Current through April 3, 2024
(1) Performance
Improvement.
(a) The nursing home must ensure
that there is an effective, facility-wide performance improvement program to
evaluate resident care and performance of the organization.
(b) The performance improvement program must
be ongoing and have a written plan of implementation which assures that:
1. All organized services related to resident
care, including services furnished by a contractor, are evaluated;
2. Nosocomial infections and medication
therapy are evaluated;
3. All
services performed in the facility are evaluated as to the appropriateness of
diagnosis and treatment; and
4. The
facility shall develop and implement a system for measuring improvements in
adherence to the hand hygiene program and influenza vaccination
program.
(c) The nursing
home must have an ongoing plan, consistent with available community and
facility resources, to provide or make available services that meet the
medically-related needs of its residents.
(d) The facility must develop and implement
plans for improvement to address deficiencies identified by the performance
improvement program and must document the outcome of the remedial
action.
(e) Performance improvement
program records are not disclosable, except when such disclosure is required to
demonstrate compliance with this section.
(f) Good faith attempts by the performance
improvement program committee to identify and correct deficiencies will not be
used as a basis for sanctions.
(2) Physician Services.
(a) Policies and procedures concerning
services provided by the nursing home shall be available for the admitting
physicians.
(b) Residents shall be
aided in receiving dental care as deemed necessary.
(c) Each nursing home shall retain by written
agreement a physician to serve as a Medical Director.
(d) The Medical Director shall be responsible
for the medical care in the nursing home. The Medical Director shall:
1. Delineate the responsibilities of and
communicate with attending physicians to ensure that each resident receives
medical care;
2. Ensure the
delivery of emergency and medical care when the resident's attending physician
or his/her designated alternate is unavailable;
3. Review reports of all accidents or unusual
incidents occurring on the premises, identifying hazards to health and safety
and recommending corrective action to the administrator;
4. Make periodic visits to the nursing home
to evaluate the existing conditions and make recommendations for
improvements;
5. Review and take
appropriate action on reports from the Director of Nursing regarding
significant clinical developments;
6. Monitor the health status of nursing home
personnel to ensure that no health conditions exist which would adversely
affect residents; and,
7. Advise
and provide consultation on matters regarding medical care, standards of care,
surveillance and infection control.
(3) Infection Control.
(a) The nursing home must provide a sanitary
environment to avoid sources and transmission of infections and communicable
diseases. There must be an active program for the prevention, control, and
investigation of infections and communicable diseases.
(b) The physical environment shall be
maintained in such a manner to assure the safety and well being of the
residents.
1. Any condition on the nursing
home site conducive to the harboring or breeding of insects, rodents or other
vermin shall be prohibited. Chemical substances of a poisonous nature used to
control or eliminate vermin shall be properly identified. Such substances shall
not be stored with or near food or medications.
2. Cats, dogs or other animals shall not be
allowed in any part of the facility except for specially trained animals for
the handicapped and except as addressed by facility policy for pet therapy
programs. The facility shall designate in its policies and procedures those
areas where animals will be excluded. The areas designated shall be determined
based upon an assessment of the facility performed by medically trained
personnel.
3. Telephones shall be
readily accessible and at least one (1) shall be equipped with sound
amplification and shall be accessible to wheelchair residents.
4. Equipment and supplies for physical
examination and emergency treatment of residents shall be available.
5. A bed complete with mattress and pillow
shall be provided. In addition, resident units shall be provided with at least
one chair, a bedside table, an over bed tray and adequate storage space for
toilet articles, clothing and personal belongings.
6. Individual wash cloths, towels and bed
linens must be provided for each resident. Linen shall not be interchanged from
resident to resident until it has been properly laundered.
7. Bath basin water service, emesis basin,
bedpan and urinal shall be individually provided.
8. Water pitchers, glasses, thermometers,
emesis basins, douche apparatus, enema apparatus, urinals, mouthwash cups,
bedpans and similar items of equipment coming into intimate contact with
residents shall be disinfected or sterilized after each use unless individual
equipment for each is provided and then sterilized or disinfected between
residents and as often as necessary to maintain them in a clean and sanitary
condition. Single use, resident disposable items are acceptable but shall not
be reused.
