A. These regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws Chapter 23-17.4, and are established for the purpose of defining the minimum standards for licensed assisted living residences in Rhode Island; for the care of residents in an assisted living residence; for the maintenance and operation of assisted living residences which will:

1. Promote the dignity, individuality, independence, privacy, and autonomy of residents;

2. Provide a safe and home-like environment; and

3. Protect the safety, health and welfare of residents; for the encouragement of quality of life for all residents; and for the encouragement of quality in all aspects of the operations of assisted living residences.

A. These regulations hereby adopt and incorporate Dietary Reference Intakes: The Essential Guide to Nutrient Requirements, National Academies Press, 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.

B. These regulations hereby adopt and incorporate ANSI A117.1 - 2003 Accessible and Usable Buildings and Facilities, International Code Council, 2003 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 Kroger, Andrew, et al. “General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP),” Morbidity and Mortality Weekly Report Recommendations and Reports, vol. 60, no. RR02, 2011, https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm, 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.

A. Whenever used in these regulations, 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. Any 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. Intentionally 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. "Act" means R.I. Gen. Laws Chapter 23-17.4, entitled "Assisted Living Residence Licensing Act."

3. "Activities of daily living" means bathing, dressing, eating, toileting, mobility and transfer.

4. "Administrator" means the person who has responsibility for day to day administration or operation of an assisted living residence.

5. “Alzheimer Dementia Special Care Unit/Program” means a distinct living environment within an assisted living residence that has been physically adapted to accommodate the particular needs and behaviors of those with dementia. The 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 the unit or program have had a standard medical diagnostic evaluation and have been determined to have a diagnosis of Alzheimer's dementia or another dementia.

6. "Assisted living residence" means a publicly or privately operated residence that provides directly or indirectly by means of contracts or arrangements personal assistance and may include the delivery of limited health services, as defined under R.I. Gen. Laws § 23-17.4-2(12), to meet the resident's changing needs and preferences, lodging, and meals to six (6) or more adults who are unrelated to the licensee or administrator, excluding however, any privately operated establishment or facility licensed pursuant to R.I. Gen. Laws Chapter 23-17 and those facilities licensed by or under the jurisdiction of the Department of Behavioral Healthcare, Development Disabilities and Hospitals, the Department of Children, Youth, and Families, or any other state agency.

7. "Capable of self-preservation" means the physical mobility and judgmental ability of the individual to take appropriate action in emergency situations. Residents not capable of self- preservation are limited to facilities that meet more stringent Life Safety Code requirements as provided under R.I. Gen. Laws § 23-17.4-6(b)(3).

8. "Change in operator" means a transfer by the licensee or operator of an assisted living residence to any other person (excluding delegations of authority to the administrative employees of the residence) of the licensee's authority to:

a. Hire or fire the chief executive officer of the assisted living residence;

b. Maintain and control the books and records of assisted living residence;

c. Dispose of assets and incur liabilities on behalf of the assisted living residence; or

d. Adopt and enforce policies regarding operation of the assisted living residence.

e. This definition is not applicable to circumstances wherein the licensee of an assisted living residence for adults retains the immediate authority and jurisdiction over the activities enumerated in §§ 2.3(A)(a) through (d) of this Part above.

9. "Change in owner" means:

a. In the case of an assisted living residence 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 an assisted living residence which is an unincorporated solo proprietorship, the transfer of the title and property to another person;

c. In the case of an assisted living residence 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 an assisted living residence 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 an assisted living residence which is a non-business corporation, any change in membership which results in a new person acquiring a controlling vote in such corporation.

10. "COVID-19" means the disease caused by the novel coronavirus SARS-CoV-2.

11. “Department” means the Rhode Island Department of Health. The Department is also the “licensing agency” designated pursuant to R.I. Gen. Laws Chapter 23-17.

12. "Director" means the Director of the Rhode Island Department of Health.

13. “Center for Acute Infectious Diseases Epidemiology” means Center for Acute Infectious Diseases Epidemiology (CAIDE); Division of Preparedness, Response, Infectious Disease & Emergency Medical Services; Rhode Island Department of Health.

14. "Elopement," means leaving the premises without notice when the residence has assumed responsibility for the resident’s whereabouts.

15. “Employee” means any individual, whether paid or unpaid, directly employed by or under contract with the residence, who provides or delivers direct care services to residents and/or who has routine contact with residents without the presence of other employees.

16. "Established resident" means a person living in an assisted living residence with a contract and service plan in place based upon a complete assessment.

17. “Fiduciary agent” means one who holds a fiduciary relation or acts in a fiduciary capacity.

18. "Vaccinated" means a person has received all recommended dose(s) of a COVID-19 vaccine authorized by the U.S. Food and Drug Administration ("FDA") or World Health Organization ("WHO") or all recommended dose(s) of another COVID-19 vaccine approved by the Department (e.g., Novavax).

19. "Health oversight agency" means a public authority or other agency or organization authorized by law to investigate or otherwise oversee the reporting of allegations of failure to meet professional practice standards or misconduct.

20. "High managerial agent" means an officer of a residence, the administrator and assistant administrator of the residence, 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 residence or the supervision in a managerial capacity of subordinate employees.

21. "Level of licensure" means the licensed authority to admit residents according to the following classifications: [Note that residences must have both an "F" (fire) and an "M" (medication) classification].

22. "Licensee" means any person who holds an assisted living residence license from the Department.

23. "Life Safety Code" means the current applicable Rhode Island Fire Safety Code, R.I. Gen. Laws Chapter 23-28.1.

24. "Limited health services" means health services provided by a licensed assisted living residence, as ordered by a resident's physician, and provided by qualified licensed assisted living staff members. Limited health services includes the following:

a. Stage I and stage II pressure ulcer treatment and prevention;

b. Simple wound care including postoperative suture care/removal and stasis ulcer care;

c. Ostomy care including appliance changes for residents with established stomas;

d. Urinary catheter care.

25. “Medication aide” means a nursing assistant who has had additional training in the administration of medications and is registered with the Department pursuant to R.I. Gen. Laws Chapter 23-17.9 and rules and regulations pertaining to Rhode Island Certificates of Registration for Nursing Assistants, Medication Aides, and the Approval of Nursing Assistant and Medication Aide Training Programs (Part 05-22 of this Chapter).

26. "Mistreatment" means the inappropriate use of medications, isolation, or use of physical or chemical restraints as punishment, for employee convenience, as a substitute for treatment or care, in conflict with a physician's order, or in quantities which inhibit effective care of treatment, which harms or is likely to harm the patient or resident.

27. "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. “Neglect” also means failure to promptly act upon any change in a resident’s condition that would disqualify that resident from admission to the residence pursuant to § 2.4.14(A)of this Part, including but not limited to, the transfer of the resident to a health care facility. 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 or a well-recognized church or denomination by a duly-accredited practitioner thereof.

28. “Center for Health Facilities Regulation” means the Center for Health Facilities Regulation, Division of Customer Services, Rhode Island Department of Health.

29. “Center for Food Protection” means the Center for Food Protection, Division of Environmental Health, Rhode Island Department of Health.

30. "Person" means any individual, trust or estate, partnership, corporation (including associations, joint stock companies, or limited liability companies) state or political subdivision or instrumentality of a state.

31. "Personal assistance" means the provision of one (1) or more of the following services, as required by the resident or as reasonably requested by the resident, on a scheduled or unscheduled basis, including:

a. Assisting the resident with personal needs, including activities of daily living;

b. Assisting the resident with self-administration of medication; or administration of medications by appropriately licensed staff;

c. Providing or assisting the resident in arranging for health and supportive services as may be reasonably required;

d. Monitoring the activities of the resident while on the premises of the residence to ensure his or her health, safety, and well-being; and

e. Reasonable recreational, social and personal services.

32. “Qualified designee” means a licensed registered nurse, licensed practical nurse, or registered medication aide.

33. "Qualified licensed assisted living staff members" means a certified nursing assistant as provided under R.I. Gen. Laws § 23-17.9-2(a)(3), a licensed practical nurse as provided under R.I. Gen. Laws § 5-34-3(9) and/or a registered nurse as provided under R.I. Gen. Laws § 5-34-3(10)

34. "Resident" means an individual not requiring medical or nursing care as provided in a health care facility but who as a result of choice and/or physical or mental limitation requires personal assistance, lodging and meals and may require the administration of medication and/or limited health services. A resident must be capable of self-preservation in emergency situations, unless the facility meets a more stringent Life Safety Code as required under R.I. Gen. Laws § 23-17.4-6(b)(3). Persons needing medical or skilled nursing care, including daily professional observation and evaluation, as provided in a health care facility, and/or persons who are bedbound or in need of the assistance of more than one (1) person for ambulation are not appropriate to reside in assisted living residences. However, an established resident may receive daily skilled nursing care or therapy from a licensed health care provider for a condition that results from a temporary illness or injury for up to forty-five (45) days subject to an extension of additional days as approved by the Department, or if the resident is under the care of a Rhode Island licensed hospice agency provided the assisted living residence assumes responsibility for ensuring that the required care is received. Furthermore, a new resident may receive daily therapy services and/or limited skilled nursing care services, as defined through these regulations, from a Rhode Island licensed health care provider for a condition that results from a temporary illness or injury for up to forty-five (45) days subject to an extension of additional days as approved by the Department, or if the resident is under the care of a Rhode Island licensed hospice agency provided that assisted living residence assumes responsibility for ensuring that the care is received. Notwithstanding the aforementioned, residents who are bed bound or in need of assistance of more than one (1) staff person for ambulation may reside in a residence if they are receiving hospice care in accordance with these regulations "Resident" shall also mean the resident's agent as designated in writing or legal guardian.

35. “R.I. Gen. Laws” means the General Laws of Rhode Island.

36. "Significant change" means an improvement or decline in the resident's health status, behavior, or cognitive and/or functional abilities that results in a change in the resident's independence or quality of life, including but not limited to:

a. Resident's ability to perform activities of daily living;

b. A change in the resident’s behavior or mood resulting in behavioral symptoms that present a threat to the resident's self or others;

c. The elimination of problematic behavior on a sustained basis;

d. Requirements for resident’s level of service.

37. “State Fire Marshal” means the Division of the State Fire Marshal, Department of Public Safety, State of Rhode Island.

38. "Supervision" means the supervision requirements of qualified licensed assisted living staff delivering limited health services.

2.4.1 General Requirements for Licensing

A. No person, acting alone or jointly with any other person, shall conduct or maintain an assisted living residence in Rhode Island without a license in accordance with the requirements of R.I. Gen. Laws § 23-17.4-4 and in conformity with these regulations.

1. All assisted living residences are subject to and must meet the requirements of § 2.4 of this Part to obtain and renew an assisted living residence license.

2. Any assisted living residence which offers to provide or provides services to residents with Alzheimer disease or other dementia by means of an Alzheimer Dementia/Special Care Unit/Program is also subject to the requirements of § 2.5 of this Part to obtain and renew a license endorsement which authorized these activities.

3. Any assisted living residence which offers to provide or provides limited health services to residents is also subject to the requirements of § 2.6 of this Part to obtain and renew a license endorsement which authorized these activities.

4. Any assisted living residence which offers to provide or provides services for residents receiving hospice services that are bed-bound or in need of assistance from more than one staff person for ambulation is required to be licensed at the F1 level, as defined in § 2.4.2(A)(1)(a) of this Part, and must have a license endorsement, issued pursuant to these regulations, to provide limited health services, and shall, at a minimum provide services for stage I and stage II pressure ulcer treatment and prevention and meet the requirements of § 2.6 of this Part.

