TITLE 175 - HEALTH CARE FACILITIES AND SERVICES LICENSURE
CHAPTER 3 - REGULATIONS GOVERNING CENTERS FOR THE DEVELOPMENTALLY DISABLED
001. SCOPE AND AUTHORITY. These regulations govern the licensing of Centers for the Developmentally Disabled facilities under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.
002. DEFINITIONS. Definitions set in the Health Care Facility Licensure Act, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.
002.01 GROUP RESIDENCE. Any group of rooms located within a building or structure forming a habitable unit with living, sleeping, cooking, and eating facilities for four (4) or more, developmentally disabled persons, operated by the same or identical lessee, owner, or management is a group residence.
002.02 AMBULATORY. The ability to walk without assistance is ambulatory.
002.03 BARRIER. A circumstance or obstacle that prevents a client from making progress toward their goals is a barrier.
002.04 HABILITATION. A process aimed at helping disabled people attain, keep, or improve skills and functioning for daily living is habilitation.
002.05 NON-AMBULATORY. Inability to walk without assistance is non-ambulatory.
002.06 USABLE FLOOR AREA. The floor area in a room exclusive of space used for entrance, vestibules, closets, toilet areas, and bathing areas is usable floor area.
003. LICENSING. To receive a license, an applicant must submit a complete application and meet the requirements for a license set out in the Health Care Facility Licensure Act, 175 NAC 1, and this chapter.
004. GENERAL REQUIREMENTS. The following requirements are applicable to all licenses.
004.01 EFFECTIVE DATES AND TERM OF LICENSE. The license of a Center for the Developmentally Disabled expires annually on November 30.
004.02 INITIAL LICENSURE AND RENEWAL FEES. Initial licensure and renewal fees for Centers for the Developmentally Disabled are $150.
005. INSPECTIONS. Requirements for inspections are set out in 175 NAC 1.
006. PHYSICAL PLANT STANDARDS. Each building where services are provided must be maintained by licensee in a manner that is safe, clean, and functional for the clients who reside there.
006.01 CLIENT BEDROOMS. Single bedrooms for ambulatory clients must provide at least 80 square feet of usable floor area with a side dimension of not less than 7 feet - 0 inches. All client bedrooms must have windows which provide an unobstructed view of not less than 15 feet - 0 inches in at least 1 horizontal direction.
006.02 MULTI-BEDROOMS. Ambulatory clients must be provided at least 60 square feet of usable floor space for each client. There must be at least 3 feet - 0 inches between beds placed side-to-side and not less than 3 feet - 0 inches between the heads of the beds. The amount of usable floor space in a client bedroom is determined after taking adjustments into account as stated in this chapter. A bedroom must have no more than 4 beds.
006.03 WINDOWS. Bedrooms must be exterior rooms with at least 1 window which is easily opened to the outside. The minimum total area of the window or windows measured between stops -- clear width when opened, must be at least 10 percent of the usable floor area. All windows must be provided with screens which are maintained in good repair. Combination storm window screens are acceptable. Full length storm windows may be used during the winter months. Windowsills must not be more than 36 inches above the finished floor. All exterior windows and doors must have serviceable screens except for doors with panic hardware.
006.04 CLOSETS. There must be accessible private and adequate storage space for clothing and personal belongings in the bedroom area for each client. Built-in closets or wardrobes with doors or curtains are acceptable.
006.05 CEILING HEIGHTS. Level ceilings in sleeping rooms must not be less than 7 feet - 0 inches high. In sleeping rooms with sloped ceilings, only the areas with vertical wall heights of 5 feet or more must be included in the required usable floor area. At least half of the usable floor space must have a ceiling not less than 7 feet -0 inches.
006.06 PARTITIONS. Partitions defining each bedroom must run from floor to ceiling.
006.07 CLIENT BEDROOMS. All client bedrooms must be located at or above natural grade level. Non-ambulatory clients must not be housed in bedrooms located above the first floor level.
006.08 DOORS. Doors in a building may be lockable by the occupant if they can be unlocked by a master key from the opposite side. Master keys are to be carried by staff at all times.
006.08(A) INTERIOR DOORS. Excluding time out room doors, interior doors must not have vision panels.
006.08(B) DOOR LOCKS. Door locks installed on sleeping room doors must be lockable from the corridor side only, except where such doors open directly to the outside of the building. Sleeping room doors leading directly to the outside of the building may be lockable on the room side. All locks must permit exit from a room by a simple operation without the use of a key.
006.08(C) DOOR WIDTHS. Door widths must not be less than 3 feet wide to allow a minimum clear opening of 32 inches in the fully opened position.
006.08(D) DOOR ALARMS. Door alarms must be provided for exterior doors when clients requiring such supervision is established by the Individual Program Plan.
006.09 CORRIDORS. Corridor widths must not be less than 3 feet - 0 inches.
006.10 BEDS. Each client must have an individual bed. Adult beds must be at least 36 inches wide. Adult size beds must be provided for individuals 14 years of age and older. Each bed must have a clean, firm, comfortable mattress. Beds must be of suitable construction and dimensions to accommodate persons using them. Bunk beds, roll-aways and trundles are not permitted.
006.10(A) BEDDING. All beds provided for clients must be supplied with suitable pillowcases and bottom and top sheets. All bedding, including mattresses, mattress pads, quilts, blankets, pillows, sheets, spreads, and all bath linen must be kept clean. Bedding, including mattresses, mattress pads, quilts, blankets, pillows, and bed and bath linen which is worn out or unfit for further use must not be used. Bedding must be appropriate to the season. Pillowcases, sheets, and bath linen, after being used by one client, must be washed before they are used by other clients.
006.10(B) BED LINEN. Clean bed linen must be furnished at least once each week, or more frequently, to maintain cleanliness and a clean washcloth, towel or appropriate paper service must be available to each client.
