Title 902 | Chapter 020 | Regulation 051
902 KAR 20:051.Operation and services; intermediate care.
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 an intermediate care facility.(4)
"License" means an authorization issued by the cabinet for the purpose of operating an intermediate care facility and offering intermediate care services.(5)
"PRN medications" means medications administered as needed.(6)
"Qualified dietician" or "nutritionist" means:(a)
A person who has a bachelor of science degree in foods and nutrition, food service management, institutional management or related services and has successfully completed a dietetic internship or coordinated undergraduate program accredited by the American Dietetic Association (ADA) and is a member of the ADA or is registered as a dietician by ADA; or(b)
A person who has a master's degree in nutrition and is a member of ADA or is eligible for registration by ADA; or(c)
A person who has a bachelor of science degree in home economics and three (3) years of work experience with a registered dietician.(7)
"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 of Operations and Services. Intermediate care facilities are establishments with permanent facilities including inpatient beds. Services provided include twenty-four (24) hour supervision of patients, services including physician, nursing, pharmaceutical, personal care, activities and residential services. Patients in an intermediate care facility must have a physical or mental condition that requires intermittent nursing services along with continuous supervision of the activities of daily living.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. The administrator shall not be the nursing services supervisor in a facility with more than sixty (60) beds.(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 bound, 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 service 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 cases of abuse, neglect or exploitation of adults and children pursuant to KRS Chapters 209 and 620.(c)
Use of restraints. The facility shall have a written policy that addresses 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. The facility shall admit only persons who have a physical or mental condition which requires intermittent nursing services and continuous supervision of activities of daily living. 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 seventy-two (72) 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 facility if done within fourteen (14) days prior to admission.(c)
Before admission the patient and a responsible member of his family or committee 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 and discharge. The facility shall comply with the requirements of 900 KAR 2:050 when transferring or discharging residents.(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 the patient's condition exceeds the scope of services of the facility, the patient, upon physician's orders (except in cases of emergency), shall be transferred promptly to a hospital or a skilled nursing facility, or services shall be contracted for from another community resource.(c)
When 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 facilities providing appropriate services.(d)
Except in an emergency, the patient, his next of kin, or guardian, if any, and the attending physician shall be consulted in advance of the transfer or discharge of any patient.(e)
When a transfer is to another level of care within the same facility, the complete medical record or a current summary thereof shall be transferred with the patient.(f)
If the patient is transferred to another health care facility or home to be cared for by a home health agency, 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 a resume 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 to 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.
A 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.
Volunteers shall not be counted to make up minimum staffing requirements.5.
Supervision of nursing services shall be by a registered nurse or licensed practical nurse employed on the day shift seven (7) days per week. The supervisor shall have training in rehabilitative nursing. When a licensed practical nurse serves as the supervisor, consultation shall be provided by a registered nurse at regular intervals, not less than four (4) hours weekly. The responsibilities of the nursing services supervisor shall include:a.
Developing and maintaining nursing service objectives, standards of nursing practice, nursing procedure manuals, and written job descriptions 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 care.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.
Participating in the screening of prospective patients in terms of required nursing services and nursing skills available.h.
Assuring that a written monthly assessment of the patient's general condition is completed.i.
Assuring that the establishment, review and modification of nursing care plans for each patient is done by licensed nursing personnel.j.
Assuring that all medications are administered by licensed personnel or by other personnel who have completed a state-approved training program.k.
Assuring that a monthly review of each patient's medications is completed and notifying the physician when changes are appropriate.6.
The facility shall employ a licensed pharmacist on a full-time, part-time or consultant basis to direct pharmaceutical services.7.
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.8.
Each facility shall designate a person for the following areas who will be responsible for:a.
Medical records;b.
Arranging for social services; andc.
Developing and implementing the activities program and therapeutic recreation.9.
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 infectious disease can no longer be transmitted.(e)
Orientation program. The facility shall conduct an orientation program for all new employees to include review of all facility policies (that relate to the duties of their respective jobs), services and emergency and disaster procedures.(f)
In-service training.1.
All employees shall receive in-service training and ongoing education to correspond with the duties of their respective jobs.2.
