6 Colo. Code Regs. § 1011-1 Chapter 26, pt. 6

Current through Register Vol. 47, No. 16, August 25, 2024

Part 6 - SKILLED CARE

6.1 Governing Body

(A) An HCA shall have an organized governing body consisting of members who singularly or collectively have business and healthcare experience sufficient to oversee the services provided by the HCA.

(B) The governing body shall assume responsibility for:

(1) Compliance with all federal, state, and local laws and regulations.

(2) Quality consumer care, including annual review and approval of the HCA's Quality Management Plan.

(3) Development of policies and procedures which describe and direct functions or services of the HCA and protect consumer rights.

(4) Development of bylaws or governing document that shall include, at a minimum:

(a) A description of functions and duties of the governing body, officers, and committees, including a process for review of agency operations at least annually;

(b) A statement of the authority and responsibility delegated to the administrator; and

(c) A requirement to meet at least annually.

(5) Development of a policy and procedure for determining the qualifications of the administrator. Appointment of a qualified administrator, responsible for the HCA's overall functions, shall be documented in writing.

(6) Review of the written agency evaluation report and other communications from the administrator or group of professional personnel with evidence of written response.

(7) Establishing and ensuring the maintenance of a system of financial management and accountability.

(8) Organizing services furnished, administrative control, and lines of authority for the delegation of responsibility down to the consumer care level, that are clearly set forth in writing and are readily identifiable.

(9) Documentation of governing body meetings and activities.

6.2 Administration

(A) The HCA, under the direction of the governing body, shall be responsible for preparation of an overall plan and a budget that includes an annual operating budget and capital expenditure plan, as applicable.

(1) The governing body shall review and update the overall plan and budget at least annually.

(B) Any HCA that performs procedures in the consumer's residence that are considered waivered clinical laboratory procedures under the Clinical Laboratory Improvement Act of 1988 shall possess a certificate of waiver from the Centers for Medicare and Medicaid Services or its designated agency.

(C) Any HCA that provides equipment to consumers shall develop and implement policies and procedures for the management of medical equipment provided for use in consumer homes, including: selection, acquisition, delivery, and maintenance of the equipment.

(1) The HCA shall make full disclosure of the policies and procedures to all consumers before the equipment is provided.

(2) The policies and procedures shall include the following:

(a) A process to provide an appropriate back-up system, including emergency services twenty-four (24) hours per day where the malfunction may threaten the consumer's life;

(b) Monitoring and acting upon equipment hazard notices and recalls;

(c) Checking equipment upon delivery to the consumer to ensure it is sanitary, undamaged, and operating properly;

(d) Basic safety and operational checks on infusion pumps that include a volumetric test of accuracy of infusion rate between each consumer use; and

(e) Performance of routine and preventive maintenance conducted at defined intervals per manufacturer's guidelines.

(D) Availability After Business Hours

(1) The HCA shall have a registered nurse or other appropriate health professional available after business hours.

(2) The HCA shall have a policy describing, at a minimum, the following:

(a) How consumers will contact the agency after hours; and

(b) How the agency will ensure the health professional on call has access to all current consumer information.

6.3 Agency Evaluation

(A) The HCA's governing body or its designee shall conduct a comprehensive evaluation of the HCA's total operation at least annually.

(B) The evaluation shall assure the appropriateness and quality of the HCA's services with findings used to verify policy implementation, to identify problems, and to establish problem resolution and policy revision as necessary.

(C) The evaluation shall consist of an overall policy and administration review, including the scope of services offered, arrangements for services with other agencies or individuals, admission and discharge policies, supervision and plan of care, emergency care, service records, and personnel qualifications.

(1) The HCA shall implement an on-going mechanism for consumer involvement to provide input and comment regarding services provided by the HCA in accordance with HCA policy. Consumer input and commentary shall be provided to the governing body at least annually to identify trends or issues requiring consideration.

(D) In evaluating each aspect of its total program, the HCA shall consider four (4) main criteria:

(1) Appropriateness - assurance that the area being evaluated addresses existing and/or potential problems.