006.11 ROOM FURNISHINGS. All equipment, fixtures, furniture, and furnishings, including windows, draperies, curtains, and carpets must be kept clean and free of dust, dirt, vermin, and other contaminants and must be maintained in good order and repair. Each client must be provided with appropriate individual furniture, including at a minimum a chest of drawers, an individual wardrobe with clothes racks and shelves unless built-in closet space is provided, and a mirror, and at least one chair per bedroom will be provided. Tilted mirrors or mirrors located at a height for wheelchair use must be provided for clients where appropriate. There must be accessible private storage space for clothing in the bedroom area for each client. Each client must have individual racks or other drying space for washcloths and towels.
006.12 TOILETS AND BATHING FACILITIES. Toilet and bathing areas and fixtures must approximate normal patterns found in residential construction and must meet the following requirements:
(A)\tIf there are wheelchair clients in the home, the toilet and bath areas must be large enough for wheelchair use and also to include appropriate fixtures and appurtenances for the wheelchair clients’ use;
(B)\tShower curbs must be omitted to permit access by wheelchairs. An accessible restroom shall provide at least the following fixtures and appurtenances for the wheelchair clients’ use;
(C)\tNo bathroom must open directly into a food preparation area;
(D)\tToilets must provide bar soap or a soap dispenser to be located no higher than 48 inches from the floor;
(E)\tAll toilet and bathing area facilities and fixtures must be kept clean and in good repair;
(F)\tEach bathroom and toilet area must be well-lighted with a mirror over each lavatory; and
(G)\tWherever there is a bathroom, there must be an easily accessible toilet.
006.13 BATHROOMS. Client bathrooms must be provided as follows:
(A)\tOne sink and one toilet for each 6 clients;
(B)\tOne sink when mounted, allows 29 inches clearance from the floor to the bottom of the apron and a maximum rim height of 34 inches;
(C)\tOne toilet with the seat 15 inches to 20 inches from the floor, or 13 inches to 15 inches for children;
(D)\tGrab bars near each side or one side attached and the back of the toilet stool securely attached 32 inches to 34 inches above the parallel to the floor. Grab bars at the side must not be less than 24 inches in front of the toilet. Grab bars must have an outside diameter of not less than 1 1/2 inches and must provide a clearance of 1 1/2 inches between grab bars and adjacent surface. For children's restrooms grab bars must be securely attached 15 inches above the floor and be positioned to extend 16 inches beyond the toilet seat; and
(E)\tToilet tissue must be provided within reach of the toilet seat and at a height of no more than 48 inches from the floor.
006.14 BATHING FACILITIES. Bathing facilities must be provided as follows:
(A)\tOne bathing facility (tub or shower) for each eight clients;
(B)\tBathtubs and showers must be provided with stable grab bars to assist clients; and
(C)\tTowels or warm air hand dryers must be provided with the operating mechanism no higher than 48 inches from the floor and not mounted directly above the sinks.
006.15 DINING AND RECREATION. All facilities must have minimum areas for clients’ dining and recreation which must be at least 10 and 20 square feet respectively per client, or 30 square feet total per client when the area is used for a combination thereof. Space for non-ambulatory mobile clients must be increased by 50 percent. Under no circumstances must the combined recreation and dining space be less than 150 square feet. In residential units that have 8 beds or less, space in the kitchen may be used for dining if the kitchen was laid out to accommodate table space for eating purposes; the space must be located apart from the food preparation area, and 10 square feet per client must be allocated for dining purposes. Furnishings in the dining recreation room must include a couch, chair(s), end tables, dining table and chairs or similar furniture to provide a comfortable setting.
006.16 FOOD SERVICE. The kitchen may be residential in nature in both layout and equipment.
006.17 DISHWASHING. Utilizing an automatic dishwasher or a three compartment sink is adequate if it meets the following requirements:
(A)\tWhen automatic dishwashers are used, the final rinse cycle temperature must not be less than 150 degrees Fahrenheit; and
(B)\tFor chemical sanitization of dishes in a three compartment sink, the following procedure is followed:
(i)\tImmersion for a minimum of one minute in sanitizing solution containing: at least 50 parts per million of available chlorine in water at a temperature not less than 75 degrees Fahrenheit (one-half tablespoon of laundry bleach or similar product containing 5 1/4 percent of available chlorine to each gallon of water provides minimum concentration;
(ii)\tUse another commercial chemical sanitizer which has the equivalent bacterial effect at this level of chlorine. The quantity required will need to be determined on an individual basis. For some, quantity will depend on the hardness or mineral content of the local water supply; or
(iii)\tAt least a 2-compartment sink must be available in each kitchen. It is recommended that, when made up, the strength of sanitizing solutions be at least twice the minimum strength required for the particular sanitizing solution used. One tablespoon of laundry bleach or other solution containing 5 1/4 percent available chlorine to each gallon of water provides 100 parts per million.
006.18 FOOD STORAGE. Dry or staple foods must be stored at least 4-6 inches above the floor in a ventilated room not subject to sewage or wastewater backflow, contamination leakage, water overflow, rodents, or vermin. This requirement does not preclude the use of dry or staple food stored in cabinets in the kitchen if these requirements are met.
006.19 HANDWASHING. There must be a conveniently located handwashing facility in the kitchen.
006.20 COUNTER SPACE. There is cleanable work counter space for the preparation of meals. Formica, vinyl, or resilient type work counter coverings which are free of crevices or cracks are permitted.
006.21 REFRIGERATION. Refrigerators are provided for perishable foods and are kept clean and in good working order and maintain refrigerated foods at from 33 degrees Fahrenheit to 45 degrees Fahrenheit.
006.22 ADMINISTRATION. A room must be provided for the house manager or house parents. If the house manager or family live in the facility, their numbers must be counted in determining the number of toilets and baths, and space allocated for dining and recreation, unless a separate apartment is provided.
006.23 OUTSIDE RECREATION AREA. The lot must be large enough for an outside recreation area commensurable with the number and type of clients in order to effectively promote normalization. In areas where public recreation is not available within one city block of the block where the facility is located, at least 25 square feet of outdoor recreation area per client must be provided.
006.24 GENERAL STORAGE. General storage in addition to linen closets and clients’ room closets must be provided at the ratio of 60 cubic feet per bed.
006.25 VENTILATION. If areas used as kitchens, bathrooms, toilet areas, or laundries are located in rooms without windows, or windows that cannot be opened to the outside air, these areas must be provided with mechanical ventilation with vents leading directly to the outside. If these areas have windows that can be opened to the outside air, mechanical ventilation is not required.
