PROPOSAL
Maryland Register
Issue Date: February 15, 2019
Volume 46 • Issue 4 • Page 192-227
Comment Period Ends: March 18, 2019
Title 10
MARYLAND DEPARTMENT OF HEALTH
Subtitle 07 HOSPITALS
10.07.02 [Comprehensive Care Facilities and Extended Care Facilities] Nursing Homes
Authority: Health-General Article, §§19-308, 19-308.1, 19-323, and 19-1401 et seq.; Public Safety Article, §14-110.1; Annotated Code of Maryland
Notice of Proposed Action
[19-008-P-I]
The Secretary of Health proposes to repeal the Preface and Regulations .01, .01-1, .06, .12, .15, .25, .26, .28, .40, and .42—.44, adopt new Regulations .01, .02, .08, .18—.20, .25—.27, .41—.46, .48—51, amend and recodify existing Regulations .02, .03, .03-1, .05, .07, .07-1, .08, .08-1, .09—.11, .11-1, .11-2, .13, .14, .14-1, .14-2, .16—.21-4, .22—.24, .27, .29—.39, .41, .45, .46, .48, .49, and .56 to be Regulations .03, .04, .05, .07, .09—.17, .21—.24, .28—.40, .47, .52—.68, and .75, and recodify existing Regulations .04, .47, .50—.55, and .57—.61 to be Regulations .06, .66, .69—.74, and .76—.80 under COMAR 10.07.02 Nursing Homes.
Statement of Purpose
The purpose of this action is to:
(1) Amend, repeal, recodify, and adopt new language in order to make this chapter more cohesive, comprehensive, and clear;
(2) Enable the Department to accept electronic submissions of both initial applications and renewal applications and thereby improve efficiency and decrease the administrative burden on providers and the Department;
(3) Repeal the Preface;
(4) Revise the definitions regulation,
(5) Remove outdated references;
(6) Incorporate by reference additional documents;
(7) Require that new facilities shall satisfy the review of the Maryland Health Care Commission for the establishment of new facilities and the increase or decrease in capacity of existing facilities;
(8) Require that an existing facility that wishes to convert, alter, modify, or add to the existing infrastructure shall notify the Office of Health Care Quality in writing;
(9) Require that a nursing home shall employ supervisory personnel and a sufficient number of support personnel, to provide a minimum of 3 hours of bedside care per occupied bed per day, 7 days per week;
(10) Require that the ratio of nursing service personnel on duty providing bedside care to resident may not at any time be less than one to 15;
(11) Require that the nurse manager or the Director of Nursing of vent units shall possess a background in ventilator care or be qualified in ventilator management;
(12) Require that after January 1, 2021 social services responsibilities in the facility will be assigned to a Licensed Bachelor Social Worker, Licensed Graduate Social Worker, Licensed Certified Social Worker, or Licensed Certified Social Worker–Clinical;
(13) Require that the facility shall assign at least one infection preventionist staffed at a ratio of 1.0 Full Time Equivalents for every 200 beds;
(14) Require that facilities shall possess a functioning automated external defibrillator (AED) as of July 1, 2020;
(15) Allow Certified Dietary Managers to share cooking responsibilities with the full-time cook in facilities with fifty or fewer beds.;
(16) Require that unless the supervisor is a licensed registered dietitian, they shall receive regularly scheduled consultation from a licensed dietician;
(17) Specifying that during admission, a resident may not be accepted unless at least one service to meet the rehabilitative needs of the resident can be initiated within the 48-hour period;
(18) Allowing for the provision of a waiver of general requirements for bedrooms in long term care facilities—both for newly constructed bedrooms and already-existing bedrooms; and
(19) Clarifying that supervisory responsibilities for a food service department and food production within a facility shall be assigned to a qualified dietetic service supervisor.
Comparison to Federal Standards
In compliance with Executive Order 01.01.1996.03, this proposed regulation is more restrictive or stringent than corresponding federal standards as follows:
(1) Regulation citation and manner in which it is more restrictive than the applicable federal standard:
42 C.F.R. §483.15 (g)(1)—(3)
(g) Social Services.
(1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
(2) A facility with more than 120 beds must employ a qualified social worker on a full-time basis.
(3) Qualifications of social worker. A qualified social worker is an individual with—
(i) A bachelor’s degree in social work or a bachelor’s degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology; and
(ii) One year of supervised social work experience in a health care setting working directly with individuals.
10.07.02.30 B Social Work Staff Responsibility
The federal regulations only require the employ of a qualified social worker (a bachelor’s degree in social work or a bachelor’s degree in a human services field) if the facility has more than 120 beds. OHCQ through this proposal intends to require that after January 1, 2021 all social work services be provided by a licensed certified social worker. In cases where the facility has an individual providing medically related physical, social, and behavioral health needs of the residents that is not licensed but was providing the services both before and at the time of the adoption of this proposal, they are exempt from this requirement. If the social worker is not a licensed certified social worker LCSW or a licensed certified social worker-clinical LCSW-C, the facility shall provide for an LCSW or LCSW-C to provide sufficient hours of supervision. The agreement shall provide for sufficient hours of consultation to assure that the staff’s services meet the medically related social and emotional needs of the residents.
(2) Benefit to the public health, safety or welfare, or the environment:
This requirement ensures that a licensed social worker is providing services to residents of the facility and ensures that residents receive adequate discharge planning and care coordination. Currently, a license has not been required for an individual to operate in this role. Consequently, OHCQ has observed inadequate discharge planning and lack of coordination of care transitions. OHCQ believes that requiring a licensed social worker with adequate training will increase successful care coordination.
(3) Analysis of additional burden or cost on the regulated person:
The proposed requirement that social work services be performed by a licensed social worker becomes effective January 1, 2021. The additional cost to hire or contract with a licensed social worker is estimated to be $11,000 annually. Nursing homes that employ an individual on or before January 1, 2021 shall be exempt from the requirement to have a licensed social worker employed. However, the nursing home would need to contract with a licensed social worker to provide oversight.
The Office of Health Care Quality surveyed multiple facilities and determined that 75 percent or approximately 172 nursing homes did not employ a licensed social worker. Thus approximately 172 facilities would be impacted by this proposal.
(4) Justification for the need for more restrictive standards:
This requirement ensures that a licensed social worker is providing medically related social and emotional services to residents of the facility, and requires that residents receive adequate planning and care coordination during discharge and care transitions.
Currently, a license has not been required for an individual to operate in this role.
Federal regulations require that certain services be provided by a “qualified social worker,” the employee would have to represent themselves as a “qualified social worker” and thus under Maryland law, the employee would have to obtain a license to practice social work.
The provider industry is in agreement with the proposed changes in this requirement.
Estimate of Economic Impact
I. Summary of Economic Impact. The Office of Health Care Quality surveyed multiple facilities and determined that 25 percent of nursing homes employed or contracted with a licensed social worker. As of November 1, 2016, there were 229 licensed nursing homes, with an estimated 172 nursing homes that would be out of compliance after January 1, 2021. The additional cost to hire or contract with a licensed social worker is estimated to be $11,000 annually. Nursing homes that employ an individual on or before January 1, 2021 shall be exempt from the license requirement. However, the nursing home would need to contract with a licensed social worker to provide oversight.
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Revenue (R+/R-) |
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II. Types of Economic Impact. |
Expenditure (E+/E-) |
Magnitude |
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A. On issuing agency: |
NONE |
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B. On other State agencies: |
NONE |
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C. On local governments: |
NONE |
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Benefit (+)
Cost (-) |
Magnitude |
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D. On regulated industries or trade groups: |
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Nursing homes who hire or contract LCSW or LCSW-C |
(-) |
$1,892,000 |
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E. On other industries or trade groups: |
(+) |
$1,892,000 |
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F. Direct and indirect effects on public: |
NONE |
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III. Assumptions. (Identified by Impact Letter and Number from Section II.) |
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D. It is estimated that 25 percent of nursing homes currently have a licensed social worker (Bachelors level degree). There are currently 229 licensed nursing homes of which 75 percent or 172 nursing homes would need to hire or contract with a licensed social worker to comply with the regulations. Currently there is an estimated $11,000 salary differential between the salary of a non-licensed employee performing social work services and a licensed social work employee. Thus 172 times $11,000 equals an annual cost increase of $1,892,000 to the regulated industry. |
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E. The social work industry and trade groups would benefit due to the increase in hiring and contracting with licensed social workers. OHCQ estimates that 172 nursing homes would need to hire or contract with a licensed social worker. The estimated salary differential to hire a licensed social worker versus a non-licensed employee performing social work services is $11,000. Thus 172 times $11,000 equals an annual benefit of $1,892,000 to the social worker industry and trade groups. |
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Jake Whitaker, Acting Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through March 18, 2019. A public hearing has not been scheduled.
Editor’s Note on Incorporation by Reference
Pursuant to State Government Article, §7-207, Annotated Code of Maryland, the following have been declared documents generally available to the public and appropriate for incorporation by reference:
(1) CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (Version 1.14, October 2016);
(2) CMS Manual System, Pub. 100-07 State Operations Provider Certification (Transmittal 126, November 26, 2014, U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services);
(3) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents Healthcare Settings (Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HIPAC), 2007);
(4) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 (MMWR2005; 54, No. RR-17, Centers for Disease Control and Prevention (CDC), Atlanta, GA);
(5) Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), (MMWR2011; 60 No. SS-7, Centers for Disease Control and Prevention (CDC), Atlanta, GA);
(6) National Fire Protections Association, NFPA 99 Health Care Facilities Code (2015 Edition); and
(7) Recommended Dietary Allowances (10th Edition, Food and Nutritional Board, Commission on Life Sciences, and National Research Council, 1989).
For this reason, they will not be printed in the Maryland Register or the Code of Maryland Regulations (COMAR). Copies of these documents are filed in special public depositories located throughout the State. A list of these depositories was published in 46:1 Md. R. 9 (January 4, 2019), and is available online at www.dsd.state.md.us. These documents may also be inspected at the office of the Division of State Documents, 16 Francis Street, Annapolis, Maryland 21401.
.01 Definitions.
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) “Administrator” means the individual licensed by the Board of Examiners of Nursing Home Administrators who is responsible for the operation of the nursing home.
(2) “Attending physician” means an individual licensed to practice medicine in the State who:
(a) Admits residents to the nursing home; and
(b) Is responsible for the overall care of a resident.
(3) “Audiologist” means an individual who holds a Maryland license issued by the State Board of Audiologists, Hearing Aid Dealers, and Speech-Language Pathologists.
(4) “Authorized prescriber” has the meaning stated in Health Occupations Article, §12-101, Annotated Code of Maryland.
(5) “Certified dietary manager” means an individual who:
(a) Is licensed as a dietitian-nutritionist by the Maryland State Board of Dietetic Practice and registered as a dietitian by the Commission on Dietetic Registration;
(b) Is a graduate of a certified dietetic technician program approved by the Academy of Nutrition and Dietetics; or
(c) Has:
(i) Successfully completed the required course;
(ii) Maintains certification as required by the certifying board for the Association of Nutrition and Foodservice Professionals; and
(iii) Is a Certified Food Protection Professional (CFPP).
(6) “Certified medicine aide” means an individual who meets the requirements as stated in COMAR 10.39.01 and 10.39.03.
(7) “Certified social worker” means an individual licensed to practice as a certified social worker in this State.
(8) “Charge nurse” means the registered or licensed practical nurse who is responsible for day-to-day operations of a unit in the nursing home on which residents live.
(9) “Chemical restraint” means the administration of any drug that is used for discipline or convenience and not required to treat medical symptoms.
(10) “Comprehensive care facility” means a nursing home that admits residents requiring medical services and nursing services rendered by or under the supervision of a registered nurse, who:
(a) Are advanced in age; or
(b) Have a disease or a disability.
(11) “Concurrent review” means daily rounds by a licensed nurse which include:
(a) Appraisal and observation of all residents by the licensed nurse to determine any change in each resident’s physical or mental status;
(b) If there is a change in the resident’s physical or mental status, an evaluation by the licensed nurse of the resident’s medications, laboratory values relating to the resident, and clinical data relating to the resident, including the resident’s:
(i) Hydration and nutritional needs;
(ii) Skin integrity;
(iii) Noted weight changes; and
(iv) Appetite;
(c) Evaluation of injuries sustained by the resident that result from an accident or incident involving the resident; and
(d) Any other relevant parameters affecting or reflecting the resident’s physical and mental status.
(12) “Culture change facility” means a nursing home where physical environment and operational changes have been made to establish person-valued and person-directed care activities and services.
(13) “Deficiency” means a condition existing in a nursing home or an action or inaction by the nursing home staff that results in potential for more than minimal harm, actual harm, or serious and immediate threat to one or more residents.
(14) “Dentist” means an individual licensed to practice dentistry in this State.
(15) “Department” means the Maryland Department of Health.
(16) “Dietitian-nutritionist” means an individual who:
(a) Is licensed by the Maryland Board of Dietetic Practice to practice dietetics;
(b) Has met the certifying requirements for registration as a dietitian as administered by the Commission on Dietetic Registration; and
(c) Maintains the continuing education requirements of registration.
(17) “Discharge” means the removal of a resident from a nursing home when the releasing nursing home is no longer responsible for the resident’s care.
(18) “Discipline” means the medical, rehabilitative, nursing, dietetic, activities and social service components affiliated with the operation of a nursing home.
(19) “Distinct part extended care facility” means a portion of a nursing home that is licensed as an extended care facility.
(20) “Extended care facility” means a nursing home that offers sub-acute care and provides medical treatment services for residents who require inpatient care but who do not currently require continuous hospital services.
(21) “Facility” means a nursing home.
(22) “Fire authorities” means the official fire safety agency including the State Fire Marshal or local fire marshals or fire departments as appropriate.
(23) “Full time” means 40 hours per week or the standard work week adopted by the nursing home.
(24) “Geriatric nursing assistant” means a CNA who has successfully completed the requirements for a GNA set forth in 42 CFR §§483.151—483.156 and COMAR 10.39.01.
(25) “Grant” means the award of money to an individual or an organization to:
(a) Study an aspect for the geriatric population; or
(b) Provide a service to nursing home residents or their families.
(26) “Health officer” means the health officer or the designated representative in each of the 23 counties and the Commissioner of Health in Baltimore City.
(27) “HVAC” means heating, ventilation and air conditioning.
(28) “Infection preventionist” means a licensed healthcare worker who:
(a) Manages the infection prevention and control program in the nursing home; and
(b) Has completed a minimum of 15 contact hours of infection prevention and control training that is approved by the:
(i) Department’s Office of Infectious Disease Epidemiology and Outbreak Response; and
(ii) Office of Health Care Quality.
(29) “Licensed bachelor social worker (LBSW)” means an individual authorized to practice bachelor social work under Health Occupations Article, Title 19, Annotated Code of Maryland.
(30) “Licensed certified social worker (LCSW)” means an individual authorized to practice certified social work under Health Occupations Article, Title 19, Annotated Code of Maryland.
(31) “Licensed certified social worker–clinical (LCSW-C)” means an individual authorized to practice clinical social work under Health Occupations Article, Title 19, Annotated Code of Maryland.
(32) “Licensed graduate social worker (LGSW)” means an individual authorized to practice graduate social work under Health Occupations Article, Title 19, Annotated Code of Maryland.
(33) “Licensed or certified professional health care practitioner” means a nurse practitioner, physician assistant, or other practitioner licensed or certified under the Health Occupations Article, Annotated Code of Maryland.
(34) “Licensed pharmacist” means an individual who is licensed by the Board to practice pharmacy as defined in Health Occupations Article, §12-101(l), Annotated Code of Maryland.
(35) “Licensed practical nurse” means an individual authorized to practice licensed practical nursing under Health Occupations Article, Title 8, Annotated Code of Maryland.
(36) “Management firm” means an organization, under contract with an applicant for a license or a current licensee, that is intended to have or has full responsibility and control for the day-to-day operations of the nursing home.
(37)”MDS Care Area Assessment” means the investigation of triggered care areas, to determine if the care area or areas require interventions and care planning.
(38) “Medical director” means an individual licensed to practice medicine in this State who, pursuant to a written agreement, is responsible for the overall coordination of the medical care in the nursing home to ensure the adequacy and appropriateness of the medical services provided to residents and to maintain surveillance of the health status of employees.
(39) “Minimum Data Set (MDS)” means a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which:
(a) Forms the foundation of a comprehensive assessment for all nursing home and swing bed residents; and
(b) Standardize communication about resident problems and conditions:
(i) Within these facilities;
(ii) Between these facilities; and
(iii) Between these facilities and outside agencies.
(40) “New nursing home” means a nursing home that does not yet have plans approved by the Department at the time of the adoption of this chapter.
(41) “NFPA” means National Fire Protection Association.
(42) “Nurse” means a licensed practical nurse or registered nurse licensed in the State as defined in Health Occupations Article, §8-101, Annotated Code of Maryland.
(43) “Nurse practitioner” has the meaning stated in Health Occupations Article, §8-101(k), Annotated Code of Maryland.
(44) “Nursing care” has the meaning stated in Health-General Article, §19-301(k), Annotated Code of Maryland.
(45) “Nursing home” means a comprehensive care facility or extended care facility which offers nonacute inpatient care to patients:
(a) Suffering from a disease, chronic illness, condition, disability of advanced age, or terminal disease requiring maximal nursing care without continuous hospital services; and
(b) Who require medical services and nursing services rendered by or under the supervision of a licensed nurse together with convalescent, restorative, or rehabilitative services.
(46) “Nursing service personnel” means staff licensed or certified by the Maryland Board of Nursing.
(47) “Occupational therapist” means an individual who is currently licensed by the State Board of Occupational Therapy Practice as a registered occupational therapist.
(48) “Occupational therapy assistant” means an individual who is currently licensed by the State Board of Occupational Therapy Practice as an occupational therapy assistant.
(49) “Ongoing pattern” means the occurrence of any potential for more than minimal harm or greater deficiency on two consecutive on-site visits as a result of:
(a) Annual surveys;
(b) Follow-up visits and unscheduled visits; or
(c) Complaint investigations.
(50) “Paid feeding assistant” means an individual who:
(a) Meets the requirements of Regulation .58 of this chapter; and
(b) Is paid by a nursing home to feed residents who are unable to perform the task themselves.
(51) “Physical restraint” means any manual method or physical or mechanical devise, 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 including but not limited to:
(a) Leg restraints;
(b) Arm restraints;
(c) Hand mitts;
(d) Soft ties or vests;
(e) Lap cushions; and
(f) Lap trays the resident cannot remove easily.
(52) “Physical therapist” means an individual licensed to practice physical therapy by the State Board of Physical Therapy Examiners.
(53) “Physician” means an individual licensed to practice medicine in this State.
(54) “Physician assistant” has the meaning stated in Health Occupations Article, §15-101(o), Annotated Code of Maryland.
(55) “Plan of correction” means a written response from the nursing home addressing each deficiency cited as a result of an inspection by the Department.
(56) “Positive tuberculin skin test” means a test provided as authorized by the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings.
(57) “Principal physician” means an individual licensed to practice medicine in this State who agrees to perform certain medical services under contract with a nursing home, consistent with the policies of the nursing home.
(58) “Protective device” means any device or equipment:
(a) That is prescribed by a physician;
(b) That limits, but does not eliminate the movement of the resident’s head, body, or limbs; and
(c) That:
;
(ii) Prevents a resident from aggravating an existing physical problem; or
(iii) Prevents a resident from a precipitating potential physical problem.
(59) “Qualified medical record practitioner” means an individual who:
(a) Has:
(i) Received a baccalaureate degree from an accredited college or university including or supplemented by a successful completion of a course in health record administration approved by the Council on Medical Education of the American Medical Association; and
(ii) Passed the national registration examination for registered record administrators; or
(b) Has:
(i) Received an associate of arts degree in health record technology from a college or university approved by the American Medical Association Council on Medical Education or an equivalent approved health record technology correspondence course of the American Medical Record Association; and
(ii) Passed the national accreditation examination for accredited record technicians.
(60) “Qualified social work consultant” means an individual who:
(a) Is a licensed certified social worker; and
(b) Has a minimum of 3 years’ experience in social work programs in a long-term care setting within the last 5 years.
(61) “Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system” means the standard nationwide system to which several types of health care providers submit CMS required resident information to the National Submissions Database.
(62) “Registered nurse” means an individual licensed to practice as a registered nurse in this State.
(63) Relocation.
(a) “Relocation” means the movement of a resident from one room to another within:
(i) The same Medicare-certified nursing home;
(ii) A Medicaid-only certified nursing home; or
(iii) A licensed-only nursing home.
(b) “Relocation” does not mean the movement of a resident if the effect of the movement is to move the resident from:
(i) The distinct part of the nursing home that is a skilled nursing facility to a distinct part of the nursing home that is not a skilled nursing facility; or
(ii) A bed that is certified for Medicaid to a distinct part of the nursing home that is a skilled nursing facility.
(64) “Resident” means an individual who:
(a) Resides in the nursing home; and
(b) Receives nursing services rendered by or under the supervision of a registered nurse.
(65) “Resident activities coordinator” means an individual who:
(a) Is a:
(i) Certified therapeutic recreation specialist;
(ii) Licensed occupational therapist; or
(iii) Licensed occupational therapy assistant; or
(b) Has 2 years of experience in a social or recreational program in a licensed health care setting within the last 5 years, 1 year of which was full time in a resident activities program with guidance from an individual identified in §B(73)(a) of this regulation.
(66) Resident Assessment Instrument (RAI).
(a) “Resident Assessment Instrument (RAI)” means a standardized and reproducible resident assessment process based on completion of Minimum Data Set (MDS) screening items, and including the MDS Care Area Assessment process, and related process for care planning and evaluation.
(b) “Resident Assessment Instrument (RAI)” includes:
(i) Minimum Data Set;
(ii) MDS Care Area Assessment Process; and
(iii) RAI utilization guidelines.
(67) “Resident’s representative” means a person with the authority to act on the resident’s behalf regarding the matter at issue.
(68) “Restraint” means any physical or chemical restraint as defined in this chapter.