All nursing personnel shall receive in-service or continuing education programs at least quarterly.(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, skilled nursing facility if done within fourteen (14) days prior to admission.)3.
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, name of prescribing physician, advanced practice registered nurse, therapeutically-certified optometrist, or physician assistant, 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 or, in case of a minor, three (3) years after the patient reaches the age of majority under state law, whichever is the longest.Section 4.
Provision of Services.(1)
General requirements.(a)
Patient care equipment. There shall be a sufficient quantity of patient care equipment of satisfactory design and in good condition to carry out established patient care procedures. The equipment shall include:1.
Wheelchairs with brakes;2.
Walkers;3.
Bedside rails;4.
Bedpans and urinals (permanent or disposable);5.
Emesis basins and wash basins (permanent or disposable);6.
Footstools;7.
Bedside commodes;8.
Foot cradles;9.
Foot boards;10.
Under-the-mattress bed boards;11.
Trapeze frames;12.
Transfer board; and13.
An autoclave for sterilization of nursing equipment and supplies or an equivalent alternate method of sterilization.(b)
Infection control and communicable diseases.1.
There shall be written infection control policies, which are consistent with the Centers for Disease Control guidelines including:a.
Policies which address the prevention of disease transmission to and from patients, visitors and employees, including:(i)
Universal blood and body fluid precautions;(ii)
Precautions for infections which can be transmitted by the airborne route; and(iii)
Work restrictions for employees with infectious diseases.b.
Policies which address the cleaning, disinfection, and sterilization methods used for equipment and the environment.2.
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.3.
Sharp wastes.a.
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.b.
Needles shall not be recapped by hand, purposely bent or broken, or otherwise manipulated by hand.c.
The containers of 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 Health Services and the Natural Resources and Environmental Protection Cabinet.4.
Disposable waste.a.
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.b.
The facility shall establish specific written policies regarding handling and disposal of all wastes.c.
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.d.
Any wastes conveyed to a sanitary sewer shall comply with applicable federal, state, and local pretreatment regulations.5.
Patients infected with the following diseases shall not be admitted to the facility unless the patient's attending physician certifies in writing that the condition of the patient is not communicable to others in the long-term care environment: anthrax, campylobacteriosis, cholera, diphtheria, hepatitis A, measles, pertussis, plague, poliomyelitis, rabies (human), rubella, salmonellosis, shigellosis, typhoid fever, yersiniosis, brucellosis, giardiasis, leprosy, psittacosis, Q fever, tularemia, and typhus. If an attending physician is in doubt regarding the communicability of a patient's condition, he may contact the Department for Health Services.6.
A facility may admit a noninfectious tuberculosis patient under continuing medical supervision for his tuberculosis disease.7.
Patients with active tuberculosis may be admitted to the facility whose isolation facilities and procedures have been specifically approved by the cabinet.8.
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.(c)
Use of restraints.1.
No restraints shall be used except as permitted by KRS 216.515(6).2.
Restraints that require lock and key shall not be used.3.
Restraints shall be applied only by appropriately trained personnel.4.
Restraints shall not be used as a punishment, as discipline, as a convenience for the staff, or as a mechanism to produce regression.(2)
Physician services. All patients shall be under the medical supervision of a licensed physician. These services shall include:(a)
Physician's visit for medical evaluation as often as necessary and in no case less often than every sixty (60) days, unless justified and documented by the attending physician in the patient's medical report.(b)
Physician services for medical emergencies available on a twenty-four (24) hour, seven (7) days-a-week basis.(3)
Nursing services. Nursing services shall include:(a)
The establishment of a nursing care plan for each patient. Each plan shall be reviewed and modified as necessary, or at least quarterly. Each plan shall include goals and nursing care needs;(b)
Rehabilitative nursing care to achieve and maintain the highest degree of function, self-care and independence. Rehabilitative measures shall be practiced on a twenty-four (24) hour, seven (7) day week basis. Those procedures requiring medical approval shall be ordered by the attending physician. Rehabilitative measures shall include:1.