006.26 PLUMBING. Hot and cold water must be piped to all fixtures in the building except cold water shall be piped to the toilet. Hot water at fixtures used by clients for bathing and sinks must at a minimum be 110 degrees Fahrenheit and must not exceed 115 degrees Fahrenheit. In order to prevent a hazard to the clients, mixing valves must be utilized in cases where a client’s Individual Program Plan specifies training in temperature adjustment. Water temperature may not exceed 115 degrees Fahrenheit.
006.27 HEATING AND COOLING. The building must be equipped with a heating system and have a radiator, convertor, or register in each room used by clients that does not constitute a burn hazard. The heating system must be capable of maintaining a temperature of 70-75 degrees Fahrenheit during severe cold weather conditions at an elevation of 30 inches above the floor in all areas used by clients. For all facilities a cooling system is required which is capable of maintaining an indoor temperature of a range from 68 degrees Fahrenheit to 78 degrees Fahrenheit during hot weather conditions at an elevation of 30 inches above the floor in all areas used by clients. Indoor relative humidity must be maintained within the 30-70% range throughout the year. If hot water or steam radiators are used, they must be provided with covers to prevent inadvertent burns.
006.27(A) MECHANICAL ROOMS. Mechanical equipment rooms housing gas-fired heating and hot water equipment must have positive outside combustion air supplied for the equipment.
006.27(B) HEATING APPLIANCES. Every gas-fired or oil-fired heating appliance and hot water and other heating appliance must be vented to the outside air.
006.28 ARTIFICIAL LIGHTING. Each room or area, including storerooms must be provided with light fixtures to provide the following minimum foot candles or lumen per square foot rating at an elevation of 30 inches above the floor. Extension cords and temporary outlets are prohibited. Bare, incandescent bulbs are prohibited in client areas.
006.29 LAUNDRY. Laundry services or facilities for clients must be provided in accordance with the developmental needs of the clients. Separate storage space for soiled and clean laundry must be located in the residence. All damp soiled linen such as bed linen, towels, and washcloths must be maintained in covered waterproof containers.
006.29(A) LAUNDRY EQUIPMENT. Domestic type equipment must be provided for the laundry. Laundry equipment must not be located in the kitchen.
006.30 ELEVATORS. All elevators in a Center for the Developmentally Disabled must be inspected for safety at least once a year by the Nebraska State Department of Labor.
006.31 FLOORS, WALLS, AND CEILINGS. The floors of all rooms, hallways, bathrooms, storerooms, and all other spaces used or traversed by clients and staff must be of such construction as to be easily cleaned, shall be smooth, and shall be kept clean and in good repair. Cleaning of floors must be so done as to minimize the raising of dust and exposure of clients thereto. Ceilings in areas where food is stored or prepared and in which dishes and utensils are washed must be of such construction as to be easily cleaned, must be smooth, and must be kept clean and in good repair. The safe use of rugs, carpets, or natural stone which can be kept clean is permitted. Abrasive strips to reduce or prevent slipping shall be used where slippery surfaces present a hazard.
006.31(A) DIRT FLOORS. Dirt floors in a basement area are prohibited. Basement floors must be concrete with proper drainage.
006.31(B) WALLS. Walls must be free from spaces which may harbor vermin. Walls in other areas of the facility must have a cleanable finish. Lead based paints are not permitted in any area of the facility.
006.31(C) CEILINGS. Enamel-painted plaster, gypsum board, concrete and vinyl-coated suspended ceiling panels, or equally washable surfaces are adequate.
006.32 FOOD SERVICE. Each licensee must comply with the provisions of the Nebraska Food Code.
006.33 MENU PLANNING. Menus must be planned at least a week in advance and must be reviewed and approved by a dietician before service.
006.33(A) MEAL SUBSTITUTIONS. Records of substitutions of planned food items must be made and must be of equal nutritional value.
006.33(B) DOCUMENTATION OF MENUS. Records of menus must be filed for 6 months in the facility.
006.34 DINING ROOMS. All clients, including the mobile non-ambulatory must eat or be fed in dining areas except where contraindicated for health reasons. Table service must be provided for all who can and will eat at a table.
006.34(A) DINING EQUIPMENT. Dining areas must be equipped with tables, chairs, eating utensils and dishes to meet the developmental needs of the clients.
006.34(B) DINING SUPERVISION. Dining areas must be adequately supervised and staffed for the direction of self-help eating procedures and to assure that each client receive an adequate amount and variety of food.
006.35 WATER AND SEWER SYSTEMS. Each building must have and maintain an accessible and safe supply of potable water. Where an authorized public water supply of satisfactory quality, quantity and pressure is available, the building must be connected to it and must use it exclusively. All water distribution systems must be protected with anti-siphon devices and airgaps to prevent contamination.
006.35(A) PRIVATE WELLS. The licensee must ensure that any building with a private well or wells as the source of the water supply must have this water supply tested quarterly for coliform bacteria and a chemical analysis every 3 years by the Department or a laboratory approved by the same.
006.36 CLOTHING. Each client must have an adequate allowance of neat, clean, fashionable, and seasonable clothing.
006.36(A) CLOTHING IDENTIFICATION. Each client must have her or his own clothing which is properly marked with her or his name, and he or she shall use this clothing.
006.36(B) APPROPRIATE CLOTHING. Such clothing must make it possible for clients to go out of doors in inclement weather, to go on trips or visits appropriately dressed and to make a normal appearance in the community.
006.36(C) NON-AMBULATORY CLIENTS. Non-ambulatory clients must be dressed daily in their own clothing, including shoes, unless contraindicated in a written, medical order which is reviewed periodically.
006.36(D) CLOTHING MAINTENANCE. An ongoing wardrobe check should be kept on each client's personal and clothing items to assure proper maintenance.
007. STANDARDS OF OPERATION, CARE, AND TREATMENT. A Center for the Developmentally Disabled must be organized, managed, and administered by the licensee to ensure each client receiving services at the facility received necessary care and treatment in a safe manner, in accordance with current standards of practice, and in accordance with the Health Care Facility Licensure Act, 175 NAC 1, and this chapter.
