Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.07-043 - Electronic Records and Signatures for Nursing Facilities

Nursing homes, or related institutions, shall be operated, conducted, or maintained in this State by obtaining a license pursuant to the provisions of these Licensing Standards. Separate institutions operated by the same management require separate licenses. Separate licenses are not required for separate buildings on the same grounds. The classification of license shall be Skilled Nursing Facility, Intermediate Care Facility, and Intermediate Care Facility for the Mentally Retarded.

Whenever ownership or controlling interest in the operation of a facility is sold, both the buyer and the seller must notify the Office of Long Term Care at least thirty (30) days prior to the completed sale. The thirty (30) day notice shall be the date the paperwork is stamped received by the Office of Long Term Care.

Applicants for license shall file a notarized application with the Division upon forms prescribed by the Division and shall pay an annual license fee often cents ($0.10) per patient bed, or Ten Dollars ($10), whichever is greater. This fee shall be paid to the State Treasury. If the license is denied, the fee will be returned to the applicant. Facilities operated by any unit or division of state or local government shall be exempted from payment of a licensing fee. Application shall be signed by the owner if individually owned, by one partner if owned under partnership, by two officers of the board if operated under corporation, church or non-profit association, and incase of a governmental unit, by the head of the governmental entity having jurisdiction over it. Applicants shall set forth the full name and address of the institutions for which license is sought, the names of the persons in control, a signed statement by a registered nurse indicating responsibility for nursing services of the home, and such other information as the Division may require.

In these instances where a distinct part of a facility is to be licensed as a Skilled Nursing Facility and the remainder of the facility is to be licensed under some other category, separate applications must be filed for each license and separate licensure fees fill be required with each application.

Each home applying for and receiving a license must furnish the following information:

* The identity of each person directly or indirectly having an ownership interest of five (5) percent or more in such nursing home.

* In case such nursing home is organized as a corporation, the identify of each officer and director of the corporation.

* In case such nursing home is organized as a partnership, the identity of each partner.

* Identity of owners of building and equipment leased including ownership breakdown of leasing entity.

Application for annual license renewal shall be postmarked no later than January 2nd of the succeeding calendar year. License applications for existing institutions shall be subject to a penalty of one dollar ($1) per day after January 2nd of the succeeding year.

License shall be effective on a calendar year basis and shall expire on December 31st of each year. License shall be issued only for the premises and persons in the application and shall not be assignable or transferable.

The Division is empowered to deny, suspend, or revoke licenses on any of the following grounds:

Whenever the Division decides to deny, suspend, or revoke a license, it shall send to the applicant or licensee a notice stating the reasons for the action by certified mail. The applicant or licensee may appeal such notice to the Long Term Care Facility Advisory Board as permitted by Arkansas Statute Annotated §82-211. Procedures for appeal to the Long Term Care Facility Advisory Board are incorporated in these regulations as Appendix A.

Any applicant or licensee who considers himself injured in his person, business, or property by final agency action shall be entitled to judicial review thereof. Proceedings for review shall be made by filing a petition in the Circuit Court of any county in which the petitioner does business or in the Circuit Court of Pulaski County within thirty (30) days after service upon the petitioner of the agency's final decision. All petitions for judicial review shall be in accordance with the Administrative Procedures Act Arkansas Statute Annotated §5-713.

Any person, partnership, association, or corporation, establishing, conducting, managing, or operating any institution within the meaning of this act (§§ 82-327 - 82-354), without first obtaining a license therefor as herein provided, or who violates any provision of this act or regulations lawfully promulgated hereunder shall be guilty of a misdemeanor, and upon conviction thereof shall be liable to a fine of not less than Twenty-Five Dollars ($25) nor more than One-Hundred Dollars ($100) for the first offense and not less than One-Hundred Dollars ($100) nor more than Five-Hundred Dollars ($500) for each subsequent offense, and each day such institution shall operate after a first conviction shall be considered a subsequent offense. (Section 27, Act 414 of 1961)

All institutions to which these rules and regulations apply shall be subject to inspection for reasonable cause at any time by the authorized representation of the Division.

An initial license will not be issued until the applicant has demonstrated to the satisfaction of the Division that the facility is in substantial compliance with the licensing standards set forth in these regulations.

When noncompliance of the licensing standards are detected during surveys, licensees will be notified of the violations and will be requested to provide a plan of correction with a timetable for corrections. If an item of noncompliance is of a serious nature that affects the health and safety of patients and is not promptly corrected, action will be taken to suspend or revoke the facility's license.

