Licensing of Nursing Facilities (216-RICR-40-10-1)
216-RICR-40-10-1 INACTIVE RULE
1.1Authority
These Regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws §§ 23-17-10, 23-17.5-32, and 23-17.5-33 and are established for the purpose of establishing minimum requirements for the licensure of nursing facilities in Rhode Island, including provisions for resident-directed homes, minimum hours of direct nursing care and reimbursement of any monies that have been prepaid on behalf of a deceased patient to the nursing facility.
1.2Incorporated Materials
A.These Regulations hereby adopt and incorporate 42 C.F.R. Part 483 (1989) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
B.These Regulations hereby adopt and incorporate The National Academic Press’s “Dietary Reference Intakes: The Essential Guide to Nutrient Requirements” (2006) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
C.These Regulations hereby adopt and incorporate the U.S. Department of Health & Human Services, Office of Minority Health’s “National Standards on Culturally and Linguistically Appropriate Services (CLAS)” by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
D.These Regulations hereby adopt and incorporate the Facility Guidelines Institute’s “Guidelines for Design and Construction of Residential Health, Care and Support Facilities, 2018 edition) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
E.These Regulations hereby adopt and incorporate the American National Standards Institute’s “Accessible and Useable Buildings and Facilities (ICC A117.1-2009)” by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
F.These Regulations hereby adopt and incorporate 28 C.F.R. Part 36 (1991) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
G.These Regulations hereby adopt and incorporate the Center for Disease Control & Prevention’s “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings” (2005) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
H.These Regulations hereby adopt and incorporate the Center for Disease Control & Prevention’s “Recommendations for Preventing the Spread of Vancomycin Resistance: Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC)” (1995) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
I.These Regulations hereby adopt and incorporate the Rhode Island Department of Health’s “Guidelines for the Management of Clostridium difficile in Rhode Island Longer-Term Care Facilities (LTCF’s)", (2007) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are no inconsistent with these Regulations.
J.These Regulations hereby adopt and incorporate the Rhode Island Department of Health’s “Guidelines for the Management of Methicillin Resistant Staphylococcus Aureus Rhode Island Longer-Term Care Facilities", (2007) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are no inconsistent with these Regulations.
K.These Regulations hereby adopt and incorporate the Center for Disease Control & Prevention’s “Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC)”, (1997) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
L.These Regulations hereby adopt and incorporate the National Fire Protection Association’s “Standards on Types of Building Construction [NFPA 220]” (2012) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
M.These Regulations hereby adopt and incorporate by reference 42 C.F.R. § 483.10(c)(6) (2017), not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations.
1.3Definitions
A.Wherever used in this Part the following terms shall be construed as follows:
1."Abuse" means any assault as defined in R.I. Gen. Laws Chapter 11-5, including, but not limited to hitting, kicking, pinching, slapping or the pulling of hair, provided however, unless such is required as an element of offense, it shall not be necessary to prove that the patient or resident was injured thereby, or any assault as defined in R.I. Gen. Laws Chapter 11-37, or any offense under R.I. Gen. Laws Chapter 11-10; or
a.Conduct which harms or is likely to physically harm the resident except where the conduct is a part of the care and treatment, and in furtherance of the health and safety of the resident; or
b.Engaging in a pattern of harassing conduct which causes or is likely to cause emotional or psychological harm to the resident, including but not limited to, ridiculing or demeaning a patient or resident, making derogatory remarks to a patient or resident or cursing directed towards a patient or resident, or threatening to inflict physical or emotional harm on a patient.
2.“Advanced practice registered nurse” means an advanced practice nurse licensed in accordance with R.I. Gen. Laws Chapter 5-34.
3."Alzheimer dementia special care unit or program" means a distinct living environment within a nursing facility that has been physically adapted to accommodate the particular needs and behaviors of those with dementia. Such unit provides increased staffing, therapeutic activities designed specifically for those with dementia and trains its staff on an ongoing basis on the effective management of the physical and behavioral problems of those with dementia. The residents of such a unit/program have had a standard medical diagnostic evaluation and have been determined to have a diagnosis of Alzheimer dementia or another dementia.
4."The capacity of a facility" means the maximum potential number of beds which may be accommodated within a facility according to the dimensional limitations of § 1.19.7 of this Part.
5.“Census” means a point in time count of all residents physically present in a nursing facility and/or not officially discharged from the nursing facility.
6."Change in operator" means a transfer by the governing body or operator of a nursing facility to any other person (excluding delegations of authority to the medical or administrative staff of the facility) of the governing body's authority to:
a.Hire or fire the chief executive officer of the nursing facility;
b.Maintain and control the books and records of the nursing facility;
c.Dispose of assets and incur liabilities on behalf of the nursing facility; or
d.Adopt and enforce policies regarding operation of the nursing facility.
7."Change in owner" means:
a.In the case of a nursing facility which is a partnership, the removal, addition or substitution of a partner which results in a new partner acquiring a controlling interest in such partnership;
b.In the case of a nursing facility which is an unincorporated solo proprietorship, the transfer of the title and property to another person;
c.In the case of a nursing facility which is a corporation;
(1)A sale, lease, exchange or other disposition of all, or substantially all of the property and assets of the corporation; or
(2)A merger of the corporation into another corporation; or
(3)The consolidation of two or more corporations, resulting in the creation of a new corporation; or
(4)In the case of a nursing facility which is a business corporation, any transfer of corporate stock which results in a new person acquiring a controlling interest in such corporation; or
(5)In the case of a nursing facility which is a non-business corporation, any change in membership which results in a new person acquiring a controlling vote in such corporation.
8.“Consistent assignment” means the same direct care nursing staff, universal workers, and/or self-directed work teams, consistently caring for the same resident(s) the majority of their shifts whenever they are on duty.
9."Controlling person" means any person or entity in control of a nursing facility directly or indirectly, including:
a.In the case of a corporation or a limited liability company, or limited liability partnership, a person having a beneficial ownership interest of five percent (5%) or more in the corporation, limited liability company or limited liability partnership to which the nursing facility is licensed;
b.In the case of a general partnership or limited partnership, any general partner;
c.In the case of a limited liability company, or limited liability partnership any member;
d.A legal entity that operates or contracts with another person for the operation of a nursing facility or an owner thereof;
e.Each of the president, vice president, secretary and treasurer of a corporation that is not exempt from taxation under section 501(a) of the United States Internal Revenue Code (26 U.S.C. § 501(a)) as an organization described in section 501(c)(3) of such code; and
f.Such other ownership interest or relationship as may be determined by the Director.
10.“Credentialing” means the administrative process for reviewing, verifying, and evaluating the qualifications and credentials of licensed physicians, physician assistants and advanced practice registered nurses in accordance with criteria established by the nursing facility for the purpose of granting clinical privileges at the nursing facility.
11."Declaration of disaster emergency" means a disaster emergency declared by the Governor pursuant to R.I. Gen. Laws § 30-15-9.
12."Department" means the Rhode Island Department of Health.
13.“Direct care nursing staff” means registered nurses, licensed practical nurses, certified nursing assistants, medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech language pathologists, and physical therapy assistants who are assigned to provide direct nursing care to residents.
14."Direct caregiver" means a person who receives monetary compensation as an employee of the nursing facility or a subcontractor as a registered nurse, a licensed practical nurse, a medication technician, a certified nursing assistant, a licensed physical therapist, a licensed occupational therapist, a licensed speech-language pathologist, or a physical therapist assistant.
15.“Director” means the Director of the Rhode Island Department of Health.
16."Drug administration" means an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with this Part.
17."Employee" means an individual employed, whether directly, by the contract with another entity or as an independent contractor, by a long-term care nursing facility on a part-time or full-time basis.
18.“Equity” means non-debt funds contributed towards the capital costs related to a change in owner or change in operator of a nursing facility which funds are free and clear of any repayment or liens against the assets of the proposed owner and/or licensee and that result in a like reduction in the portion of the capital cost that is required to be financed or mortgaged.
19."Essential caregiver" means an individual, whether a family member or friend of a resident of a nursing home or long-term care facility, who is designated by the resident or appointed by an individual with decision-making authority for the resident to provide physical or emotional support to the resident during a declaration of disaster emergency.
20.“Family council” means an organized group of the family members, friends, or representatives of nursing facility residents who may meet in private without the presence of nursing facility staff.
21."Health care facility" means a facility as defined in R.I. Gen. Laws § 23-17-2.
22.“Health care provider” means any person licensed by Rhode Island to provide or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital, intermediate care facility or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist, psychiatric social worker, pharmacist, or psychologist, and any officer, employee or agent of that provider acting in the course and scope of his or her employment or agency related to or supportive of health services.
23."High managerial agent" means an officer of a nursing facility, the administrator and assistant administrator of the nursing facility, the director and assistant director of nursing services, or any other agent in a position of comparable authority with respect to the formulation of policies of the nursing facility or the supervision in a managerial capacity of subordinate employees.
24."Hours of direct nursing care" means the actual hours of work performed per patient day by a direct caregiver.
25."Immediate jeopardy" means a situation in which the nursing facility's noncompliance or alleged noncompliance with one (1) or more State or Federal requirements or conditions has caused, or is likely to cause serious injury, harm, impairment or death to a resident; or shall be defined in accordance with 42 C.F.R. Part 489 or any subsequent applicable Federal Regulations.
26."The licensed capacity of a nursing facility" means the number of beds a nursing facility is licensed to operate.
27."Licensing agency" means the Rhode Island Department of Health.
28."Lift team" means health care nursing facility employees specially trained to perform patient lifts, transfers, and repositioning in accordance with safe patient handling policy.
29."Long-term care facility or facility" means a health care facility as defined in R.I. Gen. Laws Chapter 23-17, which provides long term health care.
30.“Medication technician or aide” means a nursing assistant who has satisfactorily completed a Rhode Island-approved course in drug administration and who may administer oral or topical drugs (with the exception of Schedule II drugs) in accordance with the requirements of § 1.16.10(A) of this Part.
31."Mistreatment" means the inappropriate use of medications, isolation, or use of physical or chemical restraints as punishment, for staff convenience, as a substitute for treatment or care, in conflict with a physician's order, or in quantities which inhibit effective care or treatment, which harms or is likely to harm the patient or resident.
32."Musculoskeletal disorders" means conditions that involve the nerves, tendons, muscles, and supporting structures of the body.
33.“Naloxone or "Narcan” means a particular drug which is a competitive antagonist that binds to the opioid receptors with higher affinity than agonists but does not activate the receptors, effectively blocking the receptor, preventing the human body from making use of opiates and endorphins.
34."Neglect" means the intentional failure to provide treatment, care, goods and services necessary to maintain the health and safety of the patient or resident, or the intentional failure to carry out a plan of treatment or care prescribed by the physician of the patient or resident, or the intentional failure to report patient or resident health problems or changes in health conditions to an immediate supervisor or nurse, or the intentional lack of attention to the physical needs of a patient or resident including, but not limited to toileting, bathing, meals and safety. Provided, however, no person shall be considered to be neglected for the sole reason that he or she relies or is being furnished treatment in accordance with the tenets and teachings of a well-recognized church or denomination by a duly-accredited practitioner thereof.
35."Net operating revenue" means net patient revenue plus other operating revenue.
36."Nourishing snack" means a verbal offering of, or unrestricted access to, items, single or in combination, from the basic food groups.
37.“Nursing facility” means a licensed health care facility or an identifiable unit or distinct part thereof, however named, that provides twenty-four (24) hour inpatient and residential nursing, therapeutic, restorative or preventive and supportive nursing care services for two (2) or more residents unrelated by blood or marriage whose assessed health condition requires continuous nursing care and supervision. Resident services shall be based on person-centered principles, however named, that enhance a resident’s quality of life by ensuring the nexus of control in the living environment is resident-directed, puts the emphasis on resident autonomy and individual choices, facilitates communication and mutual respect among the residents and staff, and meets the requirements herein.
38."Nursing assistant" means a nursing, orderly, or home health aide who is a paraprofessional trained to give personal care and related health care and assistance based on his or her level of preparation to individuals who are sick, disabled, dependent, or infirmed pursuant to the provisions of R.I. Gen. Laws § 23-17.9-2.
39.“Nursing service" means a service organized, staffed and equipped to provide nursing care to residents on a continuous basis.
40.“Occupancy level of a facility" means the number of beds a nursing facility has in actual use, equal to or less than the licensed capacity, not including any beds on hold.
41."Occupational therapist" means a person licensed to practice occupational therapy in this State, pursuant to the provisions of R.I. Gen. Laws Chapter 5-40.1.
42."Person" means any individual, trust or estate, partnership, corporation (including associations, joint stock companies), limited liability company, State or political subdivision or instrumentality of a State.
43.“Person-centered care” means a holistic model that takes into consideration each resident’s physical, mental, and social needs in the development of a care and treatment plan and the delivery of services that is driven to the greatest extent possible by resident choice.
44."Physical therapist" means a person licensed to practice physical therapy in this State, pursuant to the provisions of R.I. Gen. Laws Chapter 5-40.
45."Physical therapist assistant" means a person licensed in this State to assist in the practice of physical therapy under the supervision of a physical therapist, pursuant to the provisions of R.I. Gen. Laws Chapter 5-40.
46."Physician" means a person licensed to practice allopathic or osteopathic medicine in this State, pursuant to the provisions of R.I. Gen. Laws Chapter 5-37.
47."Physician assistant" or "PA" means a person who is qualified by academic and practical training to provide medical and surgical services in collaboration with physicians and pursuant to the provisions of R.I. Gen. Laws Chapter 5-54.
48."Resident" means a person who resides in a long-term care facility as defined in R.I. Gen. Laws Chapter 23-17.
49.“Resident attendant” means an individual who is trained to assist residents in a nursing facility with the activities of eating and drinking. A resident attendant shall not include an individual who:
a.Is a licensed health professional, including but not limited to a nursing assistant, registered dietitian; or
b.Volunteers without monetary compensation as authorized by the resident, or the resident’s appropriate legal representative.
50.“Residential area” means a distinct living environment within a nursing facility that includes no more than sixty (60) beds.
51.“Resident-directed” means a resident, the resident’s family members, and appointed guardians participating in the decision and determination processes that directly impact the personal and collective preferences of the residents and that involve the day to day activities and the operation of the nursing facility or Resident-directed home.
52.“Resident-directed home” means the expansion of the bed capacity of a nursing facility pursuant to R.I. Gen. Laws § 23-17-44(e) that includes programs and physical structures that adhere to “Eden Alternative™”, “Green House™”, “Small House”, or any other resident-directed operational model. Primary characteristics of the model as a condition of license require a decentralization of operational systems in support of resident-directed and person-centered care policies and procedures, self-directed work teams, consistent assignment for direct care givers, and an environment that is non-institutional by design and facilitates resident-directed activities.
53"R.I. Gen. Laws" means the General Laws of Rhode Island.
54.“Safe patient handling" means the use of engineering controls, transfer aids, or assistive devices whenever feasible and appropriate instead of manual lifting to perform the acts of lifting, transferring, and/or repositioning health care patients and residents.
55."Safe patient handling policy" means protocols established to implement safe patient handling.
56.“Self-directed work team” means small, organized groups of nursing facility workers who have day-to-day responsibility for managing themselves and their work.
57."Speech-language pathologist" means a person licensed to practice speech-language pathology in this State, pursuant to the provisions of R.I. Gen. Laws Chapter 5-48.
58."Standing orders" means orders to be automatically implemented for a class of patients without physician direction for an individual patient within the class.
59."Substantial evening meal" means an offering of three (3) or more menu items at one time, one (1) of which includes a high-quality protein such as meat, fish, eggs, or cheese. The meal should represent no less than twenty percent (20%) of the day's total nutritional requirements.
60.“This Part” means all parts of Rhode Island Rules and Regulations for Licensing of Nursing Facilities (216-RICR-40-10-1).
61.“Turnover rate” means the total number of terminations in a given calendar year divided by the average number of personnel employed for the same calendar year and multiplied by one hundred (100) (for the percentage).
62.“Universal worker” means a direct care nursing staff, who is qualified as outlined in § 1.14.6 of this Part, and through consistent assignment with residents may perform assistance with dietary, laundry, housekeeping activities, and other related services directly related to meeting the needs of that resident.
1.4Certificate of Need Requirements
A.Any person individually or jointly with any other person(s) who proposes to undertake any substantial construction shall be subject to review by the Department.
B.A certificate of need is required as a precondition to the establishment of a new nursing facility in accordance with R.I. Gen. Laws Chapter 23-15.
C.Any nursing facility which has received a certificate of need as evidence by written approval of the Director of Health after review by the Health Services Council, shall submit plans and specifications for review, prior to signing a construction contract, to the Center for Health Facilities Regulation, Rhode Island Department of Health, to the Division of Fire Safety, Executive Department, and to the Center for Food Protection of the Rhode Island Department of Health in accordance with R.I. Gen. Laws Chapter 23-1.
1.5General Requirements for Licensure
A.No person or governmental unit acting severally or jointly with any other person or governmental unit shall conduct, maintain or operate a or hold itself out as a nursing facility without a license in accordance with the requirements of R.I. Gen. Laws Chapter 23-17.
B.The provisions of this Part, in addition to the provisions of R.I. Gen. Laws Chapter 23-17, shall apply to all nursing facilities and to all residents housed therein, except that persons caring exclusively for relatives shall be exempted from the provisions of R.I. Gen. Laws Chapter 23-17 and herein.
C.Facilities meeting the definition of nursing facilities by virtue of the residence therein of persons who are mentally, physically and/or emotionally dependent on others for fulfilling the requirements of daily life but which do not include primary medical and nursing components shall not be subject to this Part but shall be subject to the requirements of R.I. Gen. Laws Chapter 23-17.4 and to Part 2 of this Subchapter, Licensing Assisted Living Residences.
D.Any nursing facility that utilizes latex gloves shall do so in accordance with the provisions of the Rules and Regulations pertaining to Part 20-15-3 of this Title, Use of Latex Gloves by Health Care Workers, in Licensed Health Care Facilities, and by Other Persons, Firms, or Corporations Licensed or Registered by the Department, promulgated by the Department of Health.
E.The nursing facility shall maintain sufficient financial resources to provide adequate staffing and supplies to care for the residents.
1.5.1Safe Resident Handling
A.Each licensed nursing facility shall comply with the following as a condition of licensure:
1.Each licensed nursing facility shall maintain a safe patient handling committee, which shall be chaired by a professional nurse or other appropriate licensed health care professional. A nursing facility may utilize any appropriately configured committee to perform the responsibilities of this section. At least one half (1/2) of the members of the committee shall be hourly, non-managerial employees who provide direct resident care.
2.The nursing facility shall have a written safe patient handling program, with input from the safe patient handling committee, to prevent musculoskeletal disorders among health care workers and injuries to residents. As part of this program, each licensed nursing facility shall:
a.Implement a safe resident handling policy for all shifts and units of the nursing facility that will achieve the maximum reasonable reduction of manual lifting, transferring, and repositioning of all or most of a resident's weight, except in emergency, life-threatening, or otherwise exceptional circumstances;
b.Conduct a resident handling hazard assessment. This assessment should consider such variables as patient-handling tasks, types of nursing units, resident populations, and the physical environment of resident care areas;
c.Develop a process to identify the appropriate use of the safe resident handling policy based on the resident’s physical and mental condition, the resident's choice, and the availability of lifting equipment or lift teams. The policy shall include a means to address circumstances under which it would be medically contraindicated to use lifting or transfer aids or assistive devices for particular residents;
d.Designate and train a registered nurse or other appropriate licensed health care professional to serve as an expert resource, and train all clinical staff on safe resident handling policies, equipment, and devices before implementation, and at least annually or as changes are made to the safe patient handling policies, equipment and/or devices being used;
e.Conduct an annual performance evaluation of the safe resident handling with the results of the evaluation reported to the safe resident handling committee or other appropriately designated committee. The evaluation shall determine the extent to which implementation of the program has resulted in a reduction in musculoskeletal disorder claims and days of lost work attributable to musculoskeletal disorder caused by resident handling, and include recommendations to increase the program's effectiveness; and
f.Submit an annual report to the safe resident handling committee of the nursing facility, which shall be made available to the public upon request, on activities related to the identification, assessment, development, and evaluation of strategies to control risk of injury to patients, nurses, and other health care workers associated with the lifting, transferring, repositioning, or movement of a resident.
4.Nothing in § 1.5.1 of this Part precludes lift team members from performing other duties as assigned during their shift.
5.An employee may, in accordance with established facility protocols, report to the committee, as soon as possible, after being required to perform a resident handling activity that he or she believes in good faith exposed the resident and/or employee to an unacceptable risk of injury. Such employee reporting shall not be cause for discipline or be subject to other adverse consequences by his or her employer. These reportable incidents shall be included in the facility's annual performance evaluation.
1.6Application for License or for Changes in Owner, Operator, or Lessee
A.Application for License and Renewal
1.Application for an initial license to conduct, maintain or operate a nursing facility shall be made in writing and submitted on forms provided by the licensing agency prior to the opening date for a new nursing facility to begin admitting residents.
2.Licenses will expire at the end of each calendar year unless a renewal application is completed prior to the expiration date. Renewal applications are completed electronically on the licensing agency web site and will be available for on-line renewal seventy (70) days prior to the expiration date.
B.A notarized listing of names and addresses of direct and indirect owners whether individual, partnership, or corporation, with percentages of ownership designated, shall be provided with the application for licensure and shall be updated annually. If a corporation, the list shall include all officers, directors and other persons or any subsidiary corporation owning stock.
