Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 150.000 - Standards for Long-Term Care Facilities
Section 150.002 - Administration
Universal Citation: 105 MA Code of Regs 105.150
Current through Register 1531, September 27, 2024
(A) Every licensee shall designate a qualified administrator and shall establish by-laws or policies describing the organization of the facility, establish authority and responsibility, and identify programs and goals.
(B) Administration.
(1)
Facilities providing Level I care, Level II care in more than one unit, or
Level III or IV care in more than two units shall employ a full-time
administrator.
(2) Facilities
providing Level II care with only a single unit, and facilities providing Level
III or IV care with less than two units shall employ an administrator for the
number of hours as needed in accordance with the size and services provided by
the facility.
(3) No more than one
full-time administrator is required even in facilities providing multiple units
or multiple levels of care.
(4) A
full-time administrator shall be on the premises during the working
day.
(5) In facilities providing
Level I, II or III care, the administrator shall be a nursing home
administrator licensed by the Board of Registration of Nursing Home
Administrators.
(6) The
administrator shall be a suitable and responsible person.
(7) A responsible person shall be designated
to act in the absence of the administrator.
(8) The names and telephone numbers of the
administrator and his or her alternate shall be posted and available to the
individual in charge at all times.
(C) The administrator of the facility shall be responsible to the licensee and shall operate the facility to ensure services required by residents at each level of care are available on a regular basis and provided in an appropriate environment in accordance with established policies.
(D) The licensee shall be responsible for procurement of competent personnel, and the licensee and the administrator shall be jointly and severally responsible for the direction of such personnel and for establishing and maintaining current written personnel policies, and personnel practices and procedures that encourage good resident care.
(1) At all times, each facility shall
provide a sufficient number of trained, experienced and competent personnel to
provide appropriate care and supervision for all residents and to ensure their
personal needs are met. Accurate time records shall be kept on all
personnel.
(2) There shall be
written job descriptions for all positions including qualifications, duties and
responsibilities. Work assignments shall be consistent with job descriptions
and qualifications.
(3) There shall
be an organized orientation program for all new employees to explain job
responsibilities, duties and employment policies.
(4) Personnel shall be currently licensed or
registered where applicable laws require licensure and registration.
(5) Completed and signed application forms
and employee records shall be maintained. They shall be accurate, current and
available on the premises. Such records shall include the following:
(a) Pertinent information regarding
identification (including any other name previously used).
(b) Social Security number, Massachusetts
license or registration number (if applicable) and year of original licensure
or registration.
(c) Names and
addresses of educational institutions attended, dates of graduation, degrees or
certificates conferred and name at the time of graduation.
(d) All professional experience, on-the-job
training and previous employment in chronological order with name and location
of employer, dates of employment, and reasons for terminating
employment.
(6) Employee
records shall contain evidence of adequate health supervision.
(a) A pre-employment physical examination,
including a chest X-ray or an intradermal skin test for tuberculosis, and
periodic physical examinations at least every two years shall be performed and
recorded.
(b) Accurate records of
illnesses and incidents involving personnel while on duty shall be
kept.
(7) No individual
shall be employed, or employee permitted to work, if infected with a contagious
disease in a communicable form that might endanger the health of residents or
other employees.
(8)
Requirement for Personnel to Be Vaccinated against Influenza
Virus.
(a)
Definitions.
1. For
purposes of
105
CMR 150.002(D)(8), personnel
means an individual or individuals who either work at or come to the licensed
facility site and who are employed by or affiliated with the facility, whether
directly, by contract with another entity, or as an independent contractor,
paid or unpaid including, but not limited to, employees, members of the medical
staff, contract employees or staff, students, and volunteers, whether or not
such individual(s) provide direct care.
2. For purposes of
105
CMR 150.002(D)(8), the
requirement for influenza vaccine or vaccination means immunization by either
influenza vaccine, inactivated or live; attenuated influenza vaccine including
seasonal influenza vaccine pursuant to
105
CMR 150.002(D)(8)(b); and/or
other influenza vaccine pursuant to
105
CMR
150.002(D)(8)(c).
3. For purposes of
105
CMR 150.002(D)(8),
mitigation measures mean measures that personnel who are exempt from
vaccination must take to prevent viral infection and transmission.
(b) Each facility shall ensure all
personnel are vaccinated annually with seasonal influenza vaccine, consistent
with any guidelines of the Commissioner, unless an individual is exempt from
vaccination in accordance with
105
CMR 150.002(D)(8)(f).