(2) Adequacy - a determination as to whether the HCA has the capacity to overcome or minimize existing or potential problems.

(3) Effectiveness - the services offered accomplish the objectives of the HCA and anticipated consumer outcomes.

(4) Efficiency - whether there is a minimal expenditure of resources by the HCA to achieve desired goals and anticipated consumer outcomes.

(E) Documentation of the annual evaluation shall include the names and titles of the persons carrying out the evaluation, the criteria and methods used to accomplish it, and any action taken by the HCA as a result of its findings.

(F) Appropriate professionals representing the scope of the HCA's program shall evaluate the HCA's consumer records at least quarterly.

(1) The evaluation shall include a review of sample active and closed consumer records to ensure that HCA policies are followed in providing services, both directly and under arrangement, and to assure that the quality of service is satisfactory and appropriate. The review shall consist of a representative sample of all home care services provided by the HCA.

6.4 Administrator

(A) The administrator shall assume authority for the operation of the HCA's skilled health services, including but not limited to:

(1) Organizing and directing the HCA's ongoing functions;

(2) Employing qualified personnel and ensuring appropriate ongoing education and supervision of all personnel;

(3) Ensuring the accuracy of public information materials and activities;

(4) Implementing a budgeting and accounting system; and

(5) Designating in writing a qualified alternate administrator to act in the administrator's absence.

(B) The administrator shall:

(1) Be at least twenty-one (21) years of age;

(2) Be a licensed physician, registered nurse, or other licensed healthcare professional, or have experience and education in health service administration;

(3) Be qualified by education, knowledge, and experience to oversee the services provided; and

(4) Have at least two (2) years healthcare or health service administration experience with at least one (1) year of supervisory experience in home care or a closely related health program.

(C) The administrator shall have the overall responsibility to ensure the following:

(1) The HCA's skilled health services are in compliance with all applicable federal, state, and local laws;

(2) The completion, maintenance, and submission of such reports and records as required by the Department;

(3) Ongoing liaison with the governing body, personnel, and the community;

(4) Maintenance of a current organizational chart to show lines of authority down to the consumer level;

(5) The management of the business affairs and the overall operation of the HCA;

(6) Maintenance of appropriate personnel, financial, and administrative records and all policies and procedures of the agency;

(7) Employment of qualified personnel in accordance with written job descriptions;

(8) Orientation of new personnel, and regularly scheduled in-service education programs and opportunities for continuing education are provided for the personnel;

(9) Availability of the administrator or designee at all hours personnel are providing services, at minimum, any eight (8) hour period between 7 a.m. and 7 p.m. Monday through Friday;

(10) Marketing, advertising, and promotional information accurately represents the HCA and addresses the care, treatment, and services that the HCA can provide directly or through contractual arrangement; and

(11) Maintenance of a coordinated HCA-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HCA's quality management program.

(D) Curriculum for administrator training

(1) A first-time administrator or alternate administrator shall complete a total of twenty-four (24) clock hours of training in the administration of an HCA before the end of the first twelve (12) months after designation to the position.

(2) A first-time administrator or alternate administrator shall complete eight (8) clock hours of educational training in the administration of an HCA within the first month of employment. The eight (8) clock hours shall include, at a minimum, the following topics:

(a) Home care overview;

(b) Information on the licensing standards for the HCA; and

(c) Information on state and local laws applicable to the HCA.

(3) A first-time administrator or alternate administrator shall complete an additional sixteen (16) clock hours of educational training before the end of the first twelve (12) months after designation to the position. Any of the sixteen (16) clock hours may be completed prior to designation if completed during the twelve (12) months immediately preceding the date of designation to the position. The additional sixteen (16) clock hours shall include the following subjects and may include other topics related to the duties of an administrator:

(a) Consumer rights, governing body and administrator responsibilities, quality management plans, occurrence reporting, and complaint investigation and resolution process;

(b) Personnel qualifications, experience, competency, and evaluations;

(c) Financial management;

(d) Ethics in healthcare;

(e) Needs of the fragile, ill, and physically and cognitively disabled in the community setting with special training and staffing considerations;

(f) Behavior management techniques;

(g) Staffing methodologies and oversight of scheduling;

(h) Staff training and supervision; and

(i) Limitations of personal care versus health care services.

