Ch. 110: Regulations Governing the Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities

Section 1 – Definitions 1

Section 2 - Obtaining a License 7

Requirements 7

Appointment of Administrator 7

First Church of Christ, Scientist Homes 7

Application Procedure 7

Initial Licensing 8

Issuance of License 9

New Construction or Additions 10

Changes 10

Waiver Provisions 11

Posting of License 12

Availability of Survey Results 12

Section 3 - Loss Of, Renewal Of, Temporary & Conditional License 13

Refusal to Issue a License 13

Right of Entry and Inspection 13

Renewal of License 13

Temporary or Conditional License 13

Suspension or Revocation of License 13

Emergency Suspension 14

Public Notice 14

Involuntary Closing of a Licensed Facility 14

Voluntary Closing of a Licensed Facility 14

Section 4 – Administration 15

Administrator 15

Register 16

Daily Census 16

Transfer Agreement 16

Outside Resources 17

Rebating Prohibited 17

Admissions, Discharges and Transfers 17

Quality Assurance Committee 18

Complaints 19

Reporting of Abuse, Neglect or Misappropriation of Resident Property 20

Section 5 - Facility Policies 21

Professional Policy Group 21

Written Policies 21

Section 6 - Contracts with Residents 23

Contract Between Resident and Representative of Facility 23

Provisions of Contract 23

Contract Requirements 23

Obligations 23

Section 7 - Residents' Property and Finances 26

Authority and Responsibility 26

Protection of Resident Funds 26

Management of Personal Funds

s with Residents 23

Contract Between Resident and Representative of Facility 23

Provisions of Contract 23

Contract Requirements 23

Obligations 23

Section 7 - Residents' Property and Finances 26

Authority and Responsibility 26

Protection of Resident Funds 26

Management of Personal Funds 26

Deposit of Funds 26

Accounting and Records 27

Notice of Certain Balances 27

Conveyance Upon Death 27

Assurance of Financial Security 27

Limitation on Charges to Personal Funds 27

Section 8 – Personnel 29

Personnel Policies 29

Staff Qualifications 29

Employees 29

Personnel Records 31

Weekly Time Schedule 32

Laws of the Maine Department of Labor 32

Identification Badges 32

Section 9 - Resident Care Staffing 33

Minimum Nursing Staff Requirements 33

Assignment of Tasks 35

Sharing of Staff 36

Staffing Patterns 36

Section 10 - Residents' Rights 37

Written Policies 37

Procedures 37

Exercise of Rights 37

Notification of Changes 38

Protection of Resident Funds 39

Free Choice 39

Privacy 39

Grievances and Complaints 40

Examination of Survey Results 40

Work 40

Mail 40

Access and Visitation Rights 41

Telephone 41

Personal Property 41

Married Couples 41

Self-Administration of Drugs 42

Transfer and Discharge Rights 42

Content of Notice 42

Physical or Chemical Restraints 44

Freedom From Abuse, Punishment or In

40

Mail 40

Access and Visitation Rights 41

Telephone 41

Personal Property 41

Married Couples 41

Self-Administration of Drugs 42

Transfer and Discharge Rights 42

Content of Notice 42

Physical or Chemical Restraints 44

Freedom From Abuse, Punishment or Involuntary Seclusion 44

Organization and Participation 44

Residents' Council 45

Participation in Other Activities 45

Section 11 - Physical/Chemical Restraints 46

Physical Restraints 46

Chemical Restraints 47

Section 12 - Pre-Admission Screening, Comprehensive Assessments and

Plans of Care 49

Pre-Admission Screening 49

Comprehensive Assessment 49

Comprehensive Care Plan 51

Documentation 52

Specialized Therapy Services 52

Section 13 - Nursing Services 54

Quality of Care 54

Section 14 - Social Services 58

Social Services 58

Section 15 – Activities 60

Section 16 - Physician Services 62

Physician Services 62

Section 17 - Pharmaceutical Services 64

Pharmaceutical Services 64

Definitions 64

Supervision of Drugs and Biologicals 64

Handling of Drugs and Biologicals 65

Administration 67

Control of Narcotics, Barbiturates and Other Controlled Substances 68

Recording of Medications 70

Reporting of Medication Errors and Adverse Reactions 70

Equipment and Supplies 70

Section 18 - Dietary Services 72

Policies and Procedures 72

Staffing 72

Adequacy of Diets 74

Menus 75

Therapeutic Diets 75

Food Sup

tances 68

Recording of Medications 70

Reporting of Medication Errors and Adverse Reactions 70

Equipment and Supplies 70

Section 18 - Dietary Services 72

Policies and Procedures 72

Staffing 72

Adequacy of Diets 74

Menus 75

Therapeutic Diets 75

Food Supplies 77

Food Storage and Protection 77

Refrigerator and Freezer 77

Hot Food Storage 78

Food Preparation 78

Food Service 79

Cleaning, Sanitization and Storage of Equipment and Utensils 80

Garbage and Rubbish 81

Dietary Areas 82

Section 19 – Records 85

Clinical Records 85

Retention of Records 85

Miscellaneous Records 86

Inactive Clinical Records 86

Readmissions 87

Transfers and Discharges 87

Incident and Accident Records 87

Individual Administrative Records 88

Confidentiality 88

Access 88

Storage of Records 88

Section 20 - Physical Plant 90

Structure 90

Utilities 92

Maintenance 93

Fire Safety 94

Residents' Bedrooms 96

Provision for Isolation 98

Bathing, Lavatory and Toilet Fixtures 98

Nurses Station 100

Utility Area 100

Living Room and Dining Area 101

Therapy Areas 102

Smoking 102

Laundry 102

Housekeeping 104

Control of Odors 105

Use of Nursing Personnel 105

Section 21 - Infection Control and Biomedical Waste 106

Infection Control 106

Biomedical Waste Management 107

and Dining Area 101

Therapy Areas 102

Smoking 102

Laundry 102

Housekeeping 104

Control of Odors 105

Use of Nursing Personnel 105

Section 21 - Infection Control and Biomedical Waste 106

Infection Control 106

Biomedical Waste Management 107

Section 22 – Enforcement 109

Definitions 109

General Procedures for Enforcement 110

Intermediate Sanctions 110

Grounds for Intermediate Sanctions 111

Procedures for Imposing Financial Penalties on Nursing Facilities 111

Amount of Penalties 112

Other Sanctions for Failure to Comply with Applicable Laws/Regulations 113

Section 23 - Alzheimer’s/Dementia Care Units 116

Definitions 116

Alzheimer’s/Dementia Care Unit Program Disclosure 116

Standards for Alzheimer’s/Dementia Care Units 117

ADDENDUM Addendum

Appendix A A1

Attachment A Attach A1

Attachment B Attach B1

Section 1 - Definitions

The following terms shall have the meanings as specified:

“Abuse” means the infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish, sexual abuse or exploitation or the willful deprivation of essential needs. “Willful”, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

“Activities Coordinator” means a person with one of the following qualifications:

a. Completion of a training course approved by the Department of Education; or

b. A Registered Occupational Therapist or an Occupational Therapy Assistant; or

c. A degree in Therapeutic Recreation

ans the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

“Activities Coordinator” means a person with one of the following qualifications:

a. Completion of a training course approved by the Department of Education; or

b. A Registered Occupational Therapist or an Occupational Therapy Assistant; or

c. A degree in Therapeutic Recreation.

“Administrator” means a person licensed under the provisions of Section 32 MRSA Section 61, having the authority and responsibility for the operation of the institution and for staff performance in caring for residents in accordance with applicable legal requirements and policies approved by the governing authority.

“Adult Day Services” means the care and supervision of consumers who attend the facility during day time or night time hours, but are not residents of the facility.

“Advance Directives” means a written document signed by the resident, guardian or agent under durable power of attorney, giving or withholding consent or approval related to medical or other professional care, counsel, treatment or service for the resident, in the event that the resident becomes unable to provide that direction.

“Ambulatory” means a person who is physically and mentally capable of moving from place to place without the aid of another person.

“Applicant” means any person in whose behalf an application for a license is submitted.

“Approved” means acceptable to the Department.

“Automatic Call System” means an audio and visual alert system in which residents may press a button, and nursing personnel are automatically notified by means of a light or a buzzer that a resident is calling for assistance

place without the aid of another person.

“Applicant” means any person in whose behalf an application for a license is submitted.

“Approved” means acceptable to the Department.

“Automatic Call System” means an audio and visual alert system in which residents may press a button, and nursing personnel are automatically notified by means of a light or a buzzer that a resident is calling for assistance.

“Certified Nursing Assistant (CNA)” means a person who has successfully completed a training program or course with a curriculum prescribed by the Maine State Board of Nursing, or is deemed to have had comparable training according to rules established by the Maine State Board of Nursing and whose duties are assigned by a Registered Professional Nurse.

“Certified Nursing Assistant/Medications (CNA/M)” means a certified nursing assistant who has satisfactorily completed the standardized medication course for certified nursing assistants, the curriculum for which is prescribed by the Maine State Board of Nursing.

“Charge Nurse/Nurse Manager” means the licensed nurse on duty who is assigned responsibility for the supervision of nursing services during a particular shift.

“Clinical Record” means the medical record maintained on each resident in accordance with professional standards and practices.

“Convenience” means any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the residents’ best interest.

“Danger” means a situation or condition of abuse, neglect, exploitation, or serious harm or immediate risk thereof.

“Department” means the Department of Human Services.

“Dependent Adult” means any adult who is wholly or partially dependent upon one or more other persons for care or support, either emotional or physical, and who would be in danger if that care or support were withdrawn.

“Dietetic Service Supervisor,” to be used interchangeably with Food Service Supervisor, means a person who:

a. Is a qualified dietitian; or

b

eans the Department of Human Services.

“Dependent Adult” means any adult who is wholly or partially dependent upon one or more other persons for care or support, either emotional or physical, and who would be in danger if that care or support were withdrawn.

“Dietetic Service Supervisor,” to be used interchangeably with Food Service Supervisor, means a person who:

a. Is a qualified dietitian; or

b. Is a graduate of a dietetic technician program, approved by the American Dietetic Association; or is a graduate of the Dietary Managers Association approved course and has passed the Certifying Board for Dietary Managers credentialing exam; or

c. Is a graduate of a State-approved course in food service supervision; or

d. Has training and experience in food service supervision and management in a military service, equivalent to the requirements in (b) or (c) above.

“Dietitian” means any individual currently licensed to practice dietetics in the State of Maine.

“Direct Care” means hands-on care provided to residents, including, but not limited to feeding, bathing, toileting, dressing, lifting, moving residents, treatments, and medication administration. Direct care does not include food preparation, housekeeping or laundry services except in circumstances when such services are required to meet the needs of an individual resident on a given occasion.

“Direct Care Provider” means Registered Professional Nurses and Licensed Practical Nurses, Certified Nursing Assistants, and Personal Support Specialists who provide direct care to nursing facility residents.

“Director of Nursing/Director of Nursing Services” means a Registered Professional Nurse who has the responsibility for the management and direction of nursing services.

“Discipline” is defined as any action taken by the facility for the purpose of punishing or penalizing residents.

“Distinct Part” means a physically separate unit that is clearly identifiable from the remainder of the facility

ts.

“Director of Nursing/Director of Nursing Services” means a Registered Professional Nurse who has the responsibility for the management and direction of nursing services.

“Discipline” is defined as any action taken by the facility for the purpose of punishing or penalizing residents.

“Distinct Part” means a physically separate unit that is clearly identifiable from the remainder of the facility. The "distinct part" must represent an entire, physically identifiable unit, consisting of all the beds within that unit, such as a separate building, floor, wing, or ward. Several rooms at one end of a hall, or a side of a corridor, may be accepted as a "distinct part" only if they constitute a wing or ward. Various beds scattered throughout the facility would not comprise a "distinct part". The "distinct part" of a facility provides a level of care distinguishable from other levels of care in the facility.

“Exploitation” means the illegal or improper use of an incapacitated or dependent adult or his/her resources for another's profit or advantage.

“Facility” means a skilled nursing facility (SNF) or a nursing facility (NF) or a distinct part of an institution.

“Feeding Assistants” are paid staff, who have successfully completed a State approved training program and who assist residents with their meals. Feeding assistants are not considered direct care staff.

“Food Service Supervisor” has the same meaning as “Dietetic Service Supervisor”.

“Incapacitated Adult” means any adult who is impaired by reason of mental health condition , intellectual disability, physical illness or disability to the extent that he/she lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his/her person, or to the extent the adult cannot effectively manage or apply his/her estate to necessary ends.

“Incident and Accident” means any occurrence which affects the safety, health, or well-being of a resident, staff or visitor

bility, physical illness or disability to the extent that he/she lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his/her person, or to the extent the adult cannot effectively manage or apply his/her estate to necessary ends.

“Incident and Accident” means any occurrence which affects the safety, health, or well-being of a resident, staff or visitor. This could include falls, lacerations, abuse, bruises (whether origin is known or unknown), etc.

“Infection Control Program” means a program that is designed to provide a safe, sanitary, and comfortable environment for the residents and to help prevent the development and transmission of disease and infection.

“In-Service Training Program” means a program of orientation and continuing education for all employees.

“Interdisciplinary Team” is used interchangeably with Multidisciplinary Team (MDT) and means the attending physician, a registered nurse and other appropriate staff and residents/family and others of their choice, in disciplines as determined by the resident's needs.

“Legend Drug” or prescription drug means those drugs that are required by Federal or state law or rule to be dispensed only on prescription.

“Licensed Practical Nurse (LPN)” means an individual currently licensed to practice practical nursing in the State of Maine.

“Maine Registry of Certified Nursing Assistants” is a listing of certified nursing assistants who meet the educational requirements of the Maine State Board of Nursing. The Registry includes notation of conviction(s) and/or substantiations of resident abuse, neglect and/or misappropriation of residents' property by the CNA in accordance with the Rules and Regulations Governing the Functioning of the Maine Registry of Certified Nursing Assistants.

“Medical Director” means a physician contracted by the facility to provide consultation regarding resident care policies and services and to participate in related committees

ubstantiations of resident abuse, neglect and/or misappropriation of residents' property by the CNA in accordance with the Rules and Regulations Governing the Functioning of the Maine Registry of Certified Nursing Assistants.

