TITLE 175 - HEALTH CARE FACILITIES AND SERVICES LICENSURE
CHAPTER 12 - SKILLED NURSING FACILITIES, NURSING FACILITIES, AND INTERMEDIATE CARE FACILITIES
001. SCOPE AND AUTHORITY. These regulations govern licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities. The regulations are authorized by and implement the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479, Alzheimer’s Special Care Disclosure Act, Neb. Rev. Stat. §§ 71-516.01 to 71-516.04, Neb. Rev. Stat. § 38-2419, Emergency Box Drug Act, Neb. Rev. Stat. §§ 71-2410 to 71-2417, Nebraska Nursing Home Act, Neb. Rev. Stat. §§ 71-6008 to 71-6037, and Neb. Rev. Stat. §§ 71-6039 to 71-6042.
002. DEFINITIONS. The definitions set out in the Health Care Facility Licensure Act, Neb. Rev. Stat. §§ 71-6038, 71-6721, 28-401, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.
002.01 ABUSE. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
002.02 ACCIDENT. An unexpected, unintended event that can cause a resident bodily injury.
002.03 DEHYDRATION. A lack of sufficient water in the body.
002.04 DEVICE. An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.
002.05 DWELLING. A building that contains: living and sleeping areas; storage room(s); separate room(s) containing a toilet, lavatory, and bathtub or shower; and a kitchen area with a sink and cooking and refrigeration appliances.
002.06 EXPLOITATION. Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.
002.07 FACILITY. A skilled nursing facility, nursing facility, or intermediate care facility.
002.08 INCIDENT. An occurrence likely to have a grave outcome.
002.09 LICENSED NURSE. A licensed registered nurse or a licensed practical nurse.
002.10 MEDICATION ERROR. The preparation, provision or administration of medications which is not in accordance with:
(A) Physician orders;
(B) Manufacturers specifications regarding the preparation and administration of the drug or biological;
(C) Accepted professional standards and principles that apply to professionals providing services; or
(D) The five rights.
002.11 MEDICATION ERROR RATE. Determined by calculating the percentage of errors. The numerator is the total number of errors that the survey team observes, both significant and non-significant. The denominator is called “opportunities for error” and includes all the doses the survey team observed being administered plus the doses ordered but not administered.
002.12 MENTAL ABUSE. The use of verbal or nonverbal conduct which causes or has the potential to cause a resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.
002.13 MISAPPROPRIATION OF MONEY OR PROPERTY. The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent.
002.14 NEGLECT. The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
002.15 PHYSICAL ABUSE. Hitting, punching, slapping, pinching, kicking, or other actions causing injury to the body. Injury includes damage to bodily tissue caused by nontherapeutic conduct, including, but not limited to, fractures, bruises, lacerations, internal injuries, or dislocations and shall include, but not limited to, physical pain, illness, or impairment of physical function.
002.16 QUALIFIED PERSONNEL. Professional staff who are licensed, certified or registered to provide specialized therapy or rehabilitative services in accordance with applicable state laws.
002.17 SEXUAL ABUSE. Non-consensual sexual contact of any type with a resident.
002.18 SIGNIFICANT WEIGHT LOSS. 5% loss of body weight in 1 month, 7.5% loss of body weight in 3 months, or 10% body weight loss in 6 months.
002.19 SPECIALIZED REHABILITATIVE SERVICES. Services provided by qualified personnel, including but not limited to, physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and developmental disability.
002.20 SUFFICIENT FLUID. The amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident and fluctuates as the resident’s condition fluctuates.
002.21 VERBAL ABUSE. The use of oral, written, or gestured language including disparaging and derogatory terms to residents or within their hearing distance.
003. LICENSING REQUIREMENTS AND PROCEDURES. To receive a license, an applicant must submit a complete application and meet the requirements for a license set out in statute, 175 NAC 1, and in this chapter. All standards referenced in this chapter can be obtained at the Department of Health and Human Services, Health Care Facilities and Services Licensure Unit, 301 Centennial Mall South, Lincoln, NE 68509 or be viewed on the Department’s website.
004. GENERAL REQUIREMENTS. These requirements are outlined in 175 NAC 1 and this chapter and are applicable to all licenses.
004.01 EFFECTIVE DATE AND TERM OF LICENSE. Skilled nursing facility, nursing facility, and intermediate care facility licenses expire on March 31st of each year.
004.02 LICENSE NOT TRANSFERABLE. Change of ownership or premises terminates the license. If there is a change of ownership and the facility remains on the same premises, the inspection in 175 NAC 12-005 is not required. If there is a change of premises, the facility must pass the inspection specified in 175 NAC 12-005.
004.03 FEES. The licensee must pay fees for licensure and services as authorized by Neb. Rev. Stat. § 71-434 and set forth below:
(A) Initial and renewal licensure fees:
(i) 1 to 50 Beds $1,550
(ii) 51 to 100 Beds $1,750
(iii) 101 or more Beds $1,950
(B) Duplicate license: $ 10
005. INSPECTIONS. Inspection requirements for licensees are set out in the Health Care Facility Licensure Act and 175 NAC 1.
006. STANDARDS OF OPERATION, CARE, AND TREATMENT. To provide adequate protection and promotion of the health, safety, and well-being of facility residents and compliance with state statutes, skilled nursing facilities, nursing facilities, and intermediate care facilities must meet the following in this section.
006.01 LICENSEE RESPONSIBILITIES. The responsibilities of the licensee include:
(A) Total operation of the facility;
(B) Monitoring policies to assure the appropriate administration and management of the facility;
(C) Ensuring the facility’s compliance with all applicable statutes and relevant regulations;
(D) Periodically reviewing reports and recommendations regarding the quality assurance and performance improvement program and implementing programs and policies to maintain and improve the quality of resident care and treatment;
(E) Appointing a Nebraska-licensed administrator who is responsible for the day-to-day management of the facility;
(F) Defining the duties and responsibilities of the administrator in writing;
(G) Notifying the Department in writing within 5 working days when a vacancy in the administrator position occurs, including who will be responsible for the position until another administrator is appointed; and
(H) Notifying the Department in writing within 5 working days when the vacancy in the administrator position is filled, including the effective date, license number, and the name of the person appointed administrator.
006.02 ADMINISTRATOR. Every skilled nursing facility, nursing facility, and intermediate care facility must have a Nebraska-licensed administrator who is responsible for the overall management of the facility. Each administrator must be responsible for and oversee the operation of a facility in compliance with Neb. Rev. Stat. § 38-2419. The administrator must:
(A) Ensure compliance with statutes and regulations;
(B) Plan, organize, and direct responsibilities delegated to the administrator by the licensee;
(C) Maintain liaison, through meetings and periodic reports, among the governing body, medical and nursing staff, and other professional and supervisory staff of the facility;
(D) Protect and promote residents’ health, safety and well-being; residents’ individuality, privacy and dignity; and residents’ participation in decisions regarding care and services;
(E) Ensure staffing appropriate in number and qualification to meet the resident needs;
(F) Designate an appropriate person to act as a substitute in the administrator’s absence who is responsible and accountable for management of the facility. The administrator remains responsible for the acts of the designated person. In case of an extended absence, an appropriate person means one who holds a current license or provisional license issued by the Department to act as a nursing home administrator;
(G) Ensure that facility staff identify and review incidents and accidents, resident complaints and concerns, patterns and trends in overall facility operation such as provisions of resident care and service and take action to alleviate problems and prevent recurrence;
(H) Ensure that a report is made on any alleged abuse of a resident by a staff member, volunteer, family member, visitor, or any other person to Adult Protective Services or local law enforcement as directed in the Adult Protective Services Act, Neb. Rev. Stat. § 28-372 and in the case of a child, Neb. Rev. Stat. § 28-711. All alleged abuse must be investigated, and residents protected from further abuse throughout the investigation; and
(I) Ensure the establishment of a quality assurance and performance improvement committee and that the recommendations of the committee are addressed.
006.03 MEDICAL DIRECTOR. Each licensee must have a medical director who is a physician. The medical director is responsible for:
(A) Ensuring adequate medical practitioner availability and support;
(B) Ensuring effective medical practitioner and facility compliance with requirements;
(C) Evaluating and improving the quality of the care; and
(D) Evaluating and improving the quality of the systems and processes that influence the care.