B. No person, acting severally or jointly with any other person, shall admit or retain a resident in an assisted living residence which residence:

1. does not meet the definition and requirements of the Act; or

2. is not able to provide the services needed by a resident as agreed to in the service plan required under R.I. Gen. Laws § 23-17.4-15.6.

C. Each license shall specify the licensed resident capacity of the residence. The occupancy of the residence shall never exceed the licensed resident capacity.

1. The residence shall identify to the Department the location of beds and shall maintain proper space and furnishings for such locations.

2. The residence may not house more assisted living residents than the licensed capacity at any given time.

D. Proposed changes in bed capacity within a residence shall be submitted to the Department in writing and shall be subject to the approval of the Department.

E. No person and/or combination per area of residence shall represent itself as an assisted living residence or use the term residential care or any other similar term in its title, advertising, publication or other form of communication, unless licensed as an assisted living residence in accordance with the provisions herein.

2.4.2 Levels of Licensure

A. An assisted living residence shall only admit and retain residents according to the level of licensure for which the residence has been licensed. A residence may have areas which are licensed separately.

1. Fire Code Classifications

a. Level F1 licensure: for residents who are not capable of self-preservation. This level requires a more stringent Life Safety Code, as defined in § 2.3(A)(21) of this Part; or

b. Level F2 licensure: for residents who are capable of self-preservation.

2. Medication Classifications

a. Level M1 licensure: for one (1) or more residents who require central storage and/or administration of medications; or

b. Level M2 licensure: for residents who require assistance (as elaborated in § 2.4.24(A)(3)(a) of this Part) with self-administration of medications;

3. Dementia Care

This category of licensure shall be required when one (1) or more resident's dementia symptoms impact their ability to function as demonstrated by any of the following:

a. Safety concerns due to elopement risk or other behaviors;

b. Inappropriate social behaviors that adversely impact the rights of others;

c. Inability to self-preserve due to dementia;

d. A physician's recommendation that the resident needs dementia support consistent with this level; or if the residence advertises or represents special dementia services or if the residence segregates residents with dementia. In addition to the requirements for the basic license, licensing requirements for the "dementia care" level shall include the following:

(1) Staff training and/or requirements specific to dementia care as determined by the Department;

(2) A registered nurse on staff and available for consultation at all times;

(3) The residence shall provide for a secure environment appropriate for the resident population.

e. A residence licensed at the "dementia care" level shall:

(1) Be licensed as an "F1--M1" residence in accordance with the requirements of §§ 2.4.2(A)(1)(a) and (2)(a) of this Part; and

(2) Meet the requirements of §§ 2.4 and 2.5 of this Part.

4. Limited Health Care Services:

a. This category of licensure shall be required for any assisted living residence that provides or offers to provide services in a manner as defined in § 2.3(A)(22) of this Part.

2.4.3 Quality Assurance

A. In accordance with R.I. Gen. Laws § 23-17.4-10.1, each assisted living residence shall develop, implement and maintain a documented, ongoing quality assurance program.

1. The purpose of this program shall be to attain and maintain a high quality assisted living residence through an on-going process of quality improvement that monitors quality, identifies areas to improve, methods to improve them, and evaluates the progress achieved.

2. Each licensed residence shall establish a quality improvement committee which shall include at least the following: assisted living administrator, registered nurse and a representative of dietary services.

3. 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 Department during any on-site visit.

4. The quality improvement committee shall review and approve the quality improvement plan for the residence at intervals not to exceed twelve (12) months. Said plan shall be available to the public upon request.

5. Each assisted living residence shall establish a written quality improvement plan that includes:

a. Program objectives;

b. Oversight responsibility (e.g., reports to the governing body, QI records);

c. Includes methods to identify, evaluate, and correct identified problems;

d. Provides criteria to monitor personal assistance and resident services, including, but not limited to:

(1) Resident/family satisfaction;

(2) Medication administration/errors;

(3) Reportable incidents as specified in § 2.4.17 of this Part;

(4) Resident falls;

(5) Plans of correction developed in response to the Department’s inspection reports.

B. In addition to the requirements of §§ 2.4.3(A)(1) through (5) of this Part, all assisted living residences with a “dementia care” license and/or a “limited health services license” shall also address the following areas in their quality improvement plan:

a. Prevention and treatment of decubitus ulcers;

b. Dehydration, and nutritional status and weight loss or gain; and

c. Changes in mental or psychological status.

1. Quality improvement documentation shall be kept on file for a minimum of five (5) years.

2.4.4 Financial Interest Disclosure

A. Any licensed assisted living residence which refers clients to any health care facility licensed pursuant to R.I. Gen. Laws Chapter 23-17, or to another assisted living residence licensed pursuant to the Act, 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 the following information to the client:

1. That the referring entity has a financial interest in the residence or provider to which the referral is being made; and

2. That the client has the option of seeking care from a different residence or provider which is also licensed and/or certified by the State of Rhode Island to provide similar services to the client.

B. The referring entity shall also offer the client a written list prepared by the Department of all such alternative licensed and/or certified facilities or providers. Said written list may be obtained by contacting the Department as specified in § 2.4.6 of this Part.

C. Non-compliance with §§ 2.4.4(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.

2.4.5 Safe Resident Handling

A. Each licensed assisted living residence with an “Alzheimer’s Dementia Special Care Unit or Program” license and/or offers to provide or provides coordination of hospice services for residents who are bed-bound or in need of assistance from more than one staff person for ambulation shall comply with the provisions of §§ 2.4.5(B) through (E) of this Part as a condition of licensure.

1. Notwithstanding the requirements of § 2.4.5(A) of this Part, assisted living residences licensed for an “Alzheimer’s Dementia Special Care Unit or Program” prior to 1 June 2015 shall be in compliance with the requirements of §§ 2.4.5(B) through (E) of this Part not later than 1 July 2015.

2. A currently licensed assisted living residence who applies for a new level of licensure on or after 1 June 2015 will be required to meet the requirements of §§ 2.4.5(B) through (E) of this Part prior to a new license level being approved.

B. Shall maintain a safe resident handling committee, which shall be chaired by a professional nurse or other appropriate licensed health care professional. An assisted living may utilize any appropriately configured committee to perform the responsibilities of this section. At least half of the members of the committee shall be hourly, non-managerial employees who provide direct resident care.

C. Shall have a written safe resident handling program, with input from the safe handling committee, to prevent musculoskeletal disorders among health care workers and injuries to residents. As part of this program, each licensed assisted living shall:

1. Implement a safe resident handling policy for all shifts and units of the residence 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;

2. Conduct a resident handling hazard assessment. This assessment should consider such variables as handling-handling tasks, types of units, resident populations, and the physical environment of resident care areas;

3. 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;

4. Designate and train a registered nurse or other appropriate licensed health care professional to serve as an expert resource, and train all direct care staff on safe resident handling policies, equipment, and devices before implementation, and at intervals not to exceed twelve (12) months, or as changes are made to the safe handling policies, equipment and/or devices being used; and

5. Conduct a performance evaluation of the safe resident handling policy at intervals not to exceed twelve (12) months, 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 musculo-skeletal disorder caused by resident handling, and include recommendations to increase the program's effectiveness.

D. Nothing in § 2.4.5(A) of this Part precludes lift team members from performing other duties as assigned during their shift.

E. An employee may, in accordance with established residence protocols, report to the committee, as soon as possible, after being required to perform a resident handling activity that he/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/her employer. These reportable incidents shall be included in the residence's annual performance evaluation.

2.4.6 Communications

A. All communications and reports required to be submitted to the Department pursuant to these regulations shall be sent to:

B. The information in § 2.4.6(A) of this Part shall be displayed in a conspicuous public area of the residence and shall be identified as the Department point of contact for complaints concerning potential violations of the Act or these regulations.

C. Each assisted living residence shall establish and maintain a facility specific electronic mail address (i.e., e-mail address) to be provided to the Department for the purposes of contacting a high managerial agent for the residence with both routine communications and emergency notices. The residence shall be responsible for providing notice to the Department at any time that the residence’s specific electronic mail address is changed or updated.

D. In the event or in the preparation of an onsite, local area, or statewide emergency or natural disaster, the assisted living residence will respond to requests for information and/or status reports as requested by the Department and/or designated situation/incident commander.

2.4.7 Application for License

A. Application for a license to conduct, maintain or operate an assisted living residence shall be made to the Department upon forms provided by the Department and shall contain such information as the Department reasonably requires which may include affirmative evidence of ability to comply with the provisions of the Act, these regulations and compliance with federal, state, and local laws and rules and regulations pertaining to, but not limited to: the management and operation of assisted living residences, fire, safety, zoning, building codes, sanitation, food service, communicable and reportable diseases, and other relevant health and safety requirements. The licensing application shall include evidence from the applicant that criminal background checks on owners and operators of licensed assisted living residences have been completed.

1. Each application shall be accompanied by a non-refundable application fee per license plus an additional fee per licensed bed, as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

2. Each application for a license endorsement to provide an Alzheimer Dementia/ Special Care Unit/Program or limited health services shall be accompanied by a non-refundable application fee, per license endorsement, as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

B. A notarized listing of the 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 at intervals not to exceed twelve (12) months. If a corporation, the list shall include all officers, directors and other persons or any subsidiary corporation owning stock.

2.4.8 Issuance and Renewal of License

A. Upon receipt of an application for a license, the Department shall issue a license if the applicant meets the requirements of the Act and these regulations. The license issued, unless sooner suspended or revoked, shall expire by limitation on the 31st day of December following its issuance and may be renewed from year to year subject to inspection and approval by the Department.

1. All renewal applications shall be accompanied by a non-refundable application fee per license plus an additional fee per licensed bed, as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

2. A renewal application for a license endorsement to provide an Alzheimer Dementia / Special Care Unit/Program or limited health services shall be accompanied by a non- refundable application fee, per license endorsement, as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

B. Each license shall be issued only for the premises and persons named in the application, and shall not be transferable or assignable except with the written approval of the Department.

C. The license will specify names of the owner and operator, the level of licensure or combination of services that the residence may provide, and the area where service can be provided (i.e., residents requiring assistance with self-preservation, and/or medication may only be admitted to facilities [or areas] with appropriate licensing level).

D. A license issued pursuant to these regulations 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 premises.

E. In cases where a building has a mixed population of independent and assisted living residents, the location of the units on the assisted living license shall be documented in a roster available at all times and certified by the administrator, or his/her designee, and kept current on a daily basis.

2.4.9 Inspections

A. The Department shall make or cause to be made such inspections and investigations as it deems necessary by duly authorized agents of the Director at such time and frequencies as determined by the Department.

B. A duly authorized representative of the Department shall have the right to enter at any time without prior notice, to inspect the premises and services for which an application has been received, or for which a license has been issued.

1. Refusal to permit inspection or investigation shall constitute a valid ground for suspension or revocation of license or curtailment of activities.

C. Every residence shall be given notice by the Department of all deficiencies reported as a result of an inspection or investigation.

2.4.10 Change of Ownership, Operation and/or Location

A. When a change of ownership or operation or location of an assisted living residence or when discontinuation of services is contemplated, the Department shall be given written notice of pending changes.

B. A license shall immediately expire and become void and shall be returned to the Department when operation of an assisted living residence is discontinued or when any changes in ownership occur.

1. Prior to operating under a new owner or operator, the prospective licensee shall apply for a new license in accordance with § 2.4.7 of this Part, “Application for License.” Upon receipt of a complete application and if there are no changes in existing operations of the residence, including:

a. Resident capacity,

b. Level of licensure,

c. Modifications or construction of the physical plant,

2. The Department may, following a review of the complete application, issue a license to the prospective licensee without first inspecting the premises.