Any nursing home, or related institution, that voluntarily closes must meet the regulations for new construction to be eligible for re-licensure.

The Division reserves the right to make temporary exceptions to these standards where it is determined that the health and welfare of the community requires the services of the institution. Exceptions will be limited to unusual circumstances and the safety and well-being of the residents will be carefully evaluated prior to making such exceptions.

Overbeds will be authorized only in cases of emergency. An emergency exits when it can be demonstrated that the resident's health or safety would be placed in immediate jeopardy if relocation were not accomplished. A fire, natural disaster (e.g., tornado, flood, etc.) or other catastrophic event that necessitates resident relocation will be considered an emergency. The Office of Long Term Care must be contacted for prior authorization of the overbed, and all authorizations must be in writing.

Subject to the requirements below, a provisional license shall be issued to the Applicant and new operator of the long-term care facility when the Office of Long Term Care has received the Application for Licensure to Conduct a Long Term Care Facility. A provisional license shall be effective from the date the Office of Long-Term Care provides notice to the Applicant and new operator, until the date the long-term care license is issued. With the exception of Medicaid or Medicare provider status, a provisional license confers upon the holder all the rights and duties of licensure.

Prior to the issuance of a provisional license:

The administrator shall be responsible for ensuring that emergency call information is posted in a conspicuous place so as to be immediately available to all personnel of the nursing home. Emergency call data shall include at least the following:

* Telephone number of fire and police departments.

* Names, addresses, and telephone numbers for emergency supplies, ambulance, minister, advisory dentist, Red Cross, and poison control center.

* Name, address, and telephone number of all personnel to be called in case of fire or emergency (to include the administrator and the director of nursing services).

* Name, address, and telephone number of an available physician to furnish necessary medical care in case of emergency.

Pursuant to federal regulation 42 CFR 483.13 and state law Ark. Code Ann. § 5-28-101 et seq. and 12-12-501et seq., the facility must develop and implement written policies and procedures to ensure incidents, including:

* alleged or suspected abuse or neglect of residents;

* accidents, including accidents resulting in death;

* unusual deaths or deaths from violence;

* unusual occurrences; and,

* exploitation of residents or any misappropriation of resident property,

are prohibited, reported, investigated and documented as required by these regulations.

A facility is not required under this regulation to report death by natural causes. However, nothing in this regulation negates, waives or alters the reporting requirements of a facility under other regulations or statutes.

Facility policies and procedures regarding reporting, as addressed in these regulations, must be included in orientation training for all new employees, and must be addressed at least annually during in-service training for all facility staff.

The administrator, in consultation with one or more physicians and one or more registered professional nurses, department heads, and other related professional health care personnel, shall develop and at least annually review appropriate written policies and procedures for all services and/or patient care practices to include but not limited to dietary, medical records, nursing, pharmaceutical, diagnostic services, laboratory and radiological, housekeeping, maintenance, and laundry services.

Patients shall not be unduly restrained. Patients shall not be confined to rooms or restrained except when necessary to prevent injury to the patient or others and when alternative measures are not sufficient to accomplish these purposes. In any event, no locked doors or locked restraints are to be used at any time to restrain a patient. Doors (screen type), or the lower one half of a dutch door or approved type louvered doors may be hooked on the hall side of the door. Restraints, of the non-locking type, may be used only upon the order of a physician. In the event the order is obtained by phone, the signature of a physician shall be obtained within five days (Note: The aforementioned restraining type doors shall be installed in addition to the regular door to the room. They shall be removed during periods when they are not needed for the restraint of patients.) Upon the advice of the attending physician, unruly or excessively noisy patients shall be transferred from the home to an institution equipped for such patient care, since this type patient creates a disturbance for other patients in the home.

The written policy and procedures governing the use of restraints shall specify which staff member may authorize the use of restraints and clearly delineate at least the following:

* Orders indicating the specific reasons for the use of restraints.

* Their use is temporary, and the resident will not be restrained for an indefinite amount of time.

* Orders for restraints shall not be enforced for longer than twelve (12) hours, unless the patient's condition warrants.

* Restraints must be checked every thirty (30) minutes and loosened every two (2) hours for range of motion to restrained extremities.

An inventory of patient's personal belongings should be maintained for all items brought to the facility on admission and up-dated as appropriate for items added or sent home/disposed of.

There shall be written polices and procedures available at each nurses' station for personnel to follow requiring the notification of the patient's attending physician and other responsible persons in the event of severe illness, accident, or death of the patient or other significant change in the patient's status.

The name, address and telephone number of the patient's attending physician shall be recorded for ready reference.