006.04 STAFF REQUIREMENTS. Sufficient number of staff with the required credentials, experience, orientation, training and competency necessary to meet the resident population’s requirements for assistance or provision of personal care, activities of daily living, supervision, supportive services and medical care where appropriate. Any unlicensed staff who assist in the provision of care and treatment provided to residents must be supervised by a health care professional. Staff cannot provide care or treatment that is outside the scope of practice permitted by the credential held by the individual.
006.04(A) EMPLOYMENT ELIGIBILITY. Each licensee must maintain evidence of the following in this section.
006.04(A)(i) STAFF CREDENTIALS. Staff credentials are to be verified prior to staff assuming assigned job duties, and the licensee must maintain evidence that such status is checked and maintained throughout the entire time of employment.
006.04(A)(ii) HEALTH STATUS. A health history screening for all staff must be completed prior to staff assuming job duties. A licensee is to ensure staff health status is maintained in a manner to prevent the potential transmission of disease to residents, visitors, and other staff.
006.04(A)(iii) CRIMINAL BACKGROUND AND REGISTRY CHECKS. Criminal background and registry checks must be completed on any staff members who have direct and unsupervised access to or who provide care and treatment to residents. These checks must be completed prior to the staff having unsupervised contact with any resident. Documentation of such checks is to be maintained for as long as the staff member is employed.
006.04(A)(iii)(1) CRIMINAL BACKGROUND CHECKS. Criminal background checks must be completed through a governmental law enforcement agency or a private entity that maintains criminal background information.
006.04(A)(iii)(2) REGISTRY CHECKS. A check for adverse findings must include the following registries:
(a) Nurse Aide Registry;
(b) Adult Protective Services Central Registry;
(c) Central Register of Child Protection Cases; and
(d) Sex Offender Registry.
006.04(A)(iii)(3) USE OF CRIMINAL BACKGROUND AND REGISTRY INFORMATION. Written policies and procedures are to be implemented and revised as necessary related to the use of information obtained through pre-employment criminal background and registry checks. These are to include the following:
(a) How the criminal background and registry information, except for the Nurse Aide Registry, is used in making hiring decisions;
(b) Whether employment can begin prior to receiving the criminal background and registry information, how the safety or property of residents will be safeguarded until the results are available, and what happens if the results have adverse findings;
(c) How any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry, is documented. Documentation must include the basis for the decision and how it will not pose a threat to resident safety or resident property; and
(d) A person with adverse findings on the Nurse Aide Registry regarding resident abuse, neglect, or misappropriation of resident property cannot be employed.
006.04(B) TRAINING. The licensee must provide initial and ongoing training designed to meet the needs of the resident population. Training must be provided by a person qualified by education, experience, and knowledge in the area of the service being provided. Records of each orientation and in-service or other training program, including names of staff attending, subject matter of the training, names and qualifications of instructors, dates of training, length of training sessions and any written materials provided must be maintained in a format and location that is easily and readily accessible to an agent or employee of the Department for 7 years from the date of orientation or the date of the training.
006.04(B)(i) INITIAL ORIENTATION. Each employee must receive initial orientation within 2 weeks after beginning employment that includes at a minimum, but is not limited to:
(1) Resident rights;
(2) Emergency procedures including fire safety and disaster preparedness plans including availability and notification;
(3) Information on abuse, neglect, and misappropriation of money or property of a resident and reporting requirements according to the Adult Protective Services Act, and facility procedures;
(4) Job duties and responsibilities;
(5) Nursing staff must receive information on medical emergency directives; and
(6) Alzheimer’s care and dementia care if the licensee cares for residents with Alzheimer’s or dementia.
006.04(B)(ii) ONGOING TRAINING. Each employee must receive ongoing training to ensure competency and continued compliance with regulations and facility policy. This training must include 4 hours of Alzheimer’s care and dementia care if the licensee cares for residents with Alzheimer’s or dementia.
006.04(B)(ii)(1) NURSE AIDE TRAINING. Ongoing training for nurse aides must consist of at least 12 hours per year on topics appropriate to the employee’s job duties, including meeting the physical, psychosocial, and mental needs of the residents.
006.04(B)(ii)(2) MEDICATION AIDES. When medication aides are utilized by the facility, there must be ongoing training to ensure competencies are met as provided in 172 NAC 95.
006.04(B)(ii)(3) DIRECTOR OF FOOD SERVICE. When the director of food service is not a qualified dietitian, the director must have at least 15 hours of continuing education related to dietetics each year, 5 hours of which relate to sanitation. Evidence of credentials and of continuing education must be available within the facility.
006.04(C) EMPLOYMENT RECORDS. Current employment records for each staff person must be maintained for 7 years from the date of termination of employment. Information kept in the record must include information on the length of service; orientation; in-service; competency testing; licensure, certification registration, or other credentials; health history screening; and previous work experience.
006.04(D) NURSING STAFF RESOURCES AND RESPONSIBILITIES. The licensee must provide sufficient nursing staff on a 24-hour basis, with specified qualifications as follows, to provide nursing care to all residents in accordance with resident care plans.
006.04(D)(i) DIRECTOR OF NURSING SERVICES. The licensee must employ a Director of Nursing Services as required by Neb. Rev. Stat. §§ 71-6018.01 and 71-6018.02. The Director of Nursing Services is responsible for the following:
(1) Administrative authority, function, and activity of the nursing department;
(2) Orientation and in-service education of the nursing services staff;
(3) Establishment and implementation of nursing services, objectives, standards of nursing practices, nursing policy and procedure manuals and written job descriptions for each level of nursing personnel;
(4) Establishment and implementation of methods of coordination of nursing services with other resident services in meeting each resident’s needs;
(5) Preadmission evaluation of residents; establishment and implementation of criteria for admission to the facility;
(6) Recommendation of the number and levels of nursing personnel to be employed;
(7) Nursing staff development; and
(8) Establishment and implementation of complete nursing assessments and nursing care plans for residents, and ongoing evaluation and updating of care plans to reflect the current overall condition of the residents.
006.04(E) DIRECTOR OF NURSING VACANCY. The licensee must notify the Department in writing within 5 working days when a vacancy in the Director of Nursing Services position occurs, including who will be responsible for the position until a full-time Director of Nursing Services is secured. The Department must be notified in writing within 5 working days when the vacancy is filled indicating effective date, name, and license number of the person assuming Director of Nursing Services responsibilities.
006.04(F) CHARGE NURSE REQUIREMENT. Except when waived in accordance with Neb. Rev. Stat. §§ 71-6018.01 and 71-6018.02, skilled nursing facilities and nursing facilities must designate a licensed nurse to serve as a charge nurse on each tour of duty. Intermediate care facilities must designate a licensed nurse to serve as a charge nurse for 1 tour of duty each 24 hours.
006.04(F)(i) CHARGE NURSE. The charge nurse is responsible for the total nursing care delivered during the tour of duty on the assigned unit. A charge nurse is responsible for the following:
(1) The direct nursing care of the specific residents. Such care may be provided personally, or through assignment, delegation, or direction of duties to other nursing personnel, as appropriate;
(2) Being knowledgeable and responsive to the physical and emotional needs of all residents;
(3) Complete and accurate medication administration;
(4) Participating in the review, revising and implementation of residents’ plans of care;
(5) Notifying the Director of Nursing Services, physician, and family of changes in resident condition, i.e., injury, accident, or adverse change; and
(6) Completing documentation describing nursing care provided, including resident response and status.
006.04(G) OTHER NURSING PERSONNEL. A sufficient number of qualified nursing personnel who are awake, dressed and assigned to resident care duties at all times must be provided. The licensee must ensure personnel who provide direct resident care meet the following requirements:
(i) Nurse Aides must meet the requirements in Neb. Rev. Stat. § 71-6039;
(ii) Medication Aides must meet the requirements in Neb. Rev. Stat. §§ 71-6718 to 71-6742;
(iii) Have the ability to speak and understand the English language or a language understood by a substantial portion of the facility’s residents; and
(iv) When the licensee utilizes persons other than a licensed nurse or a nurse aide for the feeding of residents, the licensee must comply with Neb. Rev. Stat. § 71-6039.
006.04(H) DIETARY SERVICES STAFFING. Sufficient personnel competent to carry out the functions of the dietary services in a safe and timely manner must be provided.
