[26 Pa.B. 867]
[Continued from previous Web Page]
Subchapter F. THERAPEUTIC PROGRAM Sec.
5320.51. Treatment plan. 5320.52. Review and periodic reexamination. 5320.53. Medication. 5320.54. Seclusion and restraints. § 5320.51. Treatment plan.
The interdisciplinary treatment team shall:
(1) Complete an initial assessment, on admission by the interdisciplinary team of the resident's mental, physical and social needs including a mobility assessment.
(i) Reflect the reason for the resident's admission.
(ii) Indicate what less restrictive alternatives to an LTSR were considered and why they were not utilized.
(2) Develop an initial treatment plan, within 72 hours, based on the initial assessment by the interdisciplinary team.
(3) The plan, developed with the participation of the resident or a designee, shall identify the problem areas, initial goals and objectives for the resident to meet, modalities of treatment, and responsible staff indicated in helping the resident meet their goals.
(4) Develop a comprehensive treatment plan within 10 days of admission. The plan shall:
(i) Be formulated, to the extent feasible, with the participation of the resident. With the resident's consent, designated persons could participate in the planning process.
(ii) Be based upon diagnostic evaluation of the resident's medical, psychological, social, cultural, behavioral, familial, educational, vocational and developmental strengths and needs.
(iii) Set forth measurable, time limited treatment goals and objectives and prescribe an integrated program of therapies, activities, experiences and appropriate education designed to meet these goals and objectives.
(iv) Specify the person responsible for carrying out the modalities described in the plan.
(v) Result from the collaborative recommendation of the resident's interdisciplinary treatment team.
(vi) Be easily understood by a lay person and a copy of the current treatment plan shall be available for review by the person in treatment.
(vii) Address major psychiatric, psychosocial, medical, behavioral and rehabilitative needs of the resident and the manner in which they are to be met, including those needs to be addressed by contractors who are not employed by the LTSR.
§ 5320.52. Review and periodic reexamination.
The interdisciplinary treatment team shall review treatment plans at least every 30 days or more frequently as the resident's condition changes. A report of the review and findings and the resident's progress toward meeting program goals and objectives shall be documented by the interdisciplinary team in the resident's record.
(1) The interdisciplinary treatment team shall maintain a record of each reexamination and review to include:
(i) A report of the reexamination.
(ii) A brief description of the treatment provided to the person during the period preceding the reexamination and the results of that treatment.
(iii) Continuation or revision of the individual treatment plan for the next period.
(iv) Criteria for discharge and recommendation for discharge if these criteria have been met.
(2) Changes to the treatment plan and the reasons for the changes shall be made by the interdisciplinary treatment team and recorded in the resident's record as a progress note or on another form specifically designed for that purpose.
(3) The record shall include information required by § 5100.16 (relating to review and periodic reexamination).
(4) Reassessment of each resident's mental, physical and social needs, including a mobility assessment as follows:
(i) Annually.
(ii) If the condition of the resident materially changes prior to the annual assessment.
(iii) At the request of the county administrator or the Department if there is cause to believe that an additional assessment is required.
§ 5320.53. Medication.
(a) The provider shall establish and implement written medication policies and procedures that conform to Pennsylvania law. Medication administration policies and procedures shall address:
(1) How the education of residents regarding their medication will be accomplished.
(2) How residents who need assistance with medication precribed by a physician for self-administration receive it.
(i) For residents who need assistance, the least assistance necessary should be provided within the context of a planned program toward self-administration of medication.
(ii) Assistance with self-medication including handling the medication containers or taking medication out of its container for the resident is considered medication administration and shall be done by licensed medical staff.
(3) How medications and treatments shall be administered by the licensed medical staff person who prepared the dose for administration.
(4) Documentation of the written orders provided by the attending physician for each resident receiving medication.
(5) Recording of physicians' orders in each resident's clinical record that is reviewed, renewed and signed by the physician every 30 days.
(6) Documentation of the reason a prescribed medication was not given and notice of same to the prescribing physician.
(7) The taking and recording of telephone orders by only licensed medical staff, pharmacists or other individuals authorized by law to accept a physician's telephone orders for medication.
(i) Oral orders are recorded immediately on the resident's record, dated and signed by the person receiving the order.
(ii) Oral orders are countersigned by the prescribing physician within 48 hours.
(8) Training by a physician or other licensed medical staff person that will cover, at minimum, medications used by the residents, their purposes and function, major side effects and recognition of signs that the medication is not being taken or is being misused.
(b) The circumstances under which the provider stores medication for residents shall include the following limitations:
(1) Only medications which are prescribed for self-administration or that will be administered by an individual appropriately licensed to administer medication is stored in the LTSR.