(69) “Secretary” means the Secretary of Health.
(70) “Serious and immediate threat” means a situation in which immediate corrective action is necessary because a deficiency has caused or is likely to cause serious injury, harm, impairment to, or death of a resident receiving care in the nursing home.
(71) “Special care unit” means a nursing home unit that provides intensive specialized care, such as respiratory, rehabilitative, dementia, or dialysis care, continuously on a 24-hour basis.
(72) “Speech-language pathologist” means an individual licensed by the State Board of Audiologists, Hearing Aid Dispensers, and Speech-Language Pathologists.
(73) “Support personnel” means an aide who:
(a) Is assigned to a particular service such as:
(i) Nursing;
(ii) Dietary;
(iii) Physical therapy; or
(iv) Occupational therapy; and
(b) Has been approved by the manager of the services as having sufficient training and experience to perform the assigned duties.
(74) “Tuberculin skin test” means a test to diagnose tuberculosis infection using purified protein derivative (PPD) that is injected intradermally and read within 48—72 hours with results recorded in millimeters of induration.
(75) Tuberculosis in a Communicable Form.
(a) “Tuberculosis in a communicable form” means that an individual:
(i) Is presumed to have active pulmonary or laryngeal tuberculosis as evidenced by positive X-ray findings with or without positive acid-fast bacilli (AFB) sputum smear or positive AFB sputum culture; and
(ii) Has received chemotherapy for less than 14 days.
(b) “Tuberculosis in a communicable form” does not include:
(i) When the individual who has presumptive or confirmed active disease, has had three negative AFB smears, collected 8—24 hours apart, shows clinical improvement, and has received chemotherapy to which the strain is susceptible for at least 14 days; or
(ii) The individual who has inactive pulmonary scarring, calcification, or a normal chest X-ray.
(76) “Two-step tuberculin skin testing” means the administration of a second tuberculin skin test 1 to 3 weeks after the initial skin test is negative, to identify individuals with a past TB infection who may now have reduced skin reactivity.
.02 Incorporation by Reference.
A. In this chapter, the following documents are incorporated by reference.
B. Documents Incorporated.
(1) CMS Long-term Care Facility Resident Assessment Instrument 3.0 User’s Manual, (Version 1.14, October 2016).
(2) CMS Manual System, Pub. 100-07 State Operations Provider Certification, (Transmittal 127, November 26, 2014, U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services).
(3) Guidelines for Design and Construction of Residential Health, Care, and Support Facilities. (2014) Facility Guidelines Institute, which is incorporated in COMAR 10.07.01.02.
(4) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HIPAC), 2007).
(5) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 (MMWR2005; 54, No. RR-17, Centers for Disease Control and Prevention (CDC), Atlanta, GA).
(6) Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), (MMWR2011; 60 No. SS-07, Centers for Disease Control and Prevention (CDC), Atlanta, GA).
(7) National Fire Protection Association, NFPA 99 Health Care Facilities Code (2015 Edition).
(8) National Fire Protection Association, NFPA 101 “Life Safety Code”, which is incorporated by reference at COMAR 29.06.01.06.
(9) Recommended Dietary Allowances, (10th Edition, Food and Nutritional Board, Commission on Life Sciences, and National Research Council, 1989).
[.02] .03 License Required.
A.—E. (text unchanged)
F. Provisional License.
(1) The Secretary may issue a license to a [comprehensive care facility] nursing home or an extended care facility for less than a 24-month period under any of the following conditions:
(a)—(c) (text unchanged)
(d) If new construction is completed to the point of being able to provide all necessary services to its residents but certain substantial items of equipment [of] for optional services are temporarily lacking, which in the opinion of the Department will have no immediate adverse effect on the safety or health of its residents[, are lacking temporarily]; or
(e) (text unchanged)
(2)—(3) (text unchanged)
G.—H. (text unchanged)
[.03] .04 Licensing Procedure.
A. Application for License.
(1) An applicant desiring to open a comprehensive care facility or an extended care facility [or to continue the operation of an existing facility as a comprehensive care facility or an extended care facility] shall file an application with the Secretary, on a written or electronic form provided by the Secretary.
(2)—(6) (text unchanged)
(7) Additional Requirements.
(a) The Secretary shall require an applicant for licensure to submit to the Secretary the following information concerning the applicant’s:
(i) (text unchanged)
(ii) Ability to comply with [minimum] the applicable standards of medical and nursing care and applicable State or federal laws and regulations by disclosing the identities of its medical director, director of nursing, and administrator, and by providing the [facility’s] nursing home’s quality assurance plan, as required in Regulation [.46] .66 of this chapter; and
(iii) (text unchanged)
(b) (text unchanged)
(c) A [party aggrieved by a] person that disagrees with the decision of the Secretary to deny a license application under this section [shall have the right to appeal as provided under the authority of Health-General Article, §2-207, Annotated Code of Maryland] may appeal the Secretary’s action by filing a request for a hearing in accordance with Regulation .78 of this chapter.
B. Restrictions of License.
(1) Nomenclature. [Comprehensive care facilities or extended care facilities] A nursing home licensed under this regulation may not use the word “hospital” in [their] its title [the word “Hospital”].
(2) (text unchanged)
(3) Local Law or Ordinance, Where Applicable. [Comprehensive care facilities or extended care facilities] A nursing home located in a political [subdivisions] subdivision which [require them] requires it to meet certain standards shall submit proof to the Secretary that [they meet] the nursing home meets local laws, regulations, or ordinances at the time application for license is submitted.
[(4) Renewal of License.
(a) A facility shall file an application to renew its license every 2 years at least 60 days before expiration of the issued license.
(b) The renewal application shall be submitted on written or electronic forms provided by the Secretary.]
[(5)] (4) Transfer or Assignment of License.
(a) If the sale, transfer, assignment, or lease of a [facility] nursing home causes a change in the person or persons who control or operate the [facility] nursing home, the [facility] nursing home shall be considered a “new [facility] nursing home” and the licensee shall conform to all regulations applicable at the time of transfer of operations.
(b) The transfer of any stock which results in a change of the person or persons who control the [facility] nursing home, or a 25 percent or greater change in any form of ownership interest, constitutes a sale.
(c) For purposes of Life Safety Code enforcement, the [facility] nursing home is considered [as] to be an existing [facility] nursing home if it has been in continuous use as a nursing home. Waivers may be granted under Regulation [.02F] .03F of this chapter.
[(6) Return of License or Renewal Certificate to the Secretary of Health and Mental Hygiene. If the comprehensive care facility or the extended care facility is sold, leased, discontinued, the operation moved to a new location, the license revoked, or its renewal denied, the current license immediately shall become void and shall be returned to the Secretary.]
(5) Return of License or Renewal Certificate to the Secretary of Health. The current license shall immediately become void and shall be returned to the Secretary if the:
(a) Nursing home is sold, leased, or discontinued;
(b) Operation moved to a new location;
(c) License is revoked; or
(d) License renewal is denied.
[.03-1] .05 Licensed Bed Capacity.
A.—B. (text unchanged)
C. Request for Departmental Permission to Exceed Capacity.
(1)—(2) (text unchanged)
(3) The [facility] nursing home shall:
(a) (text unchanged)
(b) [Be] Make the request for a term not to exceed 30 days.
(4)—(6) (text unchanged)
[.05] .07 Inspection by Secretary [of Health and Mental Hygiene].
A. Open at all Times for Inspection. Licensed [comprehensive care facilities and extended care facilities] nursing homes and any premises [proposed] that an applicant for a license proposes to [be operated by an applicant for a license] operate shall be open at all times to inspection by the Secretary and by any agency designated by the Secretary.
B.—D. (text unchanged)
E. The Department shall make a site visit and conduct a full survey of each licensed nursing home at least once per calendar year.
.08 New Construction, Conversion, Alteration, or Addition.
A. Submission of Plans.
(1) The architect or professional engineer of record shall submit stamped and sealed final construction drawings to the Department.
(2) The architect or professional engineer of record shall submit a letter certifying that the project has been designed in accordance with all applicable federal, State, and local codes, laws, ordinances, and regulations for construction.
B. Plan Approval.
(1) A system of water supply, plumbing, sewerage, electrical power, garbage or refuse disposal may not be installed or extended until the architect or professional engineer of record submits stamped and sealed final construction drawings for Department record and provisional approval in accordance with §A of this regulation.
(2) The architect or professional engineer of record shall also submit a letter certifying that the project has been designed in accordance with all applicable federal, State, and local codes, laws, ordinances, and regulations.
C. New Construction.
(1) A new nursing home shall satisfy the review of the Maryland Health Care Commission for the:
(a) Establishment of a new nursing home; and
(b) Increase or decrease in capacity of an existing nursing home.
(2) After obtaining approval by the Maryland Health Care Commission, the nursing home shall provide written verification of the approval to the Office of Health Care Quality.
(3) Verification shall include:
(a) Details of the proposed nursing home changes; and
(b) Written plans that describe how all residents, staff, and the general public will be kept safe during the duration of the project.
D. Conversion, Alteration, and Additions.
(1) An existing nursing home that wishes to convert, alter, modify, or add to the existing infrastructure shall notify the Office of Health Care Quality in writing.
(2) The nursing home shall provide the Office of Health Care Quality with the documentation that verifies that the applicable local and State governmental authorities have approved work that was done.
(3) The nursing home shall provide additional information upon request.
[.07] .09 Administration and Resident Care.
A. (text unchanged)
B. Delegation to Administrator.
(1) The licensee, if not acting as an administrator, shall appoint as administrator a responsible person who is [qualified]:
(a) Qualified by training and experience[,]; and [is licensed]
(b) Licensed by the Board of Examiners of Nursing Home Administrators for the State.
(2) The administrator shall [be]:
(a) Be responsible for the control of the operation on a 24-hour basis; and [shall serve]
(b) With the exception of §B(3) of this regulation, serve full-time [except that].
(3) With the Department’s approval, an administrator may[, with the Department’s approval,] serve on a less than full-time basis for a maximum of two nursing facilities, one of which shall have a licensed capacity of 35 beds or less.
[(2)] (4) The Department shall consider the following factors when [considering] deciding whether to approve an administrator to serve on a less than full-time basis:
(a) [Geographical] Geographic location of the facilities;
(b)—(e) (text unchanged)
C. Absence of Administrator.
(1) In the absence of the administrator, the [facility] nursing home at all times shall be under the direct and personal supervision of an experienced, trained, competent employee.
(2) When [the director of nursing serves] serving as relief for the administrator, [he] the director of nursing shall designate an experienced, qualified registered nurse to direct the nursing service.
(3) The relief director of nursing shall be freed from other responsibilities.
D. Excessive Absenteeism of Administrator.
(1) If the [administrator is absent from the facility an excessive amount of time and the Department determines that the] director of nursing’s absence [from nursing service] while covering for the administrator is having an adverse effect on [patient] resident care, the Department may require the designation of a specific registered nurse who shall be named the [“]assistant director of nursing[”].
(2) The Department shall be notified of the name of the assistant director of nursing.
(3) When the designee is replaced, the Department shall be notified of the name of the registered nurse filling the vacancy.
E. Character. The administrator shall [be]:
(1) Be of good moral character[,];
(2) Be in good physical and mental health[,]; and [shall demonstrate]
(3) Demonstrate a genuine interest in the well-being and welfare of [patients] residents in the [facility] nursing home.
F. Staffing.
(1) The administrator shall employ sufficient and satisfactory personnel as specified in this chapter to [give adequate patient care and to do feeding,]:
(a) Provide maintenance, cleaning, and housekeeping;
(b) Assist residents with eating; and
(c) Give adequate resident care.
(2) Voluntary Admissions Ceiling.
(a) A [facility] nursing home may request a [“]voluntary admissions ceiling[”] by submitting a written request to the Department to authorize a temporary restriction on [patient] resident admissions based upon anticipated bed usage.
(b) When the [facility] nursing home wishes to request that the restriction be removed, the request shall include the specific effective date and a statement that personnel staffing is sufficient to meet the State’s requirements at the designated census [figure] level.
(c) The Department shall approve the increase in beds within 72 hours following receipt of the [facility’s] nursing home’s documentation that the required additional staff is [“]in [place”] position to serve the increased number of beds.
(d) Management of the [facility] nursing home may not permit the [patient] resident census to exceed the admissions ceiling without prior approval from the Department.
[(3) As requested by the Department, the administrator or his designee shall telephone the Department’s central bed registry, advising the Department of:
(a) The number of vacant licensed beds in the facility;
(b) The levels of care of the beds reported vacant;
(c) The types of patients who will be accepted —private, Medicare, or Medicaid.]
G. Educational Program. [An]
(1) The administrator shall plan an ongoing educational program [shall be planned and conducted for the development and improvement of] to develop and improve the skills of all the [facility’s] nursing home’s personnel, including training related to problems and needs of the aged, ill, and disabled. [Records shall be maintained]
(2) The administrator shall maintain records reflecting attendance, by name and title, and training content.
(3) In-service training shall include at least:
[(1)] (a) (text unchanged)
[(2)] (b) Fire prevention programs and [patient] resident related safety procedures in emergency situations or conditions;
[(3)] (c) (text unchanged)
[(4)] (d) Confidentiality of [patient] resident information;
[(5)] (e) Preservation of [patient] resident dignity, including protection of the [patient’s] resident’s privacy and personal and property rights;
[(6)] (f) [Psychophysical] Physical, functional, and psychosocial needs of the aged ill;
[(7)] (g)—[(8)] (h) (text unchanged)
H. Employment Records. A written application shall be on file for each employee and shall contain at least the:
(1) Employee’s [social security] Social Security number[.];
(2) Home address[.];
(3) Educational background[.];
(4) Past employment [with] documentation [that] with references [have been considered by the facility. If the employee formerly worked in a];
(5) Past nursing home[, consideration shall be given to the record as it relates to] employment documentation, including any past instances of abuse of [patients] residents, theft, and fires[.];
[(5)] (6) [The] Verified licensure of personnel employed [as registered or licensed practical nurses shall be verified by the facility.]; and
(7) Proof of criminal background check.
I. [Supportive] Support Personnel.
(1) To support placement in a specific position, there shall be sufficient documentation in the employee’s record reflecting his training and experience.
(2) In instances when an aide is to be assigned to a particular service such as dietary, physical therapy, or occupational therapy, the person in charge of the service shall be responsible for the evaluation and approval of the qualifications.
J. New [Supportive] Support Personnel.
(1) New [supportive] support personnel shall be credited for 50 percent of their working time until the employee’s orientation program, as approved by the Department, is completed.
(2) Employee Orientation Program.
(a) New support personnel shall have an employee orientation program.
(b) The person in charge of the service to which the employee is assigned shall [have]:
(i) Have input into the contents of the orientation program; [Policies for the orientation program shall include]
(ii) Determine the number of hours of orientation required for the various levels of [supportive] support personnel; and
(iii) Following the period of orientation, [the person responsible for the orientation program and the person in charge of the service shall] indicate the satisfactory completion of the orientation program of the employee.
(3) The responsible department’s approval shall be in writing, signed by the appropriate department head whose license number, if applicable, shall be recorded in the record.
(4) In new facilities, the director of nursing and supervisors of [the various services,] dietary services, housekeeping, rehabilitation services, and social services[,] shall be responsible for orienting the new [supportive] support personnel to the [facility’s] nursing home policies and procedures and to the physical plant.
(5) There shall be a complete orientation for all the employees in life safety and disaster preparedness.
(6) The number of daily admissions of [patients] residents shall be controlled to allow sufficient time for on-the-job training.
(7) Before the opening of the [facility all supportive] nursing home, support personnel shall have a minimum of 2 days of orientation training.
K.—L. (text unchanged)
M. Except where inappropriate for safety reasons, an employee and any other individual who provides a health care service within or on the premises of the nursing home shall wear a personal identification tag that:
(1) States the name of the individual;
(2) States the profession or other title of the individual; and
(3) Is in a readily visible type font and size.
[.07-1] .10 Employee Training on Cognitive Impairment and Mental Illness.
A. (text unchanged)
B. The training on cognitive impairment and mental illness shall be designed to meet the specific needs of the [facility’s] nursing home’s population as determined by the staff trainer, including the following as appropriate:
(1)—(2) (text unchanged)
(3) Behavioral [intervention] interventions including:
(a)—(d) (text unchanged)
(4)—(7) (text unchanged)
C.—F. (text unchanged)
[.08] .11 Admission and Discharge.
A. Written Policy. The nursing home shall develop written policies, consistent with this chapter and COMAR 10.07.09, to govern the nursing care, related medical, and other services that the nursing home provides regarding:
(1) Admissions, transfers, and discharges;
(2) Acceptable payment sources; and
(3) Medical Assistance program information.
B. The nursing home shall make its admission and discharge policies available for review by residents and the resident’s representative.
[A.] C. Discrimination Prohibited. A [facility] nursing home licensed under [these regulations] this chapter may not discriminate in admitting or providing care to an individual because of [the race, color, national origin, or physical or mental handicap] the individual’s:
(1) Race;
(2) Color;
(3) National origin;
(4) Sexual orientation;
(5) Gender identity;
(6) Physical disability; or
(7) Mental disability [of the individual].
[B.] D. Contract. Before or at admission, a contract shall be executed by the administrator and [patient] resident, guardian, or responsible agency which is consistent with the requirements of Health-General Article, §19-344, Annotated Code of Maryland, “Rights of Individuals”.
[C.] E. Registry. [Facilities] A nursing home shall maintain a permanent [patient] resident registry in which the name of each [patient] resident is entered in chronological order with the date and number of entry.
[D.] F. Admission Record. A copy of the clinical record, identification, and summary sheet described in Regulation [.20B] .32 shall be used as an admission record.
G. Before discharge the nursing home shall:
(1) Verify that the transfer and discharge to an assisted living nursing home is licensed and appropriate to meet the needs of the resident; and
(2) Document the verification in the resident’s medical record.
[E.] I. Notification of Responsible Persons When [Patient] Resident Moves. [The administrator or the administrator’s designee shall notify the private or public agency or relative responsible for the patient when the patient is transferred from the facility for any reason or at time of death. The attending physician shall also be notified.] When the resident is transferred from the nursing home for any reason or at time of death, the administrator or the administrator’s designee shall notify the attending physician and the:
(1) Private agency;
(2) Public agency; or
(3) Responsible party designated by the resident.
[F.] J. Restrictions on Admission and Retention of [Patients] Residents. [Patients] Residents may not be admitted or retained if, in the judgment of the attending physician, they are:
(1)—(2) (text unchanged)
[G. Admissions Procedures for Patients With Communicable Diseases. The following procedures are to be used when admitting an individual with a communicable disease into a nursing facility:
(1) A facility may not deny admissions to, or involuntarily discharge, an individual solely because the individual has a communicable disease;
(2) Any facility that intends to accept an individual with a communicable disease shall notify the Department before admitting the individual; and
(3) The Secretary or a designee of the Secretary may prohibit a facility from accepting an individual with a communicable disease if it is determined that admitting the individual with a communicable disease could pose a risk to the health, safety, or welfare of any other resident or individual associated with the facility.]
[.08-1] .12 Resident’s Representative.
A. A [comprehensive or extended care facility] nursing home shall recognize the authority of:
(1)—(2) (text unchanged)
(3) An [advanced] advance directive that meets the requirements of Health-General Article, §5-602, Annotated Code of Maryland;
(4)—(7) (text unchanged)
B.—C. (text unchanged)
[.09] .13 Resident Care Policies.
[A. Written Policies. Comprehensive care facilities and extended care facilities shall develop written policies, consistent with these regulations, to govern the nursing care and related medical or other services they provide covering the following:
(1) Admission, transfer, and discharge policies including categories of patients accepted and not accepted by the facility, or those who are required to transfer to another level of care. The facility’s admission policy shall include a statement as to whether or not medical assistance patients will be admitted and if admitted, under what circumstances.]
A. A nursing home shall develop written policies consistent with Regulation .11 of this chapter pertaining to:
[(2)] (1) Physician services[.];
[(3)] (2) [Patients’] Residents’ rights[.];
[(4)] (3) Nursing services[.];
[(5)] (4) Dietetic services[.];
[(6)] (5) Specialized rehabilitative services[—] including occupational therapy [services], physical therapy [services], speech pathology and audiology services[.];
[(7)] (6) Pharmaceutical services[.];
[(8)] (7) Laboratory and radiologic services[.];
[(9)] (8) Dental services[.];
[(10)] (9) Social services[.];
[(11)] (10) [Patient] Resident activities[.];
[(12)] (11) Clinical records[.];
[(13)] (12) Reports and action required in unusual circumstances[.];
[(14)] (13) Utilization review[.];
[(15)] (14) Infection control[.];
[(16)] (15) Tuberculosis [Surveillance. All comprehensive care facilities and extended care facilities shall have written policies and procedures, acceptable to the Department, for tuberculosis surveillance of all residents. See Regulation .21G of this chapter for tuberculosis surveillance requirements.] surveillance;
[(17)] (16) Disaster plan[.];
[(18)] (17) Housekeeping services, pest control, and laundry[.]; and
[(19)] (18) [Patient] Resident care management.
B. [The patient] Resident Care Policy.
(1) A nursing home shall develop resident care policies [shall be developed] with the advice of [the]:
(a) The principal physician [(] or medical staff or medical director, if applicable [)]; and [at]
(b) At least one registered nurse. [Policies shall be reviewed at least annually by a]
(2) A group of professional personnel including one or more physicians and one or more registered nurses shall review the policies at least annually.
(3) Written policies shall be kept current with the policies used to administer the [facility] nursing home.
(4) For reference purposes, copies of the [patient] resident care policies shall be readily available to all personnel responsible for [patient] resident care.
(5) The nursing home shall make its resident care policies available for review by residents and the resident’s representative.
C. (text unchanged)
D. Use of Protective Device or Devices.
(1)—(3) (text unchanged)
(4) A [patient] resident in a protective device or devices shall be observed periodically by personnel, to [insure] ensure that the [patient’s] resident’s health and personal care needs are met.
(5) A [patient] resident who is in a protective device or devices may not be left in the same postural position for more than 2 consecutive hours.