006.04(H)(i) QUALIFIED DIETITIAN. A qualified dietitian must be employed on a full-time, part-time, or consultant basis. The qualified dietitian is responsible for the general guidance and direction of dietary services, assessing special nutritional needs, developing therapeutic diets, regular diets, developing and implementing in-service education programs, participating in interdisciplinary care planning when necessary, supervising institutional food preparation, service, and storage.
006.04(H)(ii) FOOD SERVICE DIRECTOR. A person to serve as the director of food service who receives scheduled consultation from a registered dietitian or licensed medical nutrition therapist must be designated if a qualified dietitian is not employed full-time.
006.04(H)(ii)(1) FOOD SERVICE DIRECTOR QUALIFICATIONS. To qualify as director of food service, the employee must be one of the following:
(a) A graduate of a dietetic technician program approved by the American Dietetic Association;
(b) An individual with a bachelor’s degree in foods and nutrition;
(c) An individual with an associate’s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution in higher learning;
(d) A graduate of a dietetic assistant program approved by the American Dietetic Association, qualifying for certification by the Dietary Managers Association;
(e) A graduate of a dietary manager program approved by the Dietary Managers Association and qualifying for certification by the Dietary Managers Association; or
(f) An individual who successfully completes a course in food service management offered by an accredited university, community college, or technical college, whose curriculum meets at least the minimum requirements of any of the programs described in 175 NAC 12-006.04 (H)(ii)(1), items (a) to (d), whether or not formally approved by the entities named in those sections.
006.04(H)(ii)(2) FOOD SERVICE DIRECTOR QUALIFICATIONS NOT MET. If the designated person does not meet the qualifications of a food service director, the licensee must have a written agreement with a qualified food service director for consultation and assistance on a regularly scheduled basis as required to meet the needs of the residents.
006.04(H)(ii)(3) FOOD SERVICE DIRECTOR RESPONSIBILITIES. The dietitian or director of food service is responsible for ensuring residents are provided with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. The director of food service or designee must participate in the interdisciplinary care plan for each resident.
006.04(I) SOCIAL SERVICES STAFFING. Sufficient staff to meet the social service needs of the residents must be provided.
006.04(I)(i) SOCIAL SERVICES DIRECTOR QUALIFICATIONS. A social services director must be designated to be responsible for arranging and integrating social services with other elements of the care plan. To qualify as social services director; the employee must have:
(1) A certificate issued by the Department to practice social work as a certified master social worker;
(2) A Master of Social Work (M.S.W.) degree with 1-year experience in the provision of social services in a long-term care facility, or geriatric setting;
(3) A graduate degree in social or behavioral sciences with a specialty in gerontology with 1-year experience in the provision of social services in a long-term care facility, or geriatric setting;
(4) A Bachelor of Social Work degree from a college or university with an undergraduate social work program accredited by the Council on Social Work Education with 1-year of experience in the provision of social services in a long-term care facility or geriatric setting;
(5) A Bachelor of Arts (B.A.) or Bachelor of Science (B.S.) degree in social or behavioral sciences with 1-year of experience in the provision of social service in a long-term care facility, or geriatric setting;
(6) An Associate of Arts degree in social or behavioral sciences with 2 years of experience in the provision of social services in a long-term care facility, or the services of a qualified consultant;
(7) Successfully completed a course of instruction in social services of at least 36 hours established by the Provider Associations; or
(8) 2 years of experience in the provision of social services in a long-term care facility.
006.04(I)(ii) SOCIAL SERVICES DIRECTOR QUALIFICATIONS NOT MET. If the designated person does not meet the qualifications of a social service director, the licensee must have a written agreement with a qualified social worker for consultation and assistance on a regularly scheduled basis as required to meet the needs of the residents.
006.04(I)(iii) SOCIAL SERVICE DIRECTOR RESPONSIBILITIES. The social service director or designee must act as part of the interdisciplinary team in assessing the individual needs of the resident and participate in development and implementation of the interdisciplinary care plan. Social service interventions to assist the resident in meeting treatment goals, address resident needs and provide social service support in meeting resident needs and individuality must be implemented. The social service staff must establish and maintain relationships with the resident’s family or designee.
006.04(J) RESIDENT ACTIVITY STAFFING. Sufficient staff to provide activities of interest to residents must be provided.
006.04(J)(i) RESIDENT ACTIVITIES DIRECTOR QUALIFICATIONS. A qualified resident activities director must be designated. The activities director must meet 1 of the following qualifications:
(1) A qualified therapeutic recreation specialist with 1-year of experience in a long-term care facility or geriatric setting;
(2) A licensed occupational therapist with 1-year of experience in a long-term care facility or geriatric setting;
(3) A qualified therapeutic recreation assistant with 1-year of experience in a long-term care facility or geriatric setting;
(4) An individual who has a Bachelor of Arts (B.A.) or Bachelor of Science (B.S.) degree in social or behavioral sciences with 1-year of experience in the provision of recreational services in a long-term care facility or geriatric setting;
(5) An individual who has successfully completed a course of instruction in recreational services of at least 36 hours established by the provider associations, or a substantially equivalent course established by any other health care association or entity; or
(6) Has 2 years of full-time experience in a resident activities program in a health care setting.
006.04(J)(ii) RESIDENT ACTIVITIES DIRECTOR QUALIFICATIONS NOT MET. If the designated person does not meet the qualifications of an activity’s director, the licensee must have a written agreement with a qualified consultant for consultation and assistance on a regularly scheduled basis as required to meet the needs of the residents.
006.04(J)(iii) RESIDENT ACTIVITIES DIRECTOR RESPONSIBILITIES. The activity director or designee must act as a member of the interdisciplinary team and participate in the development of the interdisciplinary care plan. The activity director is responsible for providing daily activities for residents to stimulate and promote the physical, spiritual, social, emotional, and intellectual well-being of each resident.
006.04(K) MEDICAL RECORDS STAFFING. Overall supervisory responsibility for the medical record service must be the responsibility of a full-time employee of the facility. Sufficient supporting personnel competent to carry out the functions of the medical record services must be provided.
006.05 RESIDENT RIGHTS. The operations of the licensee must afford residents the opportunity to exercise their rights in accordance with Neb. Rev. Stat. §§ 71-6019 to 71-6023 and the following:
(A) Be informed of their rights in writing;(B) Be fully informed in writing prior to or at the time of admission and during the resident’s stay, of services available in the facility, and of related charges including any charges for services not covered by the facility’s basic per diem rate;
(C) Be fully informed of rights and responsibilities as a resident and of all rules and regulations governing resident conduct and responsibilities. This information must be provided prior to or at the time of admission and its receipt acknowledged by the resident in writing, or, in the case of residents already in the facility, upon the facility’s adoption or amendment of resident rights policies;
(D) Be fully informed by a physician of the residents health and medical condition unless medically contraindicated;
(E) Participate in the planning of total care and medical treatment, or to refuse treatment. A resident may participate in experimental research only upon informed written consent;
(F) Exercise rights as a resident of the licensee and as a citizen of the United States;
(G) Be free from chemical and physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident’s medical symptoms;
(H) Be free from abuse, neglect and misappropriation of their money and personal property;
(I) Refuse to perform services for the licensee;
(J) Examine the results of the most recent survey of the licensee conducted by the Department;
(K) Privacy in written communication including sending and receiving mail;
(L) Have access to the use of a telephone with auxiliary aides where calls can be made in private;
(M) Retain and use personal possessions, including furnishings, and clothing as space permits, unless to do so would infringe upon the rights and safety of other residents;
(N) Self-administer medications if it is safe to do so;
(O) Form and participate in an organized resident group that functions to address licensee issues;
(P) Review and receive a copy of their permanent record, within 2 working days;
(Q) Manage his or her personal financial affairs. Under specific written authorization by the resident, the licensee may assist in such management to the extent specified by the resident;
(R) Receive confidential treatment of all information contained in his or her records, including information contained in an electronic data bank. Resident written consent or that of the resident’s designee is required for the release of information to persons not otherwise authorized under law to receive it; and
(S) Be treated with consideration, respect, and full recognition of resident dignity and individuality, including privacy in treatment and in care for the residents personal needs.
006.06 COMPLAINTS AND GRIEVANCES. The licensee must establish and implement procedures for addressing complaints and grievances as outlined in 175 NAC 1 and this section.