(2) Medications stored in the LTSR are kept in a locked container in a locked room.
(3) Each prescription medication ordered for a resident is kept in the original prescription container labeled by the dispensing pharmacist for the sole use of the resident.
(4) If over-the-counter drugs are maintained in the facility, they will bear the original label and the name of the resident for whom the drug is ordered.
(c) Pharmaceutical services shall include:
(1) A written quarterly review of the drug regimen of each resident by a licensed pharmacist and the findings submitted to the program director and prescribing physicians.
(2) A pharmacist or licensed medical staff annual review of the provider's medication policies and procedures including inspection of the medication storage areas. A written report of the review including inservice training recommendations, if any, is submitted to the program director.
(3) A policy developed or approved by a pharmacist that specifies the disposition of discontinued, unused, outdated or deteriorated medication.
(4) A written procedure for accessing pharmaceutical services on an emergency basis.
§ 5320.54. Seclusion and restraints.
(a) The use of seclusion is prohibited in LTSRs.
(b) The use of restraints for behavior management is prohibited in LTSRs.
(c) The use of restraints to promote body alignment, positioning and physical functioning is allowable in an LTSR only when the following conditions are met:
(1) The requirements of § 13.4 (relating to use of restraints to control involuntary movement due to organic causes or conditions).
(2) State or local standards for hospital, nursing home and residential care occupancy governing these facilities when a resident's mobility is compromised by the use of this type of restraint. See, for example, 28 Pa. Code Part IV (relating to health facilities); 34 Pa. Code Chapters 49--59, National Fire Protection Agency related to institutional occupancy (current applicable standards of Life Safety Code) and equivalent standards of cities with 1st class status; and Chapter 5300 (relating to private psychiatric hospitals).
Subchapter G. PERSONAL CARE SERVICES/RESIDENT RECORDS Sec.
5320.61. Tasks of daily living. 5320.62. Personal care. 5320.63. Resident funds. 5320.64. Resident records. 5320.65. Recordkeeping. § 5320.61. Tasks of daily living.
The direct-care staff shall provide residents with assistance and skill training in tasks of daily living as needed. These tasks include:
(1) Securing transportation.
(2) Shopping.
(3) Making and keeping appointments.
(4) Care of personal possessions.
(5) Use of the telephone.
(6) Use of interpersonal skills.
(7) Self-care skills.
(8) Use of social and leisure activities.
(9) Securing health care.
(10) Money management skills.
§ 5320.62. Personal care.
The direct-care staff shall provide residents with assistance and skill training in personal care, as needed, including the following:
(1) Bathing.
(2) Oral hygiene.
(3) Hair grooming and shampooing.
(4) Dressing and care of clothes.
(5) Shaving.
§ 5320.63. Resident funds.
The provider shall develop written policies and procedures addressing:
(1) Costs and liabilities for service according to the Letter of Agreement between the LTSR provider and the county administrator, described in § 5320.11 (relating to prerequisites to licensure) and in the resident/provider contract described in § 5320.33 (relating to resident/ provider contract; information on resident rights).
(2) Training for residents who require assistance in the management of their financial affairs.
(3) Maintenance of a separate and current individual record of financial transactions made on behalf of the resident that is available on request to the resident or the resident's designated person, if any.
(4) Financial assistance by the provider, which shall include:
(i) Written receipts and quarterly statements of transactions, deposits and expenditures made on behalf of residents as well as disbursement of funds. The provider shall obtain written acknowldgement by the resident of the receipt of funds.
(ii) Provisions for the availability to the resident of documented accounting of deposits, receipts of funds, dispersal of funds and the current balance.
(iii) Assistance with financial arrangements if a resident's accumulated cash assets (after per diem care costs) exceeds $200. The provider shall notify the resident and offer assistance in establishing an interest-bearing account in the resident's name at a local financial institution protected by the Federal Deposit Insurance Corporation, or another appropriate arrangement indicated by the resident.
(iv) Transfer of the resident's funds and possessions to the administrator or the executor of the resident's estate, together with an itemized written account upon the death of a resident. A signed receipt shall be obtained and retained by the provider.
(v) Providing the resident with an itemized written account of funds upon termination of service. A balance remaining on the resident's account with the provider shall be immediately returned to the resident.
§ 5320.64. Resident records.
(a) The provider shall maintain individual resident records which shall be reviewed by the resident or a designee and the Department or its authorized agents upon request.
(b) The provider shall retain resident records for at least 4 years after the resident has left the LTSR.