(c) Each facility also shall ensure
all personnel are vaccinated against other pandemic or novel influenza
virus(es) as specified in guidelines of the Commissioner, unless an individual
is exempt from vaccination in accordance with
105
CMR 150.002(D)(8)(f). Such
guidelines may specify:
1. The categories of
personnel to be vaccinated and the order of priority of vaccination of
personnel, with priority for personnel with responsibility for direct
care;
2. The influenza vaccine(s)
to be administered;
3. The dates by
which personnel must be vaccinated; and
4. Any required reporting and data collection
relating to the personnel vaccination requirement of
105
CMR
150.002(D)(8)(c).
(d) Each facility shall provide all personnel
with information about the risks and benefits of influenza vaccine.
(e) Each facility shall notify all personnel
of the influenza vaccination requirements of
105
CMR 150.002(D)(8) and
shall, at no cost to any personnel, provide or arrange for vaccination of all
personnel who cannot provide proof of current immunization against influenza
unless an individual is exempt from vaccination in accordance with
105
CMR
150.002(D)(8)(f).
(f)
Exemptions.
1. Subject to the provisions set forth in
105
CMR 150.002(D)(8)(f)(2), a
facility shall not require an individual to receive an influenza vaccine
pursuant to
105
CMR 150.000(D)(8)(b) or (c)
if the individual declines the vaccine.
2. For any individual subject to the
exemption, a facility shall require such individual take mitigation measures,
consistent with guidance from the Department.
3. An individual who is exempt from
vaccination shall sign a statement certifying that they are exempt from
vaccination and they received information about the risks and benefits of
influenza vaccine.
(g)
Unavailability of Vaccine. A facility shall not be
required to provide or arrange for influenza vaccination during such times the
vaccine is unavailable for purchase, shipment, distribution, or administration
by a third-party or when complying with an order of the Commissioner
restricting the use of the vaccine. A facility shall obtain and administer
influenza vaccine in accordance with
105
CMR 150.002(D)(8) as soon
as vaccine becomes available.
(h)
Documentation.
1. A
facility shall require and maintain for each individual proof of current
vaccination against influenza virus pursuant to
105
CMR 150.008(D)(8)(b) and
(c), or the individual's exemption statement
pursuant to
105
CMR
150.002(D)(8)(f).
2. Each facility shall maintain a central
system to track the vaccination status of all personnel.
3. If a facility is unable to provide or
arrange for influenza vaccination for any individual, it shall document the
reasons such vaccination could not be provided or arranged for.
(i)
Reporting and Data
Collection. Each facility shall report information to the
Department documenting the facility's compliance with the personnel vaccination
requirements of
105
CMR 150.002(D)(8), in
accordance with reporting and data collection guidelines of the
Commissioner.
(j)
105
CMR 150.002(D) establishes
requirements for influenza vaccination of long-term care facility personnel.
Nothing in
105 CMR
150.000 shall be read to prohibit facilities from
establishing policies and procedures for influenza vaccination of personnel
that exceed the requirements set forth in
105
CMR 150.002(D).
(9) A facility may not hire any
individual, whom the facility knows or should have reason to know, who cannot
perform the duties of his or her job or whose employment could pose a threat to
the health, safety or welfare of the residents.
(10) The Department shall be notified as
specified in the guidelines of the department of the resignation or dismissal
of the administrator, the director of nurses and the name and qualifications of
the new employee. In the case of dismissal, notice to the Department shall
state the reasons.
(11)
Requirement for Personnel to Be Vaccinated against Coronavirus
Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2.
(a)
Definitions.
1. For purposes of
105
CMR 150.002(D)(11),
personnel means an individual or individuals who either work at or come to the
licensed facility site and who are employed by or affiliated with the facility,
whether directly, by contract with another entity, or as an independent
contractor, paid or unpaid including, but not limited to, employees, members of
the medical staff, contract employees or staff, students, and volunteers,
whether or not such individual(s) provide direct care.
2. For purposes of
105
CMR 150.002(D)(11), COVID-19
vaccination means being up to date with COVID-19 vaccines as recommended by the
Centers for Disease Control and Prevention (CDC).
3. For purposes of
105
CMR 150.002(D)(11),
mitigation measures mean measures that personnel who are exempt from
vaccination must take to prevent viral infection and transmission.
(b) Each facility shall ensure all
personnel have received COVID-19 vaccination in the timeframe specified in
Department guidelines, unless an individual is exempt from vaccination in
accordance with
105
CMR
150.002(D)(11)(e).
(c) Each facility shall provide all personnel
with information about the risks and benefits of COVID-19
vaccination.