006.06(A) SUBMISSION OF COMPLAINTS AND GRIEVANCES. The procedure for submitting complaints and grievances must be displayed in plain view of residents, employees, and others in a prominent location.
006.06(B) COMPLAINT AND GRIEVANCE RESOURCES. The licensee must ensure that the telephone numbers and addresses of the Department’s Investigations Unit and the state long term care ombudsman are readily available to residents, employees and others.
006.07 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT. The licensee must have a quality assurance and performance improvement committee responsible for identifying issues which necessitate action, development and implementation of the action plan to correct problems and reevaluation of the problem to promote quality care and treatment provided to residents.
006.07(A) COMMITTEE PARTICIPANTS. The following individuals are to serve on the quality assurance and performance improvement committee:
(i) Director of Nursing Services;
(ii) Medical Director or designee; and
(iii) At least 3 other members of the facility’s staff.
006.07(B) OTHER PARTICIPANTS. The participation of other members of the facility staff as well as consultants on the quality assurance and performance improvement committee must be requested as necessary to identify issues which necessitate action and to participate in development and implementation of action plan to correct the problem and reevaluation of the problem.
006.07(C) COMMITTEE RESPONSIBILITIES. The quality assurance and performance improvement committee is responsible for:
(i) Identifying issues that necessitate action by the committee;
(ii) Developing and implementing plans of action to correct identified problems;
(iii) Monitoring the appropriateness and effectiveness of corrective actions; and
(iv) Reevaluating corrective actions, revising of plans of corrective action, and revising licensee policies and clinical policies as necessary.
006.08 MEDICAL SERVICES. The medical care of each resident is to be supervised by a medical practitioner, and another medical practitioner is to supervise the medical care of the residents when their attending medical practitioner is unavailable.
006.08(A) ADMISSION CRITERIA. Each individual admitted to the licensee must have written approval of a recommendation for admittance from a medical practitioner. Each resident must have a history and physical examination completed by a medical practitioner within 30 days prior to or 14 days after admission. Each resident must remain under the care of a medical practitioner.
006.08(B) MEDICAL PRACTITIONER RESPONSIBILITIES. The medical practitioner must:
(i) Review the resident’s total program of care, including medications and treatments, at each visit required;
(ii) Write, sign, and date progress notes at each visit; and
(iii) Sign any order the medical practitioner gives.
006.09 CARE AND TREATMENT. The physical, mental and psychosocial needs of all residents are to be met in accordance with each resident’s individualized needs and physician orders.
006.09(A) RESIDENT ADMISSION AND RETENTION. The licensee must ensure the resident’s identified needs for care and treatment can be met both before admission and for retention.
006.09(A)(i) ADMISSION CRITERIA. The licensee must implement written criteria for admission to the facility. The written criteria must include how eligibility for admission is determined based on the following:
(1) Identification of resident need in relationship to care and treatment, including severity of presenting problem; and
(2) Need for supervision and other issues related to providing care and treatment and licensee resources.
006.09(A)(ii) RETENTION OF RESIDENTS. The licensee must continue to provide care and treatment to residents as long as the licensee can continue to meet the identified needs for care, treatment, and supervision, and other issues related to providing care and treatment.
006.09(B) RESIDENT ASSESSMENT. A comprehensive, accurate, and reproducible assessment of each resident’s functional capacity designed to identify the resident’s abilities and needs must be completed as set out in this chapter. The assessment must include review and assessment of current and history of the following:
(i) Body systems and functions, including vital signs;
(ii) Psychosocial function;
(iii) Diagnoses, disease processes, and presenting symptoms; and
(iv) Medication with therapeutic and adverse effects.
006.09(C) ASSESSMENT FREQUENCY. The comprehensive assessment is to be completed:
(i) No later than 14 days after the date of admission;
(ii) By the end of the 14th calendar day following the determination that a significant change has occurred; and
(iii) In no case less often than once every 12 months.
006.09(D) REVIEW OF ASSESSMENTS. A review of the comprehensive assessment of each resident is to be completed and documented no less than once every 3 months. As appropriate, the resident’s comprehensive assessment is to be revised to ensure accuracy of the assessment.
006.09(E) COMPREHENSIVE CARE PLANS. A comprehensive interdisciplinary care plan for each resident based on the comprehensive assessment must be developed and implemented to ensure the resident achieves optimal functional status and independence. The care plan must include and specify:
(i) An interdisciplinary evaluation of resident needs;
(ii) Measurable objectives and timetables to meet a resident’s needs that are identified in the comprehensive assessment;
(iii) The services that are to be furnished to attain or maintain the resident’s highest practicable well-being;
(iv) Goals for the residents that are time limited and measurable;
(v) A discharge plan based on the needs of the resident; and
(vi) The discipline(s) responsible for providing specific care and the frequency of the interventions.
006.09(F) FREQUENCY OF CARE PLANS. Care plans are to be developed and implemented as follows:
(i) Within 24 hours of the resident’s admission, and a preliminary nursing assessment and nursing care plan that implements the medical practitioner’s admission orders must be completed;
(ii) A comprehensive interdisciplinary care plan and discharge plan must be completed within 7 days after the completion of the comprehensive assessment; and(iii) The care plan is to be reviewed and revised at least quarterly or with change in condition or services provided. Review of the care plan must include an interdisciplinary evaluation of the resident’s progress relative to the goals established.
006.09(G) DISCHARGE PLANNING. A post discharge plan of care for any resident is to be developed when there is anticipated discharge to a home, same level, or a different level of care. The discharge plan of care must be developed with the participation of the resident and resident’s family.
006.09(G)(i) DISCHARGE SUMMARY. When a resident is discharged, a discharge summary must be completed and be available for release to authorized persons and agencies with the consent of the resident or resident’s designee. The discharge summary must include:
(1) Resident’s full name;
(2) Medical record number;
(3) Admission date;
(4) Discharge date and time;
(5) Name of attending medical practitioner;
(6) Destination discharged to;
(7) Recapitulation of resident’s stay;
(8) Final diagnosis and resident status;
(9) Date summary completed; and
(10) Signature of the person completing the summary.
006.09(G)(ii) DISCHARGE TO ANOTHER SETTING. When a resident is discharged to a different facility setting or service, in addition to the information required in 175 NAC 12-006.09(G)(i), the discharge summary must include:
(1) Medically defined conditions;
(2) Medical status measurement;
(3) Functional status;
(4) Sensory and physical impairments;
(5) Nutritional status and requirements;
(6) Special treatments and procedures;
(7) Psychosocial status;
(8) Discharge potential;
(9) Dental condition;
(10) Activities potential;
(11) Rehabilitation potential;
(12) Cognitive status; and
(13) Drug therapy, including education.
006.09(H) PROVISION OF CARE AND TREATMENT. The necessary care and treatment to permit achievement and maintenance of optimal mental, physical, and psychosocial functional status and independence in accordance with the comprehensive assessment and plan of care for each resident must be provided.
006.09(H)(i) RESIDENT ABILITIES. Care and treatment is provided to improve or maintain a resident’s abilities when the resident is capable of some level of independence in performing these abilities. When the resident is not capable of independent functioning, the licensee is responsible for provision of these cares.
006.09(H)(i)(1) DIMINISHED ABILITIES. A resident is to receive the appropriate standards of care and treatment to prevent a diminution of the resident’s abilities unless circumstances of the individual’s medical condition demonstrates the diminution was unavoidable. This includes the residents ability to:
(a) Bathe, dress, and groom;
(b) Transfer and ambulate;
(c) Toilet;
(d) Eat; and
(e) Use speech, language, or other functional communication systems.
006.09(H)(i)(2) MAINTENANCE OR IMPROVEMENT IN ABILITIES. A resident is to receive the appropriate standards of care and treatment to maintain or improve the resident’s abilities as described in 175 NAC 12-006.09(H)(i)(1).
006.09(H)(i)(3) INABILITY TO SELF-PERFORM. A resident who is unable to carry out activities of daily living is to receive the appropriate standards of care and treatment to maintain good nutrition, grooming, and personal and oral hygiene.
006.09(H)(ii) VISION AND HEARING. Residents are to receive appropriate standards of care and treatment and assistive devices to maintain vision and hearing abilities. Residents, as needed, are to be assisted in:
(1) Making appointments; and
(2) Arranging for transportation to and from the office of a practitioner or professional specializing in hearing and vision or provision of vision or hearing assistive devices.
