[40 Pa.B. 4073]
[Saturday, July 17, 2010]
[Continued from previous Web Page] § 2800.190. Medication administration training.
(a) A staff person who has successfully completed a Department-approved medications administration course that includes the passing of the Department's performance-based competency test within the past 2 years may administer oral; topical; eye, nose and ear drop prescription medications and epinephrine injections for insect bites or other allergies.
(b) A staff person is permitted to administer insulin injections following successful completion of a Department-approved medications administration course that includes the passing of a written performance-based competency test within the past 2 years, as well as successful completion of a Department-approved diabetes patient education program within the past 12 months.
(c) A record of the training shall be kept including the staff person trained, the date, source, name of trainer and documentation that the course was successfully completed.
§ 2800.191. Resident education.
The residence shall educate the resident of the right to question or refuse a medication if the resident believes there may be a medication error. Documentation of this resident education shall be kept.
SAFE MANAGEMENT TECHNIQUES § 2800.201. Safe management techniques.
The residence shall use positive interventions to modify or eliminate a behavior that endangers the resident himself or others. Positive interventions include improving communications, reinforcing appropriate behavior, redirection, conflict resolution, violence prevention, praise, deescalation techniques and alternative techniques or methods to identify and defuse potential emergency situations.
§ 2800.202. Prohibitions.
The following procedures are prohibited:
(1) Seclusion, defined as involuntary confinement of a resident in a room or living unit from which the resident is physically prevented from leaving, is prohibited. This does not include the admission of a resident in a secured dementia care unit in accordance with § 2800.231 (relating to admission).
(2) Aversive conditioning, defined as the application of startling, painful or noxious stimuli, is prohibited.
(3) Pressure point techniques, defined as the application of pain for the purpose of achieving compliance, is prohibited.
(4) A chemical restraint, defined as use of drugs or chemicals for the specific and exclusive purpose of controlling acute or episodic aggressive behavior, is prohibited. A chemical restraint does not include a drug ordered by a physician or dentist to treat the symptoms of a specific mental, emotional or behavioral condition, or as pretreatment prior to a medical or dental examination or treatment.
(5) A mechanical restraint, defined as a device that restricts the movement or function of a resident or portion of a resident's body, is prohibited. Mechanical restraints include geriatric chairs, handcuffs, anklets, wristlets, camisoles, helmet with fasteners, muffs and mitts with fasteners, poseys, waist straps, head straps, papoose boards, restraining sheets, chest restraints and other types of locked restraints. A mechanical restraint does not include a device used to provide support for the achievement of functional body position or proper balance that has been prescribed by a medical professional as long as the resident can easily remove the device or the resident or his designee understands the need for the device and consents to its use.
(6) A manual restraint, defined as a hands-on physical means that restricts, immobilizes or reduces a resident's ability to move his arms, legs, head or other body parts freely, is prohibited. A manual restraint does not include prompting, escorting or guiding a resident to assist in the ADLs or IADLs.
§ 2800.203. Bedside rails.
(a) Bedside rails may not be used unless the resident can raise and lower the rails on his own. Bedside rails may not be used to keep a resident in bed. Use of any length rail longer than half the length of the bed is considered a restraint and is prohibited. Use of more than one rail on the same side of the bed is not permitted.
(b) Half-length rails are permitted only if the following conditions are met:
(1) The resident's assessment or support plan, or both, addresses the medical symptoms necessitating the use of half-length rails and the health and safety protection necessary in order to safely use half-length rails.
(2) The residence has attempted to use less restrictive alternatives.
(3) The resident or legal representative consented to the use of half-length rails after the risk, benefits and alternatives were explained.
SERVICES § 2800.220. Service provision.
(a) Services. The residence shall provide assisted living services as specified in subsection (b). The residence shall offer and provide the core service packages specified in subsection (c). The residence shall provide or arrange for the provision of supplemental health care services as specified in subsection (e). Other individuals or agencies may furnish services directly or under arrangements with the residence in accordance with a mutually agreed upon charge or fee between the residence, resident and other individual or agency. These other services shall be supplemental to the assisted living services provided by the residence and do not supplant them.
(b) Assisted living services. The residence shall, at a minimum, provide the following services:
(1) Nutritious meals and snacks in accordance with §§ 2800.161 and 2800.162 (relating to nutritional adequacy; and meals).
(2) Laundry services in accordance with § 2800.105 (relating to laundry).
(3) A daily program of social and recreational activities in accordance with § 2800.221 (relating to activities program).
(4) Assistance with performing ADLs and IADLs in accordance with §§ 2800.23 and 2800.24 (relating to activities; and personal hygiene).
(5) Assistance with self-administration of medication or medication administration as indicated in the resident's assessment and support plan in accordance with §§ 2800.181 and 2800.182 (relating to self-administration; and medication administration).
(6) Housekeeping services essential for the health, safety and comfort of the resident based upon the resident's needs and preferences.
(7) Transportation in accordance with § 2800.171 (relating to transportation).
(8) Financial management in accordance with § 2800.20 (relating to financial management).
(9) 24-hour supervision, monitoring and emergency response.
(10) Activities and socialization.
(11) Basic cognitive support services as defined in § 2800.4 (relating to definitions).
(c) Core service packages. The residence shall, at a minimum, provide the following core service packages:
(1) Independent Core Package. This core package shall be provided to residents who do not require assistance with ADLs. The services must include the following:
(i) 24-hour supervision, monitoring and emergency response.
(ii) Nutritious meals and snacks in accordance with §§ 2800.161 and 2800.162.