9. The facility shall
have written policies and procedures governing care of residents during the
failure of the air conditioning, heating or ventilation system, including plans
for hypothermia and hyperthermia. When the temperature of any resident area
falls below 65°F or exceeds 85°F, or is reasonably expected to do so,
the facility shall be alerted to the potential danger, and the department shall
be notified.
(c) The
administrator shall assure that an infection control program including members
of the medical staff, nursing staff and administrative staff develop guidelines
and techniques for the prevention, surveillance, control and reporting of
facility infections. Duties of the program shall include the establishment of:
1. Written infection control
policies;
2. Techniques and systems
for identifying, reporting, investigating and controlling infections in the
facility;
3. Written procedures
governing the use of aseptic techniques and procedures in the
facility;
4. Written procedures
concerning food handling, laundry practices, disposal of environmental and
resident wastes, traffic control and visiting rules, sources of air pollution,
and routine culturing of autoclaves and sterilizers;
5. A log of incidents related to infectious
and communicable diseases;
6.
Formal provisions to educate and orient all appropriate personnel in the
practice of aseptic techniques such as handwashing, proper grooming, masking,
dressing care techniques, disinfecting and sterilizing techniques, and the
handling and storage of resident care equipment and supplies; and,
7. Continuing education for all facility
personnel on the cause, effect, transmission, prevention, and elimination of
infections.
(d) The
administrator, the medical staff and director of nursing services must ensure
that the facility-wide performance improvement program and training programs
address problems identified by the infection control program and must be
responsible for the implementation of successful corrective action plans in
affected problem areas.
(e) The
facility shall develop policies and procedures for testing a resident's blood
for the presence of the hepatitis B virus and the HIV virus in the event that
an employee of the facility, a student studying at the facility, or other
health care provider rendering services at the facility is exposed to a
resident's blood or other body fluid. The testing shall be performed at no
charge to the resident, and the test results shall be confidential.
(f) The facility and its employees shall
adopt and utilize standard precautions (per CDC) for preventing transmission of
infections, HIV, and communicable diseases, including adherence to a hand
hygiene program which shall include:
1. Use of
alcohol-based hand rubs or use of non-antimicrobial or antimicrobial soap and
water before and after each patient contact if hands are not visibly
soiled;
2. Use of gloves during
each patient contact with blood or where other potentially infectious
materials, mucous membranes, and non-intact skin could occur and gloves changed
before and after each patient contact;
3. Use of either a non-antimicrobial soap and
water or an antimicrobial soap and water for visibly soiled hands;
and
4. Health care worker education
programs which may include:
(i) Types of
patient care activities that can result in hand contamination;
(ii) Advantages and disadvantages of various
methods used to clean hands;
(iii)
Potential risks of health care workers' colonization or infection caused by
organisms acquired from patients; and
(iv) Morbidity, mortality, and costs
associated with health care associated infections.
(g) All nursing homes shall adopt
appropriate policies regarding the testing of residents and staff for HIV and
any other identified causative agent of acquired immune deficiency
syndrome.
(h) The facility shall
document evidence of annual vaccination against influenza for each resident, in
accordance with the recommendations of the Advisory Committee on Immunization
Practices of the Centers for Disease Control most recent to the time of the
vaccine. Influenza vaccination is medically contraindicated or the resident has
refused the vaccine. Influenza vaccination for all residents accepting the
vaccine shall be completed by November 30 of each year or within ten (10) days
of the vaccine becoming available. Residents admitted after this date during
the flu season and up to February 1, shall as medically appropriate, receive
influenza vaccination prior to or on admission unless refused by the resident.
The facility shall document evidence of vaccination against
pneumococcal disease for all residents who are 65 years of age or older, in
accordance with the recommendation of the Advisory Committee on Immunization
Practices of the Centers for Disease Control at the time of vaccination, unless
such vaccination is medically contraindicated or the resident has refused offer
of the vaccine. The facility shall provide or arrange the pneumococcal
vaccination of residents who have not received this immunization prior to or on
admission unless the resident refuses offer of the vaccine.