(4) The twenty-four (24) clock hour education requirement shall be met through structured, formalized classes, correspondence courses, competency-based computer courses, training videos, distance learning programs, or other training courses. Subject matter that deals with the internal affairs of an organization does not qualify for credit. The training shall be provided or produced by an academic institution, a recognized state or national organization or association, an independent contractor, or an HCA.

(a) If an HCA or independent contractor provides or produces training, the training shall first be approved by the Department or recognized by a national organization or association. The HCA shall maintain documentation of this approval for review by inspectors.

(5) Documentation of administrator or alternate administrator training must be on file at the HCA and contain the name of the class or workshop, the course content or curriculum, the hours and dates of the training, and the name and contact information of the entity and trainer who provided the training.

(6) After completion of the twenty-four (24) clock hours of educational training within the first twelve (12) months after designation as a first-time administrator or alternate administrator, each must then complete the continuing education requirements in each subsequent twelve (12)-month period after designation.

(7) An administrator shall complete twelve (12) clock hours of continuing education within each twelve (12)-month period beginning with the date of designation. The education shall include at least two (2) of the following topics and may include other topics related to the duties of the administrator.

(a) Any of the topics listed under the initial training requirements;

(b) Development and implementation of agency policies;

(c) Healthcare management;

(d) Ethics;

(e) Quality improvement;

(f) Risk assessment and management;

(g) Financial management;

(h) Skills for working with consumers, families, and other professional service providers, including considerations for special populations served by the HCA;

(i) Community resources; and

(j) Marketing.

(8) For an administrator or alternate administrator who has not served as an administrator for 180 days or more immediately preceding the date of designation, at least eight (8) of the twelve (12) clock hours within the first twelve (12) months after designation shall include the topics listed for first time administrators. The remaining four (4) clock hours shall include topics related to the duties of the administrator and include at least two (2) of the topics listed under continuing education. If a previous administrator has not been employed as such for two (2) years or more, the requirements for a first time administrator apply.

6.5 Nursing or Healthcare Supervisor

(A) The skilled nursing services furnished shall be under the supervision and direction of a physician or registered nurse who has at least two (2) years of nursing experience including one (1) year in home care or a closely related service.

(1) Other healthcare services shall be under the supervision and direction of a physician, registered nurse, or other licensed healthcare professional who has at least two (2) years of healthcare experience in the field of supervision including one (1) year of experience in home care or a closely related service.

(B) The nursing or healthcare supervisor, or similarly qualified alternate, shall be available at all times during operating hours and participate in all activities relevant to the professional services furnished, including the development of qualifications and the assignment of personnel.

(C) The nursing or healthcare supervisor shall ensure oversight of all consumer care services and personnel, including but not limited to:

(1) Making consumer and personnel assignments;

(2) Coordinating consumer care;

(3) Coordinating referrals;

(4) Assuring that consumer needs are continually assessed; and

(5) Assuring the development, implementation, and updates of the individualized plan of care.

6.6 Personnel

(A) All personnel shall possess the education and experience to provide services in the homes of consumers in accordance with HCA policy, state practice acts, and professional standards of practice as set forth in this chapter.

(B) Licensed, certified, and/or registered personnel shall have an active license, certification, or registration, issued by DORA with no restriction that would affect the ability to perform required duties, and shall provide services within their scope of practice.

(C) Personnel not licensed, certified, or registered by DORA shall, at a minimum, meet the following requirements:

(1) A phlebotomist shall:

(a) Have successfully completed an approved phlebotomy training course or equivalent experience through previous employment; and

(b) Have two (2) years of verifiable phlebotomy experience.

(D) Ongoing training shall be provided to all direct care personnel. Training requirements shall be consistent with the program, services, and equipment the HCA provides and appropriate to the needs of the populations served.