The facility shall have a written policy indicating that the health care of every patient is under the supervision of a physician, who based on a medical evaluation of the patient's immediate and long term needs, prescribes a planned regimen of total care.

If a facility offers specialized rehabilitative services, written administrative and patient care policies and procedure for rehabilitative services shall be developed for appropriate therapists and representatives of the medical, administrative, and nursing staffs.

Facilities which do not directly provide social service shall have written procedures for referring patients in need of social services to appropriate service agencies.

Policies and procedures shall be established for ensuring the confidentiality of all patients' social information.

Facilities shall establish policies and procedures setting forth the rights of resident and prohibiting their mistreatment or abuse.

Facilities shall establish policies for the registration and disposition of complaints without threat of discharge or other reprisal against any patient.

These policies shall include, as a minimum, the following:

There shall be written policies adopted by the management of the nursing home covering confidentiality of medical records and procedures regarding release of medical information.

Written policies and procedures shall be established for investigating, controlling and preventing infections. Procedures shall be reviewed annually and revised as necessary for effectiveness and improvement. The policies and procedures shall include as a minimum:

* Aseptic and isolation techniques.

* Proper disposal techniques for infected dressings, disposable syringes, needles, etc.

* Prohibiting the use of the common towel, common bath and hand soap, and the common drinking cup or glass.

Policies shall be written for the proper handling of oxygen and flammable gases.

Written personnel policies shall be provided and shall be available to all personnel and to the Division.

The facility shall establish a written policy regarding transportation of residents, when necessary, to the hospital, medical clinics, and dentist offices. The facility must assume responsibility for seeing that the patient's transportation needs are met.

Written policies shall be established to ensure all individually assigned bed pans are sanitized by the boiling method for a minimum of twenty (20) minutes at least once a week or by other methods approved by the Division.

If the facility does not offer specialized rehabilitative services directly, patients in need of such services, i.e., physical therapy, occupational therapy, speech pathology, and audiology, shall not be admitted or retained in the facility unless arrangements for these services have been provided with an outside resource. Terms of the agreement should include reimbursement, responsibility of each party, and documentation responsibilities.

Facilities shall establish a written cooperative agreement with an advisory dentist or dental service. The agreement shall include provisions for a dentist or dental service. The agreement shall include provisions for a dentist to participate annually in the staff development program and to recommend oral hygiene policies and practices.

If a facility provides social services directly and the designated staff member is not a qualified social worker, a written agreement shall be established to provide consultation from such a qualified person or a recognized social agency.

In a nursing facility, if the staff member designated responsible for the activity program is not a qualified patient activity coordinator, a written agreement shall be established with a person so qualified. The MSW consultant may also serve as consultant to the activity director.

If a facility does not employ a licensed pharmacist, it shall establish a written agreement with a licensed pharmacist to provide consultation on methods and procedures for ordering, storage, administration, disposal, and record keeping of drugs and biologicals.

A nursing home shall establish a written agreement for all medical and remedial services, i.e., laboratory, radiological, and other services, required by the resident but not regularly provided within the facility.

A facility shall have in effect a written transfer agreement with one or more hospitals sufficiently close to the facility to make feasible the transfer of patients. It shall be the duty of each nursing home administrator to supply basic information at the time of a patient's transfer from one nursing home to another or to a hospital.

Every institution must be maintained, managed, and equipped to provide adequate care, safety, and treatment of each resident.

* All homes shall be provided with dust free drives and parking lots.

* Parking areas shall be provided in a ratio of one (1) individual parking space for each five (5) licensed beds.

* All exterior doors shall be effectively weather stripped

* Doors shall swing into rooms except closet, toilet, and exit doors.

* The doors to all rooms, toilets, baths, and closets shall be legibly marked with names or numbers, as appropriate to identify the area.

* Exit doors shall not be locked in such a way that a key is necessary to open the door from the inside of the building. A latch or other fastening device on the door shall be provided with a knob, handle, panic bar or other simple type of releasing device, which is part of the door handle hardware, of which the method of operation is obvious even in darkness.

An intensive care room shall be provided for each thirty-five (35) beds or major portion thereof and shall be located near the nurses' station. Each room shall have the standard square footage as set forth in these regulations. The room shall be provided with standard unit equipment and a lavatory with a gooseneck spout and elbow or wrist-action blade-handle controls, and a soap and a towel dispenser. At least one of these rooms is a single room which can be used for isolation.

Corridors in facilities licensed prior to 1973 shall be at least six (6) feet wide.