“Medical Director” means a physician contracted by the facility to provide consultation regarding resident care policies and services and to participate in related committees.

“Medication Error” means the administration of any medication incorrectly; i.e., dosage, selection of drug, selection of resident, time or method of administration, omission of prescribed medication, or the administration of a medication without a valid order.

“Intellectual Disability and Mental Health Condition” mean, as defined for Pre-Admission Screening and Annual Resident Review (PASARR) requirements:

Intellectual Disability is "significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period".

Mental Health Condition is a primary or secondary diagnosis of a mental disorder as defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-III 1R), current edition, and which does not include dementia.

“Minimum Data Set (MDS)” means the state-approved resident assessment instrument.

“Multilevel Facilities” means any nursing facilities that are located on the same contiguous grounds with licensed assisted living services, congregate housing services or home health services.

“Multidisciplinary Team” (MDT) may be used interchangeably with Interdisciplinary Team) and refers to the attending physician, a registered nurse and other appropriate staff and residents/family and others of their choice, in disciplines as determined by the residents’ needs.

“Neglect” means a threat to an adult's health or welfare by physical or mental injury or impairment, lack of protection or prevention from these, or the deprivation of or lack of essential needs

sciplinary Team) and refers to the attending physician, a registered nurse and other appropriate staff and residents/family and others of their choice, in disciplines as determined by the residents’ needs.

“Neglect” means a threat to an adult's health or welfare by physical or mental injury or impairment, lack of protection or prevention from these, or the deprivation of or lack of essential needs. Neglect occurs on an individual basis when a resident receives a lack of care (e.g., absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces).

“Nursing Assistant” means an individual who is enrolled in a training program for assistants to nurses, for which the curriculum has been approved by the Maine State Board of Nursing.

“Nursing Facility or Nursing Home” means a facility licensed by the Department to provide nursing services.

“Nursing Staff” means Registered Professional Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Certified Nursing Assistants/Medications and nursing assistants.

“Personal Support Specialist (PSS)” means an individual who has successfully completed Departmentally-approved course requirements and is registered as a PSS in accordance with 10-144 CMR Ch.129, Rules and Regulations Governing In-Home Personal Care and Support Workers, and 22 MRS §1717.

“Pharmacist” means an individual currently registered as a pharmacist in the State of Maine.

“Physician” means an individual currently licensed to practice medicine or osteopathy in the State of Maine.

“Potentially Hazardous Foods” means any food or ingredient, natural or synthetic, capable of supporting the rapid and progressive growth of infectious or toxigenic microorganisms

, and 22 MRS §1717.

“Pharmacist” means an individual currently registered as a pharmacist in the State of Maine.

“Physician” means an individual currently licensed to practice medicine or osteopathy in the State of Maine.

“Potentially Hazardous Foods” means any food or ingredient, natural or synthetic, capable of supporting the rapid and progressive growth of infectious or toxigenic microorganisms.

“Pre-Admission Screening” means the procedure that screens each applicant for admission to a nursing facility in order to ensure that the facility does not admit an individual with a mental health condition or intellectual disability unless the Department has determined that the individual requires the level of care furnished by the facility.

“Principles of Reimbursement” means the principles of reimbursement for nursing facilities promulgated from time to time by the Department.

“Prospective Case-Mix Reimbursement System” means a method of paying health care providers rates that are established in advance. These rates take into account the fact that some residents are more costly to care for than others.

“Qualified Social Worker” means a person holding a current and valid license as required by State law to practice social work services.

“Registered Nurse” or “Registered Professional Nurse” means an individual currently licensed to practice professional nursing in the State of Maine.

“Resident” means a person who resides and receives services or care in a nursing facility.

“Resident Assessment Instrument (RAI)” means a standardized approach for applying a problem identification process. It gathers definitive information on a resident’s strengths and needs which must be addressed in an individual care plan.

“Resident Assessment Protocol (RAP)” means the required structured approach to resident assessment and problem identification

vices or care in a nursing facility.

“Resident Assessment Instrument (RAI)” means a standardized approach for applying a problem identification process. It gathers definitive information on a resident’s strengths and needs which must be addressed in an individual care plan.

“Resident Assessment Protocol (RAP)” means the required structured approach to resident assessment and problem identification.

“Respite Care” means care anticipated to be provided for a period of thirty (30) days or less for the purpose of temporarily relieving a family member or other caregiver from his or her daily caregiving duties. All nursing facility regulations shall apply to admissions for respite care.

“Restraint” means any device which is intended to restrict freedom of movement or access to one's body or any medication which alters cognition or behavior and which is used for discipline or convenience and is not required to treat medical symptoms.

“Physical Restraints” are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily and which restricts freedom of movement or normal access to one’s body.

“Chemical Restraint” is defined as a psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.

“Risk” means that there is reasonable cause to believe that injury, hazard, damage or loss may occur.

“Safe Temperatures” as applied to potentially hazardous foods, means internal temperatures of 41 degrees Fahrenheit or below (for cold food) and 140 degrees Fahrenheit or above (for hot foods), unless otherwise specified in these regulations, and 0 degrees Fahrenheit or below for frozen foods.

“Serious Harm” means:

a. Serious physical injury;

b. Serious mental injury or impairment evidenced by severe anxiety, depression, or withdrawal, untoward aggressive behavior, or similar dysfunctional behavior; or

c. Sexual abuse or exploitation

and 140 degrees Fahrenheit or above (for hot foods), unless otherwise specified in these regulations, and 0 degrees Fahrenheit or below for frozen foods.

“Serious Harm” means:

a. Serious physical injury;

b. Serious mental injury or impairment evidenced by severe anxiety, depression, or withdrawal, untoward aggressive behavior, or similar dysfunctional behavior; or

c. Sexual abuse or exploitation.

“Skilled Nursing Care,” for the purpose of these regulations, means that:

a. The service would constitute a skilled service where the inherent complexity of a service prescribed for a resident is such that it can be safely and effectively performed only by or under the direct supervision of professional nursing personnel;

b. The restoration potential of a resident is not the deciding factor in determining whether a service is to be considered skilled or unskilled. Even where full recovery or medical improvement is not possible, skilled care may be needed to prevent, to the extent possible, deterioration of the condition or to sustain current capacities; and

c. A service that is generally unskilled would be considered skilled where, because of special medical complications, its performance or supervision and the observation of the resident necessitates the use of skilled nursing personnel.

“Skilled Nursing Facility” is a nursing facility which is certified to provide Medicare-reimbursed skilled nursing services.

“Specialized Rehabilitative Services” means services such as physical therapy, speech-hearing therapy, and occupational therapy.

“Specialized Unit” means a unit that provides the care to meet the specific needs of special groupings of residents, i.e., residents with Alzheimer’s or head trauma, etc.

“Transfer Agreement” means an agreement with one or more hospitals which provides reasonable assurance that transfer of residents will be effected between facilities whenever such transfer is medically appropriate.

Section 2 - Obtaining a License

2.A. Requirements

2.A.1

ides the care to meet the specific needs of special groupings of residents, i.e., residents with Alzheimer’s or head trauma, etc.

“Transfer Agreement” means an agreement with one or more hospitals which provides reasonable assurance that transfer of residents will be effected between facilities whenever such transfer is medically appropriate.

Section 2 - Obtaining a License

2.A. Requirements

2.A.1. No person or entity shall operate a nursing facility without a license from the Department in force, authorizing such operation. (Title 22, Section 1811)

2.A.2. The person or entity applying for the license shall be responsible for complying with Maine Statutes and all rules and regulations adopted pursuant thereto. (Title 22, Section 1811)

2.A.3. Reimbursement shall not be accepted, by any person, for rendering nursing facility care for even one person not a relative within the third degree of kinship, without such person having first secured a license in force, authorizing such operation in accordance with these regulations.

2.B. Appointment of Administrator

Each licensee shall appoint an administrator for each facility. The licensee and the administrator may be one and the same person.

2.C. First Church of Christ, Scientist Homes

Nursing facilities conducted in accordance with the practice and principle of the body known as the Church of Christ, Scientist, shall be subject to the provisions for licensure by the Department. Approval shall be based upon conditions of public safety and sanitation. Certification shall be required by the First Church of Christ, Scientist, Boston, Massachusetts, that the home is operated in accordance with the practice and principle of that body, and the public shall be informed through the name of the home and any publicity thereon that such home is operated in accordance with the practice and principle of the Church body as indicated above

ty and sanitation. Certification shall be required by the First Church of Christ, Scientist, Boston, Massachusetts, that the home is operated in accordance with the practice and principle of that body, and the public shall be informed through the name of the home and any publicity thereon that such home is operated in accordance with the practice and principle of the Church body as indicated above. Nothing in these rules and regulations shall be construed to authorize any medical supervision, regulation or control of the remedial care and treatment of residents in certified Christian Science facilities.

2.D. Application Procedure

2.D.1. Filing of Application

Any person, partnership, association or corporation, including state, county or local governmental units desiring a license to operate a nursing facility shall, prior to the commencement of such operation, file with the Department a verified application containing the information required in this section. Application on behalf of a corporation or association shall be made by any two officers thereof or by its managing agent. All applicants shall submit satisfactory evidence of their ability to comply with the minimum standards of Title 22, and all rules and regulations adopted thereunder, and whether the applicant(s) are at least 18 years of age. (Title 22, Section 1814) Such application shall be on a form approved by the Department.

2.D.2. Statement by Commissioner of the Department of Public Safety

Each applicant shall provide to the Department a written statement signed by an authorized representative of the Department of Public Safety or the proper municipal official designated in Title 25, Chapters 311 to 321, M.R.S.A., Maine, 1964, to make fire safety inspections that the facility and premises comply with said Chapters 311 to 321 relating to fire safety.

2.D.3

epartment of Public Safety

Each applicant shall provide to the Department a written statement signed by an authorized representative of the Department of Public Safety or the proper municipal official designated in Title 25, Chapters 311 to 321, M.R.S.A., Maine, 1964, to make fire safety inspections that the facility and premises comply with said Chapters 311 to 321 relating to fire safety.

2.D.3. Policies

Each applicant for a skilled nursing facility or nursing facility shall provide the Department with a signed statement from the professional group of advisors indicating approval of the policies.

2.D.4. Fees

Each application, submitted on or after July 1, 2003, for a license to operate a skilled nursing facility or nursing facility shall be accompanied by a fee of twenty-six (26) dollars for each bed contained within the facility. No such fee shall be refunded. All licenses issued shall be renewed annually upon payment of a like fee and compliance with Maine Statutes and any rules and regulations issued thereunder. No license granted is assignable or transferable. (Title 22, Section 1815 and 1815A)

2.D.5. Additional Information

Each applicant shall provide to the Department such information as the Department may require, in order to determine the suitability of the applicant for licensure, in conformity with the provisions of the Statutes of Maine and rules and regulations promulgated thereunder.

2.E. Initial Licensing

In addition to the requirements in Sections A, B, C, and D of this Section, each applicant for initial licensing shall provide:

2.E.1. Floor Plans

A set of plans and specifications of the facility drawn to scale showing the name or number of each resident bedroom, service area, etc., and including the source of utilities, water and methods of waste disposal. If there is a distinct part, this part must be identified.

2.E.2

ents in Sections A, B, C, and D of this Section, each applicant for initial licensing shall provide:

2.E.1. Floor Plans

A set of plans and specifications of the facility drawn to scale showing the name or number of each resident bedroom, service area, etc., and including the source of utilities, water and methods of waste disposal. If there is a distinct part, this part must be identified.

2.E.2. Certificate of Need Approval

There must be an approved written Certificate of Need, signed by the Commissioner, Department of Human Services, or a written determination from the Department of Human Services that a Certificate of Need is not required.

2.E.3. Statement by Bureau of Health

A written statement signed by an authorized representative of the Bureau of Health of the Department indicating compliance of the facility with all applicable State Statutes and appropriate rules and regulations promulgated thereunder relating to plumbing, water supply and sewage disposal.

2.E.4. Policies

A copy of the policies governing the services the facility provides to be available to representatives of the Department and submitted to the Department only if specifically requested in writing. The Department will notify the facility in writing of any policies which are not approved, as being contrary to the provisions of Title 22 M.R.S.A. or rules promulgated thereunder.

2.E.5. Transfer Agreement

Each applicant for a skilled nursing facility or nursing facility license shall provide a copy of all transfer agreements with licensed hospitals, upon request of the Department.

2.E.6. Copy of the Lease

When a building or buildings is or are leased to the person or persons to operate as a licensed facility, a copy of the lease, showing clearly in its context which party to the agreement is to be held responsible for the maintenance and upkeep of the property, shall be filed with the application for a license

ements with licensed hospitals, upon request of the Department.

2.E.6. Copy of the Lease

When a building or buildings is or are leased to the person or persons to operate as a licensed facility, a copy of the lease, showing clearly in its context which party to the agreement is to be held responsible for the maintenance and upkeep of the property, shall be filed with the application for a license. The Department shall be notified within seventy-two (72) hours, if there is any change in the lease agreements that may in any way affect the responsibility for maintenance and upkeep of this property.

2.E.7. Compliance with Local Laws

A letter from the appropriate municipal official having jurisdiction over the premises where the facility is to be located indicating compliance with all local laws or codes relative to the type of facility for which licensure is requested.

2.E.8. Default License for New Nursing Facilities

When a new applicant has filed a completed application and has a building ready for inspection, but has not been provided the necessary notifications, inspections or services from the Division of Licensing and Certification and the Department of Public Safety within ninety (90) days, a provisional license will be issued. All required application materials must be submitted for the application to be considered complete. The Division shall notify a new applicant within two (2) weeks of filing of the application on whether the application is complete. The Division and the Department of Public Safety shall provide necessary services and inspections within ninety (90) days of filing of the complete application. If initial services and inspections are satisfactorily completed within the ninety (90) day time period, an initial license will be issued and no default licensing will occur.

2.F. Issuance of License

2.F.1. Specifications of License

For nursing facilities, each license issued by the Department shall specify:

a. The name of the facility;

b. The location of the facility;

c

te application. If initial services and inspections are satisfactorily completed within the ninety (90) day time period, an initial license will be issued and no default licensing will occur.