(i) A Nursing Home shall have an annual
influenza vaccination program which shall include at least:
1. The offer of influenza vaccination to all
staff and independent practitioners at no cost to the person or acceptance of
documented evidence of vaccination from another vaccine source or facility. The
Nursing Home will encourage all staff and independent practitioners to obtain
an influenza vaccination;
2. A
signed declination statement on record from all who refuse the influenza
vaccination for reasons other than medical contraindications (a sample form is
available at http://tennessee.gov/health/topic/hcf-provider);
3. Education of all employees about the
following:
(i) Flu vaccination,
(ii) Non-vaccine control measures,
and
(iii) The diagnosis,
transmission, and potential impact of influenza;
4. An annual evaluation of the influenza
vaccination program and reasons for nonparticipation; and
5. A statement that the requirements to
complete vaccinations or declination statements shall be suspended by the
administrator in the event of a vaccine shortage as declared by the
Commissioner or the Commissioner's designee.
(j) Precautions shall be taken to prevent the
contamination of sterile supplies by soiled supplies. Sterile supplies shall be
packaged and stored in a manner that protects the sterility of the contents.
Decontamination and preparation areas shall be separated.
(k) Space and facilities for housekeeping
equipment and supply storage shall be provided in each service area. Storage
for bulk supplies and equipment shall be located away from patient care areas.
The building shall be kept in good repair, clean, sanitary and safe at all
times.
(l) The facility shall
appoint a housekeeping supervisor who shall be responsible for:
1. Organizing and coordinating the facility's
housekeeping service;
2. Acquiring
and storing sufficient housekeeping supplies and equipment for facility
maintenance; and,
3. Assuring the
clean and sanitary condition of the facility to provide a safe and hygienic
environment for residents and staff. Cleaning shall be accomplished in
accordance with the infection control rules herein and facility
policy.
(m) Laundry
facilities located in the nursing home shall:
1. Be equipped with an area for receiving,
processing, storing and distributing clean linen;
2. Be located in an area that does not
require transportation for storage of soiled or contaminated linen through food
preparation, storage or dining areas;
3. Provide space for storage of clean linen
within nursing units and for bulk storage within clean areas of the facility;
and,
4. Provide carts, bags or
other acceptable containers appropriately marked to identify those used for
soiled linen and those used for clean linen to prevent dual utilization of the
equipment and cross contamination.
(n) The facility shall name an individual who
is responsible for laundry service. This individual shall be responsible for:
1. Establishing a laundry service, either
within the nursing home or by contract, that provides the facility with
sufficient clean, sanitary linen at all times;
2. Knowing and enforcing infection control
rules and regulations for the laundry service;
3. Assuring the collection, packaging,
transportation and storage of soiled, contaminated, and clean linen is in
accordance with all applicable infection control rules and procedures;
and,
4. Assuring that a contract
laundry service complies with all applicable infection control rules and
procedures.
(4)
Nursing Services.
(a) Each nursing home must
have an organized nursing service that provides twenty-four (24) hour nursing
services furnished or supervised by a registered nurse. Each home shall have a
licensed practical nurse or registered nurse on duty at all times and at least
two (2) nursing personnel on duty each shift.
(b) The facility must have a well-organized
nursing service with a plan of administrative authority and delineation of
responsibilities for resident care. The Director of Nursing (DON) must be a
licensed registered nurse who has no current disciplinary actions against
his/her license. The DON is responsible for the operation of the service,
including determining the types and numbers of nursing personnel and staff
necessary to provide nursing care for all areas of the facility.
(c) The Director of Nursing shall have the
following responsibilities:
1. Develop,
maintain and periodically update:
(i) Nursing
service objectives and standards of practice;
(ii) Nursing service policy and procedure
manuals;
(iii) Written job
descriptions for each level of nursing personnel;
(iv) Methods for coordination of nursing
service with other resident services; and,
(v) Mechanisms for monitoring quality of
nursing care, including the periodic review of medical records.
2. Participate in selecting
prospective residents in terms of the nursing services they need and nursing
competencies available.
3. Make
daily rounds to see residents.