(1) Training shall consist of at least twelve (12) topics applicable to the HCA's care and services every twelve (12) months after the starting date of employment or calendar year as designated by HCA policy. The training requirement shall be prorated in accordance with the number of months the individual was actively working for the agency.

(2) Training shall include, but not be limited to, the following items:

(a) Promoting consumer dignity, independence, self-determination, privacy, choice, and rights; including abuse and neglect prevention and reporting requirements;

(b) Behavior management techniques;

(c) Disaster and emergency procedures; and

(d) Infection prevention and control.

(3) All training shall be documented by the HCA.

(a) Documentation of training shall include: the date of training; length of training; entity or instructor(s) that offered or produced the training; a short description of the content; and staff member's written or electronic signature or proof of attendance.

6.7 Initial and Comprehensive Assessments

(A) Initial assessment visit

(1) A registered nurse shall conduct an initial assessment visit to determine the immediate care and support needs of the consumer. The initial assessment visit shall be held either within forty-eight (48) hours of referral, or within forty-eight (48) hours of the consumer's return home, or on the ordered start-of-care date.

(2) When an alternate professional healthcare service is the only service ordered, the initial assessment visit may be made by the appropriate healthcare professional.

(3) The initial assessment visit and comprehensive assessment may be conducted during the same visit.

(B) Comprehensive assessment of consumers

(1) The HCA shall conduct an individualized comprehensive assessment that accurately reflects each consumer's current health status and includes information that may be used to demonstrate the consumer's progress toward achievement of the desired outcomes.

(2) The comprehensive assessment shall identify the consumer's need for home care and meet the consumer's medical, nursing, rehabilitative, social, and discharge planning needs.

(3) The comprehensive assessment shall be completed in a timely manner, consistent with the consumer's immediate needs, but no later than five (5) calendar days after the start of care.

(4) Except as otherwise indicated in this section, a registered nurse shall complete the comprehensive assessment.

(5) When healthcare services other than nursing are ordered by the physician or licensed independent practitioner, the primary professional healthcare worker shall complete the comprehensive assessment.

(6) When nursing services are provided, the comprehensive assessment shall include a review of all medications the consumer is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

(a) The HCA shall report any concerns to the attending physician or licensed independent practitioner and to the nursing or healthcare supervisor, and these reports shall be acted upon.

(7) For consumers receiving intermittent respite and waiver services that are not provided within a continuous sixty (60) day period, a comprehensive assessment shall be accomplished before reinitiating services rather than the minimum time frames set forth below.

(8) The comprehensive assessment shall be updated and revised as frequently as the consumer's condition warrants due to a major decline or improvement in the consumer's health status. At a minimum, it shall be updated and revised:

(a) Every sixty (60) days beginning with the start-of-care date; and

(b) Within forty-eight (48) hours of the consumer's return to the home from a hospital admission of twenty-four (24) hours or more, for any reason other than diagnostic tests or, for non-certified agencies, as ordered by the physician or licensed independent practitioner.

(C) Provision of skilled services

(1) The HCA shall have written policies regarding nurse delegation. The policy shall delineate what tasks or procedures may or may not be delegated, the delegation process, documentation, and how the delegate shall be supervised in accordance with 3 CCR 716-1, Nursing Rules and Regulations. If the HCA prohibits nurse delegation, the HCA shall have a policy that specifies such prohibition.

6.8 Plan of Care

(A) Consumer care follow a written plan of care established and periodically reviewed by a physician or licensed independent practitioner. For PACE participants, the interdisciplinary team shall establish, follow, and periodically review the plan of care.

(B) The plan of care shall be developed in consultation with the HCA personnel and covers all pertinent diagnoses, including mental status, types of services, identification of any services furnished by other providers, and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, instructions for timely discharge or referral, and any other appropriate items.

(1) The plan of care shall identify the consumer's continuing need for home care and meet the consumer's medical, nursing, rehabilitative, social, and discharge planning needs.

