Section 144-113-IV-10 - Administration10.1 Administrator required. There shall be an on-site administrator who shall perform such duties as the licensee may properly delegate to him/her. The administrator shall perform such functions in compliance with all applicable laws and regulations and consistent with the standard of conduct that a reasonable and prudent person would observe in the same situation. [Class III]10.2 Administrator's age. The administrator shall be at least twenty-one (21) years of age. [Class III]10.3 Qualifications of the applicant/licensee and administrator. The applicant/licensee and administrator must meet the following requirements: 10.3.1 The applicant/licensee and administrator must demonstrate to the Department's satisfaction the capacity to operate and manage the facility with regard for the best interests of residents and consistent compliance with these regulations and all relevant laws. The applicant/licensee and administrator, as part of the license application and renewal process, shall consent to the release of all information that may be reviewed in this Section. In making any determination under this Section, the Department may consider:10.3.1.1 Records of professional licensing boards or registers, any criminal record, child protective record or adult protective record relating to the applicant/licensee and administrator;10.3.1.2 Whether the facility is required to have a licensed administrator by the Nursing Home Administrator's Licensing Board, and whether the administrator's license is current and valid;10.3.1.3 Financial ability and fiscal responsibility of the applicant/licensee (such as a history of timely payment of employee Federal withholding taxes, and capability of obtaining financing for working capital and repairs);10.3.1.4 Management and supervisory experience, including the capacity to manage the financial operations and staff of the facility for which the license is sought. A Residential Care or Multi-Level Facility Administrator's License will be accepted as evidence that this standard is met;10.3.1.5 Experience in the field of health care, social services or areas related to the provision of assisted living services. A Residential Care or Multi-Level Facility Administrator's License will be accepted as evidence that this standard is met;10.3.1.6 Understanding of and compliance with resident rights;10.3.1.7 Any information reasonably related to the ability to provide safe and compassionate services.10.4 Administrator training. The administrator must have successfully completed a Department-approved training program for administrators unless they have a license from the Nursing Home Administrators Licensing Board as a Residential Care Administrator or Multi-Level Facility Administrator. On-going training of at least twelve (12) classroom hours annually is required for all administrators in areas related to care of the population served by the facility. Classroom hours from the Department-approved administrator training may count towards meeting these twelve (12) hours.10.5 Acting administrator. A competent individual, authorized to act in the absence of the administrator during the normal working day, shall be designated. Any planned absence of the administrator for a period longer than thirty (30) calendar days shall be reported in writing to the Department, including the name of the acting administrator.10.6 Change of administrator. In the event of a change of administrator, the licensee must notify the Department in writing within seventy-two (72) hours and submit a change of administrator application with the name of the new administrator within thirty (30) calendar days of hire. The facility may have an acting administrator for a period not to exceed sixty (60) calendar days. If no permanent administrator has been secured and no new application is submitted by the end of the sixty (60) calendar day period an extension of the time must be requested by the licensee in writing, and the request must be approved by the Department. No extension will be granted unless the licensee demonstrates that a reasonable attempt has been made to find a replacement meeting the requirements of in accordance with Section 10.3 of these regulations. If the Department does not grant an extension, the licensee shall be notified of the opportunity to request an administrative hearing pursuant to Title 5 M.R.S.A. §9051 et seq.10.7 Physical and emotional health of administrator. The administrator shall possess physical health, mental health and the good judgment determined necessary by the Department to capably operate the facility and supervise residents. An administrator with a documented history or substantiated complaints of substance abuse or mental illness must provide evidence of satisfactory treatment/rehabilitation or references regarding current condition. An examination may be required at the discretion of the Department. Failure to disclose the above information may be grounds to deny an (re) application. [Class III]10.8 Number of hours for administration. Hours spent for administration shall include those hours spent on-site at the facility performing administrative duties and those off-site hours spent conducting activities specifically related to the administration of the facility, but shall not include so-called "on-call" hours. In no event shall an administrator fulfill the requirements for administrative hours solely with off-site hours. The number of hours that an administrator shall perform administrative duties each week shall be as follows:10.8.1 At least forty (40) hours each week during normal business hours is required for any facility having fifty (50) or more beds. If a person administers more than one (1) facility with a combined total of fifty (50) or more beds, there shall be a distribution of forty (40) hours between the facilities. In the case of one administrator having responsibilities in more than one facility, the Department may limit the number of beds for which that administrator can be responsible. Such limitations may be set when the allocation of hours is not sufficient to comply with all applicable laws and regulations.10.8.2 Facilities or a combination of facilities having less than fifty (50) beds are permitted to have less than forty (40) hours of on-site administration per week. The Department may require up to forty (40) hours of on-site administration in a facility or combination of facilities of 20-49 beds and up to twenty (20) hours in facilities of 5-19 beds when there is evidence that less hours are not sufficient to fully comply with all applicable laws and regulations. Administrative hours shall be indicated on the time schedule, as required by Section 13.3.4 of these regulations, except in facilities of ten (10) or fewer beds.10.8.3 When an administrator is shared with another facility, prior approval by the Department is required and will be granted subject to conditions in Sections 10.8.1 and 10.8.2 of these regulations.10.9 Administrative responsibilities. The administrator is responsible for the overall operation of the facility. Notwithstanding Section 10.1, the administrator shall perform the following duties: 10.9.1 Ensure that all staff are qualified and competent and are performing their duties consistent with all regulations and provisions of law.10.9.2 Assure that each resident's abilities and needs are adequately assessed, that a pertinent service plan based upon assessment is developed and that each resident is offered all services as indicated in the service plan.10.9.3 Make work assignments according to the qualifications of staff and the number and needs of the residents.10.9.4 Develop, maintain and carry out written policies and procedures to implement these regulations. Other policies may be developed at the discretion of the facility to ensure the orderly conduct of resident care. Policies shall indicate what staff are responsible for coordination or implementation of policies and procedures. Required policies include:10.9.4.2 Resident grievance procedures;10.9.4.3 Personnel (including hiring procedures, reference checks, job qualifications and descriptions, lines of authority, employee benefits, work rules, evaluation of performance of tasks as described in the job description and disciplinary procedures);10.9.4.5 Medications (administration, ordering, returning, discontinuing, destroying, charting, pharmacy consultation);10.9.4.6 Fire and emergency procedures;10.9.4.7 Maintenance/service agreements and schedules;10.9.4.8 Admission /discharge and scope of services policy;10.9.4.9 Confidentiality;10.9.4.10 Activities/Social Services;10.9.4.11 Staff training and development (including orientation and in-service education);10.9.4.12 Nursing services;10.9.4.13 Refusal of treatment/care/services; and10.9.4.14 Emergency medical procedures, including emergency transfers. Written policies and licensing regulations are to be reviewed by and shall be available to all staff members. The facility shall also make available a copy of paragraph 67.02-3 Chapter III Section 67 of the MaineCare Benefits Manual for limitations on nursing care. These policies are also to be available for review by interested parties.
10.9.5 Provide a safe environment which supports residents' rights and aging in place.10-144 C.M.R. ch. 113, § IV-10