Statutes, codes, and regulations
Maine Administrative Code
Department 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICESDivision 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERALChapter 113 - Regulations Governing the Licensing and Functioning of Assisted Housing Programs (includes Assisted Living Programs, Residential Care Facilities, and Private Non-Medical Institutions) (formerly 10-149 Ch. 113)
Residential Care Facilities
Section 144-113-IV-12 - Standards for Resident Care

10-144-113 Me. Code R. § IV-12

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Current through 2024-51, December 18, 2024
Section 144-113-IV-12 - Standards for Resident Care
12.1 General rule. Residents shall have the opportunity to receive individualized services that help them age in place, function optimally in the facility and in the community, engage in constructive activity, and manage their health conditions. The facility will assure, to a practicable extent, that residents' needs will be accommodated regarding individual choices and preferences. This shall be evidenced in the assessment of individual needs, development and implementation of individual service plans and in regular progress notes.
12.2 Resident assessment. Residents shall be assessed within thirty (30) calendar days of admission and reassessed annually or if there is a significant change in a resident's condition, to determine their abilities and need for services. The resident and resident's legal representative, as well as staff or other persons approved by the resident or resident's legal representative who are knowledgeable about the resident, shall participate in or be consulted concerning the assessment. The areas identified below are to be assessed. The listing of these areas is not meant to exclude assessment of any other obvious needs which the residents may exhibit.
12.2.1 Ability and need for psychological or supportive services, as may be evidenced by his/her adjustment to the facility, social and emotional issues, communications/relations with others, behaviors, compatibility with staff and other residents, or adapting/controlling personal habits;
12.2.2 Ability and need to maintain or develop family and community ties;
12.2.3 Need for educational, religious or community vocational services;
12.2.4 Ability and need for assistance with legal or financial problems;
12.2.5 Ability and need for assistance with personal care or ADLs as defined in Section 2 of these regulations;
12.2.6 Ability to manage personal affairs, use the telephone, handle finances, read and write correspondence, express likes and dislikes and register to vote;
12.2.7 Ability and need regarding social, recreational and leisure time activities, specifying likes and dislikes;
12.2.8 Abilities and needs regarding hearing, vision, speech, communication, mobility and memory impairments and use of related adaptive equipment;
12.2.9 Ability and need for assistance with securing necessary health care, including medical, nursing, dental, day treatment, psychological or mental health services, qualified sign language interpreters and other communication assistance;
12.2.10 Ability and need for arranging transportation to meet medical, social and business needs;
12.2.11 Ability and need for assistance to be independent in the community;
12.2.12 Ability and need for assistance regarding administration of medications;
12.2.13 Need for discharge planning.
12.3 Service plan. A service plan shall be developed and implemented within thirty (30) calendar days of admission for each resident based upon the findings of the assessment. The plan shall address those areas in which the resident needs encouragement, assistance or an intervention strategy. The resident, his/her legal representative (if applicable) and others chosen by the resident shall be actively involved in the development of the service plan, unless he/she is unable or unwilling to participate. There shall be documentation in the resident's record identifying who participated in the development of the service plan. The service plan shall describe strategies and approaches to meet the resident's needs, names of who will arrange and/or deliver services, when and how often services will be provided and goals to improve or maintain the resident's level of functioning. Residents shall be encouraged to be as independent as possible in their functioning, including ADLs and IADL's if they choose, unless contraindicated by the resident's duly authorized licensed practitioner. The service plan shall be modified, as necessary, based upon identified changes. Residents shall never be required to perform activities specified in the residential service plan or any other activities and cannot be used to replace paid staff.
12.4 Progress notes. The facility shall maintain ongoing progress notes at least monthly, on implementation of the service plan and for any significant changes in the resident's life, including any increases or declines in the resident's physical and mental functioning that should be considered at the time of reassessment or adjustment in the service plan. Progress notes shall begin within twenty-four (24) hours of admission and include an initial summary of basic care needs, circumstances of resident's placement and resident's adjustment to the facility.
12.5 Preferred activities. Providers shall make a variety of activities available which are of interest to the residents, in addition to television and movies. Activities shall be oriented to individual resident preferences.
12.6 Planned activity program. In addition to the requirements of Section 12.5, there shall be a planned program for diversional and motivational activities suited to the residents' needs and interests, as identified under Section 12.2. The program shall consist of a variety of activities designed for both group and individual participation and shall include activities outside the home, during the week and on weekends. Reasonable, accessible transportation to outside activities shall be provided or arranged. In facilities with more than ten (10) beds, an activity schedule shall be posted in resident areas. Where necessary, activities shall be modified to eliminate or reduce barriers to resident participation due to physical or cognitive limitations or language differences, including assisting the resident in learning the skills or knowledge to participate in activities.
12.7 Residents rising and retiring. Individual preferences of the residents shall be considered for times of rising and retiring, except as may be provided in the service plan.
12.8 Reading and recreational materials. A variety of reading and recreational materials which shall be available to the residents at all times. These shall include at a minimum, a daily newspaper, a variety of current magazines, radio and an operational television set. A facility's obligation to provide these materials is not waived when residents have their own.
12.9 Resident instruction in evacuation procedures. Residents and staff shall participate in regularly scheduled fire drills. This shall include instructions or action to be taken when the primary escape route is blocked. There shall be posted evacuation plans clearly showing the location of all exits. Fire and emergency policies and procedures, required pursuant to Section 10.9.4.6, shall contain procedures for the protection of all persons in the event of fire and for their remaining in place, for their evacuation to areas of refuge and from the building when necessary. These policies shall include special staff actions, including fire protection procedures needed to ensure the safety of any resident, and shall be amended or revised upon admission to the home of any resident with special needs. [Class II]
12.10 Medical and health care. The facility is responsible for promptly coordinating and assisting in accessing appropriate services for residents. The health care of every resident shall be under the supervision of a duly authorized licensed practitioner. Each resident shall have an annual physical, unless otherwise specified by the licensed medical professional.
12.11 Residents with communicable diseases. The facility shall not admit residents with a communicable disease if that resident's condition or behavior endangers the health and welfare of other residents and if no accommodation can be made to protect other residents. If an accommodation such as Standard Precautions reduces or eliminates the risk of exposure, then accommodations shall be made.
12.12 Employees with communicable diseases. No facility shall knowingly employ or otherwise permit any person to serve therein, in any capacity, if such person has a communicable or contagious disease which would threaten the health and welfare of the residents unless Standard Precautions reduce or eliminate exposure or risk to the residents.
12.13 Transportation. The facility shall provide or arrange transportation to medical and other appointments. Other transportation to meet residents' recreational, social and business needs of a reasonable nature will also be provided or arranged by the facility. This does not apply to transportation which is necessary to be provided by ambulance.
12.14 Refusal of care or treatment. In the event that a resident refuses necessary care or treatment, the facility shall document reasonable efforts made to consult with the resident's licensed medical professional, the registered nurse consultant, caseworker or other appropriate individuals in order to ensure that residents receive necessary services. However, in no case shall a person who does not have legal authority to do so, order treatment that has not been consented to by a competent resident. [Class III]
12.15 Discharge summary. Discharge summaries must be completed in conjunction with the resident and/or guardian. Documentation shall be inclusive of, but not limited to the following:
12.15.1 Reason for discharge;
12.15.2 Targeted living arrangement;
12.15.3 Identification and coordination of skills and supports and steps necessary for discharge to occur.

10-144 C.M.R. ch. 113, § IV-12