007.01 ADMINISTRATION. The licensee may be the administrator or may appoint a person to be the administrator. If the administrator is not the licensee, the administrator is directly responsible to the licensee in all matters related to the maintenance, operation, and management of the facility. The administrator is the contact person for the facility. The licensee’s responsibilities include:
(A)\tDesignating a house manager in writing;
(B)\tBeing available or ensuring the administrator is available to the house manager at all times;
(C)\tEnsuring the health, safety and protection of clients residing at the facility;
(D)\tMaintaining compliance with all applicable state statutes, codes, rules, and regulations;
(E)\tNotifying the Department in writing within 5 working days when:
(i) A vacancy in the administrator position occurs including the name of who will be responsible for the position until another administrator is appointed; and
(ii) A vacancy in the administrator position is filled including the effective date and name of person appointed to that position; and
(F)\tEstablishing, implementing, and revising as necessary, written policies and procedures governing the facility operations.
007.02 STAFFING. The licensee must maintain a sufficient number of staff with the required experience, orientation, training, and competency necessary to meet the care and treatment needs of clients and the operations needs of the facility.
007.02(A) PERSONNEL POLICIES. Written personnel policies and procedures must be established and made available to each employee. Personnel policies and procedures must be read by each employee upon employment and as revisions are made. Documentation of this must be maintained in the employee's personnel file. Personnel policies must address hiring, assignment, and promotion of employees; grievance procedures; suspension or dismissal of an employee; and ensure that employees with symptoms or signs of communicable disease are not permitted to work.
007.02(B) JOB DECRIPTIONS. Job descriptions for each consultant and staff position must be established and made available to each consultant and staff person upon employment. Each job description must include but not necessarily be limited to a description of the person's duties and responsibilities and the person's role, if any, in implementing the individual program, plan job descriptions for consultants must be included as a part of the contract with a consultant.
007.02(C) VOLUNTEERS. Policies and procedures must be implemented which specify the training and supervision to be given to volunteers. A volunteer must never be left in charge of the facility.
007.02(D) TRAINING. Policies and procedures must be available which specify the training to be received during the 3 months orientation period and provide for in-service training and staff development on a regular basis thereafter.
007.02(D)(i) INITIAL TRAINING. Staff orientation for new employees must take place during the first 3 months of employment and must begin on the first day of employment. Orientation during the first 3 months must be consistent with the job description for the individual and the needs of the clients served. Training during the first 3 months must include: basic first aid and cardiopulmonary resuscitation, drug administration, (in-service must be completed prior to administration of drugs), Individual Program Plan development and implementation, client rights, and facility policies and procedures.
007.02(D)(ii) ONGOING TRAINING. In-service training and staff development must be available to and attended by all staff on a regular basis. Training must be consistent with the job description for the individual and the needs of the clients to be served. A plan of in-service training and staff development must be established for a 3 month period and must provide for ongoing in-service training and staff development.
007.02(D)(iii) TRAINING DOCUMENTATION. Documentation of all staff training and in-services attended must be kept in each employee's personnel record. In-service records must include topic and content, actual training time and date of training.
007.02(E) STAFFING. Regardless of the organization or design of living units, the staff- client ratios, must be, morning, awake and present, afternoon and evening, awake and present, and overnight sleeping. For time periods when clients are not present in the facility, staff-ratios will not apply.
007.02(E)(i) STAFFING RATIOS FOR DISABLED. For any unit within a facility that includes clients who are children under the age of 6 years, disabled, physically handicapped, or who are aggressive, assaultive, security risks, or who manifest severely hyperactive or psychotic-like behavior, or who require considerable adult guidance and supervision, the following minimum staff-client ratio must be met:
(1)\tMorning - 1:4;
(2)\tAfternoon and evening - 1:4; and
(3)\tOvernight - 1:8.
007.02(E)(ii) STAFFING RATIOS FOR BASIC INDEPENDENT SKILLS. For any unit within a facility that includes clients in basic independent living skills, who do not attend vocational training programs but may attend prevocational training programs, the following minimum staff client ratios must be met:
(1)\tMorning - 1:8;
(2)\tAfternoon and evening - 1:8; and
(3)\tOvernight - 1:10.
007.02(E)(iii) STAFFING RATIOS FOR TRAINING PROGRAMS. For any unit serving clients in vocational training programs and adults who work in sheltered employment situations, the following minimum staff client ratios must be met:
(1)\tMorning - 1:8;
(2)\tAfternoon and evening - 1:8; and
(3)\tOvernight - 1:10.
007.02(E)(iv) ADDITIONAL STAFFING. Additional staff coverage must be provided on call as necessary during emergencies, including illness of a client or clients. Additional staff coverage must be provided on call during emergencies in accordance with the previously stated ratios. These individuals and their phone numbers must be listed near the main telephone for the facility. Volunteers are not included in meeting the staff client ratios. A licensee that accepts any client whose needs require awake overnight care must provide awake and present staff in the prescribed ratios.
007.03 EMERGENCY MEDICAL SERVICES. Each licensee must establish, implement, and revise as necessary policies and procedures regarding the handling of emergency situations. All employees and volunteers must have immediate access to such information along with the names, telephone numbers, location, and type of medical services available. Emergency information must be maintained in the facility at a location known to all facility employees.
007.03(A) MEDICAL INFORMATION. All staff must have immediate access to clients' medical information including, name of physician(s), person to notify in case of emergency, current medications, and known allergies. Medical information must be maintained in the facility at a location known to all facility employees.
007.03(B) EMERGENCY SITUATIONS. The licensee must maintain a first aid kit adequate to deal with possible emergency situations at each location. This kit must be checked on at least an annual basis and restocked as needed.
007.04 PERSONNEL. Personnel files must be maintained in a centralized system and must be subject to inspection by authorized representatives of the Department at any time. Personnel files must be maintained for all personnel and must include:
(1)\tJob description;
(2)\tDocumentation of completed training and in-service attended;
(3)\tDocumentation of annual performance evaluation;
(4)\tPre-employment physical;
(5)\tJob application;
(6)\tCredential verification;
(7)\tDate of hiring; and
(8)\tDisciplinary actions, if any.