(c) The provider shall divide the resident records into two sections: a clinical and nonclinical section.
(1) The clinical section of the resident records shall, at a minimum, contain the following information:
(i) The resident's name.
(ii) The resident's gender, race and ethnicity.
(iii) The resident's birth date.
(iv) The resident's Social Security number.
(v) The name, phone number and address of the designated person to be contacted in case an emergency, illness or injury, transfer, termination of service, or death occurs to the resident or in the case of LTSR closure.
(vi) The names and telephone numbers of the resident's personal physician and dentist, if any.
(vii) The dates of entrance into the LTSR, transfers and discharges.
(viii) The most recent annual physical examination.
(ix) The principal mental health diagnosis as designated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM IV) or most recent edition available from the American Psychiatric Association, 1700 18th Street, NW, Washington, D.C. 20009. The International Classification of Diagnoses, Clinical Modification (ICD-9-CM), available from HCIA, Inc., 300 East Lombard Street, Suite 1500, Baltimore, Maryland 21202, telephone (800) 568-3282, shall be used for the purpose of classifying diseases.
(x) A copy of the resident's treatment plan and progress notes describing the treatment and rehabilitative services provided with the resident's response to those services as well as reviews and periodic reexaminations.
(xi) A copy of the written contract between the provider and the resident.
(xii) Physicians' orders for medication to be administered at the LTSR as well as other medical orders to be carried out at the LTSR, and records of medication administration.
(xiii) The initial assessment and most recent update.
(xiv) Dietary restrictions, if any.
(2) The nonclinical section of the resident records shall, at a minimum, contain the following information:
(i) An inventory of the personal property, except consumable items, which the resident brings to the LTSR.
(ii) An inventory of the resident's property entrusted to the provider for safekeeping.
(iii) The financial records of the resident receiving assistance with financial management.
(iv) The reason for the termination of services, or transfer of the resident or reason for death, as applicable, to be included as part of a discharge summary.
(v) Documentation of the resident's current commitment status.
(vi) Written authorization for admission signed by the county administrator.
§ 5320.65. Recordkeeping.
Provision of services and the resident's progress toward treatment goals shall be documented by direct-care staff completing a progress note in the resident's record at least weekly, or more often as warranted by specific changes in the resident's behavior status. Additionally, special treatment interventions ordered in the treatment plan shall be documented by the direct-care or consulting direct-care staff authorized to provide the special treatment on a monthly basis or more frequently if warranted.
Subchapter H. QUALITY IMPROVEMENT/SERVICE UTILIZATION Sec.
5320.71. Quality improvement program. 5320.72. Indicators for duration of stay. 5320.73. Ancillary support services. 5320.74. Health services. § 5320.71. Quality improvement program.
The provider shall have a written quality improvement (QI) plan and program that the program director reviews for the quality and appropriateness of services provided and monitors for compliance with standards of treatment and care. The plan shall:
(1) Specify who has responsibility for QI activities, to whom findings are reported, the frequency of reviews, what critical indicators are to be evaluated and acceptable levels for the critical indicators.
(2) Have indicators of quality care that include at least the following:
(i) The level of resident satisfaction and program input.
(ii) The level of family satisfaction and program input.
(iii) Appropriateness, completeness, timeliness and implementation of the treatment plans.
(iv) Case and trend review of crisis events and unusual situations.
(v) Direct-care staff performance.
(vi) Clinical case or peer reviews, quarterly or more often as indicated.
(vii) Medications management, including errors and adverse effects.
(viii) The appropriate documentation in the resident's record.
(3) Include the names of the individuals who participated in the quality improvement activities and plans of correction.
§ 5320.72. Indicators for duration of stay.
Decisions which determine the duration of stay shall take into account:
(1) The resident's needs, therapeutic requirements and recommendations of the interdisciplinary treatment team.
(2) The commitment status of the resident.
(3) Measurable indicators established by the provider that address expectations in the following areas in determining resident duration of stay.
(i) Resident and program outcomes.
(ii) Stability of the resident's psychiatric condition.
(iii) Stability of the resident's medication regime.
(iv) The length of time without the need for acute psychiatric interventions.
(v) The attainment of treatment goals.
(vi) Successful trial leaves.
(vii) The establishment of a support system.
(viii) A plan for continuity of care.
§ 5320.73. Ancillary support services.
The provider shall either directly or through arrangement, provide services needed by the residents. To provide services that are not available at the LTSR, the provider shall:
(1) Collaborate with the county administrator's office case management services, and other programs to provide services as identified by the treatment plan and to ensure continuity of care.
(2) Ensure that transportation is available for residents who must be transported for services, recreation and other activities.