(d) Each facility
shall notify all personnel of the COVID-19 vaccination requirements of
105
CMR 150.002(D)(11) and
shall, at no cost to any personnel, provide or arrange for vaccination of all
personnel who cannot provide proof of current vaccination against COVID-19
unless an individual is exempt from vaccination in accordance with
105
CMR
150.002(D)(11)(e).
(e)
Exemptions.
1. Subject to the provisions set forth in
105
CMR 150.002(D)(11)(e)(2), a
facility shall not require an individual to receive a COVID-19 vaccine pursuant
to 105 CMR 150.002(D)(11)(b)
if the individual declines the
vaccine.
2. For any individual
subject to the exemption, a facility shall require such individual take
mitigation measures, consistent with guidance from the Department.
3. An individual who is exempt from
vaccination shall sign a statement certifying that they are exempt from
vaccination and they received information about the risks and benefits of
COVID-19 vaccine.
(f)
Unavailability of Vaccine. A facility shall not be
required to provide or arrange for COVID-19 vaccination during such times the
vaccine is unavailable for purchase, shipment, distribution, or administration
by a third-party or when complying with an order of the Commissioner
restricting the use of the vaccine. A facility shall obtain and administer
COVID-19 vaccine in accordance with
105
CMR 150.002(D)(11) as soon
as vaccine becomes available.
(g)
Documentation.
1. A
facility shall require and maintain for each individual proof of current
vaccination against COVID-19 virus pursuant to
105
CMR 150.002(D)(11)(b) or
the individual's exemption statement pursuant to
105
CMR
150.002(D)(11)(e).
2. Each facility shall maintain a central
system to track the vaccination status of all personnel.
3. If a facility is unable to provide or
arrange for COVID-19 vaccination for any individual, it shall document the
reasons such vaccination could not be provided or arranged for.
(h)
Reporting and Data
Collection. Each facility shall report information to the
Department documenting the facility's compliance with the personnel vaccination
requirements of
105
CMR 150.002(D)(11) in
accordance with reporting and data collection guidelines of the
Commissioner.
(i)
105
CMR 150.002(D) establishes
requirements for COVID-19 vaccination of long-term care facility personnel.
Nothing in
105 CMR
150.000 shall be read to prohibit facilities from
establishing policies and procedures for COVID-19 vaccination of personnel that
exceed the requirements set forth in
105
CMR 150.002(D).
(E) The administrator shall establish procedures for notifying the resident or the resident's legal representative in the event of significant change in a resident's charges, billings, benefit status and other related administrative matters.
(1) The administrator shall establish
provisions for the safekeeping of personal effects, funds and other property
brought to the facility by residents except, when necessary for the protection
of valuables and to avoid unreasonable responsibility, the administrator may
require such valuables be excluded or removed from the premises.
(2) If the facility assumes the
responsibility for safekeeping of residents' possessions and valuables, an
accurate, written record of all valuables and possessions shall be maintained.
A receipt for all items placed in safekeeping shall be provided to the resident
or resident's guardian.
(3) If the
facility assumes the responsibility for managing a resident's funds, such funds
shall be placed in an insured interest bearing account with the clear written
understanding the facility has only a fiduciary interest in the funds of this
account. The account may be either individual or collective at the election of
the facility and shall be deposited at the prevailing market rate of interest
for deposits in Massachusetts and shall conform to the requirements associated
with the particular account.
(a) Interest
earned by any such funds so deposited shall be credited to each
resident.
(b) For individual
accounts, the interest earned must be prorated to each resident on an actual
interest earned basis.
(c) The
interest earned on any collective account must be prorated to each resident on
the basis of his or her end of quarter or nearest end of the month
balance.
(d) The facility may keep a
portion of a resident's money in a personal needs petty cash fund. The amount
kept in this petty cash fund shall not be greater than the limit set and must
be administered in accordance with the Department of Transitional Assistance.
The personal needs petty cash fund shall not be co-mingled with any operational
petty cash fund the facility may maintain nor shall it be used for facility
operational expenses. A record of money spent for each resident shall be
kept.
(e) No fee or other charges
shall be applied to any individual resident for such managing of funds or
distribution of interest.
(f) The
facility shall provide the resident or the resident's guardian with an
accounting report every three months of financial transactions made in his or
her behalf.
(g) In the event of
discharge of a resident, except if the resident's bed is being held for
anticipated readmission, all funds of that resident shall be returned to the
resident or to the resident's guardian with a written accounting in exchange
for a signed receipt. Funds maintained outside of the facility shall be
returned within ten business days.