[.10] .14 Physician Services.
A. Responsibility for the Resident’s Care. The attending physician shall:
(1)—(4) (text unchanged)
(5) For a resident who is to be transferred to the care of another [health care practitioner] attending physician, continue to provide all necessary medical care and services pending transfer until another attending physician has accepted responsibility for the resident.
B.—F. (text unchanged)
G. Appropriate Care of Residents. The attending physician shall:
(1)—(6) (text unchanged)
(7) Respond promptly to notification of, and assess and manage adequately, reported acute and other significant clinical condition changes in residents; [and]
(8) Ensure that individuals receiving palliative care have appropriate comfort and supportive care measures; and
(9) Properly refer residents to specialty services and providers when the care needs of the resident exceed the scope of the attending physician’s knowledge and skill.
H.—I. (text unchanged)
[.11] .15 Medical Director Qualifications.
A. Medical Director Qualifications. The nursing [facility] nursing home shall:
(1) Designate a medical director who has at least the following qualifications:
(a) (text unchanged)
(b) At least 2 years of experience or specialized training in the medical care of geriatric or chronically ill and impaired residents; and
(c) Successful completion of a curriculum in physician management or administration from [the American Medical Directors Association or another curriculum approved by the Department or its designee; and]:
(i) AMDA: The Society for Post-Acute and Long-Term Care Medicine; or
(ii) A curriculum approved by the Department or its designee;
[(d) Privileges at a hospital in this state, participant in an HMO network, or credentialed by a credentialing organization approved by the Department.]
(2) (text unchanged)
(3) Submit a copy of the medical director’s credentials to the Department upon:
(a) The first license renewal of the [facility] nursing home after the effective date of this regulation; and
(b) (text unchanged)
B. (text unchanged)
[.11–1] .16 Medical Director Responsibilities.
A. General Responsibilities. The medical director is responsible for:
(1) (text unchanged)
(2) Monitoring and evaluating the health care services and outcomes [of the health care], including clinical and physician services provided to the [facility’s] nursing home’s residents; and
(3) (text unchanged)
B.—D. (text unchanged)
E. Quality Assurance. The medical director shall actively participate in the [facility’s] nursing home’s quality improvement process. Participation shall include:
(1) Regular reports and attendance at[, and reporting to,] the [facility’s] nursing home’s quality improvement committee meetings; and
(2) (text unchanged)
F. Employee Health Oversight. The [facility] nursing home, in consultation with the medical director and other physicians, if necessary, shall establish and maintain surveillance of the health status of employees, including:
(1) Advising on the development and execution of an employee health program, which shall include provisions for determining that employees are free of communicable diseases according to current [acceptable] accepted standards of practice; and
(2) (text unchanged)
G.—I. (text unchanged)
[.11-2] .17 [Facility’s ] Nursing Home’s Responsibilities in Relation to the [Facility’s] Nursing Home’s Medical Director.
A. (text unchanged)
B. When the attending physician and medical director document a resident’s medical need for a particular treatment, assistive device, or equipment, the nursing home shall provide that treatment, assistive device, or equipment [shall be provided by the facility] unless the [facility] nursing home documents in the quality assurance committee minutes the reason or reasons why the treatment, assistive device, or equipment should not be provided.
C. When the attending physician and medical director agree that a particular [facility-developed] nursing home developed protocol is required to ensure that quality medical care is delivered to the [facility’s] nursing home’s residents, that protocol shall be implemented unless the [facility] nursing home documents in the [facility’s patient] nursing home’s resident care committee minutes the reason or reasons why the protocol should not be implemented.
D. (text unchanged)
.18 Nursing Services.
A. Organization, Policies, and Procedures.
(1) Nursing service personnel shall provide care appropriate to the residents’ needs with the organizational plan, authority, functions, and duties clearly defined.
(2) Nurses and support personnel shall be chosen for their training, experience, and ability.
(3) Policies and procedures shall be adopted and made available to all nursing service personnel.
B. Signed Agreement.
(1) A signed copy of the agreement between the nursing home and the director of nursing, showing the license number of the nurse, shall be filed with the Department upon:
(a) Application for an initial nursing home license; and
(b) A change of director of nursing.
(2) The agreement shall specify the duties of the director of nursing.
C. Nursing Care 24 Hours a Day. The administrator shall employ sufficient and satisfactory licensed nursing service personnel and support personnel to:
(1) Be on duty 24 hours a day;
(2) Provide appropriate bedside care; and
(3) Assure that a resident:
(a) Receives treatments, medications, and diet as prescribed;
(b) Receives rehabilitative nursing care as needed;
(c) Receives proper care to prevent pressure ulcers and deformities;
(d) Is kept comfortable, clean, and well-groomed;
(e) Is protected from accident, injury, and infection;
(f) Is encouraged, assisted, and trained in self-care and group activities; and
(g) Receives prompt and appropriate responses to requests for assistance.
D. Assistance by Nursing Service Personnel. Nursing service personnel shall help the resident perform daily routine dental hygiene.
E. Charge Nurse.
(1) At least one licensed nurse shall be:
(a) On duty at all times; and
(b) Be designated by the director of nursing to be in charge of the nursing activities during each tour of duty.
(2) The charge nurse or nurses shall have the ability to recognize significant changes in the condition of residents and to take necessary action.
F. Charge Nurses’ Daily Rounds. The charge nurse or nurses shall make daily rounds on all nursing units for which they are responsible, performing such functions as:
(1) Visiting each resident;
(2) Reviewing clinical records, medication orders, resident care plans, and staff assignments; and
(3) To the degree possible, accompanying physicians when visiting residents.
G. Program of Restorative Nursing Care. There shall be an active program of restorative nursing care aimed at assisting each resident to achieve and maintain the individual’s highest level of independent function, including activities of daily living. This program shall include:
(1) Ambulation and range of motion;
(2) Maintaining good body alignment and proper positioning of bedfast residents;
(3) Encouraging and assisting residents to change positions at least every 2 hours to stimulate circulation and prevent pressure ulcers and deformities;
(4) Encouraging and assisting residents to keep active and out of bed for reasonable periods of time, within the limitations permitted by physicians’ orders;
(5) Encouraging residents to engage in resident-chosen community and independent activities and achieve independence; and
(6) Assisting residents to adjust to their disabilities and ensuring availability and use of their prosthetic and assistive devices.
H. Coordination of Nursing and Dietetic Services. Nursing and dietetic services shall establish an effective policy to ensure that:
(1) Nursing service personnel are aware of the nutritional needs and food and fluid intake of residents;
(2) Nursing service personnel provide special meals and nourishment when required;
(3) Residents’ food choices and preferences are honored as much as practical;
(4) Nursing service personnel promptly aid residents when necessary in eating;
(5) The dietetic service is informed of physicians’ diet orders and of residents’ nutrition-related issues; and
(6) Food and fluid intake of residents is observed, and deviations from normal are recorded and reported to the:
(a) Charge nurse;
(b) Physician; and
(c) Dietetic service.
I. In-Service Education Program.
(1) The director of nursing shall:
(a) Provide a continuing in-service education program for all nursing service personnel;
(b) Provide a thorough job orientation for new personnel; and
(c) Document the content of the continuing in-service education program and include the names and titles of participants.
(2) The director of nursing shall obtain approval from the Department.
J. Responsibility to Report Care that Is Considered Questionable.
(1) If a nurse questions the care provided to any resident or believes that appropriate consultation is needed and has not been obtained, the nurse shall inform the supervisor.
(2) If indicated, the supervisor shall refer the matter to the director of nursing.
(3) If warranted, the director of nursing shall report the matter to the medical director or principal physician.
.19 Nursing Services — Staffing.
A. Supervisory Personnel—Nursing Homes.
(1) Nursing homes shall provide at least the following supervisory personnel:
|
Residents |
Registered Nurses |
|
(a) 2—99 |
One—full-time |
|
(b) 100—199 |
Two—full-time |
|
(c) 200—299 |
Three—full-time |
|
(d) 300—399 |
Four—full-time |
(2) The director of nursing’s time is included in §A(1) of this regulation.
B. Hours of Bedside Care — Nursing Home.
(1) A nursing home shall employ supervisory personnel and a sufficient number of support personnel to provide a minimum of 3 hours of bedside care per occupied bed per day, 7 days per week.
(2) Bedside hours include the care provided by:
(a) Registered nurses;
(b) Licensed practical nurses; and
(c) Support personnel.
(3) Only those hours which the director of nursing spends in bedside care may be counted in the 3-hour minimum requirement.
(4) The director of nursing’s time counted in bedside care shall be documented.
C. Staffing in Nursing Home.
(1) A nursing home shall be staffed with at least one registered nurse, 24 hours per day and 7 days per week.
(2) Additional registered nurses, licensed practical nurses, and support personnel shall be employed to meet the needs of all the residents admitted. The nursing home shall be staffed as referenced in §§A and B of this regulation.
D. Nursing Service Personnel on Duty. The ratio of nursing service personnel on duty providing bedside care to residents may not at any time be less than one to 15.
.20 Nursing Services — Director of Nursing.
A. Director of Nursing. The nursing home shall provide for an organized nursing service, under the direction of a full-time registered nurse.
B. Termination of Services of Director of Nursing.
(1) If the nursing home terminates the services of the director of nursing, the nursing home immediately shall notify the Department of the termination.
(2) The name and license number of the replacement director of nursing shall be supplied to the Department as soon as employment begins.
(3) A copy of the agreement between the nursing home and the replacement shall be sent to the Department.
C. Director of Nursing’s Vacancy Exceeding 30 Days. If the position of director of nursing remains vacant for a period exceeding 30 days, the nursing home’s license may be revoked unless the administrator and the governing body are able to demonstrate that they have made every effort to obtain a replacement.
D. Relief for Director of Nursing.
(1) When the director of nursing is absent, the individual shall designate an experienced, qualified registered nurse to direct the nursing service.
(2) In a nursing home in which the director of nursing serves as relief for the administrator, the director of nursing shall designate a specific registered nurse who shall be in charge of the nursing service while the director of nursing covers for the administrator.
E. Responsibilities of the Director of Nursing. The responsibilities of the director of nursing shall include:
(1) Assisting in the development and updating of statements of nursing philosophy and objectives to define the type of nursing care the nursing home shall provide;
(2) Preparation of written job descriptions for nursing service personnel;
(3) Planning to meet the total nursing needs of residents to be met and recommending the assignment of a sufficient number of supervisory and support personnel for each tour of duty;
(4) Development and maintenance of nursing service policies and procedures to implement the program of care;
(5) Participation in the coordination of resident services through appropriate staff committee meetings on issues relating to:
(a) Pharmacy;
(b) Infection control;
(c) Resident care policies;
(d) Quality assurance programs; and
(e) Departmental meetings;
(6) Cooperation with administration in planning the orientation program and the staff development program to upgrade the competency of personnel;
(7) Assurance that nursing personnel understand the philosophy and meet the objectives;
(8) Participation in planning and budgeting for nursing services;
(9) Establishment of a procedure to ensure that nursing service personnel, including private duty nurses, have valid and current Maryland licenses;
(10) Execution of resident care policies unless delegated to the principal physician or medical director;
(11) Participation in the selection of prospective admissions to ensure that the nursing home’s staff is capable of meeting the needs of all residents admitted;
(12) Coordination of the interdisciplinary resident care management efforts; and
(13) Supervision of certified medicine aides to ensure that the aides act within the limitations and restrictions placed on them.
F. Delegation of Responsibilities. Responsibilities delegated to other staff besides the director of nursing shall have a clear delegation of authority.
G. Daily Rounds — Director of Nursing.
(1) Although daily rounds are primarily the responsibility of the charge nurse or nurses, the director or assistant director of nursing shall periodically make clinical rounds to nursing units, randomly reviewing clinical records, medication orders, resident care plans, and staff assignments and visiting residents.
(2) Upon request, the director or assistant director of nursing may accompany physicians visiting residents.
H. Director of Nursing’s Continuing Education. The director of nursing shall assume responsibility for maintaining professional competence of staff through their participation in education programs.
[.13] .21 Dietetic Services.
A. (text unchanged)
B. Supervision.
(1) In [facilities exceeding] a nursing home with more than 50 beds, overall supervisory responsibilities for the [dietetic] food service department and food production shall be assigned to a full-time qualified dietetic service supervisor. It shall be the responsibility of the supervisor to delegate relief duties to [a person] an individual qualified to serve as relief [(See Supportive Personnel, Regulation .07, of this chapter.)] as stated in Regulation .14 of this chapter.
(2) In [facilities] a nursing home with [26 — 50] 50 or fewer beds, exceptions may be made by the Department to allow the supervisor to share cooking responsibilities with the full-time cook.
[(3) In facilities with 25 beds or fewer, responsibility may be assigned to the full-time cook.
(4) If a facility can demonstrate that because of the experience and training of its personnel and the physical layout and equipment, less supervisory personnel is required, the Department may modify the above requirements for supervision.]
C. Consultation.
(1) If the supervisor is not a licensed registered dietitian, the individual shall receive regularly scheduled consultation from a licensed registered dietitian or other qualified person. In all instances sufficient consultation shall be provided to fulfill all required responsibilities.
(2)—(3) (text unchanged)
D. Staffing.
(1) A sufficient number of food service personnel shall be employed to [carry out] perform efficiently the functions of the [dietetic] food and nutrition service and meet the dietary needs of the [patient] residents.
(2) Working hours shall be scheduled to ensure that the [dietetic] nutritional needs of the [patients] residents are met.
(3) Nursing, housekeeping, laundry, or other personnel may not be [utilized] used as [dietetic] food service staff. Exceptions [may], such as in a culture change setting, shall be [made only upon] based on the written approval of the Department. The kitchen may not be used for any purpose other than the preparation of food.
E. Adequacy of Diet.
(1) The food and nutritional needs of [patients] residents shall be met in accordance with physicians’ orders.
(2) To the extent medically possible, the [current] “Recommended Dietary Allowances” of the Food and Nutrition Board [of the], Commission on Life Sciences, and National Research Council[, National Academy of Sciences”], adjusted for age, sex, and activity, shall be observed. [Agency Note:]
(3) The “Diet Manual for Long-Term Care [Patients] Residents”, as published by the Department, [which] or any other similar reference material that contains food allowances and guides for regular and therapeutic diets [may], shall be used.
F. Therapeutic Diets. Therapeutic diets shall be planned, prepared, and served as prescribed by the attending physician:
(1) Therapeutic diets shall be planned by a licensed registered dietitian [or other qualified person];
(2) Preparation and serving shall be supervised by a qualified dietetic supervisor; and
(3) (text unchanged)
G. Frequency and Quality of Meals.
(1) At least three meals or their equivalent shall be [served] offered daily, at regular times, with not more than 14-hour intervals between the substantial evening meal and breakfast.
(2) A substantial evening meal is an offering of three or more menu items at one time, one of which includes a high quality protein such as meat, fish, eggs, or cheese. This meal represents [no less than] at least 20 percent of the day’s total nutritional requirements.
(3) To the extent medical orders permit, bedtime nourishments shall be offered routinely to all [patients] residents.
(4) If [the] a four or five meal a day plan is used, the meal pattern to provide this plan shall be approved by the Department.
H. Advance Planning and Posting of Menus.
(1) Residents shall be given the opportunity to participate in planning menus. Menus shall be written at least 1 week in advance.
(2) The current week’s basic menu shall be posted in one or more easily accessible places in the [dietetic service] food services department and in the [patient area] common areas.
(3) Menus shall include alternatives of similar nutritive value that give residents the opportunity to choose meals that they prefer. The dietary preferences of a resident shall be ascertained, including preferences arising from a resident’s religious, cultural, and ethnic heritage, and efforts shall be made to meet those preferences.
I.—J. (text unchanged)
K. Preparation of Food.
(1) Foods shall be prepared by methods that conserve nutritive value, flavor, and appearance, and shall be served at proper temperatures, in a form to meet individual needs.
(2) Standardized recipes adjusted to appropriate yield shall be followed. Standardized recipes are those recipes which have been tested by the [facility] nursing home or another source [which assure consistency in] and that ensure consistent quality and quantity.
L. Resident Directed Meal Pattern. If a resident-directed meal pattern is provided, the following is required:
(1) Counseling regarding the risks and benefits of a resident-selected diet which is documented within the medical record; and
(2) Approval of the pattern by both the resident’s physician and a licensed registered dietitian.
[.14] .22 Specialized Rehabilitative Services — Occupational Therapy Services, Physical Therapy Services, Speech Pathology and Audiology Services.
A. Rehabilitative Services—Admission Policies. In [those facilities] a nursing home which [do] does not accept [patients] residents in need of specialized rehabilitative services, the minimal acceptable restorative service shall be the restorative nursing care plan designed to maintain function or improve the [patient’s] resident’s ability to carry out [the]activities of daily living as set forth in Regulation [.12S] .18G, of this chapter[, Program of Restorative Nursing Care].
B. Arrangements for Services.
(1) If a [facility’s] nursing home’s admission policies include the admission of [patients] residents requiring rehabilitative services, the [facility] nursing home shall provide, or arrange for under written agreement, specialized rehabilitative services by qualified personnel [(], such as a physical therapist, speech-language pathologist and audiologist, and occupational therapist[)].
(2) Initiation of services to meet the rehabilitative needs of the [patient] resident shall occur within 48 hours [(], excluding Saturday [and], Sunday [)], and State and federal holidays, of the physician’s order for the specialized service.
(3) The [patient] resident may not be accepted for admission if at least one service [could not] to meet the rehabilitative needs of the resident cannot be initiated within the 48-hour period [(], excluding Saturday, Sunday, and State and federal holidays[)].
C. Policies and Procedures.
(1) Written administrative and [patient] resident care policies and procedures shall be developed for rehabilitative services by appropriate rehabilitation team members and representatives of the medical, administrative, and nursing staff.
(2) Policies shall provide for the coordination of rehabilitative services and the rehabilitative aspects of nursing.
(3) The nursing home shall make its administrative and resident care policies available for review by residents and the resident’s representative.
D. (text unchanged)
E. [Physicians’] Physician’s Orders.
(1) Specialized rehabilitative services shall be provided only [upon] on written orders of the attending physician.
(2) Orders shall include modalities to be used, frequency, and anticipated goals[,] and shall be made a part of the [patient] resident care plan.
(3) [Unless medically contraindicated, the] The physician shall [discuss] review with the [patient] resident or [his] the family or [sponsor] resident’s representative the goals and the treatment program. The frequency of communications between the physician and the rehabilitation team members shall [be governed by the status and] depend onchanges in the [patient] resident and [his] the resident’s medical status.
F. Progress Notes.
(1) Within 2 weeks of [the] referral to specialized rehabilitative services, the rehabilitation team members shall provide [to] the attending physician with a written report of the evaluation, including goals and progress of the [patient] resident.
(2) Progress notes related to rehabilitative services shall be written at least every 2 weeks.
G. Reevaluation of [Patient’s] Resident’s Progress.
(1) The physician and the rehabilitation team members shall reevaluate the [patient’s] resident’s progress as necessary, but at least every 30 days.
(2) The physician may document on the record that [his] the reevaluation may be less frequent but in no case may [his] the reevaluation exceed 60 days. [Appropriate action shall be taken.]
H. [Patient’s] Resident’s Record.
(1) The physician’s orders, the initial evaluations, the plan of rehabilitative care, goals, services rendered, evaluations of progress, and other pertinent information shall be [recorded]:
(a) Recorded in the [patient’s] resident’s medical record[,]; and [shall be dated]
(b) Dated and signed by the [physician]:
(i) Physician ordering the service; and [the person or persons]
(ii) Those disciplines who provided the service.
(2) The record and progress notes concerning the [patient] resident shall reflect at all times the most recent and current status of the [patient] resident, including current short-term and long-term goals.
I.—J. (text unchanged)
[.14-1] .23 Special Care Units — General.
A. A [facility] nursing home which holds a current and valid operating license may establish special care units with the approval of the:
(1) Office of [Licensing and Certification Programs and the Department’s Division of Engineering and Maintenance] Health Care Quality; and
(2) Department’s Office of Capital Planning, Budgeting and Engineering Services.
B. (text unchanged)
C. The [facility] nursing home shall obtain Departmental approval of the following pertaining to the special care unit:
(1) (text unchanged)
(2) An organization chart of the special care unit and its [inter-relatedness] relationship to the rest of the nursing [facility] home;
(3)—(4) (text unchanged)
(5) A quality assurance plan which includes:
(a) (text unchanged)
(b) Identification of the [most important] predominant aspects of care provided;
(c)—(i) (text unchanged)
(6) Policies and procedures, including:
(a) (text unchanged)
(b) The administration of [medicines unique to the needs of] medications that are relevant to the special care residents;
(c)—(e) (text unchanged)
(7)—(8) (text unchanged)
(9) An inventory of [the] any specialized equipment to be housed [in] on the unit to provide services in the special care unit.
D.—E. (text unchanged)
F. Staffing. The [facility] nursing home shall ensure that each unit is sufficiently staffed with qualified personnel to provide appropriate treatment and [special] meet the care needs of the residents.
G. (text unchanged)
H. Design.
(1) A special care unit shall meet the general construction requirements of Regulations [.06, and .26] .08, .42, and .41 of this chapter, and the requirements in this regulation.
(2) The [facility] nursing home shall ensure that floor space allocated to each bed meets minimum requirements listed in Regulation [.28C] .49 of this chapter, and is sufficient to accommodate the special equipment necessary to meet the needs of residents.
I.—J. (text unchanged)
[.14-2] .24 Special Care Units — Respiratory Care Unit.