007.04(A) INDIVIDUAL LICENSE REQUIREMENTS. The licensee must ensure all persons who provide a service to clients meet applicable state laws. The licensee must ensure that all persons for whom a license, certification or registration is required hold the license, certification, or registration in accordance with applicable state laws.
007.04(A)(i) REPORTING. Each licensee must ensure that any incident where there is reason to believe that abuse, neglect, or exploitation of a client has occurred are reported to:
(1) The Adult and Child Abuse and Neglect Hotline via telephone immediately; and
(2) Local law enforcement as required by state and federal laws.
007.04(B) INVESTIGATION. A licensee must ensure any incident where there is reason to believe that abuse, neglect, or exploitation of a client has occurred is thoroughly investigated and the investigation documented in a written report. Within 5 working days of the incident, the facility must submit the written investigative report to the Department.
007.04(C) PROTECTION. A licensee must ensure that clients are protected throughout the investigation. Actions must be taken as a result of the investigation to ensure patient safety and to prevent the potential for recurrence.
007.04(D) CRIMINAL BACKGROUND AND REGISTRY CHECKS. A licensee must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff member.
007.04(D)(i) CRIMINAL BACKGROUND CHECKS. A licensee must complete criminal background checks through a governmental law enforcement agency or a private entity that maintains criminal background information.
007.04(D)(ii) REGISTRY CHECKS. A licensee must check for adverse findings on the following registries:
(1) \tNurse Aide Registry;
(2)\tAdult Protective Services Central Registry;
(3)\tCentral Register of Child Protection Cases; and
(4)\tNebraska State Patrol Sex Offender Registry.
007.04(D)(iii) NURSE AIDE REGISTRY CHECKS. A licensee must not employ staff with adverse findings on the Nurse Aide Registry regarding abuse or neglect of clients served, or misappropriation of the property of clients served. The licensee must:
(1)\tDetermine how to use the criminal background and registry information, except for the Nurse Aide Registry, in making hiring decisions;
(2)\tDecide whether employment can begin prior to receiving the criminal background information; and
(3)\tDocument any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to clients’ safety or property.
007.05 CLIENT RECORDS. The licensee must establish, implement, and revise as necessary policies and procedures regarding the confidentiality, maintenance, storage, and destruction of client records. Client records must include:
(A)\tDocumentation of all current evaluations;
(B)\tDocumentation of incident reports;
(C)\tDocumentation of clothing and personal possession inventory;
(D)\tDocumentation of medication histories and response profiles;
(E)\tDocumentation of client consent forms; and
(F)\tIf vocational services are offered to the clients of the facility, the records of the facility must indicate whether or not such services have been approved by the state.
007.06 POST-ADMISSION INDIVIDUAL PROGRAM PLAN. A post-admission Individual Program Plan must include measurable goals and objectives, must be developed, and implemented within 30 days after admission of any client, and be completed by the interdisciplinary team. Continued placement and programs must be determined, by the interdisciplinary team, in accordance with developmental needs as identified in comprehensive assessments and must not be contingent on age or time restrictions.
007.07 RESTRAINT DOCUMENTATION. Documentation of monitoring of restraints and time-out rooms which includes extent of time in time-out, reason for use, 15 minute checks of the restraint, release from restraints and exercise every 2 hours, and signature of the individual documenting monitoring of restraints. If a time-out room is used for behavior modification programs the room must provide a minimum of 60 square feet of floor space and have a ceiling height of 9 feet. There must be a means of observing the client while in the time-out room. Appropriate furniture, at least a bed or chair and a light must be provided. The door must be lockable from only the outside.
007.08 CLIENT RIGHTS. Each licensee must establish, implement, and revise as necessary policies and procedures assuring that each client has the same civil rights unless specific rights have been removed by a court of law after the client has been afforded his or her full due process rights, or for the particular circumstances and with specific safeguards outlined.
007.08(A) HUMAN RIGHTS COMMITTEE. The licensee must have a Human Rights Committee for each facility. Policies and procedures regarding Clients’ Rights must be reviewed by the Human Rights Committee at least annually. Any compromise of these rights must be documented with justification. Clients must have a right to treatment, services and habilitation designed to maximize developmental potential of the person and provided in a setting that is least restrictive of the client’s personal liberty. A Human Rights Committee must be established for each facility. Reports of the Committee meetings must be available in each facility served or locale and must specify what occurred during the Committee meetings.
007.08(B) PROTECTIVE SAFEGUARDS OF THE CLIENT’S RIGHTS. The Human Rights Committee must review and take action in accordance with written policies and procedures, with respect to alleged instances of mistreatment, neglect, abuse, exploitation, and situations where restraints, psychotropic medication or aversive conditioning are used. Documentation of reviews and actions by the Human Rights Committee must be maintained in the facility for clients. Composition of the Human Rights Committee must be as follows:
(i)\tAdministrative staff representative;
(ii)\tResidential and service staff;
(iii)\tClient;
(iv)\tIndirect consumer, i.e., the parents or guardian of a client; and
(v)\tRepresentatives from community concerned with rights of individuals with developmental disabilities.
007.08(C) INFORMATION REGARDING CLIENT RIGHTS. Each client must be informed, by an appropriate communication system, of his or her rights and responsibilities as a client, and of all rules and regulations governing client conduct and responsibilities. Receipt of such information must be acknowledged in writing by the client or his or her family, guardian, or representative, where applicable, and maintained in the client’s record in the facility. If written acknowledgement cannot be obtained, information regarding client’s rights must be sent to his or her family, guardian, or representative by certified mail.
007.08(C)(i) RECOGNITION OF HUMAN DIGNITY. Each client must be treated with consideration, respect, truthfulness, and full recognition of his or her dignity and individuality, including privacy in treatment and in care of his or her personal needs. Clients’ individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainments must be elicited and respected by the facility. Privacy of a client’s body must be maintained during toileting, bathing, and other activities of personal hygiene, except as needed for client safety or assistance.