4.
Notify the resident's physician when medically indicated.
5. Review each resident's medications
periodically and notify the physician where changes are indicated.
6. Supervise the administration of
medications.
7. Supervise
assignments of the nursing staff for the direct care of all
residents.
8. Plan, develop and
conduct monthly in-service education programs for nursing personnel and other
employees of the nursing home where indicated. An organized orientation program
shall be developed and implemented for all nursing personnel.
9. Supervise and coordinate the feeding of
all residents who need assistance.
10. Coordinate the dietary requirements of
residents with the staff responsible for the dietary service.
11. Coordinate housekeeping
personnel.
12. Assure that
discharge planning is initiated in a timely manner.
13. Assure that residents, along with their
necessary medical information, are transferred or referred to appropriate
facilities, agencies or outpatient services, as needed, for follow-up or
ancillary care.
(d) The
nursing service must have adequate numbers of licensed registered nurses,
licensed practical nurses, and certified nurse aides to provide nursing care to
all residents as needed. Nursing homes shall provide a minimum of two (2) hours
of direct care to each resident every day including 0.4 hours of licensed
nursing personnel time. There must be supervisory and staff personnel for each
department or nursing unit to ensure, when needed, the availability of a
licensed nurse for bedside care of any resident.
(e) A registered nurse must supervise and
evaluate the nursing care for each resident.
(f) The facility must ensure that an
appropriate individualized plan of care is prepared for each resident with
input from appropriate disciplines, the resident and/or the resident's family
or the resident's representative.
(g) A registered nurse must assign the
nursing care of each resident to other nursing personnel in accordance with the
resident's needs and the specialized qualifications and competence of the
nursing staff available.
(h)
Non-employee licensed nurses who are working in the nursing home must adhere to
the policies and procedures of the facility. The director of the nursing
service must provide for the adequate supervision and evaluation of the
clinical activities of nonemployee nursing personnel which occur within the
responsibility of the nursing service.
(i) All drugs, devices and related materials
must be administered by, or under the supervision of, nursing or other
personnel in accordance with federal and state laws and regulations, including
applicable licensing requirements, and in accordance with the approved medical
staff policies and procedures.
(j)
There must be a facility procedure for reporting adverse drug reactions and
errors in administration of drugs.
(k) When non-employees are utilized as
sitters or attendants, they shall be under the authority of the nursing service
and their duties shall be set forth clearly in written nursing service
policies.
(l) Each resident shall
be given proper personal attention and care of skin, feet, nails and oral
hygiene in addition to the specific professional nursing care as ordered by the
resident's physician.
(m)
Medications, treatments, and diet shall be carried out as prescribed to
safeguard the resident, to minimize discomfort and to attain the physician's
objective.
(n) Residents shall have
baths or showers at least two (2) times each week, or more often if requested
by the resident.
(o) Body position
of residents in bed or chair bound shall be changed at least every two (2)
hours, day and night, while maintaining good body alignment. Proper skin care
shall be provided for bony prominences and weight bearing parts to prevent
discomfort and the development of pressure areas, unless contraindicated by
physician's orders.
(p) Residents
who are incontinent shall have partial baths each time the bed or bed clothing
has been wet or soiled. The soiled or wet bed linen and the bed clothing shall
be replaced with clean, dry linen and clothing immediately after being
soiled.
(q) Residents shall have
shampoos, haircuts and shaves as needed, or desired.
(r) Rehabilitation measures such as assisting
patients with range of motion, prescribed exercises and bowel and bladder
retraining programs shall be carried out according to the individual needs and
abilities of the resident.
(s)
Residents shall be active and out of bed except when contraindicated by written
physician's orders.
(t) Residents
shall be encouraged to achieve independence in activities of daily living,
self-care, and ambulation as a part of daily care.
(u) Residents shall have clean clothing as
needed and shall be kept free from odor.
(v) Residents' weights shall be taken and
recorded at least monthly unless contraindicated by a physician's
order.
(w) Physical restraints
shall be checked every thirty (30) minutes and released every two (2) hours so
the resident may be exercised and offered toilet access.
