Kentucky Administrative Regulations
Title 902 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR PUBLIC HEALTH
Chapter 20 - Health Services and Facilities
Section 902 KAR 20:291 - Alzheimer's nursing homes
Universal Citation: 902 KY Admin Regs Service 20:291
Current through Register Vol. 51, No. 3, September 1, 2024
RELATES TO: KRS 216B.010-216B.131, 216B.990
NECESSITY, FUNCTION, AND CONFORMITY: The administrative regulation establishing standards for freestanding facilities limited to the care of patients with Alzheimer's or related disorders, 902 KAR 20:290, was found deficient by the Administrative Regulation Review Subcommittee at its August 6, 1991, meeting. The finding of deficiency resulted from the staff/patient ratio specified in Section 3(10)(c)2 ("Staffing requirements"). Legislation to establish the staff/patient ratio in KRS Chapter 216B was not enacted during the 1992 regular session of the General Assembly. Therefore, pursuant to KRS 13A.333(1), 902 KAR 20:290 expired. KRS 216B.042 requires the cabinet to establish standards for health facilities and health services, and authorizes it to promulgate administrative regulations. Without an administrative regulation establishing standards for freestanding facilities for patients suffering from Alzheimer's or related disorders, the cabinet would be in violation of the legislative mandate expressed in KRS 216B.042. KRS 13A.333(6) prohibits an administrative body from promulgating an administrative regulation that is identical to or substantially the same as an administrative regulation that has expired. This administrative regulation is not identical to or substantially the same as 902 KAR 20:290, because:
(1) Only the section relating to the staff/patient ratio was found deficient;
(2) this administrative regulation does not establish or require a staff/patient ratio; and
(3) it is required, by legislative mandate, by KRS 216B.042.
Section 1. Definitions.
(1) "Activities of daily living" means
activities of self-help (e.g., being able to feed, bathe and/or dress oneself),
communication (e.g., being able to place phone calls, write letters and
understanding instructions) and socialization (e.g., being able to shop, being
considerate of others, working with others and participating in
activities).
(2) "Administrator"
means a person who is licensed as a nursing home administrator pursuant to
KRS
216A.080.
(3) "Facility" means a nursing home facility
constructed pursuant to
KRS 216B.071.
(4) "License" means an authorization issued
by the Cabinet for Human Resources for the purpose of operating a nursing home
and offering nursing home services.
(5) "PRN medications" means medications
administered as needed.
(6)
"Qualified dietician" or "nutritionist" means a person certified pursuant to
KRS 310.010 or
310.030.
(7) "Patient" means any resident admitted to
an Alzheimer's facility.
(8)
"Restraint" means any pharmaceutical agent or physical or mechanical device
used to restrict the movement of a patient or the movement of a portion of a
patient's body.
Section 2. Scope.
(1) Facilities
constructed and operated pursuant to
KRS 216B.071 and this
administrative regulation shall provide care to residents with a primary
diagnosis of Alzheimer's disease or related disorder.
(2) Facilities constructed pursuant to
KRS 216B.071 shall be
constructed in accordance with
902 KAR
20:046 and this administrative regulation.
(3) These facilities shall be subject to the
provisions of
KRS
216.535 to
216.593.
Section 3. Administration and Operation.
(1) Licensee. The licensee shall be legally
responsible for the facility and for compliance with federal, state and local
laws and regulations pertaining to the operation of the facility.
(2) Administrator.
(a) All facilities shall have an
administrator who is responsible for the operation of the facility and who
shall delegate such responsibility in his absence.
(b) The licensee shall contract for
professional and supportive services not available in the facility as dictated
by the needs of the patient. The contract shall be in writing.
(3) Administrative records.
(a) The facility shall maintain a permanent,
chronological patient registry showing date of admission, name of patient, and
date of discharge.
(b) The facility
shall require and maintain written recommendations or comments from consultants
regarding the program and its development on a per visit basis.
(c) Menu and food purchase records shall be
maintained.
(d) A written report of
any incident or accident involving a patient (including medication errors or
drug reactions), visitor or staff shall be made and signed by the administrator
or nursing services supervisor, and any staff member who witnessed the
incident. The report shall be filed in an incident file.
(4) Policies. The facility shall establish
written policies and procedures that govern all services provided by the
facility. The written policies shall include:
(a) Patient care and services to include
physician, nursing, pharmaceutical (including medication stop orders policy),
and residential services.
(b) Adult
and child protection. The facility shall have written policies which assure the
reporting of allegations of abuse, neglect or exploitation of adults and
children to the Cabinet for Human Resources pursuant to KRS Chapter 209 and KRS
620.
(c) Use of restraints. The
facility shall have a written policy that addresses minimizing the use of
restraints and a mechanism for monitoring and controlling their use.
(d) Missing patient procedures. The facility
shall have a written procedure to specify in a step-by-step manner the actions
which shall be taken by staff when a patient is determined to be lost,
unaccounted for or on other unauthorized absence.
(5) Patient rights. Patient rights shall be
provided for pursuant to
KRS
216.510 to
216.525.
(6) Admission.
(a) Patients shall be admitted only upon the
referral of a physician. Additionally, the facility shall admit only persons
who have a primary diagnosis of Alzheimer's disease or related disorder. The
facility shall not admit persons whose care needs exceed the capability of the
facility.
(b) Upon admission the
facility shall obtain the patient's medical diagnosis, physician's orders for
the care of the patient and the transfer form. Within forty-eight (48) hours
after admission the facility shall obtain a medical evaluation from the
patient's physician including current medical findings, medical history and
physical examination. The medical evaluation may be a copy of the discharge
summary or history and physical report from a hospital or long-term care
facility, if done within seven (7) days prior to admission.
(c) Upon admission the patient and a
responsible member of his family or legal representative shall be informed in
writing of the established policies of the facility including fees,
reimbursement, visitation rights during serious illness, visiting hours, type
of diets offered and services rendered.