(iii) Housekeeping services essential for the health, safety and comfort of the resident based upon the resident's needs and preferences.
(iv) Laundry services in accordance with § 2800.105.
(v) Assistance with unanticipated ADLs for a defined recovery period.
(vi) A daily program of social and recreational activities in accordance with § 2800.221.
(vii) Basic cognitive support services as defined in § 2800.4.
(2) Enhanced Core Package. This core package shall be available to residents who require assistance with ADLs. The services must include the following:
(i) The services provided in the basic core package under paragraph (c)(1)(i)—(vii).
(ii) Assistance with ADLs and unanticipated ADLs for an undefined period of time.
(iii) Transportation in accordance with § 2800.171.
(iv) Assistance with self-administration of medication or medication administration as indicated in the resident's assessment and support plan in accordance with §§ 2800.181 and 2800.182.
(d) Opt-out. If a resident wishes not to have the residence provide a service under subsection (c)(1)(ii)—(iv), the resident-residence contract must state the following:
(1) The service not being provided.
(2) The corresponding fee schedule charge adjustment that takes into account the reduction in service.
(e) Supplemental health care services. The residence shall provide or arrange for the provision of supplemental health care services, including, but not limited to, the following:
(1) Hospice services.
(2) Occupational therapy.
(3) Skilled nursing services.
(4) Physical therapy.
(5) Behavioral health services.
(6) Home health services.
(7) Escort service if indicated in the resident's support plan or requested by the resident to and from medical appointments.
(8) Specialized cognitive support services as defined in § 2800.4.
§ 2800.221. Activities program.
(a) The residence shall develop a program of daily activities designed to promote each resident's active involvement with other residents, the resident's family and the community and provide the necessary space and equipment for the activities in accordance with §§ 2800.98 and 2800.99 (relating to indoor activity space; and recreation space). The residence shall offer the opportunity for the residents' active participation in the development of the daily activities calendar.
(b) The program must be based upon individual and group interests and provide social, physical, intellectual and recreational activities in a planned, coordinated and structured manner and shall encourage active participation in the community at large.
(c) The week's daily activity calendar shall be posted in advance in a conspicuous and public place in the residence. The residence shall provide verbal cueing and reminders of activities, their start times and locations within the residence.
§ 2800.222. Community social services.
Residents shall be encouraged and assisted in the access to and use of social services in the community which may benefit the resident, including a county mental health and mental retardation program, a drug and alcohol program, a senior citizens center, an area agency on aging or a home health care agency.
§ 2800.223. Description of services.
(a) The residence shall have a current written description of services and activities that the residence provides including the following:
(1) The scope and general description of the services and activities that the residence provides.
(2) The criteria for admission and discharge.
(3) Specific services that the residence does not provide, but will arrange or coordinate.
(b) The residence shall develop written procedures for the delivery and management of services from admission to discharge.
§ 2800.224. Initial assessment and preliminary support plan.
(a) Initial assessment.
(1) The administrator, administrator designee, or LPN, under the supervision of an RN, or an RN shall complete the initial assessment.
(2) An individual shall have a written initial assessment that is documented on the Department's assessment form within 30 days prior to admission unless one of the conditions contained in paragraph (3) apply.
(3) A resident shall have a written initial assessment that is documented on the Department's assessment form within 15 days after admission if one of the following conditions applies:
(i) The resident is being admitted directly to the residence from an acute care hospital.
(ii) The resident is being admitted to escape from an abusive situation.
(iii) The resident has no alternative living arrangement.
(4) A residence may use its own assessment form if it includes the same information as the Department's assessment form.
(5) The written initial assessment must, at a minimum include the following:
(i) The individual's need for assistance with ADLs and IADLs.
(ii) The mobility needs of the individual.
(iii) The ability of the individual to self-administer medication.
(iv) The individual's medical history, medical conditions, and current medical status and how they impact or interact with the individual's service needs.
(v) The individual's need for supplemental health care services.
(vi) The individual's need for special diet or meal requirements.
(vii) The individual's ability to safely operate key-locking devices.
(viii) The individual's ability to evacuate from the residence.
(b) An initial assessment will not be required to commence supplemental health care services to a resident of a residence under any of the following circumstances:
(1) If the resident was not receiving the services at the time of the resident's admission.
(2) To transfer a resident from a portion of a residence that does not provide supplemental health care services to a portion of the residence that provides such service.
(3) To transfer a resident from a personal care home to a residence licensed by the same operator.
(c) Preliminary support plan.
(1) An individual requiring services shall have a written preliminary support plan developed within 30 days prior to admission to the residence unless one of the conditions contained in paragraph (2) applies.
(2) A resident requiring services shall have a written preliminary support plan developed within 15 days after admission if one of the following conditions applies:
(i) The resident is being admitted directly to the residence from an acute care hospital.
(ii) The resident is being admitted to escape from an abusive situation.
(iii) Any other situation where the resident has no alternative living arrangement.
(3) The written preliminary support plan must document the dietary, medical, dental, vision, hearing, mental health or other behavioral care services that will be made available to the individual, or referrals for the individual to outside services if the individual's physician, physician's assistant or certified registered nurse practitioner, determine the necessity of these services. This requirement does not require a residence to pay for the cost of these medical and behavioral care services. The preliminary support plan must document the assisted living services and supplemental health care services, if applicable, that will be provided to the individual.
(4) The preliminary support plan shall be documented on the Department's support plan form.