007.08(C)(ii) INPUT INTO DECISION MAKING. There must be documentation that each client is afforded maximum opportunity to participate in any decisions concerning his or her person, including those decisions involving medical care and treatment, residency, and the development and implementation of the Individual Program Plan. If it is determined that informing clients of their condition is medically contraindicated, this decision and reasons for it must be documented in the facility in the client’s record by the physician.
007.08(C)(iii) FREEDOM FROM RESTRAINTS. Physical restraints, psychotropic medications or aversive conditioning techniques must be employed only in accordance with policies and procedures approved by the Human Rights Committee and must be employed only after approval by the same. Physical restraints, psychotropic medication, and aversive conditioning techniques, such as using noxious or aversive stimuli, must never be used as a punishment, for the convenience of staff, or as a substitute for programs, and must be applied only after other means of controlling behavior have been tried and have failed. Documentation of the failure of these alternative techniques must be included in a client’s record and reviewed by the Human Rights Committee. Prior to the incorporation of physical restraints, psychotropic medications, or aversive conditioning techniques in a client’s habilitation plan, except when absolutely necessary in an emergency situation to prevent a client from seriously injuring himself or others:
(1)\tIt must be documented in the client’s record in the facility that physical restraints, psychotropic medications, or aversive conditioning techniques, or any or all of them, are essential for the client’s habilitation and that less restrictive techniques have been attempted and have failed; and
(2)\tIncorporation of aversive conditioning techniques, physical restraints, or psychotropic medications in the client’s habilitation plans has been with the informed consent of the client, or his or her family, guardian, or representative, when applicable, and documented in the client’s record in the facility. The written policies and procedures of the facility governing the use of restraints must delineate the following:
(a)\tPhysician's orders must indicate the specific reasons for the use of restraints and must specify the type of restraints used;
(b)\tThe use of restraints must be temporary and the client must not be restrained for an indefinite amount of time;
(c)\tOrders for restraints must not be enforced for longer than 12 hours, unless the client’s condition warrants and must be reordered every 12 hours by the physician;
(d)\tA client placed in the restraint must be checked at least every 15 minutes by appropriately trained staff and an account must be kept of this surveillance;
(e)\tReorders shall be issued only after a review of the client’s condition;
(f)\tThe use of restraints must not be employed as punishment, for the convenience of the staff, or as a substitute for supervision;
(g)\tMechanical restraints must avoid physical injury to the client and provide a minimum of discomfort;
(h)\tThe opportunity for motion and exercise must be provided for a period of not less than 10 minutes during each 2 hours in which restraints are employed, except at night, if the client is asleep; and
(i)\tThe following documentation is required before incorporation in the client’s habilitation plan of more restrictive methods of managing behavior, i.e., psychotropic medication, restraint, and a complete description of the maladaptive behavior must include:
(i)\tThe form of the behavior;
(ii)\tWhere and when the behavior occurred;
(iii)\tThe frequency of the occurrence of the behavior;
(iv)\tThe results of this occurrence;
(v)\tThe previous intervention approaches tried;
(vi)\tThe description of the teaching procedures;
(vii)\tThe persons responsible;
(viii)\tThe setting;
(ix)\tThe time spent per day and week;
(x)\tThe results of the alternative approaches;
(xi)\tThe proposed procedure;
(xii)\tThe description of the proposed procedure;
(xiii)\tThe persons responsible;
(xiv)\tThe setting;
(xv)\tThe rationale for choosing this specific procedure;
(xvi)\tThe evaluation of the program (data collection);
(xvii)\tWho will review it;
(xviii)\tThe proposed length of the implementation;
(xix)\tWho can terminate the procedure; and
(xx)\tWho will monitor and how frequently will monitoring occur.
007.08(C)(iv) FREEDOM FROM SECLUSION. Seclusion is prohibited.
007.08(C)(v) FREEDOM FROM ABUSE AND NEGLECT. Mistreatment, neglect, physical, mental, or verbal abuse, or exploitation of clients in any form is prohibited. The licensee must have a written policy that defines use of behavior modification programs, the staff members who may authorize their use, and a mechanism for monitoring and controlling their use.
007.08(C)(vi) BEHAVIOR MANAGEMENT CONSENT. For discontinuation of a behavior management program associated with the use of psychotropic medication(s), the client record must contain documentation that the cessation of psychotropic medication does not interfere with a client’s habilitation program and that there is documentation of no problematic behavior. Once a maintenance dose for psychotropic medication has been established, there must be provision in the client’s Individual Program Plan for quarterly review of the client’s status and documentation of the review maintained in the facility’s records for the client.
007.08(C)(vii) DISCIPLINE OF CLIENTS. Clients must not discipline other clients, except as, part of an organized self-government program which is conducted in accordance with written policy of the facility.
007.08(C)(viii) FREEDOM OF ASSOCIATION AND COMMUNICATION. Each client must be afforded the right to communicate, associate, and meet privately with persons of his or her own choice; to send and receive his or her personal mail unopened; and to participate in activities of social, religious, and community groups at his or her discretion. There will be documentation of the rationale for the restriction of any of these rights. A decision to restrict a visitor is reviewed and re-evaluated each time the client’s Individual Program Plan is reviewed by the Interdisciplinary Team and medical orders are reviewed by the physician or at the client’s request. Close relatives must be permitted to visit clients at reasonable hours without prior notice.
007.08(C)(ix) CONFIDENTIAL TREATMENT OF CLIENT INFORMATION. Each client must be assured of confidential treatment of all information contained in his or her records and his or her written, informed consent, or the written, informed consent of his or her family, guardian, or representative, if applicable, must be required for the release of information to persons not authorized under law to receive it.
007.08(C)(x) FREEDOM FROM INTERFERENCE WITH PERSONAL FINANCIAL AFFAIRS. Each client must be afforded the right to manage his or her personal financial affairs. In the event a client has had a conservator appointed by a court of law, the conservator must be free to manage the client’s personal financial affairs within the bounds of the court order appointing the conservator. Each client and his or her parent(s), or conservator, if applicable, shall be informed orally and in writing of all financial responsibilities involved in being a client.
007.08(D) AUTHORIZATION. Written authorization from the client or his or her conservator, if applicable, must be obtained when the licensee is handling the client's funds and the authorization must be in the client's record in the facility.
