Current through September 17, 2024
These requirements pertain to all applicants and licensees
governed by Neb. Rev. Stat. §§
71-401 to
71-475.
005.01
NOTIFICATIONS. An applicant or licensee must notify
the Department electronically, in writing, or via facsimile of the following:
(A) At least 30 calendar days before a
facility or service is sold, leased, discontinued, or moved to a new
location;
(B) A change in the use,
location of beds, or both;
(C) At
least 30 calendar days prior to the date the facility or service would like to:
(i) Increase the number of beds for which the
facility or service is currently licensed;
(ii) Change the usage of beds or rooms;
or
(iii) Change the type of
services provided;
(D)
To request a single license document;
(E) To request simultaneous facility or
service licensure inspections for all types of licensure held or
sought;
(F) Prior to the start of
the construction process if a facility is having construction done;
and
(G) Within 24 hours of the
following:
(i) When the licensee has reason to
believe abuse, neglect or exploitation of a consumer has occurred;
(ii) When the death of a consumer at the
facility or service occurred due to:
(1)
Suicide;
(2) A violent
act;
(3) Drowning; or
(4) The use of restraint or seclusion;
and
(iii) When a
consumer who needs supervision, leaves a facility or service without staff
knowledge.
(iv) A fire in the
facility or service; or
(v) Any
natural disaster or accident resulting in damage to the physical plant which
has a direct or immediate effect on a consumer in the facility or service.
Notification must include the steps included to assure the consumer's
safety.
005.02
CAPACITY AND
USAGE. The licensee must ensure:
(A) When providing beds for the consumer, the
licensee must not utilize more beds than are licensed and approved by the
Department and must not exceed the maxi-mum occupancy approval of the State
Fire Marshal or their delegated authority; and
(B) The total number of consumers receiving
care, treatment or services at one time from the facility or service must not
exceed the licensed capacity approved by the Department and must not exceed the
maximum occupancy approval of the State Fire Marshal or their delegated
authority.
005.03
PUBLIC INFORMATION. The licensee must make licenses,
the most recent inspection reports, and any disciplinary action notices that
are currently in effect, if any, available for public inspection upon request.
All facility or service licenses must be displayed on the licensed
premises.
005.04
COMPLAINTS AND GRIEVANCES. A licensee must establish,
implement and revise as necessary, written policies and procedures to promptly
address complaints or grievances filed verbally or in writing. The policies and
procedures must include:
(A) Information
regarding how the consumer or designee may submit a complaint or
grievance;
(B) Timeframes for
investigative review and for a response to the consumer or designee;
(C) How the licensee will utilize information
from complaints and grievances to improve the quality of care and treatment
provided; and
(D) How the licensee
will maintain records of complaints and grievances received, actions taken and
resolution.
005.05
QUALITY ASSURANCE AND IMPROVEMENT. The licensee must
have a quality assurance and improvement program to collect data and assess
care and treatment provided to the consumer, both concurrently and
retrospectively. The program must include involvement by all disciplines.
Results must be recorded quarterly and reported to the licensee's governing
authority or licensee annually. The program must address:
(A) Goals and objectives;
(B) How problems or issues to be addressed
will be identified;
(C) How
recommended changes or actions will be identified;
(D) How recommendations will be
implemented;
(E) How changes made
will be monitored for effectiveness;
(F) A plan to review and revise actions,
policies and recommendations as necessary; and
(G) Identification, by job title, of the
person responsible for the effectiveness of the program.
005.06
INFECTION
CONTROL. The licensee must have an infection control program to
minimize sources and transmissions of infections and communicable diseases. The
program must address:
(A) How the licensee
will identify, report, investigate and control infections;
(B) How trends will be tracked and
identified;
(C) How treatment of
any infections or communicable diseases will be monitored for appropriateness
and for alteration of treatment when necessary;
(D) Hand hygiene techniques and how the
licensee will ensure compliance;
(E) Use of safe work practices and personal
protective equipment;
(F) Handling,
cleaning, and disinfection of equipment, supplies and linens used to provide
care and treatment to the consumer;
(G) How the licensee will educate staff,
volunteers, and the consumer regarding infections, modes of transmission,
hygienic practices, and methods of infection prevention; and
(H) Identification of the person, by job
title, who is responsible for the effectiveness of the overall
program.
005.07
DISASTER PREPAREDNESS AND MANAGEMENT. The licensee
must have a disaster preparedness program to ensure the safety, well-being and
continuity of care and treatment for the consumer, visitors and staff during
natural or other disasters, disease outbreaks, or other similar situations. The
program must address:
(A) How consumer
identification will be maintained;
(B) How communication will be
maintained;
(C) How consumers,
staff and visitors will be moved or relocated to points of safety;
(D) How consumers, staff and visitors will be
protected from the threat of exposure, ingestion, absorption, or inhalation of
hazardous substances or materials;
(E) How food, water, medicine, medical
supplies and other necessary items will continue to be provided to the
consumer, staff and visitors;
(F)
How the consumer will be provided with necessary care and treatment;
and
(G) How the facility will
educate staff, visitors and consumers on the disaster preparedness
plans.
005.08
COMMUNICATION. Each licensee must implement
interventions to ensure communication with consumers or their designee occurs
in a manner and format the consumer or designee can understand.
