, condition, medications, or treatments shall be reported to the facility and documented in the resident's medical examination record. In addition to any other items specified in the facility's policies and procedures, and in addition to any information deemed necessary, pertinent, or recommended by the resident's treating physician, this physical examination shall contain a listing of the following:

(d) Vaccines. Specialty care assisted living facilities shall immunize residents in accordance with current recommended CDC guidelines. Any particular vaccination requirement may be waived or delayed by the State Health Officer in the event of a vaccine shortage.

(a) Initial Assessment. No more than 30 days prior to admission, the facility RN or care coordinator shall screen prospective residents for eligibility for admission into the specialty care assisted living facility. The screening shall include a clinical history, a mental status examination to include aphasia screening, a geriatric depression screen, a physical self-maintenance screen, and a behavior screen.

Appendix A herein, contains the Physical Self Maintenance Scale (PSMS) form and the Behavior Screening form. These forms shall be completed to screen physical functioning and behaviors. The PSMS and Behavior Screen assessments shall be completed by the R.N. or care coordinator upon admission, annually, and when there is a change in the resident's status.

The facility R.N. shall perform a comprehensive assessment of each prospective resident for facility eligibility. This assessment shall document identified care needs and serve as a baseline for the R.N. plan of care and future assessments.

(b) Monthly Assessments. The R.N. shall assess each resident monthly and more often when necessary to identify changes in the resident's health status. The monthly assessment shall include a review of monthly weights, falls, incidents, elopements, behavioral symptoms, medications, changes in resident status, and appropriateness of the resident's plan of care.

(c) Comprehensive Assessment. The facility R.N. shall perform a comprehensive assessment and communicate with the resident's attending physician and with the resident's sponsor or responsible family member when a decline in health status or behavior occurs, or if the resident develops any of the following problems:

(d) Focused Assessments. The R.N. or L.P.N. shall conduct focused assessments when necessary to identify changes in resident status.

(e) Any change in resident status requires immediate documentation and implementation of interventions or reassessment of existing interventions.

(f) Observation. Each specialty care assisted living facility shall provide general observation and health supervision of the residents to identify changes in all residents' health conditions and physical abilities, and awareness of the need for medical attention or nursing services as the changes develop. Whenever a resident requires medical attention, nursing services, or changes in personal care and assistance with activities of daily living provided by the facility, the facility shall arrange for or assist the residents in obtaining necessary services.

(g) Services Beyond Capability of Specialty Care Assisted Living Facility. Whenever a resident requires hospitalization, medical, nursing, or other care beyond the capabilities of the specialty care assisted living facility, arrangements shall be made to discharge the resident to an appropriate setting, or to transfer the resident promptly to a hospital or other health care facility able to provide the appropriate level of care.

(h) Care During Emergency or Illness. The resident's attending physician, or a backup physician or facility Medical Director, if the attending physician is unavailable, shall be promptly called at the onset of an illness or in case of accident or injury to a resident. In case of a medical emergency that could result in death, serious medical impairment, or disability to a resident, the local EMS system shall be activated by calling 911 or other emergency local telephone numbers.

(i) A specialty care assisted living facility shall maintain the following telephone numbers, properly identified, and posted in a prominent location readily accessible and known to all staff members:

(j) Mechanical Restraint and Seclusion. No form of physical restraint or seclusion shall be applied to residents of a specialty care assisted living facility except in extreme emergency situations when the resident presents a danger of harm to himself or herself or to other residents. In such an event, the facility shall use the least restrictive intervention that will be effective to protect residents, immediately notify the resident's physician and sponsor, and appropriate treatment, transfer to an appropriate health care facility, or both shall be provided without any avoidable delay. In no event shall emergency behavioral symptoms of residents be treated with sedative medications, anti-psychotic medications, anti-anxiety medications, or other psychoactive medications in a specialty care assisted living facility.