(2) The plan of care reflects the participation of the consumer to the extent possible. The HCA communicates the plan of care to the consumer or authorized representative in a comprehensible way.

(C) If a physician or licensed independent practitioner refers a consumer under a plan of care that cannot be completed until after an evaluation visit, the attending physician or licensed independent practitioner shall be consulted to approve additions or modifications to the original plan.

(D) Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration. The therapist, other HCA personnel, and external home care providers, where applicable, shall participate in developing the plan of care.

(E) The plan of care shall be reviewed in its entirety by the attending physician or licensed independent practitioner and HCA personnel as often as the severity of the consumer's condition requires, but at least once every sixty (60) days or more frequently when there is a significant change in condition.

(1) For consumers receiving intermittent respite and waiver services that are not provided within a continuous sixty (60) day period, the time frame for review begins upon the re-initiation of care.

(F) Licensed HCA personnel shall promptly alert the physician or licensed independent practitioner to any changes that suggest a need to alter the plan of care.

(G) If person-to-person contact with the physician or licensed independent practitioner or their designated representative was not completed or if awaiting a return response, all contacts and interactions shall be documented. The HCA shall have a written policy regarding how the HCA will intervene if the attending physician or licensed independent practitioner cannot be contacted or does not respond in a timely manner.

(H) All orders shall contain sufficient information to carry out the order, name of the physician or licensed independent practitioner, and, if appropriate, representative conferring the order to the HCA.

(I) Any program or service offered by the HCA, directly or under arrangement, shall be provided in accordance with the plan of care and HCA policy and procedure.

6.9 Medication Management

(A) If the plan of care includes medication administration, medication management, or medication set-up, there shall be documentation in the consumer record as to who is responsible to monitor the medication supply, order refills, and ensure the timely delivery of medications. There shall be evidence that the plan has been developed with input from the consumer or authorized representative.

(1) Medication review shall be documented when new medications are prescribed.

(2) Medication review shall be documented periodically throughout the episode of care to determine if the consumer has added or eliminated medications or herbal products from the medication regime.

(B) Drugs and treatments shall be administered by HCA personnel only as ordered by the physician or licensed independent practitioner and in accordance with professional standards of practice.

(1) Vaccines may be administered per HCA policy, developed in consultation with a physician and after an assessment for contraindications.

(2) For consumers receiving medication administration services, a current medication administration record shall be maintained as part of the consumer record.

(3) The personnel administering medication(s) shall monitor for effectiveness, interactions, and adverse effects.

(C) If controlled drugs are being administered by the HCA, there shall be a policy regarding how the drugs will be administered and monitored.

(1) HCAs shall have a written policy stating how controlled drugs will be monitored if HCA personnel transport the drugs from the pharmacy to the consumer.

6.10 Care Coordination

(A) Care coordination shall be demonstrated for each consumer at least every sixty (60) days for cases where there is more than one (1) agency sharing the provision of the same home health services. The minutes of these case conferences shall reflect discussion and input by all the disciplines providing care to the consumer.

(B) The HCA shall be responsible for the coordination of consumer services both with internal personnel and known external services providing care and services to the same consumer.

(C) All personnel providing care on behalf of the HCA shall maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the plan of care and as delineated through outside home care services.

(D) The clinical record, care coordination notes, or minutes of case conferences establish that effective interchange, reporting, and coordination of consumer care do occur.

(E) The HCA shall prepare a written summary report which shall be sent to the attending primary care provider every sixty (60) days. This report is only required for consumers who experienced a change in status or needs that necessitated a change in the plan of care during the sixty (60)-day period.

6.11 Extended Care

(A) Extended care is defined as a total of six (6) or more hours of home health services provided in a twenty-four (24)-hour period by a licensed agency that provides skilled health services on a continuous basis.

(B) The HCA shall have a contingency plan regarding how the care is managed if the scheduled personnel cannot provide care.

(C) A communication record shall also be available in the home if a consumer is receiving extended care.