Standard handrails shall be provided on each side of the corridor in all areas used by patients; however, a six (6) foot passageway must be maintained. For six (6) foot corridors, a handrail shall be required only on one side.

There shall be one properly equipped bedpan cleaning room with deep metal sink. In addition to bedpan cleaning equipment, appropriate hand-washing facilities shall be provided. The room shall include equipment for sterilization (unless a separate central sterilization is provided).

A well lighted, clean, orderly, and ventilated room or rooms shall be provided for patient activities and for dining areas. A minimum of twenty (20) square feet per bed shall be provided for this purpose. At least half of the required area may be used for dining.

The facility shall provide an emergency source of electrical power necessary to protect the health and safety of patients in the event the normal electrical supply is interrupted. The emergency electrical power system must supply power adequate at least for lighting in all means of egress; equipment to maintain fire detection, alarm, and extinguishing systems. Dry battery or wet-cell batteries may be used as emergency power in facilities where life support systems are not used.

Where life support systems are used, emergency electrical service is provided by an emergency generator located on the premises.

Nurses' stations shall be provided and so designated that they contain a minimum of sixty (60) square feet per each thirty-five (35) bed patient unit, and are not more than one-hundred twenty (120) linear feet from each patient room. The station shall include adequate storage and preparation areas(s), medication, toilet and hand-washing facilities, and sufficient lighting.

Janitors' closets shall be provided for each nursing unit, and a separate janitor's closet shall be provided within the kitchen area. These closets shall be provided with hot and cold running water, a floor receptor or service sink, and shelves for the storage of janitorial equipment and supplies. The closets shall be mechanically vented to the outside. Janitor closets in patient areas must be kept locked.

A nurses' call system comprised of an electric buzzer and/or light system shall be so designed that the location of a call can be determined from the corridor and nurses' station. In addition emergency call stations shall be provided in all patient bath, toilet and shower areas.

Each nursing home shall have an electrically-supervised, manually-operated fire alarm system in accordance with Section 6-3 NFPA 101, Life Safety Code handbook that applies to their nursing home.

The following codes and standards are incorporated into and made a part of these regulations:

Other than requirements set forth for existing structures, 406, an intensive care room shall be mechanically vented to the outside and provided with a standard private toilet and hand-washing facility. The intensive care room may also serve as an isolation room.

Corridors shall be at least eight (8) feet wide.

Laundry in new facilities must provide complete separation (by partition) of the soiled laundry area (including washer) and the clean laundry area. A lavatory with soap and towel dispensers must be provided for the staff in each area, and a rinsing sink provided in the soiled laundry area. A linen folding table must be provided in the clean laundry area. If the laundry area is included in the main nursing home building, it shall be so located as to be as remove as possible from the patient area.

There shall be a minimum of five (5) square feet per bed for general storage space provided in those cases where built-in closets are provided in patient rooms. It is recommended that this be concentrated in one general area except for small storage areas within the nursing units for wheelchairs, patient lifts, walkers, etc.

Separate office space shall be provided for administrative and business functions as follows:

* Office for the administrator.

* Office for the director of nursing services.

* Office or space for social and activity director.

The total area set aside for residents' dining and recreation purposes shall be not less than twenty (20) square feet per bed. Additional space shall be provided if the facility participates in a day care program. The areas shall be well lighted and well ventilated.

There shall be at least one bedpan cleaning room. In addition to the bedpan cleaning equipment, hand-washing facilities with blade-handle controls shall be provided. There shall be provisions for equipment sterilization.

Janitors' closets shall be provided for each nursing unit, and a separate janitor's closet shall be provided within the kitchen area. These closets shall be provided with hot and cold running water, a floor receptor and service sink, and shelves for the storage of janitorial equipment and supplies. The closets shall be mechanically vented to the outside. Janitor closets in patient areas must be kept locked.

Closets for clean linens shall be provided for each nurses' station.

Closet for soiled linens shall be provided for each nurses' station. This dirty linen storage shall be in a separate room and ventilated to the outside.

Nurses' station shall be provided and so designed that they contain a minimum of sixty (60) square feet per each thirty-five (35) bed patient unit, and are not more than one-hundred-twenty (120) linear feet from each patient room. The station shall include adequate storage and preparation area(s), medication, toilet and hand-washing facilities, and sufficient lighting.

Each nursing home shall be an electrically supervised, manually operated fire alarm system in accordance with Section 6-3 NFPA 101, Life Safety Code handbook that applies to their nursing home.

The following limitations shall apply:

* Ceilings shall be a minimum of eight (8) feet. (Refer to Section 411 for surfaces.)

* Walls (Refer to Section 411).