A. A respiratory care unit shall meet the:
(1) General requirements established for all special care units as outlined in Regulation [.14-1] .23 of this chapter; and
(2) (text unchanged)
B. The [facility] nursing home shall submit to the Department and obtain approval of the following:
(1) All documents required in Regulation [.14-1] .23 of this chapter;
(2) Policies and procedures for all aspects of care as outlined in Regulation [.14-1C(6)] .23 of this chapter, and the following:
(a) Qualifications, duties, and responsibilities of staff, including the staff who are permitted to perform the following procedures:
(i)—(iii) (text unchanged)
(iv) Therapeutic chest percussion and vibration;
(v)—(viii) (text unchanged)
(b)—(c) (text unchanged)
C. Physician Coordinator. If the [facility’s] nursing home’s medical director does not have special training and experience in diagnosing, treating, and assessing respiratory problems, the [facility] nursing home shall [hire] employ or contract with a [physician] Board-certified pulmonologist who has the special knowledge and experience to provide:
(1)—(2) (text unchanged)
D. Staffing. The [facility] nursing home shall ensure that:
(1) The nurse manager or the director of nursing of vent units has a background in ventilator care or is qualified in ventilator management;
[(1)] (2) Respiratory care services are provided by a sufficient number of qualified personnel; and
[(2)] (3) Respiratory care personnel provide respiratory care services commensurate with their documented training, experience, and competence[; and].
[(3) As appropriate, respiratory care personnel are competent in the following:
(a) The fundamentals of cardiopulmonary physiology and of fluids and electrolytes;
(b) The recognition, interpretation, and recording of signs and symptoms of respiratory dysfunction and medication side effects, particularly those that require notification of a physician;
(c) The initiation and maintenance of cardiopulmonary resuscitation and other related life-support procedures;
(d) The mechanics of ventilation and ventilator function;
(e) The principles of airway maintenance, including endotracheal and tracheostomy care;
(f) The effective and safe use of equipment for administering oxygen and other therapeutic gases and for providing humidification, nebulization, and medication;
(g) Pulmonary function testing and blood gas analysis, when these procedures are performed within the respiratory care unit;
(h) Methods that assist in the removal of secretions from the bronchial tree, such as hydration, breathing and coughing exercises, postural drainage, therapeutic percussion and vibration, and mechanical clearing of the airway through proper suctioning technique;
(i) Procedures and observations to be followed during and after extubation; and
(j) Recognition of and attention to the psychosocial needs of residents and their families.]
E. Design.
(1) Emergency Power. The [facility] nursing home unit shall meet all applicable requirements in Regulation [.26F] .46 of this chapter for emergency electrical power, including the provision of:
(a)—(b) (text unchanged)
(2) (text unchanged)
(3) Piped Medical Gas Systems.
(a) To service the medical gas systems, a vendor or staff shall be trained and accredited in accordance with NFPA 99 Health Care Facilities Code.
(b) The vendor or staff may provide the following services:
(i) Installation;
(ii) Inspection; or
(iii) Testing.
(c) The nursing home shall ensure that all piped medical gas systems adhere to the following standards:
(i) NFPA 99 Health Care Facilities Code; and
(ii) NFPA 101 Life Safety Code.
F. The [facility] nursing home shall provide pulmonary function testing[,] and blood gas or pulse analysis capability [onsite] on-site or through contractual arrangements with providers who meet applicable State and federal laws and regulations.
G. (text unchanged)
.25 Special Care Units — Dementia Care.
A. A dementia care unit shall meet the:
(1) General requirements established for all special care units as outlined in Regulation .24 of this chapter; and
(2) Requirements of this regulation.
B. Dementia Unit Disclosure.
(1) The disclosure shall be made to the Department and to any person seeking placement or receiving care in a Dementia special care unit or program of a nursing home.
(2) The information disclosed shall explain the additional care provided in each of the following areas:
(a) The Dementia special care unit’s written statement of its overall philosophy and mission, which reflects the needs of residents with dementia;
(b) The process and criteria for placement, transfer, or discharge from the unit;
(c) The process used for individualized assessment and establishing the resident-centered plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in the individual’s condition;
(d) Staff training and continuing education practices;
(e) The physical environment and design features appropriate to support the functioning of cognitively impaired adult residents;
(f) The frequency and types of resident activities;
(g) The involvement of families and family support programs; and
(h) The cost of care and any additional fees.
C. Secured units shall meet the established standards applicable to nursing home set forth in NFPA 99 Health Care Facilities Code and NFPA 101 Life Safety Code.
.26 Pharmaceutical Services.
A. Definition. In this regulation, the term “committee” means the pharmaceutical services committee.
B. Duties of the Nursing Home.
(1) The nursing home shall provide appropriate methods and procedures for administering drugs and biologicals to the nursing home’s res
idents.
(2) The nursing home shall provide pharmaceutical services in accordance with accepted professional standards and related federal, State, and local laws.
C. Duties of the Pharmaceutical Services Committee.
(1) A pharmaceutical services committee, or its equivalent, shall develop written policies and procedures for safe and effective drug therapy, distribution, control, and use.
(2) The composition of the committee shall include at least:
(a) The licensed pharmacist;
(b) The director of nursing;
(c) The consultant dietitian-nutritionist;
(d) One physician; and
(e) The administrator.
(3) The committee shall meet at least quarterly to establish policies and procedures.
(4) There shall be an agenda to guide meeting participants.
(5) All members of the committee shall review revisions of policies and procedures before implementing any changes.
(6) The pharmaceutical services committee may not develop policies and procedures that prohibit or restrict a resident from receiving medications from the pharmacy of the resident’s choice.
(7) In cases where the cost of any medication obtained from the pharmacy selected by the resident exceeds the cost of the same or equivalent medication available through a pharmacy that the nursing home has contracted with to provide pharmaceutical services, the resident shall be responsible for the additional amount.
(8) The committee may not require the pharmacy to provide drugs by way of a specific drug distribution system such as unit dose or use of a particular packaging system.
(9) The committee shall establish the contents of sealed emergency drug kits.
(10) The committee shall oversee the accuracy and adequacy of pharmaceutical services to the nursing home.
(11) The committee shall make recommendations for improvements to pharmaceutical services.
(12) The committee shall document its actions and recommendations.
D. Labeling.
(1) Medications shall be accurately and plainly labeled. Except for those over-the-counter medications that the Department may list as suitable for purchasing in bulk and dispensing as needed, the labels for all medications shall bear at least:
(a) The resident’s full name;
(b) The name of the drug;
(c) Strength;
(d) Original filling date and date refilled, if applicable;
(e) Name of authorized prescriber;
(f) Expiration date of medication (month, year);
(g) Any special handling and storage instructions;
(h) Name and address of dispensing pharmacy;
;
(j) Number of tablets or capsules; and
(k) Accessory federal labels.
(2) A nurse may not package, repackage, bottle, or label any medication, in whole or in part, or alter any labeled medication in any way.
E. Storage.
(1) The nursing home shall store medications in a locked medication storage area that:
(a) Is well lighted;
(b) Is located where personnel preparing drugs for administration will not be interrupted;
(c) Is spacious enough to allow separate storage of external and internal medications;
(d) Is kept in a clean, orderly and uncluttered manner; and
(e) Contains a refrigerator to be used for medication storage only.
(2) The nursing home shall keep poisons and medications marked “for external use only” separate from general medications and Schedule II drugs.
F. Schedule II—IV Drugs.
(1) Schedule II drugs shall be kept in separately locked, securely fixed boxes or drawers in the storage area, under two locks. The lock on the door of a medication room shall be counted as one of the two locks.
(2) A nurse and a second staff member who is a nurse or an administrator may destroy controlled dangerous substances in Schedules II—V on the premises of the nursing home.
(3) If a controlled dangerous substance is destroyed on the nursing home premises in accordance with §F(2) of this regulation:
(a) A record of the disposal, in addition to any other required records, shall be maintained in the nursing home; and
(b) A copy of the record of disposal shall be forwarded to the Office of Controlled Substances Administration.
(4) A nursing home, whether or not operating a licensed pharmacy, shall maintain a signed record of a Schedule II count at each change of shift.
(5) A nursing home that administers Schedule II drugs shall maintain a drug record that documents:
(a) The name of the resident;
(b) The date, time, kind, dosage, and method of administration of all Schedule II drugs; and
(c) The name of the authorized prescriber who prescribed the medication.
.27 Pharmaceutical Management.
A. Administration Procedures.
(1) Medications, legend and non-legend, administered to residents shall be ordered in writing by the resident’s physician.
(2) Medications shall be administered by:
(a) Appropriately licensed personnel in accordance with laws and regulations governing these acts; or
(b) Certified graduates of a State-approved medicine aide course.
(3) The individual who prepares medications shall give and record them.
(4) Medicine may not be returned to the container. If the resident refuses the drug or if a mistake occurs:
(a) The drug shall be discarded; and
(b) The occurrence shall be documented in the resident’s chart.
(5) Before invoking stop order policies, the resident’s attending physician shall be contacted for instructions so that continuity of the resident’s therapeutic regimen is not interrupted. If the attending physician cannot be reached, the medical director shall be contacted for instructions.
B. Pharmaceutical Services.
(1) The nursing home shall arrange for pharmacies that provide medications for residents in the nursing home. The pharmacy shall agree in writing to maintain at the pharmacy a resident profile record system for each resident in the nursing home for whom prescriptions are dispensed.
(2) If the nursing home does not employ a licensed pharmacist, the nursing home shall arrange by written contract for a pharmacy to provide consultation on administering the pharmacy services in accordance with the policies and procedures established by the pharmaceutical services committee. Pharmaceutical services shall be under the general supervision of a licensed pharmacist who shall:
(a) With the advice of the pharmaceutical services committee, be responsible for developing, coordinating, and supervising pharmaceutical services and provide in-service training at least twice yearly;
(b) Visit the nursing home frequently enough to assure that policies and procedures established by the pharmaceutical services committee are enforced;
(c) Notify the attending physician of any potential drug problems found during the drug regimen review; and
(d) At least quarterly, submit a report to the pharmaceutical services committee on the status of the nursing home’s pharmaceutical services and staff adherence to policies and procedures.
C. Resident Designated Pharmacy.
(1) The nursing home shall inform a resident’s designated pharmacy about the nursing home’s written policies concerning the provision of drugs.
(2) To provide services to the resident, a designated pharmacy shall agree to comply with the nursing home’s policies.
(3) If the pharmacy fails to comply with the policies, a representative of the nursing home shall discuss the situation with the pharmacy and the resident, and if the pharmacy subsequently refuses to follow the policies, the resident shall select another pharmacy that agrees to comply.
(4) The pharmacy shall have access to a copy of the written pharmaceutical care policies.
(5) The pharmacy shall be responsible for delivering medications to the nursing home. Members of the resident’s family or the responsible party for the resident may not deliver medications to the resident or to the nursing home.
D. Medication Return and Disposal.
(1) The nursing home shall return all prescribed medications, for residents who have been discharged or otherwise departed, to the pharmacy in accordance with the nursing home’s policy.
(2) The nursing home shall destroy adulterated, deteriorated, or outdated medications in the following manner:
(a) Disposal shall occur in the presence of two witnesses who are authorized by the nursing home; and
(b) The witnesses shall document the disposal in the resident’s chart.
(3) The nursing home shall only release prescribed medications to residents at the time of discharge based on the written authorization of the resident’s authorized prescriber.
(4) Each month, the nursing home shall perform a drug regimen review on each resident’s records at the nursing home and document the findings in the resident’s medical record.
E. Administration of Medications for Leave of Absence of 24 Hours or Less.
(1) A nursing home shall develop policies and procedures to ensure that a resident or, if the resident lacks the capacity, the resident’s family or other individual accompanying the resident is informed, both orally and in writing, on how the resident shall safely and correctly take the resident’s medications during a short-term leave of absence of 24 hours or less.
(2) In accordance with a nursing home-developed procedure, a licensed nurse shall prepare medications to be sent with a resident during a short-term leave of absence of 24 hours or less.
[.16] .28 Laboratory and Radiologic Services.
A.—C. (text unchanged)
D. Reports of Findings. The nursing home shall notify the attending physician [shall be notified] promptly of the findings. [Signed] The nursing home shall file signed and dated reports of diagnostic services [shall be filed with] in the [patient’s] resident’s medical record.
E. Transportation. The [facility] nursing home shall assist the [patient] resident, if necessary, in arranging [for] transportation to and from the source of service.
F.—G. (text unchanged)
H. Transfusion Services. If the [facility does not provide its own facilities but does provide] nursing home only provides transfusion services [alone], it shall meet at least the requirements [in Regulation.09F—H] established under COMAR 10.10.02.
[.17] .29 Dental Services.
A. Provision for Dental Care. [Patients] Residents shall be assisted to obtain routine and emergency dental care.
B. Advisory Dentist. There shall be an advisory dentist[, licensed to practice in the State,] who shall:
(1) Recommend oral hygiene policies and practices for the care of the [patients] residents and for arrangements for emergency treatment;
(2) (text unchanged)
(3) Provide direction for in-service training to give the nursing staff an understanding of [patients’] residents’ dental problems.
C. Assistance by Nursing Personnel. Nursing personnel shall assist the [patient] resident in carrying out routine dental hygiene.
D. (text unchanged)
E. Transportation. Arrangements shall be made, when necessary, for the [patient] resident to be transported to the dentist’s office.
[.18] .30 Social Work Services.
A. Services Provided. The [facility] nursing home shall provide or make arrangements for services to identify and meet the [patient’s] resident’s medically related physical, social, and [emotional] behavioral health needs.
[B. Designated Staff Responsibility. A member of the facility’s staff shall be assigned responsibility for social services. If the designee is not a certified social worker, the facility shall effect an agreement with a qualified social work consultant. The agreement shall provide for sufficient hours of consultation to assure that the staff’s services meet the medically related social and emotional needs of the patients.]
B. Social Work Staff Responsibility.
(1) Social services responsibilities in the nursing home shall be assigned to a:
(a) Licensed bachelor social worker;
(b) Licensed graduate social worker;
(c) Licensed certified social worker; or
(d) Licensed certified social worker–clinical.
(2) If the social worker is not a licensed certified social worker (LCSW) or a licensed certified social worker-clinical (LCSW-C), the nursing home shall arrange for an LCSW or LCSW-C to provide sufficient hours of supervision.
(3) As of January 1, 2021, a license is required for an employee to provide social services except if:
(a) On the effective date of these regulations, the employee was assigned responsibility for social services; and
(b) The nursing home has an agreement with a qualified social work consultant that provides for sufficient hours of supervision to assure that the employee’s services meet the medically related physical, social, and behavioral health needs of the residents.
C. Social History. [The written social history] Within 7 days after admission, the social worker shall [be initiated within 7 days after admission. The] initiate a written social history, which shall be as complete as possible and shall include:
(1) Social data about personal and family background to provide understanding of the [patient] resident and how [he] the resident functions; [and]
(2) Information regarding current personal and family circumstances and attitudes as they relate to [patient’s] the resident’s illness and care[.]; and
(3) Information regarding the resident’s and family’s plans regarding discharge.
D. Records. Records shall include[:
(1) Social history; and
(2) Recommendations made by the social work consultant, if applicable] the information required in §C of this regulation.
E. Space. [Facilities] A nursing home shall provide:
(1) Space for social work personnel, accessible to [patients] residents, medical, and other staff; and
(2) (text unchanged)
[.19] .31 [Patient] Resident Activities.
A. Activities Program. The [facility] nursing home shall provide [for a]:
(1) A program of structured and unstructured activities[,]; and
(2) Activities designed and monitored appropriately to meet the day-to-day needs and interests of each [patient, to] resident and encourage [self-care, resumption of normal activities, and maintenance]:
(a) Self-care;
(b) Engagement in resident-selected activities; and
(c) Maintenance of an [optional] optimal level of psychosocial functioning.
B. Staffing. A staff member who is qualified by experience or training shall be appointed to be responsible for the activities program. If the designee is not a qualified [patient] resident activities coordinator as defined in Regulation [.01Y,] .01 of this chapter, the Department may approve the designee based on the person’s education, performance, and experience.
C. (text unchanged)
D. Restrictions on Participation Documented on Chart. The physician shall [note on] document in the [patient’s] resident’s chart any restrictions applicable to the [patient’s] resident’s participation in the activities program.
E. Objective. The activities shall be designed to promote the general health[,] and physical, social, and mental well-being of the [patients] residents.
F. Space, Supplies. [Adequate] The nursing home shall provide adequate space and a variety of supplies and equipment [shall be provided by the facility] to satisfy the appropriate individual activity needs of [patients] residents.
[.20] .32 Clinical Records.
A. Records for all [Patients] Residents. Records for all [patients] residents shall be maintained in accordance with accepted professional standards and practices.
B. Contents of Record. Contents of record shall [be] include:
(1) Identification and summary sheet or sheets including [patient’s name, social security number, armed forces status, citizenship, marital status, age, sex, home address, and religion]:
(a) Resident’s name;
(b) Social Security number;
(c) Armed forces status;
(d) Citizenship;
(e) Marital status;
(f) Age;
(g) Sex;
(h) Home address; and
(i) Religion;
(2) Names, addresses, and telephone numbers of referral agencies [(], including [hospital from which admitted), personal physician, dentist, parents’ names or next of kin, or authorized]:
(a) Hospital from which admitted;
(b) Personal physician;
(c) Dentist;
(d) Parents’ names or next of kin; and
(e) Resident’s representative;
(3) [Documented evidence of assessment of the needs] Documentation of the:
(a) Needs of the [patient] resident[, of establishment];
(b) Establishment of an appropriate [plan of] initial and ongoing treatment [, of the care] plan; and
(c) Care and services provided;
(4) Authentication of hospital diagnoses [(], based on a [discharge]:
(a) Discharge summary[, report];
(b) Report from the [patient’s] resident’s attending physician[, or transfer]; or
(c) Transfer form[)];
(5) Consent forms when required, [(]such as [consent for administering]:
(a) Administration of investigational drugs[, for burial];
(b) Burial arrangements made in advance[, for release];
(c) Release of medical record information[, for handling]; and
(d) Handling of finances[)];
(6) Medical and social history of the [patient] resident;
(7)—(12) (text unchanged)
(13) [Discipline assessment] Assessments done by various disciplines; and
(14) (text unchanged)
C. Staffing. An employee of the [facility] nursing home shall be designated as the person responsible for the overall supervision of the medical [record] records service. There shall be sufficient [supportive] support staff to accomplish all medical [record] records functions.
D. Consultation. If the medical records supervisor is not a qualified medical record practitioner, the Department may require that the supervisor receive consultation from a qualified person [so qualified].
E. Completion of Records and Centralization of Reports.
(1) Current medical records and those of discharged [patients] residents shall be completed promptly.
(2) All clinical information pertaining to a [patient’s] resident’s stay shall be centralized in the [patient’s] resident’s medical record.
F. Retention and Preservation of Records.
(1) Medical records shall be retained for a period of [not less than] at least 5 years from the date of discharge or, in the case of a minor, 3 years after the [patient] resident becomes of age or 5 years, whichever is longer.
(2) The nursing home shall maintain and dispose of a client’s medical records in accordance with Health-General Article, Title 4, Subtitles 3 and 4, Annotated Code of Maryland.
G. Current Records—Location and Facilities. The [facility] nursing home shall maintain adequate space and equipment, conveniently located, to provide for efficient processing [of medical records (], reviewing, indexing, filing, and prompt retrieval[)] of medical records.
H. Closed or Inactive Records. Closed or inactive records shall be filed and stored in a safe place [(], free from fire hazards[)], which provides for confidentiality and, when necessary, retrieval.
I. Electronic Health Records.
(1) A nursing home that uses electronic health records exclusively or along with a paper based medical record shall comply with this chapter and all applicable State and federal laws, including laws governing privacy and security of records.
(2) Staff and nursing home-approved practitioners shall be trained in the use of electronic health records.
(3) A nursing home that uses electronic health records shall:
(a) Ensure access to residents as specified in COMAR 10.07.09.08C(13) and (14); and
(b) On request, provide the resident with copies of the resident’s medical records at a reasonable cost and in the resident’s preferred format.
(4) A nursing home shall provide full access to electronic health records in accordance with all applicable laws and regulations to:
(a) Representatives of the Department as set forth in COMAR 10.07.02.07;
(b) An ombudsman as set forth in Human Services Article, §10-905, Annotated Code of Maryland; and
(c) Other legal representatives as set forth in COMAR 10.07.09.08 and authorized by law to obtain access.
(5) A nursing home shall develop a system to ensure that nursing home staff have access to residents’ health records in the event of a failure of the nursing home’s electronic medical record system.
[.21] .33 Infection Prevention and Control Program.
A. Infection Prevention and Control Program. The [facility] nursing home shall establish, implement, and maintain[, and implement] an effective infection prevention and control program that:
(1)—(2) (text unchanged)
(3) Maintains a record of infections in the [facility,] nursing home and the corrective actions that were taken related to infections; and
(4) Monitors and evaluates the:
(a) Effectiveness of the infection prevention and control program by surveying rates of infection, especially of [those residents who have an especially high risk of] infection rates that are significantly higher than usual; and
(b) Effective implementation of the policies and procedures that are outlined in [§F(1)] §E(1) of this regulation.
B. Infection Preventionist.
(1) The [facility] nursing home shall assign at least one [individual with education and] infection preventionist that has attended training in infection surveillance, prevention, and control to [be responsible for approving actions to prevent and control infections.] actively manage the nursing home’s infection prevention and control program.
(2) The infection preventionist shall attend or have attended a basic infection prevention and control training course that is approved by the:
(a) Office of Health Care Quality; and
(b) Office of Infectious Disease Epidemiology and Outbreak Response for the Department.
(3) This position shall be staffed at a ratio of 1.0 Full Time Equivalents for every 200 beds.
[C. Effective January 1, 2005, the facility’s infection control coordinator shall attend a basic infection control training course that is approved by the Office of Health Care Quality and the Office of Epidemiology and Disease Control Program for the Department.]
[D.] C. The [facility] nursing home shall have mechanisms for communicating the results of infection control activities to employees[,] and to the individual or individuals who are responsible for improving the [facility’s] nursing home’s performance.
[E.] D. The [facility’s] nursing home’s communication mechanism shall ensure that the administrator, director of nursing, and the medical director receive and address reports of infection prevention and control findings and recommendations in a timely manner.
[F.] E. Infection Prevention and Control Policies and Procedures.