2.F. Issuance of License

2.F.1. Specifications of License

For nursing facilities, each license issued by the Department shall specify:

a. The name of the facility;

b. The location of the facility;

c. The name of the administrator;

d. The maximum number of licensed beds, whether Skilled Nursing, Nursing or Dual;

e. The effective dates of the license.

2.F.2. Multilevel Facility License

For multilevel facilities, a single license will be issued by the Department, identifying each level of service.

2.F.3. Facilities Located in Two Structures on the Same Grounds

When one owner, organization or corporation has separate facilities located in physically separated structures on the same grounds, separate licenses shall not be required.

2.F.4. Facilities Operated by Same Management on Different Premises

Facilities operated by the same management on different grounds shall be required to have in effect a separate license for each facility.

2.G. New Construction or Additions

No new construction or additions or alterations shall commence without the applicant having first referred the plans to the Office of Planning, Research and Development for their recommendations, and without having prior written approval by the Department. The provisions of these rules and regulations do not prohibit the use of equivalent alternate space utilizations, new concepts of facility plan design and new finish materials.

2.G.1. An application for approval of new construction or additions or alterations shall be submitted on forms to be furnished by the Department.

2.G.2. Commencement of construction shall not occur until a certificate of approval has been issued by the Department.

2.G.3

o not prohibit the use of equivalent alternate space utilizations, new concepts of facility plan design and new finish materials.

2.G.1. An application for approval of new construction or additions or alterations shall be submitted on forms to be furnished by the Department.

2.G.2. Commencement of construction shall not occur until a certificate of approval has been issued by the Department.

2.G.3. Unless construction is commenced within one year from date of written approval of final working drawings and specifications, the application and the drawings shall be resubmitted for renewal of review and approval.

2.G.4. Minor alterations which do not affect the structural integrity of the building, which do not affect fire safety, which do not change primary functional operation, or which do not change the number of beds for which the facility is licensed, need not be submitted.

2.G.5. Routine maintenance and repairs do not require prior approval by the Department.

2.H. Changes

2.H.1. Changes in Number of Beds

All requests for any increase or decrease in the number of beds shall be made in writing to the Department, at least forty five (45) days prior to the effective date. No changes in the number and/or location of beds, or the distinct part, shall be made without prior written approval of the Department.

2.H.2. Changes in a Licensed Facility

No change shall be made in a licensed facility's operation, program or services without prior written approval of the Department.

2.H.3. Proposed Changes in Physical Plant

No changes in the physical plant or its utilities shall be made until approved in writing by the Department.

2.H.4. Utilization of Additions and Renovations

No new resident rooms or new areas to be used by residents shall be occupied or utilized by residents without prior written approval of the Department.

2.H.5. Change in Ownership of Facility

a. No license shall be assigned or transferred.

b

o changes in the physical plant or its utilities shall be made until approved in writing by the Department.

2.H.4. Utilization of Additions and Renovations

No new resident rooms or new areas to be used by residents shall be occupied or utilized by residents without prior written approval of the Department.

2.H.5. Change in Ownership of Facility

a. No license shall be assigned or transferred.

b. An application for a change of ownership must be submitted in accordance with the Certificate of Need requirements.

c. Each application for a license from a new owner shall be accompanied by a copy of the approved Certificate of Need and a statement from the previous owner or his/her duly authorized representative concerning the change of ownership, or a copy of the deed or other validating document.

d. When the ownership of an occupied facility changes, upon receipt of a completed application and fee, the Department may issue a temporary license for a period not to exceed ninety (90) days. During this period of time, the Department may elect to conduct on-site visits to determine compliance of the new owner with the requirements for initial licensure, unless cause is found for refusal to issue a license which cannot reasonably be expected to change during such ninety (90) day period. If the new owner is in full compliance with the requirements, a license will be issued for the remaining period of time of the current license.

2.H.6. Change of Administrator

A change of administrator shall be reported, in writing, to the Department no later than seventy-two (72) hours prior to the change taking effect. The name and administrator license number of the individual who is to become administrator is to be submitted at that time. The license to operate the facility shall also be returned to the Department to be voided, and a new license issued bearing the name of the new administrator.

2.I

e reported, in writing, to the Department no later than seventy-two (72) hours prior to the change taking effect. The name and administrator license number of the individual who is to become administrator is to be submitted at that time. The license to operate the facility shall also be returned to the Department to be voided, and a new license issued bearing the name of the new administrator.

2.I. Waiver Provisions

Where structural changes in an existing facility are necessary for such facility to comply with the provisions of these regulations and the change would result in an unreasonable hardship to the owners or operators, the Department may grant a waiver of one or more of the specific provisions of these regulations to an operator or owner, in accordance with the following requirements:

2.I.1. Prior to the issuance or renewal of any license, the facility must make written application requesting a waiver to the Department. Such application shall contain a written justification for the request and shall state the specific provisions of these regulations for which a waiver is being requested, and shall document what steps the facility is taking or will take to bring such facility into compliance with those provisions of these regulations, for which a waiver is requested.

2.I.2. The Department may request additional information before making a decision as to granting or denying an application for a waiver.

2.I.3. No waiver shall extend beyond the term of the license and a new waiver shall be required when the license of the facility is renewed. Failure of a facility to implement reasonable steps in order to bring the facility into conformance with these regulations shall be grounds for the denial of a waiver.

2.I.4. No waiver or waivers shall be granted if there would be an adverse effect to the health or safety of the residents of a facility.

2.I.5. The facility will be notified in writing when a waiver is granted, and the specific area for which a waiver has been granted shall be noted on the license.

2.J

he facility into conformance with these regulations shall be grounds for the denial of a waiver.

2.I.4. No waiver or waivers shall be granted if there would be an adverse effect to the health or safety of the residents of a facility.

2.I.5. The facility will be notified in writing when a waiver is granted, and the specific area for which a waiver has been granted shall be noted on the license.

2.J. Posting of License

The license shall be conspicuously posted in an area highly visible to residents and the public.

2.K. Availability of Survey Results

Facilities will have the results of State and Federal surveys, which include the plan of correction, in a place readily accessible to residents, resident representatives and the general public and must post a notice of their availability. Copies of these may be provided by the facility upon reasonable request.

Section 3 - Loss Of, Renewal Of, Temporary & Conditional License

3.A. Refusal to Issue a License

The Department shall refuse to issue a license to the applicant covering the premises identified in the application, if it finds the representation made in the application to be materially incorrect or insufficient, or if it finds that the applicant, the premises, or the designated administrator of the facility do not meet all requirements of law and regulations. Any person who is aggrieved by the decision of the Department in refusing to issue a license or the renewal of a license, may file a statement or complaint with the Administrative Court designated in Title 5, Chapter 375 M.R.S.A., Section 8001 et seq.

3.B. Right of Entry and Inspection

The Department and any duly designated representative thereof shall have the right to enter upon and into the premises of any facility licensed pursuant to these rules and regulations at any time, without threat of injury, verbal abuse or harassment, in order to determine the state of compliance with the provisions of rules and regulations in force pursuant thereto

B. Right of Entry and Inspection

The Department and any duly designated representative thereof shall have the right to enter upon and into the premises of any facility licensed pursuant to these rules and regulations at any time, without threat of injury, verbal abuse or harassment, in order to determine the state of compliance with the provisions of rules and regulations in force pursuant thereto. Such right of entry and inspection shall extend to any premises which the Department has reason to believe are being operated or maintained as a health care facility without a license, but no such entry or inspection of any premises shall be made without the permission of the owner or person in charge thereof, unless a warrant is first obtained from the court of jurisdiction authorizing the same. Any application for a license made pursuant to these rules and regulations shall constitute permission for, and complete acquiescence in, any entry or inspection of the premises for which the license is sought in order to facilitate verification of the information submitted on or in connection with such application. (Title 22, Section 1820-A)

3.C. Renewal of License

At least twenty (20) days prior to the expiration of a license to operate a facility, an application and the required fee for a renewal thereof shall be submitted to the Department on a form approved by the Department, and accompanied by such additional information as may be required. Upon receipt and review of applications and determination of compliance with the requirements of the State Statutes and any rules and regulations adopted pursuant thereto, the Department shall renew such license for a period of one year, unless it finds that there are specific and sufficient grounds either for the denial of the application for renewal or for renewing the license on a temporary or conditional basis.

3.D

w of applications and determination of compliance with the requirements of the State Statutes and any rules and regulations adopted pursuant thereto, the Department shall renew such license for a period of one year, unless it finds that there are specific and sufficient grounds either for the denial of the application for renewal or for renewing the license on a temporary or conditional basis.

3.D. Temporary or Conditional License

If the Department finds that the immediate interests of the residents in a licensed facility and the interest of the general public would be best served by offering such facility the opportunity to correct a condition forming the grounds for revocation of, or refusal to renew a license, it may afford such opportunity. For such purposes, it may issue a temporary or conditional license in accordance with Title 22, Section 1817.

3.E. Suspension or Revocation of License

The Department may, in addition to any other rights or remedies which it may have, file a statement or complaint with the Administrative Court designated in Title 5, Chapter 375 M.R.S.A., Sections 8001 et seq., requesting suspension or revocation of any license on the following grounds: Violation of Title 22, M.R.S.A., Maine, 1964, or the rules and regulations issued pursuant thereto; permitting, aiding or abetting the commission of any illegal act in such institutions; conduct of practices detrimental to the welfare of the residents or any other violation of applicable law or regulation. Upon suspension or revocation of a license, the license shall be immediately surrendered to the Department. The Department may set forth the conditions which shall be met by the facility to the satisfaction of the Department. (See Section 22)

3.F

llegal act in such institutions; conduct of practices detrimental to the welfare of the residents or any other violation of applicable law or regulation. Upon suspension or revocation of a license, the license shall be immediately surrendered to the Department. The Department may set forth the conditions which shall be met by the facility to the satisfaction of the Department. (See Section 22)

3.F. Emergency Suspension

Whenever, on inspection by the Department, conditions are found to exist which violate this chapter or departmental regulation issued thereunder which, in the opinion of the Court, immediately endanger the health or safety of patients, or both such health or safety, in any of such institutions to such an extent as to create an emergency, the Department by its duly authorized agents, may suspend said license until such time as the Department determines that the emergency no longer exists or until a decision is rendered by the Administrative Court. The Department shall give written notice of such emergency suspension by delivering notice in hand to the licensee. If the licensee cannot be reached for personal service, the notice may be left at the licensed premises with a licensed staff person. Whenever a license is suspended by the Department under this emergency provision, the Department shall file a complaint with the Administrative Court requesting suspension or revocation of such license. (See Section 22)

3.G. Public Notice

If the license is revoked or suspended, or a conditional license is voided, the Department will advise the public of such action. The notice to the public will be in the form of a paid legal notice in the local newspaper(s), published within fifteen (15) days following the termination, suspension or revocation of the license.

3.H

n or revocation of such license. (See Section 22)

3.G. Public Notice

If the license is revoked or suspended, or a conditional license is voided, the Department will advise the public of such action. The notice to the public will be in the form of a paid legal notice in the local newspaper(s), published within fifteen (15) days following the termination, suspension or revocation of the license.

3.H. Involuntary Closing of a Licensed Facility

If the license is revoked or suspended, or a conditional license is voided, or the Department refuses to issue or renew a license, the facility shall, in consultation with the Department, make appropriate arrangements for the orderly transfer of all residents.

3.I. Voluntary Closing of a Licensed Facility

Whenever a licensed facility voluntarily discontinues operation, the facility shall notify the Department, and during the period when it is preparing for such discontinuance, the facility shall inform the resident, the next of kin, legal representative or agency acting on the resident's behalf of the fact and the proposed time of such discontinuance, with at least thirty (30) days notice so that suitable arrangements may be made for the orderly transfer and care of such resident. In the case of any resident who has no person acting on his/her behalf, the facility shall be responsible for assisting such resident to arrange for a suitable transfer prior to the discontinuance of operation. Immediately upon discontinuance of operation of a licensed facility, the owner shall surrender the license to the Department.

Section 4 – Administration

4.A. Administrator

4.A.1. Qualifications

The administrator of a facility licensed pursuant to these regulations shall have a current administrator's license or a temporary permit issued by the Nursing Home Administrators Licensing Board. Hospital based facilities are not required to have a licensed nursing home administrator.

4.A.2. Functions

The administrator designated on the license shall be responsible for:

a

.1. Qualifications

The administrator of a facility licensed pursuant to these regulations shall have a current administrator's license or a temporary permit issued by the Nursing Home Administrators Licensing Board. Hospital based facilities are not required to have a licensed nursing home administrator.

4.A.2. Functions

The administrator designated on the license shall be responsible for:

a. Carrying out the policies of the facility;

b. The day-to-day operation and management;

c. The control, conservation and utilization of physical and financial resources;

d. The hiring of an adequate number of qualified, competent personnel;

e. The discharge of such functions as the licensee may properly delegate to him/her;

f. Ensuring that the facility is in compliance with State licensing and Federal certification regulations.

4.A.3. Non-Licensed Person to Act in Absence of Administrator

An individual, authorized to act in the absence of the administrator during the normal working day, shall be designated. Any planned absence of the administrator for a period longer than thirty (30) days shall be reported in writing to the Department.

4.A.4. Non-Licensed Acting Administrator for Emergency Conditions

If the licensee of a licensed skilled nursing facility and/or a nursing facility is required to secure a new administrator as a result of an unexpected vacancy, he/she may, upon seventy-two (72) hours notice to the Department and in accordance with the rules and regulations thereof, place the facility in charge of an acting administrator qualified through current experience in administrative long term care responsibilities. This shall be for such limited time mutually agreed upon between the Department and the licensee, as may be necessary to permit the securing of a licensed administrator, but in no event to exceed sixty (60) days. When a licensed administrator has been secured, the provisions of Section 2.H.6., Change of Administrator, shall apply

urrent experience in administrative long term care responsibilities. This shall be for such limited time mutually agreed upon between the Department and the licensee, as may be necessary to permit the securing of a licensed administrator, but in no event to exceed sixty (60) days. When a licensed administrator has been secured, the provisions of Section 2.H.6., Change of Administrator, shall apply. If unable to secure a licensed administrator within sixty (60) days, the facility shall submit to the Department written evidence of action taken to secure an administrator.