(5) A residence may use its own support plan form it if includes the same information as the Department's support plan form. An LPN, under the supervision of an RN, or an RN shall review and approve the preliminary support plan.
(6) An individual's preliminary support plan must document the ability of the individual to self-administer medications or the need for medication reminders or medication administration and the ability of the resident to safely operate key-locking devices.
(7) An individual shall be encouraged to participate in the development of the preliminary support plan. An individual may include a designated person or family member in making decisions about services.
(8) Individuals who participate in the development of the preliminary support plan shall sign and date the preliminary support plan.
(9) If an individual or designated person is unable or chooses not to sign the preliminary support plan, a notation of inability or refusal to sign shall be documented.
(10) The residence shall give a copy of the preliminary support plan to the resident and the resident's designated person.
§ 2800.225. Additional assessments.
(a) The administrator or administrator designee, or an LPN, under the supervision of an RN, or an RN shall complete additional written assessments for each resident. A residence may use its own assessment form if it includes the same information as the Department's assessment form. Additional written assessments shall be completed as follows:
(1) Annually.
(2) If the condition of the resident significantly changes prior to the annual assessment.
(3) At the request of the Department upon cause to believe that an update is required.
(b) The assessment must, at a minimum include the following:
(1) The resident's need for assistance with ADLs and IADLs.
(2) The mobility needs of the resident.
(3) The ability of the resident to self-administer medication.
(4) The resident's medical history, medical conditions, and current medical status and how these impact or interact with the individual's service needs.
(5) The resident's need for supplemental health care services.
(6) The resident's need for special diet or meal requirements.
(7) The resident's ability to safely operate key-locking devices.
§ 2800.226. Mobility criteria.
(a) The resident shall be assessed for mobility needs as part of the resident's assessment.
(b) If a resident is determined to have mobility needs as part of the resident's initial or annual assessment, specific requirements relating to the care, health and safety of the resident shall be met immediately.
(c) The administrator or the administrator designee shall notify the Department within 30 days after a resident with mobility needs is admitted to the residence and compile a monthly list of when a resident develops mobility needs.
§ 2800.227. Development of the final support plan.
(a) Each resident requiring services shall have a written final support plan developed and implemented within 30 days after admission to the residence. The final support plan shall be documented on the Department's support plan form.
(b) A residence may use its own support plan form if it includes the same information as the Department's support plan form. An LPN, under the supervision of an RN, shall review and approve the final support plan.
(c) The final support plan shall be revised within 30 days upon completion of the annual assessment or upon changes in the resident's needs as indicated on the current assessment. The residence shall review each resident's final support plan on a quarterly basis and modify as necessary to meet the resident's needs.
(d) Each residence shall document in the resident's final support plan the dietary, medical, dental, vision, hearing, mental health or other behavioral care services that will be made available to the resident, or referrals for the resident to outside services if the resident's physician, physician's assistant or certified registered nurse practitioner, determine the necessity of these services. This requirement does not require a residence to pay for the cost of these medical and behavioral care services. The final support plan must document the assisted living services and supplemental health care services, if applicable, that will be provided to the resident.
(e) The resident's final support plan must document the ability of the resident to self-administer medications or the need for medication reminders or medication administration and the ability of the resident to safely operate key-locking devices. Strategies that promote interactive communication on the part of and between direct care staff and individual residents shall also be included in the final support plan.
(f) A resident shall be encouraged to participate in the development and implementation of the final support plan. A resident may include a designated person or family member in making decisions about services.
(g) Individuals who participate in the development of the final support plan shall sign and date the support plan.
(h) If a resident or designated person is unable or chooses not to sign the final support plan, a notation of inability or refusal to sign shall be documented.
(i) The final support plan shall be accessible by direct care staff persons at all times.
(j) A resident or a designated person has a right to request the review and modification of his support plan.
(k) The residence shall give a copy of the final support plan to the resident and the resident's designated person. The final support plan shall be attached to or incorporated into and serve as part of the resident-residence contract.
§ 2800.228. Transfer and discharge.
(a) The facility shall ensure that a transfer or discharge is safe and orderly and that the transfer or discharge is appropriate to meet the resident's needs. This includes ensuring that a resident is transferred or discharged with all his medications, durable medical equipment and personal property. The residence shall permit the resident to participate in the decision relating to the relocation.
(b) If the residence initiates a transfer or discharge of a resident, or if the legal entity chooses to close the residence, the residence shall provide a 30-day advance written notice to the resident, the resident's family or designated person and the referral agent citing the reasons for the transfer or discharge. This shall be stipulated in the resident-residence contract.
(1) The 30-day advance written notice must be written in language in which the resident understands, or performed in American Sign Language or presented orally in a language the resident understands if the resident does not speak standard English. The notice must include the following:
(i) The specific reason for the transfer or discharge.
(ii) The effective date of the transfer or discharge.
(iii) The location to which the resident will be transferred or discharged.
(iv) An explanation of the measures the resident or the resident's designated person can take if they disagree with the residence decision to transfer or discharge which includes the name, mailing address, and telephone number of the State and local long-term care ombudsman.
(v) The resident's transfer or discharge rights, as applicable.
(2) Prior to initiating a transfer or discharge of a resident, the residence shall make reasonable accommodation for aging in place that may include services from outside providers. The residence shall demonstrate through support plan modification and documentation the attempts to resolve the reason for the transfer or discharge. Supplemental services may be provided by the resident's family, residence staff or private duty staff as agreed to by the resident and the residence. This shall be stipulated in the resident-residence contract.