(1) The infection prevention and control program shall establish written policies and procedures to identify, investigate, control, and prevent infections in the [facility] nursing home, including policies and procedures to:
(a) Identify [facility] health care-associated infections and communicable diseases in accordance with COMAR 10.06.01;
(b) Report occurrences of certain [communicable] infectious diseases and outbreaks of [communicable] infectious diseases to the local health department in a timely manner in accordance with COMAR 10.06.01 and Health-General Article, §18-202, Annotated Code of Maryland;
(c) Institute appropriate [infection control steps] control measures when an infection or outbreak of infections is suspected or identified in order to control infection and prevent spread to other residents;
(d) Perform surveillance for health care-associated and community-associated infections of residents and employees [at appropriate intervals] using definitions and methods approved by the infection prevention and control oversight committee to monitor and investigate causes of infection, [facility-associated and community acquired,] and the manner in which [it was] the infection is spread;
(e) Train employees about infection prevention and control, [and hygiene] including:
(i) [Hand] Standard precautions and hand hygiene;
(ii) Respiratory [protection] hygiene and cough etiquette;
(iii) (text unchanged)
[(iv) Needles, sharps, or both;]
(iv) Safe handling of needles and sharps and safe injection techniques;
(v) Special medical waste handling and disposal; [and]
(vi) Appropriate use of antiseptics and disinfectants[.] ;
(vii) Blood borne pathogens, including hepatitis B and C and human immunodeficiency virus;
(viii) Tuberculosis exposure; and
(ix) Proper use and wearing of personal protective equipment, such as gloves, gowns, and eye protection;
(f) Train and [monitor] perform compliance monitoring of employee application of infection prevention and control [and aseptic techniques; and] activities, such as hand hygiene and personal protective equipment used for isolation precautions;
(g) Review the infection prevention and control program elements at least annually and revise as necessary[.]; and
(h) Obtain annual approval of infection prevention and control program activities by the infection prevention and control oversight committee.
(2) The [facility] nursing home shall provide information concerning the [communicable] infectious disease status of any resident being transferred or discharged to any other [facility] nursing home, including a funeral home.
(3) The [facility] nursing home shall obtain information concerning the [communicable] infectious disease status of any resident being transferred or [discharged] admitted to the [facility] nursing home from elsewhere.
[G.] F. Preventing Spread of Infection.
(1) (text unchanged)
(2) The [facility] nursing home shall take appropriate infection prevention and control [steps] measures to prevent the transmission of [a communicable] an infectious disease to residents, employees, and visitors as outlined in the following guidelines:
(a) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in [Hospitals] Healthcare Settings; and
(b) (text unchanged)
(3) The [facility] nursing home shall prohibit employees with [a communicable] an infectious disease or with infected skin lesions from having direct contact with residents or their food if direct contact could transmit the disease.
(4) The [facility] nursing home shall require employees to perform hand hygiene before and after each direct resident contact for which hand hygiene is indicated by accepted professional practice.
(5) (text unchanged)
[.21-1] .34 Employee Health Program.
A. The [facility’s] nursing home’s infection prevention and control program shall monitor the relevant health status of all employees, as it relates to infection prevention and control. [The following guidelines shall aid the facility] The nursing home shall refer to the following guidelines in implementing its employee health program:
(1) (text unchanged)
(2) Immunization of [Health-Care Workers] Health Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC); and
(3) (text unchanged)
B. Tuberculosis Exposure Control.
(1) The infection control program shall include a risk assessment program, including monitoring for tuberculosis infection for employees that is in accordance with the [following guidelines:]
[(a)] Guidelines for Preventing the Transmission of Mycobacterium [Tuberculosis] tuberculosis in Health-Care [Facilities; and] Settings.
[(b) Guideline for Infection Control in Health Care Personnel.]
(2) The [facility] nursing home shall ensure that [all] employees [who] may not provide services that require direct access to residents [may not provide such services] without documented evidence that the employee is free from communicable tuberculosis [in a communicable form].
[(3) The facility shall monitor the purified protein derivative (PPD) status of employees at any time that symptoms suggestive of tuberculosis develop, and periodically, consistent with the tuberculosis control plan. All employees shall be assessed for risk of tuberculosis following guidelines referenced in §B of this regulation.]
(3) A new employee shall be assessed for risk of tuberculosis through:
(a) A two-step tuberculin skin testing at the time of hire following guidelines referenced in the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings; or
(b) An interferon-gamma release assay (IGRA) blood test.
(4) The [facility] nursing home shall maintain written documentation of the following:
(a) Results of tuberculin skin tests, recorded in millimeters of induration with dates of administration, dates of reading, results of test, and the manufacturer and lot number of the purified protein derivative (PPD) solution used; and
[(b) Results of chest x-rays required in this regulation; and
(c) Documentation of any]
(b) Any previous tuberculin skin tests, chest x-ray, or blood test results, chemotherapy, and chemoprophylaxis[, which] that are the basis for [the certification] certifying that the individual is free from tuberculosis in a communicable form.
C. Measles, Mumps, Rubella, and Chickenpox.
[(5)] (1) The [facility] nursing home shall screen [all new employees for immunity to common childhood infections such as mumps, rubella, measles, and chicken pox (varicella), through the use of pre-employment questionnaires and, if appropriate, serologic testing for presence of antibodies of these diseases, to prevent adult exposure of new employees to residents with communicable forms of such disease organisms.] and maintain written documentation of each employee’s proof of immunity to common childhood infections including measles, mumps, rubella, and chickenpox (varicella). Proof of immunity to these diseases shall be verified by:
(a) Documented evidence of administration of vaccine; or
(b) Laboratory evidence of immunity.
(2) The nursing home shall require that employees who are not immune to measles, mumps, rubella, and varicella receive immunization for measles, mumps, rubella, or varicella, unless medically contraindicated or against the employee’s religious beliefs. If the employee refuses to be immunized, the nursing home shall document the refusal and the reason for it.
[(6)] D. Hepatitis B. The [facility] nursing home shall [request] require that all new employees receive immunization for Hepatitis B[. The employee may refuse to be immunized if medically contraindicated, against the employee’s religious beliefs, or after being fully informed], unless medically contraindicated, against the employee’s religious beliefs, or after being fully informed of the health risks of not being immunized. The nursing home shall inform all new and current employees of the health risks of not being immunized. If the employee refuses to be immunized, the [facility] nursing home shall document the refusal and the reason for the refusal.
[(7) The facility shall request that each employee receive immunization from influenza virus in accordance with Health-General Article, §18-404, Annotated Code of Maryland. The facility shall make information available to all employees concerning other conditions in which pneumococcal vaccine may be of benefit for certain other underlying medical conditions. The facility shall document refusals and shall conduct surveillance of nonimmune employees during the recognized influenza season.]
[(8)] E. Influenza.
(1) The [facility] nursing home shall [inquire about a history of varicella for each new employee. If the employee’s history is unclear, then the facility shall request a serology for varicella. If the serology for varicella is nonreactive, the facility shall request that the employee receive immunization for varicella. If the employee refuses to be immunized, the facility shall document the refusal and the reason for the refusal.] require that all employees receive annual immunization for influenza, unless:
(a) Medically contraindicated;
(b) Against the employee’s religious beliefs; or
(c) After being fully informed of the health risks associated with not receiving a vaccine, the employee refuses the immunization.
(2) The nursing home shall:
(a) Comply with Health-General Article, §18-404, Annotated Code of Maryland, regarding immunizations of employees;
(b) Inform all new and current employees of the health risks of not being immunized;
(c) Document refusals; and
(d) Require that any employee who is not vaccinated with the current influenza vaccine wear a mask when:
(i) Within 6 feet of a resident; and
(ii) During the influenza season as specified by the State’s Prevention and Health Promotion Administration, based on influenza activity in Maryland.
F. Pertussis. The nursing home shall:
(1) Require that each new employee receive a one-dose booster immunization for pertussis, unless medically contraindicated or against the employee’s religious beliefs;
(2) Inform all new and current employees of the health risks of not being immunized;
(3) Document any refusals of immunization; and
(4) Ensure that the immunization is given in the form of Tdap (tetanus, diphtheria, acellular pertussis) vaccine, in accordance with the guidelines prescribed in Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Health Care Infection Control Practices Advisory Committee (HICPAC).
[.21-2] .35 Resident Health Program.
[A. The facility’s infection control program shall include monitoring of the health status of all residents to determine if the residents are free from tuberculosis in a communicable form.]
A. Immunization.
(1) The nursing home shall offer influenza and pneumococcal immunization to each resident.
(2) The nursing home shall obtain written consent to administer the immunization from:
(a) The resident; or
(b) The legal guardian of the resident.
(3) A resident is not required to receive the influenza and pneumococcal immunization if it is:
(a) Medically contraindicated;
(b) Against the resident’s religious beliefs; or
(c) After being fully informed of the health risks associated with not receiving a vaccine, the resident refuses the immunization.
(4) If the resident refuses to be immunized, the nursing home shall document the refusal and the reason for the refusal.
(5) The nursing home shall notify each prospective resident of the immunization requirements and request that the resident agree to be immunized.
(6) The nursing home shall make available to residents educational and informational materials relating to immunization against influenza virus and immunization against pneumococcal disease.
B. Tuberculosis Assessment.
(1) The [facility] nursing home shall assess residents for tuberculosis according to the [following guidelines:
(a)] Guidelines for Preventing the Transmission of Mycobacterium [Tuberculosis] tuberculosis in Health Care [Facilities; and] Settings.
[(b) Guideline for Infection Control in Health Care Personnel.]
(2) [All residents] A new resident shall receive a two-step tuberculin skin test within 10 days of [initial] admission to the nursing home unless the resident has had [a] :
(a) A documented negative tuberculin skin test within the previous [month, a] 12 months;
(b) A previous positive tuberculin skin test[,];
(c) A history of preventive therapy[, or] treatment;
(d) A latent infection; or
(e) The treatment of active tuberculosis.
[(3) The tuberculin skin test for new admissions may be a two-step skin test that is performed by the facility according to the established infection control policy of the facility. Approved employees shall read the skin test and manage the results of the skin test in accordance with Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Facilities.]
[(4)] (3) The [facility] nursing home shall continue to monitor residents for signs and symptoms of tuberculosis by performing a yearly symptom review. When a resident has signs and symptoms of tuberculosis, a physician shall [within 48 hours] be notified to:
(a) Evaluate the resident for possible tuberculosis in a communicable form;
(b) (text unchanged)
(c) Coordinate management of the resident and the resident’s contacts with the local health officer.
[(5)] (4) The [facility] nursing home shall assess and manage a resident with a history of a previous positive tuberculin skin test, a history of latent infection, or a previous history of active tuberculosis, [or positive skin test conversion] in accordance with Guidelines for Preventing the Transmission of Mycobacterium [Tuberculosis] tuberculosis in Health-Care [Facilities] Settings.
[.21-3] .36 Volunteer Health Program.
A. The [facility] nursing home shall urge that volunteers, defined as individuals who spend an average of 8 hours per week or more in the institution [patient] resident care areas and who receive no pay or benefits, [accept] receive annual influenza vaccination and tuberculin skin testing as considered necessary by the [facility] nursing home.
B. The [facility] nursing home shall give appropriate health care information to such volunteers to provide maximum protection to residents.
[B.] C. The [facility] nursing home shall maintain documentation of the discussion between the [facility] nursing home and the volunteer concerning influenza vaccine and tuberculin skin testing.
[.21-4] .37 Infection Control — Standard Precautions.
A. Standard Precautions. All employees shall routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or the body fluids of any resident is anticipated as outlined in:
(1) 2007 Guideline for Isolation Precautions [in Hospitals]: Preventing Transmission of Infectious Agents in Healthcare Settings; and
(2) (text unchanged)
B. The infection prevention and control program shall include the handling of special medical waste as defined in COMAR 10.06.06.
C. A nursing home shall maintain, at all times, the capability to physically isolate any resident who may contract a communicable disease from the remaining resident population. To provide for this, a nursing home shall have at least one private bedroom with an attached private bathroom that includes a:
(1) Toilet;
(2) Hand washing sink; and
(3) Bathing device or shower.
[.22] .38 Reports and Action Required in Unusual Circumstances.
A.—B. (text unchanged)
[C. Locked Doors Prohibited. Patients may not be kept behind locked doors, that is, doors which patients cannot open. If the patient becomes too difficult to manage, the patient shall be transferred to a suitable facility selected by the attending physician. If the physician so orders, patients who have a tendency to wander may be confined to their rooms by screen doors or folding gates.
Agency Note: Supervision should be adequate to prevent patients from intruding into the rooms of other patients.
D. Unusual Occurrences. Any occurrence such as the occurrence of suspected mental disturbance, communicable disease, or symptomatic condition of importance to public health, poisoning, or other serious occurrence which threatens the welfare, safety, or health of any patient shall be reported immediately to the local health department. The administrator of the facility shall be responsible for seeing that appropriate procedures and reporting are carried out. An occurrence of a communicable or suspected communicable disease shall be reported and acted upon in accordance with medical asepsis as described in COMAR 10.06.01 Communicable Diseases and COMAR 10.15.03 Food Service Facilities.
Agency Note: Utilization Review. A utilization review plan should be developed with the advice of the professional personnel responsible for the establishment and enforcement of patient care policies. It is suggested that there be established a multi-discipline audit team to participate in an ongoing system of internal patient care audit.]
C. Unusual Occurrences.
(1) The administrator of the nursing home shall immediately report to the local health department and the Department the occurrence of:
(a) Infectious disease;
(b) Poisoning;
(c) Internal emergency or disaster;
(d) External emergency or disaster,
(e) Any symptomatic condition of importance to public health that affects the nursing home; or
(f) Any other serious occurrence that threatens the welfare, safety, or health of any resident.
(2) The administrator of the nursing home shall be responsible for ensuring that appropriate procedures and reporting are carried out for all reportable infections. An occurrence of a confirmed or suspected infection shall be reported and acted on in accordance with COMAR 10.06.01 and COMAR 10.15.03.
[.23] .39 Transfer Agreement.
A. Written Agreement. A written agreement with at least one acute hospital shall be effected which shall provide for the following actions:
(1) Planning to ensure that all services required for the continuity of [patient] resident care will be made available promptly;
(2) Advance discussion with the [patient] resident regarding the reason for the transfer and any available alternatives;
(3) (text unchanged)
(4) Interchange of medical and other information necessary in the care and treatment of [patients] residents transferred between [the] facilities, including notification of the licensed pharmacist of resident transfer;
[(5) Timely admission to the hospital when the attending physician determines acute hospital care is medically appropriate;]
[(6)] (5) Safe and timely transportation and care of the [patient] resident during transfer;
[(7)] (6) Security and accountability for the [patient’s] resident’s personal effects;
[(8)] (7) Prompt readmission to the [comprehensive care facility or the extended care facility] nursing home at the end of the hospital stay [(when program fiscal controls permit)];
[(9)] (8) Annual review of [execution of] transfer arrangements [(]by a utilization review committee or other designated group[)] to assure that each party is fulfilling the needs of [both] the [patients and] residents, the providers [(], the hospital, and the [comprehensive care facility or the extended care facility)] nursing home;
[(10)] (9) If needs are not being met, [it is the responsibility of] the administrator of the [comprehensive care facility or the extended care facility to] nursing home shall act on recommendations of the reviewing group [and] to effect compliance;
[(11)] (10)—[(12)] (11)(text unchanged)
B. (text unchanged)
[C. Exception for Comprehensive Care Facility. If a comprehensive care facility is unable to effect a transfer agreement with a hospital in the community and can document its attempts to secure an agreement, the facility shall be considered to have such an agreement in effect.]
[Agency Note: It is recommended that the comprehensive care facility arrange for a similar transfer agreement with an extended care facility.]
C. Human remains shall be transported pursuant to COMAR 10.29.21.
[.24] .40 Emergency and Disaster Plan.
A. Emergency and Disaster Plan.
(1)—(2) (text unchanged)
(3) When the nursing [facility] home relocates residents, the [facility] nursing home shall send a [brief] medical fact sheet and any medically related information with each resident that includes at a minimum the resident’s:
(a)—(d) (text unchanged)
(e) Special diets or dietary restrictions; [and]
(f) Family or legal representative contact information; and
(g) Advance directives, living will, or a copy of the resident’s Maryland’s Medical Orders for Life-Sustaining Treatment (MOLST) form.
(4) The brief medical fact sheet for each resident described in §A(3) of this regulation shall be:
(a)—(b) (text unchanged)
(c) Maintained in a written, electronic, or printed form in a central location readily accessible and available to accompany residents in case of an emergency evacuation.
(5)—(10) (text unchanged)
(11) Maryland Health Alert Network.
(a) A nursing home shall register with the Maryland Health Alert Network.
(b) A nursing home shall register at least four representatives, including the administrator and the director of nursing.
(c) Following any changes in the initial registration of the four representatives, a nursing home shall update the information within 5 business days of the change.
(12) The licensee shall:
(a) Identify an emergency and disaster planning liaison for the nursing home; and
(b) Provide the liaison’s contact information to the local emergency management organization.
(13) The licensee shall prepare an executive summary of the nursing home’s evacuation procedures to provide to a resident, family member, or resident’s representative upon request. The summary shall, at a minimum:
(a) List means of potential transportation to be used in the event of evacuation;
(b) List potential alternative facilities or locations to be used in the event of evacuation;
(c) Describe means of communication with family members and resident’s representatives;
(d) Describe the role and responsibilities of the resident, family member, or resident’s representative in the event of an emergency situation; and
(e) Notify families that the information provided may change depending on the nature or scope of the emergency or disaster.
B. (text unchanged)
C. Orientation and Drills.
(1) The licensee shall:
(a) Orient staff to the emergency and disaster plan and to their individual responsibilities in relation to the plan within 24 hours of the commencement of job duties; [and]
(b) Document completion of the orientation in the staff member’s personnel file through the signature of the employee; and
(c) Within 24 hours of admission, notify and direct residents to the nursing home’s emergency plans and maps, including evacuation procedures.
(2)—(4) (text unchanged)
.41 Physical Plant New and Existing Construction Requirements.
A. Construction of a New Nursing Home.
(1) A new nursing home shall be constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public.
(2) A nursing home desiring to provide services other than those for which it is already licensed shall obtain prior approval from the Department.
(3) The nursing home shall obtain prior approval from the Department for any part of the premises to be used for tenant occupancy or for unrelated business purposes.
(4) A nursing home shall be constructed in accordance with the provisions of the NFPA 101 Life Safety Code.
B. Construction in an Existing Structure. In existing structures, the Department shall entertain requests for waivers on items that:
(1) Will not endanger the health and safety of residents, visitors, employees, and other individuals using the nursing home; and
(2) If corrected, will result in an unreasonable, substantial financial burden on the nursing home.
C. Conversion of an Existing Structure. When an owner plans to convert an existing structure that has not been licensed as a nursing or care home to a nursing home, the owner shall be required to meet all conditions set forth in this chapter.
D. Preventative Maintenance Program. A nursing home shall have a documented preventative maintenance program. This program shall include:
(1) Periodic service and testing of items as recommended by manufacturers of at least the following:
(a) Building systems;
(b) Building components;
(c) Resident care equipment;
(d) Resident therapy equipment;
(e) Resident bathing and shower equipment;
(f) Furniture and furnishings;
(g) Wheelchairs;
(h) Walkers;
(i) Body lifts;
(j) Scales;
(k) Electronics; and
(l) Electrical switches and outlets;
(2) Ongoing staff monitoring for evidence of malfunction or deterioration; and
(3) A centralized system for reporting and monitoring repairs.
.42 Physical Plant General Requirements.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
B. A nursing home shall comply with all applicable federal, State, and local governing laws, regulations, standards, ordinances, and codes.
C. A nursing home shall be constructed to comply with the provisions of the NFPA 101 Life Safety Code, as promulgated by the State Fire Prevention Commission, that are applicable to nursing homes.
D. Securely anchored handrails:
(1) Shall be provided on each side of all corridors in resident areas; and
(2) May not be more than 36 inches high as measured from the floor to the top of the handrail.
E. Elevators.
(1) New Construction. Elevators shall meet the requirements for elevators in a long-term care nursing home as set forth in the Guidelines for Design and Construction of Health Care Facilities.
(2) Existing Facilities. An existing nursing home shall meet all local codes and standards for safety and maintenance of institutional elevators.
F. Lighting.
(1) A resident’s room shall:
(a) Be lighted by outside windows; and
(b) Have artificial light adequate for reading and other uses as required.
(2) In order to prevent accidents and promote efficiency of service, the nursing home shall ensure that the following areas have sufficient artificial lighting:
(a) Entrances;
(b) Hallways;
(c) Stairways;
(d) Inclines;
(e) Ramps;
(f) Basements;
(g) Attics;
(h) Storerooms;
(i) Kitchens;
(j) Laundries; and
(k) Service units.
G. Minimally Maintained Lighting Levels. The following table lists the minimum lighting requirements in the following given areas:
|
Area |
Minimum Lighting |
|
(1) Administrative areas |
30 foot-candles |
|
(2) Dining areas |
30 foot-candles |
|
(3) Recreation areas |
100 foot-candles |
|
(4) Resident’s room |
10 foot-candles |
|
(5) Resident’s reading lamps |
30 foot-candles |
|
(6) Nurses station |
20 foot-candles |
|
(7) Medicine storage and preparation area |
100 foot-candles |
|
(8) Stairways |
20 foot-candles |
|
(9) Corridors |
20 foot-candles |
H. Night Lights.
(1) A nursing home shall have sufficient lighting at night in the following areas:
(a) Hallways;
(b) Stairs; and
(c) Designated toilets of the nursing home for the safety of the resident who gets up during the night.
(2) There shall be at least one night light in each bedroom for residents.
(3) In new construction, the night light shall be switched at the resident room door.
I. Screens.
(1) A nursing home shall ensure that screened doors and windows are installed and maintained in accordance with applicable fire and safety codes and COMAR 10.15.03 Food Service Facilities.
(2) Maintenance and installation may not conflict with other applicable laws, regulations, codes, or ordinances.
(3) A nursing home shall equip all screened doors with self-closing devices, to provide for the normal flow of ingress and egress of traffic.
(4) A nursing home shall screen with wire screen or its equivalent, not less than 16 meshes per linear inch for doors and windows that provide ventilation.