C.Application for changes in the owner, operator, or lessee of a nursing facility shall be made on forms provided by the licensing agency and shall contain but not be limited to information pertinent to the statutory purpose expressed in R.I. Gen. Laws § 23-17-3 or to the considerations enumerated in § 1.7(F) of this Part. Three (3) paper copies and an electronic copy of such applications are required to be provided.
1.Each application filed pursuant the provisions of § 1.6 of this Part shall be accompanied by a non-returnable, non-refundable application fee, as set forth in Part 10-05-2 of this Title, Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health.
1.7Issuance and Renewal of License
A.The licensing agency shall issue a license or renewal thereof for a period of no longer than one (1) year. Said license, unless sooner suspended or revoked, shall expire by limitation on the thirty-first (31st) day of December following its issuance and may be renewed from year to year after inspection, and approval by the licensing agency, provided the applicant meets the appropriate requirements of R.I. Gen. Laws Chapter 23-17 and this Part.
B.A license shall be issued to a specific licensee for a specific location and shall not be transferable. The license shall be issued to the individual owner, operator or lessee, or to the corporate entity responsible for its governance.
1.Any initial licensure or change in owner, operator, or lessee of a licensed nursing facility shall require prior review by the Health Services Council and approval of the licensing agency as provided in §§ 1.7(E) and (F) of this Part as a condition precedent to the transfer, assignment or issuance of a new license.
C.A license issued pursuant to this Part shall be the property of the State of Rhode Island and loaned to such licensee, and it shall be kept posted in a conspicuous place on the licensed premises.
D.A distinct part of a nursing facility which is designed, maintained and primarily devoted to the provision of residential care and assisted living in accordance with R.I. Gen. Laws Chapter 23-17.4 shall obtain a separate license in accordance with the requirements of R.I. Gen. Laws Chapter 23-17.4 and Part 2 of this Subchapter, Licensing Assisted Living Residences.
E.Reviews of applications for initial licensure or changes in the owner, operator, or lessee of licensed nursing facilities shall be conducted according to the following procedures:
1.Applicants for initial licensure or a change in effective control of a nursing facility shall submit all required information as contained in the application provided by the licensing agency.
2.Within ten (10) working days of receipt, in acceptable form, of an application for a license in connection with an initial licensure or a change in the owner, operator or lessee of an existing nursing facility, the licensing agency will notify and afford the public thirty (30) days to comment on such application.
3.The decision of the licensing agency will be rendered within ninety (90) days from acceptance of the application for license.
4.The decision of the licensing agency shall be based upon the findings and recommendations of the Health Services Council unless the licensing agency shall afford written justification for variance therefrom.
5.All applications reviewed by the licensing agency and all written materials pertinent to the licensing agency review, including minutes of all Health Services Council meetings, shall be accessible to the public upon request.
F.Except as otherwise provided in R.I. Gen. Laws Chapter 23-17 a review by the Health Services Council of an application for a license in the case of an initial licensure or a proposed change in the owner, operator, or lessee of a licensed nursing facility may not be made subject to any criterion unless the criterion directly relates to the statutory purpose expressed in R.I. Gen. Laws § 23-17-3. In conducting reviews of such applications, the Health Services Council shall specifically consider and it shall be the applicant’s burden of proof to demonstrate:
1.The character, commitment, competence, and standing in the community of the proposed owners, operators or directors of the nursing facility as evidenced by:
a.In cases where the proposed owners, operators, or directors of the nursing facility currently own, operate, or direct a nursing facility, or in the past five (5) years owned, operated or directed a nursing facility, whether within or outside Rhode Island, the demonstrated commitment and record of that (those) person(s):
(1)In providing safe and adequate treatment to the individuals receiving the nursing facility’s services;
(2)In encouraging, promoting and effecting quality improvement in all aspects of nursing facility services; and
(3)In providing appropriate access to nursing facility services;
b.A complete disclosure of all individuals and entities comprising the applicant; and
c.The applicant’s proposed and demonstrated financial commitment to the nursing facility.
2.The extent to which the nursing facility will continue, without material effect on its viability at the time of change of owner, operator, or lessee, to provide safe and adequate treatment for individuals receiving the nursing facility's services as evidenced by:
a.The immediate and long term financial feasibility of the proposed financing plan;
(1)The proposed amount and sources of owner's equity to be provided by the applicant;
(2)The proposed financial plan for operating and capital expenses and income for the period immediately prior to, during and after the implementation of the change in owner, operator or lessee of the nursing facility;
(3)The relative availability of funds for capital and operating needs;
(4)The applicant's demonstrated financial capability;
(5)Such other financial indicators as may be requested by the state agency;
3.The extent to which the nursing facility will continue to provide safe and adequate treatment for individuals receiving the nursing facility's services and the extent to which the nursing facility will encourage quality improvement in all aspects of the operation of the nursing facility as evidenced by:
a.The applicant’s demonstrated record in providing safe and adequate treatment to individuals receiving services at facilities owned, operated, or directed by the applicant; and
b.The credibility and demonstrated or potential effectiveness of the applicant’s proposed quality assurance programs;
4.The extent to which the nursing facility will continue to provide appropriate access with respect to traditionally underserved populations and in consideration of the proposed continuance or termination of health care services by the nursing facility as evidenced by:
a.In cases where the proposed owners, operators, or directors of the nursing facility currently own, operate, or direct a nursing facility, or in the past five (5) years owned, operated or directed a nursing facility, both within and outside of Rhode Island, the demonstrated record of that person(s) with respect to access of traditionally underserved populations to its nursing facilities; and
b.The proposed immediate and long-term plans of the applicant to ensure adequate and appropriate access to the programs and health care services to be provided by the nursing facility;
5.In consideration of the proposed continuation or termination of health care services by the nursing facility:
a.The effect(s) of such continuation or termination on access to safe and adequate treatment of individuals, including but not limited to traditionally underserved populations;
6.And, in cases where the application involves a merger, consolidation or otherwise legal affiliation of two (2) or more health care facilities, the proposed immediate and long-term plans of such health care facilities with respect to the health care programs to be offered and health care services to be provided by such health care facilities as a result of the merger, consolidation or otherwise legal affiliation.
G.Subsequent to reviews conducted under §§ 1.7(E) and (F) of this Part, the issuance of a license by the licensing agency may be made subject to any condition, provided that no condition may be made unless it directly relates to the statutory purpose expressed in R.I. Gen. Laws § 23-17-3, or to the review criteria set forth in § 1.7(F) of this Part. This shall not limit the authority of the licensing agency to require correction of conditions or defects which existed prior to the proposed change of owner, operator, or lessee and of which notice had been given to the nursing facility by the licensing agency.
1.7.1Background and Qualifications of the Applicant or Proposed License Holder
A.For purposes of § 1.7 of this Part, applicants must meet a financial threshold that shall include, as a minimum, that the applicant or proposed license holder shall have sufficient resources to operate the nursing facility at licensed capacity for thirty (30) days, evidenced by an unencumbered line of credit, a joint escrow account established with the licensing agency, or a performance bond secured in favor of the State or a similar form of security satisfactory to the licensing agency.
B.The licensing agency may also require background information to be submitted relating to any partner, officer, director, manager or member (if member-managed) of the applicant or proposed license holder, or information relating to each person having a beneficial ownership interest of five percent (5%) or more in the applicant or proposed license holder.
C.In reviewing information required by §§ 1.7.1(A) and (B) of this Part, the licensing agency may require the applicant or proposed license holder to file a sworn affidavit substantiating the validity of any submitted information as required by the licensing agency to substantiate a satisfactory compliance history relating to each State or other jurisdiction in which the applicant, proposed license holder or any other person described by §§ 1.7.1(A) and (B) of this Part operated a nursing facility at any time during the five (5) year period preceding the date on which the application is made. The licensing agency shall determine what constitutes a satisfactory compliance history.
D.The licensing agency may also require the applicant or proposed license holder to file information relating to the current financial condition of the applicant, proposed license holder or any other person described by §§ 1.7.1(A) and (B) of this Part and the history of the financial condition of the applicant, proposed license holder or any other person described by §§ 1.7.1(A) and (B) of this Part with respect to a nursing facility operated in another State or jurisdiction at any time during the five (5) year period preceding the date on which the application is made.
E.In addition to the information required to be provided in §§ 1.7.1(A) through (D) of this Part, the licensing agency shall gather information from State departments and agencies relating to the background and qualifications of the applicant, proposed license holder, or any person having a five percent (5%) or more beneficial ownership interest.
F.Notwithstanding any other provision of the law to the contrary, including any moratorium on increasing bed capacity in nursing facilities that may otherwise apply, a nursing facility may take out of service any or all beds of its licensed capacity without impediment to its right to place back into service such beds at a future date under the same terms and conditions as applied at the time of taking them out of service.
1."Take out of service," as used in § 1.7.1(F) of this Part, shall be referred to as “beds on hold” and means an action by a nursing facility to leave a bed(s) unutilized as a nursing facility bed for a specified period of time. Specified periods of time shall be in six (6) month increments, at a minimum.
2.The nursing facility shall inform the licensing agency in writing no less than ten (10) days prior to placing beds on hold and shall describe the alteration of physical space (if any) resulting from taking such bed(s) out of service.
3.Beds on hold and out of service shall reduce a nursing facility's licensed bed capacity by the number of beds on hold.
4.The licensing agency shall maintain a public record of all nursing facility beds on hold.
5.Bed(s) on hold will not automatically be returned to service at the expiration of the specified time-period. Nursing facilities shall request, in writing, that the beds be re-licensed. The request will be reviewed and must be approved for licensure before the nursing facility beds can be occupied.
6.If applicable, the nursing facility shall attest, as part of annual renewal of the nursing facility’s license, to their intent to maintain their current number of bed(s) on hold into the next licensing period.
1.7.2Additional Information Required of all Nursing Facilities
A.Notwithstanding any other provision of the law to the contrary, including any moratorium, any nursing facility applying for initial licensure or renewal of its license that contracts with a management company to assist with the nursing facility's operation shall file a copy of the management contract with the licensing agency including the management fee and, if the management company is a corporation or limited liability company, shall identify every person having an ownership interest of five percent (5%) or more in such corporation or limited liability company and, if the management company is a general partnership or limited partnership, shall identify all general or limited partners of such general partnership or limited partnership.
1.Any nursing facility planning to shift operational control to a management company or change management companies during the license period shall notify the licensing agency in writing thirty (30) days prior to the implementation date of the contract and provide documentation of information as outlined in § 1.7.2 of this Part.
2.Any nursing facility with any significant changes in its management contract shall submit a copy of the revised management contract to the licensing agency within thirty (30) days of the effective date of the new contract provisions.
1.8Capacity and Classifications
A.Each license shall specify the licensed bed capacity of the nursing facility. No nursing facility shall have more residents than the number of beds for which it is licensed.
1.The nursing facility shall identify to the licensing agency the location of licensed beds and shall maintain proper space and furnishings for such locations.
B.Proposed changes in bed capacity within a nursing facility shall be submitted to the licensing agency in writing and shall be subject to the approval of the licensing agency in accordance with the provisions of R.I. Gen. Laws Chapter 23-15.
1.9Change of Ownership, Operation and/or Location
A.When a change of ownership, as defined in Part 22 of this Subchapter, Determination of Need for New Health Care Equipment and New Institutional Health Care Services, or in operation or location of a nursing facility or when discontinuation of services is contemplated the owner and/or operator shall notify the licensing agency in writing no later than six (6) weeks prior to the proposed action.
B.A license shall immediately become void and shall be returned to the licensing agency when operation of the nursing facility is discontinued, or when any changes in ownership occur in accordance with Part 22 of this Subchapter, Determination of Need for New Health Care Equipment and New Institutional Health Care Services.
C.When there is a change in ownership as defined in Part 22 of this Subchapter, Determination of Need for New Health Care Equipment and New Institutional Health Care Services, or in the operation or control of an existing nursing facility, the licensing agency reserves the right to extend the expiration date of such license, allowing the nursing facility to operate under the same conditions which applied to the prior operator, for such time as shall be required for the processing of a new application or for transfer of residents, not to exceed six (6) weeks.
1.The licensing agency shall be notified immediately when a licensee/owner determines to cease operations and close a nursing facility. A meeting shall be conducted with the licensing agency and prior to notice or notification to residents and the public to ensure there is a formal and comprehensive plan for an orderly closure, sixty (60) days' notice to residents, their guardian, or relative so appointed or elected to be his or her decision maker, and the safe, orderly discharge and transfer of residents.
2.The nursing facility closure plan shall include, but is not limited to the following:
a.Letter of intent and/or determining factors/justification for the closure (i.e., voluntary, financial), to include:
(1)Proposed closure date;
(2)Contact information for staff member responsible for implementing the closure plan;
(3)Projected fiscal management plan covering operations during the closure period.
b.Staffing plan(s)
(1)By unit/program/location;
(2)Time line for individual closures of any unit/program/service location;
(3)Staff scale-down process as appropriate given planned transition/reduction of patients/residents.
c.Plans for providing notification and estimated implementation of notices
(1)Notice to third (3rd) party payers (i.e., Medicare/Medicaid);
(2)Notice to Accreditation entities – where appropriate;
(3)Notice to staff/union – meeting date(s);
(4)Public notice;
(5)Community/public meetings – if appropriate and/or planned.
d.Storage/access to medical records
(1)Location for self-storage, or
(2)Company/agency providing contract storage services
1.10Inspections
A.The licensing agency shall make such inspections and investigations as deemed necessary and in accordance with R.I. Gen. Laws Chapters 23-17 and 23-15 and this Part. Such inspections shall apply to all nursing facilities licensed under R.I. Gen. Laws Chapter 23-17 and shall apply to all residents housed therein without regard to source of payment.
B.A duly authorized representative of the licensing agency shall have the right to enter at any time without prior notice to inspect the entire premises and services, including all records of any nursing facility for which an application has been received or for which a license has been issued. Any application shall constitute permission for and willingness to comply with such inspections. The duly authorized representative shall provide necessary identification information and shall sign the log or journal of the nursing facility provided in accordance with R.I. Gen. Laws Chapter 23-17.2.
C.Refusal to permit inspections shall constitute a valid ground for license revocation.
D.Every nursing facility shall be given prompt notice within ten (10) business days by the licensing agency of all deficiencies reported as a result of an inspection or investigation and in accordance with the procedures incorporated in R.I. Gen. Laws Chapters 23-17 and 23-1.
E.Written reports and recommendations of inspections and inspection logs or journals shall be maintained on file in each nursing facility for a period of no less than three (3) years.
1.11Denial, Suspension, Revocation of License or Curtailment of Activities & Sanctions
A.The licensing agency is authorized to deny, suspend, revoke the license, or curtail the activities of any nursing facility which has:
1.Failed to comply with this Part;
2.Aided, abetted or permitted any illegal act or conduct adverse to the health, welfare and safety of residents or of the general public; or
3.Failed to comply with municipal, State or Federal law.
B.In those instances wherein the licensing agency determines that a nursing facility licensed in accordance with R.I. Gen. Laws Chapter 23-17 is not being operated in conformity with all of the requirements herein, the licensing agency may (in lieu of suspension or revocation) curtail activities of the nursing facility, order the licensee to be placed on probationary status and set conditions with which the licensee must comply within a set period of time, order the licensee to admit no additional persons to the nursing facility, to provide health services to no additional persons through the nursing facility, to transfer all or some of the persons occupying the nursing facility to other suitable accommodations, or to take any other corrective action necessary to secure compliance with the requirements established under the Act. Notice of the order and any subsequent hearing that may be scheduled shall comply with the requirements of procedural due process stipulated in R.I. Gen. Laws § 23-17-8. Such action may be taken only when the licensing agency determines that operation of the nursing facility shall not result in undue hardship to residents.
1.Notice of an order to curtail any or all activities of a nursing facility in accordance with § 1.12(B) of this Part shall be made in writing by certified mail and shall state the reason thereof, the action to be taken by the licensee and the time within which said action shall be taken.
C.When the licensing agency deems that operation of a nursing facility results in undue hardship to residents as a result of deficiencies enumerated in the notice of deficiencies, the licensing agency is authorized to suspend the license for a stipulated period of time or to revoke the license of a nursing facility.
D.Whenever an action shall be proposed to deny, suspend or revoke the license or curtail activities of a licensee, the licensing agency shall notify the nursing facility by certified mail (or may be hand delivered), setting forth reasons for the proposed action, and the applicant or licensee shall be given an opportunity for a prompt and fair hearing in accordance with R.I. Gen. Laws Chapter 42-35.
1.However, if the licensing agency finds that public health, safety, or welfare, including the health and safety of residents, imperatively requires emergency action and incorporates a finding to that effect in its order, the licensing agency may order summary suspension of license pending proceedings for revocation or other action.
E.The appropriate State and Federal placement and reimbursement agencies shall be notified of any action taken by the licensing agency pertaining to either denial, suspension or revocation of license or curtailment of activities of any nursing facility.
1.12Sanctions
A.The licensing agency may take appropriate action from within the following array for dealing with violations of R.I. Gen. Laws Chapters 23-17, 23-15, or herein.
1.As a result of denial, the rights and privileges attendant upon licensure will not accrue to a nursing facility.
2.As a result of an order to curtail any or all activities of a nursing facility, a licensee may be ordered to admit no additional persons to said nursing facility, and/or transfer to other suitable accommodations all or some of the residents residing in said nursing facility, and/or take any other corrective action necessary to secure compliance with the requirements established by R.I. Gen. Laws Chapter 23-17 and this Part.
3.As a result of suspension, a nursing facility shall be restrained from admitting any residents during the period of suspension and shall be required to transfer all residents to another nursing facility during the period of suspension. The difference between suspension and revocation of license is essentially a temporal one, such that the sanctions imposed as a result of suspension are so imposed until such time as the deficiency is corrected or until such other time as the licensing agency determines, whereas the sanctions imposed as a result of revocation are considered to be permanent and re-application for license would be necessary.
4.As a result of license revocation, a nursing facility loses all rights and privileges related to licensure and will be required to transfer all residents, will be restrained from admitting any residents and will be subject to prosecution for operation without a license if the foregoing actions are not accomplished.
B.In accordance with the requirements of R.I. Gen. Laws § 23-17-12.3, every person including a controlling person, or corporation who shall willfully and continually violate the provisions of R.I. Gen. Laws §§ 23-17-12 through 23-17-12.2, will be subject to a fine up to three hundred dollars ($300.00) for each violation of these sections.
1.12.1Adverse Change in Financial Condition
A.Whenever the licensing agency, or the licensing agency in consultation with the Rhode Island Department of Human Services, determines that a nursing facility's financial status is of concern and determines, through inspection of the nursing facility or investigation of a complaint, that incident(s), event(s) or patterns of care exist that harm or have the potential to result in harm or danger to the residents of a nursing facility, the Departments, acting jointly, shall convene a meeting, as soon as possible but in no event later than ten (10) days after the finding(s) cited above, with the license holder to communicate the State's concerns with respect to the operation of the nursing facility. The license holder shall be given the opportunity to respond to the State's concerns and to offer explanation as to why the concerns are not valid or accurate.
B.In the event that the explanation provided by the license holder is not found by the licensing agency to be adequate or otherwise satisfactory, the licensing agency shall direct the license holder to prepare and submit, within ten (10) days of the meeting cited above, or for good cause shown no later than twenty (20) days after said meeting, a plan of correction and remediation for the licensing agency review and approval, including, but not limited to, the following elements:
1.Specific targeted improvements;
2.Definite deadlines for accomplishing those targeted improvements;
3.Measurable standards that will be used to judge whether the targeted improvements have been accomplished;
4.A spending plan that supports all costs associated with accomplishment of the targeted improvements;
5.Monthly reporting of cash availability, the status of vendor payments and employee payrolls, and staffing levels, as metrics concerning financial status and quality of care; and
6.With regard to concerns regarding resident care, and if directed by the licensing agency, a proposal to engage an independent quality monitor or independent quality consultant, to work, in consultation with the nursing facility administrator and medical director, the implementation of the plan of correction and remediation, and to provide progress updates to the licensing agency.
C.Whenever a nursing facility’s financial status is determined to be marginal, the licensing agency shall cause such a nursing facility to be inspected in order to determine if financial problems are causing the nursing facility to be out of compliance with nursing facility regulatory standards.
D.Whenever a nursing facility is determined to be having severe financial difficulties, the licensing agency shall cause the nursing facility to have more frequent inspections and the Director may, at the nursing facility’s expense:
1.Appoint an independent consultant to review the nursing facility’s management and financial status and make recommendations to improve the nursing facility’s financial status; or
2.Require the hiring of a temporary manager of the nursing facility's operations.
E.With the exception of the plan of correction and remediation, as allowed in § 1.12.1(F) of this Part, the information obtained by the licensing agency under § 1.11 of this Part is confidential and is not subject to disclosure under R.I. Gen. Laws Chapter 38-2 (“Access to Public Records”). However, upon request, the licensing agency shall release the information to the following who shall treat the information as confidential:
1.The nursing facility;
2.A person other than the nursing facility if the nursing facility consents in writing to the disclosure;
3.The State Medicaid agency responsible for rate setting of nursing facilities;
4.The State long-term care ombudsman; or
5.The Department of Attorney General.