3. When there is a change in ownership or in the operation or control of the residence, and provided a complete application is submitted in accordance with § 2.4.10(B)(1) of this Part, the Department reserves the right to extend the expiration date of the existing license, allowing the residence to operate under the same license which applied to the prior licensee for such time as shall be required for the processing of a new application or reassignment of residents, not to exceed six (6) weeks.

C. When a change of certified administrator is contemplated, the Department shall be given written notice prior to the change and at the time of the actual change.

D. The Department shall be notified immediately when a licensee/owner determines to cease operations and close an assisted living residence. A meeting shall be conducted with the Department and prior to notice or notification to residents and the public to ensure there is a formal and comprehensive plan for an orderly closure, thirty (30) days or more 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.

1. The assisted living residence 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) Any required notice to 3rd party payers (i.e., Medicaid, long-term care insurance);

(2) Notice to Accreditation entities – if 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.

2.4.11 Denial, Suspension, Revocation of License or Curtailment of Activities

A. The Department is authorized to deny, suspend or revoke the license or curtail activities of any assisted living residence which:

1. Has failed to comply with these regulations;

2. Has offered or provided service to residents outside of the scope of its appropriate level of license;

3. Has failed to correct deficiencies or complete corrective action plan; or

4. Has failed to comply with the provisions of the Act.

B. Reports of deficiencies shall be maintained on file in the Department and shall be considered by the Department in rendering determinations to deny, suspend or revoke the license or to curtail activities of the assisted living residence.

C. Whenever an action shall be proposed to deny, suspend or revoke an assisted living residence license, or curtail its activities, the Department shall notify the residence by certified or registered mail or by personal service 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 §§ 23-17.4-8 and 42-35-9, and the provisions of § 2.4.33 of this Part.

1. However, if the Department finds that the safety and welfare of residents requires emergency action and incorporates a finding to that effect in its order, the Department may order summary suspension of license or curtailment of activities pending proceedings for revocation or other action in accordance with R.I. Gen. Laws §§ 42-35-14(c) and 23-1-21.

D. The appropriate state and federal agencies shall be notified of any action taken by the Department pertaining to either denial, suspension, or revocation of license, or curtailment of activities.

2.4.12 Administrative Management

A. All licensees shall provide staffing which is sufficient to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of the residents, according to the appropriate level of licensing. At least one (1) staff person who has completed employee training as outlined in § 2.4.12(G) of this Part shall be on the premises at all times.

B. Each licensee shall have responsible adult(s) who are employee(s) or who have a contractual relationship with the residence to provide the services required by these regulations who is at least eighteen (18) years of age and

1. Awake and on the premises at all times,

2. Designated in charge of the operation of the residence; and

3. Physically and mentally capable of communication with emergency personnel.

C. Pursuant to R.I. Gen. Laws § 23-17.4-15.1.1, each assisted living residence shall have an administrator who is certified by the Department in accordance with regulations established pursuant to R.I. Gen. Laws § 23-17.4-21.1, in charge of the maintenance and operation of the residence and the services to the residents. The name and contact information for the current administrator shall be displayed in a conspicuous public area of the residence. The administrator is responsible for the safe and proper operation of the residence at all times by competent and appropriate employee(s) and shall be responsible for no less than the following:

1. The management and operation of the residence and services to the residents;

2. Compliance with federal, state, and local laws and rules and regulations pertaining to, but not limited to: the management and operation of assisted living residences, fire, safety, zoning, building codes, sanitation, food service, communicable and reportable diseases, Americans with Disabilities Act, employee health and safety, other relevant health and safety requirements, and these regulations.

3. Staffing the residence with adequate and qualified personnel to attend to the food preparation, general housekeeping, assistance with personal care, medication administration, if applicable, and other such services;

4. Establishment of written policies and procedures governing the operation of the residence which are aimed, to the extent possible, at maintaining the independence of residents. Such policies shall include provisions to implement no less than the following:

a. The appropriate provisions of § 2.4.18 of this Part and other applicable provisions pertaining to admission, transfer, discharge, visitation privileges, availability and utilization of community resources, leisure time and such other;

b. Accountability of the residence when acting as a fiduciary agent for the resident pursuant to § 2.4.18 of this Part;

c. Notification of next of kin or other responsible person designated by the resident in the event of illness, accident or death; and

d. Such other provisions as may be deemed appropriate.

5. Compliance with all requirements appropriate to the service level for which the residence is licensed.

D. Cardiopulmonary Resuscitation

1. At all times, one person on-site shall have successfully completed instruction by the American Heart Association, the American Red Cross, or the National Safety Council at the minimal ("Heartsaver") level to perform cardiopulmonary resuscitation.

E. A certified administrator shall be in charge of no more than three (3) residences with an aggregate resident total of no more than one hundred twenty (120) residents.

F. The certified administrator shall not leave the premises without delegating necessary authority for operation of the residence to a competent employee(s).

G. Employee Training

1. The administrator shall ensure that all new employees shall receive at least two (2) hours of orientation and training within ten (10) days of hire and prior to beginning work alone in the assisted living residence, in addition to any training that may be required for a specific job classification at the residence. Such areas include:

a. Fire prevention;

b. Recognition and reporting of abuse, neglect, and mistreatment;

c. Assisted living philosophy (goals/values: dignity, independence, autonomy, choice);

d. Resident's rights;

e. Confidentiality.

f. Emergency preparedness and procedures;

g. Medical emergency procedures;

h. Infection control policies and procedures; and

i. Resident elopement.

2. The administrator shall ensure that all new employees who will have regular contact with residents and provide residents with personal care shall receive at least ten (10) hours of orientation and training within thirty (30) days of hire and prior to beginning work alone in the assisted living residence, in addition to the areas stipulated in § 2.4.12(G) of this Part. Such areas include:

a. Basic sanitation;

b. Food service;

c. Basic knowledge of cultural differences;

d. Basic knowledge of aging-related behaviors including dementia and Alzheimer’s disease;

e. Personal assistance;

f. Assistance with medications;

g. Safety of residents;

h. Body Mechanics;

i. Resident Transfers (required for residences licensed at the F1 level for fire safety);

j. Record-keeping;

k. Service plans; and

l. Internal reporting.

H. In-service Training

1. Employees shall have on-going, at intervals not to exceed twelve (12) months, in-service training as appropriate for their job classifications and including the topics cited in § 2.4.12(G) of this Part.

2. All new employee orientation and on-going in-service training shall be documented in the employee's personnel file, and maintained onsite at the licensed residence.

I. Personnel Records

1. The residence shall maintain comprehensive personnel records for each employee. Personnel records shall be maintained onsite of the licensed residence and/or electronically available at all times.

2. Said personnel records shall be reviewed and updated at intervals not to exceed twelve (12) months and shall include, but not be limited to, all of the following components:

a. Completed job application and/or resume;

b. Written statements of references or documentation of verbal reference check;

c. Written functional job descriptions;

(1) These descriptions shall be updated at intervals not to exceed twelve (12) months and shall include, but not be limited to, minimal qualifications for the position, major duties and responsibilities, and shall be signed and dated by the individual employee.

d. Evidence of credentials, current professional licensure and/or certification;

e. Documentation of education and/or continuing training, including continuing education units (CEUs) related to administrator certification, food management, etc., medication administration, and dementia care;

f. Documentation of attendance at in-service training and/or orientation;

g. Documentation of at least one (1) performance evaluation at intervals not to exceed twelve (12) months;

h. Signed copy of employee’s awareness of resident’s rights;

i. Results of the criminal record (BCI) check.

J. Personnel Criminal Records Check

1. Pursuant to R.I. Gen. Laws § 23-17.4-27, all employees of assisted living residences licensed under the Act, hired after September 30, 2014, and having routine contact with a resident or having access to a resident's belongings or funds shall undergo a national criminal background records check which shall include fingerprints submitted to the Federal Bureau of Investigation (FBI) by the Bureau of Criminal Identification of the Department of Attorney General. The national criminal records check shall be processed, prior to, or within one (1) week of employment.

2. Said employee, through the employer, shall apply to the Bureau of Criminal Identification of the Department of Attorney General for a national criminal records check.

3. In those situations in which no disqualifying information has been found, the Bureau of Criminal Identification of the Department of Attorney General shall inform the applicant and the employer in writing of this fact.

4. Upon the discovery of any disqualifying information, as defined in R.I. Gen. Laws § 23-17.4-30 and in these regulations, the Bureau of Criminal Identification of the Department of Attorney General will inform the applicant in writing of the nature of the disqualifying information; and, without disclosing the nature of the disqualifying information, will notify the employer in writing that disqualifying information has been discovered.

5. The employer shall maintain on file, subject to inspection by the Department, evidence that statewide criminal records checks have been initiated on all employees seeking employment between October 1, 1991 and September 30, 2014, and the results of those checks.

6. The employer shall maintain on file, subject to inspection by the Department, evidence that national criminal records checks have been initiated on all employees seeking employment on or after October 1, 2014, and the results of those checks.

7. Failure to maintain this evidence shall be grounds to revoke the license or registration of the employer.

8. An employee against whom disqualifying information has been found may provide a copy of the national criminal records check to the employer. The administrator shall make a judgment regarding the continued employment of the employee.

2.4.13 Management of Services

A. Each residence shall provide services with adequate professional and ancillary employees and in accordance with applicable state law. Further, the residence shall assure that all services are rendered in a safe and effective manner and consistent with the requirements herein. The residence shall provide all care and services to all residents in accordance with the prevailing community standard of care.

B. The residence shall have a policy and procedure manual that is reviewed and updated by the administrator at intervals not to exceed twelve (12) months, and shall include, but not be limited to, the following items:

1. A written description of all services available to residents that shall be designed to promote the resident’s efforts to maintain independence;

2. A written statement of admission criteria that shall include, at a minimum, the following information regarding the resident population:

a. Nature and extent of disabling condition(s) served; and

b. Restrictions (if any).

(1) The statement of admission criteria shall include a statement that no otherwise qualified applicant shall be denied admission to the residence solely on the basis of race, creed, color, religion, sexual orientation, or national origin.

C. The residence shall develop and maintain written admission procedures that shall include no less than the following components:

1. Procedures for informing residents of house rules (e.g., necessary information, tour of residence);

2. A resident assessment process;

3. Provision of information to each resident related to:

a. Results of initial assessment;

b. Procedures for involuntary transfer within the residence;

c. Procedures for involuntary discharge;

d. Procedures for advanced directives;

e. Grievance procedures;

f. Availability of nursing services, if any.

4. Policies and procedures on elopement;

5. Procedures to be followed, including those for referral (in those cases where an applicant is found to be ineligible for admission);

D. Prior to admission, the resident and/or legal guardian shall be informed of any charges for services rendered, including charges for special diets, if any.

E. The residence shall develop, maintain, and enforce written policies and procedures for employee documentation of personal care services/activities of daily living (ADLs) rendered to residents.

F. The residence shall maintain a written policy and procedures for assisting a resident in locating and/or obtaining needed services, as appropriate.

G. The residence shall maintain a written policy regarding reportable incidents and events in accordance with § 2.4.17 of this Part.

H. The residence shall develop and maintain a statement of discharge criteria that specifies the conditions under which a resident is considered to be ineligible for continued residency and conditions under which a resident’s advanced rental fees are refunded.