006.09(H)(iii) SKIN INTEGRITY. A resident is to receive appropriate standards of care and treatment to maintain or improve skin integrity.
006.09(H)(iii)(1) PREVENT PRESSURE SORES. Appropriate standards of care and treatment are to be implemented to prevent a resident who enters the facility without a pressure sore from developing pressure sores unless the individual’s clinical condition demonstrates that pressure sores were unavoidable.
006.09(H)(iii)(2) PROMOTE HEALING. Appropriate standards of care and treatment are to be implemented for each resident with a pressure sore to promote healing, prevent infection and prevent other areas from occurring.
006.09(H)(iii)(3) OTHER OPEN AREAS. Appropriate standards of care and treatment are to be implemented to prevent a resident from developing skin excoriation, skin tears, other open areas unless the individual’s condition demonstrates that they were unavoidable.
006.09(H)(iv) URINARY AND BOWEL FUNCTION. Appropriate standards of care and treatment are to be implemented for residents who have or are at risk for elimination problems. Care and treatment must be provided to:
(1) Prevent urinary tract infection;
(2) Restore bladder and bowel function unless the resident’s condition demonstrates that the loss in bladder and bowel function is unavoidable;
(3) Keep residents free of odors not caused by a clinical condition;
(4) Keep residents free from skin breakdown related to bladder or bowel incontinence;
(5) Keep residents free of fecal impactions and signs of discomfort from bowel constipation; and
(6) Ensure a resident who enters the facility without an indwelling catheter does not receive an indwelling catheter unless the resident’s clinical condition demonstrates that catheterization was necessary.
006.09(H)(v) RANGE OF MOTION. Appropriate standards of care and treatment are to be implemented to improve or maintain each resident’s range of motion unless the resident’s clinical condition demonstrates a decline in range of motion was unavoidable.
006.09(H)(vi) MENTAL AND PSYCHOSOCIAL FUNCTIONING. Appropriate standards of care and treatment are to be implemented to promote each resident’s mental and psychosocial functioning.
006.09(H)(vi)(1) SOCIAL SERVICE SUPPORT. Appropriate methods must be implemented to assist the resident in meeting treatment goals, address resident needs, and provide social service support in meeting each resident’s needs and individuality, including:
(a) Decreased social interaction; and
(b) Increased withdrawn, angry, or depressive behaviors.
006.09(H)(vi)(2) PROVISION OF ACTIVITIES. Daily activities to stimulate and promote the physical, spiritual, social, emotional, and intellectual well-being of each resident are to be provided. The activity program must promote the resident’s self-respect, self-expression, and choice.
006.09(H)(vi)(3) SPECIAL NEEDS. Appropriate standards of care and treatment are to be implemented to prevent complications, infections, discomfort, and skin excoriations to residents receiving the following special services:
(a) Gastric tubes;
(b) Colostomy, ureterostomy, or ileostomy care;
(c) Parenteral and enteral fluids;
(d) Injections;
(e) Tracheostomy care;
(f) Tracheal suctioning;
(g) Respiratory care;
(h) Foot care; and
(i) Prostheses.
006.09(I) ACCIDENTS. Appropriate standards of care and treatment must be implemented to prevent resident accidents. The environment must be free from hazards over which the licensee has control.
006.09(I)(i) ACCIDENT POLICIES AND PROCEDURES. Policies and procedures must be implemented which address:
(1) Investigation, including documentation of the accidents to include identification and evaluation of individual resident causal factors;
(2) Method for tracking and identification of trends;
(3) Development of interventions to prevent the accident from recurring; and
(4) Reevaluation of the effectiveness of the interventions.
006.09(J) NUTRITION. Appropriate standards of care and treatment must be implemented to maintain nutritional status of each resident.
006.09(J)(i) FOOD SERVICE. How each resident is to receive a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. When a licensee contracts for the services of an outside food service management company, the licensee remains responsible for compliance with this chapter.
006.09(J)(i)(1) UNPLANNED WEIGHT LOSS. A resident may not incur an unplanned significant weight loss or other indicator of malnourishment unless the resident’s clinical condition demonstrates that this is not possible. The licensee must evaluate current height and weight status of each resident. Each resident must have a recorded weight no less than monthly with follow-up on unexplained gains and losses. Alternative methods of anthropometric assessment may be used, and the results documented.
006.09(J)(ii) ASSISTIVE DEVICES. Assistive devices for eating are to be provided to residents who need them.
006.09(J)(iii) HYDRATION. Each resident must be provided with sufficient fluid intake to maintain proper hydration and health.
006.10 ADMINISTRATION OF MEDICATION. The licensee must implement policies and procedures to ensure residents receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and prevailing professional standards.
006.10(A) METHODS OF ADMINISTRATION OF MEDICATION. When the licensee is responsible for the administration of medication, it must be accomplished by the following methods:
006.10(A)(i) SELF-ADMINISTRATION. The licensee must allow residents of the facility to self-administer medication, with or without supervision, when resident assessment determines resident is capable of doing so.
006.10(A)(ii) LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes licensed health care professionals for whom medication administration is included in the scope of practice, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards.
006.10(A)(iii) PROVISION OF MEDICATION BY A PERSON OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes persons other than a Licensed Health Care Professional in the provision of medications, the licensee must comply with Neb. Rev. Stat. §§ 71-6718 to 71-6742.
006.10(A)4(iv) FACILITY NOT RESPONSIBLE FOR MEDICATION ADMINISTRATION. When the licensee is not responsible for the administration or provision of medications, the licensee is responsible for the overall supervision, safety, and welfare of the resident.
006.10(B) MEDICATION RECORD. Each resident must have an individual medication administration record, which is to include the following:
(i) The name of the facility;
(ii) The name of the resident;
(iii) The room and bed number of the resident;
(iv) Resident identification number;
(v) The name of the medication prescribed;
(vi) The strength of the individual dose;
(vii) Directions for administration of the medication;
(viii) Name of physician; and
(ix) Drug allergies and sensitivities.
006.10(C) MEDICATION DOCUMENTATION. The dose administered to the resident must be properly documented on the medication record by the person who administered the drug, after the drug is administered. For oral medications, the actual act of swallowing must be observed.
(i) If the resident refuses the medication, the refusal and the reason for the refusal must be documented as refused on the medication record; and
(ii) Medications must be administered by the same person who prepared the dose, except under single unit dose package distribution systems.
006.10(D) MEDICATION ERRORS. The licensee must ensure that its medication error rates are not 5% or greater, residents are free from significant medication errors, and the licensee has a system for recording and reporting medication errors and adverse medication effects to the prescribing medical practitioner.
006.11 DIETARY SERVICES. The licensee must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. In the event that a licensee contracts for the services of an outside food service management company, the licensee remains responsible for compliance with this chapter.
006.11(A) MENUS AND NUTRITIONAL ADEQUACY. The menus must:
(i) Be developed and implemented to meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, with provision for ensuring adequate intake of calories and fluids;
(ii) Be designed to be compatible with the food preferences of the majority of the residents of the facility, with the physicians’ orders, and with the physical needs of each resident;
(iii) Offer substitutes of similar nutritive value to residents who refuse food; and
(iv) Include therapeutic diets when prescribed by the medical practitioner.
006.11(B) FREQUENCY OF MEALS. At least 3 meals daily, at regular times comparable to normal mealtimes in the community, must be provided.
006.11(C) FOOD SUPPLY. Supplies of staple foods for a minimum of a 7-day period and perishable foods for a 3-day period must be maintained on the premises. Food must be procured from sources approved or considered satisfactory by federal, state, or local authorities.
006.11(D) FOOD PREPARATION. Foods are to be prepared by methods that conserve the food’s nutritive value, flavor, and appearance. Foods must be attractively served at the proper temperatures. Recipe resources must be available.
006.11(E) FOOD CODE. The licensee must comply with the Food Code.
006.12 PHARMACOTHERAPY SERVICES. The licensee must provide routine and emergency drugs, devices and biologicals to its residents, or obtain them under an agreement. The storage, control, handling, administration, and provision of drugs, devices, and biologicals must be in accordance with state laws and regulations relating to same, and to the practice of pharmacy and medicine and surgery.