F.Within ten (10) days, or twenty (20) days for good cause shown, of the submission of the plan of correction and remediation by the nursing facility, the licensing agency shall either:
1.Accept the plan, at which time it shall be considered to be a public record, and the nursing facility shall make it, and all reports that follow and are related to it, available for public inspection, and shall provide a written summary of the plan to each resident of the nursing facility or his or her legal representative, and each resident's family representative;
2.Conditionally accept the plan with modifications made by the licensing agency, at which time the plan shall be considered to be a public record and the nursing facility shall make it, and all reports that follow and are related to it, available in accordance with § 1.12.1(F)(1) of this Part; or
3.Reject the plan, at which time all records acquired in accordance with § 1.11 of this Part that do not violate resident confidentiality shall be considered to be a public record, and a notice of said plan rejection shall be sent, along with directions on obtaining the complete record to each resident of the nursing facility or his or her legal representative and each resident's family representative.
G.The provisions in § 1.12.1(D) of this Part relating to the confidentiality of records do not apply:
1.To a nursing facility whose license has been revoked or suspended;
2.To the use of the information in an administrative proceeding initiated by the licensing agency, including implementing enforcement actions, and in judicial proceedings relating thereto.
H.This Part adopts by reference the Regulations that incorporate the criteria to measure financial status as shall be promulgated by the Department of Human Services pursuant to R.I. Gen. Laws § 40-8-19.1.
1.13Organization and Management
1.13.1Governing Body or Other Legal Authority
A.Each nursing facility shall have an organized governing body or other legal authority, responsible for:
1.The management and fiduciary control of the operation and maintenance of the nursing facility; and
2.The conformity of the nursing facility with all Federal, State and local Rules and Regulations relating to fire, safety, sanitation, communicable and reportable diseases, resident quality of care and quality of life, and other relevant health and safety requirements and with this Part.
3.The administration of a policy of non-discrimination in the provision of services to residents and the employment of persons without regard to race, color, creed, national origin, gender, religion, sexual orientation, age, handicapping condition or degree of handicap, in accordance with Title VI of the Civil Rights Act of 1964; U.S. Executive Order #11246 entitled “Equal Employment Opportunity,” U.S. Department of Labor Regulations; Title V of the Rehabilitation Act of 1973, the Rhode Island Fair Employment Practices Act, R.I. Gen. Laws Chapter 28-5 et seq.; the Americans with Disabilities Act; and any other Federal or State laws relating to discriminatory practices.
B.The governing body or other legal authority shall provide facilities, personnel and other resources necessary to meet resident and program needs and also:
1.Describe the structure of the nursing facility’s governing body, including functional and staff organizational charts;
2.Provide names and affiliations of members of the nursing facility’s governing body;
3.Provide a copy of the organization’s charter, constitution and/or by-laws.
C.The governing body or other legal authority shall designate a licensed administrator in accordance with R.I. Gen. Laws Chapter 5-45 and shall establish by-laws or policies to govern the organization of the nursing facility, to establish authority and responsibility, to identify program goals, and to provide for an annual evaluation of administrator performance.
D.The governing body or other legal authority shall adopt a written policy statement relating to conflict of interest on the part of members of the governing body receiving financial gain from ownership, medical staff and employees who may influence corporate decisions.
E.The governing body or other legal authority, through the administrator, shall be responsible for the procurement of a sufficient number of trained, experienced and competent personnel to provide appropriate care and supervision for all residents and to ensure that their personal needs are met.
1.13.2Quality Improvement Program
A.Pursuant to R.I. Gen. Laws § 23-17-12.11, each licensed nursing facility shall develop and implement a quality improvement program and establish a quality improvement committee. The governing body shall ensure that this program is effective, ongoing, nursing facility-wide and shall have a written plan of implementation.
B.Each licensed nursing facility shall designate a qualified individual, who shall be determined by the nursing facility’s administrator, to coordinate and manage the nursing facility’s quality improvement program.
1.The nursing facility’s quality improvement committee shall include at least the following members:
2.The nursing facility administrator;
3.The director of nursing;
4.The medical director;
5.A social worker; and
6.A representative of dietary services.
C.The quality improvement committee shall meet at least quarterly; shall maintain records of all quality improvement activities; and shall keep records of committee meetings that shall be available to the licensing agency during any on-site visit.
D.The quality improvement committee for a nursing facility shall annually review and approve the quality improvement plan for the nursing facility. Said plan shall be available to the public upon request.
E.Each nursing facility shall establish a written quality improvement plan that shall be reviewed by the licensing agency during the nursing facility’s annual survey and that includes:
1.Program objectives;
2.Oversight responsibility (e.g., reports to the governing body, QI records);
3.Nursing facility-wide scope;
4.Involvement of all resident care disciplines/services;
5.Includes methods to identify, evaluate, and correct identified problems;
6.Provides criteria to monitor nursing care and services, including, but not limited to:
a.Medication administration;
b.Prevention and treatment of decubitus ulcers;
c.Dehydration, and nutritional status and weight loss or gain;
d.Accidents, injuries and unexpected deaths;
7.Changes in mental or psychological status;
8.Resident and/or Family Council grievances;
9.Plans of correction developed in response to licensing agency’s inspection reports, and
10.Any other data appropriate to monitor resident’s quality of care and quality of life.
F.All resident care services, including services rendered by a contractor, shall be evaluated.
G.The nursing facility shall take and document appropriate remedial action to address problems identified through the quality improvement program. The nursing facility administrator shall take appropriate remedial actions based on the recommendations of the nursing facility’s quality improvement committee. The outcome(s) of the remedial action shall be documented and submitted to the governing body for their consideration.
H.The Director may not require the quality improvement committee to disclose the records and the reports prepared by the committee except as necessary to assure compliance with the requirements of this section.
I.Good faith attempts by the quality improvement committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
J.If the licensing agency determines that a nursing facility is not implementing its quality improvement program effectively and that quality improvement activities are inadequate, the licensing agency may impose sanctions on the nursing facility to improve quality of resident care including mandated hiring of, directly or by contract, an independent quality consultant acceptable to the licensing agency.
1.13.3Health Care Quality Program
All nursing facilities licensed under R.I. Gen. Laws Chapter 23-17 shall meet all applicable requirements of Part 10-10-7, Health Care Quality Program, promulgated by the licensing agency.
1.13.4Administrator
A.Every nursing facility shall have a full-time administrator licensed in accordance with R.I. Gen. Laws Chapter 5-45, who shall be directly responsible to the governing body or other legal authority for its management and operation, and shall provide liaison between the governing body, medical and nursing staff and other professional staff.
1.When the administrator does not spend full-time in the nursing facility, a substitute shall be designated only with the approval of the licensing agency.
2.In the absence of the administrator, a person shall be designated or authorized in writing, as a substitute on an interim basis.
3.A substitute must be licensed in Rhode Island as a nursing home administrator.
B.The administrator shall be responsible to ensure that services required by residents shall be available on a regular basis, and provided in an appropriate environment in accordance with established policies and the prevailing community standard. Direct resident care shall be provided through a system of consistent assignment and utilizing self-directed work teams whenever possible.
C.The administrator shall be responsible for maintaining accurate time records on all personnel and for posting the work schedule of all direct resident care personnel on a weekly basis. Time records shall be retained by the nursing facility for no less than three (3) years.
D.Nursing facilities shall provide the licensing agency with prompt notice of pending and actual labor disputes/actions which would impact delivery of patient care services including, but not limited to, strikes, walk-outs, and strike notices. Nursing facilities shall provide a plan, acceptable to the Director, for continued operation of the nursing facility, suspension of operations, or closure in the event of such actual or potential labor dispute/action.
E.The licensing agency shall be notified of any change of the administrator of a nursing facility.
1.13.5Medical Director and Attending Physicians
The governing body or other legal authority shall designate a physician to serve as medical director. The medical director shall be a physician licensed to practice in Rhode Island in accordance with the provisions of Subchapter 05 Part 1 of this Chapter, Licensure and Discipline of Physicians. Upon appointment, the name of the medical director shall be submitted to the licensing agency. Each time a new medical director is appointed, the name of said physician shall be reported promptly to the licensing agency. The medical director's Rhode Island medical license number, medical office address, telephone number, emergency telephone number, hospital affiliation and other credentialing information shall be maintained on file at the nursing facility and updated as needed.
1.13.6Duties and Responsibilities of the Medical Director
A.Responsibilities of the medical director shall include, but not be limited to:
1.Coordination of medical care in the nursing facility,
2.Ensuring completion of employee health screening and immunization requirements contained in §§ 1.14.4(A) and 1.14.5 of this Part.
3.The implementation of nursing facility policies and procedures related to the medical care delivered in the nursing facility;
4.Physician and advanced practice practitioner credentialing;
5.Practitioner performance reviews;
6.Employee health including infection control measures;
7.Evaluation of health care delivery, including oversight of medical records and participation in quality improvement;
8.Provision of staff education on medical issues;
9.Participation in State survey process, including the resolution of deficiencies, as needed.
B.The medical director, charged with the aforementioned duties and responsibilities for the delivery of medical care in the nursing facility, shall be immune from civil or criminal prosecution for reporting to the Board of Medical Licensure and Discipline the unprofessional conduct, incompetence or negligence of a nursing facility physician or limited registrant;
C.Provided, that the report, testimony, or other communication was made in good faith and while acting within the scope of authority conferred by § 1.13.5 of this Part.
D.The administrator shall notify the medical director immediately when any enforcement order as described in § 1.11 of this Part is issued by the licensing agency or when the administrator is notified of any Medicare/Medicaid certification enforcement action. The administrator shall provide copies of all statements of deficiencies and related plans of correction to the medical director in a timely fashion.
E.The medical director shall attend the quarterly quality assurance/improvement meetings, as required in § 1.13.2(C) of this Part. The administrator, or his or her designee, shall provide the medical director with adequate notice of the quarterly quality assurance/improvement meeting.
F.Each nursing facility shall maintain an active file of all physicians attending residents for any reason(s), including their phone numbers and addresses, an emergency phone number, their current medical license numbers, and the physician's preferred admitting hospital. This file of physicians shall be revised and updated, as needed, but no less than annually.
G.The governing body or other legal authority shall make available to each physician attending residents in the nursing facility all of the policies governing resident care management and services.
1.13.7COVID-19 Practices and Procedures
A.Nursing Home Residents
1.The nursing facility must have policies and procedures in place for addressing residents who refuse testing or are unable to be tested. In accordance with the provisions of 42 C.F.R. § 483.10(c)(6), residents (or their representatives) may exercise their right to decline COVID-19 testing.
2.Upon the identification of residents who test positive for COVID-19, the facility shall take proper actions to prevent the transmission of COVID-19 in accordance with Department guidance.
3.The nursing facility shall document all COVID-19 testing. The documentation shall at a minimum include the individual's name, date of test, and test result.
B.Nursing Home Personnel
1.For the purposes of § 1.13.7 of this Part, "Personnel" includes employees, as well as volunteers, students, trainees, and any individuals whether paid or unpaid, directly employed by or under contract with the nursing facility on a part-time or full-time basis.
2.The nursing facility shall develop and implement policies and procedures for ongoing tracking of personnel who are employed outside of the nursing facility. Tracking shall include the name and location of the establishment, and any other pertinent information.
1.14Personnel
1.14.1Criminal Records Check
A.Criminal record review requirements are pursuant to R.I. Gen. Laws §§ 23-17-34 and 28-5.1-14.
B.If an applicant has undergone a statewide criminal records check within eighteen (18) months of an application for employment, then an employer may request from the bureau a letter indicating if any disqualifying information was discovered. The bureau will respond without disclosing the nature of the disqualifying information. This letter must be maintained on file to satisfy the requirements of R.I. Gen. Laws § 23-17-34.
C.Due to the fact that juvenile proceedings before the Rhode Island Family Court are exempt from disclosure, the requirement for a statewide criminal records check shall be waived for nursing facility employees under the age of eighteen (18). Provided, however, the nursing facility must perform a reference check for employees under age eighteen (18). Once the employee turns eighteen (18) years old, the required criminal records check must be completed within seven (7) days of his or her eighteenth birthday.
1.14.2Policies and Procedures
A.Each nursing facility shall maintain and implement written personnel policies and procedures supporting long-term care industry standards for personnel practices and sound resident care practices, including but not limited to:
1.Resident-directed care; and
2.Person-centered care practices;
B.Such policies shall be reviewed annually and updated as necessary.
1.14.3Job Descriptions
A.There shall be a job description for each classification of position which delineates qualifications, duties, authority and responsibilities inherent in each position.
1.For those licensed personnel authorized to administer medications in accordance with § 1.16.10(A) of this Part, a job description delineating qualifications, duties and responsibilities shall be provided.
1.14.4Employee Immunization(s) and Health Screening
A.Nursing Facilities are required to adopt, at a minimum, the standards of immunization and communicable disease testing and standards for health screening in accordance with Part 20-15-7 of this Title, Immunization, Testing, and Health Screening for Health Care Workers.
B.Nursing Facilities are required to obtain evidence of immunity for all health care workers in accordance with Part 20-15-7 of this Title, Immunization, Testing, and Health Screening for Health Care Workers.
1.14.5Personnel Records
A.Personnel records shall be maintained for each employee, shall be available at all times for inspection and shall include no less than the following:
1.Current and background information covering qualifications for employment;
2.Records of completion of required orientation training and in-service educational programs, as indicated in § 1.14.6 of this Part;
3.Records of all required health examinations which shall be kept confidential and in accordance with R.I. Gen. Laws Chapter 5-37.3;
4.Evidence of current registration, certification or licensure of personnel subject to statutory Regulation;
5.Annual work performance evaluation records; and
6.Evidence of authorization to administer medications for licensed personnel in accordance with § 1.16.10(A) of this Part.
1.14.6In-Service Education
A.An in-service educational program shall be conducted on an ongoing basis, which shall include an orientation program for new personnel and a program for the development and improvement of skills of all personnel. The in-service program shall be geared to the needs of the elderly, physically disabled, and individuals with dementia, and shall include annual programs on but not limited to:
1.Prevention and control of infection;
2.Food services and sanitation,
3.Emergency preparedness, fire prevention and safety;
4.Confidentiality of resident information;
5.Rights of residents, resident-directed care, and person-centered care; and
6.Any other area related to resident care or services routinely provided at the nursing.
a.Provision shall be made for written documentation of programs, including attendance. Flexible program schedules shall be formulated at least two (2) months in advance.
b.In addition to any State or Federal training requirements pertaining to long term care facilities, or training deemed appropriate by the nursing, each designated universal worker shall maintain a current certification as a Manager Certified in Food Safety pursuant to Part 50-10-2 of this Title, Certification of Managers in Food Safety.
1.14.7Photo Identification
A nursing facility shall require all persons, including students, and as directed by the nursing facility, who examine, observe, treat or assist a patient or resident of such nursing facility to wear a photo identification badge which states, in a reasonably legible manner, the first name, licensure/registration status, if any, and staff position of such person. This badge shall be worn in a manner that makes the badge easily seen and read by the resident or visitor.
1.14.8Licensure Verification
For every person employed by the nursing facility who is licensed, certified, or registered by the licensing agency, a mechanism shall be in place to electronically verify such licensure via the licensing agency licensure verification database. [https://healthri.mylicense.com/Verification/Search.aspx?facility=N&SubmitComplaint=Y]
1.14.9Handling of Resident Fund
A.Any assignment of residents' property either by contractual agreement or by transfer of real estate, bank accounts or insurance benefits, must be reported together with the terms of the assignment to the residents' guardian, next of kin, sponsoring agency(ies) or representative payor and to the licensing agency.
B.Each operator of a nursing facility acting or intending to act as fiduciary agent for a resident is required to have written revocable authorization from any resident so served. The certification will attest to the resident's understanding of the significance of his or her action and will be required to be on file for inspection by authorized surveyors of the licensing agency.
C.The operator shall maintain adequate safeguards and accurate records of each resident's monies and valuables and shall provide at least quarterly, and on request, accounting in accordance with § 1.15.4(Q) of this Part. Such records shall be available for inspection.
D.In addition to requirements of §§ 1.14.9(A) through (C) of this Part, each nursing facility shall conform to the standards of Title XIX Section 1919 Protection of Resident Funds in relation to Title XIX Medicaid recipients.
1.15Reporting of Resident Abuse or Neglect, Accidents & Death
A.Any physician, physician assistant, nurse or other employee of a nursing facility who has reasonable cause to believe that a resident has been abused, exploited, mistreated, neglected or experiences an injury of unknown origin, as outlined in R.I. Gen. Laws Chapter 23-17.8 shall make, within twenty-four (24) hours of the receipt of said information, a report to the licensing agency and to the office of the State long-term care ombudsman. Any person required to make a report pursuant to this section shall be deemed to have complied with these requirements if a report is made to a high managerial agent. Once notified, the administrator or the director of nursing services shall be required to meet the above reporting requirements.
1.All reports, as required by this Part, shall be provided to the licensing agency in writing via facsimile or electronic transmission to [email protected] on forms supplied by the licensing agency. A copy of each report shall be retained by the nursing facility for review during subsequent inspections by the licensing agency.
2.The nursing facility shall maintain evidence that all allegations of abuse, neglect, and/or mistreatment have been thoroughly investigated and that further potential abuse has been prevented while the investigation is in progress. Appropriate corrective action shall be taken, as necessary. The results of said investigation shall be reported to the licensing agency within five (5) business days.
B.Accidents resulting in hospitalization or death in the nursing facility of any resident shall be reported in writing to the licensing agency before the end of the next working day. A copy of each report shall be retained by the nursing facility for review during subsequent surveys.
C.The death of any resident of a nursing facility occurring within twenty-four (24) hours of admission or prior to the performance of a physical examination in accordance with § 1.16.5(C) of this Part, shall be reported to the Office of the State Medical Examiners.
D.In addition, all resident deaths occurring within a nursing facility which are sudden or unexpected, suspicious or unnatural, the result of trauma, remote or otherwise or when unattended by a physician shall be reported to the nursing facility medical director and to the Office of the State Medical Examiners in accordance with R.I. Gen. Laws Chapter 23-4.
E.Reporting requirements, pursuant to R.I. Gen. Laws Chapter 23-17.8 must be posted.
F.Report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury (in accordance with 42 C.F.R. § 483.12(c)(1)).
G.Any elopement of a resident that results in police being called must be reported in writing to the licensing agency within twenty-four (24) hours or by the end of the next business day.
H.Unscheduled implementation of fire/evacuation/disaster plan. Report immediately via phone (401) 222-5200, then fax the information to the licensing agency within three (3) business days.
1.15.1Medical Records
A.A medical record shall be established and maintained for every person admitted to a nursing facility in accordance with accepted professional standards and practices. The administrator shall have ultimate responsibility for the maintenance of medical records; such responsibility may be delegated in writing to a staff member.
B.Entries in the medical record relating to treatment, medication, diagnostic tests and other similar services rendered shall be made by the responsible persons at the time of administration. Only physicians shall enter or authenticate medical opinions or judgment.
C.All accidents, including falls, whether resulting in an injury or not, shall be immediately recorded in the resident's record.
D.Detailed descriptions of all pressure ulcers, or other skin lesions, shall be recorded in the resident's record.
E.Each medical record shall contain sufficient information to identify the resident and to justify diagnosis, treatment, care and documented results and shall include as deemed appropriate:
1.Identification data;
2.Pre-admission screening including mental status (or PASARR (Pre-Admission Screening and Annual Resident Review), where appropriate);
3.Medical history;
4.Plan of care and services provided;
5.Physical examination reports;
6.Admitting diagnosis;
7.Diagnostic and therapeutic orders;
8.Consent forms;
9.Physicians', physician assistants’, and advance practice registered nurse practitioners’ progress notes and observations;
10.Nursing notes;
11.Medication and treatment records, including any immunizations;
12.Laboratory reports, X-ray reports, or other clinical findings; consultation reports;
13.Documentation of all care and services rendered (e.g., dental reports, physical and occupational therapy reports, social service summaries, podiatry reports, inhalation therapy reports, etc.);
14.Resident referral forms;
15.Diagnosis at time of discharge; and
16.Disposition and final summary notes.
F.At time of discharge, a discharge summary, summarizing the resident's stay, shall be completed promptly and signed by the attending physician, advanced nurse practitioner or physician assistant.
G.Medical records of discharged residents shall be completed within a reasonable period of time (not to exceed sixty (60) days) with all clinical information pertaining to the resident's stay made part of the resident's medical record.
H.Confidentiality of medical records shall be governed by the provisions of R.I. Gen. Laws Chapter 5-37.3 and the following;
1.Only authorized personnel shall have access to the records.
2.The nursing facility shall release resident's medical information only with the written consent of the resident, parent, guardian or legal representative in accordance with R.I. Gen. Laws Chapter 5-37.3.
I.Provisions shall be made for the safe storage of medical records to safeguard them against loss, destruction or unauthorized use.
J.All medical records, either original or accurately reproduced, shall be preserved for a minimum of five (5) years following discharge or death of the resident in accordance with R.I. Gen. Laws Chapter 23-3.
1.Medical records of minors, however, shall be kept for at least five (5) years after such minor would have reached the age of eighteen (18) years.
K.The medical records of all residents shall be opened for inspection to duly authorized representatives of the licensing agency whose duty it is to enforce the Regulations herein consistent with § 1.15.5(P)(1) of this Part.
1.Information contained in medical records gathered and collected for the purpose of enforcing this Part is confidential in nature and shall not be publicly disclosed by any person obtaining such information by virtue of his office, unless by court order or as otherwise required by law.