I. Policies and procedures pertaining to the provision of services, and supported by appropriate manuals or reference materials where applicable, shall be established by a designated professional employee or administrator and approved by the licensee. Such policies shall pertain to no less than the following:

1. Residence staffing patterns;

2. Employee responsibility(ies) for the provision of services;

3. A statement that services rendered shall be performed in accordance with all applicable laws and regulations for each service provided;

4. A description of services that are included in the monthly charge(s) and the additional cost(s), if any, for other available services or amenities;

5. Policies/procedures regarding medication management and/or assistance with medication(s);

6. A policy that medical waste, as defined in the Department of Environmental Management’s Medical Waste Regulations (250-RICR-140-15-1) shall be managed in accordance with the provisions of the aforementioned regulations;

7. A policy regarding compliance with food service and Food Code (Part 50-10-1 of this Title) requirements;

8. Disclosure of resident information in accordance with the requirements of R.I. Gen. Laws § 23-3-26;

9. The procedure(s) for resolution of resident grievances, including the inclusion of the name, address, and telephone number of all pertinent resident advocacy groups, the State Ombudsman, and the Department.

10. Quality assurance program.

J. Smoking Policy

1. If the residence permits smoking, it shall have a policy that includes the following:

a. Location of designated smoking area(s) separate from the common area;

b. Prohibition of smoking in any area other than the designated area(s);

c. Adequate ventilation in smoking areas;

d. Assessment (upon admission, quarterly, and when a significant change in function occurs) of all residents that smoke to ensure safe smoking capabilities.

K. Advance Directives

1. The residence shall have written policies and procedures that address advanced directives that shall include, but not be limited to, sufficient instructions for employees to follow in the event of emergencies and the resuscitation of residents.

L. Medical Orders for Life Sustaining Treatment (MOLST)

1. The residence shall have written policies/procedures to accept, update if appropriate, and offer each qualified patient the opportunity to complete a MOLST in accordance with the rules and regulations pertaining to Medical Orders for Life Sustaining Treatment (Part 20-15-4 of this Title).

2.4.14 Residency Requirements

A. Each licensee, or his/her designee, through the assessment and evaluation procedures delineated in these regulations (see § 2.4.16(C) of this Part) shall be responsible to ensure that admission to and residency in an assisted living residence be limited to those individuals who meet the definition of "resident" in accordance with § 2.3(A)(32) of this Part.

B. Disclosure

1. Each assisted living residence shall disclose certain information about the residence to each potential resident, the resident's interested family, and the resident's agent as early as practical in the decision-making process and at least prior to the admission decision being made. The disclosed information shall be in print format and shall include at a minimum:

a. Identification of the residence and its owner and operator;

b. Level of license and an explanation of each level of licensure;

c. Admission and discharge criteria;

d. Services available;

e. Financial terms to include all fees and deposits, including any first month rental arrangements, and the residence's policy regarding notification to tenants of increases in fees, rates, services and deposits;

f. Terms of the residency agreement, including the process used in the event that a resident can no longer afford the cost of care being provided.

g. The names, addresses, and telephone numbers of: the Department; the Medicaid Fraud and Patient Abuse Unit of the Department of Attorney General; the state ombudsperson, and local police offices.

C. Residency Agreement or Contract

1. Pursuant to R.I. Gen. Laws § 23-17.4-16, prior to exchange of any funds and prior to admission, the residence shall execute a residency agreement or contract, signed by both the residence and the resident, that defines the services the residence will provide and the financial agreements between the residence and the resident or the resident's representative.

a. Any advanced deposit, application fee, or other pre-admission payment shall be subject to a signed document explaining fully the terms of the payment.

b. In cases of emergency placement, the residency agreement or contract shall be executed within five (5) working days of admissions.

2. The residency agreement or contract shall include (or reference other documents that include) no less than the following items:

a. Resident's rights;

b. Admission criteria;

c. Discharge criteria;

d. Discharge policies;

e. Description of the unit to be rented by the resident;

f. Description of shared space and facilities;

g. Services to be provided;

h. Services that can be arranged;

i. Financial terms between resident and residence;

(1) Basic rates;

(2) Extra charges at signing;

(3) Extra charges that may apply in the future;

(4) Deposits and advanced fees;

(5) Rate increase policy.

j. Special care provisions (as applicable);

k. Resident's responsibilities and house rules;

l. Initial and on-going assessment and service plan;

m. Grievance procedure.

D. The minimum prior notification time for changes in rates, fees, service charges, or any other payments required by the residence shall be thirty (30) days written notice to the resident.

2.4.15 Resident Records

A. Each residence shall, at a minimum, maintain the following information for each resident:

1. The resident's name;

2. The resident's last address;

3. The name of the person or agency referring the resident to the home;

4. The name, specialty (if any), telephone number, and emergency telephone number of each physician who is currently treating the resident;

5. The date the resident began residing in the home;

6. A list of medications taken by the resident, including dosage, and specific records of medication administration as required by the Department;

a. In residences licensed at the M2 level, if a resident refuses to provide the information cited in § 2.4.15(A)(6) of this Part, this fact shall be documented in the resident’s service agreement.

7. Written acknowledgments that the resident has signed and received copies of the rights as provided in R.I. Gen. Laws § 23-17.4-16;

8. Information about any specific health problems of the resident, which may be useful in a medical emergency, including diagnostic and/or therapeutic orders;

9. A record of personal property and funds which the resident has entrusted to the residence;

10. The name, address, and telephone number of a person identified by the resident who should be contacted in the event of an emergency or death of the resident and the name, address, and telephone number of the legal guardian;

11. Any other health-related emergency, or pertinent information which the resident requests the residence to keep on record;

12. A copy of the initial and periodic assessments described in § 2.4.16 of this Part;

13. A copy of the service plan and nurse review as described in § 2.4.16 of this Part;

14. A copy of the residency agreement as described in § 2.4.14(C) of this Part.

B. Entries in the resident’s record relating to treatment, medication and diagnostic tests shall be made by the responsible persons at the time of administration and/or service. Only physicians shall enter or authenticate medical opinions or judgment.

1. Detailed descriptions of all pressure ulcers, or other skin lesions, shall be recorded in the resident's record.

C. At time of discharge, a discharge summary, summarizing the resident's stay, shall be completed promptly and signed by the residence’s administrator or registered nurse.

D. Resident 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 record.

E. Confidentiality of resident 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 residence 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.

F. Such information shall be contained in record formats appropriate to the efficient and effective delivery of resident services and accessible for review upon request by the licensure agency or other appropriate health oversight agency.

G. The licensee shall retain resident records for five (5) years from the date of discharge in accordance with the provisions of R.I. Gen. Laws § 23-3-26.

H. Statement of Resident's Rights

1. In accordance with R.I. Gen. Laws § 23-17.4-16.1, each resident and/or legal guardian shall be given a written statement of the resident’s rights and responsibilities in the residence that shall be signed by the resident and/or guardian attesting to his/her comprehension of these rights and responsibilities as explained by the employee who shall witness the resident’s signature. A copy of the signed document shall also be placed in the resident’s record.

2.4.16 Resident Assessments and Service Plans

A. Prior to the admission of a resident, or the signing of a residency agreement with a resident, the administrator shall have a comprehensive assessment of the resident's health, physical, social, functional, activity, and cognitive needs and preferences conducted and signed by a registered nurse.

B. This assessment shall be used to determine if the resident's needs and preferences can be met by the assisted living residence within the range of services offered by the residence at its licensure level. The conclusions shall be shared with the resident or the resident's representative. If a reasonable accommodation can enable a resident to live in an assisted living residence, the nature of that accommodation and a plan for implementation or reason for denial should be included in the assessment. Provided, however, any reasonable accommodation provided to a resident shall be provided within the range of services offered by the residence at its licensure level.

1. As part of the initial resident admission and assessment process, the residence 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.

C. The Department-approved assessment form, or such other assessment form as approved by the Department, shall be utilized in completing the assessment on each resident who is admitted to the residence. (Approved Department form is available for downloading online at http://health.ri.gov/forms/assessment/AssistedLivingResident.pdf).

1. Assisted living residences not intending to use the Department’s assessment form shall submit their proposed assessment forms with a cover letter of intent to the Center for Health Facilities Regulation as specified in § 2.4.6(A) of this Part.

2. All assessment forms shall report information appropriate to determine compatibility and compliance with the residency criteria, and shall indicate that the resident’s needs can be met by the assisted living residence within its licensure level, and shall gather information appropriate for the development of an individualized service plan.

a. The assessment form shall be designed to demonstrate compliance with the assisted living residence’s criteria for residency.

b. The assessment form shall also be designed to demonstrate that the assisted living residence can meet the resident’s needs and preferences.

3. The assessment form shall also be designed to provide information appropriate for the development of an individualized service plan in accordance with § 2.4.16(G)(1) of this Part.

D. The assessment shall be reviewed and at intervals not to exceed twelve (12) months and each time a resident's condition changes significantly.

E. In the event a resident has an admission to a health care facility and is scheduled to return to the residence without a significant change in status, then the assessment shall be updated within five (5) working days of readmission.

1. In case of an emergency admission, the required assessment shall take place within five (5) working days and shall include the following:

a. An immediate admission necessitated by natural disaster, crisis, or threat to public safety at another licensed assisted living residence, independent living situation, community residential facility, or private residence;

b. An immediate admission necessitated by the unanticipated incapacitation of the primary caregiver of the person to be admitted;

c. Conditions or circumstances warranting emergency admission and as approved by Center for Health Facilities Regulation staff within forty-eight (48) hours.

F. Nurse Review

1. Nurse review is necessary for all levels of licensure.

a. A registered nurse shall visit the residence at least once every thirty (30) days except as provided in § 2.4.16(F)(1)(b) of this Part and shall complete a review to include the following:

(1) Monitor the medication regimen for all residents;

(2) Review any new physician orders and evaluate the health status of all residents by identifying symptoms of illness and/or changes in mental/physical health status;

(3) Evaluate the appropriateness of placement for each resident;

(4) Make any necessary recommendations to the administrator;

(5) Follow up on previous recommendations;

(6) Provide a signed, written report in the residence documenting:

(AA) Date and time of assessment;

(BB) Recommendations for follow-up;

(CC) Progress on previous recommendations;

(DD) Verification that the medication listed by the pharmacist on the mediset, blister pack or medication container is current with physician orders (M-1 level only);

(EE) Physical assessment identifying symptoms of illness and/or changes in mental or physical health status and appropriateness of placement;

(FF) Such reports shall be on file at the residence.

(7) Complete the quarterly evaluation of the residence’s registered medication aide(s) administration of medication. (Approved Department form is available for downloading online).

b. In those residences that have one or more licensed registered nurses (i.e., at least one full-time equivalent equal to thirty-five (35) hours) on-site, the nurse review shall be completed at least once every ninety (90) days.

G. Service Plans

1. Within a reasonable time after move-in, not to exceed seven (7) days, the Administrator shall be responsible for the development of a written service plan based on the initial assessment. The service plan shall include at least:

a. The services and interventions needed, including all services provided by outside healthcare agencies (e.g., home nursing care, hospice);

b. Description, frequency, duration relating to the service or intervention, including personal assistance, medication, special diets, recreational activities, and other similar services rendered;

c. Party responsible for arranging and/or providing the service; and

d. The resident’s requested and/or therapeutically needed recreational and social activities.

2. The service plan shall be developed by a registered nurse and/or the certified assisted living residence administrator, and shall be signed, approved, and dated by both parties.

3. The service plan shall be reviewed by both parties at intervals not to exceed twelve (12) months and each time a resident's condition changes significantly and all changes shall be acknowledged in writing by both parties.

4. A copy of the service plan shall be placed in the resident's record.

2.4.17 Reporting Requirements

A. The person responsible for the operation of the residence shall promptly notify the next of kin as instructed or other responsible person designated by the resident or guardian of any illness, injury or death of a resident.