4.A.5. Full-Time Administrator

Each nursing facility larger than forty (40) beds in size shall have a full-time administrator.

4.A.6. Part-Time Administrator

a. Each nursing facility of forty (40) beds or less in size, may have a part-time administrator.

b. All duties and schedules of working hours of part-time administrators of nursing facilities shall be outlined in the policies of the facility.

4.A.7. Shared Administrator

a. Separately licensed nursing facilities and/or assisted living facilities may share the same administrator as long as the number of beds for which the administrator is responsible does not exceed one hundred (100), subject to approval of the Department.

b. Requests to the Department for exceptions to (a) above may be made in writing when administrative functions for two (2) or more licensed facilities are carried out in a central office. Such requests shall define the functions being handled centrally. The Department shall indicate in writing whether or not the request for an exception is granted.

c. Any sharing of the same administrator shall be defined and the duties and schedule of working hours for each facility shall be outlined in the policy material of the facilities involved.

4.A.8. Administrator In Training

Any facility that has an administrator in training (AIT) must ensure that a licensed administrator or designee other than the AIT is in charge of the facility

ption is granted.

c. Any sharing of the same administrator shall be defined and the duties and schedule of working hours for each facility shall be outlined in the policy material of the facilities involved.

4.A.8. Administrator In Training

Any facility that has an administrator in training (AIT) must ensure that a licensed administrator or designee other than the AIT is in charge of the facility. No AIT is to be listed on any facility license as the administrator.

4.B. Register

4.B.1. There shall be a waiting list for facility admissions which shall be maintained in a bound book or on a computer, updated as necessary.

4.B.2. There shall be a resident admission and discharge register in a bound book or on a computer identifying each resident and the date admitted to and discharged from the facility.

4.C. Daily Census

Each facility shall maintain a daily census of residents, including the following:

4.C.1. Admissions;

4.C.2. Discharges;

4.C.3. The number and bed locations of each resident in the facility as of each day.

4.D. Transfer Agreement

4.D.1. Requirements

Each facility shall have in effect a written agreement with a hospital sufficiently close to the facility to make feasible the transfer between them of residents and their records, which provides the basis for effective working arrangements under which inpatient hospital care or other hospital services are available promptly to the facility's residents when needed.

4.D.2. Content

a. The transfer agreement shall provide for the transfer of written information pertaining to the care which the resident has been receiving.

b. The transfer agreement shall provide for the transfer of written information relative to personal effects of significant value.

4.D.3. Execution

Each transfer agreement shall be signed by the administrator or authorized representative of each facility participating in the agreement.

4.E. Outside Resources

4.E.1

written information pertaining to the care which the resident has been receiving.

b. The transfer agreement shall provide for the transfer of written information relative to personal effects of significant value.

4.D.3. Execution

Each transfer agreement shall be signed by the administrator or authorized representative of each facility participating in the agreement.

4.E. Outside Resources

4.E.1. Requirements

If the facility does not employ a qualified professional person such as a physical therapist, occupational therapist or speech therapist to render a specific service to be provided by the facility, there shall be arrangements for such a service through a written agreement with an outside resource, a person or agency, that will render direct service to residents or act as a consultant.

4.E.2. Contents of Agreement

a. The responsibilities, functions, objectives, and terms of the agreement, including financial arrangements and charges, of each such outside resource shall be delineated in writing

b. The agreement shall specify that the facility retains administrative responsibility for the services rendered.

c. When the agreement is with a consultant, there shall be provision for dated, signed reports to the administrator of assessments and/or recommendations. These shall be retained by the administrator for follow-up action and evaluation of performance.

4.E.3. Execution

The agreement shall be signed by the administrator or authorized representative and the person or agency providing the service.

4.F. Rebating Prohibited

No owner, administrator, employee or representative of a licensed facility shall directly or indirectly pay any commission, bonus, or gratuity in any form whatsoever to any physician, organization, agency or person for residents referred.

4.G. Admissions

A facility must establish identical practices for admissions, transfers and discharges for all individuals regardless of source of payment, as addressed below.

4.G.1. Admissions

a. The facility must not:

1

ed facility shall directly or indirectly pay any commission, bonus, or gratuity in any form whatsoever to any physician, organization, agency or person for residents referred.

4.G. Admissions

A facility must establish identical practices for admissions, transfers and discharges for all individuals regardless of source of payment, as addressed below.

4.G.1. Admissions

a. The facility must not:

1. Require a third party guarantee of payment to the facility as a condition of admission, or to expedite admission, or continued stay in the facility;

2. Charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility;

3. Require residents or potential residents to waive their rights to Medicare or Medicaid;

4. Require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.

b. A facility may:

1. Charge any amount for services furnished to non-Medicaid residents consistent with the requirement in 4.G.1.a.

2. Require an individual who has legal access to a resident's income or resources available to pay for facility care, to sign a contract, or to provide facility payment from the resident's income or resources, without incurring personal financial liability.

3. Charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the Maine Medical Assistance Manual as included in the term "nursing facility services".

4. Solicit, accept or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the resident, or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility.

5

in the Maine Medical Assistance Manual as included in the term "nursing facility services".

4. Solicit, accept or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the resident, or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility.

5. A nursing facility may decline to admit a prospective resident after an evaluation of the person’s clinical condition and related care needs and a determination that the facility lacks qualified staff to meet the level of care required for that person. A nursing facility is not subject to penalty or sanction for declining to admit a prospective resident for whom the facility lacks sufficient staff to meet the resident’s level of care.

4.G.2. Deceased Residents

A facility shall comply with all appropriate Maine statutes and regulations pertinent to deceased residents.

4.H. Quality Assurance Committee

All nursing facilities must maintain a quality assurance committee, which may act as a committee of the whole, and which reports to the administrator or the Governing Body.

4.H.1. Composition of Committee

a. The Director of Nursing Services;

b. The Medical Director;

c. A Pharmacist;

d. At least three (3) other members of the facility staff.

4.H.2. Responsibilities of the Committee

a. Meet at least quarterly;

b. Monitor the quality, quantity and necessity of services. Identify and document problems or deficiencies.

c. Develop and implement appropriate plans of action to correct identified problems or deficiencies which shall be available for review upon request of the Department.

4.H.3. Components and Functions of the Committee

a. Infection Control

1. Assure policies and procedures are based upon current standards and Centers for Disease Control guidelines for:

a. Prevention of infection;

b. Universal precautions;

c. Employee and resident infections;

d. Linen handling;

e

deficiencies which shall be available for review upon request of the Department.

4.H.3. Components and Functions of the Committee

a. Infection Control

1. Assure policies and procedures are based upon current standards and Centers for Disease Control guidelines for:

a. Prevention of infection;

b. Universal precautions;

c. Employee and resident infections;

d. Linen handling;

e. Food handling;

2. Monitor and investigate infections.

b. Accident Prevention

Monitor and analyze incident reports and recommend policies and procedures for accident prevention.

c. Pharmaceutical Services

Monitor pharmaceutical practices, identify concerns, and recommend changes, when necessary.

d. Utilization Review

Establish and monitor a Utilization Review plan that shall include:

1. Monitoring of admissions (regardless of payment source), and necessity of services;

2. Review of all residents (regardless of payment source), continued stays and discharge planning; and

3. Review the implementation of monitoring of appeal rights and the process of transfer and discharge notice.

4.I. Complaints

4.I.1. Any person may file a complaint with the administrator or any member of the facility staff.

4.I.2. A system must be established for the review, within forty-eight (48) hours, of each complaint received by the administrator and/or any designated member of the facility staff. A report of findings and action taken shall be prepared and submitted to the Quality Assurance Committee, and be available for review upon request of the Department.

4.J. Reporting of Abuse, Neglect or Misappropriation of Resident Property

4.J.1

blished for the review, within forty-eight (48) hours, of each complaint received by the administrator and/or any designated member of the facility staff. A report of findings and action taken shall be prepared and submitted to the Quality Assurance Committee, and be available for review upon request of the Department.

4.J. Reporting of Abuse, Neglect or Misappropriation of Resident Property

4.J.1. The facility must ensure that all staff are knowledgeable of the Adult Protective Services Act and that all alleged violations involving mistreatment, neglect, and abuse, including injuries of unknown source and/or misappropriation of resident property, are reported immediately, through established procedures, to the administrator of the facility and to other officials in accordance with State law.

4.J.2. The facility must have evidence that all alleged violations are thoroughly investigated and in a timely manner. Policies must address administrative procedures to be implemented to prevent further potential abuse while the investigation is in progress.

4.J.3. The results of all investigations conducted in-house must be reported to the administrator or his/her designated representative and to other officials in accordance with State law. If the alleged violation is verified, appropriate corrective action must be taken. All reports must be made available to the Department upon request.

Section 5 - Facility Policies

5.A. Professional Policy Group

5.A.1. Requirements

Each facility shall have written policies which govern all areas of services provided and are developed with the advice of, and with provisions for, annual review by a group of professional personnel including the administrator, Director of Nurses, a physician, a registered pharmacist, and such other professional personnel as necessary.

5.A.2. Meetings

The professional policy group shall meet as necessary, but at least annually, to review written policies and reports of the Quality Assurance and other Committees

e of, and with provisions for, annual review by a group of professional personnel including the administrator, Director of Nurses, a physician, a registered pharmacist, and such other professional personnel as necessary.

5.A.2. Meetings

The professional policy group shall meet as necessary, but at least annually, to review written policies and reports of the Quality Assurance and other Committees. All members of the group should be present or have input and minutes of meetings shall be recorded and reflect the activities.

5.A.3. The professional policy group meetings may be incorporated within the Quality Assurance Committee.

5.B. Written Policies

5.B.1. The written policies of each facility shall be consistent with State licensing and Federal certification requirements and shall include:

a. Specific reference to indicate the person or persons responsible for the execution of such policies;

b. A written outline of the objectives of the facility;

c. Provision for these written policies to be available at all times to residents, families, admitting physicians, sponsoring agencies, staff, and the public;

d. Provision for implementation of policies and training of staff;

5.B.2. Policies shall address all areas of services provided and facility practices regarding:

a. Resident Rights, including advanced directives for care and treatment, and grievance procedures;

b. The types and extent of services that are available in the facility;

c. The extent of medical and nursing practices that may be provided by the facility;

d. The type of residents that the facility will accept, based on sex, mental status, source of referral, etc. Policies should also provide that residents will be accepted regardless of race, color, national origin, sexual orientation or reimbursement source;

e. The waiting list for facility admissions;

f. The Quality Assurance Committee;

g. Admissions, transfers and discharges:

1

e facility;

d. The type of residents that the facility will accept, based on sex, mental status, source of referral, etc. Policies should also provide that residents will be accepted regardless of race, color, national origin, sexual orientation or reimbursement source;

e. The waiting list for facility admissions;

f. The Quality Assurance Committee;

g. Admissions, transfers and discharges:

1. Provision for prevention of resident transfer from one part of the facility to another, except from a private room, solely because of Medicaid status;

2. Provision for prevention of discharging a patient from a nursing facility solely because of Medicaid status;

3. A nursing facility must establish and follow written readmission policies which are consistent with all applicable regulations and statutes.

h. Physician services;

i. Emergencies;

j. Pharmaceutical services;

k. Dietary services;

l. Diagnostic and other services, including the tests which may be done within the facility;

m. Written agreements with outside resources;

n. Social services;

o. Independent and group activities;

p. Physical and chemical restraints;

q. Resident records;

r. Maintenance, laundry and housekeeping services;

s. Infection control and waste management;

t. Smoking restrictions;

u. Dental services;

v. Disaster preparedness;

w. Reporting of abuse, neglect and/or misappropriation of resident property;

x. Nursing services;

y. Staff orientation and in-service;

z. Rehabilitative services.

Section 6 - Contracts with Residents

6.A. Contract Between Resident and Representative of Facility

The presence of each resident admitted after the effective date of these regulations in a licensed facility shall be covered by a standardized contract executed at the time of admission, or prior thereto, by the resident or legal representative and the licensed facility (see Appendix A of these Regulations)

6 - Contracts with Residents

6.A. Contract Between Resident and Representative of Facility

The presence of each resident admitted after the effective date of these regulations in a licensed facility shall be covered by a standardized contract executed at the time of admission, or prior thereto, by the resident or legal representative and the licensed facility (see Appendix A of these Regulations). Each party to such contract shall be entitled to a copy thereof and the licensed facility shall keep on file all contracts which it has with residents. The licensed facility shall not destroy or otherwise dispose of any such contract except as otherwise permitted by law.

6.B. Provisions of Contract

Each contract to which this section applies shall contain express provisions specifically setting forth the following:

6.B.1. The services and accommodations to be provided by the facility and the rates and charges therefor, including an outline of responsibilities for and payment of treatment and medications, special equipment and appliances, dressings, clothing, personal supplies of the resident; services of related medical and paramedical personnel; and any other related charges not covered by the facility's basic per diem rate;

6.B.2. The identity of the person or party who is to be responsible for personal funds of the resident, including the name, address and telephone number of the person to be responsible, if other than the resident or an agent of the facility;

6.B.3. The specification of any rights, duties and obligations of both residents and the facility in addition to those required by law;

6.B.4. Provision that a resident may obtain medical care from any qualified institution, agency or person of his/her choice, as long as that health care provider complies with any applicable laws or rules concerning the provision of care to the resident and with the reasonable policies of the facility;

6.B.5

s and obligations of both residents and the facility in addition to those required by law;

6.B.4. Provision that a resident may obtain medical care from any qualified institution, agency or person of his/her choice, as long as that health care provider complies with any applicable laws or rules concerning the provision of care to the resident and with the reasonable policies of the facility;

6.B.5. Provision that a resident may obtain medication from any qualified pharmacy, as long as that pharmacy complies with any applicable State rules and federal regulations and with the reasonable policies of the facility concerning procurement of medication;

6.B.6. The established procedures to be followed in an emergency which cover immediate care of the residents, persons to be notified and reports to be prepared;

6.B.7. Those facilities that decide to use the Standardized Contract, without any additions, are considered to meet State licensing requirements for contracts with residents. The standardized contract may contain any other provisions in a separate addendum/rider, which do not violate State law or rule or federal law or regulation and that are specifically allowed by the standardized contract found in Appendix A of these Regulations.

6.B.8. Provision for addressing discharge potential and planning.