1.15.2Transfer Agreements, Contracts, or Agreements
A.The nursing facility shall have in effect transfer agreements with one (1) or more hospitals for the provision of hospital care or other hospital services to be made available promptly to the residents of the nursing facility, as needed. The written transfer agreement shall ensure:
1.Timely transfer or admission of residents between the hospital and the nursing facility, whenever deemed medically appropriate in writing by a physician;
2.Interchange of medical and other information necessary or useful in the care and treatment of residents transferred or to determine the kind of care the resident requires that includes, but is not limited to the following:
a.Clear statement of the reason(s) resident is being transferred to the hospital or for consultation;
b.Name of resident, address, insurance status;
c.Name of attending physician and his or her telephone number;
d.Resident’s next-of-kin and his or her telephone number;
e.Name of contact staff person at the nursing facility;
f.List of all diagnoses and complaints;
g.List of all current medications, including adequate indications for use;
h.Recent x-ray reports and laboratory reports, as applicable;
i.Existence, and copies, of any advance directives;
j.Any additional information as cited in the “Continuity of Care” form ("Long Form") available from the licensing agency; and
3.Security and accountability for the resident's personal effects during transfer.
B.Designated nursing facility personnel shall complete, in its entirety:
1.The “Continuity of Care” form approved by the licensing agency, for each resident who is discharged to another health care facility, such as a hospital, or who is discharged home, or any other licensed residential program, with follow-up home care required. Said form shall be provided to the receiving facility, care agency, or appropriate treating provider (e.g., primary care physician) prior to or upon transfer of the resident; or
2.The appropriate “Short Form”, approved by the licensing agency, for each resident who is transferred to an emergency care facility, or to a physician’s office, or other scheduled consultative appointment, prior to or upon transfer of the resident.
3.In the event of an emergency situation that requires a partial or full evacuation of residents, the nursing facility may supplement the Continuity of Care form with forms available through the State's Long-Term Care Mutual Aid Plan, or any form(s) as directed by the Licensing agency.
C.If the nursing facility does not employ full-time qualified professional personnel to render required services, or obtains services from an outside source, arrangements for such services shall be made through written agreements or contracts.
1.The responsibilities, functions, objectives, terms of agreement, financial arrangements, charges and other pertinent requirements shall be clearly delineated in the terms of any contract negotiated by a nursing facility.
2.All contracts or agreements negotiated by a nursing facility shall be consistent with the policies established in accordance with § 1.13.1(D) of this Part concerning conflict of interest.
3.Each consultant or outside source providing services to a nursing facility shall submit monthly reports as services are provided. Said reports and contracts shall be kept on file for inspection for a period of no less than three (3) years.
1.15.3Financial Interest Disclosure
A.Any nursing facility licensed pursuant to R.I. Gen. Laws Chapter 23-17 which refers clients/residents to another such licensed nursing facility or to an assisted living facility licensed pursuant to R.I. Gen. Laws Chapter 23-17.4 or a Supported Care Home, licensed pursuant to R.I. Gen. Laws Chapter 23-17.24, or to a certified adult day care program in which the referring entity has a financial interest shall, at the time a referral is made, disclose in writing the following information to the client/resident:
1.That the referring entity has a financial interest in the nursing facility or provider to which the referral is being made;
2.That the client/resident has the option of seeking care from a different nursing facility or provider which is also licensed and/or certified by the State of Rhode Island to provide similar services to the client/resident.
B.The referring entity shall also offer the client/resident a written list prepared by the Department of Health of all such alternative licensed and/or certified facilities or providers. Said written list may be obtained by contacting:
Rhode Island Department of Health, |
Center for Health Facilities Regulation 3 Capitol Hill, Room 306 |
Providence, RI 02908 |
401.222.2566 |
C.Non-compliance with §§ 1.15.4(A) and (B) of this Part shall constitute grounds to revoke, suspend or otherwise discipline the licensee or to deny an application for licensure by the Director, or may result in imposition of an administrative penalty in accordance with R.I. Gen. Laws Chapter 23-17.10.
1.15.4Rights of Residents
A.As part of the procedure for admission of a resident to a nursing facility a written contract shall be entered into between the said resident or his next of kin or legal representative and the nursing facility and the following Rules shall be observed in accordance with R.I. Gen. Laws Chapter 23-17.5 (Rights of Nursing Patients).
B.Each resident shall be offered treatment without discrimination as to gender, age, race, color, religion, national origin, handicap, or source of payment.
C.Each resident shall be treated and cared for with consideration, respect and dignity and shall be afforded his right to privacy to the extent consistent with providing adequate medical care and with efficient administration.
D.Each resident shall have the right to choose his or her own physician subject to the physician's concurrence.
E.Each resident or responsible party shall be fully informed, as evidenced by the resident's written acknowledgment, prior to or at the time of admission or during stay, of all Rules and Regulations and policies pertaining to rights of residents and governing resident conduct and responsibilities.
F.Each resident or responsible party shall be informed in writing, prior to, or at the time of admission and during stay, of services available and of related charges including all charges not covered either under Federal and/or State programs by other third (3rd) party payers or by the nursing facility’s basic per diem rate.
G.Each resident admitted to a nursing facility shall be and remain under the care of a physician as specified in policies adopted by the governing body.
H.Each resident shall be informed by a physician of his medical condition unless medically contraindicated, (as documented by a physician in his medical record), and shall participate in the planning and selection of his medical treatment and care.
I.If it is proposed that a resident be used in any human experimentation project, the resident shall first be thoroughly informed in writing of such proposal and shall be offered the right to refuse to participate in such project. A resident who, after being thoroughly informed, wishes to participate must execute a written statement of informed consent. The informed consent documentation shall be maintained on file in the nursing facility.
J.Residents shall be encouraged and assisted to voice their grievances through a documented grievance mechanism established by the nursing facility, involving residents, staff and relatives of residents, which will ensure resident's freedom from restraints, interference, coercion, discrimination or reprisal.
1.There shall be prompt efforts by the nursing facility staff to resolve resident's grievances.
K.Residents shall not be subject to mental and physical abuse and shall be free from chemical and (except in emergencies) physical restraints.
1.Restraining devices are generally prohibited. A controlling device to be used for the protection of the resident may be utilized only as ordered in writing and signed by a physician, physician assistant, or advanced practice registered nurse. The length of time, the purpose and the kind of restraint shall be specified in the physician's, physician assistant’s, or advanced practice registered nurse’s order.
2.If after a trial of less restrictive measures, the nursing facility decides that a physical restraint would enable and promote greater functional independence, then the use of the restraining device must first be explained to the resident, family member, or legal representative, and if the resident, family member or legal representative agrees to this treatment alternative, then the restraining device may be used for the specific periods for which the restraint has been determined to serve the purpose defined above. This does not allow the use of restraints for convenience sake.
3.The restraining device must be authorized by the physician, physician assistant, or advanced practice registered nurse for use for specific periods for which the restraint has been determined to serve the purpose defined in § 1.15.5(K)(2) of this Part. This does not allow the use of restraints for convenience sake.
L.A resident shall not be required to perform services for the nursing facility that are not included for therapeutic purposes in his plan of care.
M.Residents may meet with and participate in activities of social, religious and community groups at their discretion unless medically contraindicated per written medical order.
N.Residents may associate and communicate privately with persons of their choice and shall be allowed freedom and privacy in sending and receiving mail.
1.Posted reasonable visiting hours must be maintained in each nursing facility, with a minimum of four (4) hours daily. The nursing facility must provide immediate access to residents by properly identified appropriate government personnel, family members, physicians, and relatives. However, the resident reserves the right to refuse visitation by any of the aforementioned.
2.All health care providers, as licensed under the provisions of R.I. Gen. Laws Chapters 5-29 or 5-37 and all health care facilities, as defined in R.I. Gen. Laws § 23-17-2(5) shall be required to note in their residents’ permanent medical records, the name of individual(s) not legally related by blood or marriage to the resident, who the resident wishes to be considered as immediate family member(s), for the purpose of granting extended visitation rights to said individual(s), so said individual(s) may visit the resident while he or she is receiving inpatient health care services in a nursing facility.
a.A resident choosing to designate said individual(s) as immediate family members for the purpose of extending visitation rights may choose up to five (5) individuals and do so either verbally or in writing. This designation shall be made only by the resident and can be initiated and/or rescinded by the resident at any time, either prior to, during, or subsequent to an inpatient stay at the nursing facility.
b.The full names of individual(s) so designated, along with their relationship to the resident, shall be recorded in the resident’s permanent medical records, both at the inpatient nursing facility and with the resident’s primary care physician.
c.In the event the resident has not had the opportunity to have said designation recorded in his or her medical records, a signed statement in the resident’s own handwriting attesting to the designation of said individual(s) as an immediate family member for the purpose of extending visitation right during the provision of health care services in an inpatient health care facility, along with their relationship to said individual(s) shall meet all the requirements of § 1.15.5 of this Part. The resident’s signature on said signed statement shall be witnessed by two (2) individuals, neither of whom can be the designated individual(s). In the event such signed statement is not available, those designated as agents on a durable power of attorney for health care form shall be allowed visitation privileges.
d.§ 1.15.5 of this Part shall not be construed to prohibit legally recognized members of the resident’s family from visiting the resident if they have not been so designated through the provisions of § 1.15.5 of this Part. No resident shall be required to designate individual(s) under the provisions of § 1.15.5 of this Part.
O.Residents shall have the right to obtain personal services or to purchase needs outside of the nursing facility.
P.The resident's right to privacy and confidentiality shall extend to all records pertaining to the resident. Release of any records shall be subject to the resident's approval except as otherwise provided by law.
1.The right to privacy and confidentiality relates to the public dissemination of specific information contained within resident records and to the identification of specific individuals, but does not abrogate the responsibility of the licensing agency to review all resident records.
Q.A resident shall have the right to manage his or her own personal financial affairs. The resident may delegate the management of his or her financial affairs to the nursing facility by means of a formal written request. The written request should specify the period of time for which transfer of financial responsibility is desired. If the nursing facility agrees to accept such responsibility, it shall convey acknowledgment of acceptance to the residents in writing. The nursing facility shall have the obligation to conduct the resident's affairs in conformity with State laws and to provide a written accounting statement at least quarterly or at any time upon demand of the resident.
R.Residents shall be assured privacy for visits by the spouse or other partner. If both are residents in the nursing facility, they may share a room unless medically contraindicated per written order of the physician and subject to the availability of such accommodations within the nursing facility.
S.Before transferring a resident to another nursing facility or level of care within a nursing facility, the resident shall be informed of the need for such a transfer and of any alternatives to such a transfer.
1.A resident shall be transferred or discharged only for medical reasons, or for his welfare or that of other residents or for nonpayment of his stay.
2.Reasonable advance notice for transfers to health care facilities other than hospitals shall be given to ensure orderly transfer or discharge and such actions shall be documented in the medical record.
3.Bed-Hold and Readmission: A nursing facility must provide written information pertaining to bed-hold and readmission for residents transferred for hospitalization or therapeutic leave as follows:
a.Notice before transfer: Before a resident of a nursing facility is transferred for hospitalization or therapeutic leave, a nursing facility must provide written information to the resident and a family member or legal representative concerning:
(1)The provisions of the medical assistance program State plan regarding the period (if any) during which the resident will be permitted under the State plan to return and resume residence in the nursing facility; and
(2)The policies of the nursing facility regarding such a period, which policies must be consistent with § 1.15.5(S)(3)(b) of this Part;
b.Notice upon transfer: At the time of the transfer of a resident to a hospital or for therapeutic leave, a nursing facility must provide written notice to the resident and a family member or legal representative of the duration of any period described in § 1.15.5(S)(3)(c) of this Part; except in an emergency, said notice must be given within twenty-four (24) hours of the transfer.
c.Permitting resident to return: A nursing facility must establish and follow a written policy under which a resident:
(1)Who is transferred from the nursing facility for hospitalization or therapeutic leave; and
(2)Whose hospitalization or therapeutic leave exceeds a period paid for under the State plan for the holding of a bed in the nursing facility for the resident, will be readmitted to the nursing facility immediately upon the first availability of a bed of appropriate level of care in a semi-private room in the nursing facility if at time of readmission, the resident requires the services provided by the nursing facility;
(3)Any nursing facility that accepts private payment for purposes of reserving a bed in the nursing facility for a resident who is transferred from the nursing facility for hospitalization or other institutional therapeutic leave, and that resident’s medical and health care is being paid for by the State Medical Assistance Program, shall not charge an amount per day for reserving a bed in the nursing facility that exceeds the nursing facility’s current Medicaid daily rate; for a minimum of the first five (5) days of said hospitalization or the institutional therapeutic leave.
(4)The Departments of Human Services and of Health shall receive, on a monthly basis, the names from each nursing facility of those persons awaiting readmission under these provisions.
T.A resident shall have the right to live in a tobacco smoke-free environment. It shall be prohibited for any person other than a nursing facility resident to smoke in a nursing facility.
1.Nursing facility residents who smoke may do so only in private or semi-private rooms where both residents smoke, or rooms designated by the administration of the nursing facility.
a.A designated smoking area shall be a room or rooms other than the largest living or assembly room or lounge.
b.A designated smoking area shall be ventilated in such a way that the air therefrom shall not enter other parts of the nursing facility.
2.The resident shall have the right to have his or her pain assessed on a regular basis.
3.Notwithstanding any other provisions of § 1.15.5 of this Part, upon request, patients receiving care through hospitals, nursing facilities, assisted living residences and home health care providers, shall have the right to receive information concerning hospice care, including the benefits of hospice care, the cost, and how to enroll in hospice care.
U.The nursing facility shall respond in a reasonable manner to the request of a resident's physician, certified nurse practitioner and/or a physician assistant for medical services to the resident. The nursing facility shall also respond in a reasonable manner to the resident's request for other services customarily rendered by the nursing facility to the extent the services do not require the approval of the resident's physician, certified nurse practitioner and/or a physician's assistant or are not inconsistent with the resident's treatment.
V.Heat relief: Pursuant to R.I. Gen. Laws § 23-17.5-27, any nursing facility which does not provide air conditioning in every patient room shall provide an air conditioned room or rooms in a residential section(s) of the facility to provide relief to patients when the outdoor temperature exceeds eighty degrees Fahrenheit (80° F).
W.All rights and responsibilities specified in §§ 1.15.5(D), (I), (Q), and (S) of this Part shall devolve, in order of priority, to a resident's guardian, next of kin, sponsoring agency(ies) or representative payor (except when the nursing facility itself is the representative payor) for residents who are:
1.Adjudicated incompetent in accordance with State law; or
2.Found by the physician, physician assistant, or advanced practice registered nurse to be medically incapable of understanding their rights; or
3.Found to exhibit a communication barrier. If however, the communication barrier is one of speaking a language other than English, then an attempt shall be made to find a qualified and competent medical interpreter in accordance with the National Standards on Culturally and Linguistically Appropriate Services (CLAS) and Title VI of the Civil Rights Act for nursing facilities receiving Medicare/Medicaid reimbursements to allow the resident to knowingly exercise his or her rights.
X.Posting a Copy of Rights of Residents: Each nursing facility shall provide each resident or his or her representative upon admission, a copy of the provisions of R.I. Gen. Laws Chapter 23-17.5, entitled "Rights of Nursing Home Patients", and shall display in a conspicuous place, in the nursing facility a copy of the "Rights of Residents" and related information. At a minimum the display must include the following:
1.A summary of the major provisions of the Rights of Residents as set forth in this Part;
2.The address and telephone number of: Health Facilities Regulation, Rhode Island Department of Health, Three Capitol Hill, Providence, R.I. 02908 (Telephone Number: 401-222-2566), the agency which will accept complaints or notice of violations of the provisions of this Part;
3.The results of the most recent State and Federal licensing and certification surveys of nursing facilities must be posted.
4.The telephone number of the State long-term care ombudsman: 401-785-3340.
5.The telephone number of the State Medicaid Fraud Unit: 401-274-4400 x2269.
1.15.5Resident and Family Notification
A.When directed to do so by the Department, the nursing facility shall:
1.Notify the resident, or his or her legal representative, the resident’s family representative, the resident’s attending physicians of record and the nursing facility’s medical director, if that resident has been found to be in immediate jeopardy (IJ) to health and safety and/or substandard quality of care.
B.The nursing facility shall provide for notification of changes regarding resident condition as provided in Federal Regulation 42 C.F.R. § 483.10 or successor Regulation.
C.A nursing facility citation for substandard quality of care shall be considered to be a public record ten (10) days following the citation.
1.15.6Essential Caregivers During a Declared Emergency
A.The provisions of this section shall apply for the period commencing fifteen (15) days after a declaration of disaster emergency and last until sixty (60) days after the termination or expiration of the declaration of disaster emergency by executive order, proclamation, or operation of law.
B.Each facility shall allow a resident of a nursing home, or an individual with decision-making authority for the resident, to designate an individual as the resident's essential caregiver during a declaration of a disaster emergency.
C.Qualifications and Caregiver Designation
1.In order to be designated as an essential caregiver to provide in-person physical or emotional support to a resident during a declaration of disaster emergency, the individual must be at least eighteen (18) years old.
2.One (1) essential caregiver may be designated at any given time for each resident.
D.Safety Measures
1.Each facility shall develop and implement safety protocols for essential caregivers within fifteen (15) days of a declaration of disaster emergency. Such protocols must be consistent with the Department, State and Federal guidance. Facilities must update safety protocols in the event of any new guidance from State or Federal partners within seventy-two (72) hours.
2.The safety protocols for an essential caregiver, shall include, but not be limited to, procedures on:
a.Restrictions on travel;
Restrictions on travel must not be more restrictive than travel restrictions for all Rhode Island residents for the declaration of disaster emergency.
b.Enhanced testing for communicable diseases, as applicable; and
Enhanced testing, also known as surveillance testing, for essential caregivers must not be more stringent than surveillance testing required for nursing home staff.
c.Use of personal protective equipment (PPE)
(1)The required PPE for essential caregivers will vary depending on tasks, actions, and nature of emergency.
(2)A nursing home is not required to provide personal protective equipment (PPE) to essential caregivers.
3.An essential caregiver must comply with routine surveillance testing during the course of a declared disaster emergency.
4.The nursing facility shall be responsible for verifying/tracking the testing status, as applicable, of essential caregivers.
5.The essential caregiver must adhere to face-masking, hand hygiene, social distancing, and other safety measures at the direction of nursing facility staff.
6.In accordance with R.I. Gen. Laws § 23-17.5-37(b)(4), a facility that enters a lock down phase to establish safety measures for residents and essential caregivers shall not exceed a period of thirty (30) days. During the lock-down phase, essential caregivers are not permitted to enter.
7.A nursing home may establish additional safety requirements to protect the residents of the nursing home if the requirements meet all of the following criteria:
a.The requirements are directly linked to a declaration of disaster emergency.
b.The requirements are not so burdensome and onerous as to substantially prevent an essential caregiver from being able to physically or emotionally support a resident of the nursing home in person.
E.Administration
1.The nursing facility must establish and implement policies and procedures for designating and utilizing essential caregivers during the period of a declared disaster emergency.
2.The nursing facility must allow an essential caregiver to have regular and sustained in-person visitation and physical access to a nursing home resident.
a.The nursing home must ensure visits with essential caregivers are conducted with a reasonable degree of privacy.
3.The essential caregiver may sign an agreement with the nursing facility that outlines what support and activities will be provided by the essential caregiver.
4.An essential caregiver visit may be suspended in the event of the essential caregiver's failure to comply with the facility requirements or these Regulations during a visit.
5.A nursing home must have a policy or procedure in place for a resident or an individual with decision making authority for the resident, to immediately designate a replacement essential caregiver in the event an essential caregiver is suspended.
7.The nursing facility must have a policy or procedures in place to replace an essential caregiver due to necessary circumstances, including but not limited to, illness or death of the essential caregiver.
8.Nursing facilities shall provide training to essential caregivers that includes, but is not limited, to the following:
a.Infection prevention and control, including proper donning and doffing of PPE, hand hygiene, and mask use;
b.Signs and symptoms of any communicable disease(s) that are associated with the declared disaster emergency;
c.Safety and efficacy of any available vaccination(s) for communicable disease(s) associated with the declared disaster emergency.
1.15.7Family Councils
A.Upon the admission of a resident, the nursing facility shall inform the resident and the resident’s family members, in writing, of their right to form a family council, or if a family council already exists, of the date, time, and location of scheduled meetings.
B.If a family council exists, its role shall be to address issues affecting residents generally at the nursing facility, not to pursue individual grievances. Issues may include, but are not limited to:
1.How the nursing facility facilitates resident choice and resident directed activities; and
2.How the nursing facility staff implements person-centered care practices.
C.The family council shall not be entitled to obtain information about individual residents or staff members, or any other information deemed confidential under State or Federal law.
D.No licensed nursing facility may prohibit the formation of a family council.
E.When requested by a member of a resident’s family or a resident’s representative, a family council shall be allowed to meet in a common meeting room of the nursing facility at least once a month during mutually agreed upon hours.
F.The nursing facility administration shall notify the State long-term care ombudsman of the existence or planned formation of a family council at that nursing facility.
G.The family council may exclude members only for good cause shown, subject to appeal by the excluded party to the State long-term care ombudsman. No member shall be excluded on the basis of race or color, religion, gender, sexual orientation, disability, age, or country of ancestral origin.