J. Garbage Disposal.
(1) Garbage shall be:
(a) Stored in water-tight containers with tight-fitting covers; and
(b) Emptied at frequent intervals.
(2) Soiled containers shall be thoroughly scoured and aired before using again.
K. Garbage Storage Space. Storage space shall be provided for garbage and trash awaiting pickup.
L. Burning. A nursing home may not burn or incinerate garbage at the nursing home.
M. Special Medical Wastes. The nursing home shall meet the requirements for handling, treatment, and disposal of special medical wastes as provided in COMAR 10.06.06.
N. Smoking.
(1) Resident Smoking Requirements.
(a) A resident who smokes shall be assessed for safe smoking behaviors at admission and on significant changes in condition.
(b) A resident assessed to exhibit unsafe behaviors shall have a care plan to ensure the resident is safe when smoking.
(2) Nursing Home Smoking Requirements.
(a) Smoking areas shall be designated.
(b) Smoking shall be prohibited at the main entrance to all facilities.
(c) All tobacco products shall be extinguished and disposed of in noncombustible containers with self-closing lids in accordance with the provisions of NFPA 101 Life Safety Code.
O. A nursing home shall be protected throughout the entire building by an automatic fire extinguishing system.
.43 Plumbing.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
B. Plumbing.
(1) Plumbing shall be installed in conformance with all applicable federal, State, and local codes and ordinances.
(2) Plumbing and water supplies shall be protected against backflow within a nursing home.
(3) Prevention of backflow shall be ensured by proper installation of:
(a) Plumbing cross-connections;
(b) Submerged inlets; and
(c) Back siphonage.
C. Sewage. The nursing home shall be serviced by a public sewage disposal system if available.
D. Private Sewage Disposal Approval.
(1) If no approved public sewerage system is available, a private sewage disposal may be accepted, if approved by the Department.
(2) Private sewage disposal systems shall comply with COMAR 26.04.02.
E. Water Supply. A nursing home shall be served by water from a safe public water supply, if available, as determined by the Department.
F. Approval of Private Water Supply.
(1) If a safe public water supply is not available, a private water supply may be used if it is approved by the Department.
(2) Private water systems shall comply with all federal, State, and local requirements.
G. Emergency Procedures. Emergency procedures shall be established and documented that enable the nursing home to provide water in all essential areas in the event of the loss of the normal water supply or if the nursing home would have to shelter in place during an emergency or disaster. These written procedures shall:
(1) Be a part of the nursing home’s Emergency and Disaster Plan, in conformance with Regulation .40 of this chapter; and
(2) Describe the nursing home’s plan to assure that there is an adequate amount of safe drinking water for all residents and staff for a minimum of 72 hours.
H. Adequacy of Pressure.
(1) The water supply shall be adequate in quantity and delivered under sufficient pressure to satisfactorily serve equipment in the nursing home.
(2) A minimum pressure of 15 psi during demand period is required at top floor equipment.
I. Temperature. The water heating equipment shall supply adequate amounts of heated water according to the following temperature guidelines for:
(1) Resident use, the water temperature shall be between 100°F (38°C) and 120°F (49°C):
(a) Washing;
(b) Bathing; and
(c) Other personal use;
(2) Food preparation use, as referenced in COMAR 10.15.03; and
(3) Laundry use, as referenced in the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.
.44 Physical Plant — Heating and Cooling.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
B. Temperatures. A nursing home shall maintain a minimum design temperature of 75°F or 24°C for all occupied areas.
C. Heating System. A nursing home shall be equipped with a properly maintained and operational central heating system. The heating system shall be:
(1) Capable of maintaining 75°F or 24°C throughout the residents’ section of the building with the outside temperature as prescribed in the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities; and
(2) In compliance with NFPA 101 Life Safety Code, NFPA 99 Health Care Facilities Code, and other applicable codes, and all federal, State, and local codes.
D. Humidity. The humidity shall be controlled according to the guidelines prescribed in the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.
E. Auxiliary Heat. Appropriate provisions shall be made for emergency auxiliary heat by means of alternate sources of electric power, alternate fuels, or standby equipment.
F. Space Heaters. Space heaters and portable heaters may not be used.
G. Boiler rooms. Boiler rooms shall be provided with sufficient outdoor air to maintain combustion rates of equipment and to limit temperatures in working stations to 97°F or 36°C.
H. Air Conditioning.
(1) A nursing home shall be equipped with a properly maintained air conditioning system.
(2) The air conditioning system shall be in compliance with NFPA 101 Life Safety Code, NFPA 99 Health Care Facilities Code, and all federal, State, and local codes.
(3) In an existing structure, the nursing home shall comply with the regulations and building codes effective at the date of construction.
(4) In new construction or renovation, the nursing home shall comply with the regulations and building codes effective at the date of construction or renovation.
.45 Physical Plant — Ventilation.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
B. An existing nursing home shall provide for adequate ventilation through windows or mechanical means or a combination of both.
C. A new nursing home shall adhere to the requirements of this chapter.
D. Ventilation System Details.
(1) All air-supply and air-exhaust systems shall be mechanically operated.
(2) The ventilation rates shown in Table 1 under §D(10)of this regulation shall be considered the minimum acceptable rates and may not be construed as precluding the use of higher ventilation rates.
(3) All fans serving exhaust systems shall be located at the discharge end of the system.
(4) Outdoor air intakes shall be located:
(a) As far as practical but not less than 25 feet from:
(i) Exhaust outlets of ventilating systems;
(ii) Combustion equipment stacks;
(iii) Medical-surgical vacuum systems;
(iv) Plumbing vent stacks; or
(v) Areas that may collect vehicular exhaust and other noxious fumes; and
(b) As high as practical, as such the bottom of the outdoor air intake is:
(i) At least 6 feet above ground level; or
(ii) At least 3 feet above roof level.
(5) The ventilation systems shall be designed and balanced to provide the pressure relationships as shown in Table 1 under §D(10) of this regulation.
(6) The bottoms of ventilation openings may not be not less than 3 inches above the floor of any room.
(7) Corridors may not be used to supply air to or exhaust air from any room, except that air from corridors may be used to ventilate bathrooms, toilet rooms, janitors’ closets, and small electrical or telephone closets opening directly on corridors.
(8) Filters.
(a) A central ventilation or air conditioning system shall be equipped with filters having efficiencies no less than those specified in Table 2 under §D(11) of this regulation.
(b) The filter bed shall be located upstream of the air conditioning equipment, unless a prefilter is employe
d.
(
c) If a
prefilter is employed, the prefilter shall be upstream of the equipment and the main filter bed may be located further downstream.
(d) A filter or filter efficiency shall comply with the standards of the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.
(e) A filter frame shall be durable and carefully dimensioned and shall have an airtight fit with the enclosing duct work.
(f) A joint between filter segments and the enclosing duct work shall be gasketed or sealed to provide a positive seal against air leakage.
(g) A manometer shall be installed across each filter bed serving central air systems.
(9) Air Ducts.
(a) Air handling duct systems shall meet the requirements applicable to nursing homes cited in NFPA 99 Health Care Facilities Code.
(b) Fire and smoke dampers shall be constructed, located, and installed in accordance with the requirements of NFPA 101 Life Safety Code.
(c) Air ducts that pass through a required smoke barrier shall be provided with a smoke damper at the barrier.
(d) Smoke dampers shall activate by smoke detectors located in the ducts at the smoke barrier, or by the smoke detectors used to close smoke barrier doors.
(e) Smoke dampers shall be controlled to close automatically to prevent flow of smoke-laden air in either direction.
(f) Smoke dampers shall be equipped with automatic remote control reset devices, except that manual reopening will be permitted if smoke dampers are accessible.
(g) All devices shall be interlocked with the fire alarm system.
(10) Table 1. This table refers to the pressure relationships and ventilation of certain areas of a nursing home other than chronic disease hospitals.
|
Area Designation |
Pressure
Relationship
To Adjacent
Areas |
Minimum Air
Changes of
Outdoor Air
per Hour
Supplied to Room |
Minimum Total
Air Changes
per Hour
Supplied to
Room |
All Air
Exhausted
Directly to
Outdoors |
Recirculated
Within
Room Units |
|
|
(a) Resident Room |
E |
2 |
2 |
Optional |
Optional |
|
|
( |
b) Resident Area Corridor |
E |
2 |
4 |
Optional |
Optional |
|
|
(c) Examination and Treatment Room |
E |
2 |
6 |
Optional |
Optional |
|
|
(d) Physical Therapy |
N |
2 |
6 |
Optional |
Optional |
|
|
(e) Occupational Therapy |
N |
2 |
6 |
Optional |
Optional |
|
|
(f) Soiled Workroom or Soiled Holding |
N |
2 |
10 |
Yes |
No |
|
|
(g) Clean Workroom or Clean Holding |
P |
2 |
4 |
Optional |
Optional |
|
|
(h) Toilet Room |
N |
Optional |
10 |
Yes |
No |
|
|
(i) Bathroom |
N |
Optional |
10 |
Yes |
No |
|
|
(j) Janitors’ Closet(s) |
N |
Optional |
10 |
Yes |
No |
|
|
(k) Sterilizer Equipment Room |
N |
Optional |
10 |
Yes |
No |
|
|
(l) Linen and Trash Chute Room |
N |
Optional |
10 |
Yes |
No |
|
|
(m) Food Preparation Center |
E |
2 |
10 |
Yes |
No |
|
|
(n) Warewashing Room |
|
N |
Optional |
10 |
Yes |
No |
|
(o) Dietary Day Storage |
E |
Optional |
10 |
Yes |
No |
|
|
(p) Laundry, General |
E |
2 |
10 |
Yes |
No |
|
|
(q) Soiled Linen Sorting and Storage |
N |
Optional |
10 |
Yes |
No |
|
|
(r) Clean Linen Storage |
P |
2 |
2 |
Optional |
Optional |
|
|
Key: P
= Positive, N = Negative, E = Equal |
|
(11) Table 2. This table below refers to the filter efficiencies for central ventilation and air conditioning systems in a nursing home other than chronic disease hospitals.
|
Area Designation |
Minimum Number
of Filter Beds |
Filter Efficiencies
(Percent)
Main Filter Bed |
|
(a) Resident Care, Treatment, Diagnostic,
and Related Areas. These areas may be reduced to 35 percent for all-outdoor air systems. |
1 |
80 |
|
(b) Food Preparation Areas and Laundries. |
1 |
80 |
|
(c) Administrative, Bulk Storage and Soiled
Holding Areas. |
1 |
25 |
(12) Exhaust Hoods. All hoods over cooking surfaces shall comply with the requirements as provided in COMAR 10.15.03.
.46 Physical Plant Emergency Power.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
B. Emergency Electrical Power.
(1) The nursing home shall provide emergency electrical power.
(2) Emergency power for the purpose of egress lighting and protection shall be as required by NFPA 101 Life Safety Code.
(3) Other emergency lighting shall be as follows:
(a) Nursing station;
(b) Drug distribution station or unit dose storage;
(c) A lighted area for emergency telephone use;
(d) Boiler or mechanical room;
(e) Kitchen;
(f) Generator set location and switch gear location;
(g) Elevator, if operable on emergency power;
(h) Areas where life support equipment is used;
(i) If applicable, lighting for the common area of refuge; and
(j) If applicable, lighting in toilet rooms of the common area of refuge.
(4) Emergency power shall be provided for the:
(a) Nurses’ call system;
(b) Duplex receptacles installed 50 feet apart in all corridors in resident areas or appropriately located duplex receptacles in the common area of refuge;
(c) Telephone service with at least one telephone available for incoming and outgoing calls;
(d) Fire pump;
(e) Sewerage pump and sump pump;
(f) Elevator, if required, for evacuation as referenced in NFPA 101 Life Safety Code;
(g) Heating equipment, if applicable, to maintain a minimum temperature of 71°F or 22°C in the common areas of refuge;
(h) Life support equipment;
(i) Nonflammable medical gas systems;
(j) Computer system, if applicable, to enable use of electronic medical records system; and
(k) Refrigerated medication storage.
(5) Common Area or Areas of Refuge.
(a) The nursing home shall provide a common area or areas of refuge in an emergency situation if all resident rooms, day rooms, and toilet rooms are not tied into the emergency generator to provide heat and cooling.
(b) The common area or areas of refuge:
(i) Shall be at least 30 square feet per bed, not including corridors;
(ii) May not include toilet rooms in the 30 square feet per bed; and
(iii) Shall maintain a minimum temperature of 71°F or 22°C and a maximum temperature of 81°F or 27°C.
(c) The nursing home shall provide heated toilet rooms adjacent to the common areas of refuge.
(d) The nursing home shall provide a Department-approved written plan that:
(i) Defines the specified area of refuge;
(ii) Outlines paths of egress from the common areas of refuge; and
(iii) Describes provisions for light, heat, food service, washing, and toileting residents.
(6) Emergency Power Source.
(a) The emergency power source shall be a generating set and prime mover located on the premises with automatic transfer.
(b) The emergency generator shall:
(i) In the event of failure of the normal electrical service, be activated immediately;
(ii) Come to full speed and load acceptance within 10 seconds;
(iii) Have a capacity of 48 hours of operation from fuel stored on-site; and
(iv) Be tested once a month, for at least 30 minutes under normal emergency nursing home connected load, and the test recorded in a permanent log book maintained for that purpose.
[.27] .47 Nursing Care Unit.
A. (text unchanged)
B. [Service Areas Required in New Construction or for New Facilities.] Common Space. The nursing home shall provide a living room for residents’ use with a sufficient number of reading lamps, tables, and comfortable chairs or sofas.
C. Service Areas Required.
(1) Nurses’ [Station.] Work Area.
(a) The nurses’ [station] work area shall be [centrally] located [in relation to beds served] on the unit and [shall provide] within easy view of corridors outside of residents’ rooms.
(b) The Department may specify the location and size of a nurses’ [station] work area which serves a nursing care unit exceeding 40 beds.
(2) Nursing Care Unit.
(a) A nursing care unit, regardless of size, including special care units, shall be equipped as described in this regulation.
(b) A nursing care unit [also] bathroom shall include:
[(a)] (i) A toilet, within the care unit, for the use of personnel[, a]; and
(ii) A hand washing sink equipped with [4 inch wrist blades,] goose-neck spout, [and] separate soap dispensers, and disposable paper towel dispensers.
[(b) Medicine storage cabinet with locks. Schedule II drugs shall be kept in separately locked, securely fixed boxes or drawers in a cabinet, under two locks, keyed differently; medicine storage and preparation area with illumination of 100 footcandles at the work counter; preparation area shall include a small sink set into the counter or with drain boards; biological refrigerator. Spaces housing medicine storage cabinet, medicine preparation area, and biological refrigerator shall be under the direct visual control of the nursing or pharmacy staff.]
(c) A nursing care unit’s medicine shall be stored in accordance with the following procedures:
(i) Shall be stored in a cabinet with locks;
(ii) Schedule II drugs shall be kept in a separately locked, securely fixed box or drawer in the medicine storage cabinet under two locks, keyed differently;
(iii) The medicine storage and preparation area shall be illuminated with at least 100 foot-candles at the work counter;
(iv) The preparation area shall include a small sink set into the counter or with drain boards and a biological refrigerator; and
(v) The medicine storage cabinet, medicine preparation area, and biological refrigerator shall be under the direct visual control of the nursing or pharmacy staff.
[(c)] (d)—[(e)] (f) (text unchanged)
[(f)] (g) [Sufficient] A nursing care unit shall have sufficient space and equipment for medical records [which enables] so that personnel [to] can function [in an effective manner] effectively and [to] maintain easily accessible records on all [patients so they are easily accessible] residents.
[(2) Nurses’ Station—Existing Facility. Each care unit shall have a nurses’ station provided with a medicine storage cabinet and preparation counter or table having adequate lighting overhead. A handsink with hot and cold running water shall be convenient to the nurses’ station.]
(3) Medication Storage in Nursing Home.
(a) [Because specific temperatures are often required for the safe storage of drugs, the] The storage [facilities] facility shall provide for the [following] conditions listed in §C(3)(b)—(g) of this regulation when prescribed [:].
[(a)] (b) Cold—Any temperature [not exceeding 8°C (46°F)] at or below 46°F or 8°C. A refrigerator is a cold place in which the temperature is maintained thermostatically between [2°C and 8°C (46° and 59°F)] 46°F and 59°F or 8°C and 15°C. A freezer is a cold place in which the temperature is maintained thermostatically between [-20°C and -10°C (-4° and -14°F)] -4°F and -14°F or -20°C and -26°C.
[(b)] (c) Cool—Any temperature between [8°C and 15°C (46° and 59°F)] 46°F and 59°F or 8°C and 15°. An article for which storage in a cool place is directed may, alternatively, be stored in a refrigerator, unless otherwise specified in the individual monograph.
[(c)] (d) Room Temperature—The temperature prevailing in a working area. Controlled room temperature is a temperature maintained thermostatically between [15°C and 30°C (59° and 86°F)] 59°F and 86° F or 15°C and 30°C.
[(d)] (e) Warm—Any temperature between [30°C and 40°C (86° and 104°F)] 86°F and 104°F or 30°C and 40°C.
[(e)] (f) Excessive Heat—Any temperature above [40°C (104°F)] 104°F or 40°C.
[(f)] (g) Protection from Freezing. The container label bears appropriate instructions to protect the product from freezing [When in addition to the risk] when freezing it may subject a product to:
(i) Loss of strength or potency;
(ii) Risk of breakage of the container[, freezing subjects a product to loss of strength or potency,]; or [to destructive]
(iii) Destructive alteration of the dosage form [, the container label bears an appropriate instruction to protect the product from freezing].
[(g)] (h) Storage under Non-specific Conditions. When no specific storage directions or limitations are provided in the individual monograph, [it is to be understood that] the storage conditions shall include protection from moisture, freezing, and excessive heat.
(4) Space for Storage of Linen [New Construction and Existing Facilities]. Capacity shall be provided for [storage] storing of at least two complete linen changes per bed. Clean linen shall be stored separately from [non-clean] unclean items.
(5) Janitors’ Closet—New Construction. [Each]
(a) A nursing unit shall contain at least one janitors’ closet containing a floor receptor or service sink and storage space for housekeeping equipment and supplies.
(b) The janitor’s closet shall be equipped for [handwashing] hand washing.
(c) The janitor’s closet shall be connected to mechanically operated exhaust ventilation.
(d) The plumbing fixture for the utility or service sink within a janitor’s closet must be provided with a back-flow prevention device.
(6) Utility Rooms[—New Construction].
(a) There shall be separate clean and soiled utility rooms in each nursing unit:
(i) [, accessible] Accessible to the [patient] resident area[, no];
(ii) Each having separate entrances; and
(iii) No more than 120 feet to the most remote [patient] resident bedroom[. There shall be a separate entrance into each room].
(b) The clean utility room shall contain:
(i) [Wall and base cabinets with stain resistant countertop;
(ii)] A small sink [set into the counter, or with drainboards; sink shall be] equipped with gooseneck spout and wrist blades;
(ii) Soap and individual paper towels in a dispenser;
(iii) Adequate storage and work counter space for storage and assembly of supplies for nursing procedures; and
(iv) [Provision for storing and transporting clean linen in covered container.] Clean linen [may also be stored in] stored and transported in covered containers, closed linen carts, or rooms exclusively provided for this purpose[, if approved by the Department].
(c) The soiled utility room shall contain:
(i) (text unchanged)
[(ii) A separate wall-hung hand sink for handwashing, equipped with wrist blades and soap and towel dispensers;]
(ii) A small sink equipped with soap and individual paper towels in a dispenser;
(iii) (text unchanged)
(iv) Equipment[, approved by the Department,] to clean and sanitize bedpans, urinals, and basins; and
(v) Equipment for the disposal of liquid and semi-solid wastes and bodily fluids via the nursing home’s sanitary sewer connection or on-site sewage disposal system.
[(7) Utility Rooms—Existing Facility. In existing facilities service areas shall be provided for patient care items which are acceptable to the Department.]
(7) Culture Change Nursing Home. In a culture change nursing home, service areas shall be provided for resident care needs as approved by the Department. The culture change nursing home shall be required to have service areas that meet the specifications in this chapter for:
(a) Clean storage;
(b) Soiled holding;
(c) Laundry;
(d) Janitorial services; and
(e) Medication storage.
[C. Call System—New Construction. A call system shall be installed and maintained in operating order in all nursing units. Call systems shall be maintained in a manner that will provide visible and audible signal communication between nursing personnel and patients. The minimum requirements are:
(1) A call station or stations providing detachable extension cords to each patient’s bed in the patients’ rooms. These extension cords shall be readily accessible to patients at all times.
(2) A visible signal in the corridor above the corridor door of each patient’s bedroom, visible from all parts of the corridor.
(3) An audible signal and a nurses’ call enunciator indicating the room from which the call originates or an alternate system approved in writing by the Department, shall be located at the nurses’ station. The sounding of the audible signal shall be continuous or intermittent until answered. The audible signal may not be turned off at the nursing station.
(4) A call system shall be provided in each patient’s toilet room, bathroom, and shower stall in locations easily accessible to the patients. The call system shall enable patients in the rehabilitation area to summon rehabilitation staff.
(5) The nurses’ call system shall be so designed as to require resetting at the station where the call originates.
D. Call System—Existing Facilities. Existing facilities (those facilities licensed at the time this regulation becomes effective) shall provide some method/means of a patient summoning aid that shall include as minimum a combined visual and audible signal that is audible at the nurses’ station and simultaneously activates a light located in the hall, outside of and adjacent to the patient’s room. The activating device for those signals shall be located in each patient’s room and each and every bathing compartment and toilet room or compartment used by patients. Exceptions may be made in part at the discretion of the Department for an individual facility only when the facility can demonstrate compliance with the intent of this section by showing an effective patient call system to provide quality patient care.]
[E.] D. Drinking Fountains. One public drinking fountain or comparable equipment as preapproved by the Department shall be provided [one] on each floor, usable from a wheelchair. Alternative means to provide drinking water to residents, staff, and the general public may be used as approved by the Department.