Positioning and turning. Nursing personnel shall encourage and assist patients in maintaining good body alignment while standing, sitting, or lying in bed.2.
Exercises. Nursing personnel shall assist patients in maintaining maximum joint range of motion or active range of motion.3.
Bowel and bladder training. Nursing personnel shall make every effort to train incontinent patients to gain bowel and bladder control.4.
Training in activities of daily living. Nursing personnel shall encourage and when necessary teach patients to function at their maximum level in appropriate activities of daily living for as long as, and to the degree that, they are able.5.
Ambulation. Nursing personnel shall assist and encourage patients with daily ambulation unless otherwise ordered by the physician.(c)
Administration of medications including oral, rectal, hypodermic, and intramuscular;(d)
Written monthly assessment of the patient's general condition by licensed nursing personnel;(e)
Treatments such as: enemas, irrigations, catheterizations, applications of dressings or bandages, supervision of special diets;(f)
The recording of any changes, as they occur, in the patient's condition, actions, responses, attitudes, appetite, etc.(g)
Implementing a regular program to prevent decubiti with emphasis on the following:1.
Procedures to maintain cleanliness of the patient, his clothes and linens shall be followed each time the bed or the clothing is soiled. Rubber, plastic, or other type of linen protectors shall be properly cleaned and completely covered to prevent direct contact with the patient.2.
Special effort shall be made to assist the patient in being up and out of bed as much as his condition permits, unless medically contraindicated. If the patient cannot move himself, he shall have his position changed as often as necessary but not less than every two (2) hours.(4)
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 be employed to administer the pharmacy 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)
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.(e)
Medication requirement and services.1.
All medications administered to patients shall be ordered in writing by the prescribing physician, advanced practice registered nurse as authorized in KRS 314.011(8) and 314.042(8), therapeutically-certified optometrist in the practice of optometry as defined in KRS 320.210(2), or physician assistant as authorized in KRS 311.560(3) and (4). Oral orders shall be given only to a licensed nurse or pharmacist, immediately reduced to writing, and signed. 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 the pharmacist shall review each patient's medical profile monthly. Medications shall be reviewed at least quarterly by the attending or staff physician. 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 shall be released to patients on discharge or visits only after being labeled appropriately and on the written authorization of the physician.2.
Administration of medications. All medications shall be administered by licensed nurses or personnel who have completed a state-approved training program, from a state approved training provider. Each dose administered shall be recorded in the medical record. 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.a.
The nursing station shall have items required for the proper administration of medications.b.
Medications prescribed for one (1) patient shall not be administered to any other patient.c.
Self-administration of medications by patients shall not be permitted except on special order of the patient's physician and a predischarge program under the supervision of a licensed nurse.d.
Medication errors and drug reactions shall be immediately reported to the patient's physician and pharmacist and an entry thereof made in the patient's medical record as well as on an incident report.3.
The facility shall provide up-to-date medication reference texts for use by the nursing staff (e.g., Physician's Desk Reference).4.
Labeling and storing medications. 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.5.
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 21 CFR 1307.21.(5)
Personal care services.(a)
All facilities shall provide services to assist patients to achieve and maintain good personal hygiene including the level of assistance necessary with:1.
Bathing of the body to maintain clean skin and freedom from offensive odors. In addition to assistance with bathing, the facility shall provide soap, clean towels, and wash cloths for each patient. Toilet articles such as brushes and combs shall not be used in common.2.
Shaving.3.
Cleaning and trimming of fingernails and toenails.4.
Cleaning of the mouth and teeth to maintain good oral hygiene as well as care of the lips to prevent dryness and cracking. All patients shall be provided with tooth brushes, a dentifrice, and denture containers, when applicable.5.