007.08(D)(i) CLIENT FUNDS. Licensee must maintain a written account of all clients’ funds received by or deposited with the facility. The facility may, at the client’s request, keep on deposit personal funds over which the client has control. Should the client or conservator, where applicable, request these funds, they must be given to him or her on request with receipts maintained by the facility and a copy to the client.
007.08(D)(ii) FINANCIAL TRANSACTIONS. If the licensee makes financial transactions on a client’s behalf, the client or his or her representative must receive, or acknowledge that he or she has seen, an itemized accounting of disbursements and current balances at least quarterly. A copy of this statement must be maintained in the client’s financial or business record.
007.08(D)(iii) FREEDOM FROM INVOLUNTARY SERVITUDE. No client must ever be required to perform labor which involves the operation and maintenance of the facility or the regular care, treatment, or supervision of other clients. Clients may voluntarily perform any work available to them. Clients may be required however, to perform tasks of a housekeeping nature (such as the making of their own beds) without compensation.
007.08(D)(iv) TRANSFER OR DISCHARGE OF CLIENTS. When the client is transferred or discharged, the reason for the transfer or discharge and a summary of findings, progress and plans must be recorded and made available to both the transferring facility and the facility to which the client is transferred. Except in an emergency, the client or his or her parents, guardian, or representative, if applicable, must be informed in writing at least 30 days in advance of transfer and at least 60 days in advance of discharge, and his or her written consent obtained. The Interdisciplinary Team must convene prior to transfer or discharge of a client and must review the move.
007.08(D)(v) FEE SCHEDULE. Each client has the right to a copy and to view a fee schedule of charges for services to the client.
007.09 CLIENT SERVICES. A licensee must not admit any client to a facility if the individual need for that client cannot be met. An evaluation by a physician, a psychologist, a social worker, and residential staff must be completed prior to admission for each client.
007.09(A) INTERDISCIPLINARY TEAM. The interdisciplinary team is responsible for development of a preliminary program plan at the time of admission, complete Individual Program Plan with 30 days, after the date of admission and must complete an annual review of each client’s program plan. The Interdisciplinary Team must include:
(i)\tThe client’s case manager;
(ii)\tThe client’s parent or guardian, if applicable;
(iii)\tThe client to be served, or reason for nonattendance;
(iv)\tA representative from the residential program staff; and
(v)\tProfessionals from those disciplines for which the individual has specialized needs, including vocational staff, if applicable and school system representatives, if applicable.
007.09(B) NONPARTICIPATION IN INTERDISCIPLINARY TEAM. If any member(s) of the previous team are not involved in the development or review of the program plan, the reasons for their nonparticipation must be documented in the minutes of the Interdisciplinary Team meeting. Program Plans must include signatures of the individual or the individual’s legal representative participation, in the Interdisciplinary Team meeting.
007.09(C) PROFESSIONALS WHO PARTICIPATE ON THE INTERDISCIPLINARY TEAM. Professionals who participate on the Interdisciplinary Team must meet the following requirements:
(i)\tA psychologist must have a current active license in Nebraska;
(ii)\tSocial Services Workers must have a bachelor’s degree in social work, developmental or intellectual disabilities, or a related field;
(iii)\tPhysicians must have a current active license in Nebraska;
(iv)\tDentists must have an active license in Nebraska;
(v)\tLicensed Medical Nutrition Therapists must have a current active license in Nebraska;
(vi)\tSpeech pathologists or audiologists must have a current active license in Nebraska;
(vii)\tPhysical Therapists must have a current active license in Nebraska; and
(viii)\tOccupational Therapists must be:
(1)\tGraduates of an occupational therapy curriculum accredited jointly by the Council on Medical Education of the American Medical Association and the American Occupational Therapy Association; or
(2)\tEligible for certification by the American Occupational Therapy Association under its requirements in effect on the effective date of these regulations; or
(3)\tHave 2 years of competent experience as an occupational therapist.
007.10 CLIENT EVALUATIONS. Client evaluations conducted by the disciplinary areas must include:
(A)\tSummary of progress towards meeting the current Individual Program Plan's goal and objectives and assessments of continuing need for care;
(B)\tIdentification of the tools or methods used for assessment;
(C)\tNeeds, strengths, and weaknesses (barriers);
(D)\tRecommendations if the client has habilitative needs; and
(E)\tWritten in language clearly understandable by all.
007.11 INDIVIDUAL PROGRAM PLAN. The Individual Program Plan must include:
(A)\tLong term goals and short term objectives, that are stated separately, and each objective is stated in terms of a single behavioral outcome;
(B)\tProjected completion dates;
(C)\tMeasurable indicators of progress expressed in behavioral terms inclusive of a pass or fail criteria;
(D)\tBe sequenced within a developmental progression appropriate to the individual; and
(E)\tAssigned priorities.
007.11(A) INDIVIDUAL PROGRAM PLAN OBJECTIVES. The Individual Program Plan objectives must include a description of the manner in which objectives will be achieved and possible barriers to the achievement of them in common language understandable by all concerned; a training plan shall be written for the implementation of each objective specifying:
(i)\tData collection procedures;
(ii)\tTraining procedures;
(iii)\tStaff responsible for training;
(iv)\tConditions or (environment) and materials needed; and
(v)\tMethod by which effectiveness of program will be evaluated.
007.11(B) INDIVIDUAL PROGRAM PLAN SPECIFICATIONS. The Individual Program Plan must include statements (in readily understandable form) of specific habilitation services to be provided, containing the identity of the client (by name and title) or agency which will deliver each service, and specifying the date of the initiation of each service to be provided and the proposed duration of each service.
007.11(C) ACTIVITY SCHEDULES. Activity schedules are an active extension of the Individual Program Plan. The schedule must be recorded and must include:
(i)\tClient’s schedules on a weekly basis;
(ii)\tTime periods in which staff are working with clients on their Individual Program Plans;
(iii)\tTime periods clients are working alone or together on skill attainment;
(iv)\tTimes for the client to choose activities that interest him or her;
(v)\tOngoing staff services (responsible persons);
(vi)\tRestrictions of client rights;
(vii)\tBarriers to programming, i.e., blind, non-ambulatory;
(viii)\tGuardianship status;
(ix)\tAdmission date; and
(x)\tPrimary relative, guardian or advocate.