(d) The facility shall provide and maintain a
system for identifying each patient's personal property and facilities for
safekeeping of his declared valuables. Each patient's clothing and other
property shall be reserved for his own use.
(7) Discharge planning. The facility shall
have a discharge planning program to assure the continuity of care for patients
being transferred to another health care facility or being discharged to the
home.
(8) Transfer procedures and
agreements.
(a) The facility shall have
written transfer procedures and agreements for the transfer of patients to
other health care facilities which can provide a level of inpatient care not
provided by the facility. Any facility which does not have a transfer agreement
in effect but which documents a good faith attempt to enter into such an
agreement shall be considered to be in compliance with the licensure
requirement. The transfer procedures and agreements shall specify the
responsibilities each institution assumes in the transfer of patients and
establish responsibility for notifying the other institution promptly of the
impending transfer of a patient and arrange for appropriate and safe
transportation.
(b) When a
patient's condition exceeds the scope of services of the facility, the patient,
upon physician's orders (except in cases of life threatening emergency), shall
be transferred promptly to an appropriate facility to meet the patient's needs,
or services shall be contracted for from another community resource.
(c) If changes and progress occur which would
enable the patient to function in a less structured and restrictive
environment, and the less restrictive environment cannot be offered at the
facility, the facility shall offer assistance in making arrangements for
patients to be transferred to a setting which provides appropriate
services.
(d) Except in an
emergency, the patient, his next of kin, or guardian, if any, and the attending
physician shall be consulted at least thirty (30) days in advance of the
transfer or discharge of any patient.
(e) If the patient is transferred, a transfer
form shall accompany the patient. The transfer form shall include at least:
physician's orders (if available), current information relative to diagnosis
with history of problems requiring special care, a summary of the course of
prior treatment, special supplies or equipment needed for patient care, and
pertinent social information on the patient and his family.
(9) Tuberculosis testing. All
employees and patients shall be tested for tuberculosis in accordance with the
provisions of
902
KAR 20:200, Tuberculosis testing in long-term care
facilities.
(10) Personnel.
(a) Job descriptions. Written job
descriptions shall be developed for each category of personnel, to include
qualifications, lines of authority and specific duty assignments.
(b) Employee records. Current employee
records shall be maintained and shall include an employment application and a
record of each employee's training and experience, evidence of current
licensure or registration where required by law, health records, records of
in-service training and ongoing education, and the employee's name, address and
Social Security number.
(c)
Staffing requirements.
1. The facility shall
have adequate personnel to meet the needs of the patients on a twenty-four (24)
hour basis. The number and classification of personnel required shall be based
on the number of patients and the amount and kind of personal care, nursing
care, supervision and program needed to meet the needs of the patients as
determined by medical orders and by services required by this administrative
regulation.
2. When the
staff/patient ratio does not meet the needs of the patients, the Division for
Licensing and Regulation shall determine and inform the administrator in
writing how many additional personnel are to be added and of what job
classification and shall give the basis for this determination.
3. Responsible staff member shall be on duty
and awake at all times to assure prompt, appropriate action in cases of injury,
illness, fire or other emergencies.
4. Although emergency scheduling may require
substitution of staff, every effort should be made to provide residents with
familiar staff members in order to minimize resident confusion.
5. Volunteers shall not be counted to make up
minimum staffing requirements.
6.
The facility shall have a director of nursing service who is a registered nurse
and who works full time during the day, and who devotes full time to the
nursing service of the facility. If the director of nursing has administrative
responsibility for the facility, there shall be an assistant director of
nursing, who is a registered nurse, so that there shall be the equivalent of a
full-time director of nursing service. The director of nursing shall be trained
or experienced in areas of nursing service, administration, rehabilitation
nursing, psychiatric or geriatric nursing. The director of the nursing service
shall be responsible for:
a. Developing and
maintaining nursing service objectives, standards of nursing practice, nursing
procedure manuals, and written job description for each level of nursing
personnel.
b. Recommending to the
administrator the number and levels of nursing personnel to be employed,
participating in their recruitment and selection and recommending termination
of employment when necessary.
c.
Assigning and supervising all levels of nursing personnel.
d. Participating in planning and budgeting
for nursing care.
e. Participating
in the development and implementation of patient care policies.
f. Coordinating nursing services with other
patient care services.
g. Planning
and conducting orientation programs for new nursing personnel and continuing
in-service education for all nursing personnel.
h. Participating in the screening of
prospective patients in terms of required nursing services and nursing skills
available.
i. Assuring that a
written monthly assessment of the patient's general condition is
completed.
j. Assuring that a
nursing care plan shall be established for each patient and that his plan shall
be reviewed and modified as necessary.
k. Assuring that registered nurses, licensed
practical nurses, nursing assistants, and certified medication aides are
assigned duties consistent with their training and experience.
I. Assuring that a monthly review of each
patient's medications is completed and notifying the physician when changes are
appropriate.
7.
Supervising nurse. Nursing care shall be provided by or under the direction of
a full-time registered nurse. The supervising nurse may be the director of
nursing or the assistant director of nursing and shall be trained or
experienced in the areas of nursing administration and supervision,
rehabilitative nursing, psychiatric or geriatric nursing. The supervising nurse
shall make daily rounds to all nursing units performing such functions as
visiting each patient, and staff assignments, and whenever possible
accompanying physicians when visiting patients.
8. Charge nurse. There shall be at least one
(1) registered nurse or licensed practical nurse on duty at all times who is
responsible for the nursing care of patients during the nurse's tour of duty.
When a licensed practical nurse is on duty, a registered nurse shall be on
call.
9. Pharmacist. The facility
shall retain a licensed pharmacist on a full-time, part-time or consultant
basis to direct pharmaceutical services.