Washing, grooming, and cutting of hair.(b)
The staff shall encourage and assist the patients to dress in their own street clothing (unless otherwise indicated by the physician).(6)
Dental services. The facility shall assist patients in obtaining dental services. Conditions necessitating dental services shall be noted and such dental procedures and services provided shall be recorded in the patient's record.(7)
Social services. The facility shall provide or arrange for social services as needed by the patient.(a)
Social services shall be integrated with other elements of the plan of care.(b)
A plan for such care shall be recorded in the patient's record and periodically evaluated in conjunction with the patient's total plan of care.(c)
Social services records shall be maintained as an integral part of case record maintained on each patient.(8)
Activities and therapeutic recreation.(a)
All facilities shall provide a program to stimulate physical and mental abilities to the fullest extent, to encourage and develop a sense of usefulness and self respect and to prevent, inhibit or correct the development of symptoms of physical and mental regression due to illness or old age. The program shall provide sufficient variety to meet the needs of the various types of patients in the facility. When possible, the patient shall be included in the planning of activities.(b)
All facilities shall meet the following program requirements:1.
Staff. A person designated by the administrator shall be responsible for the program.2.
A program shall be developed for each patient and shall be incorporated in the patient's plan of care and revised according to the patient's needs. Changes in his response to the program shall be recorded in the medical record.3.
There shall be a planned and supervised activity period each day. The schedule shall be current and posted.4.
The program shall be planned for group and individual activities, both within and outside of the facility, weather permitting.5.
The person responsible for activities shall maintain a current list of patients on which precautions are noted regarding a patient's condition that might restrict or modify his participation in the program.6.
A living or recreation room and outdoor recreational space shall be provided for patients and their guests.7.
The facility shall provide supplies and equipment for the activities program.8.
Reading materials, radios, games and TV sets shall be provided for the patients.9.
The program may include religious activities for each patient if it is the desire of the patient to participate. Requests from a patient to be seen by a clergyman shall be acted upon as soon as possible, and an area of private consultation shall be made available.10.
The facility shall allow the patient to leave the facility to visit, shop, attend church, or other social activities provided this does not endanger his health or safety.(9)
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.(10)
Residential care services. All facilities shall provide residential care services to all patients including: room accommodations, housekeeping and maintenance services, and dietary services. All facilities shall meet the following requirements relating to the provision of residential care services.(a)
Room accommodations.1.
Each patient shall be provided a standard size bed 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.(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 (1) patient shall not be used by another until it has been laundered or dry cleaned.3.
Soiled linen shall be placed in washable or disposable containers, transported in a sanitary manner and stored in separate, well-ventilated areas in a manner to prevent contamination and odors. Equipment or areas used to transport or store soiled linen shall not be used for handling or storing of clean linen.4.
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.5.
Clean linen shall be sorted, dried, ironed, folded, transported, stored and distributed in a sanitary manner.6.
Clean linen shall be stored in clean linen closets on each floor, close to the nurses' station.7.
Personal laundry of patients or staff shall be collected, transported, sorted, washed and dried in a sanitary manner, separate from bed linens.8.
Patients' personal clothing shall be laundered by the facility as often as is necessary. Patients' personal clothing shall be laundered by the facility unless the patient or the patient's family accepts this responsibility. Patients capable of laundering their own personal clothing and wishing to do so may, instead, be provided the facilities to do so. Patient's personal clothing laundered by the facility shall be marked to identify the patient-owner and returned to the correct patient.9.
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)
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 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.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, advanced practice registered nurse as authorized in KRS 314.011(8) and 314.042(8), or physician assistant as authorized in KRS 311.560(3) and (4).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 overbed 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.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 KRS 219.081 and 902 KAR 45:005.Section 5.
Separability. If any clause, sentence, paragraph, section or part of these administrative regulations shall be adjudged by any court of competent jurisdiction to be invalid, the judgment shall not affect, impair or invalidate the remainder thereof, but shall be confined in its operation to the clause, sentence, paragraph, section or part thereof, directly involved in the controversy in which the judgment was rendered.HISTORY: (8 Ky.R. 406; 900; eff. 4-7-1982; 11 Ky.R. 832; eff. 12-11-1984; 13 Ky.R. 365; eff. 9-4-1986; 1151; eff. 2-10-1987; 16 Ky.R. 2496; 17 Ky.R. 76; eff. 7-18-1990; 1590; eff. 12-18-1990; 24 Ky.R. 2233; 25 Ky.R. 328; eff. 8-17-1998; TAm eff. 3-11-2011; Crt eff. 4-30-2019.)