* Floors (Refer to Section 411).

An electrically operated water fountain of an approved type shall be provided for each nurses' station. The water fountain shall be accessible to the physically handicapped. Water fountains must be recessed not to obstruct the corridor.

Nursing equipment and supplies shall be provided to meet the patients' needs and maintained in good condition to ensure adequate nursing care of the patients.

NOTE:* These items shall be assigned to individual patients, kept clean, and maintained or stored at patient's bedside cabinet.

Patients shall be admitted to the facility only on recommendation of a physician. At the time of admission the physician must document level of care needed by the patient. A Certification Statement by the physician explaining the reason for nursing home placement should be obtained on the date of admission and a re-certification statement obtained every sixty (60) days.

The health care of every patient shall be under the continuing supervision of a physician, who, based on a medical evaluation of the patient's immediate and long term needs, prescribes a planned regimen of total patient care. Patients in need of skilled care should be seen by a physician at least every sixty (60) days, and all others seen at least every one hundred twenty (120) days. A notation should be made at each visit and orders for treatment and medication renewed.

The medical evaluation of the patient shall be based on a history and physical examination done within seventy-two (72) hours of admission unless such examination was performed within fifteen (15) days prior to admission. A history and physical completed during the patient's hospitalization may have been completed up to thirty (30) days prior to admission to the nursing home; however, the hospital discharge summary (upon completion) is to be forwarded to the nursing home.

The planned regimen of total care for each patient shall be based on the attending physician's order and shall cover medication, treatment, rehabilitative services (where appropriate), diets, precautions related to activities undertaken by the patient, and plans for continuing care and discharge.

The attending physician shall establish at the time of admission a restoration potential for the patient. This should be updated as needed but not less than on an annual basis.

The facility should make arrangements for emergency coverage by a physician if the attending physician or his attendant cannot be located. This should be done by a written agreement signed by the physician and the facility administrator.

No person who has been a patient in a mental hospital and who has not been completely discharged by that institution shall be employed in a nursing home in a supervisory capacity.

Nursing personnel shall be aware of the nutritional needs, food, and fluid in-take of patients and assist promptly where necessary in the feeding of patients.

Upon admission to the nursing home, physician orders shall be obtained to administer a PPD (intermediate strength) tuberculosis skin test to the resident and to repeat in ten (10) to fourteen (14) days if necessary. If this initial test reacts positively, the physician should be notified and a chest X-ray obtained and read. The record of this X-ray should be placed on the resident's chart. If it is not possible to obtain a chest X-ray, a sputum sample should be taken and forwarded for culture. If treatment is indicated, orders are obtained from the attending physician.

If the result of the initial skin test is negative, the skin test should be repeated in ten (10) to fourteen (14) days. If the result of this test is positive, the physician should be notified and a chest X-ray or sputum culture obtained. If treatment is indicated as a result of these tests, orders are obtained from the attending physician.

Once a resident has shown a positive skin test (regardless of whether or not further testing indicated treatment), he/she must be re-evaluated yearly. Either a chest X-ray or sputum culture should be obtained. If neither of these is possible, the resident should be evaluated for any visible signs of the disease such as productive cough or weight loss. Alternatively, if a nurse familiar with the resident finds no fever, no weight loss and no significant cough, this can be recorded in the medical record and will suffice for annual surveillance; if any symptoms are present, then a chest film should be is indicated on medical grounds, and should be noted in the medical record. There should be evidence in the medical record of this yearly re-evaluation. If, however, the second skin test after admission is also negative, there need be no further testing of this resident unless an active case of tuberculosis is identified in the facility.

The medical record of all residents who have shown a positive skin test should be flagged to note that this resident does need to be re-evaluated yearly and that a sputum culture should be obtained following any pulmonary infection.

Recordation of tuberculin information shall be maintained in each resident's medical record and shall be recorded on forms provided by the Arkansas Department of Health.

In addition to rehabilitative nursing, the facility shall, as ordered by a physician, provide, according to the needs of each patient, specialized and supportive services, i.e., physical therapy, speech pathology, audiology and occupational therapy, either directly, by referral, or through arrangements with qualified personnel.

If provided, specialized rehabilitative services shall be provided under a written plan of care, initiated by the attending physician, and developed in consultation with appropriate therapist(s) and nursing services.

A report of the patient's progress shall be communicated to the attending physician within two (2) weeks of the initiation of the specialized rehabilitative services and regularly thereafter.

The plan of specialized rehabilitative care shall be re-evaluated as necessary, but at least every thirty (30) days by the physician and/or the therapist.