10. Therapists.
a. If rehabilitative services beyond
rehabilitative nursing care are offered, whether directly or through
cooperative arrangements with agencies that offer therapeutic services, these
services shall be provided or supervised by qualified therapists to include
licensed physical therapists, speech pathologists and occupational
therapists.
b. When supervision is
less than full time, it shall be provided on a planned basis and shall be
frequent enough, in relation to the staff therapist's training and experience,
to assure sufficient review of individual treatment plans and
progress.
c. In a facility with an
organized rehabilitation service using a multidisciplinary team approach to
meet all the needs of the patient, and where all therapists' services are
administered under the direct supervision of a physician qualified in physical
medicine who will determine the goals and limits of the therapists' work, and
prescribes modalities and frequency of therapy, persons with qualifications
other than those described in clause a. of this subparagraph may be assigned
duties appropriate to their training and experience.
11. Dietary. Each facility shall have a
full-time person designated by the administrator, responsible for the total
food service operation of the facility and on duty a minimum of thirty-five
(35) hours each week.
12. The
facility shall designate a person for the following areas who will be
responsible for:
a. Medical
records;
b. Arranging for social
services;
c. Developing and
implementing the activities program and therapeutic recreation; and
d. Developing and implementing staff training
program.
13. Community
family support coordinator. A social worker licensed pursuant to
KRS
335.090 or who has two (2) years of social
work supervised experience in a health care setting working directly with
individuals; or similar professional qualifications shall be utilized whose
functions shall include:
a. Evaluation of
resident's initial social history on admission;
b. Utilization of community
resources;
c. Conducting quarterly
family support group meetings; and
d. Identification and utilization of existing Alzheimer's
network.
14. Supportive
personnel, consultants, assistants and volunteers shall be supervised and shall
function within the policies and procedures of the
facility.
(d) Health
requirements. No employee contracting an infectious disease shall appear at
work until the infection can no longer be transmitted.
(e) Orientation and in-service training. All
staff members and consultants shall have documented training in the care and
handling of Alzheimer's patients, including at least:
1. Eight (8) hours of orientation to cover
the following:
a. Facility Alzheimer's
policies;
b. Etiology and treatment
of dementias;
c. Stages of
Alzheimer's disease;
d. Behavior
management; and
e.
Communication.
f. Resident's
rights.
2. Quarterly
continuing education is required, six (6) hours of which shall be in
Alzheimer's disease or related disorders.
(11) Medical records.
(a) The facility shall develop and maintain a
system of records retention and filing to insure completeness and prompt
location of each patient's record. The records shall be held confidential. The
records shall be in ink or typed and shall be legible. Each entry shall be
dated and signed. Each record shall include:
1. Identification data including the
patient's name, address and Social Security number (if available); name,
address and telephone number of referral agency; name and telephone number of
personal physician; name, address and telephone number of next of kin or other
responsible person; and date of admission.
2. Admitting medical evaluation by a
physician including current medical findings, medical history, physical
examination and diagnosis. (The medical evaluation may be a copy of the
discharge summary or history and physical report from a hospital, or long-term
care facility if done within seven (7) days prior to admission.)
3. The physician's dated and signed orders
for medication, diet, and therapeutic services.
4. Physician's progress notes describing
significant changes in the patient's condition, written at the time of each
visit.
5. Findings and
recommendations of consultants.
6.
A medication sheet which contains the date, time given, name of each
medication, dosage, administration method, name of prescribing physician and
name of person who administered the medication.
7. Nurse's notes indicating changes in
patient's condition, actions, responses, attitudes, appetite, etc. Nursing
personnel shall make notation of response to medications, response to
treatments, mode and frequency of PRN medications administered, condition
necessitating administration of PRN medication, reaction following PRN
medication, visits by physician and phone calls to the physician, medically
prescribed diets and preventive maintenance or rehabilitative nursing
measures.
8. Written assessment of
the patient's monthly general condition.
9. Reports of dental, laboratory and x-ray
services (if applicable).
10.
Changes in patient's response to the activity and therapeutic recreation
program.
11. A discharge summary,
signed and dated by the attending physician within one (1) month of discharge
from the facility.
(b)
Retention of records. After patient's death or discharge the completed medical
record shall be placed in an inactive file and retained for five (5)
years.
Section 4. Provision of Services.
(1)
Physician services.
(a) The health care of
every patient shall be under the supervision of a physician who, based on an
evaluation of the patient's immediate and long-term needs, prescribes a planned
regimen of medical care which covers indicated medications, treatments,
rehabilitative services, diet, special procedures recommended for the health
and safety of the patient, activities, plans for continuing care and
discharge.
(b) Patients shall be
evaluated by a physician at least once every thirty (30) days for the first
sixty (60) days following admission. Subsequent to the 60th day following
admission, the patients shall be evaluated by a physician every sixty (60) days
unless justified and documented by the attending physician in the patient's
medical record. There shall be evidence in the patient's medical record of the
physician visits to the patient at medically appropriate intervals.
(c) There shall be evidence in the patient's
medical record that the patient's attending physician has made arrangement for
the medical care of the patient in the physician's absence.
(d) Availability of physicians for emergency
care. The facility shall have arrangements with one (1) or more physicians who
will be available to furnish necessary medical care in case of an emergency if
the physician responsible for the care of the patient is not immediately
available. A schedule listing the names and telephone numbers of these
physicians and the specific days each shall be on call and shall be posted in
each nursing station. There shall be established procedures to be followed in
an emergency, which cover immediate care of the patient, persons to be
notified, and reports to be prepared.
(2) Nursing services.
(a) Twenty-four (24) hour nursing service.
There shall be twenty-four (24) hour nursing service with a sufficient number
of nursing personnel on duty at all times to meet the total needs of patients.