902 KAR 20:051.Operation and services; intermediate care.
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 an intermediate care facility.(4)
"License" means an authorization issued by the cabinet for the purpose of operating an intermediate care facility and offering intermediate care services.(5)
"PRN medications" means medications administered as needed.(6)
"Qualified dietician" or "nutritionist" means:(a)
A person who has a bachelor of science degree in foods and nutrition, food service management, institutional management or related services and has successfully completed a dietetic internship or coordinated undergraduate program accredited by the American Dietetic Association (ADA) and is a member of the ADA or is registered as a dietician by ADA; or(b)
A person who has a master's degree in nutrition and is a member of ADA or is eligible for registration by ADA; or(c)
A person who has a bachelor of science degree in home economics and three (3) years of work experience with a registered dietician.(7)
"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 of Operations and Services. Intermediate care facilities are establishments with permanent facilities including inpatient beds. Services provided include twenty-four (24) hour supervision of patients, services including physician, nursing, pharmaceutical, personal care, activities and residential services. Patients in an intermediate care facility must have a physical or mental condition that requires intermittent nursing services along with continuous supervision of the activities of daily living.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. The administrator shall not be the nursing services supervisor in a facility with more than sixty (60) beds.(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 bound, 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 service 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 cases of abuse, neglect or exploitation of adults and children pursuant to KRS Chapters 209 and 620.(c)
Use of restraints. The facility shall have a written policy that addresses 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. The facility shall admit only persons who have a physical or mental condition which requires intermittent nursing services and continuous supervision of activities of daily living. 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 seventy-two (72) 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 facility if done within fourteen (14) days prior to admission.(c)
Before admission the patient and a responsible member of his family or committee 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 and discharge. The facility shall comply with the requirements of 900 KAR 2:050 when transferring or discharging residents.(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 the patient's condition exceeds the scope of services of the facility, the patient, upon physician's orders (except in cases of emergency), shall be transferred promptly to a hospital or a skilled nursing facility, or services shall be contracted for from another community resource.(c)
When 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 facilities providing appropriate services.(d)
Except in an emergency, the patient, his next of kin, or guardian, if any, and the attending physician shall be consulted in advance of the transfer or discharge of any patient.(e)
When a transfer is to another level of care within the same facility, the complete medical record or a current summary thereof shall be transferred with the patient.(f)
If the patient is transferred to another health care facility or home to be cared for by a home health agency, 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 a resume 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 to 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.
A 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.
Volunteers shall not be counted to make up minimum staffing requirements.5.
Supervision of nursing services shall be by a registered nurse or licensed practical nurse employed on the day shift seven (7) days per week. The supervisor shall have training in rehabilitative nursing. When a licensed practical nurse serves as the supervisor, consultation shall be provided by a registered nurse at regular intervals, not less than four (4) hours weekly. The responsibilities of the nursing services supervisor shall include:a.
Developing and maintaining nursing service objectives, standards of nursing practice, nursing procedure manuals, and written job descriptions 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 care.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.
Participating in the screening of prospective patients in terms of required nursing services and nursing skills available.h.
Assuring that a written monthly assessment of the patient's general condition is completed.i.
Assuring that the establishment, review and modification of nursing care plans for each patient is done by licensed nursing personnel.j.
Assuring that all medications are administered by licensed personnel or by other personnel who have completed a state-approved training program.k.
Assuring that a monthly review of each patient's medications is completed and notifying the physician when changes are appropriate.6.
The facility shall employ a licensed pharmacist on a full-time, part-time or consultant basis to direct pharmaceutical services.7.
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.8.
Each facility shall designate a person for the following areas who will be responsible for:a.
Medical records;b.
Arranging for social services; andc.
Developing and implementing the activities program and therapeutic recreation.9.
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 infectious disease can no longer be transmitted.(e)
Orientation program. The facility shall conduct an orientation program for all new employees to include review of all facility policies (that relate to the duties of their respective jobs), services and emergency and disaster procedures.(f)
In-service training.1.
All employees shall receive in-service training and ongoing education to correspond with the duties of their respective jobs.2.