007.11(C)(1) INDIVIUALIZED SERVICE PLAN. At the time of admission, a preliminary program plan shall be developed by an Interdisciplinary Team which may provide for the continuation of existing programs from previous facility. Comprehensive evaluations of a client’s developmental must be completed within 30 days following admission. Reassessments must be completed annually or more frequently if needed as determined by the needs of the client. Comprehensive evaluations must include:
(a)\tMedical evaluation, upon admission and thereafter as needed, must address physical and mental health, and include a medication history;
(b)\tDental evaluation, upon admission and thereafter as needed, must include complete extra and intra-oral examinations;
(c)\tSensorimotor Development evaluation;
(d)\tCommunicative Development evaluation;
(e)\tSocial Development evaluation; upon admission and thereafter as needed;
(f)\tAffective Development evaluation;
(g)\tCognitive Development evaluation;
(h)\tAdaptive behaviors or independent living skills evaluation;
(i)\tDietary, if applicable. Dietary evaluations must address eating skills; adaptive equipment; modified diets; edible reinforcers, and nutritional inducements;
(j)\tSpeech, if applicable. Speech evaluations must include appraisal of articulation, voice, rhythm, and language;
(k)\tAudiology, if applicable. Audiology evaluations must include tests of pure tone air and bone conduction, speech audiometry, and other procedures as necessary, and include assessment of the use of visual cues, and use of amplification;
(l)\tPhysical therapy, if applicable. Physical therapy evaluations must address the preservation and improvement of abilities for independent function such as range of motion, strength tolerance, coordination, and activities of daily living; and prevention, insofar as possible of irreducible or progressive disabilities through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations, and sensory stimulation;
(m)\tOccupational therapy, if applicable. Occupational therapy evaluations must address the preservation and improvement of abilities for independent function such as range of motion, strength, tolerance, coordination, and activities of daily living; and prevention, insofar as possible of irreducible or progressive disabilities through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations, and sensory stimulation;
(n)\tPsychological initial evaluation upon admission and bi-annually. Psychological evaluations must address perceptual skills, social skills, self-direction, emotional stability, and effective use of time, including leisure time. Full-scale must include non-adaptive and adaptive behavior scale; and
(o)\tVocational, if applicable. Vocational evaluations must address client aptitudes, abilities, interests, work attitudes, work habits, work tolerances, community, and social skills.
007.11(C)(2) POST-ADMISSION INDIVIDUAL PROGRAM PLAN. The post-admission Individual Program Plan, which must include measurable goals and objectives, is developed, and implemented within 30 calendar days after admission by the Interdisciplinary Team.
(a)\tContinued placement and programs must be determined in accordance with developmental needs as identified by comprehensive assessments and not be contingent on age or time restrictions.
007.11(D) PROGRAMS. Programs must be implemented as specified on the Individual Program Plan. The frequency of implementation of a program must be in accordance with normal life activities.
007.11(E) ONGOING IMPLEMENTATION AND CONTINUING APPROPRIATENESS. The Individual Program Plan must be reviewed at least quarterly by the client’s Interdisciplinary Team for assuring implementation and whether it continues to be appropriate for the client.
007.11(F) MODIFICATION AND REVIEW OF THE INDIVIDUAL PROGRAM PLAN. The Individual Program Plan itself must also be reviewed and modified as necessary by the client’s Interdisciplinary Team at intervals determined by the team, and at least annually.
007.11(G) LEISURE TIME ACTIVITIES. Clients must be provided with leisure time activities and must be directed at keeping the client both physically and mentally alert and active.
007.11(H) GENERIC SERVICES AND RESOURCES. The licensee must utilize, as extensively as possible, generic services and resources appropriate to the needs of the clients served, including introducing clients into the environments available in the community that are most appropriate to addressing their needs. There must be written policies and procedures to utilize these resources within the scope of availability.
007.11(I) COMMUNITY ACTIVITIES. Services must be provided in settings that are appropriate for and that encourage disabled clients to experience relationships with non-disabled persons in community activities.
007.11(J) STAFF PERSON RESPONSIBILITY FOR SERVICES. The Interdisciplinary Team must identify one staff person as responsible for coordinating all services provided to the client by the facility. This person must be designated on the client’s Individual Program Plan.
007.12 MEDICATIONS. Each licensee must establish, implement, and revise as necessary policies and procedures governing the handling, storage and administration of medications that must be in compliance with current standards of practice and state and federal law.
007.12(A) MEDICATION STORAGE AND HANDLING. All medications must be prescribed for the client by a licensed medical practitioner and dispensed by a licensed pharmacist.
007.12(B) ADMINISTRATION OF MEDICATION. The licensee must ensure clients receive medications only as legally prescribed by a medical practitioner in accordance with the prescription and prevailing professional standards.
007.12(B)(i) METHODS OF ADMINISTRATION. When the licensee is responsible for the administration of medication, it must be accomplished by the following methods:
007.12(B)(i)(1) SELF ADMINISTRATION. The licensee must allow clients to self-administer medication, with or without supervision, unless an Interdisciplinary Team has determined the client is not capable of doing so safely.
007.12(B)(i)(2) LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes licensed health care professionals for whom medication administration is included in their scope of practice, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards.
007.12(B)(i)(3) PERSONS OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes persons other than licensed health care professionals in the provision of medications, the licensee must follow 172 NAC 95, Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons, and 172 NAC 96, Regulations Governing the Medication Aide Registry.
007.12(C) FACILITY RESPONSIBILITY. When the licensee is not responsible for medication administration or provision of medication, the licensee maintains responsibility for the overall supervision, safety, and welfare of the client.
007.12(D) DISPOSAL OF MEDICATIONS. Medications that are discontinued by the medical practitioner, and those medications which are beyond their expiration date, must be destroyed. The licensee must identify who will be responsible for disposal of medications and the method to dispose of medications in a timely and safe manner. Documentation of the disposal should be documented, and such documentation should be retained for a minimum of 5 years.
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