§ 5320.74. Health services.
The LTSR provider shall:
(1) Develop written arrangements for providing routine and emergency medical and dental care for residents.
(2) Notify the resident's designated person and the county administrator or a designee who shall ensure whatever assistance is necessary in making arrangements for the resident's transfer to an appropriate facility. A physician shall determine if the resident's physical condition indicates the need for a transfer to a hospital, nursing home or rehabilitation center.
(3) Have first aid supplies available and adhere to current Centers for Disease Control and the Department of Health's recommendations for universal precautions in the administration of first aid and CPR.
Subchapter I. BUILDING, FIRE PROTECTION, FURNISHINGS AND MAINTENANCE Sec.
5320.81. Building, physical plant and grounds. 5320.82. Fire protection and safety. 5320.83. Living/sleeping quarters. 5320.84. Furnishings and equipment. 5320.85. Housekeeping and maintenance. 5320.86. Laundry service. § 5320.81. Building, physical plant and grounds.
(a) An LTSR may not house more than 16 residents. One provider who had been licensed/approved to operate an LTSR with bed capacity in excess of 16 prior to January 1, 1993, is exempt from this provision.
(b) An LTSR shall have the capacity to allow locks on entrances and exits to preclude elopement of involuntarily committed individuals and to prevent unauthorized entrance. Physical attributes of the facility that are intended to maintain necessary levels of protection shall be as unobtrustive as possible to maintain a home-like environment.
(c) The LTSR shall have an adequate supply of hot and cold water piped to each wash basin, bathtub/shower, kitchen sink, commercial dishwasher, and to laundry equipment. Hot water accessible to residents may not exceed 130°F at the outlets.
(d) Heating in rooms used by residents shall be maintained at a temperature of not less than 65°F or, when there are residents 65 years of age and older, not less than 70°F.
(e) Portable space heaters are prohibited. Space heaters shall be adequately vented and installed with permanent connections and protectors.
(f) Steam heat radiators and pipes in rooms and areas used by residents and within reach of residents shall be covered.
(g) Fireplaces shall be securely screened when in use.
§ 5320.82. Fire protection and safety.
(a) The program director shall arrange for the local fire department or another outside safety consultant to inspect and approve each LTSR site for fire safety and to determine the number, location and type of fire extinguishers and smoke detectors required. This fire safety inspection shall be done before initial occupancy and repeated at least every 2 years thereafter. Inspections shall be documented.
(b) Emergency telephone numbers for the fire department, local police and on-call direct care staff shall be posted at each telephone in the LTSR.
(c) The staff shall be instructed in the operation of the fire extinguishers.
(d) Residents may be permitted to smoke only in designated areas. Proper safeguards shall be taken against the fire hazards involved in smoking, such as providing ash trays.
(e) Fire drills at each LTSR site shall be documented and held at least every 2 months; night time drills shall be conducted semiannually.
§ 5320.83. Living/sleeping quarters.
(a) No more than two residents may be housed in any room regardless of its size.
(b) A single occupancy room shall have at least 80 square feet of floor space. Bedrooms for two persons shall have at least 60 square feet of floor space per person and have sufficient floor space to accommodate the items required in § 5320.84 (relating to furnishings and equipment). If a bedroom has a built-in closet, up to 9 square feet per closet may be counted in calculating the square footage of floor space. Bedrooms for one or more immobile residents may require additional square footage sufficient to accommodate the special needs of the resident, such as a wheelchair or special furniture or equipment.
(c) Bedroom windows shall have curtains, shades or blinds that cover the entire window when drawn.
(d) Residents shall have direct access to bathrooms, kitchens and other living areas without having to pass through the bedroom of another resident.
(e) Residents who are immobile shall be given bedrooms on the ground floor closest to the exit.
(f) Bunk beds or other raised beds of any type which require a resident to climb steps or ladders to get into or out of bed may not be used.
(g) Resident bedrooms are reserved for use by their occupants; they may not be used as common rooms for group activities.
(h) There shall be one tub or shower for every six or fewer residents. Each LTSR shall have at least one bathtub.
(i) Bathrooms shall be equipped with soap, toilet paper and sanitary towels or a hand blow dryer. Rack space shall be provided in the bathroom for personal towels. The use of common towels is prohibited.
(j) Toilet and bath areas shall have grab bars, hand rails and assist bars as needed. Tubs and showers shall have nonslip surfaces. Multiple toilets, bathtubs or showers in the same room shall be enclosed to provide privacy.