All nursing personnel shall receive in-service or continuing education programs at least quarterly.(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, skilled nursing facility if done within fourteen (14) days prior to admission.)3.
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, name of prescribing physician, advanced practice registered nurse, therapeutically-certified optometrist, or physician assistant, 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 or, in case of a minor, three (3) years after the patient reaches the age of majority under state law, whichever is the longest.Section 4.
Provision of Services.(1)
General requirements.(a)
Patient care equipment. There shall be a sufficient quantity of patient care equipment of satisfactory design and in good condition to carry out established patient care procedures. The equipment shall include:1.
Wheelchairs with brakes;2.
Walkers;3.
Bedside rails;4.
Bedpans and urinals (permanent or disposable);5.
Emesis basins and wash basins (permanent or disposable);6.
Footstools;7.
Bedside commodes;8.
Foot cradles;9.
Foot boards;10.
Under-the-mattress bed boards;11.
Trapeze frames;12.
Transfer board; and13.
An autoclave for sterilization of nursing equipment and supplies or an equivalent alternate method of sterilization.(b)
Infection control and communicable diseases.1.
There shall be written infection control policies, which are consistent with the Centers for Disease Control guidelines including:a.
Policies which address the prevention of disease transmission to and from patients, visitors and employees, including:(i)
Universal blood and body fluid precautions;(ii)
Precautions for infections which can be transmitted by the airborne route; and(iii)
Work restrictions for employees with infectious diseases.b.
Policies which address the cleaning, disinfection, and sterilization methods used for equipment and the environment.2.
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.3.
Sharp wastes.a.
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.b.
Needles shall not be recapped by hand, purposely bent or broken, or otherwise manipulated by hand.c.
The containers of 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 Health Services and the Natural Resources and Environmental Protection Cabinet.4.
Disposable waste.a.
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.b.
The facility shall establish specific written policies regarding handling and disposal of all wastes.c.
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.d.
Any wastes conveyed to a sanitary sewer shall comply with applicable federal, state, and local pretreatment regulations.5.
Patients infected with the following diseases shall not be admitted to the facility unless the patient's attending physician certifies in writing that the condition of the patient is not communicable to others in the long-term care environment: anthrax, campylobacteriosis, cholera, diphtheria, hepatitis A, measles, pertussis, plague, poliomyelitis, rabies (human), rubella, salmonellosis, shigellosis, typhoid fever, yersiniosis, brucellosis, giardiasis, leprosy, psittacosis, Q fever, tularemia, and typhus. If an attending physician is in doubt regarding the communicability of a patient's condition, he may contact the Department for Health Services.6.
A facility may admit a noninfectious tuberculosis patient under continuing medical supervision for his tuberculosis disease.7.
Patients with active tuberculosis may be admitted to the facility whose isolation facilities and procedures have been specifically approved by the cabinet.8.
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.(c)
Use of restraints.1.
No restraints shall be used except as permitted by KRS 216.515(6).2.
Restraints that require lock and key shall not be used.3.
Restraints shall be applied only by appropriately trained personnel.4.
Restraints shall not be used as a punishment, as discipline, as a convenience for the staff, or as a mechanism to produce regression.(2)
Physician services. All patients shall be under the medical supervision of a licensed physician. These services shall include:(a)
Physician's visit for medical evaluation as often as necessary and in no case less often than every sixty (60) days, unless justified and documented by the attending physician in the patient's medical report.(b)
Physician services for medical emergencies available on a twenty-four (24) hour, seven (7) days-a-week basis.(3)
Nursing services. Nursing services shall include:(a)
The establishment of a nursing care plan for each patient. Each plan shall be reviewed and modified as necessary, or at least quarterly. Each plan shall include goals and nursing care needs;(b)
Rehabilitative nursing care to achieve and maintain the highest degree of function, self-care and independence. Rehabilitative measures shall be practiced on a twenty-four (24) hour, seven (7) day week basis. Those procedures requiring medical approval shall be ordered by the attending physician. Rehabilitative measures shall include:1.
Positioning and turning. Nursing personnel shall encourage and assist patients in maintaining good body alignment while standing, sitting, or lying in bed.2.
