175 Neb. Admin. Code, ch. 1, § 005

Current through September 17, 2024

Section 175-1-005 - GENERAL REQUIREMENTS

These requirements pertain to all applicants and licensees governed by Neb. Rev. Stat. §§ 71-401 to 71-475.

005.01NOTIFICATIONS. An applicant or licensee must notify the Department electronically, in writing, or via facsimile of the following:

(A) At least 30 calendar days before a facility or service is sold, leased, discontinued, or moved to a new location;

(B) A change in the use, location of beds, or both;

(C) At least 30 calendar days prior to the date the facility or service would like to:

(i) Increase the number of beds for which the facility or service is currently licensed;

(ii) Change the usage of beds or rooms; or

(iii) Change the type of services provided;

(D) To request a single license document;

(E) To request simultaneous facility or service licensure inspections for all types of licensure held or sought;

(F) Prior to the start of the construction process if a facility is having construction done; and

(G) Within 24 hours of the following:

(i) When the licensee has reason to believe abuse, neglect or exploitation of a consumer has occurred;

(ii) When the death of a consumer at the facility or service occurred due to:

(1) Suicide;

(2) A violent act;

(3) Drowning; or

(4) The use of restraint or seclusion; and

(iii) When a consumer who needs supervision, leaves a facility or service without staff knowledge.

(iv) A fire in the facility or service; or

(v) Any natural disaster or accident resulting in damage to the physical plant which has a direct or immediate effect on a consumer in the facility or service. Notification must include the steps included to assure the consumer's safety.

005.02CAPACITY AND USAGE. The licensee must ensure:

(A) When providing beds for the consumer, the licensee must not utilize more beds than are licensed and approved by the Department and must not exceed the maxi-mum occupancy approval of the State Fire Marshal or their delegated authority; and

(B) The total number of consumers receiving care, treatment or services at one time from the facility or service must not exceed the licensed capacity approved by the Department and must not exceed the maximum occupancy approval of the State Fire Marshal or their delegated authority.

005.03PUBLIC INFORMATION. The licensee must make licenses, the most recent inspection reports, and any disciplinary action notices that are currently in effect, if any, available for public inspection upon request. All facility or service licenses must be displayed on the licensed premises.

005.04COMPLAINTS AND GRIEVANCES. A licensee must establish, implement and revise as necessary, written policies and procedures to promptly address complaints or grievances filed verbally or in writing. The policies and procedures must include:

(A) Information regarding how the consumer or designee may submit a complaint or grievance;

(B) Timeframes for investigative review and for a response to the consumer or designee;

(C) How the licensee will utilize information from complaints and grievances to improve the quality of care and treatment provided; and

(D) How the licensee will maintain records of complaints and grievances received, actions taken and resolution.

005.05QUALITY ASSURANCE AND IMPROVEMENT. The licensee must have a quality assurance and improvement program to collect data and assess care and treatment provided to the consumer, both concurrently and retrospectively. The program must include involvement by all disciplines. Results must be recorded quarterly and reported to the licensee's governing authority or licensee annually. The program must address:

(A) Goals and objectives;

(B) How problems or issues to be addressed will be identified;

(C) How recommended changes or actions will be identified;

(D) How recommendations will be implemented;

(E) How changes made will be monitored for effectiveness;

(F) A plan to review and revise actions, policies and recommendations as necessary; and

(G) Identification, by job title, of the person responsible for the effectiveness of the program.

005.06INFECTION CONTROL. The licensee must have an infection control program to minimize sources and transmissions of infections and communicable diseases. The program must address:

(A) How the licensee will identify, report, investigate and control infections;

(B) How trends will be tracked and identified;

(C) How treatment of any infections or communicable diseases will be monitored for appropriateness and for alteration of treatment when necessary;

(D) Hand hygiene techniques and how the licensee will ensure compliance;

(E) Use of safe work practices and personal protective equipment;

(F) Handling, cleaning, and disinfection of equipment, supplies and linens used to provide care and treatment to the consumer;

(G) How the licensee will educate staff, volunteers, and the consumer regarding infections, modes of transmission, hygienic practices, and methods of infection prevention; and

(H) Identification of the person, by job title, who is responsible for the effectiveness of the overall program.

005.07DISASTER PREPAREDNESS AND MANAGEMENT. The licensee must have a disaster preparedness program to ensure the safety, well-being and continuity of care and treatment for the consumer, visitors and staff during natural or other disasters, disease outbreaks, or other similar situations. The program must address:

(A) How consumer identification will be maintained;

(B) How communication will be maintained;

(C) How consumers, staff and visitors will be moved or relocated to points of safety;

(D) How consumers, staff and visitors will be protected from the threat of exposure, ingestion, absorption, or inhalation of hazardous substances or materials;

(E) How food, water, medicine, medical supplies and other necessary items will continue to be provided to the consumer, staff and visitors;

(F) How the consumer will be provided with necessary care and treatment; and

(G) How the facility will educate staff, visitors and consumers on the disaster preparedness plans.

005.08COMMUNICATION. Each licensee must implement interventions to ensure communication with consumers or their designee occurs in a manner and format the consumer or designee can understand.

175 Neb. Admin. Code, ch. 1, § 005

Adopted effective 3/12/2023