B. Accidents, incidents, and medication errors resulting in out-of-residence emergency medical services resulting in a hospital admission of any resident shall be reported to the Center for Health Facilities Regulation in writing, via facsimile or electronic transmission to [email protected] by the end of the next working day. A copy of each report shall be retained by the residence for review during subsequent inspections by the Department.

C. The death of any resident of an assisted living residence occurring on the premises within twenty-four (24) hours of assuming residency shall be reported to the Office of the State Medical Examiners and the Center for Health Facilities Regulation. Also, all deaths occurring in the residence which are sudden or unexpected, suspicious or unnatural, the result of trauma, remote or otherwise, or when unattended by a physician or are otherwise reportable in accordance with the provisions of R.I. Gen. Laws Chapter 23-4 shall be reported to the State Medical Examiner’s Office and the Center for Health Facilities Regulation.

D. Any employee of an assisted living residence who has reasonable cause to believe that a resident has been abused, exploited, neglected, or mistreated shall within twenty-four (24) hours of the receipt of said information, transfer such to the Director and to the Office of the 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, said agent shall be required to meet the above reporting requirements. The residence shall establish a written policy or procedure for reporting abused, exploited or neglected residents that complies with the provisions of this section. The report may be submitted by telephone but shall be followed up in writing.

1. Upon receipt of such information or allegation, the Director shall forthwith conduct such investigation as may be necessary and submit a report of findings of the investigation(s) to the Attorney General of the State of Rhode Island.

E. Unscheduled implementation of the residence’s fire, evacuation, and/or disaster plan shall be reported immediately via telephone, but shall be followed up in writing, on forms supplied by the Department, by the end of the next working day.

F. All reports, as required by these regulations, shall be provided to the Department in writing via facsimile or electronic transmission to [email protected] on forms supplied by the Department. A copy of each report shall be retained by the residence for review during subsequent inspections by the Department.

G. The residence shall maintain evidence that all reportable incidents have been thoroughly investigated and that actions have been taken to prevent further incidents while the investigation is in progress. Appropriate corrective action shall be taken, as necessary. The results of said investigation shall be reported to the Department, within five (5) business days, on forms supplied by the Department.

H. Reporting requirements, pursuant to R.I. Gen. Laws Chapter 23-17.8 must be posted in the residence in plain view of all residents and employees.

I. The administrator shall notify the Department in writing of any emergency admissions in accordance with § 2.4.16(E)(1)(c) of this Part within forty-eight (48) hours.

J. The administrator shall be responsible for the investigation and documentation of incidents that involve residence operations, resident services, or related event(s) that directly or indirectly jeopardize the health and safety of residents, or that results in a resident injury that requires assessment by a licensed practitioner or where the injury was not witnessed or explained by the resident.

1. Documentation of incidents shall include:

a. Date and time of incident;

b. Reporter’s name;

c. Name of resident(s) involved or affected;

d. Any injury(ies) to resident(s); and

e. Action taken by the residence in response to the incident.

2. Such documentation shall be made available for review during a survey inspection by the licensing agency Department or as required by any health oversight agency.

3. Such documentation shall be retained by the licensee for no less than five (5) years after the event or incident.

2.4.18 Rights of Residents

A. Every assisted living residence for adults licensed pursuant to these regulations shall observe the standards stated in R.I. Gen. Laws § 23-17.4-16, “Rights of Residents” and such other appropriate standards as may be prescribed in rules and regulations promulgated by the Department with respect to each resident of the residence.

B. For purposes of the following standards stated in §§ 2.4.18(B)(1) through (7) of this Part the term "resident" shall also mean the resident's agent as designated in writing or legal guardian.

1. Upon request have access to all records pertaining to the resident, including clinical records, within the next business day or immediately in emergency situations;

2. Upon admission and during the resident's stay be fully informed in a language the resident understands, of all resident rights and rules governing resident conduct and responsibilities;

a. Each resident shall receive a copy of their rights.

b. Each resident shall acknowledge receipt in writing; and

c. Each resident shall be informed promptly of any changes.

3. Be informed in writing, prior to, or at the time of admission or at the signing of a residential contract or agreement of:

a. The scope of the services available through the residence's service program, including health services, and of all related fees and charges, including charges not covered either under federal and/or state programs by other third party payers or by the residence's basic rate;

b. The residence's policies regarding overdue payment including notice provisions and a schedule for late fee charges;

c. The residence's policy regarding acceptance of state and federal government reimbursement for care in the residence both at time of admission and during the course of residency if the resident depletes his or her own private resources;

d. The residence's criteria for occupancy and termination of residency agreements;

e. The residence's capacity to serve residents with physical and cognitive impairments;

f. Support any health services that the residence includes in its service package or will make appropriate arrangements to provide these services;

4. Upon provision of at least thirty (30) days notice, if a resident chooses to leave a residence, the resident shall be refunded any advanced payment made provided that the resident is current in all payments;

5. The residence can discharge a resident only for the following reasons and within the following guidelines:

a. Except in life-threatening emergencies and for nonpayment of fees and costs, the residence gives thirty (30) days' advance written notice of termination of residency agreement with a statement containing the reason, the effective date of termination, the resident's right to an appeal under state law, and the name/address of the State Ombudsperson’s office;

b. If resident does not meet the requirements for residency criteria stated in the residency agreement or requirements of state or local laws or regulations;

c. If resident is a danger to self or the welfare of others; and the residence has attempted to make a reasonable accommodation without success to address resident behavior in ways that would make termination of residency agreement or change unnecessary; which would be documented in the resident's records;

d. For failure to pay all fees and costs stated in the contract, resulting in bills more than thirty (30) days outstanding. A resident who has been given notice to vacate for nonpayment of rent has the right to retain possession of the premises, up to any time prior to eviction from the premises, by tendering to the provider the entire amount of fees for services, rent, interest, and costs then due. The provider may impose reasonable late fees for overdue payment; provided that the resident has received due notice of such charges in accordance with the residence's policies. Chronic and repeated failure to pay rent is a violation of the lease covenant. However the residence must make reasonable efforts to accommodate temporary financial hardship and provide information on government or private subsidies available that may be available to help with costs; and

e. The residence makes a good faith effort to counsel the resident if the resident shows indications of no longer meeting residence criteria or if service with a termination notice is anticipated;

6. To be able to share a room or unit with a spouse or other consenting resident of the residence in accordance with terms of the resident contract;

7. To live in a safe and clean environment.

C. In addition to the standards stated in R.I. Gen. Laws § 23-17.4-16, residents are entitled to the following:

1. Receive dental services from a dentist of his/her choice;

2. Each resident shall be given, in writing, the names, addresses, and telephone numbers of: the Department; the Medicaid Fraud and Patient Abuse Unit of the Department of Attorney General; the State Ombudsperson; and local police offices.

D. The residence must:

1. Implement written policies and procedures to ensure that all residence employees are aware of and protect the resident's rights contained in these regulations;

2. Have prominently displayed a posting of the most recent state licensing survey of the assisted living residence; and

3. Provide each resident or his or her representative upon admission, a copy of the provisions of § 2.4.18 of this Part and shall display in a conspicuous place on the premises a copy of the "Rights of Residents."

2.4.19 Accessibility to the Residence and Residents

Access to assisted living residences for adults and its residents by individuals other than relatives and friends of the residents shall be pursuant to R.I. Gen. Laws § 23-17.4-11.

2.4.20 Illness and Emergencies

A. Each residence shall have written procedures for residents in the event of temporary illness and emergencies which shall include procedures for the evacuation of the premises.

B. Residents shall not be restricted from obtaining community health services at any time or when confined to the residence for a temporary illness.

C. Reporting of Communicable Diseases

1. Each residence shall report promptly to the Center for Acute Infectious Diseases Epidemiology (IDE), cases of communicable diseases designated as "reportable diseases" when such cases are diagnosed in the residence in accordance with rules and regulations pertaining to the "Rules and Regulations Pertaining to Counseling, Testing, Reporting and Confidentiality".

2. When infectious diseases present a potential hazard to residents or personnel, these shall be reported to the Center for Acute Infectious Diseases Epidemiology (IDE) even if not designated as "reportable diseases."

3. When outbreaks of food-borne illness are suspected, such occurrences shall be reported immediately to the Center for Acute Infectious Diseases Epidemiology (IDE) or to the Center for Food Protection.

4. Residences 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.

5. Infection Control

Infection control provisions shall be established for the mutual protection of residents, employees, and the public. The residence shall be responsible for no less than the following:

a. Establishing and maintaining a residence-specific infection prevention program;

b. Establishing policies governing the admission and isolation of residents with known or suspected infectious diseases;

c. Developing, evaluating and revising on a continuing basis infection control policies, procedures and techniques for all appropriate areas of the residence;

d. Developing and implementing protocols for:

(1) Discharge planning to home that include full instructions to the family or caregivers regarding necessary infection control measures; and

(2) Hospital and/or nursing facility 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;

6. Resident Immunization Policies/Practices

Except as provided in § 2.4.20(C)(6)(e) of this Part, every residence in Rhode Island shall request that residents be immunized for influenza virus and pneumococcal disease. Influenza, pneumococcal, and other adult vaccination policies and protocols shall be developed and implemented by the residence and shall contain no less than the following provisions:

a. Notice to Resident. Upon admission, the residence shall notify the resident and legal guardian of the immunization requirements and request that the resident agree to be immunized against influenza virus and pneumococcal disease.

b. Records and Immunizations. Every residence shall document the annual immunization against influenza virus and immunization against pneumococcal disease for each resident which includes written evidence from a health care provider indicating the date and location the vaccine was administered.

c. Other Immunizations. An individual who becomes a resident shall have his status for influenza and pneumococcal immunization determined by the residence, and, if found to be deficient, the residence shall assist the resident in obtaining the necessary immunizations.

d. Vaccinations must be provided in accordance with “General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP),” incorporated above at § 2.2(C) of this Part.

e. Exceptions. No resident shall be required to receive either the influenza or pneumococcal vaccine if any of the following apply:

(1) The vaccine is contraindicated;

(2) It is against his/her religious beliefs; or

(3) The resident or the resident's legal guardian refuses the vaccine after being fully informed of the health risks of such action.

2.4.21 Dietetic Services

A. Residents shall be provided three (3) balanced, varied meals each day (refer to Dietary Reference Intakes: The Essential Guide to Nutrient Requirements incorporated above at § 2.2(A) of this Part).

B. Food shall be served on dinnerware of good quality, such as ceramic, plastic or other materials that are durable.

C. The food service in each residence shall comply with the appropriate requirements of R.I. Gen. Laws Chapters 21-27 and 21-31, Rhode Island Food Code (Part 50-10-1 of this Title), and such other applicable statutory or regulatory provisions.

D. In the event of any construction, addition or alteration, the residence shall comply with the requirements of R.I. Gen. Laws § 23-1-31.

E. Weekly menus shall be posted in each residence and followed accordingly.

F. Residences must provide residents with a diet appropriate to their medical regime.

G. All food services shall be conducted in accordance with the rules and regulations pertaining to Certification of Managers in Food Safety (Part 50-10-2 of this Title) that include but are not limited to the following provisions:

1. Each residence where potentially hazardous foods are prepared shall employ at least one (1) full-time, on-site manager certified in food safety who is at least eighteen (18) years of age.

2. Residences that primarily serve the elderly and individuals with diminished immune systems shall have a manager certified in food safety present during preparation of all hot potentially hazardous foods.