(k) Residents shall have the use of recreation or lounge areas which, in combination, shall be large enough to accommodate all residents at once. Lounge areas shall be equipped with adequate and appropriate seating, lighting sufficient for reading and tables. A working television and radio shall be available in at least one lounge area. The LTSR provider shall provide reading and recreational materials for residents.
§ 5320.84. Furnishings and equipment.
(a) Each resident's bedroom or bed area shall be equipped with the following items, which shall be clean and maintained in good repair:
(1) A single or double bed with a mattress and firm box spring.
(2) A bed pillow.
(3) Bed linens and blankets.
(4) Towels and wash cloths.
(5) A chair.
(6) A bedside table or shelf.
(7) A bedside lamp.
(8) A towel bar.
(9) A dresser and mirror.
(10) A clothes closet or wardrobe.
(b) In two-bed bedrooms, items listed in subsection (a)(9) and (10) may be shared by two residents.
(c) The resident may furnish some or all of the items listed in subsection (a) and other personal possessions such as radios and televisions as space permits, unless the possession constitutes a hazard or interferes with the rights of other residents. Residents should be encouraged to personalize their bedrooms. LTSR house restrictions on the amount or type of personal furnishings permitted should be stipulated in the resident/provider contract.
(d) Space for storage of personal property, such as trunks, suitcases and seasonal clothing, shall be provided in a dry, protected area.
§ 5320.85. Housekeeping and maintenance.
(a) Furniture shall be arranged to provide for the safety and comfort of the residents and to permit quiet privacy zones and areas that foster social interactions.
(b) Furnishings and housekeeping shall be maintained so that the LTSR is comfortable, ''home-like'' and clean.
(c) Residents shall be encouraged to keep their bedrooms neat and tidy and to assist with cleanup of program areas after group or individual activities. The LTSR shall provide basic housekeeping, cleaning and maintenance of the physical plant.
(d) The LTSR shall be free of hazards, such as loose or broken window glass, loose or cracked floors and floor coverings, and cracked or loose plaster on walls or ceilings.
(e) Interior and exterior stairways shall have securely fastened handrails and nonskid surfaces. If present, stair coverings shall also be securely fastened.
(f) Exterior doors and windows opened for ventilation shall be screened.
(g) Appropriate vector control measures shall be used to keep the LTSR free from insects, rodents and other pests.
§ 5320.86. Laundry service.
Laundry service for bed linens, towels and personal clothing shall be provided unless otherwise indicated in the resident/provider contract, and shall meet the following requirements:
(1) The supply of linen shall be sufficient to ensure a complete bed linen change at least once per week.
(2) Clean linens shall be stored in an area separate from soiled linen and clothing. Soiled articles shall be kept in covered containers.
(3) The provider shall take measures to ensure that the resident's clothing is not lost or misplaced in the process of laundering.
(4) A washer and dryer shall be provided for resident use. Residents shall be encouraged and trained in their use to care for personal clothes.
Subchapter J. FOOD SERVICE Sec.
5320.91. Food service. § 5320.91. Food service.
(a) Residents shall be provided with at least three well-balanced, nutritious meals daily. Snacks shall also be available.
(b) When a resident unavoidably misses a scheduled meal, the provider shall ensure that a substitute meal is provided to the resident.
(c) Special diets, dietary restrictions and supplements that are prescribed by the resident's physician shall be accommodated by the LTSR.
(d) Enough flexibility shall be built into mealtimes to accommodate the regular schedules of individual residents.
(e) The week's menu shall be prepared at least 7 days in advance. The current week's menu shall be posted in a resident accessible location.
(f) Meals shall be provided to residents in a dining room or dining area, except that service in the resident's room shall be available when clinically indicated.
(g) The dining area shall be furnished with sufficient tables and chairs to accommodate all residents at one sitting.
(h) Utensils used to prepare and serve food and beverages shall be free from chips and cracks.
(i) Food stored, prepared or served by the LTSR shall be clean and safe for human consumption and meet applicable Federal standards.
(j) Food returned from individual plates may not be reused or reserved.
(k) Refrigerators shall be maintained below 45°F.
Subchapter K. WAIVER OF STANDARDS Sec.
5320.101. Waiver of standards. § 5320.101. Waiver of standards.
It is the policy of the Department that the licensees comply with applicable Departmental regulations to assure quality of care. The Department may, within its discretion and for good reason, grant waivers to specific requirements contained in this chapter. A waiver will be granted only when the health, safety and welfare of the residents and the quality of services provided to residents are not affected. The Department reserves the right to revoke a waiver if the conditions required by the waiver are not met.
[Pa.B. Doc. No. 96-287. Filed for public inspection March 1, 1996, 9:00 a.m.]
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