(k) Resident Abuse, Neglect, and Exploitation. Each facility shall develop and implement a policy and procedure to protect each resident of the facility from abuse, neglect, and exploitation. The facility shall ensure that all staff can demonstrate an understanding of what constitutes abuse, neglect, and exploitation, and shall ensure that all staff understands his or her responsibility to immediately report suspected, alleged, confessed, witnessed, or actual incidents of abuse, neglect, or exploitation of a resident to the administrator. When abuse, neglect, or exploitation is suspected, alleged, confessed, witnessed, or actual the facility shall conduct and document a thorough investigation and take appropriate action to prevent further abuse. All allegations, suspicions, confessions, witnessed, or actual incidents shall be reported to the Assisted Living Unit of the Alabama Department of Public Health and to the victim's sponsor or responsible family member within 24 hours. Suspected, alleged, confessed, witnessed, or actual abuse, neglect, or exploitation of a resident shall be reported to the Department of Human Resources or law enforcement in accordance with Code of Ala. 1975, Section 38-9-8. At any time that a resident has been the victim of sexual assault or sexual abuse perpetrated by a staff member or visitor, local law enforcement authorities shall be immediately notified.

(l) Laboratory Tests. Any facility conducting or offering laboratory tests for its residents, including routine blood glucose monitoring, shall comply with federal law, and specifically with the applicable requirements of the federal Clinical Laboratory Improvement Amendments (CLIA) as well as with applicable federal regulations. This requirement in some cases would require the facility to obtain a CLIA certificate, and in other cases would require the facility to obtain a CLIA waiver. For more information about CLIA requirements, a facility may contact the department, Bureau of Health Provider Standards. For testing or monitoring requiring blood, either the resident must draw his or her own blood or the blood must be drawn by a physician, an R.N. or L.P.N., or a phlebotomist from a licensed Independent Clinical Laboratory. Blood and blood products, needles, sharps, and other paraphernalia involved in collecting blood must be handled in a manner consistent with requirements of the federal Occupational Safety and Health Administration (OSHA). Personnel handling such materials must be vaccinated against blood borne diseases if such vaccinations are required by OSHA. Blood, blood products, needles, sharps, and other paraphernalia involved in collecting blood shall be treated as medical waste and shall be disposed of in a manner compliant with the requirements of the State of Alabama Department of Environmental Management.

(a) Portions of residents' records necessary for staff to provide care, including the plans of care and relevant portions of the medical examination records and admission records, shall be accessible to the direct care staff at all times.

(b) Plan of Care. The R.N. shall develop written plans of care for each resident prior to or at the time of admission. The plans of care shall be based on resident's assessments, diagnoses, and recommendations of the resident's physician. The plan of care shall be developed in cooperation with the resident, if appropriate, and the sponsor. The R.N. shall identify resident care problem areas and formulate written interventions to address those problems. The R.N. shall evaluate the implementation of the interventions and the resident's response to the interventions and modify the plan of care as necessary.

(c) Activity Program. There shall be an activity program designed to meet the individual needs of each resident. The facility shall maintain supplies and equipment as necessary to implement the activity programs. Every day the facility shall provide activities appropriate to residents with dementia. Residents who have wandering behaviors shall have a documented activity program to manage this behavior.

(d) Pets residing at the facility or used in activity programs shall be in good health and shall have current vaccinations as required by law. Vaccination certificates, or copies of vaccination certificates, shall be kept on file at the facility to demonstrate compliance with this requirement.

(e) Mail, Telegrams, and Other Communications.

(f) Appointments. Residents shall be assisted in making and keeping appointments.

(a) Medications, as defined in these rules, shall be prescribed specifically for the resident by an individual currently licensed to prescribe medications in Alabama. A currently licensed physician in good standing with the Medical Licensure Commission of any state may prescribe medications to a resident of an assisted living facility only during the initial physical examination.

(b) A physician order is required for a resident to manage and have custody of his or her own medications.

(c) A resident may have custody of and manage over the counter topical medications with the written approval of a physician. A physician order is not required for over the counter topical medications that are self-administered by residents and approved by the physician for resident possession.

(d) Medication administration, as defined in these rules, shall be conducted only by a physician or an R.N. or L.P.N. An R.N. or L.P.N. shall administer medications to residents in the specialty care assisted living facility only in accordance with physician orders and the Nurse Practice Act.

(e) A current copy of A Short Practical Guide for Psychotropic Medications in Dementia Patients or the equivalent shall be in each specialty care assisted living facility as a reference guide.

(f) A specialty care assisted living facility resident may self-manage his or her own medications. For the purposes of these rules, self-manage shall mean the resident is capable of maintaining possession and control of his or her medications, who does maintain possession and control of his or her medications and self-administers his or her medications without creating an unreasonable risk to health and safety.