3. Residences that have a licensed capacity of twenty-six (26) or more residents and that employ ten (10) or more full-time equivalent employees directly involved in food preparation shall employ at least two (2) full time, on-site managers certified in food safety.

4. Residences that have a licensed capacity of twenty-five (25) or fewer residents and that employ five (5) or fewer full-time equivalent employees involved in preparation and serving of food, shall only be required to employ one (1) full time manager certified in food safety.

5. Once a manager certified in food safety terminates employment, establishments shall have sixty (60) days to employ a new manager certified in food safety, or have an individual enrolled in a Center for Food Protection approved food manager certification program in food safety. However, said time period may be extended by the Center for Food Protection.

a. Residences that have a licensed capacity of twenty-five (25) or fewer residents and that employ five (5) or fewer full-time equivalent employees involved in preparation and serving of food shall only have fifteen (15) days to employ a new manager certified in food safety. However, said time period may be extended by the Center for Food Protection.

6. Department certificates for managers certified in food safety shall be prominently posted in the residence next to the license to operate. The certificate shall be removed when the individual is no longer employed by the residence.

7. No person shall use the title "Manager Certified in Food Safety," or in any way represent himself as a manager certified in food safety unless they hold a current certificate pursuant to the rules and regulations pertaining to Certification of Managers in Food Safety (Part 50-10-2 of this Title).

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, incorporated above at § 2.2(A) of this Part, and to provide for a variety of foods, adjusted for seasonal changes, and reflecting the dietary preferences of residents.

1. Menus shall indicate nourishments available 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.

2.4.22 Housekeeping

The residence shall maintain a comfortable, safe, clean, sanitary and orderly environment, free of litter, rubbish and offensive odors.

2.4.23 Laundry Services

Each residence shall make provisions for the cleaning of personal laundry of residents and all linens and other washable goods either directly or through other suitable arrangement.

2.4.24 Medication Services

A. Medication Services

1. For M1 and M2 licensure levels, each resident shall have the right to:

a. Retain the services of his/her own personal physician and dentist;

b. Select the pharmacy or pharmacist of his/her choice provided that the pharmacy or pharmacist supplies medications suitably packaged for the residence's program;

c. Refuse any or all medications;

d. Retain possession and control of his/her medications, provided that such possession and control is deemed safe by the resident, the resident's guardian, if appropriate, and the administrator or his/her designee in consultation with the resident's physician(s).

2. For M1 and M2 licensure levels, the residence shall have the right:

a. To inform family, guardian, physician, or other party designated by the resident or guardian if a resident has refused medication(s).

b. Not to accept, and/or to evict a resident who refuses assistance with medications if the residence reasonably feels that the resident cannot safely possess and control medications without danger to self or others, in accordance with the requirements of the Resident’s Rights statement.

3. Each residence shall provide medication services only in accordance with the appropriate level of licensure for which the residence is licensed, which shall be as follows:

a. For assisted living residences licensed at the M2 Level, assistance with self- administration by unlicensed employees means that the residence shall only be responsible for reminding residents to take medications, and:

(1) The resident or guardian must provide written authorization for the residence to provide assistance with the self-administration of medications;

(2) The residence must provide, in writing, a description of services provided by the residence to each physician prescribing for a resident, including limitations on services;

(3) Employees may only remind the resident and observe the self-administration of medication;

(4) The resident shall not require nursing assessment of health status before receiving the medication, nor nursing assessment of the therapeutic or side effects after the medication is taken;

(5) Except as provided in § 2.4.24(A)(3)(a)(7) of this Part, the medication shall be in the original pharmacy-dispensed container with proper label and directions attached;

(6) Unlicensed employees shall not monitor health indicators, make medication decisions, adjust medications or provide other medical or nursing decisions;

(7) For residents capable of self-administration of medication but who wish to ask assisted living residence employees to use a medi-set (pre-poured packaging distribution system), only registered medication aide, licensed nurse, or pharmacist shall organize the medications for up to one (1) week;

(8) All medication in the residence, regardless of whether controlled by employees or by the resident, shall be stored securely. All medications shall be stored in a manner to prevent spoilage, dosage errors, administration errors or inappropriate access by other residents, visitors, or unauthorized employees. Provisions for safe storage may include lockable containers, secure spaces, or lockable units, as appropriate to the residence and the resident population.

(9) There shall be documented policies or procedures regarding medication disposal and inventory procedures in the policies and procedures manual.

(10) Each person assisting residents with self-administration of medications shall:

(AA) Be an employee of the residence;

(BB) Be literate in English; and

(CC) Receive orientation, instruction and on-the-job training regarding relevant policies and procedures; or

(DD) Be a licensed nurse.

(EE) M2 level facilities may limit record keeping for residents who retain possession and control of medications to the requirements of § 2.4.15(A)(6) of this Part.

b. For assisted living residences licensed at the M1 level, licensed employees (registered medication aides, registered nurses, licensed practical nurses) may administer oral or topical drugs and monitor health indicators. However, schedule II medications shall only be administered by licensed personnel. The physician or nurse supervisor shall conduct and document quarterly evaluations of the registered medication aides who are administering drugs and place a copy in the employee's personnel record.

B. Administration of Medications

1. Residences licensed at the M1 level may administer medications to residents including, but not limited to, removing medication containers from storage, assisting with the removal of a medication from a container for residents with disability which prevents independence in this act, and/or administering the medication directly to the resident.

a. The resident or guardian must provide written authorization for the residence to provide administration of medications.

b. Medications shall be administered in accordance with written orders of a physician. The residence must provide in writing, a description of services provided by the residence to each physician, including limitations on service.

c. All medications must be checked against a physician's orders by a licensed nurse, or pharmacist.

d. The resident must be identified prior to administration of any medication.

e. The medication must be in the original pharmacy-dispensed container with proper label and directions attached and be administered in accordance with such label.

f. Injectable medications, including but not limited to insulin, which cannot be self- administered by the resident, must be administered by a licensed nurse.

g. There shall be written a policy/procedure for the disposal of hypodermic needles, syringes and other such instruments that is in compliance with rules and regulations governing Hypodermic Needles, Syringes & Other Such Instruments (Part 20-15-6 of this Title).

(1) The legal destruction of hypodermic needles, syringes or other such instruments is the responsibility of the last entitled or authorized possessor.

(AA) All personnel or residents legally authorized to use disposal syringes and needles, shall destroy them after one (1) use.

(BB) Excess and undesired needles, syringes and other such instruments shall be stored in impervious, rigid, puncture-resistant container for disposal. Intact needles shall be placed directly into the collection containers.

(CC) Personnel handling disposal waste materials such as needles, syringes, and other such instruments may treat and destroy such waste by a DEM-approved alternative treatment/destruction technology or prepare the regulated medical waste for off-site transport by a DEM-permitted medical waste transporter.

h. Individual medication records must be retained for each resident to whom medications are being administered and each dose administered to the resident must be properly recorded.

i. Any medication administered by the residence and refused by a resident shall be documented and reported, as appropriate.

j. Medications shall be stored securely and in such a manner to prevent spoilage, dosage errors, administration errors, and/or inappropriate access. Provisions for safe storage may include lockable containers, secure spaces, or lockable units, as appropriate to the residence and the resident population.

k. All medication in the residence, regardless of whether controlled by employees or by the resident, shall be stored securely as stated in § 2.4.24(A)(3)(a)(8) of this Part.

l. All centrally stored medications shall be maintained in accordance with manufacturer’s labeling and administered by authorized personnel.

2. For M1 and M2 licensure levels, unused or discontinued prescription medications that are left with a residence shall be inventoried and disposed of in accordance with the following requirements:

a. Disposal of Controlled Substances

(1) M1 residences that are lawfully in possession of excess and undesired controlled substances that are centrally stored shall inventory and dispose of all such controlled substances in accordance with all applicable federal, state, and local laws and regulations.

(2) Only centrally stored medications in M1 residences may be disposed of in the following manner:

(AA) The residence’s registered nurse and either another registered nurse, a licensed practical nurse, or the residence’s administrator may carry out flushing destruction activity, and appropriate records shall be maintained at the residence for two (2) years, as permitted by state and local laws and regulations. The Director is authorized to enter any premises and inspect any and all aspects of the disposal process and related records.

b. Disposal of All Other Legend Drugs (i.e., Non-Controlled Substances)

(1) All other legend drugs (i.e., those not classified as controlled substances) shall be the responsibility of the resident or authorized personnel to dispose of as provided in rules and regulations governing the "Disposal of Legend Drugs":

(AA) Legend drugs may be disposed of as solid waste provided that all of the following conditions are met:

(i) the legend drugs are rendered unrecognizable;

(ii) the legend drug would not pose a threat to the public or to the environment; and

(iii) the legend drugs cannot be recycled; or

(BB) The legend drugs may be disposed of as regulated medical waste through the use of an entity holding a regulated medical waste transporter permit issued pursuant to the requirements and in compliance with the rules and regulations Governing the Generation, Transportation, Storage, Treatment, Management and Disposal of Regulated Medical Waste in Rhode Island.

3. Ordering medications

a. In M1 and M2 facilities, when assistance is needed, the certified administrator, or his/her qualified designee, shall assist with ordering medications. Assistance shall include coordinating prescriptions and delivery of medications, reorders of prescriptions, and receiving deliveries.

2.4.25 Recreational and Other Services

A. Reasonable recreational and social activities and/or services shall be offered to each resident 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;

4. Harmonize with each resident's needs.

B. The residence shall post a calendar or schedule of social and recreational events offered to the residents and shall keep a record of the events that were actually presented to the residents. Said calendars and records shall be retained for at least one (1) year by the residence.

C. Personal assistance shall be provided as necessary, pursuant to the provisions of § 2.3(A)(29) of this Part and shall consist of activities such as bathing, oral hygiene, fingernail care, shampooing, shaving, dressing or assistance with ambulation or nutrition and hydration.

2.4.26 New Construction, Modification, Additions, or Room Conversions

All new construction, modification, additions, or room conversions of an existing residence shall be subject to the provisions of Fire Safety Code-General Provisions (R.I. Gen. Laws Chapter 23-28.1), State Building Code (R.I. Gen. Laws Chapter 23-27.3), ANSI A117.1 - 2003 Accessible and Usable Buildings and Facilities (incorporated above at § 2.2(B) of this Part), Americans with Disabilities Act (42 U.S.C. §§ 12101 through 12213), and such other applicable state and local laws, codes and regulations as may be applicable. Where there is a difference between codes, the code having the more stringent or higher standard shall apply.

2.4.27 General Provisions

A. Fire Code and Structural Requirements

1. Existing facilities shall be constructed, equipped and maintained to protect the safety and well- being of residents, and shall provide a comfortable, sanitary environment, and shall furthermore comply with the applicable requirements of the Fire Safety Code-General Provisions (R.I. Gen. Laws Chapter 23-28.1), as determined by the State Fire Marshal and the regulations.

a. Pursuant to R.I. Gen. Laws § 23-17.4-6, a residence with fire code deficiencies may be granted a license which may be renewed subject to the submission of a plan of correction acceptable to the State Fire Marshal and provided the nature of the deficiencies are such that they do not jeopardize the health, safety, and welfare of the residents.

b. A residence with residents who are blind, deaf, and physically disabled shall be subject to the applicable requirements of ANSI A117.1 - 2003 Accessible and Usable Buildings and Facilities (incorporated above at § 2.2(B) of this Part), and any other provisions that may be required by these regulations.

c. Resident occupancy shall be permitted only in those areas where building design or structural limitations do not prevent, delay or reduce a resident from exercising self- preservation in an emergency.

d. A residence that elects to comply with a higher Life Safety Code (F1) and is so approved by the State Fire Marshal and meets the Department's requirements for the appropriate level of licensure may admit residents not capable of self-preservation.

e. Facilities must have an annual inspection to assess compliance with the Fire Safety Code. The inspection shall be conducted under the authority of the State Fire Marshal.