(h) In the event of the death of a resident,
the facility shall provide a complete accounting of that resident's funds to
the administrator or executor of the resident's estate.
(4) A statement of all funds, valuables and
possessions shall be prepared on admission, transfer or discharge and shall be
verified, dated and signed by the resident or the resident's guardian and by a
witness. A copy of the list shall be given to the resident, or the resident's
guardian.
(5) The admission of a
resident to a long-term care facility and his or her presence therein shall not
confer on the facility or its owner, administrator, employees or
representatives authority to manage, use or dispose of any property (except
drugs) of such resident without written, signed permission to do so by the
resident or the resident's guardian.
(6) The name, address and the phone number of
the resident's emergency contact shall be kept readily available in the
resident's chart. The designated individual shall be contacted immediately in
an emergency involving the resident. Such notification shall be recorded in
writing in the clinical record.
(F) The administrator shall establish procedures for the notification of the primary care provider and the resident's emergency contact in the event of an emergency.
(G) The administrator shall be responsible for ensuring all required records, reports and other materials are complete, accurate, current and available within the facility and the following requirements are met:
(1) Each facility shall
immediately report to the Department any of the following events occuring on
premises covered by its license:
(a) A death
that is unanticipated, not related to the natural course of the resident's
illness or underlying condition, or is the result of an error or other incident
as specified in the Department's guidelines;
(b) Full or partial evacuation of the
facility;
(c) Fire;
(d) Suicide;
(e) Serious criminal act;
(f) Pending or actual strike action by its
employees, and contingency plans for operation of the facility;
(g) Reportable conditions and illness as
defined in
105 CMR 300.020:
Report of a Disease when such illness is:
1. Believed to be part of a suspected or
confirmed cluster or outbreak;
2.
Believed to be unusual as defined in
105 CMR 300.020:
Unusual Illness; or
3. Related to food consumption or believed to
be transmissible through food; or
(h) Other serious incidents or accidents as
specified in the Department's guidelines.
(2) Each facility shall immediately report to
the Department any suspected instance(s) of resident abuse, neglect,
mistreatment or misappropriation of a resident's personal property, as defined
in
105 CMR 155.000:
Patient and Resident Abuse Prevention, Reporting, Investigation,
Penalties and Registry.
(3) Within seven days of the date of
occurrence of the event, each facility shall report to the Department any other
incident or accident occurring on premises covered by the facility's license
that seriously affects the health or safety of a resident(s) or causes serious
physical injury to a resident(s).
(4) The Department shall establish guidelines
for reporting serious incidents and accidents, including the means of
reporting.
(5) A facility shall
provide the Department with all information that may be relevant to the
Department's investigation of any incident or complaint, regardless of how
reported to the Department.
(6) A
facility shall make all reasonable efforts to facilitate the Department's
attempts to interview all potential witnesses who may have information relevant
to the Department's investigation of any incident or complaint, regardless of
how reported to the Department.
(H) The administrator shall develop and implement policies and procedures governing emergency transport. Such policies and procedures shall include criteria for deciding whether to call the emergency telephone access number 911 or its local equivalent, or a contracted private ambulance service provider, if any, in response to an emergency medical condition. The criteria for determining whether to call 911 versus the contracted provider shall address such factors as the nature of the emergency medical condition, and the time to scene arrival specified in relevant agreements with the contracted provider, if any.
(I) The administrator of a nursing facility shall ensure the facility has an automated external defibrillator and policies and procedures for the rendering of automated external defibrillation in the facility.
(1) All persons certified to provide
automated external defibrillation shall:
(a)
successfully complete a course in cardiopulmonary resuscitation and in the use
of an automated external defibrillator that meets or exceeds the standards
established by the American Heart Association or the American National Red
Cross; and
(b) have evidence that
course completion is current and not expired.
(2) The facility shall contract with or
employ a physician who shall be the automated external defibrillation medical
director for the facility who shall oversee and coordinate the following:
(a) maintenance and testing of equipment in
accordance with manufacturer's guidelines;
(b) certification and training of facility
personnel;
(c) periodic performance
review of the facility automated external defibrillation activity;
(d) development of policies and procedures
consistent with current medical practice regarding the use of automated
external defibrillators.
(J) Upon change of ownership, the medications, funds and personal belongings of all residents shall be checked and identified by the licensee and the new owner. A complete count of controlled substances under the federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be made, recorded and signed by the licensee and the new owner.
(K) The facility shall provide Resident survey reports, annual reports and such other reports and information as may be required to the Department in the manner and within the time period prescribed.
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