(g) A resident of a specialty care assisted living facility who is incapable of self-managing his or her own medication shall have medications administered only by a physician, R.N., or L.P.N.

(h) All medications administered to residents in a specialty care assisted living facility, shall be contemporaneously recorded on a standard medication administration record. "Contemporaneously recorded" means recorded at the same time or immediately after medications are administered. The medication administration record shall include at least the following:

(i) Medications kept under the control or custody of a specialty care assisted living facility shall be packaged by the pharmacy and shall be maintained by the facility in unit dose packaging. Medications kept under the control or custody of the specialty care assisted living facility that are not available in unit dose packaging must be packaged by the pharmacy and administered by a physician, R.N., or L.P.N.

(j) Unless a resident can and does self-manage his or her own medications, a specialty care assisted living facility shall require each resident to use a single pharmacy. This does not apply to emergency pharmacy services. All residents need not use the same pharmacy that is used by other residents unless express policy of the specialty care assisted living facility provides otherwise and all residents are informed of such policy and provided a copy of such policy prior to or at the time of admission. The specialty care assisted living facility shall require pharmacies used for medication supply for residents not self-managing their medications to review all ordered medication regimens for possible errors or adverse drug interactions and to advise the facility and the prescribing health care provider when these are detected.

(k) If controlled substances prescribed for residents of any specialty care assisted living facility are kept in the custody of the specialty care assisted living facility, they shall be stored in a manner that is compliant with state and federal laws, the requirements of the Alabama State Board of Pharmacy, and any requirements prescribed by the Alabama State Board of Health. At a minimum, controlled substances in the custody of the facility shall be stored using a double lock system, under proper temperature and humidity controls and permit only authorized personnel access. The facility shall maintain a system to account for all controlled substances in its possession. All other medications in the custody of the facility shall be stored using at least a single lock, under proper temperature and humidity controls and permit only authorized personnel access. This shall include medications stored in a resident's room when the staff and not the resident have access to the medications. Medications may be kept in the custody of an individual resident who can safely manage his or her medications. Such medications may be stored in a locked container accessible only to the resident and staff, or may be stored and secured in the resident's living quarters, if the room is single occupancy and has a locking entrance.

(l) Medication administration records and written physician orders for all over-the-counter drugs, legend drugs, and controlled substances shall be retained for a period of not less than 3 years. They shall be available for inspection and copying on demand by agents of the State Board of Health. They shall be made available for inspection at reasonable times by residents, anyone authorized by the resident, and by the sponsors of residents.

(m) Labeling of Drugs and Medicines. All containers of prescribed medicines and drugs shall be labeled in accordance with the rules of the Alabama State Board of Pharmacy and shall include appropriate cautionary labels, such as, "Shake Well," or "For External Use Only."

(a) Controlled substances and legend drugs dispensed to residents, that are expired or unused because the medication is discontinued or because the resident dies, shall be destroyed within 30 days. Unused legend drugs that are not expired may be donated to a charitable clinic pursuant to Alabama Administrative Code Chapter 420-11-11, et. seq. Under no circumstances shall expired, discontinued, or unused medications be stored or housed in the facility beyond 30 days.

(b) Medications of residents who are discharged or transferred to another facility shall be returned to the residents. The responsible party will sign a statement that these medications have been received. The statement shall list the pharmacy, prescription number, date, resident's name, and strength of the medication and the amount. This statement shall be maintained in a file for at least 3 years.

(c) When medications are destroyed on the premises of the specialty care assisted living facility, a record shall be made and retained for at least 3 years. This record shall include: the name of the specialty care assisted living facility, the method of disposal, the pharmacy, the prescription number, the name of the resident, the name, strength, and dosage of the medication, and the amount and the reason for the disposal. This record shall be signed and dated by the individual performing the destruction and by at least one witness.

(a) A resident of a specialty care assisted living facility that requires oxygen therapy shall have oxygen administered only by a physician, R.N., or L.P.N.

(b) Oxygen use including date, time, rate, and proper function of the equipment shall be documented on the medication administration or medication assistance record at least once per shift.

(a) First Aid Supplies. First aid supplies shall be maintained in a place readily accessible to persons providing personal care and services in the specialty care assisted living facility. These supplies will be inspected at least annually to ensure their usability.

(a) Admission.

(b) Retention.