(3) Practicable notice, rather than a 30-day advance written notice is required if a delay in transfer or discharge would jeopardize the health, safety or well-being of the resident or others in the residence, as certified by a physician or the Department. This may occur when the resident needs psychiatric services or is abused in the residence, or the Department initiates closure of the residence.
(c) A residence shall give the Department written notice of its intent to close the residence, at least 60 days prior to the anticipated date of closing.
(d) A residence may not require a resident to leave the residence prior to 30 days following the resident's receipt of a written notice from the residence regarding the intended closure of the residence, except when the Department determines that removal of the resident at an earlier time is necessary for the protection of the health, safety and well-being of the resident.
(e) The date and reason for the transfer or discharge, and the destination of the resident, if known, shall be recorded in the resident record and tracked in a transfer and discharge tracking chart that the residence shall maintain and make available to the Department.
(f) If the legal entity chooses to voluntarily close the residence or if the Department has initiated legal action to close the residence, the Department working in conjunction with appropriate local authorities, will offer relocation assistance to the residents. Except in the case of an emergency, each resident may participate in planning the transfer, and shall have the right to choose among the available alternatives after an opportunity to visit the alternative residences. These procedures apply even if the resident is placed in a temporary living situation.
(g) Within 30 days of the residence's closure, the legal entity shall return the license to the Department.
(h) The only grounds for transfer or discharge of a resident from a residence are for the following conditions:
(1) If a resident is a danger to himself or others and the behavior cannot be managed through interventions, services planning or informed consent agreements.
(2) If the legal entity chooses to voluntarily close the residence, or a portion of the residence.
(3) If a residence determines that a resident's functional level has advanced or declined so that the resident's needs cannot be met in the residence under § 2800.229 (relating to excludable conditions; exceptions) or within the scope of licensure for a residence. In that case, the residence shall notify the resident and the resident's designated person. The residence shall provide justification for the residence's determination that the needs of the resident cannot be met. In the event that there is no disagreement related to the transfer or discharge, a plan for other placement shall be made as soon as possible by the administrator in conjunction with the resident and the resident's designated person, if any. If assistance with relocation is needed, the administrator shall contact appropriate local agencies, such as the area agency on aging, county mental health/mental retardation program or drug and alcohol program, for assistance. The administrator shall also contact the Department.
(4) If meeting the resident's needs would require a fundamental alteration in the residence's program or building site, or would create an undue financial or programmatic burden on the residence.
(5) If the resident has failed to pay after reasonable documented efforts by the residence to obtain payment.
(6) If closure of the residence is initiated by the Department.
(7) Documented, repeated violation of the residence rules.
(8) A court has ordered the transfer or discharge.
(i) If grounds for transfer or discharge is based upon subsection (h)(1) or (3), a certification from one of the following individuals shall be required to certify in writing that the resident can no longer be retained in the residence:
(1) The administrator acting in consultation with supplemental health care providers.
(2) The resident's physician or certified registered nurse practitioner.
(3) The medical director of the residence.
§ 2800.229. Excludable conditions; exceptions.
(a) Excludable conditions. Except as provided in subsection (b), a residence may not admit, retain or serve an individual with any of the following conditions or health care needs:
(1) Ventilator dependency.
(2) Stage III and IV decubiti and vascular ulcers that are not in a healing stage.
(3) Continuous intravenous fluids.
(4) Reportable infectious diseases, such as tuberculosis, in a communicable state that requires isolation of the individual or requires special precautions by a caretaker to prevent transmission of the disease unless the Department of Health directs that isolation be established within the residence.
(5) Nasogastric tubes.
(6) Physical restraints.
(7) Continuous skilled nursing care 24 hours a day.
(b) Exception. The residence may submit a written request to the Department on a form provided by the Department for an exception related to any of the conditions or health care needs listed in subsection (a) or (e) to allow the residence to admit, retain or serve an individual with one of those conditions or health care needs, unless a determination is unnecessary as set forth in subsection (e).
(c) Submission, review and determination of an exception request.
(1) The administrator of the residence shall submit the exception request. The exception request must be signed and affirmed by an individual listed in subsection (d) and accompanied by a support plan which includes the residence accommodations for treating the excludable condition requiring the exception request. Proposed accommodations must conform with the provisions contained within the resident-residence contract.
(2) The Department will review the exception request in consultation with a certified registered nurse practitioner or a physician, with experience caring for the elderly and disabled in long-term living settings.
(3) The Department will respond to the exception request in writing within 5 business days of receipt.
(4) The Department may approve the exception request if the following conditions are met:
(i) The exception request is desired by the resident or applicant.
(ii) The resident or applicant will benefit from the approval of the exception request.
(iii) The residence demonstrates to the Department's satisfaction that the residence has the staff, skills and expertise necessary to care for the resident's needs related to the excludable condition.
(iv) The residence demonstrates to the Department's satisfaction that any necessary supplemental health care provider has the staff, skills and expertise necessary to care for the resident's needs related to the excludable condition.
(v) The residence provides a written alternate care plan that ensures the availability of staff with the skills and expertise necessary to care for the resident's needs related to the excludable condition in the event the supplemental health care provider is unavailable.
(5) The Department will render decisions on exception requests on a case-by-case basis and not provide for facility-wide exceptions.
(d) Certification providers. The following persons may certify that an individual with an excludable condition may not be admitted or retained in a residence:
(1) The administrator acting in consultation with supplemental health care providers.
(2) The individual's physician or certified registered nurse practitioner.
(3) The medical director of the residence.