(x) Restraints may be applied or administered
to residents only on the signed order of a physician. The signed physician's
order must be for a specified and limited period of time and must document the
necessity of the restraint. There shall be no standing orders for
restraints.
(y) When a resident's
safety or safety of others is in jeopardy, the nurse in charge shall use
his/her judgment to use physical restraints if a physician's order cannot be
immediately obtained. A written order must be obtained as soon as
possible.
(z) Locked restraints are
prohibited.
(aa) Assistance with
eating shall be given to the resident as needed in order for the resident to
receive the diet for good health care.
(bb) Abnormal food intake will be evaluated
and recorded.
(cc) A registered
nurse may make the actual determination and pronouncement of death under the
following circumstances:
1. The deceased was a
resident of a nursing home;
2. The
death was anticipated, and the attending physician or nursing home medical
director has agreed in writing to sign the death certificate. Such agreement by
the attending physician or nursing home medical director must be present with
the deceased at the place of death;
3. The nurse is licensed by the state;
and,
4. The nurse is employed by
the nursing home in which the deceased resided.
(5) Medical Records.
(a) The nursing home shall comply with the
Tennessee Medical Records Act, T.C.A. §§
68-11-301, et seq.
(b) The nursing home must maintain a medical
record for each resident. Medical records must be accurate, promptly completed,
properly filed and retained, and accessible. The facility must use a system of
author identification and record maintenance that ensures the integrity of the
authentication and protects the security of all record entries.
(c) All medical records, in either written,
electronic, graphic or otherwise acceptable form, must be retained in their
original or legally reproduced form for a minimum period of at least ten (10)
years after which such records may be destroyed. However, in cases of residents
under mental disability or minority, their complete facility records shall be
retained for the period of minority or known mental disability, plus one (1)
year, or ten (10) years following the discharge of the resident, whichever is
longer. Records destruction shall be accomplished by burning, shredding or
other effective method in keeping with the confidential nature of the contents.
The destruction of records must be made in the ordinary course of business,
must be documented and in accordance with the facility's policies and
procedures, and no record may be destroyed on an individual basis.
(d) When a nursing home closes with no plans
of reopening, an authorized representative of the facility may request final
storage or disposition of the facility's medical records by the department.
Upon transfer to the department, the facility relinquishes all control over
final storage of the records and the files shall become property of the State
of Tennessee.
(e) The nursing home
must have a system of coding and indexing medical records. The system must
allow for timely retrieval by diagnosis and procedure.
(f) The nursing home must have a procedure
for ensuring the confidentiality of resident records. Information from or
copies of records may be released only to authorized individuals, and the
facility must ensure that unauthorized individuals cannot gain access to or
alter resident records. Original medical records must be released by the
facility only in accordance with federal and state laws, court orders or
subpoenas.
(g) The medical record
must contain information to justify admission, support the diagnosis, and
describe the resident's progress and response to medications and
services.
(h) All entries must be
legible, complete, dated and authenticated according to facility
policy.
(i) All records must
document the following:
1. Evidence of a
physical examination, including a health history, performed no more than thirty
(30) days prior to admission or within forty-eight (48) hours following
admission;
2. Admitting
diagnosis;
3. A dietary history as
part of each resident's admission record;
4. Results of all consultative evaluations of
the resident and appropriate findings by clinical and other staff involved in
the care of the resident;
5.
Documentation of complications, facility acquired infections, and unfavorable
reactions to drugs;
6. Properly
executed informed consent forms for procedures and treatments specified by
facility policy, or by federal or state law if applicable, as requiring written
resident consent;
7. All
practitioners' orders, nursing notes, reports of treatment, medication records,
radiology and laboratory reports, and vital signs and other information
necessary to monitor the resident's condition;
8. Discharge summary with disposition of case
and plan for follow-up care; and,
9. Final diagnosis with completion of medical
records within thirty (30) days following discharge.
(j) Electronic and computer-generated records
and signature entries are acceptable.
(6) Pharmaceutical Services.
(a) The nursing home shall have
pharmaceutical services that meet the needs of the residents and are in
accordance with the Tennessee Board of Pharmacy statutes and rules. The medical
staff is responsible for developing policies and procedures that minimize drug
errors.