Nursing personnel shall include registered nurses or licensed practical nurses,
aides, assistants, and certified medication aides. The amount of nursing time
available for patient care shall be exclusive of nonnursing duties. Sufficient
nursing time shall be available to assure that each patient:
1. Shall receive treatments, medication, and
diets as prescribed;
2. Shall
receive proper care to prevent decubiti and shall be kept comfortable, clean
and well-groomed;
3. Shall be
protected from accident and injury by the adoption of indicated safety
measures;
4. Shall be treated with
kindness and respect;
(b)
Rehabilitative nursing care. There shall be an active program of rehabilitative
nursing care directed toward assisting each patient to achieve and maintain his
highest level of self-care and independence.
1. Rehabilitative nursing care initiated in
the hospital shall be continued immediately upon admission to the
facility.
2. Nursing personnel
shall be taught rehabilitative nursing measures and shall practice them in
their daily care of patients. These measures shall include:
a. Maintaining good body alignment and proper
positioning of bedfast patients;
b.
Encouraging and assisting bedfast patients to change positions at least every
two (2) hours, day and night to stimulate circulation and prevent decubiti and
deformities or more often if necessary;
c. Making every effort to keep patients
active and out of bed for reasonable periods of time, except when
contraindicated by physician's orders, and encouraging patients to achieve
independence in activities of daily living by teaching self-care, transfer and
ambulation activities;
d. Assisting
patients to carry out prescribed physical therapy exercises between visits of
the physical therapists.
(c) Dietary supervision. Nursing personnel
shall assure that patients are served diets as prescribed. Patients needing
help in eating shall be assisted promptly upon receipt of meals. Food and fluid
intake of patients shall be observed and deviations from normal shall be
reported to the charge nurse. Persistent unresolved problems shall be reported
to the physician.
(d) Comprehensive
assessment of resident needs. Nursing personnel shall make a comprehensive
assessment of a resident's needs which describes the resident's capability to
perform daily life functions and significant impairments in functional
capacity:
1. The comprehensive assessment must
include at least the following information:
a.
Medically defines conditions and prior medical history;
b. Medical status measurement;
c. Functional status;
d. Sensory and physical impairment;
e. Nutritional status and
requirements;
f. Special treatments
or procedures;
g. Psychosocial
status;
h. Dental
condition;
i. Activities
potential;
j. Cognitive status;
and
k. Drug
therapy.
2. Assessments
must be conducted no later than fourteen (14) days after the date of admission
and promptly after a significant change in the resident's physical or mental
condition.
3. Each assessment must
be conducted or coordinated by a registered nurse who signs and certifies the
completion of the assessment.
(3) Comprehensive assessments and care plans.
(a) Comprehensive assessments.
1. The facility shall make a comprehensive
assessment of a resident's needs, which describes the resident's capability to
perform daily life functions and significant impairments in functional
capacity.
2. The comprehensive
assessment shall include at least the following information:
a. Medically defined conditions and prior
medical history;
b. Medical status
measurement;
c. Functional
status;
d. Sensory and physical
impairments;
e. Nutritional status
and requirements;
f. Special
treatments or procedures;
g.
Psychosocial status;
h. Discharge
potential;
i. Dental
condition;
j. Activities
potential;
k. Rehabilitation
potential;
l. Cognitive status; and
m. Drug therapy.
3. Frequency. Assessments shall be
conducted:
a. No later than fourteen (14) days
after the date of admission;
b.
Promptly after a significant change in the resident's physical or mental
condition; and
c. In no case less
often than once every twelve (12) months.
4. Review of assessments. The nursing
facility shall examine each resident no less than once every three (3) months,
and as appropriate, revise the resident's assessment to assure the continued
accuracy of the assessment.
5. Use.
The results of the assessment are used to develop, review, and revise the
resident's comprehensive plan of care, under paragraph (4) of this
section.
(b) Accuracy of
assessments.
1. Coordination. Each assessment
shall be conducted or coordinated by a registered nurse who signs and certifies
the completion of the assessment with the appropriate participation of health
professionals.
2. Certification.
Each individual who completes a portion of the assessment shall sign and
certify the accuracy of that portion of the assessment.
(c) Comprehensive care plans.
1. The facility shall develop a comprehensive
care plan for each resident that includes measurable objectives and timetables
to meet a resident's medical, nursing and psychosocial needs that are
identified in the comprehensive assessment.
2. A comprehensive care plan shall be:
a. Developed within seven (7) days after
completion of the comprehensive assessment;
b. Prepared by an interdisciplinary team,
that includes the attending physician, a registered nurse with responsibility
for the resident, and other appropriate staff in disciplines as determined by
the resident's needs, and with the participation of the resident, the
resident's family or legal representative, to the extent practicable;
and
c. Periodically reviewed and
revised by a team of qualified persons after each
assessment.
3. The
services provided or arranged by the facility shall:
a. Meet professional standards of quality;
and
b. Be provided by qualified
persons in accordance with each resident's written plan of care.
(d) Discharge summary.
When the facility anticipates discharge, a resident shall have a discharge
summary that includes:
1. A recapitulation of
the resident's stay;
2. A final
summary of the resident's status to include items in subsection (2)(d) of this
subsection, at the time of the discharge that shall be available for release to
authorized persons and agencies, with the consent of the resident or legal
representative; and
3. A
postdischarge plan of care that developed with the participation of the
resident and his or her family, which will assist the resident to adjust to his
or her new living environment.
(4) Specialized rehabilitative services.
(a) Rehabilitative services shall be provided
upon written order of the physician which indicates anticipated goals and
prescribes specific modalities to be used and frequency of physical, speech and
occupational therapy services. These services may be contracted for from
another community resource.
(b) If
therapy services are provided they shall include:
1. Physical therapy which includes:
a. Assisting the physician in his evaluation
of patients by applying muscle, nerve, joint, and functional ability
tests;
b. Treating patients to
relieve pain, develop or restore functions, and maintain maximum performance,
using physical means such as exercise, massage, heat, water, light, and
electricity.
2. Speech
therapy which includes:
a. Service in speech
pathology or audiology;
b.