6.C. Contract Requirements

Each contract or agreement is subject to the following requirements:

6.C.1. No contract or agreement may contain a provision for the discharge or transfer of a resident to another facility or another room within the same facility which is inconsistent with State law or rule.

6.C.2. Each contract or agreement shall contain a complete copy of the department rules establishing residents' rights and shall contain a written acknowledgment that the resident has been informed of those rights. In the case of a person who is adjudicated incompetent, the written acknowledgment of those rights shall be made by a representative of the resident

inconsistent with State law or rule.

6.C.2. Each contract or agreement shall contain a complete copy of the department rules establishing residents' rights and shall contain a written acknowledgment that the resident has been informed of those rights. In the case of a person who is adjudicated incompetent, the written acknowledgment of those rights shall be made by a representative of the resident. No provision in the contract or agreement may negate, limit or otherwise modify any provision of the residents' rights.

6.C.3. No provision of a contract or agreement may require or imply a lesser standard of care or responsibility than is required by law or rule.

6.C.4. No provision of a contract or agreement may state or imply a lesser degree of responsibility for the personal property of a resident than is required by law or rule.

6.C.5. No contract or agreement may require the resident to sign a waiver of liability statement as a condition of discharge, even if the discharge is against medical advice. This does not prohibit a facility from attempting to obtain a written acknowledgment that the resident has been informed of the potential risk in being discharged against medical advice.

6.C.6. Each contract or agreement shall contain a provision which provides for at least thirty (30) days’ notice prior to any changes in rates and/or charges, responsibilities, services to be provided or any other items included in the contract or agreement.

6.C.7. No contract or agreement may require the resident to authorize the facility or its staff to manage, hold or otherwise control the income or other assets of a resident.

6.C.8. No contract or agreement may contain any provisions which restrict or limit the ability of a resident to apply for and receive Medicaid or which require a specified period of residency prior to applying for Medicaid. The resident may be required to notify the facility when an application for Medicaid has been made

o manage, hold or otherwise control the income or other assets of a resident.

6.C.8. No contract or agreement may contain any provisions which restrict or limit the ability of a resident to apply for and receive Medicaid or which require a specified period of residency prior to applying for Medicaid. The resident may be required to notify the facility when an application for Medicaid has been made. No contract or agreement may require a deposit or other prepayment from Medicaid recipients. No contract or agreement may refuse to accept retroactive Medicaid benefits.

6.C.9. Medicaid Payment is payment in full when the person’s Medicaid eligibility begins. Nursing facilities are required to refund any payment, within thirty (30) days, which was received from a resident or family member for the period of time that the Medicaid eligibility was pending and the resident is then determined eligible for Medicaid.

6.C.10. No contract agreement may contain a provision which provides for the payment of attorneys’ fees or any other cost of collecting payments from the resident.

6.C.11. A nursing facility may require an identification photograph of each resident. Photographs may not be used for any other purpose without the permission of the resident for each specific use. The permission must indicate the specific purpose which the pictures are to be used for and, except for the identification photograph, may not be contained in the admission contract or agreement.

6.D. Obligations

The contract or any provision thereof shall not be construed to relieve any licensed facility of any requirement or obligation imposed upon it by Maine Statutes or any standards, rules or regulations pursuant thereto.

Section 7 - Residents' Property and Finances

7.A. Authority and Responsibility

7.A.1

cation photograph, may not be contained in the admission contract or agreement.

6.D. Obligations

The contract or any provision thereof shall not be construed to relieve any licensed facility of any requirement or obligation imposed upon it by Maine Statutes or any standards, rules or regulations pursuant thereto.

Section 7 - Residents' Property and Finances

7.A. Authority and Responsibility

7.A.1. Presence of Resident

The admission of a resident to a facility shall not confer on such facility or its owner, administrator, employees or representatives any authority to manage, use or dispose of any property of such resident, nor shall such admission or presence confer on any of the aforementioned persons any authority or responsibility for the personal affairs of the resident, except insofar as may be necessary for the safe and orderly management of the licensed facility.

7.A.2. Guardian, Trustee or Conservator

No facility, and no owner, administrator, employee or representative thereof or their relative shall act as guardian, trustee or conservator for any resident of such facility or any of such resident's property. Exceptions to this requirement may be considered by the Department for residents who are relatives of the owner, administrator, employee or representative of the licensed facility or their spouse within the third degree of kinship.

7.A.3. Safekeeping

A licensed facility shall provide for the safekeeping of personal effects, funds, and other property of the resident. For the protection of valuables, or in order to avoid unreasonable responsibility thereof, the facility may require that they be excluded or removed from the facility and kept at some place not subject to the control of the facility. Any removal or exclusion shall be done only after reasonable notice is given to the resident or his/her guardian.

7.B. Protection of Resident Funds

The facility may not require residents to deposit their personal funds with the facility.

7.C

ility thereof, the facility may require that they be excluded or removed from the facility and kept at some place not subject to the control of the facility. Any removal or exclusion shall be done only after reasonable notice is given to the resident or his/her guardian.

7.B. Protection of Resident Funds

The facility may not require residents to deposit their personal funds with the facility.

7.C. Management of Personal Funds

Upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the resident deposited with the facility under a system established and maintained by the facility in accordance with this Chapter.

7.C.1. Permission to Manage Personal Funds

No operator or agent of any nursing care facility shall manage, hold or deposit in a financial institution the personal funds of any resident of the facility, unless the operator or agent has received written permission thereof from:

a. The resident; or

b. The resident's guardian, trustee, or conservator, if such person exists and can be reached; or

c. The Department, if a guardian, trustee, or conservator exists, but cannot be reached.

7.D. Deposit of Funds

7.D.1. Funds in Excess of $50

The facility must deposit residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on those accounts to the respective residents.

7.D.2. Funds Less Than $50

The facility may maintain residents' personal funds that do not exceed $50 in a non-interest bearing account or petty cash fund which is readily available upon request during normal business working hours.

7.E. Accounting and Records

The facility must establish and maintain a system that assures a full, complete and separate accounting, according to generally accepted principles, of each resident's personal funds, regardless of source, deposited with the facility on the resident's behalf.

7.E.1

account or petty cash fund which is readily available upon request during normal business working hours.

7.E. Accounting and Records

The facility must establish and maintain a system that assures a full, complete and separate accounting, according to generally accepted principles, of each resident's personal funds, regardless of source, deposited with the facility on the resident's behalf.

7.E.1. A written quarterly accounting must be given to the resident or responsible party.

7.E.2. The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.

7.E.3. The individual financial record must be available upon request to the resident or legal representative during normal business working hours.

7.F. Notice of Certain Balances

7.F.1. The facility must notify each resident who receives Medicaid benefits:

a. When the amount in the resident's account reaches $200 less than the Social Security Supplemental Income resource limit for one person, and

b. That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the Social Security Supplemental Income resource limit for one person, the resident may lose eligibility for Medicaid or Social Security Supplemental Income.

7.G. Conveyance Upon Death

Upon death of a resident with a personal fund deposited with the facility, the facility must, within thirty (30) days, convey the resident's funds, and a final accounting of those funds, to the individual administering the resident's estate; in the case of a resident with no responsible person, to the Public Administrator of the County.

7.H. Assurance of Financial Security

The facility must purchase a surety bond, or provide self-insurance to assure the security of all personal funds of residents deposited with the facility.

7.I

dent's funds, and a final accounting of those funds, to the individual administering the resident's estate; in the case of a resident with no responsible person, to the Public Administrator of the County.

7.H. Assurance of Financial Security

The facility must purchase a surety bond, or provide self-insurance to assure the security of all personal funds of residents deposited with the facility.

7.I. Limitation on Charges to Personal Funds

The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made, or could be made, under Medicaid or Medicare or other third party insurance.

Section 8 – Personnel

8.A. Personnel Policies

The facility shall have policies that address all personnel practices.

8.B. Staff Qualifications

8.B.1. The facility must employ, on a full time, part time, or consultant basis those persons necessary to carry out the provisions of these regulations.

8.B.2. Staff must be licensed, certified, or registered in accordance with applicable State laws.

8.C. Employees

8.C.1. Nursing Staff

a. Licensed Staff

R.N.s and L.P.N.s must hold a current State of Maine license or permit, which must be verified prior to employment and upon each renewal.

b. Certified Nursing Assistant

1. A facility must not employ anyone as a nursing assistant for more than four (4) months, on a full-time, temporary, per diem, or other basis, unless that individual has completed a training and/or competency evaluation program that is based upon the standard curriculum established by the Maine State Board of Nursing and approved by the Department of Education, or has been granted reciprocity or has been deemed competent under Maine State Board of Nursing rules.

2

than four (4) months, on a full-time, temporary, per diem, or other basis, unless that individual has completed a training and/or competency evaluation program that is based upon the standard curriculum established by the Maine State Board of Nursing and approved by the Department of Education, or has been granted reciprocity or has been deemed competent under Maine State Board of Nursing rules.

2. When an individual has not performed paid nursing services for a continuous period of twenty-four (24) consecutive months since the most recent completion of a training and competency evaluation program, the individual must meet qualifications for competency established by the Maine State Board of Nursing.

3. A facility may not use staff of outside agencies to perform nursing assistant duties, unless that person is a CNA.

4. The facility must check with the State of Maine Registry of Certified Nursing Assistants to assure that the prospective CNA is listed on the Registry and has no record of a conviction or a substantiated complaint of resident abuse, neglect or misappropriation of residents' funds or property.

c. Certified Nursing Assistant/Medications (CNA/M)

A CNA/M must be qualified as a CNA, as noted above, and also must have completed a course in the administration of medications as approved by the Department of Education, the curriculum of which has been established by the Maine State Board of Nursing.

8.C.2. Non-Nursing Personnel

a. There shall be adequate numbers of non-nursing personnel to perform the necessary services and meet the needs of the residents and the facility. These persons shall not give resident care, unless staffing patterns, training, qualifications and job descriptions reflect the activities of such multi-purpose personnel.

b. Personal Support Specialists may give resident care within the scope of their training.

8.C.3. In-Service Program

a

n-nursing personnel to perform the necessary services and meet the needs of the residents and the facility. These persons shall not give resident care, unless staffing patterns, training, qualifications and job descriptions reflect the activities of such multi-purpose personnel.

b. Personal Support Specialists may give resident care within the scope of their training.

8.C.3. In-Service Program

a. There shall be an orientation program for all new employees that includes review of all applicable facility policies, including resident rights, job description, and related responsibilities.

b. The facility must provide at least twelve (12) hours per year for CNA staff and periodic in-service education to all other employees.

c. The in-service program shall be planned and include at least one program per year relating to resident rights, disaster preparedness, workplace safety and the identified educational needs of the staff.

d. In-service education must include specific training for staff providing nursing and nursing related services to residents with cognitive impairments including but not limited to people with Alzheimer’s or dementia and for those conditions which may be applicable to the resident population of the facility. For facilities with units specific to residents with Alzheimer’s or dementia, refer to Section 23 of these Regulations.

e. Records shall be maintained which indicate the content of and staff participation in all such orientation and staff development programs.

8.C.4. Employees with Contagious or Infectious Diseases

No licensed facility shall knowingly employ or otherwise permit any person to serve therein in any capacity if such person has a communicable or infectious disease or condition which would make him/her dangerous to the health and welfare of residents therein.

8.C.5

staff participation in all such orientation and staff development programs.

8.C.4. Employees with Contagious or Infectious Diseases

No licensed facility shall knowingly employ or otherwise permit any person to serve therein in any capacity if such person has a communicable or infectious disease or condition which would make him/her dangerous to the health and welfare of residents therein.

8.C.5. Employment Restrictions

The facility must not employ individuals who have been convicted by a court of law or have had complaints substantiated by the Department of abusing, neglecting, or mistreating individuals or misappropriating funds or property in a health care or related setting.

8.C.6. Reporting of Abuse (or Suspicion of)

a. The facility must ensure that all staff are knowledgeable of the State Mandatory Reporting Law and that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and/or misappropriation of resident property, are reported immediately through established procedures, to the administrator of the facility and to other officials in accordance with State law.

b. The facility must have evidence that all alleged violations were thoroughly and immediately investigated. Policies must address administrative procedures to be implemented to prevent further potential abuse while the investigation is in progress.

c. The results of all investigations conducted in-house must be reported to the administrator or his designated representative and to other officials in accordance with State law as soon as completed. If the alleged violation is verified by the facility or the State Agency, appropriate corrective action must be taken. The reports shall be made available to the Department upon request.

8.C.7. Age Requirement

No person under the age of sixteen (16) shall fulfill the staffing requirements for CNAs.

8.C.8

d representative and to other officials in accordance with State law as soon as completed. If the alleged violation is verified by the facility or the State Agency, appropriate corrective action must be taken. The reports shall be made available to the Department upon request.

8.C.7. Age Requirement

No person under the age of sixteen (16) shall fulfill the staffing requirements for CNAs.

8.C.8. Grievances

Employees may voice grievances and register complaints with the administrative staff or appropriate outside agencies without fear of reprisal or discharge and shall expect prompt response and disposition of the grievance. No facility may take any action toward an employee which would create a fear of reprisal or a fear of discharge.

8.D. Personnel Records

8.D.1. Employee Record on File

a. Employment History

A record shall be completed for each employee, kept on file in the facility, and shall be available to Department personnel for inspection. Each record shall contain documentation of references and checks, dates of employment, home address, education or background, social security number, occupational license number if applicable, past experience or type of employment, where previously employed, type of position employed for in this facility and last day employed (if no longer in present facility). The current occupational license number, when applicable, shall be on file.

b. In-services

Records shall be maintained of staff attendance at in-services and other educational programs.

c. Work Performance

A record shall be kept for each employee of signed performance evaluations.

d. Illness and Accidents

A record shall be kept for each employee of all illnesses and of all accidents occurring on duty.

e. Feeding Assistants

All nursing facilities shall maintain a record of the individuals who have successfully completed a State approved feeding assistance program

rograms.

c. Work Performance

A record shall be kept for each employee of signed performance evaluations.

d. Illness and Accidents

A record shall be kept for each employee of all illnesses and of all accidents occurring on duty.

e. Feeding Assistants

All nursing facilities shall maintain a record of the individuals who have successfully completed a State approved feeding assistance program. Feeding assistants shall not feed residents who require the assistance of staff with more specialized training, such as residents with recurrent lung aspirations, difficulty swallowing, on feeding tubes, and parenteral or IV feedings.