(e) Departmental exceptions. A residence may admit, retain or serve an individual for whom a determination is made by the Department, upon the written request of the residence, that the individual's specific health care needs can be met by a provider of assisted living services or within a residence, including an individual requiring:
(1) Gastric tubes, except that a determination will not be required if the individual is capable of self-care of the gastric tube or a licensed health care professional or other qualified individual cares for the gastric tube.
(2) Tracheostomy, except that a determination will not be required if the individual is independently capable of self-care of the tracheostomy.
(3) Skilled nursing care 24 hours a day, except that a determination will not be required if the skilled nursing care is provided on a temporary or intermittent basis.
(4) A sliding scale insulin administration, except that a determination will not be required if the individual is capable of self-administration or a licensed health care professional or other qualified individual administers the insulin.
(5) Intermittent intravenous therapy, except that a determination will not be required if a licensed health care professional manages the therapy.
(6) Insertions, sterile irrigation and replacement of a catheter, except that a determination will not be required for routine maintenance of a urinary catheter, if the individual is capable of self-administration or a licensed health care professional administers the catheter.
(7) Oxygen, except that a determination will not be required if the individual is capable of self-administration or a licensed health care professional or other qualified individual administers the oxygen.
(8) Inhalation therapy, except that a determination will not be required if the individual is capable of self-administration or a licensed health care professional or other qualified individual administers the therapy.
(9) Other types of supplemental health care services that the administrator, acting in consultation with supplemental health care providers, determines can be provided in a safe and effective manner by the residence.
(10) For purposes of paragraphs (1), (4), (7) and (8), a ''qualified individual'' means an individual who has been determined by a certification provider listed under subsection (d) to be capable of care or administration under paragraphs (1), (4), (7) and (8).
(f) Request for exception by resident. Nothing herein prevents an individual seeking admission to a residence or a resident from requesting that the residence apply for an exception from the Department for a condition listed in this section for which an exception must be granted by the Department. The residence's determination on whether or not to seek such an exception shall be documented on a form supplied by the Department.
(g) Record. A written record of the exception request, the supporting documentation to justify the exception request and the determination related to the exception request shall be kept in the records of the residence. The information required by this subsection shall also be kept in the resident's record.
(h) Decisions. The residence shall record the following decisions made on the basis of this section.
(1) Admission denials.
(2) Transfer or discharge decisions that are made on the basis of this section.
SPECIAL CARE UNITS § 2800.231. Admission.
(a) Special care units. This section and §§ 2800.232—2800.239 apply to special care units. These provisions are in addition to the other provisions of this chapter. A special care unit is a residence or portion of a residence that provides one or both of the following:
(1) Specialized care and services for residents with Alzheimer's disease or dementia in the least restrictive manner consistent with the resident's support plan to ensure the safety of the resident and others in the residence while maintaining the resident's ability to age in place.
(i) Admission of a resident shall be in consultation with the resident's family or designated person.
(ii) Prior to admission other service options that may be available to a resident shall be considered.
(2) Intense neurobehavioral rehabilitation for residents with severely disruptive and potentially dangerous behaviors as a result of brain injury in the least restrictive manner consistent with the resident's rehabilitation and support plan to ensure the safety of the resident and others in the residence.
(i) Each resident of a special care unit for INRBI shall have a rehabilitation and support plan that supports independence and promotes recovery and thereby discharge to a less restrictive setting.
(ii) Special care units for INRBI shall provide for each resident to age in place.
(iii) Admission of a resident shall be in consultation with the resident or potential resident and, when appropriate, the resident's designated person or the resident's family, or both.
(iv) Prior to admission other less restrictive service options that may be available to a resident or potential resident shall be considered.
(b) Medical evaluation. A resident or potential resident shall have a medical evaluation by a physician, physician's assistant or certified registered nurse practitioner, documented on a form provided by the Department, within 60 days prior to admission.
(1) Documentation for a special care unit for residents with Alzheimer's disease or dementia must include the resident's diagnosis of Alzheimer's disease or dementia and the need for the resident to be served in a special care unit.
(2) Documentation for a special care unit for INRBI must include the resident's or potential resident's diagnosis of brain injury and need for residential services to be provided in a special care unit for INRBI. The evaluation must include visual function, hearing, swallowing, mobility and hand function.
(c) Preadmission screening.
(1) Special care unit for residents with Alzheimer's disease or dementia.
(i) A written cognitive preadmission screening completed in collaboration with a physician or a geriatric assessment team and documented on the Department's cognitive preadmission screening form shall be completed for each resident within 72 hours prior to admission to a special care unit.
(ii) A geriatric assessment team is a group of multidisciplinary specialists in the care of adults who are older that conducts a multidimensional evaluation of a resident and assists in developing a support plan by working with the resident's physician, designated person and the resident's family to coordinate the resident's care.
(2) Special care unit for INRBI.
(i) A written CPB preadmission screening completed in collaboration with a physician, neuropsychologist or cognitive, physical, behavioral assessment team and documented on the Department's CPB preadmission screening form shall be completed for each resident or potential resident within 72 hours prior to admission to a special care unit for INRBI.
(ii) A cognitive, physical, behavioral specialist with brain injury experience shall assist in developing a rehabilitation and support plan by working with the resident's physician, neuropsychologist and, when appropriate, the resident's designated person or the resident's family, or both to develop the resident's rehabilitation and support plan. This plan must include a high level of nursing and behavioral supervision, medication management, occupational therapy, cognitive therapy, behavioral therapy, vocational services, support for social reentry, and a personalized treatment plan.