(1) Documentation of the State Fire Marshal inspection required under § 2.4.27(A)(1)(e) of this Part must be submitted with the application for renewal of licensure. The documentation must reflect compliance with the Fire Safety Code or be in accordance with § 2.4.27 (A)(1)(a) of this Part.

B. Assisted living residences shall not be utilized for any other purposes, unless such purposes are compatible with the objectives and the nature of an assisted living residence and are approved by the Department.

C. All rooms utilized by resident(s) shall have proper ventilation and shall have an outside opening with satisfactory screening.

D. All steps, stairs and corridors shall be suitably lighted, both day and night. Stairs used by residents shall have banisters, hand rails or other types of support. All stair treads shall be well maintained to prevent hazards.

E. Requirements for heat relief are pursuant to R.I. Gen. Laws § 23-17.4-16.4.

2.4.28 Residents Rooms, Toilets and Bathing Fixtures

A. The bedroom of residents shall be designed and equipped with suitable furnishings for the safety, comfort and privacy of each resident and with no more than two (2) beds per room.

1. Single rooms shall be no less than one hundred (100) square feet in area and no less than eight (8) feet wide, exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules.

2. Double bedrooms shall be no less than one hundred sixty (160) square feet in area and no less than ten (10) feet wide, exclusive of toilet rooms, closets, lockers, wardrobes, alcoves or vestibules.

B. Provisions shall be made for an area within the resident's bedroom and/or residence to be under lock for the safe keeping of personal possessions.

C. Each bedroom shall have a window which can be easily opened. The window sill shall not be higher than three (3) feet above the floor and shall be above ground level.

D. Comfortable temperature levels shall be maintained in all parts of the residence occupied by residents with a centralized heating system to maintain a minimum of seventy degrees Fahrenheit (70° F) during the coldest periods.

E. There shall be no less than one (1) bath per ten (10) beds and one (1) toilet per eight (8) beds or fraction thereof on each floor where residents rooms are located and which are not otherwise serviced by bathing facilities within the resident's room.

1. Policies and procedures shall be in place to ensure resident comfort and safety regarding water temperature at each site in the residence where residents shower or bathe. Provided, however, such policies/procedures shall state that in resident areas hot water temperatures shall not be less than one hundred degrees Fahrenheit (100°F) nor exceed one hundred eighteen degrees Fahrenheit (118° F). Thermometers shall be provided in resident areas to check water temperature periodically at each site where residents bathe or shower.

2.4.29 Dining and Living Areas

A. Each residence shall provide one (1) or more clear, orderly and appropriately furnished and easily accessible room of adequate size to include all residents for resident dining and activity, which shall be appropriately lighted.

1. If a multi-purpose room is used, there must be sufficient space to accommodate all residents for dining and activities and to prevent interference between activities.

2.4.30 Safety Requirements

A. Halls and exit ways shall be free from all encumbrances and/or impediments.

B. All locks on bedrooms shall be operable by a master key, under the control of the person in charge in accordance with §§ 2.4.12(B) and (C) of this Part.

C. Every closet door latch shall be a type that cannot be locked from the inside.

D. Every bathroom door shall be designed to permit the opening of the locked door from outside in an emergency.

E. There shall be no portable cooking equipment (employing flame, gasoline, kerosene or exposed electrical heating elements) used in residents' rooms.

F. Portable space heaters shall not be permitted.

G. Proper safeguards shall be taken at all times against the fire hazards involved in smoking.

H. A telephone shall be easily accessible to residents in the event of emergencies. (Pay phones shall not be acceptable substitutes). The telephone number of the local fire department and law enforcement agencies serving the residence shall be posted by each telephone.

I. Each residence shall develop and maintain a written plan and procedure for the evacuation of the premises in case of fire or other emergency, based on F1 / F2 licensure requirements, Fire Safety Code-General Provisions (R.I. Gen. Laws Chapter 23-28.1) requirements.

1. Emergency steps of action shall be clearly outlined and posted in conspicuous locations throughout the residence.

2. Drills simulating fire emergencies, testing the effectiveness of the fire evacuation plan shall be conducted at least six (6) times per year on a bimonthly basis with a minimum of two (2) drills conducted during the night when residents are sleeping with documentation of observed ability of residents to carry out evacuation procedures. At least fifty percent (50%) of these drills shall be obstructed drills, as defined in Fire Safety Code-General Provisions (R.I. Gen. Laws Chapter 23-28.1).

3. The drills shall be permitted to be announced in advance to the residents. The drills shall involve the actual evacuation of all residents to an assembly point as specified in the emergency plan and shall provide residents with experience in egressing through all exits and means of escape required by the Fire Safety Code-General Provisions (R.I. Gen. Laws Chapter 23-28.1). Exits and means of escape not used in any fire drill shall not be credited in meeting the requirements of the Fire Safety Code-General Provisions (R.I. Gen. Laws Chapter 23-28.1).

a. Documentation of fire drills shall be maintained and shall include no less than the following information:

(1) Name of the person conducting the drill;

(2) Date and time of the drill;

(3) Amount of time taken to evacuate the building or unit;

(4) Type of drill (i.e., obstructed or unobstructed);

(5) Record of problems encountered and steps taken to rectify them;

(6) Employee observation of each resident’s ability to carry out evacuation procedures.

4. Residents shall be instructed in all alternative methods of escape since the primary exit may be unusable due to fire and/or smoke. Such instruction shall be documented in the record described in § 2.4.30(I)(3)(a) of this Part.

5. Each new resident shall be oriented to the fire drill procedure on admission, with documentation of the orientation placed in the resident’s record.

J. Appropriate fire extinguishers shall be installed on each occupied level and maintained in a usable condition, inspected at specified intervals as stipulated by manufacturers and the State Fire Marshal.

K. Each residence shall develop written emergency plans related to internal and external disasters.

L. Disaster Preparedness

1. Each residence shall develop back-up or contingency plans to address possible internal systems and/or equipment failures.

2.4.31 COVID-19 Practices and Procedures

A. Assisted Living Residents.

1. All assisted living residences shall ensure residents who are not vaccinated are tested at least once every fourteen (14) days during a period in which COVID-19 prevalence rate is greater than or equal to ten (10) cases per one hundred thousand (100,000) people per week, as reported by RIDOH.

2. Upon the identification of residents who test positive for COVID-19, the residence shall take proper actions to prevent the transmission of COVID-19 in accordance with Department guidance.

3. Assisted living residences shall have policies and procedures in place for addressing residents who refuse testing or unable to be tested.

4. The assisted living residence shall document all COVID-19 testing, which documentation shall include at minimum the individual's name, date of test, and test result.

B. Assisted Living Personnel

1. For the purposes of § 2.4.31 of this Part, "personnel" means employees, as well as volunteers, students, trainees, and any individuals, whether paid or unpaid, directly employed by or under contract with the assisted living residence on a part time or full-time basis.

2. All assisted living residences shall ensure personnel who are not vaccinated are tested in accordance with Part 20-15-8 of this Title.

3. Assisted living residences shall ensure that all personnel who are vaccinated are tested in at least once every seven (7) days during a period in which the COVID-19 prevalence rate is greater than or equal to one hundred (100) cases per one hundred thousand (100,000) people per week, as reported by RIDOH.

4. Upon the identification of personnel who test positive for COVID-19, the residence shall take proper actions to prevent the transmission of COVID-19 in accordance with Department guidance.

a. Each assisted living residence shall deny access to any personnel who have not been tested for COVID-19 in accordance with the requirements set forth in § 2.4.31(B)(2) and (3) of this Part.

5. The assisted living residence shall document all COVID-19 testing, which documentation shall include at minimum the individual's name, date of test, and test result.

a. In the event personnel are tested for COVID-19 outside the assisted living residence, the personnel must provide proof of testing to the assisted living residence. The assisted living residence shall have procedures in place to require personnel to submit test results, or proof thereof, immediately upon receipt of the results.

6. The assisted living residence shall develop and implement policies and procedures for ongoing tracking of personnel who are employed outside of the assisted living residence. Tracking shall include the name and location of the establishment and any other pertinent information.

7. In accordance with state and federal guidance, personnel shall not incur any out of pocket expenses (e.g., copays, deductibles) for testing required pursuant to § 2.4.31 of this Part.

a. Assisted living residences must collect and transmit personnel health insurance information to the testing laboratory prior to using any other method of payment for COVID-19 testing.

C. COVID-19 Vaccination Monitoring and Reporting.

1. Each assisted living residence shall ensure the documentation in its internal records of the COVID-19 immunization status of its personnel. With such documentation, each assisted living residence shall additionally maintain documentary proof of COVID-19 vaccination. Documentation of status and proof of vaccination, including month, day, and year of vaccine administration, shall be made available to the Department upon request.

2. Acceptable documentary proof of COVID-19 vaccination shall consist of an official immunization card, health records, and/or paper/electronic documentation of vaccination given.

D. Posting.

1. Each assisted living residence shall post monthly, at a public location within the residence readily accessible to residents and personnel, and on its website as applicable, a report containing detailed, aggregated data pertaining to the COVID-19 vaccination status of its personnel.

2. Such reports shall be created in a manner and format set forth by the Director, and shall include, but not be limited to, the following:

a. The present total number of personnel;

b. The present number of personnel who have received one (1) dose of a multi-dose COVID-19 vaccine;

c. The present number of personnel who are vaccinated;

d. The present percentage of personnel who have received one (1) dose of a multi-dose COVID-19 vaccine; and

e. The present percentage of personnel who are vaccinated.

2.4.32 Variance Procedure

A. The Department may grant a variance either upon its own motion or upon request of the applicant from the provisions of any 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.

B. A request for a variance shall be filed by a high managerial agent of the assisted living residence in writing, and must set forth in detail the basis upon which the request is made including:

1. Identification of the specific regulatory section(s) herein;

2. Alternative actions, processes, or procedures that through the facility’s implementation will facilitate compliance with the specific regulatory intent, and how the Residence will ensure staff awareness and training regarding the variance, when appropriate.

3. A variance period shall not exceed the assisted living residence’s license period. An assisted living residence must request renewal of the variance when it submits its annual license renewal application.

4. Upon the filing of each request for variance with the Department, and within a reasonable time thereafter, the Department 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 residence appeals the denial and held in accordance with the provisions of § 2.4.33 of this Part.

2.4.33 Deficiencies and Plans of Correction

A. The Department shall notify the licensee and the residence's administrator or other legal authority of the residence of violations of individual standards through a notice of deficiencies which shall be forwarded to the residence within fifteen (15) days of inspection of the residence 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.

B. A licensee, or their designee, who receives a notice of deficient practices must submit a plan of correction to the Department within fifteen (15) days of the date of the notice of deficient practices. The plan of correction shall detail any requests for variances as well as document the reasons therefore.

1. An acceptable plan of correction shall include, for each individual standard cited:

a. How the licensee or their designee intends to correct each deficiency and comply with the stated regulation;

b. What measures will be put in place, or what systemic changes will be made to ensure that the deficient practice does not reoccur; and

c. The date the deficiency shall be corrected.

2. The criteria for acceptability shall be whether the submitted plan shall achieve compliance with the Act and these regulations.

3. The plan of correction shall detail any requests for variances in accordance with § 2.4.31 of this Part.

C. The Department will be required to accept or reject the plan of correction submitted by a residence in accordance with §§ 2.4.32(B)(1) and (2) of this Part within fifteen (15) days of receipt of the plan of correction.