(b) All internal and
external medications and preparations intended for human use shall be stored
separately. They shall be properly stored in medicine compartments, including
cabinets on wheels, or drug rooms. Such cabinets or drug rooms shall be kept
securely locked when not in use, and the key must be in the possession of the
supervising nurse or other authorized persons. Poisons or external medications
shall not be stored in the same compartment and shall be labeled as
such.
(c) Schedule II drugs must be
stored behind two (2) separately locked doors at all times and accessible only
to persons in charge of administering medication.
(d) Every nursing home shall comply with all
state and federal regulations governing Schedule II drugs.
(e) A notation shall be made in a Schedule II
drug book and in the resident's nursing notes each time a Schedule II drug is
given. The notation shall include the name of the resident receiving the drug,
name of the drug, the dosage given, the method of administration, the date and
time given and the name of the physician prescribing the drug.
(f) All oral orders shall be immediately
recorded, designated as such and signed by the person receiving them and
countersigned by the physician within ten (10) days.
(g) All orders for drugs, devices and related
materials must be in writing and signed by the practitioner or practitioners
responsible for the care of the resident. Electronic and computer-generated
records and signature entries are acceptable. When telephone or oral orders
must be used, they shall be:
1. Accepted only
by personnel that are authorized to do so by the medical staff policies and
procedures, consistent with federal and state law; and,
2. Signed or initialed by the prescribing
practitioner according to nursing home policy.
(h) Medications not specifically limited as
to time or number of doses when ordered are controlled by automatic stop orders
or other methods in accordance with written policies. No Schedule II drug shall
be given or continued beyond seventy-two (72) hours without a written order by
the physician.
(i) Medication
administration records (MAR) shall be checked against the physician's orders.
Each dose shall be properly recorded in the clinical record after it has been
administered.
(j) Preparation of
doses for more than one scheduled administration time shall not be
permitted.
(k) Medication shall be
administered only by licensed medical or licensed nursing personnel or other
licensed health professionals acting within the scope of their
licenses.
(l) Unless the unit dose
package system is used, individual prescriptions of drugs shall be kept in the
original container with the original label intact showing the name of the
resident, the drug, the physician, the prescription number and the date
dispensed.
(m) Legend drugs shall
be dispensed by a licensed pharmacist.
(n) Nursing homes may participate in drug
donation repository programs as defined in Title 63, Chapter 10 and may use
such programs for drug disposal services. The facility's participation in a
drug donation repository program shall be outlined in the facility's policies
and procedures.
(o) Alternatively,
if a nursing home declines to participate in the drug donation repository
program or in the case of drugs not acceptable under the program, any unused
portions of prescription drugs shall be turned over to the resident only on a
written order by the physician. If not turned over to the resident, such unused
drugs left in a nursing home must be destroyed on the premises by a licensed
nurse and a witness. The facility's policies and procedures shall outline
person(s) who may serve as a witness and methodology. The facility's policies
and procedures must be in compliance with applicable DEA regulations.
(7) Radiology Services. The
nursing home must maintain or have available diagnostic radiologic services
according to the needs of the residents. If therapeutic services are also
provided, they, as well as the diagnostic services, must meet professionally
approved standards for safety and personnel qualifications.
(8) Laboratory Services. The nursing home
must maintain or have available, either directly or through a contractual
agreement, adequate laboratory services to meet the needs of the residents. The
nursing home must ensure that all laboratory services provided to its residents
are performed in a facility licensed in accordance with the Tennessee Medical
Laboratory Act (TMLA). All technical laboratory staff shall be licensed in
accordance with the TMLA and shall be qualified by education, training and
experience for the type of services rendered.
(9) Food and Dietetic Services.
(a) The nursing home must have organized
dietary services that are directed and staffed by adequate qualified personnel.
A facility may contract with an outside food management company if the company
has a dietitian who serves the facility on a fulltime, part-time, or consultant
basis, and if the company maintains at least the minimum standards specified in
this paragraph and provides for constant liaison with the facility medical
staff for recommendations on dietetic policies affecting resident treatment. If
an outside contract is utilized for management of its dietary services, the
facility shall designate a full-time employee to be responsible for the overall
management of the services.