(d) Resident admission to special care unit. Each resident record must have documentation that the resident or potential resident and, when appropriate, the resident's designated person or the resident's family have agreed to the resident's admission or transfer to the special care unit.
(e) Additional assessments.
(1) In addition to the requirements in § 2800.225 (relating to additional assessments), residents of a special care unit for Alzheimer's disease or dementia shall also be assessed quarterly for the continuing need for the special care unit for Alzheimer's disease or dementia.
(2) In addition to the requirements in § 2800.225, residents of a special care unit for INRBI shall also be assessed at least semiannually or more frequently as necessary to assure the continuing need for residence in the special care unit for INRBI.
(f) Additional resident in special care unit. A spouse, friend or family member who does not have a primary diagnosis of Alzheimer's disease or dementia or brain injury may reside in the special care unit if desired by the resident or his designated person.
(1) The spouse, friend or family member shall have a medical evaluation by a physician, physician's assistant or certified registered nurse practitioner, documented on a form provided by the Department within 60 days prior to admission to the residence or 15 days after admission to the residence.
(2) The spouse, friend or family member shall have access to and be able to follow directions for the operation of the key pads or other lock-releasing devices to exit the special care unit.
(g) Disclosure of services. The resident-residence contract specified in § 2800.25 (relating to resident-residence contract) must also include a disclosure of services, admission and discharge criteria, change in condition policies, special programming and costs and fees.
(h) Alzheimer's disease or dementia. When the residence holds itself out to the public as providing services or housing for individuals with Alzheimer's disease or dementia, the residence shall disclose to individuals and provide materials that include the following:
(1) The residence's written statement of its philosophy and mission which reflects the needs of individuals with Alzheimer's disease or dementia.
(2) A description of the residence's physical environment and design features to support the functioning of individuals with Alzheimer's disease or dementia.
(3) A description of the frequency and types of individual and group activities designed specifically to meet the needs of individuals with Alzheimer's disease or dementia.
(4) A description of the security measures provided by the residence.
(5) A description of the training provided to staff regarding provision of care to individuals with Alzheimer's disease or dementia.
(6) A description of availability of family support programs and family involvement.
(7) The process used for assessment and establishment of a plan of services for the individual, including methods by which the plan of services will remain responsive to changes in the individual's condition.
(i) Special care unit for INRBI. When an assisted living residence holds itself out to the public as a special care unit for INRBI, the residence shall disclose and provide materials to individuals and, when appropriate, the individual's designated person or the individual's family, or both, that include the following information:
(1) The residence's written statement of its philosophy and mission which reflects the needs of individuals with brain injury for intense neurobehavioral rehabilitation and support.
(2) A description of the residence's physical environment and design features that support and promote the functioning and rehabilitation of individuals who need INRBI.
(3) A description of the types of individual and group activities that have been designed specifically to meet the requirements of the rehabilitation and support plans of specific residents with brain injury.
(4) A description of the security measures provided by the residence.
(5) A description of the credentials and experience required and the training provided to staff regarding the provision of rehabilitation and support for individuals who require INRBI.
(6) A description of availability of family support programs, family education programs, and family involvement.
(7) The process used for assessment and establishment of a plan of services for the resident, including methods by which the plan of services will remain responsive to progress in the resident's recovery.
(j) Residents who wander. The residence shall identify measures to address individuals with Alzheimer's disease or dementia or with INRBI who have tendencies to wander.
(k) Individuals with INRBI. The residence with a special care unit for INRBI shall identify measures to address individuals who require INRBI who have problems that may actually impede rehabilitation such as:
(1) Anger.
(2) Self-control.
(3) Aggression toward others.
(4) Self-injury.
(5) Deficient judgment and problem solving due to cognitive deficits.
(6) Frequent agitation.
(7) Prolonged confusional state.
(8) Seizure disorders and related behavioral problems.
(9) Significant memory and learning problems.
(10) Disruption of sleep and wake cycles.
(11) Problems with attention.
(12) Filtering and focusing.
(13) Emergence of mental health problems or exacerbation of preexisting mental health issues.
(14) Emergence of substance abuse problems or exacerbation of preexisting substance abuse issues.
(15) Other cognitive and behavioral problems which have or would prevent successful completion of traditional rehabilitation programs.
(l) Professionals caring for individuals requiring INRBI. The residence with a special care unit for INRBI shall identify at a minimum the following professionals with expertise in providing care for individuals requiring INRBI.
(1) Onsite behavioral specialist.
(2) Onsite cognitive rehabilitation therapist.
(3) A consulting physiatrist; a consulting neuro- psychologist.
(4) A consulting neuropsychiatrist or psychiatrist for prescribing and monitoring the psychiatric medications that may be needed for residents with behavioral health issues.
§ 2800.232. Environmental protection.
(a) The residence shall provide exercise space, both indoor and outdoor.
(b) No more than two residents may occupy a living unit regardless of its size. A living unit must meet the requirement in § 2800.101 (relating to resident living units), as applicable. Kitchen facilities may not be included in a living unit located in a special care unit for INRBI.
(c) The residence shall provide space for dining, group and individual activities and visits.
(d) The residence shall provide a full description of the measures implemented to enhance environmental awareness, minimize environmental stimulation and maximize independence of the residents in public and private spaces based on the needs of the individuals being served.
(e) The residence with a special care unit for INRBI shall identify the process used to assure conformity of the individual resident's living unit to the ongoing rehabilitation recommendations of the neuropsychologist and the cognitive physical, emotional behavioral assessment team as expressed in the current rehabilitation and support plan.