Cooperation in the evaluation of patients with speech, hearing, or language
disorders;
c. Determination and
recommendation of appropriate speech and hearing services;
3. Occupational therapy services which
includes:
a. Assisting the physician in his
evaluation of the patient's level of function by applying diagnostic and
prognostic tests.
b. Guiding the
patient in his use of therapeutic creative and self care activities for
improving function.
c. Therapists
shall collaborate with the facility's medical and nursing staff in developing
the patient's total plan of care.
d. Ambulation and therapeutic equipment.
Commonly used ambulation and therapeutic equipment necessary for services
offered shall be available for use in the facility such as parallel bars,
handrails, wheelchairs, walkers, walkerettes, crutches and canes. The
therapists shall advise the administrator concerning the purchase, rental,
storage and maintenance of equipment and supplies.
(5) Personal care
services. Personal care services shall include: assistance with bathing,
shaving, cleaning and trimming of fingernails and toenails, cleaning of the
mouth and teeth, and washing, grooming and cutting of hair.
(6) Pharmaceutical services.
(a) The facility shall provide appropriate
methods and procedures for obtaining, dispensing, and administering drugs and
biologicals, developed with the advice of a licensed pharmacist or a
pharmaceutical advisory committee which includes one (1) or more licensed
pharmacists.
(b) If the facility
has a pharmacy department, a licensed pharmacist shall administer the
department.
(c) If the facility
does not have a pharmacy department, it shall have provision for promptly
obtaining prescribed drugs and biologicals from a community or institutional
pharmacy holding a valid pharmacy permit issued by the Kentucky Board of
Pharmacy, pursuant to
KRS
315.035.
(d) If the facility does not have a pharmacy
department, but does maintain a supply of drugs:
1. The consultant pharmacist shall be
responsible for the control of all bulk drugs and maintain records of their
receipt and disposition.
2. The
consultant pharmacist shall dispense drugs from the drug supply, properly label
them and make them available to appropriate licensed nursing
personnel.
3. Provisions shall be
made for emergency withdrawal of medications from the drug supply.
(e) An emergency medication kit
approved by the facility's professional personnel shall be kept readily
available. The facility shall maintain a record of what drugs are in the kit
and document how the drugs are used.
(f) Medication services.
1. Conformance with physician's orders. All
medications administered to patients shall be ordered in writing by the
patient's physician. Telephone orders shall be given only to a licensed nurse
or pharmacist immediately reduced to writing, signed by the nurse and
countersigned by the physician within fourteen (14) days. Medications not
specifically limited as to time or number of doses, when ordered, shall be
automatically stopped in accordance with the facility's written policy on stop
orders. A registered nurse or pharmacist shall review each patient's medication
profile at least monthly. The prescribing physician shall review the patient's
medical profile at least every two (2) months. The patient's attending
physician shall be notified of stop order policies and contacted promptly for
renewal of such orders so that continuity of the patient's therapeutic regimen
is not interrupted. Medications are to be released to patients on discharge
only on the written authorization of the physician.
2. Administration of medications. All
medications shall be administered by licensed medical or nursing personnel in
accordance with the Medical Practice Act (KRS
311.530 to
311.620) and Nurse
Practice Act of (KRS Chapter 314) or by personnel who have completed a state
approved training program, from a state-approved source. The administration of
oral and topical medicines by certified medicine aides shall be under the
supervision of licensed medical or nursing personnel. Intramuscular injections
shall be administered by a licensed nurse or a physician. If intravenous
injections are necessary they shall be administered by a licensed physician or
registered nurse. Each dose administered shall be recorded in the medical
record.
a. The nursing station shall have
readily available items necessary for the proper administration of
medications.
b. In administering
medications, medication cards or other state approved systems shall be used and
checked against the physician's orders.
c. Medications prescribed for one patient
shall not be administered to any other patient.
d. Self-administration of medications by
patients shall not be permitted except on special order of the patient's
physician or in a predischarge program under the supervision of a licensed
nurse.
e. Medication errors and
drug reactions shall be immediately reported to the patient's physician and an
entry thereof made in the patient's medical record as well as on an incident
report.
f. Up-to-date medication
reference texts and sources of information shall be provided for use by the
nursing staff, (e.g., the American Hospital Formulary Service of the American
Society of Hospital Pharmacists, Physicians Desk Reference or other suitable
references).
3. Labeling
and storing medications.
a. All medications
shall be plainly labeled with the patient's name, the name of the drug,
strength, name of pharmacy, prescription number, date, physician name, caution
statements and directions for use except where accepted modified unit dose
systems conforming to federal and state laws are used. The medications of each
patient shall be kept and stored in their original containers and transferring
between containers shall be prohibited. All medicines kept by the facility
shall be kept in a locked place and the persons in charge shall be responsible
for giving the medicines and keeping them under lock and key. Medications
requiring refrigeration shall be kept in a separate locked box of adequate size
in the refrigerator in the medication area. Drugs for external use shall be
stored separately from those administered by mouth and injection. Provisions
shall also be made for the locked separate storage of medications of deceased
and discharged patients until such medication is surrendered or destroyed in
accordance with federal and state laws and regulations.
b. Medication containers having soiled,
damaged, incomplete, illegible, or makeshift labels shall be returned to the
issuing pharmacist or pharmacy for relabeling or disposal. Containers having no
labels shall be destroyed in accordance with state and federal laws.
c. Cabinets shall be well lighted and
sufficient size to permit storage without crowding.
d. Medications no longer in use shall be
disposed of or destroyed in accordance with federal and state laws and
regulations.
e. Medications having
an expiration date shall be removed from usage and properly disposed of after
such date.