H.A nursing facility shall provide its family council with adequate space in a prominent posting area for the display of information pertaining to the family council.
I.Staff or visitors may attend family council meetings at the council’s invitation.
J.The nursing facility shall provide a designated staff person who, at the request of the council, shall be responsible for providing assistance to the family council and for responding to recommendations and requests made by the family council.
K.The nursing facility shall consider the recommendations of the family council concerning issues and policies affecting resident care and life at the nursing facility.
1.15.8Reimbursement of Monies Prepaid to Deceased Patient's Estate
A.The nursing facility shall be required to reimburse any monies that have been prepaid on behalf of a deceased patient to the nursing within ninety (90) days of the patient's date of death. Said reimbursement shall be paid to the person(s), institution or other legal entity who has paid the monies, or if there be none, to the deceased patient's estate, and payment shall be made in the amount remaining after all items and services provided or arranged by the nursing have been paid. However, if payment is required to be made to the deceased patient’s estate, payment shall not become due until sixty (60) days after the nursing is notified that the estate has been filed.
B.A violation of the provisions of § 1.15.5 of this Part shall constitute a violation of the rights of nursing facility residents.
1.15.9Uniform Reporting System
A.Uniform Reporting System: Each nursing facility shall establish and maintain records and data in such a manner as to make uniform the system of periodic reporting. The manner in which the requirements of this reporting may be met shall be prescribed from time to time in directives promulgated by the Director with the advice of the Health Services Council.
B.Each nursing facility shall report to the licensing agency detailed financial and statistical data pertaining to its operations, services, and facilities. Such reports shall be made at such intervals and by such dates as determined by the Director and shall include but not be limited to the following:
1.Utilization of nursing services;
2.Unit cost of nursing services;
3.Charges for rooms and services;
4.Financial condition of the nursing facility;
5.Quality of care;
6.Quality of life;
7.Resident census; and
8.Licensed nursing hours and turnover.
C.The licensing agency is authorized to make the reported data available to any State agency concerned with or exercising jurisdiction over the reimbursement or utilization of nursing facilities.
D.The directives promulgated by the Director pursuant to this Part shall be sent to each nursing facility to which they apply. Such directives shall prescribe the form and manner in which the financial and statistical data required shall be furnished to the licensing agency.
1.16Resident Care Services
1.16.1Resident Care Policies
A.Each nursing facility shall have written resident care policies to govern the continuing nursing care and related medical or other services provided.
1.Care practices shall be person-centered in their implementation and resident-directed in their development whenever possible, and
2.The nursing facility shall provide care and services to all residents in accordance with the prevailing community standard of care.
B.Each nursing facility licensed under the provision of R.I. Gen. Laws Chapter 23-17 shall have a written plan for preventing the hazards of resident wandering from the nursing facility. Said plan shall be on file in the nursing facility and available to the licensing agency upon request.
C.As part of the initial resident admission and assessment process, the nursing facility shall review and consider any notice provided to the facility as required in R.I. Gen. Laws § 42-56-10(23) concerning the resident's or prospective resident's status on parole and recommendations, if any, from the Department of Corrections regarding safety and security measures.
D.Resident care policies and procedures shall be developed and reviewed annually, and revised as necessary, in all nursing facilities by a group of professional personnel including one (1) or more physicians, a registered nurse, representatives of self-directed work teams, and other professional personnel as deemed necessary (e.g., social workers, physical therapists, registered nursing assistants, universal workers, etc.). Documentation of this annual review shall be made available to the licensing agency upon request.
E.Resident care policies shall be available for review by all residents, physicians, community agencies, relatives and personnel and shall include provisions for at least the following:
1.Meeting the total medical and psychosocial needs of residents;
2.The establishment of written plans of care for each resident for medical, nursing and other related services provided;
3.The range of services available and provided to residents and constraints imposed by limitations of services, physicians, facilities, staff coverage, payment mechanism or other;
4.The frequency of physician visits shall be at a minimum of ninety (90) days;
5.The protection of residents' personal and property rights;
6.Types of clinical conditions acceptable for admission to specific levels of care and appropriate services;
7.Emergency admissions or discharges and emergency care of residents;
8.Requirements for informed consent by resident, parent, guardian or legal representative for treatment;
9.Notification of next of kin, attending physician or responsible agency of any transfer or discharge;
10.Notification of next of kin, attending physician or responsible agency of any change of condition;
11.Opportunity for resident, resident family, and/or Family Council comment or complaint;
12.Transfer of medical information in accordance with R.I. Gen. Laws Chapter 5-37.3;
13.Discharge and termination of services; and
14.Provision for continuity of resident care as related to discharge planning, which shall include a mechanism for recording, transmitting and receiving information essential to the continuity of resident care. Such information shall contain no less than the following:
a.Resident identification data; such as name, address, age, gender, name of next of kin, health insurance coverage, etc.;
b.Diagnosis and prognosis, medical status of resident, brief description of current illness, medical and nursing plans of care including such information as medications, treatments, dietary needs, baseline laboratory data;
c.Functional status;
d.Special services such as physical therapy, occupational therapy, speech therapy and such other;
e.Psychosocial needs;
f.Bed-hold policy and readmission in accordance with § 1.15.5(S)(3)(c) of this Part; and
g.Such other information pertinent to ensure continuity of resident care.
F.There shall be documented evidence of the designation of responsibility to a physician, or to a nurse or to the medical staff for the execution and implementation of resident care policies.
1.When a nurse is designated as the responsible agent for a day-to-day execution of resident care policies, a physician shall be available to provide necessary medical guidance.
1.16.2Infection Control
A.The nursing facility shall be responsible for no less than the following:
1.Establishing and maintaining a nursing facility-wide infection surveillance program;
2.Developing and implementing written policies and procedures for the surveillance, prevention, and control of infections in all resident care departments/services;
3.Establishing policies governing the admission and isolation of residents with known or suspected infectious diseases;
4.Developing, evaluating and revising on a continuing basis infection control policies, procedures and techniques for all appropriate areas of nursing facility operation and services;
5.Developing and implementing a system for evaluating and recording the occurrences of all infections relevant to employment (e.g., skin rash) among personnel and infections among residents; such records shall be made available to the licensing agency upon request;
6.Implementing a TB infection control program requiring risk assessment and development of a TB infection control plan; early identification, treatment and isolation of strongly suspected or confirmed infectious TB residents; effective engineering controls; an appropriate respiratory protection program; health care worker TB training, education, counseling and screening; and evaluation of the program's effectiveness, per guidelines in Recommendations for Preventing the Spread of Vancomycin Resistance.
a.The TB infection control plan shall include, at a minimum, a provision that residents shall be screened for TB, within fourteen (14) days of admission, and found to be free of active tuberculosis based upon the results of a negative two (2) step tuberculin skin test. If documented evidence is provided that the resident has had a two (2) step tuberculin skin test, performed within the most recent twelve (12) months prior to admission, that was negative, the requirements of this section shall be met.
7.Developing and implementing an institution-specific strategic plan for the prevention and control of vancomycin resistance, with a special focus on vancomycin-resistant enterococci, per Part 20-15-7 of this Title, Immunization, Testing, and Health Screening for Health Care Workers. (See also Guidelines for the Control of Vancomycin Resistant Enterococci (VRE) in Nursing and Extended Care Facilities for additional information on this issue).
8.Developing and implementing protocols for:
a.Discharge planning to home that include full instruction to the family or caregivers regarding necessary infection control measures; and
b.Hospital transfer of residents with infectious diseases which may present the risk of continuing transmission. Examples of such diseases include, but are not limited to, tuberculosis (TB), Methicillin resistant staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE), and clostridium difficile.
9.Assuring that all resident care staff are available in order to assist in the prevention and control of infectious diseases and are provided with adequate direction, training, staffing and facilities to perform all required infection surveillance, prevention and control functions.
B.Infection control provisions shall be established for the mutual protection of residents, employees, and the public.
C.A continuing education program on infection control shall be conducted periodically for all staff.
1.16.3Reporting of Communicable Diseases
A.Each nursing facility shall report promptly to the Rhode Island Department of Health, Division of Preparedness, Response, Infections Disease and EMS, cases of communicable diseases designated as "reportable diseases" when such cases are diagnosed in the facility in accordance with Part 30-05-1 of this Title, Reporting and Testing of Infectious, Environmental, and Occupational Diseases.
B.When infectious diseases present a potential hazard to residents or personnel, these shall be reported to the Rhode Island Department of Health, Division of Preparedness, Response, Infections Disease and Emergency Medical Services, even if not designated as "reportable diseases."
C.When outbreaks of food-borne illness are suspected, such occurrences shall be reported immediately to the Rhode Island Department of Health, Division of Preparedness, Response, Infections Disease and Emergency Medical Services, or to the Center for Food Protection.
D.Nursing Facilities must comply with the provisions of R.I. Gen. Laws § 23-28.36-3, which requires notification of fire fighters, police officers and Emergency Medical Technicians after exposure to infectious diseases.
1.16.4Resident Immunization Policies/Practices
A.Every nursing facility in Rhode Island shall request that residents be immunized for influenza virus and pneumococcal disease in accordance with R.I. Gen. Laws Chapter 23-17.19.
B.Influenza, pneumococcal, and other adult vaccination policies and protocols (such as physician’s standing orders) for nursing facility residents shall be developed and implemented by the nursing facility in accordance with the provisions of R.I. Gen. Laws §§ 23-17.19-4 (a) through(c).
C.Vaccinations must be provided in accordance with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices Standard.
1.Exceptions: No resident shall be required to receive either the influenza or pneumococcal vaccine in accordance with exceptions listed in R.I. Gen. Laws § 23-17.19-6.
1.16.5Physician Service
A.All residents shall remain or be under the care of a physician of his or her choice, subject to the physician's concurrence.
1.All physician assistant services shall be in accordance with the provisions of R.I. Gen. Laws Chapter 5-54.
2.All nurse practitioner services shall be in accordance with the provisions of R.I. Gen. Laws Chapter 5-34.
B.No less than the following resident care information shall be made available to facilities by the referring source prior to or upon admission and provided only in accordance with the requirements of R.I. Gen. Laws Chapter 5-37.3:
1.Current medical findings;
2.Summary of pre-admission treatment and care; and
3.Diagnosis and medical orders by the physician, physician assistant, or advanced practice registered nurse for immediate resident care.
C.Each nursing facility shall establish and comply with policies governing medical care supervision. Such policies shall include no less than the following:
1.That every resident be under the continued medical supervision of a physician of his or her choice;
2.That a prescribed medical care plan be established for each resident by the attending physician, or physician assistant or advanced practice registered nurse in collaboration with the attending physician. Accordingly, recommendations or orders from consultants shall be approved by the attending physician, or physician assistant or advanced practice registered nurse in collaboration with the attending physician prior to implementation of the order.
3.That the medical care plan be based on a physical examination done within forty-eight (48) hours of admission unless such was performed within five (5) days prior to admission;
4.That each resident be seen by an attending physician, or physician assistant or advanced practice registered nurse in collaboration with the attending physician and the medical care plan be renewed or revised in accordance with the needs of the resident at least every ninety (90) days;
5.That arrangements be made for physician coverage in the absence of the attending physician; and, and progress notes be written and signed by the physician at the time of each visit.
6.Any physician's, physician assistant’s, or advanced practice registered nurse’s verbal order for drugs, and biologicals shall be given in accordance with the provisions of § 1.16.9(B) of this Part.
D.Written policies and procedures pertaining to emergency medical care including a listing of physician coverage, shall be established and maintained in each residential area. The nursing facility must provide or arrange for physician's services twenty-four (24) hours a day in case of an emergency.
E.Standing orders shall not be permitted. All orders shall be recorded in the resident's medical record and shall be properly signed. However, a physician's, physician assistant’s, or advanced practice registered nurse’s order for an individual resident may refer to treatments described in a written protocol adopted by the nursing facility. An exception to the requirements of § 1.16.5 of this Part shall be made for the administration of influenza and pneumococcal immunizations as provided in § 1.16.4 of this Part and the administration of Naloxone (Narcan) in accordance with Part 20-20-5 of this Title, Opioid Overdose Prevention and Reporting.
1.16.6Nursing Service and Minimum Staffing
A.Each nursing facility shall have a formally organized nursing service with an organization chart reflecting the lines of communication. The authority, responsibilities and duties for each nursing service position and/or category shall be clearly delineated in writing through job descriptions.
B.The nursing service shall be under the direction of a Director of Nurses who shall be a registered nurse and employed full-time. A relief registered nurse shall be employed to ensure full-time coverage in the absence (including vacation, sick time, days off, or other) of the designated registered nurse.
1.The Director of Nurses shall not be the administrator nor the assistant administrator and shall:
a.Have at least two (2) years’ experience in nursing supervision or, by training and experience, shall have demonstrated competency in nursing service management;
b.Be employed by only one (1) facility in said capacity; and
c.Be responsible for the total nursing service which shall include no less than:
(1)Development, maintenance and evaluation of standards of nursing practice;
(2)Development and periodic revision of nursing policies and procedure manuals;
(3)Recommendation to the nursing facility’s administration of the number and categories of nursing personnel required to provide resident care;
(4)Training, assignment, supervision and evaluation of personnel;
(5)Coordination of nursing care services with other services, e.g., medical, nutrition, etc.; and
(6)All other functions and activities related to nursing service management.
C.Each facility shall have a registered nurse on the premises twenty-four (24) hours a day. In addition, the necessary nursing service personnel (licensed and non-licensed) shall be in sufficient numbers on a twenty-four (24) hour basis, to assess the needs of resident, to develop and implement resident care plans, to provide direct resident care services, and to perform other related activities to maintain the health, safety and welfare of residents.
1.There shall be a master plan of the staffing pattern for providing twenty-four (24) hour direct care nursing service; for the distribution of direct care nursing personnel for each floor and/or residential area; for the replacement of direct care nursing personnel; and for forecasting future needs. The staffing pattern shall include provisions for registered nurses, licensed practical nurses, nursing assistants, medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, physical therapist assistants and other personnel as required.
2.Each nursing facility shall include direct caregivers, including at least one (1) nursing assistant, in the process to create the master plan of the staffing pattern and the federally mandated facility assessment. If the nursing assistants in the nursing facility are represented under a collective bargaining agreement, the bargaining unit shall coordinate voting to allow the nursing assistants to select their representative.
3.The number and type of nursing personnel shall be based on resident care needs and classifications as determined for each residential area. Each nursing facility shall be responsible to have sufficient qualified staff to meet the needs of the residents.
4.At least one (1) individual who is certified in Basic Life Support must be available twenty-four (24) hours a day within the nursing facility.
5.Commencing on January 1, 2022, nursing facilities shall provide a quarterly minimum average specified in R.I. Gen. Laws § 23-17.5-32(c)(i).
6.Commencing on January 1, 2023, nursing facilities shall provide a quarterly minimum average specified in R.I. Gen. Laws § 23-17.5-32(c)(ii).
a.In accordance with R.I. Gen. Laws § 23-17.5-32(d), Director of Nursing hours and nursing staff hours spent on administrative duties or non-direct caregiving tasks are excluded and may not be counted toward compliance with the minimum staffing hours requirement in §§ 1.16.6(C)(5) and (6) of this Part.
b.Nursing facilities that are certified by the Federal Centers for Medicare and Medicaid Services (CMS) shall access and report data using CMS' payroll-based journal database in accordance with R.I. Gen. Laws § 23-17.5-33(a)(2).
c.Nursing facilities that are not certified by CMS (State licensure only) shall report data to the licensing agency in a form and manner as prescribed by the Director.
7.In accordance with R.I. Gen. Laws § 23-17.5-32(e), the requirements of §§ 16.6.(C)(5) and (6) of this Part are minimum standards only. Nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant State and Federal staffing requirements.
8.Compliance and enforcement for § 1.16.6 of this Part shall be done in accordance with R.I. Gen. Laws § 23-17.5-33.
1.16.7Nursing Staff Posting Requirements
A.Each nursing facility shall post its daily direct care nurse staff levels by shift in a public place within the nursing facility that is readily accessible to and visible by residents, employees, and visitors. The posting shall be accurate to the actual number of direct care nursing staff on duty for each shift per day. The posting shall be in a format prescribed by the Director, to include:
1.The number of registered nurses, licensed practical nurses, nursing assistants, medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, and physical therapy assistants;
2.The number of temporary, outside agency nursing staff;
3.The resident census as of 12:00 a.m.
4.Documentation of the use of unpaid eating assistants (if utilized by the nursing facility on that date).
5.The minimum number of nursing facility direct caregiver staff per shift that is required to comply with the minimum staffing level requirements contained in § 1.16.6 of this Part; and
6.The telephone number or internet website that a resident, employee or visitor of the nursing facility may use to report a suspected violation by the nursing facility of a regulatory requirement concerning staffing levels and direct patient care.
B.The posting information shall be maintained on file by the nursing facility for no less than three (3) years and shall be made available to the public upon request.
C.The nursing facility shall prepare an annual report showing the average daily direct care nurse staffing level for the nursing facility by shift and by category of nurse to include registered nurses, licensed practical nurses, nursing assistants medication technicians, licensed physical therapists, licensed occupational therapists, licensed speech-language pathologists, and physical therapy assistants; the use of nurse and nursing assistant staff from temporary placement agencies; and the nurse and nursing assistant turnover rates.
1.The annual report shall be submitted with the nursing facility’s renewal application and provide data for the previous twelve (12) months and ending no earlier than September 30th, for the year preceding the license renewal year. Annual reports shall be submitted in a format prescribed by the Director.
D.The information on nurse staffing shall be reviewed as part of the nursing facility’s annual licensing survey and shall be available to the public, both in printed form and on the Department’s website, by nursing facility.
E.The Director of Nurses may act as a charge nurse only when the nursing facility is licensed for thirty (30) beds or less.
F.Whenever the licensing agency determines, in the course of inspecting a nursing facility, that additional staffing is necessary on any residential area to provide adequate nursing care and treatment or to ensure the safety of residents, the licensing agency may require the nursing facility to provide such additional staffing and any or all of the following actions shall be taken to enforce compliance with the determination of the licensing agency.
1.The nursing facility shall be cited for a deficiency and shall be required to augment its staff within ten (10) days in accordance with the determination of the licensing agency.
2.If failure to augment staffing is cited, the nursing facility shall be required to curtail admission to the nursing facility.
3.If a continued failure to augment staffing is cited, the nursing facility shall be subjected to an immediate compliance order to increase the staffing, in accordance with R.I. Gen. Laws § 23-1-21.
4.The sequence and inclusion or non-inclusion of the specific sanctions enumerated in § 1.16.7(F) of this Part may be modified in accordance with the severity of the deficiency in terms of its impact on the quality of resident care.
G.No nursing staff of any nursing facility shall be regularly scheduled for double shifts.
1.16.8Selected Nursing Care Procedures
A.Written resident care plans, including problems, measurable goals, interventions, and time frames, shall be developed and maintained for each resident consonant with the attending physician, physician assistant, or advanced practice registered nurse’s plan of medical care.
1.Resident care plans shall be reviewed, evaluated and revised by professional staff no less than every three (3) months, or when there is a significant change in the resident's health status.
B.The personal hygiene of each resident shall be attended to. All residents shall receive person-centered care including care of skin, shampooing and grooming of hair, oral hygiene, shaving, cleaning and cutting of fingernails and toenails. Residents shall be kept free of offensive odors.
C.Residents shall be encouraged and/or assisted to function at their highest level of self-care and independence. Every effort shall be made to keep residents active and out of bed for reasonable periods of time except when contraindicated by physician, physician assistant, or advanced practice registered nurse orders.
D.Every nursing facility shall have an active program for rehabilitative nursing care.
E.Such supportive and restorative nursing care needed to maintain maximum functioning of the resident shall be provided.
F.Each resident shall be given care to prevent pressure ulcers, contractures and deformities, including:
1.Preventive skin care as appropriate;
2.Changing the position of bedfast and chair-fed residents;
3.Maintaining proper body alignment and joint movement to prevent contractures and deformities; and
4.Encouraging, assisting and training residents in self-care and activities of daily living.
G.Measures shall be taken to prevent and reduce incontinence for each resident which shall include no less than:
1.Written assessment by a registered nurse or physician assistant, within two (2) weeks of admission, of each incontinent resident's ability to participate in a bowel and/or bladder training program;
2.An individualized plan of care for each resident selected for training to be included in the resident's nursing care plan to restore as much normal bladder function as possible.
1.16.9Administration of Drugs
A.Drugs shall be administered in accordance with written orders of the attending physician and procedures established in accordance with §§ 1.17.4(A) and (B) of this Part. Such procedures shall include measures to assure:
1.That drugs are checked against physicians', physician assistants’, or advanced practice registered nurses’ orders;
2.That the resident is identified prior to administration of a drug;
3.That each resident has an individual medication record; and
4.That the dose of drug administered to each resident is properly recorded therein by the person administering the drug.
B.Drugs not specifically limited as to time or number of doses when ordered shall be controlled by automatic stop orders or other methods in accordance with written policies.
C.Physicians', physician assistants’, or advanced practice registered nurses’ verbal orders for drugs and biologicals shall be given only to a licensed nurse, a registered pharmacist or to a physician and shall be immediately recorded and signed by the person receiving the order. Such orders shall be countersigned by the attending physician within fifteen (15) days.