§ 2800.233. Doors, locks and alarms.
(a) Doors equipped with key-locking devices, electronic card operated systems or other devices that prevent immediate egress are permitted only if there is written approval from the Department of Labor and Industry, Department of Health or appropriate local building authority permitting the use of the specific locking system.
(b) A residence shall have a statement from the manufacturer, specific to that residence, verifying that the electronic or magnetic locking system will shut down, and that all doors will open easily and immediately when one or more of the following occurs:
(1) Upon a signal from an activated fire alarm system, heat or smoke detector.
(2) Power failure to the residence.
(3) Overriding the electronic or magnetic locking system by use of a key pad or other lock-releasing device.
(c) If key-locking devices, electronic card systems or other devices that prevent immediate egress are used to lock and unlock exits, directions for their operation shall be conspicuously posted near the device.
(d) Doors that open onto areas such as parking lots, or other potentially unsafe areas, shall be locked by an electronic or magnetic system.
(e) Fire alarm systems must be interconnected to the local fire department, when available, or a 24-hour monitoring service approved by the local fire department.
§ 2800.234. Resident care.
(a) Support or rehabilitation plan.
(1) Within 72 hours of the admission, or within 72 hours prior to the resident's admission to the special care unit, a support plan shall be developed, implemented and documented in each resident's record.
(2) For individuals being admitted into a special care unit for INRBI, a rehabilitation plan shall be developed, implemented and documented in the resident record. This rehabilitation plan and the individual's support plan shall be based on the CPB preadmission assessment and other available records and information.
(b) Plan requirements.
(1) The support plan and if applicable, the rehabilitation plan must identify the resident's physical, medical, social, cognitive and safety needs.
(2) The rehabilitation and support plan for residents of a special care unit for INRBI must identify the residents' emotional and behavioral needs.
(c) Responsible individual. The support plan and if applicable, the rehabilitation plan must identify the individual responsible to address the resident's needs.
(d) Review of plans.
(1) The support plan for a resident of a special care unit for residents with Alzheimer's disease or dementia shall be reviewed, and if necessary, revised at least quarterly and as the resident's condition changes.
(2) The support plan and rehabilitation plan for a resident of a special care unit for INRBI shall be reviewed, and if necessary, revised at least monthly and as the resident's condition changes.
(e) Resident involvement in development of plan. The resident, the resident's designated person or the resident's family shall be involved in the development and the revisions of the support plan and if applicable, the rehabilitation plan.
§ 2800.235. Discharge.
(a) If the residence initiates a discharge or transfer of a resident, or the legal entity chooses to close the residence, the administrator shall give a 30-day advance written notice to the resident, the resident's designated person and the referral agent citing the reasons for the discharge or transfer. This requirement shall be stipulated in the resident-residence contract signed prior to admission to the special care unit.
(b) If a resident of a special care unit for INRBI, or when appropriate, the resident's designated person or the resident's family, request discharge to another facility, another assisted living residence or an independent living arrangement, transition services shall be provided by the special care unit.
§ 2800.236. Training.
(a) Each direct care staff person working in a special care unit for residents with Alzheimer's disease or dementia shall have 8 hours of initial training within the first 30 days of the date of hire and a minimum of 8 hours of annual training related to dementia care and services, in addition to the 16 hours of annual training specified in § 2800.65 (relating to staff orientation and direct care staff person training and orientation).
(b) The training for each direct care staff person working in a special care unit for residents with Alzheimer's disease or dementia at a minimum must include the following topics:
(1) An overview of Alzheimer's disease and related dementias.
(2) Managing challenging behaviors.
(3) Effective communications.
(4) Assistance with ADLs.
(5) Creating a safe environment.
(c) Each direct care staff person working in a special care unit for INRBI shall have 8 hours of initial training within the first 30 days of the date of hire and a minimum of 8 hours of annual training related to brain injury, in addition to the 16 hours of annual training specified in § 2800.65 and any continuing education required for professional licensing.
(d) The training for each direct care staff person working in a special care unit for INRBI in addition to subsection (b)(3), (4) and (5), must at a minimum include the following topics:
(1) An overview of brain injury including the common cognitive, physical and behavioral effects.
(2) Understanding and managing challenging behaviors which follow from the cognitive, physical and behavioral effects of brain injury.
(3) Tailoring activities and interactions to provide individualized rehabilitation and support in accordance with the resident's rehabilitation and support plan.
(4) Coaching and cueing, interactive problem solving, promoting the initiation of self-soothing activities, and timing the fading of supports.
§ 2800.237. Program.
(a) The following types of activities shall be offered at least weekly to residents of a special care unit for residents with Alzheimer's disease or dementia:
(1) Gross motor activities, such as dancing, stretching and other exercise.
(2) Self-care activities, such as personal hygiene.
(3) Social activities, such as games, music and holiday and seasonal celebrations.
(4) Crafts, such as sewing, decorations and pictures.
(5) Sensory and memory enhancement activities, such as review of current events, movies, story telling, picture albums, cooking, pet therapy and reminiscing.
(6) Outdoor activities, as weather permits, such as walking, gardening and field trips.
(b) Resident participation for residents of a special care unit for residents with Alzheimer's disease or dementia in general activity programming shall:
(1) Be voluntary.
(2) Respect the resident's age and cognitive abilities.
(3) Support the retention of the resident's abilities.
(c) The rehabilitation and support plans of the residents in a special care unit for INRBI will determine the types and frequency of the individual and group activities to be offered.