Exercises. Nursing personnel shall assist patients in maintaining maximum joint range of motion or active range of motion.3.
Bowel and bladder training. Nursing personnel shall make every effort to train incontinent patients to gain bowel and bladder control.4.
Training in activities of daily living. Nursing personnel shall encourage and when necessary teach patients to function at their maximum level in appropriate activities of daily living for as long as, and to the degree that, they are able.5.
Ambulation. Nursing personnel shall assist and encourage patients with daily ambulation unless otherwise ordered by the physician.(c)
Administration of medications including oral, rectal, hypodermic, and intramuscular;(d)
Written monthly assessment of the patient's general condition by licensed nursing personnel;(e)
Treatments such as: enemas, irrigations, catheterizations, applications of dressings or bandages, supervision of special diets;(f)
The recording of any changes, as they occur, in the patient's condition, actions, responses, attitudes, appetite, etc.(g)
Implementing a regular program to prevent decubiti with emphasis on the following:1.
Procedures to maintain cleanliness of the patient, his clothes and linens shall be followed each time the bed or the clothing is soiled. Rubber, plastic, or other type of linen protectors shall be properly cleaned and completely covered to prevent direct contact with the patient.2.
Special effort shall be made to assist the patient in being up and out of bed as much as his condition permits, unless medically contraindicated. If the patient cannot move himself, he shall have his position changed as often as necessary but not less than every two (2) hours.(4)
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 be employed to administer the pharmacy 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)
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.(e)
Medication requirement and services.1.
All medications administered to patients shall be ordered in writing by the prescribing physician, advanced practice registered nurse as authorized in KRS 314.011(8) and 314.042(8), therapeutically-certified optometrist in the practice of optometry as defined in KRS 320.210(2), or physician assistant as authorized in KRS 311.560(3) and (4). Oral orders shall be given only to a licensed nurse or pharmacist, immediately reduced to writing, and signed. 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 the pharmacist shall review each patient's medical profile monthly. Medications shall be reviewed at least quarterly by the attending or staff physician. 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 shall be released to patients on discharge or visits only after being labeled appropriately and on the written authorization of the physician.2.
Administration of medications. All medications shall be administered by licensed nurses or personnel who have completed a state-approved training program, from a state approved training provider. Each dose administered shall be recorded in the medical record. 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.a.
The nursing station shall have items required for the proper administration of medications.b.
Medications prescribed for one (1) patient shall not be administered to any other patient.c.
Self-administration of medications by patients shall not be permitted except on special order of the patient's physician and a predischarge program under the supervision of a licensed nurse.d.
Medication errors and drug reactions shall be immediately reported to the patient's physician and pharmacist and an entry thereof made in the patient's medical record as well as on an incident report.3.
The facility shall provide up-to-date medication reference texts for use by the nursing staff (e.g., Physician's Desk Reference).4.
Labeling and storing medications. 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.5.
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 21 CFR 1307.21.(5)
Personal care services.(a)
All facilities shall provide services to assist patients to achieve and maintain good personal hygiene including the level of assistance necessary with:1.
Bathing of the body to maintain clean skin and freedom from offensive odors. In addition to assistance with bathing, the facility shall provide soap, clean towels, and wash cloths for each patient. Toilet articles such as brushes and combs shall not be used in common.2.
Shaving.3.
Cleaning and trimming of fingernails and toenails.4.
Cleaning of the mouth and teeth to maintain good oral hygiene as well as care of the lips to prevent dryness and cracking. All patients shall be provided with tooth brushes, a dentifrice, and denture containers, when applicable.5.