8.E. Weekly Time Schedule

Each facility shall post a dated employee weekly time schedule in a convenient place for employee use. This shall contain each employee's name, job title and location, hours of work and days off for each day of the week. Any changes in staff or hours of work are to be posted on the time schedule. These weekly time schedules shall be kept on file in the facility for one year and shall be available to Department personnel for inspection.

8.F. Laws of the Maine Department of Labor

The current regulations of the Maine Department of Labor shall be followed.

8.G. Identification Badges

All direct care staff shall, at all times, wear identification badges reflecting their name and title, except in situations in which wearing an identification badge would create a safety hazard.

Section 9 - Resident Care Staffing

9.A. Minimum Nursing Staff Requirements

The following minimum nursing staff requirements shall be met:

9.A.1. Director of Nursing

a. In each licensed nursing facility there shall be a Registered Professional Nurse employed full-time who shall be responsible for the direction of all nursing services delivered in the facility.

b. The Director of Nursing must be qualified by education, training and experience in both Gerontology and nursing administration.

c

m nursing staff requirements shall be met:

9.A.1. Director of Nursing

a. In each licensed nursing facility there shall be a Registered Professional Nurse employed full-time who shall be responsible for the direction of all nursing services delivered in the facility.

b. The Director of Nursing must be qualified by education, training and experience in both Gerontology and nursing administration.

c. If the Director of Nursing is functioning as a Temporary Administrator, a nurse shall be appointed to act as the Director of Nursing during that period of time.

d. Lines of responsibility shall be clearly established in writing and shall be made known to all nursing staff and other appropriate personnel.

9.A.2. Director of Nursing - Responsibilities

The Director of Nursing shall be responsible and accountable to the Administrator for:

a. Assuring the delivery of all required services to residents;

b. Developing and maintaining nursing service objectives, current standards of nursing practice, nursing policy and procedure and manuals, and written job descriptions for each level of personnel;

c. Coordination of nursing services with other resident services;

d. Establishment of the means of assessing the needs of residents and staffing to meet those needs on all shifts;

e. Assuring the delivery of orientation programs and staff development;

f. Participating in the selection of prospective residents in terms of nursing service they need and nursing competencies available;

g. Assuring that a comprehensive assessment and plan of care is established for each resident, and that his/her plan is reviewed and modified and implemented as is necessary;

h. Assuring the evaluation of the performance for all nursing personnel at regular intervals and making recommendations to the administrator;

i. Recommending action when needed to control noise, maintain, repair or replace equipment; ensuring cleanliness and safety measures; providing proper allocation and utilization of space and equipment;

j

reviewed and modified and implemented as is necessary;

h. Assuring the evaluation of the performance for all nursing personnel at regular intervals and making recommendations to the administrator;

i. Recommending action when needed to control noise, maintain, repair or replace equipment; ensuring cleanliness and safety measures; providing proper allocation and utilization of space and equipment;

j. Recommending to the administrator the number and levels of nursing personnel, supplies and equipment for safe resident care;

k. Establishing priorities for budget items that are necessary to provide services;

l. Participating in the Quality Assurance Committee and other committees as necessary.

9.A.3. Licensed Staff Coverage

a. There shall be a Registered Professional Nurse on duty for at least eight (8) consecutive hours each day of the week.

b. Licensed nurse coverage shall be provided according to the needs of the residents as determined by their levels of care. The following minimum coverage shall be met:

1. Day Shift

a. In each facility there shall be a licensed nurse on duty seven (7) days a week.

b. Each facility must designate a Registered Professional Nurse or a Licensed Practical Nurse as the charge nurse. In facilities with twenty (20) beds or less, the Director of Nursing may also be the charge nurse.

c. In facilities larger than twenty (20) beds, in addition to the Director of Nursing, there shall also be another licensed nurse on duty.

d. An additional licensed nurse shall be added for each fifty (50) beds above fifty (50).

e. In facilities of one hundred (100) beds and over, the additional licensed nurse shall be a Registered Professional Nurse for each multiple of one hundred (100) beds.

2. Evening Shift

a. There shall be a licensed nurse on duty eight (8) hours each evening.

b. An additional licensed nurse shall be added for each seventy (70) beds.

c

l be added for each fifty (50) beds above fifty (50).

e. In facilities of one hundred (100) beds and over, the additional licensed nurse shall be a Registered Professional Nurse for each multiple of one hundred (100) beds.

2. Evening Shift

a. There shall be a licensed nurse on duty eight (8) hours each evening.

b. An additional licensed nurse shall be added for each seventy (70) beds.

c. In facilities of one hundred (100) beds and over, one of the additional licensed nurses shall be a Registered Professional Nurse.

3. Night Shift

a. There shall be a licensed nurse on duty eight (8) hours each night.

b. An additional licensed nurse shall be added for each one hundred (100) beds.

c. In facilities of one hundred (100) beds and over there shall be a Registered Professional Nurse on duty.

d. Registered Professional Nurse on Call

All licensed nursing facilities, regardless of size, shall have a Registered Professional Nurse on duty or on call at all times.

e. Private Duty Nurses

The presence of private duty nurses shall have no effect on the nursing staff requirements.

9.A.4. Minimum Staffing Ratios

A. The nursing staff-to-resident ratio is the number of nursing staff to the number of occupied beds. Nursing assistants in training shall not be counted in the ratios.

The minimum nursing staff-to-resident ratio shall not be less than the following:

1. On the day shift, one direct-care provider for every 5 residents;

2. On the evening shift, one direct-care provider for every 10 residents; and

3. On the night shift, one direct-care provider for every 15 residents

The definition of direct care providers and direct care is found in Section 1 of these Regulations. (see Page 2)

9.A.5. Multi-Storied Facilities

There shall be staff assigned to each resident floor at all times when residents are present.

9.B. Assignment of Tasks

9.B.1

e direct-care provider for every 10 residents; and

3. On the night shift, one direct-care provider for every 15 residents

The definition of direct care providers and direct care is found in Section 1 of these Regulations. (see Page 2)

9.A.5. Multi-Storied Facilities

There shall be staff assigned to each resident floor at all times when residents are present.

9.B. Assignment of Tasks

9.B.1. Licensed Practical Nurse

Only nursing tasks for which that nurse has been trained and which are within the LPN scope of practice, as defined by the Maine State Board of Nursing, shall be assigned to the LPN.

9.B.2. Certified Nursing Assistants

The nursing tasks assigned to a CNA shall only be those for which the CNA has been trained and which are within the scope of the duties, as defined by the Maine State Board of Nursing rules and regulations.

9.B.3. Nursing Assistant

a. Prior to the initial assignment of a nursing task to a nursing assistant, the Registered Professional Nurse shall determine if the individual is enrolled in a course preparing nursing assistants. The Registered Professional Nurse may assign to that individual only those tasks for which the individual has been satisfactorily prepared as documented by the instructional staff. Such training program or course must be satisfactorily completed within four (4) months from the date of employment.

b. When a nursing assistant is waiting for a training program to start, he/she may participate in non-direct care activities, such as making unoccupied beds and passing trays, and water and linens.

9.B.4. Administration of Medication by a Certified Nursing Assistant/Medications

A certified nursing assistant/medications may administer medications only when this function is assigned by a registered professional nurse and there is a licensed nurse on duty.

9.B.5. Feeding Assistants

All trained feeding assistants shall work under the supervision of a registered or licensed practical nurse

nens.

9.B.4. Administration of Medication by a Certified Nursing Assistant/Medications

A certified nursing assistant/medications may administer medications only when this function is assigned by a registered professional nurse and there is a licensed nurse on duty.

9.B.5. Feeding Assistants

All trained feeding assistants shall work under the supervision of a registered or licensed practical nurse. The decision to allow a feeding assistant to feed a resident is based on the charge nurse’s assessment and the resident’s latest assessment and plan of care. Facilities are responsible for any adverse actions resulting from the use of feeding assistants.

9.B.6. Personal Support Specialists

The tasks assigned to a PSS shall only be those for which the PSS has been trained and which are within the scope of duties as defined by the PSS course curriculum.

9.C. Sharing of Staff

Sharing of nursing staff is permitted between the nursing facility and other levels of assisted living on the same premises as long as there is a clear documented audit trail and the staffing in the nursing facility remains adequate to meet the needs of residents. All sharing of nursing staff must be approved in writing by the Department. There may not be sharing of nursing staff between the nursing facility and another non-nursing facility, whether it is physically attached or in proximity to the nursing facility without written approval by the Department. The non-nursing facility must provide its own separate activities, but may share housekeeping, laundry, dietary and maintenance staff, and account for these hours.

9.D. Staffing Patterns

The facility is responsible for establishing its own staffing pattern according to the needs of the residents and in accordance with the provisions of these regulations.

Section 10 - Residents' Rights

10.A. Written Policies

Written policies shall be established by the governing body of each facility regarding the rights and responsibilities of the residents.

10.B

hese hours.

9.D. Staffing Patterns

The facility is responsible for establishing its own staffing pattern according to the needs of the residents and in accordance with the provisions of these regulations.

Section 10 - Residents' Rights

10.A. Written Policies

Written policies shall be established by the governing body of each facility regarding the rights and responsibilities of the residents.

10.B. Procedures

Procedures shall be developed and adhered to for training of facility staff concerning these policies and procedures, and for making the policies available to residents, to any guardians, next of kin, sponsoring agencies or representative payees.

10.C. Exercise of Rights

The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including the following:

10.C.1. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

10.C.2. The resident has the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising his or her rights.

10.C.3. In the case of a resident adjudicated incompetent under the laws of the State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf.

10.C.4. The facility must inform the resident, legal representative or family member, both orally and in writing, in a language that he or she understands, of the resident's rights and all rules and regulations governing resident conduct and responsibilities during the resident's stay in the facility.

Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information and any amendments to it must be acknowledged in writing.

10.C.5

both orally and in writing, in a language that he or she understands, of the resident's rights and all rules and regulations governing resident conduct and responsibilities during the resident's stay in the facility.

Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information and any amendments to it must be acknowledged in writing.

10.C.5. The resident has the right to inspect all records pertaining to himself/herself, upon oral or written request, within twenty-four (24) hours. Photocopies may be purchased and the facility must provide them within two (2) working days of the request.

10.C.6. The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

10.C.7. The resident has the right to limit and/or refuse treatment, and to refuse to participate in experimental research.

10.C.8. The facility must display information and:

a. Inform each resident how to apply for Medicaid;

b. Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or when the resident becomes eligible for Medicaid of:

1. The items and services that are included in nursing facility services in the Maine Medical Assistance Manual and for which the resident may not be charged.

2. Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services and,

c. Inform each resident when changes are made to the items and services specified in Sections 10.C.8.b.1. and 10.C.8.b.2.

10.C.9. Inform each resident before, or at the time of admission, when changes occur, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicaid/Medicare or by the facility's per diem rate.

10.C.10

made to the items and services specified in Sections 10.C.8.b.1. and 10.C.8.b.2.

10.C.9. Inform each resident before, or at the time of admission, when changes occur, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicaid/Medicare or by the facility's per diem rate.

10.C.10. The facility must furnish to each resident, before or at the time of admission, a written description of legal rights which includes:

a. A description of the manner of protecting personal funds, under Section 10.E.

b. A statement that the resident may file a complaint with the Division of Licensing and Certification, the Bureau of Elder and Adult Services or the Long Term Care Ombudsman Program concerning resident abuse, neglect, and/or misappropriation of resident property in the facility and other violations of residents' rights.

c. Information regarding Advance Directives as required by the Patient Self-Determination Act.

10.C.11. Inform each resident of the name, specialty, and method of contacting the physician responsible for his or her care.

10.D. Notification of Changes

10.D.1. Except in a medical emergency or when a resident is incompetent, a facility must consult with the resident regarding any proposed significant changes in treatment or plan of care. If the resident is not capable of making decisions, facility staff must contact the designated resident representative, consistent with his or her authority, to make any required decisions, but the resident must still be informed of any significant changes in treatment or plan of care and the reason for any such change. The facility must notify the resident's physician, the resident's legal representative and, with the resident's permission, an interested family member, when there is:

a. An accident involving the resident which results in injury.

b. A significant change in the resident's physical, mental, or psychosocial status.

c

cant changes in treatment or plan of care and the reason for any such change. The facility must notify the resident's physician, the resident's legal representative and, with the resident's permission, an interested family member, when there is:

a. An accident involving the resident which results in injury.

b. A significant change in the resident's physical, mental, or psychosocial status.

c. A need to alter treatment significantly, or

d. A decision to transfer or discharge the resident from the facility.

10.D.2. The facility must also promptly notify the resident and with the resident's permission, the resident's legal representative or interested family member when there is:

a. A change in room or roommate assignment

b. A change in resident rights under Federal or State law or regulations.

10.E. Protection of Resident Funds

10.E.1. The resident has the right to manage his or her financial affairs. The facility may not require residents to deposit their personal funds with the facility.

10.E.2. The individual financial record and a quarterly summary must be available on request to the resident or his or her legal representative.

10.F. Free Choice

The resident has the right to:

10.F.1. Choose a personal attending physician.

10.F.2. Choose a provider pharmacy.

10.F.3. Be fully informed in advance about care and treatment that may affect the resident's well-being.

10.F.4. Participate in planning care and treatment or changes in care and treatment, unless adjudicated incompetent or otherwise found to be incapacitated under the laws of the State.

10.G. Privacy

10.G.1. The resident has the right to personal privacy and confidentiality of his/her personal and clinical records.

a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting of family and resident groups, but this does not require the facility to provide a private room.

b

ated under the laws of the State.

10.G. Privacy

10.G.1. The resident has the right to personal privacy and confidentiality of his/her personal and clinical records.

a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting of family and resident groups, but this does not require the facility to provide a private room.

b. Except as provided in this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility.

10.G.2. The resident's right to refuse release of personal and clinical records does not apply when:

a. The resident is transferred to another health care institution;

b. Record release is required by law or by third-party payment contract; or

c. Copies are requested by the Department.