D. If the Department rejects the plan of correction, or if the residence does not provide a plan of correction within the fifteen (15) day period stipulated in § 2.4.32(B) of this Part, or if a residence whose plan of correction has been approved by the Department fails to execute its plan within a reasonable time, the Department may invoke the sanctions enumerated in § 2.4.11 of this Part. If the residence is aggrieved by the sanctions of the Department, the residence may appeal the decision and request a hearing in accordance with R.I. Gen. Laws Chapter 42-35.

E. The notice of the hearing to be given by the Department shall comply in all respects with the provisions of R.I. Gen. Laws Chapter 42-35. The hearing shall in all respects comply therein.

2.4.34 Rules Governing Practices and Procedures

All hearings and reviews required by these regulations shall be held in accordance with the provisions of R.I. Gen. Laws Chapter 42-35 and the rules and regulations pertaining to "Rules and Regulations Pertaining to Practices and Procedures Before the Rhode Island Department of Health [R42-35-PP]".

2.4.35 Violations and Sanctions

A. Any person establishing, conducting, managing or operating an assisted living residence without a license pursuant to the provisions of the Act and these regulations shall be liable to the penalty of R.I. Gen. Laws § 23-17.4-14.

B. Any person who obtains access to an assisted living residence or to its residents under false representation shall be subject to the provisions of R.I. Gen. Laws § 23-17.4-12.

C. The penalty for violation of R.I. Gen. Laws § 23-17.4-10 shall be in accordance with R.I. Gen. Laws § 23-17.4-10.2.

2.5.1 Applicability

Any assisted living residence which offers to provide or provides services to residents with Alzheimer disease or other dementia by means of an Alzheimer Dementia/Special Care Unit/Program shall be required to meet all requirements of §§ 2.4 and 2.5 of this Part.

2.5.2 Specific Requirements

A. A residence licensed at the "dementia care" level shall be licensed as an "F1--M1" residence in accordance with the requirements of § 2.4.10(B) of this Part; and

B. Any assisted living residence which offers to provide or provides services to residents with Alzheimer disease or other dementia by means of an Alzheimer Dementia Special Care Unit/Program shall be required to disclose in writing the type of services provided.

C. The disclosure shall be made to the Department and to any person seeking placement in an Alzheimer Dementia Special Care Unit/Program of an assisted living residence.

D. The information disclosed shall explain the additional care that is provided in each of the following areas:

1. Philosophy: The Alzheimer Dementia Special Care Unit's/Program’s written statement of its overall philosophy and mission which reflects the needs of residents afflicted with dementia;

2. Pre-Occupancy, Occupancy, and Termination of Residence: The process and criteria for occupancy, transfer or termination of residency from the unit;

3. Assessment, Service Planning & Implementation: The process used for assessment and establishing the plan of service and its implementation, including the method by which the plan of service evolves and is responsive to changes in condition;

4. Staffing Patterns & Training Ratios: Staff training and continuing education practices;

5. Physical Environment: The physical environment and design features appropriate to support the functioning of cognitively impaired adult residents;

6. Resident Activities: The frequency and types of resident activities;

7. Family Role in Providing Support and Services: The involvement in families and family support programs;

8. Program Costs: The cost of care and any additional fees, and the process used in the event that a resident can no longer afford the cost of care being provided.

E. The Department shall develop a standard disclosure form and shall review the information provided on the disclosure form by the assisted living residence to verify the accuracy of the information reported on it. Any significant changes in the information provided by the assisted living residence shall be reported to the Department at the time the changes are made.

F. Any residence that provides care for residents with Alzheimer disease or other dementia by means of an Alzheimer Dementia Special Care Unit/Program shall maintain written policies and procedures that detail specific services, including admission and discharge criteria, for residents and/or their responsible parties on the Unit/Program.

G. The Alzheimer Dementia Special Care Unit/Program shall operate and provide services to all residents of the unit/program in accordance with the prevailing community standard of care for residents with the particular needs and behaviors with dementia.

H. Staff assigned to provide direct care services to residents of the Alzheimer Dementia Special Care Unit/Program shall be a qualified licensed assisted living staff member as defined in § 2.3(A)(31) of this Part. Notwithstanding this requirement, staff hired before January 1, 2015, that are not qualified licensed assisted living staff members, may continue to provide direct care services to residents residing in existing Alzheimer Dementia Special Care Unit/Programs.

I. The Alzheimer Dementia Special Care Unit/Program shall have on staff, at a minimum, a registered nurse(s) with appropriate training and/or experience with dementia to manage and supervise all resident dementia-related health and behavioral issues. The nurse shall be on-site full-time (minimum of thirty-five (35) hours per week), and shall be available for consultation at all times.

J. Menus for the Alzheimer Dementia Special Care Unit/Program shall be developed under the direction of a nutritionist or registered dietician licensed by the Department.

K. 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, incorporated above at § 2.2(A) of this Part, and to provide for a variety of foods, adjusted for seasonal changes, and reflecting the dietary preferences of residents.

1. Menus shall indicate nourishments available 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.

L. The Alzheimer Dementia Special Care Unit/Program shall provide a secure distinct living environment appropriate for the resident population. This requirement may include, but not be limited to, a locked unit, secured perimeter, or other mechanism to ensure resident safety and quality of life. The residence shall have elopement policies in place, specific to the Unit/Program.

M. Staff Training - Dementia Care Level

The administrator shall ensure that all new employees who will assist residents with personal care at the dementia level of care receive at least four (4) hours of orientation and training in the areas listed below prior to beginning work alone in the assisted living residence, in addition to the areas stipulated in §§ 2.4.12(G) of this Part. Staff will be provided no less than twelve (12) hours of continued education in the following areas at intervals not to exceed twelve (12) months.

1. Understanding various dementias;

2. Communicating effectively with dementia residents;

3. Managing behaviors;

4. Elopement procedures for the Unit/Program;

5. Creating a safe environment for residents;

6. Medications commonly prescribed for resident residing in the unit/program and potential side effects.

2.5.3 Emergency Power

A. The residence 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.

1. Such emergency power system shall supply power adequate at least for:

a. Lighting all means of egress; and

b. Equipment to maintain detection, alarm and extinguishing systems.

2.6.1 Applicability

Any assisted living residence which offers to provide or provides limited health services to residents shall be required to meet all requirements of §§ 2.4 and 2.6 of this Part.

2.6.2 Specific Requirements

A. All limited health services provided by a licensed assisted living residence shall be ordered by the resident’s physician, and provided by qualified licensed assisted living staff members.

B. Assisted living residences licensed to provide limited health services may provide any or all of the following services:

1. Stage I and stage II pressure ulcer treatment and prevention;

2. Simple wound care including postoperative suture care/removal and stasis ulcer care;

3. Ostomy care including appliance changes for residents with established stomas;

4. Urinary catheter care.

C. An assisted living residence licensed to provide limited health services and offers to provide services to residents receiving hospice services that are bed-bound or in need of assistance from more than one staff person for ambulation is required to be licensed at the F1 licensure level as defined in § 2.4.2(A)(1)(a) of this Part.

D. When it is identified that a resident requires a limited health services as defined in § 2.6.2(B) of this Part, the residence must inform the resident in writing of his/her right to access a licensed home nursing care agency or hospice provider for the services needed.

E. Assisted living residences licensed to provide limited health services are required to disclose in writing all services offered.

F. The disclosure shall be made to the licensing agency and to any person seeking placement in an assisted living residence licensed to provide limited health services.

G. The information disclosed shall explain the care that is provided in each of the following areas:

1. Philosophy: Written statement of its overall philosophy and mission which reflects how the assisted living provides limited health services;

2. Pre-Occupancy, Occupancy, and Termination of Residence: The process and criteria for occupancy, transfer or termination of residency;

3. Assessment, Service Planning and Implementation: The process used for assessment and establishing the plan of services and its implementation, including the method by which the plan of services evolves and is responsive to changes in condition;

4. Family Role in Providing Support and Services: The involvement in families and family support programs;

5. Program Costs: The cost of care and any additional fees and the process used in the event that a resident can no longer afford the cost of care being provided.

H. Any significant changes in the disclosure information provided by the assisted living residence shall be reported to the Department at the time the changes are made.

I. An assisted living residence that determines to cease offering a limited health service(s) shall notify, in writing, the Department, all residents, their guardian, or relative so appointed or elected to be his or her decision maker, every resident’s physician and to the Office of the Long-Term Care Ombudsman of its intent thirty (30) days or more before ceasing to offer a limited health service.

1. The written notification shall include, but is not limited to the following:

a. Letter of intent and/or determining factors/justification for stopping the service(s);

b. Proposed date that services would be discontinued;

c. Plan for ensuring that residents continue to receive services until other acceptable arrangements are made; and

d. Contact information of staff member responsible for implementing plan.

J. Based upon approval by the Department, an assisted living residence that that does not provide all limited health services, as defined in § 2.6.2(B) of this Part, may add additional service(s) under its license one time per annual licensing period.

K. Assisted living residences licensed to provide limited health services are required to develop and maintain written policies and procedures that detail the services offered, including:

1. Admission and discharge criteria for residents requiring limited health services;

2. Stage I and stage II pressure ulcer treatment and prevention;

3. Simple wound care including postoperative suture care/removal and stasis ulcer care;

4. Ostomy care including appliance changes for residents with established stomas;

5. Urinary catheter care;

6. If applicable, coordination of hospice services for residents who are bed-bound or in need of assistance from more than one staff person for ambulation.

L. All written policies and procedures for limited health services shall be developed under the direction of a licensed physician which shall be reviewed and approved at intervals not to exceed twelve (12) months.

M. Assisted living residences licensed to provide limited health services are required to have a licensed physician, a certified nurse practitioner or a licensed physician assistant as a member of the Quality Improvement Committee as defined in § 2.4.3 of this Part.

N. All limited health services shall operate and provide services in accordance with the prevailing community standard of care.

O. Evidence of Pre-employment and Ongoing Health Screening

Upon hire and prior to delivering services, employment health screenings shall be required for each individual who has or may have direct contact with a resident receiving limited health services. Such health screening shall be conducted in accordance with the rules and regulations pertaining to Immunization, Testing, and Health Screening for Health Care Workers (Part 20-15-7 of this Title).

P. All staff providing direct care services to residents receiving limited health services and/or hospice services for residents that are bed-bound or in need of assistance from more than one staff person for ambulation shall be qualified licensed assisted living staff members and may only perform duties and services as permitted by their respective license and/or certificate of registration.

Q. Assisted living residences licensed to provide limited health services are required to have on staff, at a minimum, a registered nurse(s). The nurse shall be on-site full-time (minimum of thirty-five (35) hours per week), and shall be available for consultation at all times.

R. Staff Training - Limited Health Services

All employees, including those who will assist residents with personal care receive at least four (4) hours of orientation and training in the areas listed below prior to beginning work alone with a resident receiving limited health services. Staff will be provided no less than two (2) hours of continued education in the following areas at intervals not to exceed twelve (12) months.

1. Pressure ulcer treatment and prevention;

2. Simple wound care including postoperative suture care/removal and stasis ulcer care;

3. Ostomy care including appliance changes for residents with established stomas;

4. Urinary catheter care;

5. Reporting changes in condition;

6. Signs and symptoms of infection(s); and

7. Signs and symptoms of dehydration.

2.6.3 Emergency Power

A. The residence 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.

1. Such emergency power system shall supply power adequate at least for:

a. Lighting all means of egress; and

b. Equipment to maintain detection, alarm and extinguishing systems.