E. Automated External Defibrillator.
(1) A nursing home shall possess a functioning automated external defibrillator (AED).
(2) As of July 1, 2020, a nursing home shall install a functioning AED unit.
.48 Call Systems.
A. Call System.
(1) A nurse call system shall be installed and maintained in operating order in all nursing units.
(2) A call system shall be maintained in a manner that will provide visible and audible signal communication between nursing service personnel and residents.
(3) A call station shall provide readily accessible and detachable extension cords to each resident’s bed in the residents’ rooms at all times.
(4) A call system shall have a visible signal above the door of each resident’s bedroom that shall be visible from all parts of the corridor.
(5) A call system shall provide visual lights at corridor intersections, in multi-corridor nursing units.
(6) A call system shall be provided in each resident’s bathroom and bathing area in locations accessible to the residents.
(7) The call system shall enable residents in the rehabilitation area to summon rehabilitation staff.
(8) The nurses’ call system shall require resetting at the station where the call originates.
B. Wireless Call Systems.
(1) A call system that uses wireless pagers or other wireless communication devices may be used as an alternative system.
(2) A wireless device shall:
(a) Be issued to all assigned direct care staff; and
(b) Receive signals originating from residents’ bedrooms, bathrooms, bathing areas, and therapy areas.
(3) The use of an approved wireless call system shall eliminate the need to install call light indicators outside the residents’ bedrooms, bathrooms, bathing areas, and therapy areas.
(4) A computer system with a monitor or other electronic display device may be installed to replace the call system enunciator, as long as it reveals the location where the signal originated and sounds an audible alert tone. Otherwise, a dedicated enunciator connected to the wireless call system will be needed.
(5) An electrically powered call system shall be connected to the emergency power supply.
(6) The sounding of the audible signal shall be continuous or intermittent until answered.
(7) The audible signal may not be turned off at the nursing station.
(8) The audible signal shall be loud enough to be heard at the nurses’ station.
.49 Resident Bedroom in Nursing Home.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home unless a waiver has been granted by the Office of Health Care Quality in accordance with Regulation .03G of this chapter.
B. Bedroom Accommodations.
(1) Bedroom.
(a) A resident’s room shall have direct access to an exit in accordance with the requirements applicable to nursing homes specified in NFPA 101 Life Safety Code.
(b) A room that opens into the kitchen may not be used as a resident bedroom.
(c) A room may not be used as a resident bedroom if it can only be reached by passing through a kitchen.
(d) Residents may not occupy rooms extending below the ground level.
(e) No more than four individuals may occupy a multiple occupancy bedroom.
(f) Residents’ beds may not be located near radiators, registers, or sources of draft.
(g) Adequate storage space shall be provided in each bedroom to allow each resident to keep necessary items of clothing, including items that need to be hung. Adequate storage space shall be provided for residents’ personal possessions, including the storage of seasonal clothing.
(h) All occupants of any bedroom shall be of the same sex, except in the case of a two-bed room occupied by:
(i) Opposite gender siblings;
(ii) Opposite gender parent and child;
(iii) A married couple; or
(iv) Consenting residents.
(2) Bedroom—New Construction. A nursing home shall provide cubicle curtains and tracks in multiple occupancy bedrooms between beds to insure privacy of residents.
(3) Bedroom—Existing Construction. In an existing nursing home, curtains or screens shall be acceptable.
C. Floor and Window Space.
(1) Floors.
(a) A distance of at least 3 feet shall be maintained between each bed. Beds are to be placed so that all sides of the bed are at least 18 inches from heating units.
(b) The following shall be considered a minimum allowance of floor space:
(i) 100 square feet, single-bed room; and
(ii) 80 square feet, per bed, for multiple-bed rooms.
(c) The following floor areas may not be included in the calculation of floor space:
(i) Toilet rooms and bathing facilities;
(ii) Closets;
(iii) The floor area occupied by wardrobes, bureaus, or lockers, when permanently installed as part of walls or ceilings and as a permanent component of a bedroom;
(iv) HVAC equipment, including any steam, water, or electrical supply or return lines that may run parallel to the floor or interrupt the floor surface;
(v) Support columns, pipe chases, or other structures, whether free-standing or as an integral part of a wall; and
(vi) The arc of any doors that open into the room, excluding closet doors.
(d) The minimum horizontal dimensions of a bedroom are to be 10 feet to:
(i) Facilitate the placement of beds as required in Regulation .44 of this chapter; and
(ii) Maintain a minimum clearance of 3 feet at the foot of the bed.
(e) In an existing nursing home, the usable floor area for rooms having a bedroom shall have a finished ceiling height of 8 feet. For a bedroom that has sloping walls, only 50 percent of the floor area with a ceiling height between 4 feet and 7 feet, 6 inches, shall be credited, provided that at least 50 percent of the total area of the bedroom has a ceiling height of 8 feet.
(2) Windows.
(a) The window area within each bedroom shall be at least 10 square feet per bed. The window opening shall be at least 28 inches so that the total area equals 10 square feet per bed. This is to allow entry of fire fighters, removal of smoke, and emergency evacuation.
(b) The maximum height from the floor to the top of a window sill shall be 44 inches above the finished floor.
(c) A portable window air-conditioning unit may not block window space. The installation of a portable air-conditioning unit shall be approved by the:
(i) Local fire authorities; and
(ii) Department.
(d) If windows cannot be opened for ventilation, a central HVAC system shall be provided and maintained.
(e) If windows can be opened, but the nursing home has concern over the window being opened due to resident safety issues and elopement, the window sash may be restricted by hardware as approved by the Department.
D. Furnishings.
(1) Furnishings.
(a) The nursing home shall provide residents with their own bed. The bed shall be at least 36 inches wide and be substantially constructed. Rollaway type beds, cots, or folding beds may not be used.
(b) Bed.
(i) Each bed provided shall be in good repair, with a clean and comfortable standard size mattress and foundation.
(ii) To avoid injury to the resident, the mattress and foundation shall fit the bed.
(iii) Clean linen and a clean, comfortable pillow shall be provided. Extra pillows shall be available.
(c) Bedroom Furniture. A resident shall be provided with the following furnishings, which shall be convenient to the resident:
(i) Bedside stand with a drawer;
;
(iii) A comfortable chair;
(iv) A chest of drawers with at least one locking drawer;
(v) Enclosed space for hanging clothing;
(vi) A wall mirror in each room, unless contraindicated by physician’s order; and
(vii) A bedside lamp, over-bed lamp, or other directional light source for resident reading and bedside care.
(d) Resident’s Personal Furnishings.
(i) A nursing home shall develop policies and procedures to give residents the opportunity to use the resident’s own furnishings as detailed in this chapter.
(ii) The nursing home shall make its resident’s personal furnishing policies available for review by residents and the resident’s representative.
(iii) These policies shall address the condition of the personal furnishings, presence of insects or vermin, and overall safety to ensure that the use of the resident’s belongings does not create any safety or health issues.
(iv) Personal furnishings that are allowed shall be appropriate for the resident’s use.
(e) Windows shall be provided with shades or draperies adequate to control glare and maintain privacy.
(f) Each living room for residents’ use shall be provided with a sufficient number of reading lamps, tables, and comfortable chairs or sofas.
(2) Furnishings—New Construction. A bedroom shall be provided with a hand washing sink with both hot and cold running water unless a toilet or bathroom facility with a sink is connected to the bedroom.
(3) Medication Storage Cabinets.
(a) Medication storage cabinets with locks shall be permitted for the storage of resident medications that do not require refrigeration within a resident bedroom.
(b) Controlled medications to be stored within medication storage cabinets in a resident’s room shall be held within a separate compartment that is locked and inside of the larger medication storage cabinet in that room.
.50 Body Holding Room.
A. Body Holding Room—New Construction and Existing Nursing Home.
(1) A body holding room shall be equipped with ventilation by mechanical means at the same rate and specifications as designed for soiled linen sorting and storage areas.
(2) A nursing home shall develop and implement a method for body holding that minimizes the psychological effects on other residents.
B. Body Holding Room—New Construction. A body holding room shall be located to facilitate quiet and unobtrusive ingress and egress of bodies, convenient to the elevator and with an isolated exit.
C. Body Holding Room—Existing Nursing Home. If a body holding room is not provided, a holding area shall be designated that approximates the above conditions.
.51 Resident Bathroom Amenities.
A. Bathing.
(1) There shall be at least one separate room or compartment with a bathtub, shower, or other bathing device, as approved by the Department, for every 15 licensed beds.
(2) The compartment shall be large enough to accommodate:
(a) The resident;
(b) A caregiver; and
(c) A wheelchair, shower chair, or shower bed.
B. Toilets.
(1) For every eight beds, there shall be at least one toilet enclosed in a separate room or stall.
(2) Each floor shall have at least one toilet room large enough to:
(a) Accommodate:
(i) The resident;
(ii) A wheelchair; and
(iii) A caregiver; and
(b) Permit toilet assistance or training.
C. Sinks.
(1) For every four licensed beds, there shall be at least one hand washing sink.
(2) For hand washing purposes, there shall be a towel dispenser and a supply of paper towels and soap dispenser adjacent to each sink.
[.29] .52 Equipment and Supplies for Bedside Care and Therapy.
A. Needs of [Patients] Residents.
(1) There shall be sufficient equipment to meet the needs of the [type patients] residents admitted. [It shall be the responsibility of the]
(2) The administrator shall [to] obtain specific items required for individual cases where requested by the attending physician or [supervisor of care services] medical director.
(3) The Department may require that the nursing home have specific types of equipment based on the needs of the [patients] residents.
(4) [All facilities] A nursing home shall establish and enforce a written preventive maintenance program to ensure that all [essential mechanical, electrical, and patient care] resident care and therapy equipment is maintained in safe operating condition.
B. Use of [Hot Water Bottles and, Ice Caps] Hot Packs, Ice Packs, and Other Therapeutic Medical Devices.
(1) Covers shall be placed on hot [water bottles and, ice caps] packs, ice packs and other temperature-related therapeutic medical devices before they are placed in a bed or on a [patient] resident.
(2) The [water] temperatures [in hot water bottles] in the building, hot packs, and therapeutic equipment may not exceed 120°F or 49°C. [Heating pads may not be used instead of hot water bottles.]
(3) The use of hot and cold medical devices shall be:
(a) Consistent with manufacturer’ guidelines and nursing home policies; and
(b) Maintained and applied by trained staff.
10.07.02.30
[.30] .53 Rehabilitation Facilities — Space and Equipment.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
B. General Requirements.
[A.] (1) Space.
[(1)] (a) [There] A nursing home shall [be] provide adequate space [for the reception, examination, and treatment of patients; storage of] to:
(i) Receive, examine, and treat residents;
(ii) Store supplies and equipment, including wheelchairs and stretchers; and [office]
(iii) Provide office space for the employed personnel [employed;] to work.
[(2)] (b) [Seventy-five] A nursing home shall allot 75 square feet [shall be allotted] for treatment area per [patient] resident, based on peak treatment schedules.
[Agency Note: Recommended space: Storage—10 percent of area designated for exercise and rehabilitation; Office—one therapist, 110 square feet; two or more, 85 square feet per therapist.]
[(3)] (c) [Space may be planned and arranged] A nursing home shall plan and arrange space for shared use by physical therapy and occupational therapy staff and [patients] residents, if scheduling permits.
(d) A nursing home may distribute space in the following manner:
(i) Storage space shall comprise at least 10 percent of the area designated for exercise and rehabilitation; and
(ii) Office space shall be at least 110 square feet for one therapist, or 85 square feet per therapist if there are two or more.
[B.] (2) Equipment.
[(1)] (a) Equipment shall [be of a type that will provide] allow for providing safe and effective [patient] resident care.
[(2)] (b) All electrical equipment shall be calibrated according to the manufacturers’ directions and shall be [periodically] serviced periodically as part of a preventive maintenance program. A sticker bearing the date of the most current inspection shall be affixed on each piece of equipment.
[(3)] (c) All electrical equipment shall be [periodically] tested periodically for proper grounding, current leakage, and calibration where appropriate.
[(4)] (d) [Operator’s] The operator’s instruction [booklet] manual shall be available in a designated location or accessible electronically at all times.
[(5)] (e) All flammables shall be stored in compliance with NFPA [30, flammable and combustible liquids code] 99 Health Care Facilities.
[(6)] (f) [Due care] Adequate exhaust ventilation shall be [taken in] provided when using vaporous materials or pollutants.
[C.] (3) Toilet Facilities in Rehabilitation Area—New Construction. [In new construction, facilities]
(a) A nursing home with rehabilitation areas shall provide a [lavatory] hand washing sink and toilet which meet [ANSI] Guidelines for Design and Construction of Residential Health, Care, and Support Facilities standards for residents who are dependent on the use of a wheelchair [patients]. [These facilities]
(b) The nursing home shall be readily accessible to the [rehabilitation patients] residents receiving rehabilitative services.
(c) Toilets and bathing rooms within a rehabilitation area shall be equipped with a nurse call system.
[.31] .54 Dayroom and Dining Area.
A. General Requirements. Resident Dining, Occupational Therapy, and Activities Program. [There] The nursing home shall [be provided] provide one or more attractively furnished areas of adequate size for resident dining, occupational therapy, and social activities. Activities space shall be of adequate size to meet the needs of the residents and shall be located on each floor occupied by residents.
B. Dining Area. [In all facilities, the]
(1) A nursing home shall provide dining [area shall be] areas large enough to accommodate all [patients able to eat out of their rooms] residents who eat there at the same time.
(2) There shall be an allowance of at least 12 square feet per [ambulatory patient] resident[; this]. This allowance shall be substantially increased proportionate to the number of residents who depend on using a wheelchair [cases]. [There shall be at least 12 square feet per bed for 50 percent of the total licensed beds.]
(3) The height of tables provided in dining areas shall accommodate each resident using a wheelchair.
C. Dayroom Area. Dayroom areas shall be provided[, adequate] that are:
(1) Adequate for the [patients capable of using them] residents located on each nursing care unit; and
(2) Located convenient to [patients’] the residents’ bedrooms.
D. Multi-purpose Room. [If]
(1) The nursing home shall provide a multi-purpose room [is used] for dining, occupational therapy, physical therapy, and social activities[, there]. There shall be sufficient space to accommodate all activities without [interference] interfering with each other.
(2) [The total areas] The nursing home shall set aside areas for [patients’] residents’ dining and recreation [areas shall be no less than] that total at least 30 square feet per licensed bed for the first 100 beds [and], plus 27 square feet per licensed bed for all beds in excess of 100.
(3) Areas that meet this requirement may include:
(a) Reception areas;
(b) Lobbies, portion not required for egress per NFPA 101 Life Safety Code, as are applicable to nursing homes;
(c) Hair care;
(d) Salon rooms;
(e) Resident gift shops;
(f) Theater;
(g) Auditorium;
(h) Spiritual worship;
(i) Meditation areas;
(j) Dayrooms;
(k) Dining areas;
(l) Libraries; and
(m) No more than 50 percent of the floor area of all occupational therapy and physical therapy areas, and other areas as approved by the Department.
[.32] .55 Dietetic Service Area.
A. General Requirements. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
[A.] B. Food Service Department. [The location of the food service are shall be approved by the Department. A facility which holds full licensure as of the adoption date of these regulations shall be considered as having an appropriately located food service area.]
(1) The size and location of the food service area shall comply with COMAR 10.15.03.
(2) A catered or satellite system shall be covered by a contract approved by the Department.
(3) The vendor providing the food shall have a valid food service permit.
[B.] C. Outside Service Entrance. A convenient outside service entrance shall [be planned] exist to facilitate receiving food supplies and the disposal of waste.
[C.] D.—[D.] E. (text unchanged)
[E.] F. Janitor’s Closet or Service Area.
(1) [New Construction. A janitor’s] Janitors Closet—New Construction. A janitor’s closet or service alcove for the exclusive use of food service areas shall be provided in, or adjacent to, the dietetic service department. [It]
(2) The janitor’s closet or service alcove shall be [equipped]:
(a) Equipped with [a]:
(i) A utility sink[, storage];
(ii) Storage shelves[,]; and [a]
(iii) A rack for hanging brooms and mops; and
(b) Connected to mechanically operated exhaust ventilation.
[(2) Existing Facility. A utility sink shall be provided within reasonable distance from the food service department for its use, but it may be shared with other activities. Space near the utility sink shall be provided for the storage of brooms, mops, and cleaning materials.]
(3) The plumbing fixture for the utility sink within a janitor’s closet shall be provided with an approved back-flow prevention device.
[F.] G. Space.
(1) There shall be sufficient floor space in the food service department to permit all activities to function efficiently without overcrowding[:] or increasing the risk for cross-contamination of food or equipment from soiled surfaces.
[(1) New Construction. New construction providing a conventional type food service program shall have the following minimal space requirements (excluding bulk food-storage areas, dining areas, and separate floor pantries). Modification of the following minimum space will be made in the event that the facility can demonstrate that the use of convenience food, disposables, or equipment, require less space for operation. However, once a facility elects to use these procedures or systems and a modification is granted, the systems may not be changed without prior approval of the Department. The Department in these cases may require additional space to be provided.]
(2) Minimum Space Requirements—New Construction.
|
Home’s Licensed Capacity for [Patients] Residents |
Minimum Space |
|
(a)—(d) (text unchanged) |
|
[(2) Renovations of existing kitchens shall be approved by the Department which will consider modification of the minimum space requirement based on space available, costs, and type of service.]
(3) Space—Existing Nursing Home.
(a) A nursing home that holds full licensure as of the adoption date of these regulations shall be considered to have an adequate size dietetic service department.
(b) Renovations of [existing] all kitchens shall be approved by the Department, which will consider modification of the minimum space requirement based on space available, costs, and type of service.
[(3)] (4) Aisle space between working areas shall be at least 3 feet[;], and aisle space for main traffic shall be at least 5 feet wide.
[(4)] (5) (text unchanged)
[Agency Note: 10 foot ceiling height is recommended.
(5) Existing Facility. A facility which holds full licensure as of the adoption of these regulations shall be considered as having an adequate size dietetic service department.]
(6) If the licensed capacity of a [facility] nursing home is increased, or if meals are provided to anyone outside of the [facility] nursing home from the food service area of the [facility] nursing home, the [facility] nursing home shall provide an additional food service area in accordance with [§F(1), (3), and (4) of this regulation] this chapter. The additional food service area required when meals are provided to anyone outside of the [facility] nursing home is to be calculated by using the total number of individuals to whom meals are provided.
(7) The kitchen space requirement [in §F(6) of this regulation] as described in this regulation does not apply to occasional special functions such as picnics or dinners for residents, volunteers, families, or community groups [provided] as long as the [facility] nursing home certifies to the Department that [the provision of] providing meals for [the particular] a special function will not adversely affect or detract from the timely provision of meals to the nursing home’s residents [of the facility].
[G.] H. Floor Pantries—New Construction.
(1) [In a decentralized] There shall be at least one food service[, the area or areas for] floor [pantries shall be approved by the Department] pantry per nursing care unit.
(2) (text unchanged)
[Agency Note: The following equipment is recommended:
(a) Equipment to maintain food at correct temperature;
(b) Toaster;
(c) Hot plate;
(d) Refrigerator;
(e) Ice-making machine or ice-storage container;
(f) Work space for tray preparation;
(g) Equipment for delivery of completed trays;
(h) Three-compartment sink or dishwasher;
(i) Cabinet for dry storage and supplies;
(j) Storage for trays, tableware, flatware, and utensils;
(k) Hand washing sink with soap and towel dispenser or approved drying device.
(3) At least one nourishment pantry convenient to the nursing station shall be provided on each floor in facilities using a centralized food service system. Minimum equipment shall include the following:
(a) Refrigerators;
(b) Cabinets for dry storage and supplies;
(c) Work space;
(d) Sink for purposes other than handwashing;
(e) Han
dwashing sink with soap and towel dispenser or approved drying device.]
(3) The equipment provided in food service floor pantries shall comply with the requirements of the local health department.
(4) A food service floor panty shall include the following:
(a) Refrigerator;
(b) Cabinets for dry storage and supplies;
(c) Work space;
(d) Sink for purposes other than hand washing;
(e) Hand washing sink with soap dispenser and disposable paper towel dispenser; and
(f) Except for trays that are assembled in the main kitchen and then distributed to the nursing care units, equipment to hold hot food if bulk foods are plated and served to the residents on the nursing care unit.
(5) A food service floor panty shall include the following additional equipment:
(a) Toaster;
(b) Ice-making machine or ice-storage container;
(c) Work space for tray preparation;
(d) Equipment to deliver completed trays;
(e) Three-compartment sanitizing sink or dishwasher;
(f) Cabinet for dry storage, supplies, and kitchenware; and
(g) Storage for trays, tableware, flatware, and utensils.
[H.] I. Equipment for Food Preparation and [Distribution. The following requirements shall be met:] Distributions.
(1) Adequate equipment for preparation, serving, and distribution of food shall be provided[;].
(2) A dumbwaiter, elevator, or ramp shall be provided in a [facility] nursing home of more than one story where more than eight [patients] residents above or below the kitchen level[,] receive bedside tray service[;].
(3) Equipment to protect food from dust or contamination and to maintain food at proper temperature shall be provided [for transportation of] to transport food to the [patients] residents.
[I.] J. Dry Food Storage. [The following requirements shall be met:]
(1) Food Storage Space.
(a) Adequate space shall be provided [for the storage of] to store food supplies[;].
[Agency Note:]
(b) The amount of storage space needed [is dependent upon] to store food depends on the frequency of deliveries.
(c) It is recommended that 2 square feet per [patient] resident be provided and that the dry food storage area be located within easy access to the receiving area and the kitchen.
(2) The storeroom shall be cool and well-ventilated[;].
(3) (text unchanged)
[Agency Note: Care should be exercised in the rotation of stored food so that old stock is used first.]
[J.] K. Refrigerated Storage.
(1) Adequate refrigerated storage, refrigerators, and frozen food storage cabinets[,] shall be provided [which are] and regulated to maintain temperatures prescribed in COMAR 10.15.03 [Food Service Facilities].