4. Controlled
substances. Controlled substances shall be kept under double lock (e.g., in a
locked box in a locked cabinet). There shall be a controlled substances record,
in which is recorded the name of the patient, the date, time, kind, dosage,
balance remaining and method of administration of all controlled substances;
the name of the physician who prescribed the medications; and the name of the
nurse who administered it, or staff who supervised the self-administration. In
addition, there shall be a recorded and signed Schedule II controlled
substances count daily, and Schedule III, IV, and V controlled substances count
once per week by those persons who have access to controlled substances. All
controlled substances which are left over after the discharge or death of the
patient shall be destroyed in accordance with
KRS
218A.230, or
21 CFR
1307.21, or sent via registered mail to the
Controlled Substances Enforcement Branch of the Kentucky Cabinet for Human
Resources.
5. Use of restraints. If
a patient becomes disturbed or unmanageable, the patient's physician shall be
notified in order to evaluate and direct the patient's care. No form of
restraints or protective devices shall be used except under written orders of
the attending physician. There shall be no PRN orders for restraints.
Understanding that measures to prevent wandering may infringe on patient
rights, care shall be exercised in the use of physical or mechanical devices or
chemical restraints.
a. Restraints shall not
be used as punishment, as discipline, as a convenience for the staff, or when
not required to treat the resident's medical symptoms, or as a substitute for
staff.
b. Physical or mechanical
restraints that require lock and key shall not be used. Restraints shall be
applied only by personnel trained in the proper application and observation of
this equipment. Restraints shall be checked at least every one-half (1/2) hour
and released at least ten (10) minutes every two (2) hours. During the
patient's normal waking hours, the patient must be exercised during release
periods. The checks and releases of restraints shall be recorded in the
patient's medical record as they are completed. Such reports shall document the
rationale or justification for the use of the procedure, a description of the
specific procedures employed, and the physician's order. Restraints shall be
comfortable and easily removed in case of an emergency.
c. The specific purpose and time-limited
order for any restraint shall be written and reviewed according to facility
policy. The frequency of such renewal shall not exceed sixty (60)
days.
6. Infection
control and communicable diseases.
a. There
shall be written infection control policies, which are consistent with the
Center for Disease Control guidelines including:
(i) Policies which address the prevention of
disease transmission to and from patients, visitors and employees, including:
universal blood and body fluid precautions, precautions for infections which
can be transmitted by the airborne route; and work restrictions for employees
with infectious diseases.
(ii)
Policies which address the cleaning, disinfection, and sterilization methods
used for equipment and the environment.
b. The facility shall provide in-service
education programs on the cause, effect, transmission, prevention and
elimination of infections for all personnel responsible for direct patient
care.
c. Sharp wastes.
(i) Sharp wastes, including needles,
scalpels, razors, or other sharp instruments used for patient care procedures,
shall be segregated from other wastes and placed in puncture resistant
containers immediately after use.
(ii) Needles shall not be recapped by hand,
purposely bent, broken, or otherwise manipulated by hand.
(iii) The containers for sharp wastes shall
either be incinerated on- or off-site, or be rendered nonhazardous by a
technology of equal or superior efficacy, which is approved by both the Cabinet
for Human Resources and the Natural Resources and Environmental Protection
Cabinet.
d. Disposable
waste.
(i) All disposable waste shall be
placed in suitable bags or closed containers so as to prevent leakage or
spillage, and shall be handled, stored, and disposed of in such a way as to
minimize direct exposure of personnel to waste materials.
(ii) The facility shall establish specific
written policies regarding handling and disposal of all wastes.
(iii) The following wastes shall be disposed
of by incineration, autoclaved before disposal, or carefully poured down a
drain connected to a sanitary sewer: blood, blood specimens, used blood tubes,
or blood products.
(iv) Any wastes
conveyed to a sanitary sewer shall comply with applicable federal, state, and
local pretreatment regulations pursuant to 40 CFR 403 and 401 KAR 5:055,
Section 9.
(v) Any incinerator used
for the disposal of waste shall be in compliance with
401 KAR 59:020
and
401
KAR 5:055.
e. Patients infected with the following
diseases shall not be admitted to the facility: anthrax, cam-pylobacteriosis,
cholera, diphtheria, hepatitis A, measles, pertussis, plague, poliomyelitis,
rabies (human), rebella, salmonellosis, shigellosis, typhoid fever,
yersiniosis, brucellosis, giardiasis, leprosy, psittacosis, Q fever, tularemia,
and typhus.
f. A facility may admit
a (noninfectious) tuberculosis patient under continuing medical supervision for
his tuberculosis disease.
g.
Patients with active tuberculosis may be admitted to the facility whose
isolation facilities and procedures have been specifically approved by the
cabinet.
h. If, after admission, a
patient is suspected of having a communicable disease that would endanger the
health and welfare of other patients the administrator shall assure that a
physician is contacted and that appropriate measures are taken on behalf of the
patient with the communicable disease and the other
patients.
(7) Diagnostic services. The facility shall
have provisions for obtaining required clinical laboratory, x-ray and other
diagnostic services. Laboratory services may be obtained from a laboratory
which is part of a licensed hospital or a laboratory licensed pursuant to
KRS
333.030 and any administrative regulations
promulgated thereunder. Radiology services shall be obtained from a service
licensed or registered pursuant to
KRS
211.842 to
211.852
and any administrative regulations promulgated thereunder. If the facility
provides its own diagnostic services, the service shall meet the applicable
laws and administrative regulations. All diagnostic services shall be provided
only on the request of a physician. The physician shall be notified promptly of
the test results. Arrangements shall be made for the transportation of
patients, if necessary, to and from the source of service. Simple tests, such
as those customarily done by nursing personnel for diabetic patients may be
done in the facility. All reports shall be included in the medical
record.
(8) Dental services. The
facility shall assist patients to obtain regular and emergency dental care.
Provision for dental care: Patients shall be assisted to obtain regular and
emergency dental care. An advisory dentist shall provide consultation,
participate in in-service education, recommend policies concerning oral
hygiene, and shall be available in case of emergency. The facility, when
necessary, shall arrange for the patient to be transported to the dentist's
office. Nursing personnel shall assist the patient to carry out the dentist's
recommendations.
(9) Social
services.