The physician's orders, the plan of specialized rehabilitative care, services rendered, evaluation of progress and other pertinent information shall be recorded in the patient's medical record and dated and signed by the physician ordering the service and the person who provided the service.

The administrator shall be responsible for full compliance with Federal and State laws governing procurement, control, and administration of all drugs. Full compliance is expected with the Comprehensive Drug Abuse Prevention and Control Act of 1970, Public Law 91-513, and all amendments to this set and all regulations and rulings passed down by the Federal Drug Enforcement Agency (DEA), Ark. Code Ann. § 5-64-101 et seq. and all amendments to it and these rules and regulations.

Each nursing home shall have a formal arrangement with a licensed pharmacist to provide supervision and consultation on methods and procedures for ordering, storing, administering, disposition, and record keeping of drugs and biologicals.

A consultant pharmacist's permit shall be obtained yearly from the Arkansas State Board of Pharmacy and shall be displayed in a conspicuous place in the facility.

The consultant pharmacist shall visit the nursing home at least monthly to perform his consultant duties.

Before a nursing home consultant's permit shall be issued, the pharmacist must certify to the Board of Pharmacy that he has attended a seminar or meeting explaining pharmaceutical duties and responsibilities in a nursing home as approved by the Board of Pharmacy and that he has read and understands the regulations governing pharmaceutical services in a nursing home and will abide by them.

The consultant pharmacist shall submit a written report at least monthly to the administrator of the facility. This monthly report should be a summary of the duties performed by the consultant pharmacist that month, any error or problems found in the facility, delivery of pharmaceutical services, and a detailed listing of any discrepancies and/or irregularities noted by the pharmacist during his drug regimen reviews. The pharmacist, in cooperation with the facility staff, should develop and implement policies and procedures to govern all aspects of the drug distribution system. The pharmacist may also agree to abide by and function with those policies and procedures already being used by the facility at the time of his employment.

All drugs prescribed for each patient shall be on an individual prescription basis. Medications prescribed for one patient shall not be administered to another patient.

There shall be calibrated medicine containers to correctly measure liquid medications. Calibrated medicine containers include calibrated syringes when used to measure odd liquid dosages, such as 4cc, 8cc, etc. Disposable items shall not be reused. Disposable syringes and needles must be disposed of by breaking and incineration.

In administering medications, medication cards current with the physician's orders must be used. Medicine cards shall be provided to include:

* Name of patient.

* Rooms or bed number.

* Medication and dosage.

* Hours to be given.

Medications not specifically limited as to time or number of doses when ordered by the physician shall be controlled by the facility's policy regarding automatic stop orders.

The facility's automatic stop order policy, at a minimum, shall cover the following categories of medications:

* C II Narcotics.

* C II Non-narcotics.

* C III, C IV, and C V medications.

* Anticoagulants.

* Antibiotics.

A container which contains emergency stimulants and drugs for life saving measures must be maintained. This box should be located where it can be readily available to nursing personnel but kept in a secure place and should have a breakaway lock. There should be a list on the box of the drugs which are contained in the box. The drugs in the box should be checked periodically with the list to make sure that these drugs have been replaced after use and are not outdated. Only drugs which have been approved for this purpose by the Pharmaceutical Services Committee or Medical Director, as applicable, and/or the physician, can be place in this box. All controlled substances assigned to the box must be kept with the other controlled substances and labeled "Emergency Box". All controlled substances assigned to the "Emergency Box" must be entered into the bound book. The location of these controlled substances should be noted on the list of drugs. The drug list should be signed by the physician member of the committee indicating his approval. The list and contents of the box shall be reviewed annually by the appropriate committee and/or physician and so noted on the emergency drug list.

A record shall be kept in a bound ledger book with consecutively numbered pages of all controlled drugs procured and administered. This record shall contain on each separate page:

* Name, strength, and quantity of drug received.

* Date received.

* Patient's name.

* Prescribing physician.

* Name of pharmacy.

* Date and time of dosage given.

* Quantity of drug remaining.

* Signature of person administering the drug.

The person responsible for entering the controlled drug into the bound ledger should be the same person who signs for it in the drug ordering and receiving record. This record shall be retained by the facility as a permanent record and be readily available.

There shall be a count of all C II controlled medications at each change of shift. All C III, IV, and V controlled medications should be counted at least once daily unless a true unit dose system is used. This count shall be made by the off-going charge nurse and the on-coming charge nurse. If licensed personnel are not available on a shift, a non-licensed employee can co-sign as a witness with the off-going nurse, and co-sign as a witness again with the oncoming nurse. This count shall be documented. This documentation shall include the date and time of the count, a statement as to whether or not the count was correct, and if it was incorrect, an explanation of the discrepancy. This record shall be retained by the facility as a permanent record and be readily retrievable.