006.12(A) PHARMACOTHERAPY SERVICES SUPERVISION. The licensee must employ or obtain the services of a Nebraska-licensed pharmacist to provide for the development, coordination, and supervision of all pharmaceutical services. The pharmacist is responsible for:
(i) Consultation on all aspects of the provision of pharmacotherapy services in the facility;
(ii) Ensuring that the pharmacotherapy service has procedures for control and accountability of all medications throughout the facility;
(iii) Ensuring that medication records are in order and that an account of all Schedule II and III controlled substances is maintained and reconciled;
(iv) Maintaining records of receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation;
(v) Participation as an interdisciplinary team member related to medication regimen for the resident in the comprehensive assessment, assessment review, and care planning process; and
(vi) Reviewing the drug regimen of each resident at least monthly and reporting any irregularities to the primary medical practitioner and Director of Nursing Services in accordance with standards of care. The drug regimen review must include a signed and dated statement that:
(1) No potential problems were found;
(2) A problem was found but it was deemed not significant;
(3) A significant problem was found; and
(4) The statement must include a description of the situation and the information that was communicated to the individual with the authority to correct it, usually the medical practitioner.
006.12(B) CONTROLLED SUBSTANCES AND PRESCRIPTION DRUGS. The licensee must comply with the requirements of the Uniform Controlled Substances Act.
006.12(C) BULK SUPPLY. Any licensee may purchase bulk quantities of non-prescription drugs, devices, and biologicals and may administer these medications to individual residents in the facility only on the order of a medical practitioner.
006.12(D) DRUG ACCOUNTABILITY AND DISPOSITION. The licensee must implement procedures for storing and disposing of drugs, devices, and biologicals in accordance with State and local laws.
006.12(D)(i) DRUG STORAGE. All drugs, devices, and biologicals are to be stored in locked areas and stored in accordance with the manufacturer’s or pharmacist’s instructions for temperature, light, humidity, or other storage instructions. Drugs, devices and biologicals are to be stored in the container in which they are received from the pharmacy. Only authorized personnel who are designated by the licensee as responsible for administration or provision of medications may have access to the medications.
006.12(D)(i)(1) CONTROLLED SUBSTANCE STORAGE. The licensee must provide separately locked, permanently affixed compartments for storage of controlled medications listed in Schedule II of Neb. Rev. Stat. § 28-405, and other medications subject to abuse, except when the licensee uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
006.12(D)(i)(2) CONTROLLED SUBSTANCE COUNT. A shift count of all controlled substances in Schedules II and III must be completed by 2 persons with each initialing the separate medication control sheet for each medication when the count is completed. The individual medication administration record can serve as a record of the receipt and disposition of all other Controlled Substances.
006.12(D)(ii) COMPOUNDING, DISPENSING AND LABELING. Only the pharmacist, or a pharmacist intern under the direct supervision of the pharmacist, may compound or dispense drugs, devices or biologicals or make label changes. The licensee must ensure that labeling of drugs, devices, or biologicals are in accordance with Neb. Rev. Stat. § 71-476.
006.12(D)(iii) DISCONTINUED, OUTDATED, DETERIORATED DRUGS, DEVICES AND BIOLOGICALS. No discontinued, outdated, or deteriorated drugs, devices and biologicals may be used or be available for use.
006.12(D)(iv) SEPARATE STORAGE REQUIREMENT. Drugs, devices and biologicals for external use, as well as poisons, must be stored separately from all other medications.
006.12(D)(v) EMERGENCY BOX DRUG. Authorized personnel of the licensee may administer medications to residents in accordance with Neb. Rev. Stat. §§ 71-2410 through 71-2413.
006.12(D)(vi) MEDICATION INTEGRITY AND LABELING. All medications used are to be labeled in accordance with Neb. Rev. Stat. § 71-476 and currently accepted professional standards of care, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
006.12(D)(vii) DISPOSITION OF PRESCRIPTION MEDICATIONS. The licensee must properly dispose of all prescription medications that are discontinued or expired. Medications may not be saved for use by other residents or be shared with anyone.
006.12(D)(vii)(1) DISCHARGED RESIDENT MEDICATIONS. The licensee may send prescribed medication with a resident upon discharge only with the order of a medical practitioner, and all medication containers must be properly labeled by the dispensing pharmacy.
006.12(D)(vii)(2) DISCONTINUED MEDICATIONS. When any prescription medication is discontinued permanently or the resident has expired, the licensee must either:
(a) Return the medication to the dispensing pharmacy in accordance with Neb. Rev. Stat. § 38-28,107;
(b) Properly dispose of any residue; or
(c) Controlled substances must be disposed of in accordance with Neb. Rev. Stat. § 28-414.05(3).
006.13 SPECIALIZED REHABILITATIVE SERVICES. All nursing facilities and skilled nursing facilities must provide specialized rehabilitative services as ordered by the medical practitioner and identified in the resident’s comprehensive plan of care. The specialized rehabilitative services must be designed to maintain and improve the residents ability to function independently, to prevent, as much as possible, advancement of progressive disabilities, and to restore maximum function, independence and self-determination.
006.14 ALZHEIMER’S AND DEMENTIA CARE. A licensee that holds itself out to provide Alzheimer’s or dementia care must do so in accordance with Neb. Rev. Stat. §§ 71-516.01 through 71-516.04.
006.15 DENTAL SERVICES. The licensee must assist residents in obtaining routine and 24-hour dental care to meet the needs of each resident. The licensee must, if necessary, assist the resident in:
(A) Making appointments;
(B) Arranging transportation to and from the dentist’s office; and
(C) Referring residents with lost or damaged dentures, chewing difficulties, oral ulcerations, or oral pain to a medical practitioner.
006.16 OUTSIDE RESOURCES. If the licensee does not employ a qualified professional person to furnish a specific service required to meet the needs of a resident, the licensee must have the services furnished to residents by a person or agency outside the licensee under an arrangement or agreement. The licensee is responsible for obtaining services that meet professional standards that apply to professionals and the timeliness of the services.
006.17 RECORDKEEPING REQUIREMENTS. The licensee must maintain and safeguard clinical and other records in accordance with 175 NAC 1 and this chapter. These records must be maintained in accordance with accepted professional standards and practice.
006.17(A) CLINICAL RECORD. The clinical record must be complete and contain:
(i) The admission number of the resident;
(ii) The insurance and payment numbers for the resident;
(iii) The resident’s assessments, including those assessments performed by services under agreement with the licensee;
(iv) The name of the attending medical practitioner, including the dentist; and
(v) The interdisciplinary progress notes to include effect of care provided, residents’ response to treatment, change in condition, and changes in treatment.
006.17(B) ELECTRONIC RECORD SIGNATURES. If the licensee maintains a resident’s record by computer, electronic signatures are acceptable. If attestation is done on computer records, safeguards to prevent unauthorized access, and to provide for reconstruction of information must be in place.
006.17(C) RECORD RETENTION AND PRESERVATION. Resident clinical records must be maintained and preserved as required in 175 NAC 1 and this chapter. In case of a minor, records must be maintained for 7 years after the resident obtains majority under Nebraska law. In cases in which a licensee ceases operation, all records of each resident must be transferred to the health care facility to which the resident moves. All other resident records of a licensee ceasing operation must be disposed of by shredding, burning, or other similar protective measures in order to preserve the resident’s rights of confidentiality. Records or documentation of the actual fact of resident medical record destruction must be permanently maintained.
006.17(D) OTHER RESIDENT RECORDS. The licensee must maintain records pertaining to resident personal funds accounts as applicable, financial matters, resident possessions, and statements of resident rights and responsibilities. Resident possessions must be inventoried at time of admission, updated as needed, and accounted for upon discharge from the facility.
006.17(E) OTHER FACILITY RECORDS. The licensee must have and maintain the following records:
(i) A count of residents taken at the same hour each day and totaled at the end of 365 days. The total represents the number of “individual care days for the past 12 months”;
(ii) Written policies and procedures that govern all services provided by the licensee. Policies and procedures must address all areas identified in 175 NAC 1 and this chapter;
(iii) Written disaster plan;
(iv) Contracts with outside resources to furnish required services not provided directly by the licensee; and
(v) Records regarding operation and maintenance of the facility.
006.17(F) INSPECTION OF RECORDS. All records must be available for inspection and copying by authorized representatives of the Department.
006.18 INFECTION CONTROL. The licensee must maintain facility practices to provide a sanitary environment and to avoid sources and transmission of infections and communicable diseases. This includes the establishment and maintenance of an infection control program for the prevention, control, and investigation of infections and communicable disease as outlined in 175 NAC 1 and this chapter.