10.H. Grievances and Complaints

A resident has the right to:

10.H.1. Voice grievances and complaints with respect to treatment or care that is, or fails to be furnished, without discrimination or reprisal for voicing the grievances or complaints. Such grievances include those with respect to treatment which has been furnished, as well as that which has not been furnished.

10.H.2. File a complaint and/or a grievance with the State survey and certification agency, the Long Term Care Ombudsman Program, Legal Services for the Elderly and the Bureau of Elder and Adult Services respective to abuse, neglect and/or misappropriation of resident property in the facility.

10.H.3. Prompt efforts by the facility to resolve grievances and/or complaints the resident may have, including those with respect to the behavior of other residents.

10.H.4. A written response to be provided whenever possible to the grievant, describing disposition of the complaint.

10.I. Examination of Survey Results

A resident has the right to:

10.I.1. Examine the results of the most recent State licensing and Federal certification survey of the facility and any plan of correction in effect.

10.I.2

ding those with respect to the behavior of other residents.

10.H.4. A written response to be provided whenever possible to the grievant, describing disposition of the complaint.

10.I. Examination of Survey Results

A resident has the right to:

10.I.1. Examine the results of the most recent State licensing and Federal certification survey of the facility and any plan of correction in effect.

10.I.2. Receive information from agencies acting as client advocates, and be afforded the opportunity to contact agencies.

10.J. Work

The resident has the right to:

10.J.1. Refuse to perform services for the facility.

10.J.2. Perform services for the facility, if he or she chooses, when:

a. The facility has documented the need or desire for work in the plan of care.

b. The plan specifies the nature of the services performed and whether the services performed are voluntary or paid.

c. Compensation for paid services is at or above prevailing rates.

d. The resident agrees to the work arrangement described in the plan of care.

10.K. Mail

The resident has the right to privacy in written communications, including the right to:

10.K.1. Send and receive unopened mail promptly.

10.K.2. Have access to stationary, postage, and writing implements at the resident's own expense.

10.K.3. Assistance provided to the resident upon request.

10.L. Access and Visitation Rights

The resident has the right to receive visitors. The facility must allow access to the resident for such visitors at any reasonable hour.

10.L.1. The resident has the right and the facility must provide immediate access to any resident by:

a. Any representative of the Secretary of the Department of Health and Human Services.

b. Any representative of the State.

c. The resident's individual physician.

d. A representative of the Long Term Care Ombudsman Program or other authorized advocate(s).

e. Immediate family or other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time.

f

ent by:

a. Any representative of the Secretary of the Department of Health and Human Services.

b. Any representative of the State.

c. The resident's individual physician.

d. A representative of the Long Term Care Ombudsman Program or other authorized advocate(s).

e. Immediate family or other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time.

f. Others who are visiting with the consent of the resident, subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time.

10.L.2. The facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.

10.L.3. The facility must allow representatives of the Long Term Care Ombudsman Program to examine a resident's clinical records with the oral or written permission of the resident or the resident's legal representative, and consistent with State law.

10.M. Telephone

The resident has the right to have regular access to the private use of a telephone. Amplification shall be provided for the hearing impaired.

10.N. Personal Property

The resident has the right to retain and use personal possessions including some furnishings and appropriate clothing as space permits, unless to do so would infringe upon the rights or health and safety of other residents. The facility must provide prior notification to the resident, legal representative or responsible person in the event that the resident's personal possessions must be searched in order to protect the health and safety of the resident or other residents.

10.O. Married Couples

The resident has the right to share a room with his/her spouse when married residents live in the same facility and both spouses consent to the arrangement.

10.P

ication to the resident, legal representative or responsible person in the event that the resident's personal possessions must be searched in order to protect the health and safety of the resident or other residents.

10.O. Married Couples

The resident has the right to share a room with his/her spouse when married residents live in the same facility and both spouses consent to the arrangement.

10.P. Self- Administration of Drugs

The resident has a right to self-administer drugs when the interdisciplinary team has determined that this practice is safe.

10.Q. Transfer and Discharge Rights

10.Q.1. Definition

Transfer and discharge includes movement of a resident to a bed outside of the certified unit, whether that bed is in the same facility or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified unit.

10.Q.2. Transfer and Discharge Requirements

The facility must permit each resident to remain in the unit or facility, and not transfer or discharge the resident from the unit or facility unless:

a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the unit or facility.

b. The transfer or discharge is appropriate because the resident's health and/or functional ability has improved sufficiently so that the resident no longer needs the services provided by the unit or facility.

c. The safety and/or health of individuals in the facility is endangered.

d. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only charges allowable under Medicaid.

e. The facility ceases to operate.

10.Q.3

ealth of individuals in the facility is endangered.

d. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only charges allowable under Medicaid.

e. The facility ceases to operate.

10.Q.3. Notice Before Transfer

Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident, of the transfer or discharge and the reasons.

The resident’s clinical record shall contain documentation describing the basis for the transfer or discharge.

10.Q.4. Contents of the Notice

Each notice must be written and include, in a language and manner understood by the resident.

a. In order to provide for informed resident decisions, a nursing facility shall provide lists of licensed providers of care and services for all patients prior to discharge for whom home health care is needed.

(1) For all residents requiring home health care, the list must include all licensed home health care providers that request to be listed and any branch offices, including addresses and telephone numbers, that serve the area in which the resident resides.

(2) The nursing facility shall disclose to the resident any direct or indirect financial interest which the nursing facility has in the home health care provider.

b. For all residents transferring to another nursing facility, a list must be provided of all nursing facilities that request to be listed that serve the area in which the resident resides or wishes to reside.

c. The reason for the transfer or discharge, including events which are the basis for such action.

d. The effective date of the transfer or discharge.

e. The location to which the resident is transferred or discharged.

f

another nursing facility, a list must be provided of all nursing facilities that request to be listed that serve the area in which the resident resides or wishes to reside.

c. The reason for the transfer or discharge, including events which are the basis for such action.

d. The effective date of the transfer or discharge.

e. The location to which the resident is transferred or discharged.

f. Notice of the resident's right to appeal the transfer or discharge as set forth in the Maine Medical Assistance Manual.

g. The location to which the resident is transferred or discharged.

h. Notice of the resident’s right to appeal the transfer or discharge as set forth in the Maine Medical Assistance Manual.

i. The mailing address and telephone number of the Long Term Care Ombudsman Program.

j. In the case of residents with developmental disabilities or mental health conditions, the mailing address and telephone number of the Office ofAging and Disability Services, Department of Health and Human Services .

k. The resident's right to be represented by himself or herself or by legal counsel, a relative, friend or other spokesman.

10.Q.5. Timing of the Notice

Except when specified in Section 10.Q.2.c., the notice of transfer or discharge must be made by the facility at least:

a. Thirty (30) days before the resident is transferred or discharged.

b. As soon as practicable before transfer or discharge when:

1. The safety and/or health of individuals in the facility would be endangered.

2. The resident's health improves sufficiently to allow a more immediate transfer or discharge.

3. An immediate transfer or discharge is required by the resident's urgent medical needs, or

4. A resident has not resided in the facility for thirty (30) days.

10.Q.6. Appeal of Transfer or Discharge

The resident has the right to appeal a transfer or discharge to the Administrative Hearings Unit of the Department.

10.Q.7

improves sufficiently to allow a more immediate transfer or discharge.

3. An immediate transfer or discharge is required by the resident's urgent medical needs, or

4. A resident has not resided in the facility for thirty (30) days.

10.Q.6. Appeal of Transfer or Discharge

The resident has the right to appeal a transfer or discharge to the Administrative Hearings Unit of the Department.

10.Q.7. Transfer or Discharge Orientation

The resident has the right to receive sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility. This shall be documented in the resident record.

10.R. Physical or Chemical Restraints

The resident has the right to be free from any physical restraints imposed or psychoactive drug administered for purposes of punishment for certain behaviors or to accommodate the needs of the staff, and is not required to treat the resident's specific condition.

10.S. Freedom From Abuse, Punishment or Involuntary Seclusion

The resident has the right to be free from neglect, verbal, sexual, physical or mental abuse and involuntary seclusion.

10.T. The resident has the right to:

10.T.1. Choose activities, schedules, and health care consistent with his/her interests, assessments, and plans of care.

10.T.2. Interact with members of the community both inside and outside the facility.

10.T.3. Make choices that are significant to the resident about aspects of his/her life in the facility.

10.U. Organization and Participation

10.U.1. A resident has the right to organize and participate in resident groups in the facility.

10.U.2. A resident's family has the right to meet in the facility with the families of other residents.

10.U.3. The facility must provide a resident or family group, if one exists, use of private space.

10.U.4. Staff or visitors may attend meetings only at the group's invitation.

10.U.5. The facility must provide a designated staff person responsible for providing assistance and responding to written requests resulting from group meetings

meet in the facility with the families of other residents.

10.U.3. The facility must provide a resident or family group, if one exists, use of private space.

10.U.4. Staff or visitors may attend meetings only at the group's invitation.

10.U.5. The facility must provide a designated staff person responsible for providing assistance and responding to written requests resulting from group meetings.

10.U.6. When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families and report back to the group.

10.V. Residents' Council

10.V.1. Establishment and Composition

a. The facility shall inform residents of their right to establish a council. This information shall be given to all residents or a family member or designated representative.

b. The residents have the right to have assistance in establishing a council. The council shall select a staff member, not related to the administrator, to assist the residents' council.

c. If there is no council, the facility must offer the residents, at least once a year, the choice to establish one by majority vote.

d. Records of council meetings and decisions, if prepared, shall be disseminated by the council and kept on file in the facility.

e. No employee or representative of the facility may be a member of the council or attend a meeting, unless requested by the group.

f. Family members may sit in on the council, at the group’s invitation, but shall not be members.

g. Staff or visitors may attend meetings at the group’s invitation.

10.V.2. Responsibilities and Purpose

a. To review and make recommendations to strengthen the facility's policies and procedures relating to residents' rights.

b. To establish procedures for informing all residents about their rights.

c

ily members may sit in on the council, at the group’s invitation, but shall not be members.

g. Staff or visitors may attend meetings at the group’s invitation.

10.V.2. Responsibilities and Purpose

a. To review and make recommendations to strengthen the facility's policies and procedures relating to residents' rights.

b. To establish procedures for informing all residents about their rights.

c. To serve as a forum for obtaining and disseminating information, soliciting and adopting recommendations for facility programming and improvement and early identification of and recommendation for orderly resolution of residents' problems.

d. To inform the administrator about the opinions and concerns of the residents.

e. To find ways of involving the families of residents.

10.W. Participation in Other Activities

A resident has the right to participate in social, religious and community activities that do not interfere with the rights of other residents in the facility.

Section 11 - Physical/Chemical Restraints

11.A. Physical Restraints

The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.

“Physical Restraints” are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.

“Discipline” is any action taken by the facility for the purpose of punishing or penalizing residents.

“Convenience” is any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the residents’ best interest.

11.A.1. All restraints must be ordered by a physician. PRN orders for restraints are prohibited.

11.A.2. Documented evidence of less restrictive measures to promote greater functional independence must be present in the medical record if restraints are used

ty to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the residents’ best interest.

11.A.1. All restraints must be ordered by a physician. PRN orders for restraints are prohibited.

11.A.2. Documented evidence of less restrictive measures to promote greater functional independence must be present in the medical record if restraints are used. The care plan must address the medical reason for which the restraints are used. The care plan must also contain a succession of approaches to be utilized before restraints are applied. Consultation with appropriate health professionals regarding the use of less restrictive approaches must be obtained when appropriate. Locked restraints are prohibited in any case.

a. Geriatric and other chairs from which the resident cannot arise without assistance and which impede movement are considered a physical restraint.

b. Bedrails are considered restraints when they are a barrier to the resident for getting out of bed.

11.A.3. If a trial of less restrictive measures is unsuccessful, and the facility decides that a physical restraint would enable and promote greater functional independence, then the restraining device may be used only for specific time-limited periods.

11.A.4. The continued use of restraints must be evaluated as needed, but at least quarterly.

11.A.5. There must be documented evidence that the resident, family, or legal guardian is aware of and agrees with this treatment.

11.A.6. All resident care staff shall be trained in the proper application and use of restraints.

11.A.7. Restraints may not be used to permit staff to administer treatment to which the resident has not consented.

11.A.8. No resident may be in a restraint without nursing staff on duty at all times in that section of the facility;

11.A.9. Restraints are released for at least fifteen (15) minutes every two (2) hours and exercise provided. A written record is kept of the times of restraint and release.

11.A.10

ints may not be used to permit staff to administer treatment to which the resident has not consented.

11.A.8. No resident may be in a restraint without nursing staff on duty at all times in that section of the facility;

11.A.9. Restraints are released for at least fifteen (15) minutes every two (2) hours and exercise provided. A written record is kept of the times of restraint and release.

11.A.10. Every resident in restraint is offered toilet privileges at least every two (2) hours or when request is made.

11.A.11. When the resident is in bed, the restraint must be properly applied to allow the resident to turn in bed. It is not necessary to release a restraint during the resident’s normal sleeping hours, but the restraint must be checked at least every two (2) hours. A written record must be maintained of restraint checks.

11.A.12. Leather cuff and any crotch restraints shall not be used. Four-point restraints are prohibited.

11.A.13. Residents shall not be confined in a locked room; dutch doors are permissible, provided the top section is opened.

11.B. Chemical Restraints

The resident has the right to be free from any chemical restraints imposed for the purpose of discipline or convenience and not required to treat the resident’s medical symptoms. These drugs are categorized as antipsychotics, antidepressants, anxioltics and hypnotics.

“Chemical Restraint” is a psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.

“Discipline” is any action taken by the facility for the purpose of punishing or penalizing residents.

“Convenience” is any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the residents’ best interest.

11.B.1. There must be evidence of a physical examination to rule out physical cause.

11.B.2

ical symptoms.

“Discipline” is any action taken by the facility for the purpose of punishing or penalizing residents.

“Convenience” is any action taken by the facility to control resident behavior or maintain residents with a lesser amount of effort by the facility and not in the residents’ best interest.

11.B.1. There must be evidence of a physical examination to rule out physical cause.

11.B.2. Residents receiving antipsychotic medications must receive gradual dose reductions and behavioral monitoring in an effort to discontinue these drugs, unless clinically contraindicated.