1.16.10Administration of Drugs by Medication Technicians
A.Medication aides or technicians who have satisfactorily completed a State-approved course in drug administration and have demonstrated competency in accordance with the State-approved protocol in drug administration may administer oral or topical drugs, with the exception of all Schedule II drugs, with supervision in accordance with the State-approved protocol in drug administration. If such medication technicians are from temporary employment agencies, the nursing facility shall have onsite evidence of supervision in accordance with the Rhode Island-approved protocol in drug administration.
B.The director of nursing or his or her registered nurse designee shall conduct and document quarterly evaluations of the medication technicians who are administering drugs. Copies of said evaluations shall be placed in the medication technicians’ personnel records.
1.16.11Assistance with Eating and Hydration
A.Nursing facilities may employ resident attendants to assist residents with activities of eating and drinking. The resident attendant shall not be counted in the direct care staffing levels (see also § 1.16.7(A) of this Part).
B.A nursing facility shall not use any individual on a paid or unpaid basis in the capacity of a resident attendant, as defined in this Part, in the nursing facility unless the individual:
1.Has satisfactorily completed a training program approved by the Director, as described in § 1.16.12 of this Part;
2.Continues to provide competent eating and hydration assistance as determined by the facility’s professional nursing staff.
C.The nursing facility shall ensure:
1.The resident attendant works in congregate dining areas under the supervision of a registered nurse (RN) or licensed practical nurse (LPN);
2.The resident attendant wears a photo identification badge in accordance with § 1.14.7 of this Part;
3.The resident attendant only assists residents selected by the professional nursing staff, based on the charge nurse’s assessment and the resident’s latest assessment and plan of care;
4.The resident attendant assists with eating and drinking for residents who have no complicated eating or eating assistance problems, including but not limited to:
a.Tube or parenteral/enteral nutrition;
b.Recurrent lung aspirations;
c.Difficulty swallowing;
d.Residents at risk of choking while eating or drinking;
e.Residents with significant behavior management challenges while eating or drinking;
f.Residents presenting other risk factors that may require emergency intervention.
5.Maintenance of records regarding individuals acting as resident attendants and the training program attended.
1.16.12Training Program for Resident Attendants
A.Resident attendants shall be required to have successfully completed a basic training program approved by the Director to provide safe and proper eating and hydration assistance to nursing residents with no complicated eating or drinking problems. The program requirements shall include, but are not limited to, the following:
1.The training program shall be conducted by a registered nurse, and may include the assistance of a registered dietitian;
2.The training shall provide a minimum of eight (8) hours of classroom instruction, and participants shall demonstrate an understanding of topics that includes but is not limited to:
a.Eating techniques;
b.Physical mechanics of:
c.Breathing and swallowing;
d.Aspiration;
e.Choking
f.Assistance with eating and hydration (drinking);
g.Infection control;
h.Resident rights;
i.Communication and interpersonal skills;
j.Appropriate responses to resident behavior;
k.Safety and emergency procedures, including the Heimlich maneuver;
3.The training shall provide, either directly or through arrangements with a nursing facility, a minimum of four (4) hours of documented practical experience supervised by a registered nurse.
4.Certificate of classroom completion shall be signed by registered nurse trainer, bear the Department program approval certification number and include an area for documentation of satisfactory completion of practical experience.
5.Organizations or facilities interested in providing a resident attendant eating assistance program should submit a letter of intent to:
HEALTH Center for Health Facilities Regulation |
c/o Eating Assistance Program 3 Capitol Hill Providence, RI 02908. |
a.The request must include:
(1)An outline of the structure and format for the program;
(2)Resume/curriculum vita for the registered nurse trainer and other trainers;
(3)Curriculum/program outline to be utilized;
(4)Method of ensuring participants’ successful demonstration of competencies;
(5)Program contact information.
6.Following review by HEALTH, numbered program approvals will be provided.
1.16.13Pain Assessment
All health care providers licensed by Rhode Island to provide health care services and all health care facilities licensed under R.I. Gen. Laws Chapter 23-17 shall assess patient pain in accordance with the requirements of Part 20-15-2 of this Title, Pain Assessment.
1.17Special Care Units
1.17.1Alzheimer and Other Dementia Special Care Units or Programs
A.Any nursing facility that provides or offers to provide care or services for residents in a manner as defined in this Part shall disclose to the licensing agency and any person seeking placement in such Alzheimer and Other Dementia Special Care Unit/Program the form of specialized care and treatment provided that is in addition to the care and treatment required in this Part.
1.The information disclosed shall be on a form prescribed by the Department.
2.The nursing facility shall provide care and services as described in the disclosure form, and consistent with this Part. The information disclosed shall explain the additional care provided in each of the following areas:
a.Philosophy – The special care unit/program’s written statement of its overall philosophy and mission which reflects the needs of residents afflicted with dementia.
b.Pre-Admission, Admission and Discharge – The process and criteria for placement (which shall include a diagnosis of dementia), transfer or discharge from the unit.
c.Assessment, Care Planning and Implementation – The process used for assessment and establishing the plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in condition.
d.Staffing Patterns and Training – Staff patterns and training and continuing education programs, which shall emphasize the effective management of the physical and behavioral problems of those with dementia.
e.Physical Environment – The physical environment and design features shall be appropriate to support the functioning and safety of cognitively impaired adult residents.
f.Therapeutic Activities – The frequency and types of resident activities. Therapeutic activities shall be designed specifically for those with dementia.
g.Family Role in Care – The nursing facility shall provide for the involvement of families and family support program.
h.Program Costs – The cost of care and any additional fees.
3.Any significant changes in the information provided by the nursing facility will be reported to the licensing agency at the time the changes are made.
B.In accordance with R.I. Gen. Laws § 23-1.7-6, the nursing facility must complete and implement an operational plan for the recognition and management of residents with Alzheimer's disease or dementia.
1.Such plan shall include a protocol for the following:
a.Identifying the signs and symptoms of cognitive impairments, including Alzheimer's Disease;
b.Management and treatment of residents with Alzheimer's Disease;
c.Training of clinical and non-clinical staff; and
d.Advance care planning; and resources for family members.
2.Such plan shall be maintained by the nursing facility and made available to the licensing agency upon request.
1.17.2Rehabilitation Special Care Unit and Subacute Special Care Unit
A.Any nursing facility that provides or offers to provide care for patients or residents by means of a Rehabilitation Special Care Unit or a Subacute Special Care Unit shall be required to disclose to the licensing agency and to any person seeking placement in a Rehabilitation Special Care Unit or a Special Care Unit of a nursing facility the form of specialized care and treatment provided that is in addition to the care and treatment required in this Part.
1.The information disclosed shall be on a form prescribed by the licensing agency.
2.The nursing facility shall provide care and services as described in the disclosure form, and consistent with this Part.
3.Any significant changes in the information provided by the nursing facility shall be reported to the licensing agency at the time the changes are made.
1.17.3Dietetic Services
A.Each nursing facility shall maintain a dietetic service under the supervision of a full-time person who, as a minimum, is a graduate of a Rhode Island-approved course that provided instruction in food service supervision and nutrition and has experience in the organization and management of food service.
1.When the dietary manager is absent, a responsible person shall be assigned to supervise dietetic service personnel and food service operations.
B.When the dietary manager is not a qualified dietitian who is registered or eligible for registration by the commission of dietetic registration and/or licensed by Rhode Island, the nursing facility shall obtain per written contractual arrangement adequate and regularly-scheduled consultation from a qualified dietitian.
C.The responsibilities of the qualified dietitian shall include but not be limited to:
1.Advising the administration and the supervisor of dietetic services on all nutritional aspects of resident care, food service and preparation;
2.Reviewing food service policies, procedures and menus to ensure the nutritional needs of all residents are met in accordance with Dietary Reference Intakes: The Essential Guide to Nutrient Requirements;
3.Serving as liaison with medical and nursing staff on nutritional aspects of resident care;
4.Advising on resident care policies pertaining to dietetic services;
5.Providing dietary counseling to residents when necessary;
6.Planning and conducting regularly-scheduled in-service education programs which shall include training in food service sanitation;
7.Preparing reports which shall include date and time of consultation and services rendered, which reports shall be signed and kept on file in the nursing facility; and
8.Recording observations and information pertinent to dietetic treatment in the resident's medical record;
9.Input in care plan development.
D.Adequate space, equipment and supplies shall be provided for the efficient, safe and sanitary receiving, storage, refrigeration, preparation and service of food and other related aspects of the food service operation in accordance with Part 50-10-1 of this Title, Rhode Island Food Code.
E.Policies and procedures shall be established for the dietetic service, pertaining to but not limited to the following:
1.Responsibilities and functions of personnel;
2.Standards for nutritional care in accordance with Dietary Reference Intakes: The Essential Guide to Nutrient Requirements;
3.Alterations or modifications to diet orders or schedules;
4.Food purchasing storage, preparation and service;
5.Safety and sanitation relative to personnel and equipment in accordance with Part 50-10-1 of this Title, Rhode Island Food Code; and
6.Ancillary dietary services, including food storage and preparation in satellite kitchens and vending operations in accordance with Part 50-10-1 of this Title, Rhode Island Food Code; and
7.A plan to include alternate methods and procedures for food preparation and service, including provisions for potable water, to be used in emergencies.
F.All nursing facilities shall provide sufficient and adequately trained supportive personnel, competent to carry out the functions of the dietetic services.
1.The dietetic services shall have employees on duty over a period of twelve (12) or more hours per day, seven (7) days per week.
2.Except as provided in § 1.17.3(F) of this Part, those employees involved in direct preparation of food (as opposed to distribution of food, dishwashing, etc.) shall not be involved in providing resident direct care.
3.Except where employees are designated and qualified as “universal workers,” house-keeping and nursing personnel qualified in accordance with § 1.14.6(A)(6)(b) of this Part may assist in food distribution, and food preparation. Careful hand washing shall be done prior to assisting in food distribution and/or preparation.
G.The nursing facility’s food service operation shall comply with all appropriate standards of Part 50-10-1 of this Title, Rhode Island Food Code.
1.Diet kitchens, nourishment stations, and any other related areas shall be the responsibility of the dietetic service.
H.All menus including alternate choices shall be planned at least one (1) week in advance, to meet the standards for nutritional care in accordance with Dietary Reference Intakes: The Essential Guide to Nutrient Requirements and to provide for a variety of foods, adjusted for seasonal changes, and reflecting the dietary preferences of residents.
1.Menus shall indicate nourishments offered to residents between evening meal and bedtime.
2.Menus shall be posted in a conspicuous place in the dietary department and in resident areas.
3.Records of menus actually served shall be retained for thirty (30) days.
I.All diets shall be ordered in writing by the attending physician.
1.All diets shall be planned, prepared and served to conform to the physician's orders and to meet the standards of Dietary Reference Intakes: The Essential Guide to Nutrient Requirements to the extent medically possible.
2.Diet orders shall be reviewed by the attending physician on same schedule as other physician orders.
J.There shall be a diet manual, approved by the dietitian and available to all dietetic and nursing services personnel. Diets served to residents shall comply with the principles set forth in the diet manual.
K.Each resident shall receive and the nursing facility shall provide at least three (3) meals daily, at regular times comparable to normal mealtimes based upon the individual preference of a resident or group of residents in a residential area and/or at regular times comparable to normal mealtimes in the community.
1.There shall be no more than fourteen (14) hours between a substantial evening meal and breakfast the following day, except as provided in § 1.17.3(K)(3) of this Part.
2.The nursing facility shall offer snacks at bedtime daily.
3.When a nourishing snack is provided at bedtime, up to sixteen (16) hours may elapse between a substantial evening meal and breakfast the following day if a resident, or group of residents in a residential area agrees to this meal span, and there is a nourishing snack.
L.Foods shall be prepared by methods that conserve nutritive value, flavor and appearance, and shall be prepared and served at proper temperatures and in a form to meet individual needs. Food substitutes of similar nutritive value shall be offered when residents refuse foods served for good reason.
1.A file of tested recipes, adjusted to appropriate yield, shall be maintained and utilized corresponding to items on the menu.
2.House diets shall be appropriately seasoned.
3.There shall be a supply of staple foods for a minimum of seven (7) days and of perishable foods for a minimum of two (2) days in the nursing facility.
M.Food shall be attractively served on dinnerware of good quality, such as ceramic, plastic or other materials that are durable and aesthetically pleasing.
N.A dining room shall be available for those residents or residents who wish to participate in group dining in accordance with § 1.19.9(A) of this Part.
O.Self-help feeding devices shall be available to those residents who need them to maintain maximum independence in the activities of daily living.
P.A nursing facility contracting for food service shall require as part of the contract, that the contractor comply with the provisions of this Part.
1.17.4Pharmaceutical Services
A.Each nursing facility shall provide pharmaceutical services either directly within the nursing facility or per contractual arrangement. Such services shall be provided in accordance with the requirements of Subchapter 15 Part 1 of this Chapter, Pharmacists, Pharmacies and Manufacturers, Wholesalers and Distributors, and Part 20-20-4 of this Title, Pain Management, Opioid Use, and the Registration of Distributors of Controlled Substances in Rhode Island.
1.In either instance, appropriate methods and procedures for the procurement and the dispensing of drugs and biologicals shall be established in accordance with appropriate Federal and State laws and Regulations.
B.There shall be written policies and procedures relating to the pharmaceutical service which shall require no less than:
1.The authority, responsibility and duties of the registered pharmacist;
2.The selection, procurement, distribution, storage, dispensing or other disposition of drugs and biologicals in accordance with appropriate Federal and State laws and Regulations;
3.Maintenance of records of all transactions, including recording of receipt and dispensing or other disposition of all drugs and biologicals;
4.Inspection of all drug and biological storage and medication areas and documented evidence of findings;
5.Automatic stop orders for drugs or biologicals;
6.The use of only approved drugs and biologicals;
7.Control of medicines from any source;
8.A monitoring program to identify adverse drug reactions, interactions and incompatibilities and antibiotic antagonisms; and
9.Labeling of drugs and biologicals including name of resident, name of physician, drug dosage, cautionary instructions, and expiration date.
C.Adequate space, equipment, supplies and locked storage areas shall be provided for the storage of drugs and biologicals based on the scope of services provided. Refrigerated food storage units shall not be utilized for storage of drugs and/or biologicals except:
1.In facilities of thirty (30) beds or less, a refrigerated food storage unit may be used for drugs and biologicals provided they are locked in an appropriate container.
D.Drugs may be administered to residents from bulk inventories of non-legend and non-controlled substance items such as aspirin, milk of magnesia, etc. as ordered by a licensed physician.
E.An emergency medication kit, approved by the pharmaceutical service committee or its equivalent, shall be available in each residential area.
F.Each residential area shall have adequate drug and biological preparation areas with provisions for locked storage in accordance with Federal and State laws and Regulations.
1.17.5In Nursing Facilities
A.The pharmaceutical service committee or its equivalent, consisting of not less than a registered pharmacist, a registered nurse, a physician and the administrator, shall:
1.Serve as an advisory body on all matters pertaining to pharmaceutical services;
2.Establish a program of accountability for all drugs and biologicals;
3.Develop and review periodically all policies and procedures for safe and effective drug therapy in accordance with § 1.17.4(B) of this Part; and
4.Monitor the service.
B.A registered pharmacist shall assist in developing, coordinating and supervising all pharmaceutical services in conjunction with the pharmaceutical services committee. In addition, a registered pharmacist shall:
1.Review the drug and biological regimen of each resident at least monthly;
2.Report any irregularities to the attending physician and director of nurses. These reports must show evidence of review and response; and
3.Document in writing the performance of such review, which documentation shall be kept on file by the nursing facility and shall be made accessible to inspectors on request.
1.17.6Dental Services
A.Each nursing facility shall provide or obtain from outside resources, dental services for routine and emergency care.
1.Each resident shall have the right to receive dental services from a dentist of his or her choice.
B.A list of community dentists shall be maintained and available to all residents.
C.When necessary, arrangements shall be made by nursing facilities for the transportation of residents to and from the dental care office.
1.17.7Laboratory and Radiologic Services
A.All nursing facilities shall make provisions for laboratory, x-ray and other services to be provided either directly by the nursing facility or per contractual arrangements with an outside provider.
1.If the nursing facility provides its own laboratory and x-ray services, these shall meet all applicable statutory and regulatory requirements.
B.All services shall be provided only per order of the attending physician who shall be promptly notified of the findings in accordance with a protocol established by the nursing facility. Such a protocol shall describe which laboratory values mandate a call to the resident’s attending physician.
C.Signed and dated reports of all findings shall become part of the resident's medical record.
1.17.8Social Services
A.Every nursing facility shall provide social services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident. Social services must be provided either directly by a qualified social worker or by arrangement with an appropriate health or social service agency or through consultation with a qualified social worker who would supervise a social work designee appointed by the administrator.
1.Services shall pertain to no less than the following:
a.Identification of social and emotional needs of residents through a comprehensive psychosocial assessment including a social history;
b.Establishment of a plan of care based on residents' needs;
c.Procedures for referral of residents, when indicated, to appropriate social agencies and discharge planning as indicated
B.A qualified social worker is defined as an individual with a minimum of a BSW from an accredited School of Social Work. A social work designee is defined as a staff member appointed by the administrator who is suited by training or experience to implement plans and procedures enumerated in accordance with § 1.17.8(A)(1) of this Part.
C.Notwithstanding any provisions in R.I. Gen. Laws Chapter 5-39.1 or any other general or public law to the contrary, any nursing facility licensed under R.I. Gen. Laws Chapter 23-17 that employs a social worker or social worker designee who meets all of the criteria in § 1.17.8(D) of this Part shall be granted a variance to the "qualified social worker" provisions stated in this Part.
D.Such criteria shall be limited to:
1.Meets the Centers for Medicare and Medicaid requirements for long-term care facilities under 42 C.F.R. Part 483, subpart B (or any successor Regulation);
2.Is currently employed by a nursing facility licensed under R.I. Gen. Laws Chapter 23-17; and
3.Has been continuously employed in a nursing facility licensed under R.I. Gen. Laws Chapter 23-17 commencing on or before July 1, 2003.
E.Sufficient supportive personnel shall be available to meet resident needs.
F.Appropriate records shall be maintained of all social services rendered, including consultation services, and reports shall be included in the resident's medical record.
G.Policies and procedures shall be established to assure confidentiality of all resident information consistent with the requirements of R.I. Gen. Laws Chapter 5-37.3.
1.17.9Specialized Rehabilitative Services
A.Each nursing facility shall provide directly or per written agreement with outside providers specialized rehabilitative and supportive services as needed by residents to improve, restore or maintain functioning.
1.Residents shall not be admitted or retained in a nursing facility not providing either directly or per contractual arrangement, those rehabilitative or other specialized services required to meet individual medical care needs of residents.
B.The specialized rehabilitative services, which include physical therapy, speech pathology, audiology and occupational therapy shall be provided per written order of the attending physician and in accordance with accepted professional practice by licensed therapists or assistants.
C.Written administrative and resident care policies and procedures shall be developed for rehabilitative services by appropriate therapists and representatives of the medical, administrative and professional staff.
D.Rehabilitative services shall be provided under a written plan of care initiated by the attending physician and developed in consultation with appropriate therapist(s) and nursing personnel.
E.Entries of all rehabilitative or supportive services rendered, including evaluation of progress and other pertinent information, shall be recorded in the resident's medical record and signed by personnel rendering the service(s).
F.Safe and adequate space and equipment shall be available commensurate with the scope of services provided.
1.17.10Resident Activities
A.Each nursing facility shall provide for an ongoing activities program that is person-centered, appropriate to the needs and interests of each individual resident, encourages self-care, and engages residents in activities that are important to the resident, and that will assist in the maintenance of an optimal level of psychosocial functioning, socialization, and quality of life for the resident.
B.The activities program must be directed by a qualified professional as defined in Requirements for Long Term Care Facilities," 42 C.F.R. Part 483.
C.The ongoing activities program shall make provisions to:
1.Promote opportunities for engaging in normal pursuits including religious activities of the resident's choice;
2.Promote the physical, social and mental well-being of each resident;
3.Promote independent as well as group activities; and
4.Harmonize with each resident's needs and medical treatment plan, subject to approval by the resident's attending physician.
D.Adequate space, supplies and equipment shall be available to meet resident care needs in accordance with the activities program and as stipulated in § 1.19.9 of this Part.
E.Each resident must have an activities plan, and all pertinent observations and information must be recorded in the medical record.
1.17.11Equipment
A.Each nursing facility shall maintain sufficient and appropriate types of equipment consistent with resident needs and sufficient to meet emergency situations.
B.All equipment to meet the needs of the residents shall be maintained in safe and good operational condition.
1.18Environmental and Maintenance Services
1.18.1Housekeeping
A.A full-time employee of the nursing facility shall be designated responsible for housekeeping services, supervision and training of housekeeping personnel.
B.Sufficient housekeeping and maintenance personnel shall be employed to maintain a comfortable, safe, clean, sanitary and orderly environment in the nursing facility.
1.Housekeeping personnel qualified in accordance with § 1.14.6(A)(1) of this Part may assist in food distribution and food preparation. Careful hand washing shall be done prior to assisting in food distribution and/or food preparation.
2.Housekeeping personnel may provide assistance with eating and hydration of residents in accordance with § 1.16.11(B) of this Part
C.Written housekeeping policies and procedures shall be established in accordance with § 1.16.2(A) of this Part, for the operation of housekeeping services throughout the nursing facility. Copies shall be available for all housekeeping personnel.
D.All parts of the nursing facility and its premises shall be kept clean, neat and free of litter and rubbish and offensive odors.