(2) Food in storage shall be arranged so that new food items are stored behind old food items.
(3) The oldest foods shall be used first, known as the first in, first out method.
L. Mobile Food Carts.
(1) All policies and procedures for the mobile food cart shall be approved by the Department and the nursing home’s local health department before implementation.
(2) Policies and procedures shall address, at a minimum the following:
(a) Identify how many staff members will assist with serving food items, pushing the mobile cart, and delivering meals to the residents;
(b) Ensure proper food protection on three sides to protect the food;
(c) Maintain proper temperature control, hot food at a minimum of 135°F and cold food maintained at a maximum of 41°F;
(d) Record of temperatures before serving meals on each individual unit;
(e) Ensure proper food temperatures; and
(f) Hand washing.
(3) The hand washing policy and procedures referenced in §L(2)(f) of this regulation shall include the following:
(a) Use of a hand sanitizer in lieu of proper hand washing is not permitted;
(b) Bare hands may not have direct contact with ready-to-eat food;
(c) Hand washing shall be done before starting meal service on each individual unit;
(d) When and at what location hand washing will be done;
(e) Hand washing may not be done in resident rooms;
(f) Access to a hand washing sink may not require the opening of a door;
(g) The hand washing sink shall be in a central, unobstructed location;
(h) Mobile hand sinks are acceptable as long as a written procedure to meet sanitation requirements is developed;
(i) The hand sink shall be supplied with hot and cold water under pressure;
(j) The unit shall be supplied with adequate waste containers to hold dirty water until dumping is done; and
(k) The written procedure shall include the disposal of the dirty water.
[.33] .56 Administrative Areas.
A. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
[A.] B. [New Construction. In new construction,] Administrative Areas—New Construction.
(1) A nursing home shall provide a separate room or rooms [shall be provided] for the administrator and administrative support staff. Sufficient areas shall be provided to accommodate all necessary office furniture, files, and other equipment[, including provision for] and enable the safe storage of [patients’] residents’ valuables.
(2) In new construction, separate locker rooms and a toilet facility shall be provided for male and female employees in each nursing home.
[B.] C. Administrative Areas—Existing [Facilities] Nursing Homes. [In existing facilities,]
(1) The nursing home shall provide an administrative area [shall be provided which] that is suitable for conducting business or discussing [in privacy problems] problems privately with the [patient’s sponsor] resident’s representative.
(2) The nursing home shall provide a sufficient number of lockers that can be locked securely for all employees working at any one time, and provision shall be made for the employees to use the toilet facility at a convenient location.
[C. Lobby Area. In new construction, facility shall provide a lobby area. Public toilets for both sexes shall be located conveniently to this area. Telephone service and drinking fountains which meet ANSI standards also shall be provided.]
D. Lobby Area—New Nursing Home. A nursing home shall provide a lobby area that shall have:
(1) Public toilets for both sexes, either separate or unisex, located conveniently to this area;
(2) Access to telephone; and
(3) Drinking fountains or other drinking water dispensers that meet Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.
[D.] E. (text unchanged)
[E.] F. Employee Facilities—Existing Facilities. [In] An existing [facilities] nursing home shall:
(1) Have a sufficient number of lockers [capable of being] that can be securely locked [shall be provided] for all employees working at any one time[,]; and [provision shall be made]
(2) Provide for the staff use of toilet facilities at a convenient location.
[.34] .57 Housekeeping Services, Pest Control, and Laundry.
A. General Requirements. Unless otherwise indicated, all general requirements apply to both new construction and an existing nursing home.
[A.] B. (text unchanged)
[B.] C. Cleanliness and Maintenance. [The following shall be observed:]
(1) The building and all its parts and facilities shall be kept in good repair, neat, and attractive. The safety and comfort of the [patients] residents shall be the [first] primary consideration.
(2) All walls, floors, ceilings, windows, and fixtures shall be kept clean. Interior walls and floors shall be of a [character to permit] type to allow frequent and easy cleaning.
(3) The [facility] nursing home shall be kept free of unnecessary accumulations of personal possessions, boxes, trunks, suitcases, papers, unused furniture, bed clothing, linens, bric-a-brac, and similar items.
(4) Storage areas shall be:
(a) Kept clean and orderly; and
(b) Readily accessible for:
(i) Housekeeping;
(ii) Maintenance; and
(iii) Pest control servicing.
[(4)] (5) (text unchanged)
[(5)] (6) Pest Control. The [facility] nursing home shall [be]:
(a) Be maintained free of insects and rodents by operation of an active pest-control program, either by use of maintenance personnel or by contract with a pest-control company[.];
(b) [Care shall be exercised in the usage and storage of toxic] Use and store toxic and flammable insecticides and rodenticides with care [.];
(c) [Usage shall conform] Ensure that usage of toxic and flammable insecticides and rodenticides conforms to the U.S. Environmental Protection Administration and Maryland Department of Agriculture requirements[.];
[Agency Note: Refer to Regulation .26 S of this chapter for window screening requirements.]
(d) Be protected to prevent the entry and harborage of rodents and insects;
(e) Install and effectively maintain:
(i) Screen doors that fit tightly when closed;
(ii) Easily adjusted closely fitted window screens;
(iii) Rat-proofing devices; or
(iv) Other approved deterrents; and
(f) Effectively protect all openings to the outside against the entry of insects by:
(i) Closed doors;
(ii) Closed windows; or
(iii) Other means.
[C. Laundries-New Facilities. In laundries in new facilities there shall be a physical separation between the “clean” and “soil” areas. There shall be provision for the laundering of patients’ clothing. Hot water temperatures in laundries shall conform to applicable standards of the International Fabric Care Institute for laundry water supply.
D. Laundries-Existing Facilities. In existing facilities where a physical separation is not possible, exceptions as to approved laundry facilities may be made at the discretion of the Department. There shall be provision for the laundering of patients’ clothing. Hot water temperatures in laundries shall conform to applicable standards of the International Fabric Care Institute for laundry water supply.]
(7) Laundry Services.
(a) A nursing home shall provide laundry service, whether on-site or off-site.
(b) Laundry service shall be provided to meet the residents’ needs.
(c) All laundry shall be processed and handled in a manner that prevents the spread of infections. Staff working in laundry shall be given personal protective equipment, including:
(i) Disposable gloves;
(ii) Masks; and
(iii) Body coverings.
(d) All laundry shall be processed through the use of sufficiently hot water, chemical agents, or a combination of the both, to remove or destroy infectious biological materials.
(e) Clean and Soiled Areas.
(i) There shall be a physical separation between the clean and soiled areas.
(ii) The soiled area shall allow for sorting and washing soiled laundry.
(iii) The clean area shall allow for drying and folding of clean laundry.
(iv) All soiled areas within a laundry shall be connected to mechanically operated exhaust ventilation.
(f) The system provided in laundries may not allow the spread of airborne contaminants to other parts of the nursing home that are occupied by residents, staff not working in the laundry, and the general public.
(g) The plumbing fixtures for all water supply connections to washing machines and the plumbing fixtures for all utility sinks shall have an integrated atmospheric vacuum breaker or other approved back-flow prevention devices.
[.35] .58 Resident Care Management System.
A. (text unchanged)
B. The resident care management system shall [be comprised] consist of three [interrelated] related components:
(1)—(3) (text unchanged)
[.36] .59 Resident Status Assessment.
[A. Disciplines shall record all assessments on a form approved by the Department.
B. State Operations Manual for Provider Certification, Appendix R—Resident Assessment Instrument for Long-Term Care Facilities, Transmittal No. 272, April 1995 and Transmittal No. 22, December 2000, U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services, is incorporated by reference.]
[C.] A. A [facility] nursing home shall use the following forms and procedures for resident assessment as described in the [State Operations Manual for Provider Certification] CMS Manual System, Pub. 100-07 State Operations Provider Certification and in the CMS Long-term Care Facility Resident Assessment Instrument 3.0 User’s Manual:
(1) The Minimum Data Set (MDS) version as determined by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, in Transmittal No. 22, referenced in §B of this regulation.
(2) [Resident] MDS Care Area Assessment [Protocol Summary] process; and
[(3) MDS Quarterly Assessment Form;
(4) Maryland Monthly Assessment; and]
[(5)] (3) (text unchanged)
[D.] B. The [facility] nursing home shall complete all assessments in accordance with the provisions of 42 CFR [§]§483.20 [and 413.343], as amended.
[E.] C. [All facilities] A nursing home certified for participation in Medicare or Medicaid shall complete and electronically submit the assessment to the [Department not later than 31 days after completion of the assessment] Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. The assessment shall:
(1) Use a standard record layout format;
(2) Use a data dictionary as identified by the automated data processing requirements; and
(3) Pass standardized edits as defined by CMS and the State.
D. A federally certified nursing home shall:
(1) Encode assessment data as specified in the CMS Long-term Care Facility Resident Assessment Instrument 3.0 User’s Manual; and
(2) Transmit assessment data as specified in the CMS Long-term Care Facility Resident Assessment Instrument 3.0 User’s Manual except as excluded in §E of this regulation.
[F.] E. A [facility] nursing home licensed as a [comprehensive or extended care facility] nursing home but not certified for participation in the Medicare or Medicaid Program shall comply with the [State Operations Manual for Provider Certification] CMS Manual System, Pub. 100-07 State Operations Provider Certification, and with RAI instructions in the CMS Long-term Care Facility Resident Assessment Instrument 3.0 User’s Manual, except that data may not be [electronically] submitted electronically to the Department.
[.37] .60 Care Planning.
A. An interdisciplinary team shall complete or revise as necessary a [resident specific] resident-specific care plan for each resident within 7 calendar days following completion of [all] assessments, including:
(1) Admission assessment;
(2) Annual assessment;
(3) Quarterly assessment; and
(4) Significant change in the resident’s condition.
[B. A care plan under this regulation shall be based upon assessments conducted at the following times:
(1) Admission;
(2) Annual;
(3) Quarterly; and
(4) Significant change in the resident’s condition.]
[C.] B. [A facility shall give a] Care Plan Meeting. The nursing home shall, with the resident’s consent:
(1) Give an interested and appropriate family member or resident’s representative 7 calendar days advance notice, in writing, of the location, date, and time of [the] a care planning conference for a resident [for whom a family member or representative is interested.];
(2) Strive to accommodate the schedules of invited family members and resident’s representatives when scheduling care plan meetings; and
(3) [The notification shall include] Include an invitation for the family member or resident’s representative to attend the conference.
[D.] C. The [facility] nursing home shall hold the care planning conference not later than 7 calendar days after [completion of] completing the assessment, but may hold the conference [earlier] sooner if agreed to by the resident, a family member, or a resident’s representative.
[E.] D. Organization of Care Plan.
(1) [Problems] Resident’s problems and needs shall be identified, based upon the interdisciplinary assessment. The care plan shall address all of the resident’s special care requirements necessary to improve or maintain the resident’s status. The interdisciplinary team shall incorporate resident input into the care plan.
(2) The team shall establish goals for each problem or need identified, or a combination thereof. The [goal] goals shall be realistic, practical, and tailored to the resident’s needs. Goal [outcome] outcomes shall be measurable in time or degree, or both.
(3) Approaches to accomplishing each goal shall be established. Approaches shall [communicate] indicate the work to be done, [by whom it is to be done] who is to do it, and how frequently it is to be [performed] done.
[F.] E.—[G.] F. (text unchanged)
[.38] .61 [Special] Skin Record.
A. (text unchanged)
B. The staff shall document [progression] progress of the condition or conditions weekly until the condition or conditions have healed.
C. (text unchanged)
[.39] .62 Geriatric Nursing Assistant Training Program.
A. [Facility] Nursing Home Responsibilities.
(1) [Each facility] A nursing home shall conduct or arrange a [nurses’ aide] geriatric nursing assistant training program for unlicensed personnel assigned to direct [patient] resident care duties. [This requirement does not extend to physical or occupational therapy assistants or to other employees performing delegated, non-nursing functions. The facility may use an outside program if it has been reviewed and approved by the Department.] The Maryland Board of Nursing shall approve the geriatric nursing assistant training program curriculum.
[(2) Each facility shall submit a written proposal to the Department for satisfying the developmental training program requirement.]
(2) A nursing home may not employ an individual as a geriatric nursing assistant until the individual has successfully completed a competency evaluation approved by the Maryland Board of Nursing.
(3) A [nurse aide] geriatric nursing assistant is deemed to satisfy the requirements of this chapter if that individual has successfully completed a training program approved by the State before July 1, 1990, or has been “grandfathered” under previous regulations.
(4) Other persons hired as geriatric nursing assistants [nurse aides after July 1, 1990] shall complete an approved geriatric nursing assistant training program within 120 days of employment.
(5) The [facility] nursing home shall [record]:
(a) Record the satisfactory completion of the program in each employee’s personnel record[. A]; and
(b) Give the employee a certificate [evidencing] signed by the program’s teacher or trainer as evidence of completion of the program [shall be issued to the employee. The signature of the program’s teacher or trainer shall be required for authentication].
B. Course Structure.
(1) [Effective with employees hired on or after July 1, 1990, the] The geriatric nursing assistant training program [course] shall consist of 75 hours or more, and include at least 37.5 hours of classroom instruction and [not less than] at least 37.5 hours of supervised clinical experience in long-term care.
(2) The course content shall adhere to the [Geriatric Nursing Assistant Program] geriatric nursing assistant training program curriculum approved by the Maryland Board of Nursing [in Regulation .40 of this chapter].
[(3) The course instructor shall have overall supervisory responsibility for the operation of the program, and shall:
(a) Be a registered nurse licensed in Maryland;
(b) Have at least 2 years of nursing experience, at least 1 year of which shall have been in caring for the elderly or chronically ill in the past 5 years; and
(c) Have attended a program of instruction in training methodologies approved by the Department.
(4) Supplementary instructors shall be drawn from qualified resource personnel such as registered nurses, licensed practical/vocational nurses, pharmacists, dieticians, social workers, sanitarians, fire safety experts, nursing home administrators, gerontologists, psychologists, physicians, physical and occupational therapists, activities specialists, speech/language/hearing therapists, and residents’ rights experts, as well as persons with relevant experience, such as residents or experienced aides.
(5) Adequate numbers of instructors are required to ensure that each trainee is provided effective assistance and supervision which does not endanger the safety of residents.
(6) Each training program shall have behaviorally stated objectives for each unit of instruction, stating measurable performance criteria.
(7) Each trainee shall be clearly identified as a trainee during all skills training portions of the training.
(8) During training, a trainee may provide only that care for which the trainee has demonstrated competency to the satisfaction of the appropriate program instructor.
(9) An orientation program shall be provided to trainees for a nursing facility in which training is to occur. This program shall consist of:
(a) An explanation of organizational structure, policies, and procedures;
(b) Discussion of the philosophy of care;
(c) Description of the resident population; and
(d) Employee rules.
(10) The orientation may not be included in the required 75 hours of the training course.
(11) A training program shall provide at least 16 hours of training prior to a trainee’s direct assignment to resident care. This instruction shall include the following topics:
(a) Infection control;
(b) Safety and emergency procedures;
(c) Promoting residents’ independence;
(d) Respecting residents’ rights; and
(e) Communication and interpersonal skills.]
[.41] .63 Paid Feeding Assistants.
A.—B. (text unchanged)
C. A [facility] nursing home that uses a paid feeding assistant shall ensure that the paid feeding assistant feeds only residents who do not have complicated feeding conditions including, but not limited to:
(1)—(2) (text unchanged)
(3) Recurrent lung [aspirations] aspiration; or
(4) (text unchanged)
D. Protocol. The [facility] nursing home shall develop a protocol for selecting residents who are appropriate for feeding by a paid feeding assistant. The [facility] nursing home shall select [a resident] eligible residents based on the:
(1)—(3) (text unchanged)
E. State-Approved Training. A State-approved training course for paid feeding assistants shall consist of at least 8 hours of training that includes:
(1)—(8) (text unchanged)
(9) Successful completion of a two-part test that includes a:
(a) (text unchanged)
(b) Demonstration of proper feeding skills performed on a resident [under observation] while being observed.
F.—G. (text unchanged)
[.45] .64 Quality Assurance Program.
A. [By January 1, 2001, each facility] A nursing home shall establish an effective quality assurance program that includes components described in this regulation and Regulation [.46] .65 of this chapter.
B. (text unchanged)
C. The nursing [facility] nursing home shall establish a quality assurance committee that includes at least:
(1) [A] The nursing home director of nursing;
(2) [An] The nursing home administrator;
(3) (text unchanged)
(4) [A] The nursing home medical director;
(5) A [dietitian] dietitian-nutritionist; and
(6) A geriatric nursing assistant [of] at the [facility] nursing home.
D. The Quality Assurance Committee. The quality assurance committee shall:
(1) Designate [a chairperson to manage] an individual to oversee committee activities;
(2) Meet monthly to [accomplish] carry out quality assurance activities;
(3) [Assist in developing] Help develop and approve the [facility’s] nursing home’s quality assurance plan;
(4) Submit the quality assurance plan to the Department’s Office of Health Care Quality at the time of initial application for licensure or at the time of licensure renewal;
(5) Submit any [change in] changes to the quality assurance plan to the Office of Health Care Quality within 30 days of the [change] changes;
(6)—(7) (text unchanged)
E. (text unchanged)
F. Quality Assurance Committee—Non-members. Anyone not on the committee shall be informed of how to present and submit concerns to:
(1) The committee;
(2) A member of the resident council; or
(3) A member of the family council if one exists.
[.46] .65 Quality Assurance Plan.
A. The [facility’s] nursing home’s quality assurance committee shall develop and implement a quality assurance plan that includes procedures for:
(1)—(2) (text unchanged)
(3) [Patient] Resident complaints;
(4)—(5) (text unchanged)
B. Concurrent Review. The quality assurance plan shall include:
(1)—(2) (text unchanged)
(3) Procedures to take action when there is a change in the resident’s condition, including:
(a) Communicating changes to the director of nursing or the resident’s attending physician; and
(b) Changing the resident’s plan of care as necessary; and
(4) Procedure for [referral of] referring data to the quality assurance committee, when appropriate.
C. Ongoing Monitoring. The quality assurance plan shall include:
(1) A description of the measurable criteria for ongoing monitoring of all aspects of resident care including:
(a) (text unchanged)
(b) Prevention of [decubitus] pressure ulcers, dehydration, and malnutrition;
(c)—(f) (text unchanged)
(2) The methodology for [collection of] collecting data;
(3) The methodology for [evaluation] evaluating and [analysis of] analyzing data to determine trends and patterns;
(4)—(7) (text unchanged)
D. Patient Complaints. The quality assurance plan shall include:
(1) A description of a complaint process that effectively addresses resident [or] and family concerns including:
(a) The designated person or persons and their phone numbers to receive complaints [or] and concerns;
(b) (text unchanged)
(c) The time frames for investigating complaints [dependent upon], depending on the nature or seriousness of the complaint;
(2)—(3) (text unchanged)
E. Accidents and Injuries. The quality assurance plan shall include:
(1)—(2) (text unchanged)
(3) A policy statement that [includes a provision that reporting] ensures that incidents can be [done] reported without fear of reprisal;
(4) A description of how internal investigations of accidents and injuries will be handled including:
(a) (text unchanged)
(b) Interview of the resident, staff, and [witness] any witnesses;
(c)—(d) (text unchanged)
(5) A description of the process for notifying a family or guardian about the incident;
(6) A description of a process for the ongoing evaluation of patterns and trends in accidents and injuries [to determine patterns and trends]; and
(7) (text unchanged)
F. (text unchanged)
[.48] .67 Posting of Staffing.
A. A nursing home shall post a notice on each floor or unit of the nursing home, for each shift, a notice that [explains] gives the ratio of licensed and unlicensed staff to residents.
B. The posting on each floor shall include:
(1) Names of the staff members on duty and the room numbers of the residents [that] to whom each is assigned;
(2) Name of the charge nurse or person who is in charge of the unit; [and]
(3) If the person in charge is not a registered nurse, the name of the registered nurse responsible for the unit; and
[(3)] (4) (text unchanged)
C. (text unchanged)
D. A record of the posting shall be retained for 1 year.
[.49] .68 Sanctions.
A. If a deficiency exists, the Department, in addition to the sanctions set forth in this regulation and Regulations [.50—58] .69—.77 of this chapter, may:
(1)—(5) (text unchanged)
B. State Monitor.
(1) The duties of the State monitor shall be specified in a written agreement between the Department and the State monitor and shall include but are not limited to:
(a)—(b) (text unchanged)
(c) Issuing written reports to the Department and the nursing [facility] nursing home, detailing the findings of the on-site inspections and the status of [recommended actions that] requirements and recommendations for the [facility shall complete] nursing home to achieve compliance.
(2)—(4) (text unchanged)
C. (text unchanged)
D. A licensee [aggrieved by] that disagrees with the imposition of a sanction under §A(1) or (5) of this regulation may appeal the Secretary’s action by filing a request for a hearing in accordance with Regulation [.59] .78 of this chapter. A licensee [aggrieved by] that disagrees with the imposition of a sanction under §A(2) of this regulation may appeal the Secretary’s action in accordance with Health-General Article, §§19-364 and 19-367, Annotated Code of Maryland.
[.56] .75 Criminal Penalties.
A. A person maintaining or operating a nursing [facility] home without a license is guilty of a misdemeanor, and, on conviction, is liable for a fine of not more than $1,000 for the first offense and not more than $10,000 for each subsequent conviction in accordance with Health-General Article, §19-358, Annotated Code of Maryland.
B. Each day that the nursing [facility] home continues to operate without a license after the first conviction is a subsequent offense and may subject the operator to further criminal prosecution.
[B.] C. A person maintaining and operating a nursing [facility] home that is in violation of this chapter is guilty of a misdemeanor, and, on conviction, shall be fined not more than $1,000 under the authority of Health-General Article, §19-359, Annotated Code of Maryland.
D. Each day that the nursing [facility] home operates after the first conviction, without correction of the cited violation, is considered a subsequent offense and may subject the operator to further prosecution.
ROBERT R. NEALL
Secretary of Health