006.18(A) VACCINATIONS. The licensee must offer vaccinations to residents and staff in accordance with Neb. Rev. Stat. §§ 71-468 through 71-469.
006.18(B) PREVENTION OF CROSS-CONTAMINATION. The licensee must prevent cross-contamination between residents in provision of care, sanitation of equipment and supplies, and cleaning of resident’s rooms.
006.18(C) DISEASE TRANSMISSION. The licensee must prohibit employees known to be infected with any disease in communicable form to work in any area of the facility in a capacity in which there is a likelihood of the employee transmitting disease to residents or to other facility personnel, food, or food contact surfaces with pathogenic organisms.
006.18(D) HANDWASHING REQUIREMENT. The licensee must require staff to wash their hands after each direct resident contact for which handwashing is indicated by acceptable professional practice.
006.19 ENVIRONMENTAL SERVICES. The licensee must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use personal belongings to the extent possible and in compliance with 175 NAC 1 and this chapter.
006.19(A) EQUIPMENT, FIXTURES, AND FURNISHINGS. The licensee must keep all equipment, fixtures, and furnishings clean, safe and in good repair.
006.19(A)(i) EQUIPMENT. The licensee must provide equipment adequate for meeting resident needs as specified in each resident’s care plan.
006.19(A)(ii) FURNISHINGS. Common areas and resident sleeping areas must be furnished with beds, chairs, sofas, tables, and storage items that are comfortable and reflective of resident needs and preferences.
006.19(B) PREVENTIVE MAINTENANCE. The licensee must establish and implement a process designed for routine and preventive maintenance of equipment and furnishings to ensure that such equipment and furnishings are safe and function to meet their intended use.
006.19(C) LINENS. The licensee is responsible for providing each resident with an adequate supply of clean bed, bath, and other linens as necessary for care and treatment of residents. The linens must be in good repair.
006.19(C)(i) STORAGE AND HANDLING. The licensee must establish and implement procedures for the storage and handling of soiled and clean linens.
006.19(C)(ii) LAUNDRY WATER TEMPERATURES. When the licensee launders bed and bath linens, water temperatures to laundry equipment must exceed 140 degrees Fahrenheit if laundry is not appropriately sanitized or disinfected by other acceptable methods in accordance with the manufacturer’s instructions or other documentation.
007. PHYSICAL PLANT STANDARDS. The facility must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided.
007.01 SUPPORT AREAS. The licensee may share the following support service areas among the detached structures, care, and treatment suites, and with other licensed facilities in this section.
007.01(A) DIETARY. If food preparation is provided on site, the licensee must dedicate space and equipment for the preparation of meals. Food service and facilities must comply with the Food Code, except when used only for training or activity purposes.
007.01(B) LAUNDRY. The licensee must provide laundry services. Such service may be provided by contract or on-site by the licensee. If contractual services are used, the licensee must provide areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen. If on-site services are provided, the licensee must have areas dedicated to laundry.
(i) If the licensee provides personal laundry areas, the areas must be equipped with a washer and dryer for use by residents. In new construction, the licensee must have a conveniently located sink for soaking and hand washing of laundry;
(ii) A bulk laundry area must be divided into separate soiled (sort and washer areas) and clean (drying, folding, and mending areas) rooms. In new construction and new facilities, a separate soaking and hand washing sink and housekeeping room must be provided in the laundry area; and
(iii) Separate clean linen supply storage areas must be conveniently located in each care and treatment location.
007.01(C) WASTE PROCESSING. The licensee must provide areas to collect, contain, process, and dispose of medical and general waste produced within the facility in such a manner as to prevent the attraction of rodents, insects and vermin, and to minimize the transmission of infectious diseases.
007.01(D) HOUSEKEEPING ROOM. The licensee must have a room with a service sink and space for storage of supplies and housekeeping equipment.
007.02 CARE AND TREATMENT AREAS. The licensee must provide a physical environment that facilitates and supports the safety and dignity of residents and accommodates the needs of the resident population.
007.02(A) CARE AND TREATMENT AREA REQUIREMENTS. Care and treatment areas must contain a control point, medication station, and clean storage and utility room. The facility must not share these areas among detached structures.
007.02(A)(i) CONTROL POINT. The licensee must have an area or areas for charting and resident records, space for storage of emergency equipment and supplies, and call and alarm annunciation systems.
007.02(A)(ii) MEDICATION STATION. The licensee must have a medication station for storage and distribution of drugs and routine medications. Distribution may be done from a medicine preparation room or unit, from a self-contained medicine-dispensing unit, or by another system. If used, a medicine preparation room or unit must be under visual control of nursing staff and must contain a work counter, sink, refrigerator, and double-locked storage for controlled substances.
007.02(A)(iii) CLEAN STORAGE AND UTILITY ROOM. The licensee must have separate areas for soiled and clean materials. The area for soiled materials must contain a fixture for disposing waste and a handwashing sink.
007.02(B) EQUIPMENT AND SUPPLIES. The licensee must have services and space to distribute, maintain, clean and sanitize durable medical instruments, equipment, and supplies required for the care and treatment of residents.
007.02(B)(i) DURABLE MEDICAL EQUIPMENT. The licensee must ensure that durable medical equipment is tested and calibrated in accordance with the manufacturer’s recommendations.
007.02(B)(ii) EQUIPMENT STORAGE. The licensee must have space to store equipment, stretchers, wheelchairs, supplies, and linen out of the path of normal traffic.
007.02(C) REHABILITATIVE. If the licensee provides rehabilitative services, the licensee must have at least 1 treatment room or cubicle, an area for specialized treatment and care, a handwashing sink or sinks, storage for equipment and supplies, a call system, and areas to allow for resident toileting, dressing, and consultation.
007.02(D) MENTAL HEALTH. If the licensee provides a specialized area or unit designated for psychiatric or mental health services, the licensee must have space and equipment that allows for resident and staff safety. The area must have separate quiet and noisy activity areas, dining areas, private and group areas for specialized treatment and care, a handwashing sink or sinks, storage for equipment and supplies, and security systems. In rooms where care and treatment is provided to abusive or suicidal residents, the rooms must have:
(i) Tamper-resistant air distribution devices, lighting fixtures, sprinkler heads, and safety devices;
(ii) Ventilation, exhaust, heating, and cooling components that are inaccessible to residents;
(iii) Bedroom, toilet, and bathing room doors that are not lockable or capable of being obstructed from within; and
(iv) Electrical outlets protected by ground fault interrupting devices.
007.02(E) OUTPATIENT AREAS. Areas designated for the care and treatment of clients not residing in the facility must comply with the following standards:
(i) Areas must not interfere with residents currently residing in the facility;
(ii) Furniture and equipment must meet care and treatment needs;
(iii) Toilets must be easily accessible from all program areas; and
(iv) Sufficient inside and outside space that accommodates the full range of program activities and services.
007.03 CONSTRUCTION STANDARDS. The licensee must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided and in compliance with Neb. Rev. Stat. § 71-439, 175 NAC 1, and this chapter.
007.03(A) INTERPRETATIONS. All dimension, sizes, and quantities noted herein must be determined by rounding fractions to the nearest whole number.
007.03(B) FLOOR AREA. Floor area is the space with ceilings at least 7 feet in height and excludes enclosed storage, toilets and bathing rooms, corridors, and halls. The space beyond the first 2 feet of vestibules and alcoves less than 5 feet in width is not included in the required floor area. In rooms with sloped ceilings, at least half of the ceiling must be at least 7 feet in height. Areas less than 5 feet in height are not included in the required floor area.
007.03(C) DINING AREAS. Dining areas must:
(i) Provide for natural light and ventilation;
(ii) Be furnished with tables and chairs that accommodate or conform to resident needs;
(iii) Have a floor area of 15 square feet per resident in existing facilities and 20 square feet per resident in new construction;
(iv) Allow for group dining at the same time in either separate dining areas or a single dining area, dining in 2 shifts, or dining during open dining hours; and
(v) Not be used for sleeping, offices, or corridors.
007.03(D) ACTIVITY AREAS. The licensee must have space for resident socialization and leisure time activities. Activity areas must:
(i) Provide for natural light and ventilation;
(ii) Have furnishings to accommodate group and individual activities;
(iii) Have a floor area of at least 15 square feet per resident residing in bedrooms and may be combined with dining areas;
(iv) Not be used for sleeping, offices, or corridors; and
(v) Be available to all residents.