(1) The record shall contain:

(a) The current plan of care;

(b) Notes containing consumer status and continuing needs;

(c) The medication administration record; and

(d) Any other information deemed necessary by the HCA.

(2) If nurse aide service is the only service providing extended care, a home communication record is not required.

(a) Written instructions shall be maintained in the home and in the permanent record.

(D) The HCA shall have an orientation plan for the personnel providing care to the consumers. Since extended care cases may involve highly technical services, this plan shall reflect how the HCA ensures that the individuals providing the extended care are qualified to provide these types of services.

(E) Contracting for extended care services

(1) A licensed HCA may contract with another entity to provide extended care in the licensed HCA's service area provided that administration, care, and supervision down to the consumer care level are ultimately the responsibility of the primary HCA.

(2) The contract shall be in conformance with Part 5.9(F) of this chapter.

(3) The contracted personnel shall have completed the HCA orientation and competency evaluation for provisions of care and services for the extended care consumer.

(a) Documentation of personnel qualifications, orientation, and competency evaluation shall be kept at the primary HCA.

(F) Prior to withdrawing skilled nursing or nurse aide services for an extended care consumer, the HCA shall:

(1) Show continuing and documented efforts to resolve conflicts unless the safety of personnel is placed at immediate risk;

(2) Provide evidence that ongoing efforts were made to recruit personnel or place the consumer with another HCA; and

(3) Give the consumer or authorized representative fifteen (15)-business days' notice of the intent to discharge the consumer unless staff or consumer safety is at immediate risk.

(a) The HCA shall maintain evidence that such notice was delivered in person or by certified mail.

6.12 Skilled Nursing Services

(A) The registered nurse shall be responsible for the following:

(1) Conducting the initial assessment and comprehensive assessment visit;

(2) Regularly reevaluating the consumer's nursing needs;

(3) Initiating the plan of care and necessary revisions;

(4) Furnishing those services requiring substantial and specialized nursing skill;

(5) Initiating appropriate preventive and rehabilitative nursing procedures;

(6) Preparing clinical notes, coordinating services, and informing the physician and other personnel of changes in the consumer's condition and needs;

(7) Counseling the consumer and family in meeting nursing and related needs; and

(8) Participating in in-service programs, supervising, and teaching other nursing personnel.

(B) The licensed practical nurse shall be responsible for the following:

(1) Performing nursing services in accordance with their scope of practice and as assigned by the physician, licensed independent practitioner, and/or registered nurse;

(2) Furnishing services in accordance with HCA policies;

(3) Preparing clinical notes; and

(4) Assisting the consumer in learning appropriate self-care techniques.

6.13 Nurse Aide Services

(A) The HCA shall select nurse aides on the basis of such factors as the ability to read, write, carry out directions, effectively communicate to demonstrate competency in the safe and effective provision of care and services, and treat consumers with dignity and respect to person and property.

(B) The HCA shall ensure that each nurse aide it employs is certified by DORA within four (4) months of starting employment and that certification remains current. Each aide that provides care and services prior to certification shall be supervised in the home by direct observation at least weekly for the first month of employment and every two (2) weeks thereafter until certification is obtained.

(1) HCAs that employ nurse aides awaiting certification shall do so in accordance with Section 12-255-214, C.R.S.

(C) The HCA shall complete a competency assessment with direct observation of each nurse aide before assignment, in accordance with Part 6.13(E) of this chapter.

(D) For all consumers who are receiving skilled care and need nurse aide services, the supervising healthcare professional shall, during supervisory visits, accomplish the following:

(1) Obtain the consumer's input, or that of the consumer's authorized representative, regarding the nurse aide assignment form, including all tasks to be performed during each scheduled time period.

(a) Details such as, but not limited to, housekeeping duties and standby assistance shall be negotiated and included on the nurse aide assignment form so that all obligations and expectations are clear.

(b) The nurse aide assignment form shall contain information regarding special functional limitations and needs, safety considerations, special diets, special equipment, and any other information that is pertinent to the care that will be given by the nurse aide.