11.B.3. There must be documented evidence of less restrictive measures, including interventions to modify the resident’s behavior or the environment, including staff approaches to care, treat or manage the resident’s behavioral symptoms.

11.B.4. There must be evidence that the resident, family or legal guardian is made aware of potential side effects and agrees with this treatment.

11.B.5. Psychoactive drugs may not be used:

a. In quantities that interfere with the resident’s level of alertness and ability to participate in rehabilitation programs; or

b. On an as needed basis exceeding five (5) times in a seven (7) day period;

11.B.6. The use of chemical restraints will be part of the care plan, which will address the medical reason for which the medication is used, with a succession of approaches and interventions to be utilized prior to the administration of chemical restraints.

11.B.7. Close monitoring at regular intervals, as determined by the physician and multidisciplinary team, of all residents receiving psychoactive drugs will be maintained.

Section 12 - Pre-Admission Screening,

Comprehensive Assessments and Plans of Care

12.A. Pre-Admission Screening

Facilities may not admit any resident who has not had a pre-admission screening for mental health conditions and/orintellectual disability.

12.A.1. Definition: For the purposes of this Chapter:

a

multidisciplinary team, of all residents receiving psychoactive drugs will be maintained.

Section 12 - Pre-Admission Screening,

Comprehensive Assessments and Plans of Care

12.A. Pre-Admission Screening

Facilities may not admit any resident who has not had a pre-admission screening for mental health conditions and/orintellectual disability.

12.A.1. Definition: For the purposes of this Chapter:

a. Mental Health Conditions

An individual is considered to be a person with a mental health condition if the individual has a primary or secondary diagnosis of a mental disorder as defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-III 1R), 4th edition, and which does not include dementia.

b. Intellectual Disability

An individual is considered to be a person with an intellectual disability if there is "significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period".

12.A.2. Individuals With a Diagnosis or Suspicion of Mental Health Condition

Prior to admission, the state mental health authority must determine, based on biopsychosocial evaluation performed by a person or entity other than the State mental health authority whether the individual has a diagnosis of a mental health condition and whether the individual requires acute and/or "specialized services".

12.A.3. Individuals With Intellectual Disability or Related Condition(s)

The Department of Health and Human Services determines prior to admission whether the individual requires "specialized services" foran intellectual disability.

12.B. Comprehensive Assessment

Each resident of a nursing facility shall have a comprehensive assessment which will enable facility staff to develop a plan of care designed to assist the resident to reach the highest practicable level of physical, mental, and psychosocial functioning.

12.B.1. Definitions

a. Comprehensive Assessment

1

equires "specialized services" foran intellectual disability.

12.B. Comprehensive Assessment

Each resident of a nursing facility shall have a comprehensive assessment which will enable facility staff to develop a plan of care designed to assist the resident to reach the highest practicable level of physical, mental, and psychosocial functioning.

12.B.1. Definitions

a. Comprehensive Assessment

1. The comprehensive assessment includes the resident's medical, nursing and psychosocial history before admission and current medical diagnoses.

2. The comprehensive assessment must include:

a. Identification and demographic information:

b. Customary routine;

c. Cognitive patterns;

d. Communication;

e. Vision;

f. Mood and behavior patterns;

g. Psychosocial well-being;

h. Physical functioning and structural problems;

i. Continence;

j. Disease diagnosis and health conditions;

k. Dental and nutritional status;

l. Skin conditions;

m. Activity pursuit;

n. Medications;

o. Special treatments and procedures;

p. Discharge potential;

q. Documentation of summary information regarding the additional assessment performed through the resident assessment protocols;

r. Documentation of participation in assessment.

b. Minimum Data Set (MDS)

The Minimum Data Set (MDS) is the state approved assessment instrument which is the current core set of screening, clinical and functional status elements that forms the foundation of the comprehensive assessment for all residents in nursing facilities.

The MDS must be completed up to, and no later than, fourteen (14) calendar days after the date of admission.

The assessment is conducted or coordinated by a Registered Professional Nurse with participation by other appropriate health professionals. Upon completion, the Registered Professional Nurse must sign, date and certify the completion of the assessment

or all residents in nursing facilities.

The MDS must be completed up to, and no later than, fourteen (14) calendar days after the date of admission.

The assessment is conducted or coordinated by a Registered Professional Nurse with participation by other appropriate health professionals. Upon completion, the Registered Professional Nurse must sign, date and certify the completion of the assessment.

Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment..

c. Resident Assessment Protocol (RAPs)

A component of the utilization guidelines, the RAPs are structured, problem-oriented frameworks for organizing MDS information and examining additional clinically relevant information about an individual. RAPs help identify social, medical and psychological problems and form the basis for individualized care planning.

The Resident Assessment Protocols must be completed by the 14th calendar day after the admission, or according to other Federal and State requirements. Upon completion, the Registered Professional Nurse must sign and date the RAP summary sheet.

12.B.2. Frequency of Assessments

a. The annual comprehensive assessment must be completed within twelve (12) months of the most recent full assessment. The annual reassessment may be initiated at any point prior to the end of the 1-year follow-up date, but must be completed by the end of the 365th calendar day after the most recent comprehensive assessment. If a significant change reassessment is completed in the interim, the clock “restarts”, with the next assessment due within 365 days of the significant change reassessment. Routinely scheduled comprehensive assessments may be scheduled early if a facility wants to stagger due dates for assessments.

b. Nursing facilities have an ongoing responsibility to assess resident status and intervene to assist the resident to meet his or her highest practicable level of physical, mental and psychological well-being

ent due within 365 days of the significant change reassessment. Routinely scheduled comprehensive assessments may be scheduled early if a facility wants to stagger due dates for assessments.

b. Nursing facilities have an ongoing responsibility to assess resident status and intervene to assist the resident to meet his or her highest practicable level of physical, mental and psychological well-being. If interdisciplinary team members identify a significant change (either improvement or decline) in a resident’s condition, they should share this information with the resident’s physician, whom they may consult about the permanency of change. The facility’s medical director may also be consulted when differences of opinion about a resident’s status occur among team members.

Document the initial identification of a significant change in terms of the resident’s clinical status in the progress notes. Complete a full comprehensive assessment as soon as needed to provide appropriate care to the individual, but in no case, later than fourteen (14) days after determining that a significant change has occurred.

A “significant change” is defined as a major change in the resident’s status that:

1. Is not self-limiting. A condition is defined as “self-limiting” when the condition will normally resolve itself without further intervention or by staff implementing standard disease-related clinical interventions;

2. Impacts on more than one area of the resident’s health status; and

3. Requires interdisciplinary review or revision of the care plan.

c. If a resident returns to a facility following a temporary absence for hospitalization or therapeutic leave, it is considered a readmission. Facilities are not required to assess a resident if they are readmitted, unless a significant change (as defined in Section 12.B.2.b.) in the resident’s condition has occurred.

d

us; and

3. Requires interdisciplinary review or revision of the care plan.

c. If a resident returns to a facility following a temporary absence for hospitalization or therapeutic leave, it is considered a readmission. Facilities are not required to assess a resident if they are readmitted, unless a significant change (as defined in Section 12.B.2.b.) in the resident’s condition has occurred.

d. The quarterly assessment is used to track resident status between comprehensive assessments, and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status. At a minimum, three (3) quarterly reviews and one full assessment are required in each 12 month period.

12.C. Comprehensive Care Plan

12.C.1. Definitions

“Comprehensive Care Plan” is the specific document which has been developed by the multidisciplinary team (including the resident or guardian) to address residents’ medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessments. The comprehensive care plan must include measurable objectives and timetables.

Before completion of a comprehensive care plan, there must be evidence of ongoing assessments and care planning to assure care and services are being provided from the date of admission/readmission.

12.C.2. Each resident shall have an integrated comprehensive care plan that is developed by a multidisciplinary team (including the resident and/or guardian) and which is based on a comprehensive assessment using the MDS resident assessment protocols, the utilization guidelines and other assessments as necessary.

12.C.3. The comprehensive care plan shall be developed by a multidisciplinary team consisting of physician, registered Professional Nurse, and other appropriate staff in conjunction with the resident, resident's family or legal representative as appropriate.

12.C.4. The comprehensive care plan shall be developed within seven (7) days after the completion of the Resident Assessment Protocols and:

a

12.C.3. The comprehensive care plan shall be developed by a multidisciplinary team consisting of physician, registered Professional Nurse, and other appropriate staff in conjunction with the resident, resident's family or legal representative as appropriate.

12.C.4. The comprehensive care plan shall be developed within seven (7) days after the completion of the Resident Assessment Protocols and:

a. is periodically reviewed and revised as necessary by the multidisciplinary team after each assessment and reassessment;

b. must have measurable goals and timeframes, as appropriate, for the highest practicable level of functioning the resident may achieve;

c. must accurately reflect the resident's assessment;

d. must be oriented toward preventing decline in functioning and/or functional levels within the parameters of normal aging and any disease processes which are present;

e. must address identified risk factors;

f. must reflect standards of current professional practice.

g. must reflect a multidisciplinary team approach to maintain or improve functional abilities of the resident.

12.C.5. The comprehensive care plan must be continually and actively implemented by all staff.

12.C.6. The comprehensive care plan must be available at the nurses station for review and implementation as appropriate by staff on each shift. The procedures to implement the care plan need not be included in the care plan, but there must be a format, as chosen by the facility, which provides direction to the resident care staff of each shift. Eff. 2/1/01

12.D. Documentation

12.D.1. There must be ongoing documentation as necessary, but at least monthly, which reflects the resident’s condition, implementation and effectiveness of the care plan and interventions by the staff.

12.D.2. There must be documentation by the CNA of the specific tasks carried out to implement the part of the care plan assigned to the CNA.

12.E

taff of each shift. Eff. 2/1/01

12.D. Documentation

12.D.1. There must be ongoing documentation as necessary, but at least monthly, which reflects the resident’s condition, implementation and effectiveness of the care plan and interventions by the staff.

12.D.2. There must be documentation by the CNA of the specific tasks carried out to implement the part of the care plan assigned to the CNA.

12.E. Specialized Therapy Services

Based upon the resident's comprehensive assessment, the facility must provide or obtain specialized therapy services, i.e., physical therapy, speech/language therapy, occupational therapy, and mental health services for each resident as needed and prescribed in the plan of care.

12.E.1. Care Plan

a. Based on the resident's comprehensive assessment, these services shall be integrated into the resident’s comprehensive multidisciplinary care plan, as necessary.

b. The resident's care plan, progress and continued need for specialized therapy is reevaluated as necessary, and recommendations made to the physician and the multidisciplinary team.

12.E.2. Therapists' Responsibilities

a. Specialized therapy is provided only on written orders of the physician.

b. The therapist shall evaluate each resident referred and recommend a rehabilitative treatment regimen, if appropriate.

c. The therapist, in consultation with the physician, shall initiate the therapy and reevaluate the continuing need for therapy as needed.

d. The therapist shall provide training for staff and supervise the provision of care to assure acceptable level of performance for qualified support personnel.

e. The therapist shall document each treatment and progress noted in the residents' records.

12.E.3. Space and Equipment

a. Space that shall serve the needs of the residents shall be made available for specialized therapies.

b. Equipment necessary for the provision of specialized therapy services shall be available and used as needed.

Section 13 - Nursing Services

13.A

lified support personnel.

e. The therapist shall document each treatment and progress noted in the residents' records.

12.E.3. Space and Equipment

a. Space that shall serve the needs of the residents shall be made available for specialized therapies.

b. Equipment necessary for the provision of specialized therapy services shall be available and used as needed.

Section 13 - Nursing Services

13.A. Quality of Care

Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing and psychosocial needs that are identified in the comprehensive assessment that is in conformance with the current standards of the Gerontological Nursing Practice of the American Nurses Association.

13.A.1. Activities of Daily Living (ADL)

Based on the comprehensive assessment of a resident, the facility must ensure that:

a. A resident's abilities in Activities of Daily Living do not diminish unless circumstances of the resident's clinical condition demonstrate the diminution was unavoidable. This includes the resident's ability to:

1. bathe, dress, and groom;

2. transfer and ambulate;

3. toilet;

4. eat;

5. use speech, language or other functional communication systems; and

6. bed mobility.

b. A resident is given the appropriate treatment and services to maintain or improve his or her abilities to carry out his/her activities of Daily Living.

c. A resident who is unable to carry out Activities of Daily Living receives the necessary services and assistance to meet his/her needs.

d. A resident is given encouragement and assistance to be up and dressed in his/her own personal clothing which is appropriate to the time of day and season, clean, attractive, and in good repair.

13.A.2

bilities to carry out his/her activities of Daily Living.

c. A resident who is unable to carry out Activities of Daily Living receives the necessary services and assistance to meet his/her needs.

d. A resident is given encouragement and assistance to be up and dressed in his/her own personal clothing which is appropriate to the time of day and season, clean, attractive, and in good repair.

13.A.2. Personal Care

Each resident shall receive proper nursing care, as defined by the Standards of Care established by the American Nurses association. These services include, but are not limited to:

a. Good personal hygiene, such as clean, well-groomed hair, cleaned, trimmed fingernails, clean skin, and freedom from offensive odors, clean mouth and teeth, and absence of dry cracked lips;

b. Appropriate nursing measures including encouraging and assisting resident to change position at least every two (2) hours to stimulate circulation and prevent pressure sores, contractures and deformities.

c. Ensuring clean resident rooms, beds, bed linen and clothing.

d. Ensuring that resident care equipment is in sufficient supply, in good condition, properly cleaned and cared for, well organized and readily available.

13.A.3. Mental and Psychosocial Functioning

Based on the comprehensive assessment of a resident, the facility must ensure that:

a. A resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem; and

b. A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident’s clinical condition demonstrates that such a pattern is unavoidable.

13.A.4. Hydration and Nutrition

The facility must provide each resident with sufficient fluid and nourishment to maintain proper hydration and health.

a

psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident’s clinical condition demonstrates that such a pattern is unavoidable.

13.A.4. Hydration and Nutrition

The facility must provide each resident with sufficient fluid and nourishment to maintain proper hydration and health.

a. Based on a resident's comprehensive assessment, the facility must ensure that a resident:

1. Maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible; and

2. Receives a therapeutic diet when there is a n

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