E.Equipment and supplies shall be provided for cleaning of all surfaces. Such equipment shall be maintained in a safe, sanitary condition and shall be properly stored.
F.Hazardous cleaning solutions, compounds, and substances shall be labeled, stored in a safe place, and kept in an enclosed section separate from other cleaning materials.
G.Cleaning shall be performed in a manner which will minimize the development and spread of pathogenic organisms in the home environment.
H.Exhaust ducts from kitchens and other cooking areas shall be equipped with proper filters and cleaned at regular intervals. The ducts shall be cleaned as often as necessary and inspected by the nursing facility no less than twice a year.
I.Nursing facilities contracting with outside resources for housekeeping services shall require conformity with existing Regulations.
J.Each nursing facility shall be maintained free from insects and rodents through the operation of a pest control program.
1.18.2Laundry Services
A.Each nursing facility shall make provisions for the cleaning of all linens and other washable goods.
B.Nursing facilities providing laundry service shall have adequate space and equipment for the safe and effective operation of laundry service and, in unsewered areas, shall obtain approval of the sewage system by the licensing agency to ensure its adequacy.
C.Written policies and procedures for the operation of the laundry service including special procedures for the handling and processing of contaminated linens, shall be established in accordance with § 1.16.2 of this Part.
D.There shall be distinct areas for the separate storage and handling of clean and soiled linens.
1.The soiled linen area and the washing area shall be negatively pressurized or otherwise protected to prevent introduction of airborne contaminants.
2.The clean linen area and the drying area shall be physically divorced from the soiled linen area and the washing area.
E.All soiled linen shall be placed in closed containers prior to transportation.
F.To safeguard clean linens from cross-contamination they shall be transported in containers used exclusively for clean linens which shall be kept covered at all times while in transit and stored in areas designated exclusively for this purpose.
G.A quantity of linen equivalent to three (3) times the number of beds including the set of linen which is actually in use shall be available and in good repair at all times.
H.Facilities contracting for services with an outside resource in accordance with § 1.15.3(C) shall require conformity with this Part.
1.18.3Emergency Operations and Continuity of Operations Plan [EOP/COOP]
A.Each nursing facility shall develop and maintain a written emergency operations plan (EOP) that shall include plans and procedures to be followed in response to any situation, event or other emergency that impacts or threatens the normal operation of the nursing and/or the general health and safety of the residents, and shall include a Continuity of Operations Plan (COOP) detailing how essential functions shall be maintained and restored. The plan shall include provisions for evacuation of the nursing facility in the event of a natural disaster or any time or circumstance where the general health and safety of the residents cannot be maintained or provided for while remaining in place. The plan and procedures shall be developed with the assistance of qualified safety, emergency management, and/or other appropriate experts and shall be coordinated with the local emergency management agency.
B.The EOP plan shall include procedures to be followed pertaining to no less than the following:
1.Fire, explosion, severe weather, loss of power and/or water, flooding, failure of internal systems and/or equipment, and/or any other unforeseen circumstance that impacts or threatens the routine operation of services at the nursing facility;
2.Transfer of casualties;
3.Transfer, backup, and/or storage of records;
4.Location and use of alarm systems, signals and firefighting equipment;
5.Containment of fire;
6.Notification of appropriate persons inside and outside the operation of the home (i.e., local authorities);
7.Internal and external relocations of residents and potential evacuation scenarios, as coordinated with local and State emergency planning authorities;
8.The continuation of meals and hydration needs for residents;
9.Handling of all medications and biologicals;
10.Elopement and/or missing residents;
11.Back-up or contingency plans to address possible internal systems (e.g., food, power, water, sewage disposal) and/or equipment failures; and
12.Any other essentials as required by the local emergency management agency.
C.A copy of the EOP plan shall be available at every residential area.
D.Emergency steps of action shall be clearly outlined and posted in conspicuous locations throughout the nursing facility.
E.Simulated drills testing the effectiveness of the EOP plan shall be conducted at least annually and/or in conjunction with local emergency preparedness drills. Written reports and evaluation of all drills shall be developed and maintained by the nursing facility.
F.All personnel shall receive training in disaster preparedness and response as part of their employment orientation, consistent with current standards of practice (i.e., ICS 100, 200, 700).
G.The administrator of the nursing facility shall notify the licensing agency (Office of Facilities Regulation) immediately by telephone of any unscheduled implementation of any part of the nursing facility’s emergency operations plan and shall provide a follow-up report in writing within five (5) business days using a reporting form designated by the licensing agency.
H.Each nursing facility shall agree to enter into a memorandum of agreement, upon written request, with the local municipality in which the nursing facility is geographically located to participate in a distribution and dispensing plan for medications and/or vaccines in the event of a public health emergency or disease outbreak.
1.The memorandum of agreement shall, at a minimum, include the following components:
a.A plan by the nursing facility to assess residents for medical appropriateness of medication or vaccine to be administered;
b.A plan outlining the process for receipt and management of medications and/or vaccines when transferred to the nursing facility by the municipality;
c.Review of the dispensing and distribution plan and memorandum of agreement by the nursing facility medical director; and
d.An agreement by the nursing facility to participate in trainings/exercises conducted by the municipality regarding distribution of medications and/or vaccines in the event of a public health emergency or disease outbreak.
I.Each nursing facility shall establish and maintain a health care facility specific electronic mail address (i.e., e-mail address) to be provided to the licensing agency for the purposes of contacting a high managerial agent for the nursing facility with both routine communications and emergency notices. The nursing facility shall be responsible for providing notice to the licensing agency at any time that the nursing facility’s specific electronic mail address is changed or updated.
J.In the event of an onsite, local area, or statewide emergency or natural disaster, the nursing facility will respond to requests for information and/or status reports as requested by the Department and/or designated situation/incident commander.
1.19Physical Plant
1.19.1New Construction, Addition or Modification
A.All new construction, alterations, extensions or modifications of an existing nursing facility, as defined in the “Rules and Regulations for Determination of Need for New Health Care Equipment and New Institutional Health Services,” shall be subject to the following provisions:
1.R.I. Gen. Laws Chapter 23-15 (Certificate of Need).
2.R.I. Gen. Laws Chapter 23-1 (Department of Health).
3.Part 50-10-1 of this Title, Rhode Island Food Code
4.FGI “Guidelines for Design and Construction of Residential Health, Care and Support Facilities, 2018 edition.
5.R.I. Gen. Laws Chapter 23-28.1 (Fire Safety Code – General Provisions)
6.250-RICR-150-10-6, Rules Establishing Minimum Standards Relating to Location, Design, Construction and Maintenance of Onsite Wastewater Treatment Systems
7.ICC A117.1-2009
8.R.I. Gen. Laws Chapter 23-27.3 (State Building Code)
9.Americans with Disabilities Act
10.In addition, any other applicable State and local laws, codes and Regulations shall apply. Where there is a difference between codes, the code having the higher standard shall apply.
B.All plans for new construction or the renovation, alteration, extension, modification or conversion of an existing nursing facility that may affect compliance with §§ 1.19.4, 1.19.6, 1.19.7, 1.19.8, 1.19.9, and 1.19.15 of this Part, and "Guidelines for Design and Construction of Residential Health, Care and Support Facilities, 2018 edition, shall be reviewed by a Rhode Island licensed architect. Said architect shall certify that the plans conform to the construction requirements of §§ 1.19.4, 1.19.6, 1.19.7, 1.19.8, 1.19.9, and 1.19.15 of this Part, and "Guidelines for Design and Construction of Hospital and Health Care Facilities," 2010 Edition, prior to construction. The nursing facility shall maintain a copy of the plans reviewed and the architect’s signed certification, for review by the licensing agency upon request.
1.In the event of non-conformance for which the nursing facility seeks a variance, the general procedures outlined in § 1.20.2 of this Part shall be followed. Variance requests shall include a written description of the entire project, details of the non-conformance for which the variance is sought and alternate provisions made, as well as detailing the basis upon which the request is made. The Department may request additional information while evaluating variance requests.
2.In the event where plans are designed to meet resident-directed operation models per § 1.40 and §1.41 of this Part, and are non-compliant to the required construction requirements, the nursing facility may request a variance and the Department shall consider such alternative models in evaluation of the request.
3.If variances are granted, a licensed architect shall certify that the plans conform to all construction requirements of §§ 1.19.4, 1.19.6, 1.19.7, 1.19.8, 1.19.9 and 1.19.15 of this Part, and "Guidelines for Design and Construction Residential Health, Care and Support Facilities,” 2018edition, except those for which variances were granted, prior to construction. The nursing facility shall maintain a copy of the plans reviewed, the variance(s) granted and the architect’s signed certification, for review by the Department upon request.
C.Upon completion of construction, the nursing facility shall provide written notification to the Department describing the project, and a copy of the architect's certification. The nursing facility shall obtain authorization from the Department prior to occupying/re-occupying the area. At the discretion of the Department, an on-site visit may be required.
1.19.2General Provisions – Physical Environment
A.Each nursing facility shall be constructed, equipped and maintained to protect the health and safety of residents, personnel and the public. All equipment and furnishings shall be maintained in good condition, properly functioning and replaced when necessary.
B.All steps, stairs and corridors shall be suitably lighted, both day and night. Stairs used by residents shall have banisters, handrails or other types of support. All stair treads shall be well maintained to prevent hazards.
C.All rooms utilized by residents shall have proper ventilation and shall have outside openings with satisfactory screens. Shades or Venetian blinds and draperies shall be provided for each window.
D.Grounds surrounding the nursing facility shall be accessible to and usable by residents and shall be maintained in an orderly and well-kept manner.
1.19.3Fire and Safety
A.Each nursing facility shall meet the provisions of R.I. Gen. Laws Chapter 23-28.1 (Fire Safety Code – General Provisions).
B.Each nursing facility shall establish a monitoring program for the internal enforcement of all applicable fire and safety laws and Regulations. Such a program shall include written procedures for the implementation of said Rules and Regulations and logs shall be maintained.
1.19.4Emergency Power
A.An emergency electrical system shall be provided and installed in accordance with the applicable requirements as specified in the NFPA 99, 2012 Edition. The source of supply shall be an on-site fuel-fired generator.
1.Such emergency power system shall supply power adequate at least for:
a.Lighting all means of egress;
b.Equipment to maintain fire detection, alarm and extinguishing systems;
c.Life support systems, where applicable or of high probability of need to ensure an emergency response to health and safety; and
d.Continuation of normal health and safety operations of the nursing facility until normal operations resume or implementation of the ’s EOP plan and safe evacuation of all residents.
2.The nursing facility is responsible for ensuring appropriate testing and preventive maintenance of the generator in accordance with the NFPA 99, 2012 Edition and NFPA 110, 2010 Edition, including:
a.Generator is maintained and serviced in accordance with its manufacturer’s requirements;
b.Generator is inspected weekly and exercised (tested) under routine operational load for thirty (30) minutes each month.
c.In addition to its own internal resources, each nursing facility shall also have agreements with contracted service providers for emergency services, should the generator fail during testing or unscheduled use.
d.The nursing facility will maintain documentation of all testing and preventive maintenance of the generator system, and
e.The nursing facility will notify the licensing agency when the system is or is expected to be off-line for more than eight (8) hours for maintenance or when there is a significant failure of the equipment during testing or unscheduled use, or an inability of the equipment to provide for fifty (50) per cent of the operational load at any time of its operation.
B.A nursing facility without a generator upon promulgation of this Part must submit a written plan to the licensing agency within thirty (30) days detailing a time line to acquire, install, test, and place on-line a generator as required by § 1.19.4(A) of this Part no later than six (6) months after the effective date of this Part, or any extended time line acceptable to the Department.
1.Prior to the installation and availability of a generator as outlined in § 1.19.4(A) of this Part, the nursing facility shall provide an emergency source of electrical power necessary to protect the health and safety of residents in the event the normal electrical supply is interrupted.
C.In the event of a catastrophic failure or inability of a nursing facility’s emergency electrical system to protect the health and safety of residents, the nursing facility may be subject to a civil money penalty of up to ten thousand dollars ($10,000.00) if the incident or injuries are determined to be resulting from the nursing facility’s failure to routinely test and/or maintain the nursing facility’s emergency electrical system.
1.19.5Nursing Facility Requirements for the Physically Handicapped
A.Each nursing facility shall be accessible to, and functional for, residents, personnel and the public. All necessary accommodations shall be made to meet the needs of persons with mobility disabilities, or sight, hearing and coordination or perception disabilities in accordance with ICC A117.1-2009
B.Blind, non-ambulatory, physically handicapped or residents with mobility disabilities which limit self-preservation capability shall not be housed above the street level floor unless the nursing facility is equipped with an elevator and meets other requirements of ICC A117.1-2009. Further, the nursing facility must meet one (1) of the following as defined in NFPA Standard 220:
1.Is of fire resistive construction, one (1) hour protected non-combustible construction; or
2.Is fully sprinklered one (1) hour protected ordinary construction; or
3.Is fully sprinklered one (1) hour protected wood frame construction.
A.Each residential area, as defined this Part, shall have at least the following:
1.A nurses' area or office of sufficient space for the materials and work of nursing services, with adjacent hand washing facilities for all staff;
2.Storage and preparation area(s) for drugs and biologicals;
3.Storage rooms for walkers, wheelchairs and other equipment;
4.Appropriate clean and soiled utility space; and
5.A telephone or a cell phone with outside line.
B.In addition, each residential area shall be equipped with a communication system which, as a minimum, shall be:
1.Electrically activated;
2.Operated from the bedside of each occupant and from all areas used by occupants, including multipurpose rooms, toilet and bathing facilities;
3.Capable of alerting the responsible person or persons on duty twenty-four (24) hours a day, wherever their station may be; and
4.Capable of providing for calls both internal and external to the nursing facility.
1.19.7Resident Rooms and Toilet Facilities
A.Resident rooms shall be designed and equipped for adequate nursing care, the individual resident’s comfort and privacy with no more than two (2) beds per room, and amenable to resident-directed furnishings and personal property. At least five percent (5%) of the total beds (per unit or per nursing facility) shall be located in single-bed rooms, each with a private bathing facility and toilet.
1.Single bedrooms shall be no less than one hundred (100) square feet in area and no less than eight feet (8’) wide exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules. In new construction, single bedrooms shall be no less than one hundred and twenty (120) square feet in area.
2.Multi-bedrooms shall be no less than one hundred and sixty (160) square feet in area and no less than ten feet (10’) wide, exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules. In new construction, multi-bedrooms shall be no less than two hundred (200) square feet in area.
B.Each room shall have a window which can be easily opened. The window sill shall not be higher than three feet zero inches (3'0") above the floor and shall be above grade level.
C.The size of each window shall be no less than two feet six inches (2'6") wide by four feet five inches (4'5") high, double hung or an approved equivalent.
D.Each room shall have direct access to a corridor and outside exposure with the window at or above grade level.
E.Lavatories and bathing areas to be used by the handicapped shall be equipped with grab-bars for the safety of the residents and shall meet the requirements of "Guidelines for Design and Construction of Residential Health, Care and Support Facilities, 2018edition.
F.All facilities constructed after March 20, 1977 shall have as a minimum, connecting toilet rooms between residents' rooms in accordance with the requirements of § 1.19.1 of this Part.
G.In all facilities constructed after August 1, 2001, patient toilet rooms shall be equipped with facilities for cleaning bedpans.
1.However, in facilities constructed prior to March 20, 1977, there shall be no less than one (1) toilet per eight (8) beds or fraction thereof on each floor where resident rooms are located.
H.Separate lavatory and toilet facilities shall be provided for employees and the general public commensurate with the needs of the facility.
I.A minimum of one (1) bathtub or shower shall be provided for every twelve (12) residents, not otherwise served by bathing facilities in resident rooms. At least one (1) bathtub shall be provided in each residential area.
J.Each bathtub or shower shall be in an individual room or enclosure which provides space for the private use of the bathing fixture, for drying and dressing and for a wheelchair and an attendant.
K.Complete privacy shall be provided to each resident in semi-private rooms by the use of overhead type fire resistive screens and/or cubicle fire resistive curtains suspended by inset overhead tracks in accordance with R.I. Gen. Laws Chapter 23-28.1 (Fire Safety Code – General Provisions).
L.When overhead type screens and/or cubicle curtains are not provided, each semi-private room shall be equipped with a fire resistive portable screen.
M.Each resident must be provided with a bed of proper size and height for the convenience of the resident, with a clean, comfortable mattress, bedside stand, comfortable chair, dresser and individual closet space for clothing with clothes racks and shelves accessible to residents in each room, and a reading lamp equipped with bulb of adequate candlepower.
N.Bedding including bedspread, shall be seasonally appropriate.
O.In all situations where physical configuration is not comfortable to adequate nursing care, comfort or privacy in the application of the above standards, the licensing agency shall be the ultimate authority in determining standards to be applied.
1.19.8Special Care Unit
A resident room shall be designated for isolation purposes. Such room shall be properly identified with precautionary signs, shall have outside ventilation, private toilet and hand washing facilities, and shall conform to other requirements established for the control of infection in accordance with § 1.16.2 of this Part.
1.19.9Dining & Resident Activities Rooms
A.The facility shall provide one or more clean, orderly, appropriately furnished and easily accessible room(s) of adequate size designed for resident dining and resident activities.
1.These areas shall be appropriately lighted and ventilated with non-smoking areas identified.
2.If a multipurpose room is used, there must be sufficient space to accommodate dining and resident activities and prevent interference with each other.
3.The total area set aside for these purposes shall be not less than thirty (30) square feet per bed for the first one hundred (100) beds and twenty-seven (27) square feet per bed for all beds in excess of one hundred (100).
4.Storage shall be provided for recreational equipment and supplies.
1.19.10Plumbing
A.All plumbing shall be installed in such a manner as to prevent back siphonage or cross connections between potable and non-potable water supplies in accordance with R.I. Gen. Laws Chapter 23-27.3 (State Building Code).
B.Fixtures from which grease is discharged may be served by a line in which a grease trap is installed in accordance with standards of R.I. Gen. Laws Chapter 23-27.3 (State Building Code).The grease trap shall be cleaned sufficiently often to sustain efficient operation.
1.19.11Waste Disposal
A.Medical Waste: Medical waste, as defined in 250-RICR-140-15-1, Medical Waste Regulations, shall be managed in accordance with the provisions of the aforementioned Regulations.
B.Other Waste: Wastes which are not classified as infectious waste, hazardous wastes or which are not otherwise regulated by law or Rule may be disposed in dumpsters or load packers provided the following precautions are maintained:
1.Dumpsters shall be tightly covered, leak proof, inaccessible to rodents and animals, and placed on concrete slabs preferably graded to a drain. Water supply shall be available within easy accessibility for washing down of the area. In addition, the pick-up schedule shall be maintained with more frequent pick-ups when required. The dumping site of waste materials must be at a waste disposal facility approved by the Rhode Island Department of Environmental Management or a waste disposal facility located outside Rhode Island which has been approved by the appropriate regulatory agency.
2.Load packers must conform to the same restrictions required for dumpsters and in addition, load packers shall be:
a.High enough off the ground to facilitate the cleaning of the underneath areas of the stationary equipment; and
b.The loading section shall be constructed and maintained to prevent rubbish from blowing from said area site.
3.Recyclable waste: Containers for recyclable waste, including paper and cardboard, shall be tightly covered, leak proof, inaccessible to rodents and animals, and placed on concrete slabs preferably graded to a drain. In addition, the pick-up schedule shall be maintained with more frequent pick-ups when required.
1.19.12Water Supply
A.Water shall be distributed to conveniently located taps and fixtures throughout the building and shall be adequate in volume and pressure for all purposes including firefighting.
1.In resident areas, hot water temperatures shall not be less than one hundred degrees Fahrenheit (100 ºF) nor exceed one hundred and eighteen degrees Fahrenheit (118 ºF). Thermometers [accuracy of which can be plus or minus two degrees Fahrenheit (±2 ºF)] shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered.
2.Thermostatic or pressure balanced mixing valves are required at each site or fixture used for immersion or showering of residents. Thermometers and tactical (skin sense) method shall be used to verify the appropriateness of the water temperature prior to each use.
3.In addition to temperature regulating devices controlling the generation of domestic hot water, hot water supply(ies) to resident care areas shall be regulated by anti-scalding, water tempering or mixing valves (approved by the director or his or her designee) in order to maintain the temperature standards of § 1.19.12(A)(1) of this Part.
1.19.13Waste Disposal Systems
Any new nursing facility shall be connected to a public sanitary sewer if available, or otherwise shall be subject to the requirements of 250-RICR-150-10-6, Rules Establishing Minimum Standards Relating to Location, Design, Construction and Maintenance of Onsite Wastewater Treatment Systems.
1.19.14Maintenance
All essential mechanical, electrical and resident care equipment shall be maintained in safe operating condition and logs or records shall be maintained of periodic inspections.
1.19.15Other Provisions
A.Nursing facilities shall make provisions to ensure that the following are maintained:
1.Lighting levels in all areas to ensure an adequate and comfortable work environment for both the employees and for residents in accordance with acceptable community standards for workplace safety and lighting standards for the elderly;
2.Limitation of sounds at comfort levels;
3.Comfortable temperature levels for the residents in all parts of resident occupied areas with a centralized heating system to maintain a minimum of seventy degrees Fahrenheit (70° F) during the coldest periods;
4.Adequate ventilation through windows or by mechanical means; and
5.Corridors equipped with firmly secured handrails on each side.