When loss, suspected theft, or an error in the administration of controlled drugs occurs, it must be reported to the Director of Nursing Services and an incident report filled out; also, a copy of the form for reporting theft or lost controlled substances should be mailed to the Arkansas Department of Health, Division of Drug Control.

All documentation must be retained in the facility as a permanent record.

When a dose of a controlled drug is dropped or broken, two people should make a statement in the bound ledger as to what occurred, and both must sign their names. These two people shall be licensed nursing personnel whenever possible.

There shall be for each patient a separate medication/drug regimen review sheet. This sheet is to be used to document the performance of a medication/drug regimen review by the pharmacist and/or registered nurse. This monthly review must be dated and signed by the person making the review. Any discrepancy, interaction, etc., should be entered on the review sheet.

In an Intermediate Care Facility, the review of the medication/drug regimen of the skilled care patients must be done at least each month, and at least quarterly on the Intermediate and Minimum care patients. In Skilled Nursing Facilities, the review of medication/drug regimen must be done monthly on all patients.

In reviewing the medication/drug regimens of the patients, the pharmacist and registered nurse should, as a minimum, compare the doctor's orders with the medication administration record, the medication cards, cardex, actual medications, and prescription labels. Any discrepancies, interactions, irregularities, contraindications, errors, and incompatibilities will be noted on the medication/drug regimen review sheet, and if medication/drug review is being performed by the pharmacist, on the pharmacist's monthly written report to the administrator. Irregularities observed by the pharmacist that would warrant immediate action should be brought to the Director of Nursing Services' attention immediately upon their finding.

The person delegated the responsibility of correcting or following through on the errors, irregularities, and discrepancies listed on the pharmacist's monthly report should document their actions on their report, date it, and sign it. A photocopy of the report may be used for this purpose, but both must be retained in the facility. If no irregularities or discrepancies are found during the medication/drug regimen review, the person performing the review must note on the review sheet that he has reviewed that drug regimen and found no irregularities. This notation must be dated and signed.

Schedule II, III, IV, and V drugs dispensed by prescription for a patient and no longer needed by the patient must be delivered in person or by registered mail to: Drug Control Division, Arkansas Department of Health, 4815 West Markham Street, Little Rock, Arkansas 72201 along with Arkansas Department of Health Form (PHA-DC-1) Report of Drugs Surrendered for Disposition According to Law. When unused portions of controlled drugs go with a patient who leaves the facility, the controlled drug record shall be signed by the person who assumes responsibility for the patient and the person in charge of the medication in the nursing home. This shall be done only on the written order of the physician and at the time the patient is discharged, transferred, or visits home.

Except as provided in Ark. Code Ann. § 17-92-1101 et seq. and subsection 554.4, below, all medications other than Schedule II, III, IV, and V not taken out of the home by the patient with the physician's consent when he or she is discharged from the home shall be destroyed. See Section 554.3, below, on handling medication when a resident enters a hospital or is transferred. All discontinued medications (except controlled drugs) shall be destroyed on the premises of the facility. Destruction shall be made by the consultant pharmacist and a nurse with a record made as to the date, quantity, prescription number, patient's name, and strength of medications destroyed. The destruction should be by means of incineration, garbage disposal, or flushing down the commode. This record shall be kept in a bound ledger with consecutively numbered pages. This record shall be retained by the facility as a permanent record and be readily retrievable.

All policies and procedures related to systems of this type must first be approved by OLTC before that system is put into operation.

The medication shall remain in the pharmacy-prepared container up to the point of administration to the patient.

The medication container must be properly labeled by a licensed pharmacist.

Staff supervisory responsibility for the dietetic services is assigned to a full time, qualified dietetic service supervisor or Certified Dietary Manager. A qualified supervisor is one who has:

All food service employees shall wear appropriate, light-colored clothing including hairnet and shall keep themselves and their clothing clean.

All persons working as food handlers in nursing homes shall have in their possession or on file in the home in which they are employed, a current, approved health card.

Persons having symptoms of communicable or infectious diseases or lesions shall not be allowed to work in the dietetic services. Food service employees shall not be assigned duties outside dietetic services.

All patients shall be served an approved, appetizing, adequate diet that conforms to the recommended dietary allowances of the Food and Nutrition Board, National Research Council or with, "Food for Fitness - a Daily Guide" leaflet #424, United States Department of Agriculture.