§ 2800.238. Staffing.
Each resident in a special care unit shall be considered to be a resident with mobility needs under § 2800.57(c) (relating to direct care staffing).
§ 2800.239. Application to Department.
(a) The legal entity shall submit an application to the Department at least 60 days prior to the following:
(1) Opening a special care unit.
(2) Adding a special care unit to an existing residence.
(3) Increasing the maximum capacity in an existing unit.
(4) Changing the locking system, exit doors or floor plan of an existing unit.
(b) The Department will inspect and approve the special care unit prior to operation or change. The requirements of this chapter shall be met prior to operation.
(c) The following documents shall be included in the application specified in subsection (a):
(1) The name, address and legal entity of the residence.
(2) The name of the administrator of the residence.
(3) The maximum capacity of the residence.
(4) The requested resident population of the special care unit.
(5) A building description.
(6) A unit description.
(7) The type of locking system.
(8) Policy and procedures to be implemented for emergency egress and resident elopement.
(9) A sample of a 2-week staffing schedule.
(10) Verification of completion of additional training requirements.
(11) The operational description of the special care unit locking system of the doors.
(12) The manufacturer's statement regarding the special care unit locking system.
(13) A written approval or a variance permitting locked exit doors from the Department of Labor and Industry, the Department of Health or the appropriate local building authority.
(14) The name of the municipality or 24-hour monitoring service maintaining the interconnection with the residence's fire alarm system.
(15) A sample plan of care and service for the resident addressing the resident's physical, medical, social, cognitive and safety needs for the residents.
(16) The activity standards.
(17) The complete medical and cognitive preadmission assessment that is completed upon admission and reviewed and updated annually.
(18) A consent form agreeing to the resident's placement in the special care unit, to be signed by the resident or the resident's designated person.
(19) A written agreement containing full disclosure of services, admission and discharge criteria, change in condition policies, services, special programming, costs and fees.
(20) A description of environmental cues being utilized.
(21) A general floor plan of the entire residence.
(22) A specific floor plan of the special care unit, outside enclosed area and exercise space.
RESIDENT RECORDS § 2800.251. Resident records.
(a) A separate record shall be kept for each resident.
(b) The entries in a resident's record must be permanent, legible, dated and signed by the staff person making the entry.
(c) The residence shall use standardized forms to record information in the resident's record.
(d) Separate resident records shall be kept on the premises where the resident lives.
(e) Resident records shall be made available to the resident and the resident's designated person during normal working hours. Resident records shall be made available upon request to the resident and the resident's designated person.
§ 2800.252. Content of resident records.
Each resident's record must include the following information:
(1) Name, gender, admission date, birth date and Social Security number.
(2) Race, height, weight at time of admission, color of hair, color of eyes, religious affiliation, if any, and identifying marks.
(3) A photograph of the resident that is no more than 2 years old.
(4) A language, speech, hearing or vision need which requires accommodation or awareness of during oral or written communication.
(5) The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
(6) The name, address and telephone number of the resident's physician or source of health care.
(7) The current and previous 2 years' physician's examination reports, including copies of the medical evaluation forms.
(8) A list of prescribed medications, OTC medications and CAM.
(9) Dietary restrictions.
(10) A record of incident reports for the individual resident.
(11) A list of allergies.
(12) Documentation of health care services and orders, including orders for the services of visiting nurse or home health agencies.
(13) The initial assessment, the preliminary support plan and the most current version of the annual assessment.
(14) A final support plan.
(15) Applicable court order, if any.
(16) The resident's medical insurance information.
(17) The date of entrance into the residence, relocations and discharges, including the transfer of the resident to other residences owned by the same legal entity.
(18) An inventory of the resident's personal property as voluntarily declared by the resident upon admission and voluntarily updated.
(19) An inventory of the resident's property entrusted to the administrator for safekeeping.
(20) The financial records of residents receiving assistance with financial management.
(21) The reason for termination of services or transfer of the resident, the date of transfer and the destination.
(22) Copies of transfer and discharge summaries from hospitals, if available.
(23) If the resident dies in the residence, a copy of the official death certificate.
(24) Signed notification of rights, grievance procedures and applicable consent to treatment protections specified in § 2800.41 (relating to notification of rights and complaint procedures).
(25) A copy of the resident-residence contract.
(26) A termination notice, if any.
(27) A record relating to any exception request under § 2800.229 (relating to excludable conditions; exceptions).
(28) Ongoing resident progress notes.
§ 2800.253. Record retention and disposal.
(a) The resident's entire record shall be maintained for a minimum of 3 years following the resident's death, discharge from the residence or until any audit or litigation is resolved.
(b) Records shall be destroyed in a manner that protects confidentiality.
(c) The residence shall keep a log of resident records destroyed on or after January 18, 2011. This log must include the resident's name, record number, birth date, admission date and discharge date.
(d) Records required under this chapter that are not part of the resident records shall be kept for a minimum of 3 years or until any audit or litigation is resolved.
§ 2800.254. Record access and security.
(a) Records of active and discharged residents shall be maintained in a confidential manner, which prevents unauthorized access.
(b) Each residence shall develop and implement policy and procedures addressing record accessibility, security, storage, authorized use and release and who is responsible for the records.
(c) Resident records shall be stored in locked containers or a secured, enclosed area used solely for record storage and be accessible at all times to the administrator, the administrator's designee, or the nurse involved in assessment and support plan development and upon request, to the Department or representatives of the area agency on aging.
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