(b) The
nursing home must designate a person, either directly or by contractual
agreement, to serve as the food and dietetic services director with
responsibility for the daily management of the dietary services. The food and
dietetic services director shall be:
1. A
qualified dietitian; or,
2. A
graduate of a dietetic technician or dietetic assistant training program,
correspondence or classroom, approved by the American Dietetic Association;
or,
3. An individual who has
successfully completed in-person or online coursework that provided ninety (90)
or more hours of classroom instruction in food service supervision. If the
course has not been completed, this person shall be enrolled in a course and
making satisfactory progress for completion within the time limit specified by
the course requirement; or,
4. An
individual who is a certified dietary manager (CDM), or certified food
protection professional (CFPP); or,
5. A current or former member of the U.S.
military who has graduated from an approved military dietary manager training
program.
(c) There must
be a qualified dietitian, full time, part-time, or on a consultant basis, who
is responsible for the development and implementation of a nutrition care
process to meet the needs of residents for health maintenance, disease
prevention and, when necessary, medical nutrition therapy to treat an illness,
injury or condition. Medical nutrition therapy includes assessment of the
nutritional status of the resident and treatment through diet therapy,
counseling and/or use of specialized nutrition supplements.
(d) Menus must meet the needs of the
residents.
1. Therapeutic diets must be
prescribed by the practitioner or practitioners responsible for the care of the
residents and must be prepared and served as prescribed.
2. Special diets shall be prepared and served
as ordered.
3. Nutritional needs
must be met in accordance with recognized dietary practices and in accordance
with orders of the practitioner or practitioners responsible for the care of
the residents.
4. A current
therapeutic diet manual approved by the dietitian and medical staff must be
readily available to all medical, nursing, and food service
personnel.
(e) Education
programs, including orientation, on-the-job training, inservice education, and
continuing education shall be offered to dietetic services personnel on a
regular basis.
Programs shall include instruction in the use of equipment,
personal hygiene, proper inspection, and the handling, preparing and serving of
food.
(f) A minimum of three
(3) meals in each twenty-four (24) hour period shall be served. A supplemental
night meal shall be served if more than fourteen (14) hours lapse between
supper and breakfast. Additional nourishments shall be provided to patients
with special dietary needs. A minimum of three (3) days supply of food shall be
on hand.
(g) Menus shall be
prepared at least one week in advance. A dietitian shall be consulted to help
write and plan the menus. If any change in the actual food served is necessary,
the change shall be made on the menu to designate the foods actually served to
the residents. Menus of food served shall be kept on file for a thirty (30) day
period.
(h) The dietitian or
designee shall have a conference, dated on the medical chart, with each
resident and/or family within two (2) weeks of admission to discuss the diet
plan indicated by the physician. The resident's dietary preferences shall be
recorded and utilized in planning his/her daily menu.
(i) Food shall be protected from dust, flies,
rodents, unnecessary handling, droplet infection, overhead leakage and other
sources of contamination whether in storage or while being prepared and served
and/or transported through hallways.
(j) Perishable food shall not be allowed to
stand at room temperature except during necessary periods of preparation or
serving. Prepared foods shall be kept hot (140°F or above) or cold
(45°F or less). Appropriate equipment for temperature maintenance, such as
hot and cold serving units or insulated containers, shall be used.
(k) All nursing homes shall have commercial
automatic dishwashers approved by the National Sanitation Foundation.
Dishwashing machines shall be used according to manufacturer
specifications.
(l) All dishes,
glassware and utensils used in the preparation and serving of food and drink
shall be cleaned and sanitized after each use.
(m) The cleaning and sanitizing of handwashed
dishes shall be accomplished by using a three-compartment sink according to the
current "U.S. Public Health Service Sanitation Manual".
(n) The kitchen shall contain sufficient
refrigeration equipment and space for the storage of perishable
foods.
(o) All refrigerators and
freezers shall have thermometers. Refrigerators shall be kept at a temperature
not to exceed 45°F. Freezers shall be kept at a temperature not to exceed
0°F.