007.03(E) BATHING ROOMS. The licensee must have a bathing room consisting of a tub or shower adjacent to each bedroom, or a central bathing room on each sleeping floor. Tubs and showers, regardless of location, must be equipped with hand grips or other assistive devices as needed by the resident.
(i) In new construction where a central bathing room is provided, the room must open off the corridor and contain a toilet and sink or have an adjoining toilet room; and
(ii) The licensee must have 1 bathing fixture per 30 licensed beds.
007.03(F) TOILET ROOMS. Existing facilities must have a toilet and sink adjoining each bedroom or shared toilet facilities may be provided as follows:
(i) 1 toilet and sink per 8 licensed beds in existing facilities;
(ii) 1 toilet and sink per 4 licensed beds in new facilities and new construction; and
(iii) New construction must have a toilet room provided adjoining each resident bedroom or in each apartment or dwelling.
007.03(G) RESIDENT ROOM REQUIREMENTS. The licensee must have bedrooms which allow for sleeping, afford privacy, provide access to furniture and belongings, and accommodate the care and treatment provided to the resident.
007.03(G)(i) RESIDENT BEDROOMS. All resident bedrooms must:
(1) Not be located in any garage, storage area, shed, or similar detached building;
(2) Be a single room located within an apartment, dwelling, or dormitory-like structure;
(3) Not be accessed through a bathroom, food preparation area, laundry, or another bedroom;
(4) Have a window with an unobstructed view of at least 10 feet;
(5) Contain at least 45 cubic feet of enclosed storage volume per resident in dressers, closets or wardrobes;
(6) Be located within 150 feet of a control point if nursing services are provided in the room; and
(7) Allow for an accessible arrangement of furniture providing a minimum of 3 feet between the heads of the beds in multiple bedrooms.
007.03(G)(ii) EXISTING OR NEW FACILITY FLOOR AREAS. Resident bedrooms in an existing building and in new facilities must have at least the following floor areas:
(1) Single bedrooms: 100 square feet;
(2) Multiple bedrooms: 80 square feet with a maximum of 4 beds; or
(3) Apartments or dwellings: 110 square feet for 1 resident plus 100 square feet for each additional resident.
007.03(G)(iii) NEW CONTSTRUCTION FLOOR AREAS. Resident bedrooms in new construction must have at least the following floor areas:
(1) Single bedrooms: 120 square feet;
(2) Multiple bedrooms: 100 square feet per bed with a maximum of 2 beds; or
(3) Apartments or dwellings: 120 square feet for 1 resident plus 110 square feet for each additional resident.
007.03(H) ISOLATION ROOMS. Number and type of isolation rooms in the facility must be based upon infection control risk assessment of the facility.
(i) The licensee must make provisions for isolating residents with infectious diseases; and
(ii) In new construction, if the licensee has a designated isolation room, the isolation room must be equipped with handwashing and gown changing facilities at the entrance of the room.
007.03(I) EXAMINATION ROOMS. Must have a minimum floor area of 80 square feet and a minimum of 3 feet clear dimension around 3 sides of the examination table or chair.
007.03(J) TREATMENT ROOMS. Treatment rooms used for procedures performed under topical, local, or regional anesthesia without pre-operative sedation, must have a minimum floor area of 120 square feet and a minimum of 10 feet clear dimension.
007.03(K) CORRIDORS. Corridors must be wide enough to allow passage and be equipped as needed for the residents to minimize injury. All stairways and ramps must have handrails.
007.03(L) DOORS. Doors must be wide enough to allow passage and be equipped for privacy, safety, and with assistive devices to minimize resident injury.
(i) Bedroom, toilet, and bathing room doors must provide privacy yet not create seclusion or prohibit staff access for routine or emergency care; and
(ii) In new construction, all resident-used toilet and bathing rooms with less than 50 square feet of clear floor area must not have doors that swing solely inward.
007.03(M) OUTDOOR AREAS. The licensee must have an outdoor area for resident usage. It must be equipped and situated to allow for resident safety and abilities.
007.03(N) HANDWASHING SINKS. The licensee must have a handwashing sink equipped with towel and soap dispenser in all examination, treatment, isolation, and toilet rooms.
007.03(O) EMERGENCY TELEPHONE. The licensee must provide a non-coin operated telephone or telephones with emergency numbers for use by residents.
007.03(P) PRIVACY. Multiple bed resident rooms, visual privacy and window curtains must be provided for each resident. In new facilities, the curtain layout must totally surround each care and treatment location and not restrict access to the entrance to the room, lavatory, toilet, or enclosed storage.
007.03(Q) FINISHES. The licensee must have washable room finishes in isolation rooms, clean workrooms, and food preparation areas with smooth non-absorptive surfaces that are not physically affected by routine housekeeping cleaning solutions and methods. Acoustic lay-in ceilings, if used, must not interfere with infection control. Perforated, tegular, serrated cut, or highly textured tiles are not acceptable.
007.04 BUILDING SYSTEMS. Licensees must have building systems that are designed, installed, and maintained to remain operational.
007.04(A) WATER AND SEWER SYSTEMS. A licensee must have an accessible, adequate, safe, and potable supply of water and a sanitary and functioning sewage system that is maintained in compliance with applicable federal and state statutes and regulations.
007.04(B) HOT AND COLD-WATER SYSTEM. Hot and cold water must be provided to all handwashing and bathing locations. The hot water system must have the capacity to provide continuous hot water in a temperature range as required by 175 NAC 1.
007.04(C) HEATING AND COOLING SYSTEMS. The licensee must have a heating and air conditioning system capable of maintaining the following:
(i) In existing and new facilities, a temperature of at least 70 degrees Fahrenheit during heating conditions and that does not exceed 85 degrees Fahrenheit during cooling conditions;
(ii) In new construction, a temperature of at least 75 degrees Fahrenheit during heating conditions and that does not exceed 80 degrees Fahrenheit during cooling conditions;
(iii) Airflow must move from clean to soiled locations. In new construction, air movement must be designed to reduce the potential of contamination of clean areas; and
(iv) Openings to the heating and cooling system must not be located where subject to wet cleaning methods or body fluids.
007.04(D) VENTILATION SYSTEM. The licensee must have ventilation that prevents the concentrations of contaminants that impair health or cause discomfort to residents and employees.
007.04(E) ELECTRICAL SYSTEM. The licensee must have an electrical system that has sufficient capacity to maintain care and treatment services provided. The electrical system must be properly grounded. Light levels are measured at 30 inches above the floor in multiple areas in the room being evaluated and the readings are averaged. The facility must have minimum illumination levels as follows:
(i) General purpose areas: 5-foot candles;
(ii) General corridors and resident living areas: 10-foot candles;
(iii) Personal care and dining areas: 20-foot candles;
(iv) Reading and activity areas: 30-foot candles;
(v) Food preparation areas: 40-foot candles;
(vi) Hazardous work surfaces: 50-foot candles;
(vii) Care and treatment locations: 70-foot candles;
(viii) Examination task lighting: 100-foot candles; and
(ix) Reduced night lighting in resident rooms where nursing services are provided and resident-used toilet and bathing rooms and corridors.
007.04(F) ESSENTIAL POWER SYSTEM. The licensee must have an emergency power generator for any care and treatment location with electrical life support equipment. Existing and new facilities must maintain emergency power for essential care and treatment equipment and lighting, medical gas systems, and nurse call systems.
(i) In facilities constructed on or after the effective date of this chapter, emergency power must be provided for essential care and treatment equipment, lighting, nurse call systems, ventilation, heating, and medical gas systems; and
(ii) Facilities with electrical life support equipment must have an essential power system with an on-site fuel source. The minimum fuel source capacity must allow for non-interrupted system operation.
007.04(G) CALL SYSTEMS. The licensee must have a call system that is operable from resident beds, resident-used toilet and bathing areas, and examination and treatment areas. The system must transmit a receivable (visual, audible, tactile, or other) signal to on-duty staff which readily notifies and directs the staff to the location where the call was activated.
007.04(H) MEDICAL GAS SYSTEM. The licensee must safely provide medical gas and vacuum by means of portable equipment or building systems as required by residents receiving care and treatment.
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