(c) The HCA shall ensure that the consumer or the consumer's authorized representative approves and signs the form and is provided a copy at the beginning of services, and at least annually.

(d) Provide each consumer and/or the consumer's authorized representative with a new copy of the consumer rights form and explain those rights at least annually.

(e) If nurse aide services are provided to a consumer who is receiving in-home care by a health professional, the supervising health care professional, in accordance with the professional's scope of practice and state and federal law, shall make a supervisory visit no less than every two (2) weeks to supervise the nurse aide services. The visit shall be conducted either in the consumer's home or via telehealth, in accordance with the requirements in Part 6.17(A)(1).

(i) Direct observation of care being provided by the nurse aide shall occur at least every sixty (60) days in the consumer's home.

(ii) More frequent direct supervision shall occur if there are adverse changes in the consumer's condition, complaints received associated with the provision of care by a nurse aide, supervision requested by the nurse aide or consumer for specific issues, or other matters concerning the provisions of care by the nurse aide.

(f) If nurse aide services are provided to a consumer who is not receiving in-home care by a health professional, a supervisory visit with the nurse aide present at the consumer's home shall occur no less frequently than every sixty (60) days.

(i) More frequent direct supervision shall occur if there are adverse changes in the consumer's condition, complaints received associated with the provision of care by a nurse aide, supervision requested by the nurse aide or consumer for specific issues, or other matters concerning the provisions of care by the nurse aide.

(E) Nurse aide training and orientation

(1) The HCA shall ensure that skills learned or tested elsewhere can be transferred successfully to the care of the consumer in their place of residence. This review of skills may be performed when the nurse installs an aide into a new consumer care situation, during a supervisory visit, or as part of the annual performance review. A pseudo-patient may be used for this evaluation.

(2) If the HCA's admission policies and the case-mix of HCA consumers demand that the nurse aide care for individuals whose personal care and basic nursing or therapy needs require more complex training than the minimum required in the regulation, the HCA shall document how these additional skills are taught and validated.

(3) The HCA shall establish a process for standardized, step-by-step observation and evaluation of nurse aide competency in the following subject areas prior to the assignment of tasks requiring direct observation of items (c), (i), (j), and (k) of this paragraph (3).

(a) Communications skills;

(b) Observation, reporting, and documentation of consumer status and the care or service furnished;

(c) Reading and recording temperature, pulse, and respiration;

(d) Basic infection control procedures;

(e) Basic elements of body functioning and changes in body function that shall be reported to a nurse aide's supervisor;

(f) Maintenance of a clean, safe, and healthy environment;

(g) Recognizing emergencies and knowledge of emergency procedures;

(h) The physical, emotional, and developmental needs of, and methods to work with, the populations served by the HCA including the need for respect of the consumer, their privacy, and property;

(i) Appropriate and safe techniques in personal hygiene and grooming that include: bathing, including bed/sponge, tub, and shower; shampoo, including sink, tub, and bed; nail and skin care; oral hygiene; and toileting and elimination;

(j) Safe transfer techniques and ambulation;

(k) Normal range of motion and positioning; and

(l) Adequate nutrition and fluid intake.

(4) Written assignment and instructions for the nurse aide shall be prepared by the registered nurse or other appropriate professional who is responsible for the supervision of the nurse aide.

(a) The nurse aide shall be assigned and instructed to provide only those services the aide is permitted to perform under state law and deemed competent to perform.

(b) The written assignment reflects the consumer's plan of care orders.

(c) The written instructions of the assignment shall consider the skills of the nurse aide, the amount and kind of supervision needed, and the specific nursing or therapy needs of the consumer.

(i) The written instructions shall detail the procedures for the consumer's unique care needs.

(ii) The written instructions shall identify when the nurse aide should report to the supervising professional.

(d) The written assignment and instructions shall be reviewed every sixty (60) days or more frequently as changes in the consumer's status and needs occur.

6.14 Therapy Services

(A) Any therapy services offered by the HCA, directly or under arrangement, shall be provided by a qualified therapist or by a qualified therapy assistant under the supervision of a qualified therapist and in accordance with the plan of care.