(a) Provision for medically related
social needs. The medically related social needs of the patient shall be
identified, and services provided to meet them, in admission of the patient,
during his treatment and care in the facility.
1. As a part of the process of evaluating a
patient's need for services in a facility and whether the facility can offer
appropriate care, emotional and social factors shall be considered in relation
to medical and nursing requirements.
2. As soon as possible after admission, there
shall be an evaluation, based on medical, nursing and social factors, of the
probable duration of the patient's need for care and a plan shall be formulated
and recorded for providing such care.
3. Subject to the requirements of
KRS 216B.071, where
there are indications that financial help will be needed, arrangements shall be
made promptly for referral to an appropriate agency.
4. Social and emotional factors related to
the patient's illness, to his response to treatment and to his adjustment to
care in the facility shall be recognized and appropriate action shall be taken
when necessary to obtain casework services to assist in resolving problems in
these areas.
5. Knowledge of the
patient's home situation, financial resources, community resources available to
assist him, and pertinent information related to his medical and nursing
requirements shall be used in making decisions regarding his discharge from the
facility.
(b)
Confidentiality of social data. Pertinent social data, and information about
personal and family problems related to the patient's illness and care shall be
made available only to the attending physician, appropriate members of the
nursing staff, and other key personnel who are directly involved in the
patient's care, or to recognized health or welfare agencies. There shall be
appropriate policies and procedures for assuring the confidentiality of such
information.
1. The staff member responsible
for social services shall participate in clinical staff conferences and confer
with the attending physician at intervals during the patient's stay in the
facility, and there shall be evidence in the record of such
conferences.
2. The staff member
and nurses responsible for the patient's care shall confer frequently and there
shall be evidence of effective working relationships between them.
3. Records of pertinent social information
and of action taken to meet social needs shall be maintained for each patient.
Signed social service summaries shall be entered promptly in the patient's
medical record for the benefit of all staff involved in the care of the
patient.
(10)
Patient activities. Activities suited to the needs and interests of patients
shall be provided. Provision shall be made for activities which must be
appropriate for the needs and interests of each resident, taking into
consideration his or her specific impairment, state of disease. Activities
programs shall be available to all residents and shall be planned and
documented in the patient's interdisciplinary comprehensive assessment.
(a) The activity leader shall have
specialized educational preparation concerning the care of an Alzheimer's
patient, and use, to the fullest possible extent, community, social and
recreational opportunities.
(b)
Patients shall be encouraged but not forced to participate in such activities.
Suitable activities are provided for patients unable to leave their
rooms.
(c) Patients who are able
and who wish to do so shall be assisted to attend religious services.
(d) Patient's request to see their clergymen
shall be honored and space shall be provided for privacy during
visits.
(e) Visiting hours shall be
flexible and posted to permit and encourage visiting friends and
relatives.
(f) The facility shall
make available a variety of supplies and equipment adequate to satisfy the
individual interests of patients. Examples of such supplies and equipment are:
books and magazines, daily newspapers, games, stationery, radio and television
and the like.
(11)
Transportation.
(a) If transportation of
patients is provided by the facility to community agencies or other activities,
the following shall apply:
1. Special
provision shall be made for patients who use wheelchairs.
2. An escort or assistant to the driver shall
be provided in transporting patients to and from the facility if necessary for
the patient's safety.
(b)
The facility shall arrange for appropriate transportation in case of medical
emergencies.
(12)
Residential services.
(a) Dietary services.
The facility shall provide or contract for food service to meet the dietary
needs of the patients including modified diets or dietary restrictions as
prescribed by the attending physician. When a facility contracts for food
service, with an outside food management company, the company shall provide a
qualified dietician on a full-time, part-time or consultant basis to the
facility. The qualified dietician shall have continuing liaison with the
medical and nursing staff of the facility for recommendations on dietetic
policies affecting patient care. The company shall comply with all of the
appropriate requirements for dietary services in this administrative
regulation.
1. Therapeutic diets. If the
designated person responsible for food service is not a qualified dietician or
nutritionist, consultation by a qualified dietician or qualified nutritionist
shall be provided.
2. Dietary
staffing. There shall be sufficient food service personnel employed and their
working hours, schedules of hours, on duty and days off shall be posted. If any
food service personnel are assigned duties outside the dietary department, the
duties shall not interfere with the sanitation, safety or time required for
regular dietary assignments.
3.
Menu planning.
a. Menus shall be planned,
written and rotated to avoid repetition. Nutrition needs shall be met in
accordance with the current recommended dietary allowances of the Food and
Nutrition Board of the National Research Council adjusted for age, sex and
activity, and in accordance with physician's orders.
b. Meals shall correspond with the posted
menu. Menus must be planned and posted one (1) week in advance. When changes in
the menu are necessary, substitutions shall provide equal nutritive value and
the changes shall be recorded on the menu and all menus shall be kept on file
for thirty (30) days.
c. The daily
menu shall include daily diet for all modified diets served within the facility
based on an approved diet manual. The diet manual shall be a current manual
with copies available in the dietary department, that has the approval of the
professional staff of the facility. The diet manual shall indicate nutritional
deficiencies of any diet. The dietician shall correlate and integrate the
dietary aspects of the patient care with the patient and patient's chart
through such methods as patient instruction, recording diet histories and
participation in rounds and conferences.
4. Food preparation and storage.
a. There shall be at least a three (3) day
supply of food to prepare well balanced palatable meals. Records of food
purchased for preparation shall be on file for thirty (30) days.
b. Food shall be prepared with consideration
for any individual dietary requirement. Modified diets, nutrient concentrates
and supplements shall be given only on the written orders of a
physician.
c. At least three (3)
meals per day shall be served with not more than a fifteen (15) hour span
between the substantial evening meal and breakfast. Between meal snacks to
include an evening snack before bedtime shall be offered to all patients.