(p) Written policies and
procedures shall be followed concerning the scope of food services in
accordance with the current edition of the "U.S. Public Health Service
Recommended Ordinance and Code Regulating Eating and Drinking Establishments"
and the current "U.S. Public Health Service Sanitation Manual" should be used
as a guide to food sanitation.
(10) Social Work Services.
(a) Social services must be available to the
resident, the resident's family and other persons significant to the resident,
in order to facilitate adjustment of these individuals to the impact of illness
and to promote maximum benefits from the health care services
provided.
(b) Social work services
shall include psychosocial assessment, counseling, coordination of discharge
planning, community liaison services, financial assistance and
consultation.
(c) A resident's
social history shall be obtained within two (2) weeks of admission and shall be
appropriately maintained.
(d)
Social work services shall be provided by a qualified social worker.
(e) Facilities for social work services shall
be readily accessible and shall permit privacy for interviews and
counseling.
(11)
Physical, Occupational and Speech Therapy Services.
(a) Physical therapy, occupational therapy
and speech therapy shall be provided directly or through contractual agreement
by individuals who meet the qualifications specified by nursing home policy,
consistent with state law.
(b)
Speech therapy services shall be provided only by or under supervision of a
qualified speech language pathologist in good standing, or by a person
qualified as a Clinical Fellow subject to Tennessee Board of Communications
Disorders and Sciences Rule
1370-01-.10.
(c) A licensed physical therapist shall be in
charge of the physical therapy service and a licensed occupational therapist
shall be in charge of the occupational therapy service.
(d) Direct contact shall exist between the
resident and the therapist for those residents that require treatment ordered
by a physician.
(e) The physical
therapist and occupational therapist, pursuant to a physician order, shall
provide treatment and training designed to preserve and improve abilities for
independent functions, such as: range of motion, strength, tolerance,
coordination and activities of daily living.
(f) Therapy services shall be coordinated
with the nursing service and made a part of the resident care plan.
(g) Sufficient staff shall be made available
to provide the service offered.
(12) Ventilator Services. A nursing home that
provides ventilator services shall meet or exceed the following minimum
standards by:
(a) Ensuring a licensed
respiratory care practitioner as defined by Tennessee Code Annotated Section
63-27-102(7),
shall be physically present at the facility twenty four (24) hours per day,
seven (7) days per week to provide:
1.
Ventilator care;
2. Administration
of medical gases;
3. Administration
of aerosol medications; and
4.
Diagnostic testing and monitoring of life support systems;
(b) Ensuring that an appropriate,
individualized plan of care is prepared for each patient requiring ventilator
services. The plan of care shall be developed with input and participation from
a pulmonologist or a physician with experience in ventilator care;
(c) Ensuring that admissions criteria is
established to ensure the medical stability of ventilator-dependent patients
prior to transfer from an acute care setting;
(d) Ensuring that Arterial Blood Gas (ABG) is
readily available in order to document the patient's acid base status and/or
End Tidal Carbon Dioxide (etCOs) and whether continuous pulse oximetry
measurements should be performed in lieu of ABG studies;
(e) Ensuring that an audible, redundant
external alarm system is located outside of each ventilator-dependent patient's
room for the purpose of alerting caregivers of patient disconnection,
ventilator disconnection or ventilator failure;
(f) Ensuring that the nursing home is
equipped with emergency suction equipment and an adequate number of Ambu bags
for manual ventilation;
(g)
Ensuring that ventilator equipment is connected to electrical outlets connected
to backup generator power;
(h)
Ensuring that ventilators are equipped with battery back-up systems;
(i) Ensuring that the nursing home is
equipped to employ the use of current ventilator technology consistent with
meeting patients' needs for mobility and comfort; and
(j) Ensuring that a back-up ventilator is
available at all times.
Authority: T.C.A. §§
4-5-202,
4-5-204,
68-3-511,
68-11-201,
68-11-202,
68-11-204,
68-11-206, 68-11207, 68-11-209,
68-11-216, 68-11-240, 68-11-241, and 68-11-801.