Facilities are permitted to serve commodity foods provided that the facility is registered as a nonprofit organization and the foods were legally obtained directly from USDA sources. Commodity foods obtained from an individual may not be used. Commodity foods shall be utilized pursuant to USDA regulations. Facilities utilizing commodity foods shall maintain documentation, or be able to provide evidence, that the foods were obtained through proper channels. Failure to meet this requirement may result in a deficiency finding and a report to federal authorities.

The daily food allowances for each patient shall include, unless contraindicated by the patient's physician:

Separate for social services designee/worker.

Include actual functions of position.

Include other duties that may be assigned to designee/worker.

The facility will maintain an individual record on all residents admitted in accordance with accepted professional standards and practices. The resident record service must have sufficient staff, facilities, and equipment to provide records that are completely and accurately documented, readily accessible, and systematically organized.

The resident records will contain sufficient information to identify the resident, his/her diagnosis(es) and treatment, and to document the results accurately.

There will be an index of all residents admitted to the facility including:

* Name of resident.

* Record number.

* Former Address.

* Name of physician.

* Date of birth.

* Date of discharge.

The information contained in the resident records is confidential and is not to be released without legal authorization or subpoena.

The records will be available to State Survey Agency personnel.

An individual will be designated as responsible for the resident record service. There will be written job descriptions for the resident record service personnel.

All entries in the resident records will be recorded in ink. There will be no alteration of information in the resident records. If an error is made, a single line will be drawn through the error, the word "error" written above and initialed.

Services (DMS), or Office of Long Term Care (OLTC)

Each Alzheimer's Special Care Unit shall develop a mission statement that reflects the ASCU's treatment philosophy for those residents diagnosed with Alzheimer's or related dementia.

Alzheimer's Special Care Units shall staff according to the Rules and Regulations for Nursing Facilities. Furthermore, the following staffing requirements are established for Alzheimer's Special Care Units.

Immediately upon appointment of a receiver the Department shall assist the receiver and insure the following functions and responsibilities are accomplished:

Immediately upon completion of the assessment in Section 1006 above, but in no event more than 72 hours after appointment, the Department shall assist the Receiver to:

Immediately upon completion of assessment in Section 1006 above, but in no event more than 72 hours after appointment the Department shall assist the receiver to:

Upon appointment, the department shall assist in taking appropriate action with regard to the on-going operation of the facility. That action shall include:

A written request for an informal dispute resolution must be made to the Arkansas Department of Health, Health Facility Services, 5800 West 10th, Suite 400, Little Rock, AR 72204 within ten calendar days of the receipt of the Statement of Deficiencies from the Office of Long Term Care. The request must:

The IDR is limited to deficiencies cited on a Statement of Deficiencies. Issues that may not be heard at an IDR include, but are not limited to:

If a Medicaid certified facility is not satisfied with the results of the informal dispute resolution, it may request a hearing before the Long Term Care Facility Advisory Board within the 60 day time frame for appeal. If the facility chooses, it may by-pass the informal dispute resolution process and appeal directly to the board within the 60 day appeal period. Requests must be submitted in writing to:

Chairman

Long Term Care Facility Advisory Board

P.O. Box 8059, Slot S409

Little Rock, AR 72203-8059

Medicare and Medicare/Medicaid certified facilities may request a hearing by either the Associate Regional Administrator in the Dallas office of the Health Care Financing Administration or the Departmental Appeals Board at the addresses below at any point within the 60 day time frame for appeals.

HCF-2

Associate Regional Administrator Division of Health Standards and Quality Centers for Medicare and Medicaid Services 1200 Main Tower Building Dallas, TX 75202

Department of Health and Human Services Departmental Appeals Board, MS 6127 Civil Remedies Division 330 Independence Avenue, S.W. Cohen Building - Room G-644 Washington, D.C. 20201

If the facility chooses to appeal to either of these agencies, a copy of the appeal should also be forwarded to the OLTC.

As used in these regulations, the following definitions will apply, unless the context requires otherwise.

The following listed civil penalties pertaining to classified violations may be assessed by the Director against long term care facilities. In the case of Class A violations, the following civil penalties shall be assessed at the amount outlined in these regulations. In the case of Class B, C, or D violations, the Director, in his discretion, may elect to assess the following civil penalties or may allow a specified period of time for correction of said violation.

In determining whether a civil penalty is to be assessed and in affixing the amount of the penalty to be imposed, the Director shall consider:

Assessment of a civil penalty provided in this section shall not affect the right of the Office of Long Term Care to take other such action as may be authorized by law or regulation.