6.Heat relief: Pursuant to R.I. Gen. Laws § 23-17.5-27, any nursing facility which does not provide air conditioning in every patient room shall provide an air conditioned room or rooms in a residential section(s) of the nursing facility to provide relief to patients when the outdoor temperature exceeds eighty degrees Fahrenheit (80° F).
1.20Confidentiality – Variance and Appeal Procedure
1.20.1Confidentiality
Disclosure of any health care information relating to individuals shall be subject to all the statutory and regulatory provisions pertaining to confidentiality including but not limited to the provisions of R.I. Gen. Laws Chapter 5-37.3.
1.20.2Variance Procedure
A.The licensing agency may grant a variance from the provisions of a Rule or Regulation in a specific case if it finds that a literal enforcement of such provision will result in unnecessary hardship to the applicant and that such a variance will not be contrary to the public interest, public health and/or health and safety of residents.
1.Variances shall not be granted for the provisions of this Part found in §§ 1.4, 1.11, 1.15, 1.15.5, 1.16.2, 1.16.6, 1.16.8, 1.17.3(K), 1.19.11, 1.19.12, 1.19.14, and 1.20.1 of this Part.
B.A request for a variance shall be filed by a high managerial agent of the nursing facility in writing, and set forth in detail the basis upon which the request is made, including:
1.Identification of the specific regulatory section(s) of the Regulations;
2.Alternative actions, processes, or procedures that through the facility’s implementation will facilitate compliance with the specific regulatory intent, and how the home will ensure staff awareness and training regarding the variance, when appropriate.
3.A variance period shall not exceed the nursing facility’s license period. A nursing facility must request renewal of the variance when it submits its license renewal application.
4.Upon the filing of each request for variance with the licensing agency, and within a reasonable time thereafter, the licensing agency shall notify the applicant by certified mail of its approval or in the case of a denial, a hearing date, time and place may be scheduled if the nursing facility appeals the denial.
C.At a hearing held in furtherance of an appeal from a denial for a variance in accordance with § 1.20.2(B)(1) of this Part, the applicant shall present his case to the Director or his designee for quasi-judicial matters, and shall have the burden of persuading the Director or his designee as aforesaid, through the introduction of clear and convincing evidence, that a literal enforcement of the Rules will result in unnecessary hardship, and that a variance will not be contrary to the public interest, public health and/or health and safety of residents.
D.Nursing facilities that provide care in accordance with alternative service delivery models that facilitate resident-directed care may be eligible for a variance in accordance with any of the requirements contained in this Part.
1.20.3Deficiencies and Plans of Correction
A.The procedures in § 1.20.3 of this Part are exclusive of those required in accordance with § 1.16.7(B) of this Part and of those procedures required to be performed as a result of inspections and investigations conducted in accordance with R.I. Gen. Laws Chapter 23-17.
B.The licensing agency shall notify the governing body or other legal authority of a nursing facility of violations of individual standards through a statement of deficiencies which shall be forwarded to the nursing facility within fifteen (15) days of the inspection team formally exiting the nursing facility unless the Director determines that immediate action is necessary to protect the health, welfare, or safety of the public or any member thereof through the issuance of an immediate compliance order in accordance with R.I. Gen. Laws § 23-1-21.
C.A nursing facility which received a statement of deficiencies (SOD) report must submit a plan of corrections, signed by a high managerial agent of the nursing facility, to the licensing agency within fifteen (15) days of the date of the notice of deficiencies. The plan of corrections shall include and detail any requests for variances as well as document the reasons therefore, in accordance with § 1.20.2 of this Part.
D.The licensing agency will be required to approve or reject the plan of corrections submitted by a nursing facility in accordance with § 1.20.3(C) of this Part within fifteen (15) days of receipt of the plan of corrections.
1.To be deemed acceptable by the licensing agency, a plan of correction shall:
a.Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice(s);
b.Address how the nursing facility will identify other residents having the potential to be affected by the same deficient practice(s);
c.Address what measures will be put into place or systemic changes made to ensure that the deficient practice(s) will not recur;
d.Indicate how the nursing facility plans to monitor its performance to ensure that solutions are sustained;
e.Include dates when corrective action will be completed; and
f.Include any additional components deemed necessary by the licensing agency.
2.The nursing facility shall develop a plan for ensuring that correction is achieved and sustained. This plan shall be implemented and the corrective action(s) evaluated for effectiveness. The plan of correction shall be integrated into the quality assurance system.
3.All deficiencies shall be fully and wholly corrected within thirty (30) days of the date of notice of the deficiencies, unless an extension is granted for good cause shown, but in no case shall an extension exceed fifteen (15) days.
E.If the licensing agency rejects the plan of corrections, or if the nursing facility does not provide a plan of corrections within the fifteen (15) day period stipulated in § 1.20.3(C) of this Part, or if a nursing facility whose plan of corrections has been approved by the licensing agency fails to execute its plan within a reasonable time, the licensing agency may invoke the sanctions enumerated in § 1.12 of this Part. If the nursing facility is aggrieved by the action of the licensing agency, the nursing facility may appeal the decision and request a hearing in accordance with R.I. Gen. Laws Chapter 42-35.
F.The notice of the hearing to be given by the Department shall comply in all respects with the provisions of R.I. Gen. Laws § 42-35-10. The hearing shall in all respects comply with R.I. Gen. Laws §§ 42-35-9, 42-35-10, and 42-35-12.
G.A nursing facility’s SOD is a public record upon Departmental approval of the corresponding plan of correction.
1.21Exception and Severability
1.21.1Exception
Modification of any individual standard in this Part, for experimental or demonstration purposes, or as deemed appropriate by the licensing agency, provided that such modification will not be contrary to the public interest and the public health, or to the health and safety of residents, shall require advance written approval by the licensing agency and should be requested in accordance with the format outlined in § 1.20.2 of this Part.
1.21.2Judicial Review and Rules Governing Practices and Procedures
A.Judicial Review. Any person adversely affected by any final decision of the Department may seek judicial review of the decision in accordance with the provisions of R.I. Gen. Laws § 42-35-15.
B.All hearings and reviews required under the provisions of R.I. Gen. Laws Chapter 23-17 shall be held in accordance with the provisions of Part 10-05-4 of this Title, Rules and Regulations Pertaining to Practices and Procedures Before the Rhode Island Department of Health, and Part 10-05-1 of this Title, Access to Public Records.
1.22Licensing Procedures, Definitions, and Conditions for Resident-Directed Homes
1.22.1Purpose
§ 1.22 of this Part establishes requirements to implement the provisions of R.I. Gen. Laws § 23-17-44(e). For the purpose of this Part, the expansion of the bed capacity of a nursing facility pursuant to R.I. Gen. Laws § 23-17-44(e) shall be designated as a “Resident-directed Home.”
1.22.2Scope
A.Only those nursing facilities that propose to adopt a resident-directed model of care in accordance with the following provisions of this Part shall be licensed to expand their bed capacity:
1.Except for any variance(s) granted pursuant to § 1.20.2 of this Part, the provisions of § 1.22 of this Part shall be in addition to other applicable provisions of this Part.
2.A nursing facility that adopts a resident-directed home model of care shall have such a designation listed on the nursing facility’s license. No separate license shall be issued by the Department for a bed expansion and adoption of the model, as provided in this Part.
3.A nursing facility may implement resident-directed home model of care either in its existing nursing facility setting, in campus-based homes or in-home settings within the community.
4.Only nursing facilities licensed in Rhode Island are eligible to expand under the culture change initiative.
5.Any nursing facility seeking to expand its licensed bed capacity under this initiative, that will result in an expenditure that meets or exceeds the criteria for determination of need review under R.I. Gen. Laws § 23-15-2(10)(ii), shall be required to receive approval under R.I. Gen. Laws Chapter 23-15.
6.Each residential area of a resident-directed Home shall have a minimum of six (6) and a maximum of twelve (12) residents.
1.22.3Application for a Resident-directed Home
A.The Department shall develop an open and competitive process for a resident-directed Home and Requests for Applications for a resident-directed Home, to determine the licensure of expansion beds for a culture change initiative, the form and content of which shall be determined as the Department shall deem appropriate.
B.Complete Application Required. Only applications that the Department has determined to be complete shall be eligible for review. An applicant who submits an incomplete application shall receive written notification from the Department regarding the specific deficiencies and shall be allowed to resubmit a revised application to address these deficiencies within the timeframes stipulated in the Request for Applications.
C.Approval Not Implied. The announcement of an open application period does not imply that the Department will approve any or all of the submitted applications, even if the number of beds requested in the application(s) is less than the total number of available beds. The Department reserves the right to deny, or request modifications to, any and all applications consistent with its duly established statutory and regulatory authority.
D.Decision. After completion of the review process, the Department shall issue a decision granting or denying an application for a resident-directed Home. The decision of the Department is final, unless judicial review is sought in accordance with § 1.21.2 of this Part.
E.Acceptance of the Department’s decision by the applicant includes acceptance of all conditions attached thereto. Failure to comply with all conditions attached to the approval may result in the Department canceling or withdrawing an approval in accordance with § 1.21.2 of this Part.
F.Cancellation or Withdrawal of an Approval. The Department may cancel or withdraw an approval for good cause. The Department shall provide written notification to the applicant detailing the basis for cancellation or withdrawal of an approval. Within thirty (30) days from the date of notification, the applicant shall provide written justification to the Department as to why the approval should not be canceled or withdrawn. Upon receipt of this written justification or following the expiration of the allowed thirty (30) day period, the Department shall render a decision, as applicable. The decision of the Department is final, unless judicial review is sought in accordance with § 1.21.2 of this Part.
G.Application(s). Applications shall only be accepted during an open application period announced by the Department. The frequency of an open application period shall be determined by the Department.
H.Application for a resident-directed Home shall be on forms provided by the Department and shall include, but not be limited to, the following criteria:
1.A non-returnable, non-refundable application fee as set forth in Part 10-05-2 of this Title, Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health;
2.The legal name and license number of the applicant, as stated on the current nursing facility license issued by the licensing agency;
3.The total number of beds requested in the resident-directed Home application;
4.Estimated total capital expenditures, including construction and financing, and all other capital costs to implement the resident-directed Home;
5.Projected incremental annual operating expenses, for the start-up year and two (2) full years following implementation of the resident-directed Home;
6.Written evidence of financing commitment from a qualified lender for the capital expenditures to construct the resident-directed Home and working capital requirements for the first twelve (12) months of operation;
7.If no debt financing is involved, evidence that the applicant has sufficient capital to fund the proposed construction of the resident-directed Home and working capital requirements for the first twelve (12) months of operation;
8.The proposed physical address of the resident-directed Home, including a scale drawing showing the spatial relationship to the licensee’s existing nursing facility;
9.A building/floor plan (to scale), prepared in accordance with § 1.19.1 of this Part, including any proposed variances, and ensuring;
a.The floor plan shall demonstrate that residents’ rooms are constructed around a central, communal, family-style living area where residents and staff may socialize, prepare meals, and dine together;
b.The central communal area shall, at a minimum, include:
(1)A living room seating area;
(2)An open residential-style full kitchen capable to prepare and cook resident meals;
(3)A dining area large enough for a single table, where possible, serving all residents in the home plus two (2) staff members;
c.Provide a private bedroom for each resident;
(1)Rooms shall only be shared at the request of a resident to accommodate a spouse, partner, family member, or friend;
(2)A spouse, partner, family member or friend who does not meet medical criteria for placement in the resident-directed Home may reside in the room assigned to the individual who is admitted to the resident-directed Home and who does meet the medical criteria for admission, and the nursing facility may charge room and board (and other appropriate nursing facility charges) for the spouse, partner, family member or friend who does not meet medical criteria for admission;
(3)Each resident room shall have a full, accessible private bathroom that contains at a minimum, a toilet, sink, and shower, and
(4)The entrance for each resident room shall be visible from the central communal area.
d.Be designed to be fully independent, handicapped accessible, and have overhead lift tracks that run from the bed into the bathroom in each resident bedroom.
e.Includes a secured exterior patio, garden or other outdoor space that:
(1)Allows residents to ambulate, with accommodations for assistive devices such as wheelchairs or walkers;
(2)Provides for outdoor activities;
(3)Provides seating for each resident-directed Home to protect from sun and elements under a covered area; and.
(4)Where feasible, provide a space to accommodate limited overnight guests
f.Projected staffing, by staffing classifications, for the entire nursing facility, and separately for the resident-directed Home, for the start-up year and two (2) full years following implementation of the resident-directed Home;
g.A written operations manual that describes in detail the operational systems and structure that will support and facilitate that resident-directed and person-centered care is provided to residents of the resident-directed Home, and minimally includes the following components:
(1)Procedures for the establishment, training, and operationally maintaining the following:
(AA)Routinely, at least fifty percent (50%) of direct-care staff qualified as Universal Workers;
(BB)Self-directed work team(s), assigned to the day-to-day management of the resident-directed Home; and
(CC)Personnel scheduling practice of consistent assignment of direct-care staff, as defined in this Part.
(2)Procedures for the implementation of a learning culture for staff and residents that identifies and facilitates participation by the residents in making personal and group choices in the operation of the resident-directed Home;
(3)A policy for the provision of person-centered services at the highest level of care required by a resident;
(4)A policy for the provision of services to Medicaid residents at the Medicaid reimbursement rate;
(5)Such other information or documents as deemed relevant by the Department
I.Review Criteria. The Department shall use an open and competitive process to determine the licensure of expansion beds under this culture change initiative and shall evaluate applications in accordance with the criteria and considerations contained in this Part.
J.Such evaluation shall be based upon a review of the items submitted in accordance with § 1.22.3(I) of this Part. The Department may also consider any prior experience with, or knowledge of, the applicant’s provision of long-term care services and licensure record.
K.Additionally, in reviewing resident-directed Home applications, the Department shall consider the applicant’s regulatory compliance history, available quality and performance measurements, including resident and family satisfaction reports, and the impact of the licensure of expansion beds on the regional distribution of, and access to, nursing facility beds in Rhode Island. In analyzing the statewide impact of the expansion beds, the Department may consider any available plans or studies related to the geographical distribution of nursing facility beds, including measures of bed need, levels-of-care, and accessibility.
L.Certificate of Need Review. A resident-directed Home, whose implementation requires prior Certificate of Need review and approval pursuant to R.I. Gen. Laws Chapter 23-15 shall, within one (1) year of the approval date of the application for a resident-directed Home, submit a Certificate of Need application in a form deemed acceptable by the Department. Failure to submit an application within the specified time frame may result in the Department canceling or withdrawing an approval in accordance with § 1.22.3(F) of this Part.
M.Approved Applications. All nursing facilities whose resident-directed Home applications are approved by the Department and whose implementation shall not require a prior Certificate of Need review and approval, shall comply with the following conditions:
1.The applicant shall implement the project at or under the total proposed cost;
2.The applicant shall complete the project in accordance with the proposed application;
3.The applicant shall provide information to the Department upon request; including results of studies and/or reports describing the resident-directed Home’s “lessons learned” with innovative approaches to long term care, such as the culture change model of care;
4.The applicant shall obtain needed zoning approval(s) within one (1) year of the date of approval of the application;
5.The applicant shall execute a contract to initiate construction within one (1) year of the date of approval of the application and expeditiously initiate development;
6.The applicant shall file a summary progress report, including a description of costs incurred, with the Department at three (3) month intervals from the date of final Department decision until full implementation;
7.The applicant shall comply with all applicable laws, codes and Regulations unless a variance therefrom shall have been granted by the appropriate agency; and
8.Any other factors deemed relevant by the Department.
1.22.4Additional Organization and Management Requirements for a Resident-Directed Home
A.In addition to the requirements of §§ 1.5 through 1.19 of this Part, the following is required for a resident-directed Home:
1.Governing Body of Other Legal Authority: The governing body or other legal authority, through the Administrator, shall be responsible for ensuring the management and operation of the resident-directed Home routinely conforms to resident-directed and person-centered practices as defined in this Part.
2.Quality Improvement: Monitoring and review of the resident-directed Home shall be added to the review criteria for the nursing facility’s Quality Improvement Plan.
3.For QI issues related to the resident-directed Homes, a member of the resident-directed Home’s self-directed work team shall participate on the Home’s Quality Improvement Committee.
B.Administrator
1.The Nursing Home Administrator is responsible for establishing the organizational supports and operational structure for a resident-directed Home that ensures and facilitates the control and management of the day to day activities and flow-of-life in the home is resident-directed and coordinated through self-directed work teams with appropriate medical and nursing other professional supports as would be provided in any private home or residential environment.
2.Include a central administration unit for the resident-directed Home that does not contain or utilize commercial and institutional elements and products such as physical nursing stations, medication carts, hospital or office type florescent lighting, acoustical tile ceilings, institutional style railings and corner guards, room numbering, labeling and signage that would not normally be found in a private home setting. Where Regulations require specific institutional elements, every effort shall be made to provide the institutional elements in a manner that is consistent with a private home environment (e.g., residential wall sconces used for required nurse call lights). Where Regulations require specific institutional elements, every effort shall be made to provide the institutional elements in a manner that is consistent with a resident-directed environment.
C.Personnel
1.Staffing model for a resident-directed Home shall be by consistent assignment.
2.Staffing of self-directed work teams for a resident-directed Home shall be scheduled based on the service needs of the residents and adjusted as needed to continually meet the needs of residents at all times, and should be determined for each individual resident-directed Home and not the nursing facility as a whole.
a.Self-directed work teams shall be composed of universal workers and any support staff consistently assigned to the functions of the resident-directed Home and responsible for the general administrative day-to-day activities and work functions for the home, and
b.Self-directed work teams shall collaborate with and include residents, residents’ family members, and guardians in the decision making regarding the flow and content of daily living and coordination of all resident’s care needs.
3.Staff Training: In addition to any State or Federal training requirements pertaining to long term care facilities, or training deemed appropriate by the nursing facility, each universal worker in a resident-directed Home shall annually and/or as needed receive in-service training on topics directly related to:
a.Resident-directed and person-centered care practices;
b.Communication and workplace conflict management; and
c.Self-directed work teams.
D.Resident Care Services
1.All resident care services shall be person-centered in their development and implemented with a full commitment to the resident-directed Home being a restraint-free environment.
2.Professional services (i.e., physician, nursing, dietetic, social, and specialized rehabilitative) shall be organized and provided by or arranged by the nursing facility for residents of the resident-directed Home and at the convenience of the residents and coordinated with the Home’s self-directed work teams, similar to services that would be provided to residents in their private home; either as outpatient, or home nursing care.
a.Professional services provided in the nursing facility by licensed nursing facility staff shall not be construed as providing “outpatient” or “home nursing care” services for the residents of the resident-directed Home for purposes of health care facility licensing.
b.The nursing facility’s Dietary Manager and/or consulting Dietitian shall provide staff of the resident-directed Home with consultation and in-service in the development of resident-directed menus, meal planning, and meal preparation.
E.Nothing in this Part shall prohibit the consumption of foods that are:
1.Prepared outside the resident-directed Home by family, acquaintances, or social organization, such as churches, schools, etc.;
2.Grown in or on the grounds of the resident-directed Home by residents and/or staff for residents; or
3.Prepared by appropriately licensed local retail or established eating establishments.
F.The resident-directed Home shall have at least one (1) lift motor and separate slings for each resident who requires use of a lift.
G.Environmental and Maintenance Services
The resident-directed Home should be designed to provide for normal housekeeping and laundry services from within the home, however, as needed or as circumstance require, such services may be provided for under the umbrella of the nursing facility’s available services in terms of emergency support services; including the adoption or inclusion in the nursing facility’s emergency operations plan.
H.Physical Environment
1.The resident-directed Home shall:
a.Have built-in safety features (e.g., magnetic locks on cabinets with chemicals or knives) to allow all areas of the house, including the kitchen, to be accessible to the residents during the majority of the day and night.
b.Utilize a wireless communication and notification system that shall provide for escalation of response if a signal is unanswered for a designated period of time. The signal shall be repeated and sent to other staff who were not designated to receive the original signal.
(1)Wired call or alert systems and overhead paging shall not be permitted.
c.Provide ample natural light in each habitable space provided through exterior windows.
d.Provide staff and public access to bathroom facilities.
2.Have available at least one (1) portable functional fire extinguisher accessible in the kitchen area. All fire extinguishers shall be installed, inspected and maintained in accordance with applicable National Fire Protection Association (NFPA) standards.
| Title | 216 | Department of Health |
| Chapter | 40 | Professional Licensing and Facility Regulation |
| Subchapter | 10 | Facilities Regulation |
| Part | 1 | Licensing of Nursing Facilities (216-RICR-40-10-1) |
| Type of Filing | Direct Final Amendment |
| Regulation Status | Inactive |
| Effective | 08/25/2022 to 10/02/2023 |
Regulation Authority:
R.I. Gen. Laws § 23-17-10
R.I. Gen. Laws § 23-17.5-32
R.I. Gen. Laws § 23-17.5-33
Purpose and Reason:
The Rhode Island
Department of Health is proposing amendments clarify procedures for criminal record checks for individuals under the age of eighteen (18).
Rulemaking Documents are organized by document type and are part of this rule’s rulemaking record (R.I. Gen. Laws § 42-35-2.3). If multiple documents of the same type are listed below, each is a unique document. If there are multiple Public Notice of Proposed Rulemaking documents, view each document to identify the most recently amended version, as it may be amended at any point during the Public Comment Period.