(B) The qualified therapist shall assist the physician or licensed independent practitioner in evaluating level of function, help develop the plan of care (revising it as necessary), prepare clinical notes, advise and consult with the family and other agency personnel, and participate in in-service programs.

(C) Supervision of therapy assistants

(1) A physical therapist assistant, occupational therapy assistant, or respiratory therapy assistant performs services directed from a written plan of care, delegated and supervised by a qualified therapist, assists in preparing clinical notes and progress reports, participates in educating the consumer and family, and participates in in-service programs.

6.15 Medical Social Services

(A) Any medical social services offered by the HCA, directly or under arrangement, shall be provided by a qualified social worker in accordance with the plan of care.

(B) The social worker shall be responsible for the following:

(1) Assisting the physician or licensed independent practitioner and other team members in understanding the significant social and emotional factors related to the health problems;

(2) Participating in the development of the plan of care;

(3) Preparing clinical notes;

(4) Working with the family;

(5) Connecting the consumer with appropriate community resources;

(6) Participating in discharge planning and in-service programs; and

(7) Acting as a consultant to other HCA personnel.

6.16 Other Healthcare Services

(A) Any healthcare services offered by the HCA, directly or under arrangement, are given by a qualified healthcare professional or by a qualified healthcare professional assistant under the supervision of a qualified healthcare professional and in accordance with the plan of care.

(B) The qualified healthcare professional assists the physician or licensed independent practitioner in evaluating the needs of the consumer, helps develop the plan of care (revising it as necessary), prepares clinical notes, advises and consults with the family and other agency personnel, and participates in in-service programs.

(C) Supervision of assistants

(1) An assistant to the healthcare professional performs services directed from a written plan of care, delegated and supervised by a qualified health professional, assists in preparing clinical notes and progress reports, participates in educating the consumer and family, and participates in in-service programs.

6.17 Telehealth Supervisory Visits

(A) The HCA may conduct supervisory visits using telehealth for the following services, so long as the HCA continues to ensure consumer care and treatment are delivered in accordance with a plan of care that addresses the consumer's status and needs.

(1) For nurse aide services, the supervising healthcare professional may evaluate the delivery of care and services required every two (2) weeks at Part 6.13(D)(1)(e) through an interactive audiovisual connection with the consumer. The results of the supervisory visit must be documented by the supervising healthcare professional.

(a) An in-person supervisory visit with the nurse aide and consumer is required at least every sixty (60) days if nurse aide services are provided to a consumer who is receiving in-home care by a nurse aide.

(2) For therapy services, such as physical therapy, occupational therapy, and speech therapy, supervision of assistants required at Part 6.14(C) may be provided through an interactive audiovisual connection and in accordance with all applicable state laws and regulations.

(a) An in-person supervisory visit shall occur in accordance with the HCA's policies and procedures, the plan of care, and professional standards of practice.

(3) For other healthcare services, supervision of assistants required at Part 6.16(C) may be provided through an interactive audiovisual connection and in accordance with all applicable state laws and regulations.

(a) An in-person supervisory visit shall occur in accordance with the HCA's policies and procedures, the plan of care, and professional standards of practice.

(B) An in-person supervisory visit is required to evaluate consumer complaints related to the delivery of care when such concerns cannot be successfully addressed remotely through an interactive audiovisual connection.

(C) All other general requirements for supervisory visits, such as documentation and meeting the same standard of care, must be met.

6.18 Clinical Record

(A) In addition to the requirements in Part 5.15, an HCA providing skilled care shall comply with the following requirements:

(1) The initial and comprehensive assessments shall be documented in the consumer record and shall include the consumer's current comprehensive assessment, including all of the assessments from the most recent HCA admission, clinical notes, plans of care, and physician or licensed independent practitioner orders.

(2) The record shall include all interventions, including medication administration, treatments, and services, and responses to those interventions.

6 CCR 1011-1 Chapter 26, pt. 6