Adjustments shall be made when medically indicated.
d. Foods shall be prepared by methods that
conserve nutritive value, flavor and appearance and shall be attractively
served at the proper temperatures, and in a form to meet the individual needs.
A file of tested recipes, adjusted to appropriate yield shall be maintained.
Food shall be cut, chopped or ground to meet individual needs. If a patient
refuses foods served, nutritional substitutions shall be offered.
e. All opened containers or leftover food
items shall be covered and dated when refrigerated.
5. Serving of food. When a patient cannot be
served in the dining room, trays shall be provided for bedfast patients and
shall rest on firm supports such as over-bed tables. Sturdy tray stands of
proper height shall be provided for patients able to be out of bed.
a. Correct positioning of the patient to
receive his tray shall be the responsibility of the direct patient care staff.
Patients requiring help in eating shall be assisted within a reasonable length
of time.
b. Adaptive self-help
devices shall be provided to contribute to the patient's independence in
eating.
6. Sanitation.
All facilities shall comply with all applicable provisions of
KRS
219.011 to
219.081 and
902 KAR 45:005
(Kentucky's Food Service Establishment Act and Food Service
Code).
(b) Housekeeping
and maintenance services.
1. The facility
shall maintain a clean and safe facility free of unpleasant odors. Odors shall
be eliminated at their source by prompt and thorough cleaning of commodes,
urinals, bedpans and other obvious sources.
2. An adequate supply of clean linen shall be
on hand at all times. Soiled clothing and linens shall receive immediate
attention and shall not be allowed to accumulate. Clothing or bedding used by
one patient shall not be used by another until it has been laundered or dry
cleaned.
3. Soiled linen shall be
sorted and laundered in the soiled linen room in the laundry area. Hand-washing
facilities with hot and cold water, soap dispenser and paper towels shall be
provided in the laundry area.
4.
Clean linen shall be sorted, dried, ironed, folded, transported, stored and
distributed in a sanitary manner.
5. Personal laundry of patients or staff
shall be collected, transported, sorted, washed and dried in a sanitary manner,
separate from bed linens.
6.
Patients' personal clothing shall be laundered as often as is necessary.
Laundering of patients' personal clothing shall be the responsibility of the
facility unless the patient or the patient's family accepts this
responsibility. Patient's personal clothing laundered by or through the
facility shall be marked to identify the patient-owner and returned to the
correct patient.
7. Maintenance.
The premises shall be well kept and in good repair. Requirements shall include:
a. The facility shall insure that the grounds
are well kept and the exterior of the building, including the sidewalks, steps,
porches, ramps and fences are in good repair.
b. The interior of the building including
walls, ceilings, floors, windows, window coverings, doors, plumbing and
electrical fixtures shall be in good repair. Windows and doors shall be
screened.
c. Garbage and trash
shall be stored in areas separate from those used for the preparation and
storage of food and shall be removed from the premises regularly. Containers
shall be cleaned regularly.
d. A
pest control program shall be in operation in the facility. Pest control
services shall be provided by maintenance personnel of the facility or by
contract with a pest control company. The compounds shall be stored under
lock.
(c) Room
accommodations.
1. Each patient shall be
provided a standard size bed or the equivalent at least thirty-six (36) inches
wide, equipped with substantial springs, a clean comfortable mattress, a
mattress cover, two (2) sheets and a pillow, and such bed covering as is
required to keep the patients comfortable. Rubber or other impervious sheets
shall be placed over the mattress cover whenever necessary. Beds occupied by
patients shall be placed so that no patient may experience discomfort because
of proximity to radiators, heat outlets, or by exposure to drafts.
2. The facility shall provide window
coverings, bedside tables with reading lamps (if appropriate), comfortable
chairs, chest or dressers with mirrors, a night light, and storage space for
clothing and other possessions.
3.
Patients shall not be housed in unapproved rooms or unapproved detached
buildings.
4. Basement rooms shall
not be used for sleeping rooms for patients.
5. Patients may have personal items and
furniture when it is physically feasible.
6. There shall be a sufficient number of
tables provided that can be rolled over a patient's bed or be placed next to a
bed to serve patients who cannot eat in the dining room.
7. Each living room or lounge area and
recreation area shall have an adequate number of reading lamps, and tables and
chairs or settees of sound construction and satisfactory design.
8. Dining room furnishings shall be adequate
in number, well constructed and of satisfactory design for the
patients.
9. Each patient shall be
permitted to have his own radio and television set in his room unless it
interferes with or is disturbing to other patients.
Section 5. Alzheimer's Facility Requirements.
(1) The care of
residents with Alzheimer's disease and other cognitive disorders require
increased security and visual access. Measures to protect the residents from
harm and to prevent them from leaving designated areas without supervision
shall include frequent in-person observation of each resident and may also
include the use of wide angle mirrors closed-circuit television monitors, and
alarm systems.
(2) In addition to
the required facility specifications in
902 KAR
20:046, the following shall be provided:
(a) Control doors, if used for security of
the residents, shall be forty-four (44) inches in width each leaf, and swing in
opposite directions. A latch or other fastening device on a door shall be
provided with a knob, handle, panic bar, or other simple type of releasing
device, the method of operation of which is obvious, even in
darkness.
(b) Locking devices may
be used on the control doors if the following criteria are met.
1. The locking device, which shall not be a
keylock device, shall be electronic and shall be released when the following
occurs:
a. Upon activation of the fire alarm
or sprinkler systems;
b. Power
failure to the facility; and
c. By
pressing a button located at the main staff station and at the monitoring
station.
2. Key pad or
buttons may be located at the control doors for routine use by staff or
service.
(3)
Access to outdoor areas shall be provided and such areas shall be enclosed by
walls or fencing that do not present a hazard.
(4) Any security measures taken to provide
for the safety of wandering patients shall be as unobtrusive as
possible.
STATUTORY AUTHORITY: KRS 216B.042, 216B.071, 216B.105
Disclaimer: These regulations may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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