Washing, grooming, and cutting of hair.(b)
The staff shall encourage and assist the patients to dress in their own street clothing (unless otherwise indicated by the physician).(6)
Dental services. The facility shall assist patients in obtaining dental services. Conditions necessitating dental services shall be noted and such dental procedures and services provided shall be recorded in the patient's record.(7)
Social services. The facility shall provide or arrange for social services as needed by the patient.(a)
Social services shall be integrated with other elements of the plan of care.(b)
A plan for such care shall be recorded in the patient's record and periodically evaluated in conjunction with the patient's total plan of care.(c)
Social services records shall be maintained as an integral part of case record maintained on each patient.(8)
Activities and therapeutic recreation.(a)
All facilities shall provide a program to stimulate physical and mental abilities to the fullest extent, to encourage and develop a sense of usefulness and self respect and to prevent, inhibit or correct the development of symptoms of physical and mental regression due to illness or old age. The program shall provide sufficient variety to meet the needs of the various types of patients in the facility. When possible, the patient shall be included in the planning of activities.(b)
All facilities shall meet the following program requirements:1.
Staff. A person designated by the administrator shall be responsible for the program.2.
A program shall be developed for each patient and shall be incorporated in the patient's plan of care and revised according to the patient's needs. Changes in his response to the program shall be recorded in the medical record.3.
There shall be a planned and supervised activity period each day. The schedule shall be current and posted.4.
The program shall be planned for group and individual activities, both within and outside of the facility, weather permitting.5.
The person responsible for activities shall maintain a current list of patients on which precautions are noted regarding a patient's condition that might restrict or modify his participation in the program.6.
A living or recreation room and outdoor recreational space shall be provided for patients and their guests.7.
The facility shall provide supplies and equipment for the activities program.8.
Reading materials, radios, games and TV sets shall be provided for the patients.9.
The program may include religious activities for each patient if it is the desire of the patient to participate. Requests from a patient to be seen by a clergyman shall be acted upon as soon as possible, and an area of private consultation shall be made available.10.
The facility shall allow the patient to leave the facility to visit, shop, attend church, or other social activities provided this does not endanger his health or safety.(9)
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.(10)
Residential care services. All facilities shall provide residential care services to all patients including: room accommodations, housekeeping and maintenance services, and dietary services. All facilities shall meet the following requirements relating to the provision of residential care services.(a)
Room accommodations.1.
Each patient shall be provided a standard size bed 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.(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 (1) patient shall not be used by another until it has been laundered or dry cleaned.3.
Soiled linen shall be placed in washable or disposable containers, transported in a sanitary manner and stored in separate, well-ventilated areas in a manner to prevent contamination and odors. Equipment or areas used to transport or store soiled linen shall not be used for handling or storing of clean linen.4.
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.5.
Clean linen shall be sorted, dried, ironed, folded, transported, stored and distributed in a sanitary manner.6.
Clean linen shall be stored in clean linen closets on each floor, close to the nurses' station.7.
Personal laundry of patients or staff shall be collected, transported, sorted, washed and dried in a sanitary manner, separate from bed linens.8.
Patients' personal clothing shall be laundered by the facility as often as is necessary. Patients' personal clothing shall be laundered by the facility unless the patient or the patient's family accepts this responsibility. Patients capable of laundering their own personal clothing and wishing to do so may, instead, be provided the facilities to do so. Patient's personal clothing laundered by the facility shall be marked to identify the patient-owner and returned to the correct patient.9.
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)
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 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.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, advanced practice registered nurse as authorized in KRS 314.011(8) and 314.042(8), or physician assistant as authorized in KRS 311.560(3) and (4).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 overbed 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.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 KRS 219.081 and 902 KAR 45:005.Section 5.
Separability. If any clause, sentence, paragraph, section or part of these administrative regulations shall be adjudged by any court of competent jurisdiction to be invalid, the judgment shall not affect, impair or invalidate the remainder thereof, but shall be confined in its operation to the clause, sentence, paragraph, section or part thereof, directly involved in the controversy in which the judgment was rendered.HISTORY: (8 Ky.R. 406; 900; eff. 4-7-1982; 11 Ky.R. 832; eff. 12-11-1984; 13 Ky.R. 365; eff. 9-4-1986; 1151; eff. 2-10-1987; 16 Ky.R. 2496; 17 Ky.R. 76; eff. 7-18-1990; 1590; eff. 12-18-1990; 24 Ky.R. 2233; 25 Ky.R. 328; eff. 8-17-1998; TAm eff. 3-11-2011; Crt eff. 4-30-2019.)